Every finding on record at Bradford Heights Nursing & Rehabilitation

Observation, interview, and review of facility policies revealed the facility failed to provide assistance with incontinence care in a timely manner for four (4) of 10 sampled residents (R1, R6, R7, and R14).The findings include: Review of the facility's policy titled, Resident Rights Policy, reviewed 04/2026, revealed residents had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences.Review of the facility's policy titled, Activities of Daily Living Policy, revised 04/2026, revealed residents who were unable to carry out activities of daily living would receive the necessary services to maintain good personal hygiene.Review of the facility's policy titled, Perineal Care Policy, reviewed 04/2026, revealed it was the practice of the facility to provide perineal care to all incontinent residents as needed in order to promote cleanliness and comfort, as well as to prevent infection and skin breakdown.Observation of the 300 hall on 05/27/2026 at 9:38 AM revealed Resident (R)6's call light engaged. His room smelled of feces upon entry. There were two (2) staff members observed sitting at the 300 hall's nurses station.During an interview with R6 on 05/27/2026 at 9:38 AM, he reported that he signaled with his call light approximately 15 minutes before (9:23 AM) to request to be cleaned due to an episode of bowel incontinence. He stated that someone (he was unsure of whom) had responded and said they would be right back to get him cleaned up. He stated that it bothered him when he had to wait forever and with further questioning, he stated that 20 minutes was too long for him to sit in a soiled brief waiting to be cleaned. Continued observation revealed a CNA entered his room to change his brief at 9:49 AM, approximately 26 minutes after he initially made the request.During an additional interview with R6 on 05/27/2026 at 1:25 PM, he stated it bothered him to have to wait over 20 minutes to be cleaned but that the staff member did the best she could.During an interview with R1 on 05/26/2026 at 10:05 AM, she stated she only got changed one time per shift at night. She further stated that when she pressed her call light to request to be changed, the Certified Nursing Assistant (CNA) told her she (the CNA) would be back in a minute, which turned into hours. She reported that she had to sit in a wet brief for over three (3) hours a few nights prior to this interview. She also stated she was always incontinent, and it made her miserable to have to sit in a wet brief for so long.During an interview with R7 on 05/26/2026 at 2:25 PM, she stated she had to sit in feces for two (2) hours a couple weeks ago. She stated that it took two (2) people to provide incontinence care for her due to her size. She further stated there were only two CNAs on the floor working at the time, which forced her to wait until they were both available to get her cleaned up. She reported that having to sit in her feces for two (2) hours made her feel dirty and disgusting.During an interview with R14 on 05/28/2026 at 2:15 PM, she reported that she had to wait about 40 minutes in a wet brief the night prior to this interview before being changed. She stated she signaled on her call light twice while staff were having a little party at the nurse's station outside her room. Additionally, she stated the CNAs were rude to her and closed her door so she couldn't see them after the second time she called requesting to be changed. She became tearful and stated that it made her feel terrible to have to wait for 40 minutes because she got raw in her perineal area if she had to sit in a soiled brief for too long.During an interview with CNA1 on 05/26/2026 at 9:52 AM, she described her normal workload as taking care of 12 to 14 residents in the 200 hall. Additionally, she stated, if someone called out sick the resident load would increase to 18 to 20 residents per CNA, depending on the census. She further stated the increased workload made it difficult to give good care to everyone but that she did the best she could.During an interview with CNA3 on 05/26/2026 at 10:44 AM, she stated that on days when another CNA had called out sick, her assignment became unmanageable and she was not able to give adequate care to some of the residents. She further stated that people frequently called out of work.During an interview with CNA4 on 05/26/2026 at 11:05 AM, she stated it is not uncommon for a CNA to be assigned to 20 residents on a shift, which, she stated, made it extremely hard to take care of residents to an adequate standard. She further stated a normal assignment is to care for 12 to 15 residents in the 300 hall. She reported that people called out of work almost every day and that the facility attempted to find coverage, but they were not always able to do so.During an interview with CNA6 on 05/29/2026 at 11:00 AM, she stated, CNAs rounded every two hours and in between as needed.During an interview with LPN3 on 05/29/2026 at 11:20 AM, she stated, CNAs rounded every hour on residents who were care planned for that, otherwise every two hours.During an interview with the Director of Nursing (DON) on 05/29/2026 at 3:40 PM, she stated, CNAs round every two hours on residents to check for soiled briefs, and as needed. Additionally, she stated that the charge nurse monitored to make sure that rounding is done. She reported her expectation was for a resident's soiled brief to be changed within 10 minutes, and no longer than 15 minutes after an episode of incontinence.During an interview with the Administrator on 05/29/2026 at 4:15 PM, she stated, CNAs rounded every two hours on residents, which was an expectation, but that rounding was not necessarily monitored. Additionally, she stated, her expectation was for call lights to be answered within 15 minutes. She further stated that residents wouldn't want to have to sit in a soiled brief for a long time because it would make them feel yucky and gross.

Observation, interview, and facility policy review revealed the facility failed to maintain a homelike environment for residents related to peeling paint on the walls in room [ROOM NUMBER], holes in the wall in rooms [ROOM NUMBER], and stained ceiling tiles in rooms 100, 107, 109, and 119. This affected four (4) out of 20 sampled residents, R11, R12, R19, and R20.The findings include: Review of the facility's policy, titled, Resident Rights Policy, reviewed 04/2026, revealed residents had a right to a safe, clean, comfortable, and homelike environment.Request for the facility's maintenance policy revealed that they didn't have any policies pertaining to maintenance of their building.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:00 PM revealed three (3) stained ceiling tiles in the left corner of the room and above the window. The fabric window covering was also stained. The tiles were yellowish-brown from apparent moisture.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:03 PM revealed staining on two (2) ceiling tiles in the far-right corner of the room adjacent to the stain on the other side of the wall in room [ROOM NUMBER]. The tiles were stained yellowish-brown from apparent moisture.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:15 PM revealed 10 stained ceiling tiles down the middle of the room for the entirety of the room's length. The tiles were stained yellowish-brown from apparent moisture.Observation of a small supply closet on 05/26/2026 at 4:20 PM near the nurse's station in 100 hall revealed three (3) stained ceiling tiles, one of which was bowed significantly. The closet door was open and inside were open plastic cupboards containing disposable cups, spoons, isolation gowns, a box of N95 disposable respirator masks, aerosol masks with tubing, oxygen tubing, nasal cannulas, and various other oxygen tubing and supplies. The tiles were stained yellowish-brown from apparent moisture.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:30 PM revealed three (3) stained ceiling tiles, one of which was bowed significantly, in the far-right corner of the room. The tiles were stained yellowish-brown from apparent moisture.Observation of room [ROOM NUMBER] on 05/29/2026 at 9:35 AM revealed a 20-inch x 12-inch hole in drywall with paint missing above R11's bed.Further observation of room [ROOM NUMBER] on 05/29/2026 at 9:45 AM revealed an 8-inch x 1-inch line of peeling paint to the left of the window. There was a 3-inch x 2-inch hole in the ceiling tile above Bed B's TV. There was a 30-inch x 18-inch section of peeling paint below the window on the left side. There was also a 40-inch x 3-inch line of peeling paint along the right side of the window frame. There was a 13-inch x 3-inch hole in the wall at the head of bed B near the floor. There was a 5-inch x 1 inch scrape in the paint behind bed A and a 14-inch x 2-inch scrape in paint along the wall where the mattress of bed A met the wall. Additionally, there was a 2-inch x 2.5-inch round spot of missing paint below the clock above dresser B. There was a pile of R12's clothes and shoes in the corner of the room covered in white dust and particles from the crumbling paint.Observation of room [ROOM NUMBER] on 05/29/2026 revealed a 21-inch x 4-inch hole in the wall to the left of the air conditioner along the floor.During an interview with the Maintenance Director on 05/26/2026 at 12:09 PM, he stated that about 6-8 weeks ago there was heavy rain and the building's gutters were clogged, resulting in a roof leak. He further stated the gutters had since been cleaned and there were no leaks since. He stated water was coming in through the ceiling and stained the ceiling tiles in rooms [ROOM NUMBERS]. He further stated that the stained ceiling tiles were replaced. He reported that maintenance issues were always fixed promptly and that there were no other major repairs needed to the building at that time.During an interview with R20 on 05/28/2026 at 4:55 PM, she stated that the peeling paint and holes in the walls of her room did not make her feel like she was at home. She further stated that she didn't like the condition of the room.During an interview with R12 on 05/29/2026 at 9:45 AM, she stated that the crumbling paint in her room bothered her because paint dust was getting onto her belongings.During an interview with R11 on 05/29/2026 at 9:35 AM, she stated that the hole in her wall had been there since she had lived in room [ROOM NUMBER]. She further stated that it made her feel very unsafe and that she didn't like to look at it.During an interview with R19 on 05/29/2026 at 10:30 AM, she stated she wished the hole in her wall wasn't there and further stated that she tried not to look at them.During an interview with the Administrator on 05/29/2026 at 4:15 PM, she stated the residents were very comfortable with the Maintenance Director and would usually let him know if they wanted something repaired. She further stated that if the Maintenance Director knew about an issue, he would take care of it promptly.

Based on interview, record review, and review of the facility policies, the facility failed to ensure pain assessments were completed prior to and after the administration of as needed (PRN) narcotic pain medications for four (4) out of four (4) sampled residents, Resident (R)4, R8, R16, and R18.The findings include: Review of the facility's policy, titled, Pain Management Policy, revised 04/2026, revealed the facility would utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. It further revealed, the facility would use a pain assessment tool, appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The policy stated, Facility staff will reassess resident's pain management at established intervals for effectiveness and / or adverse consequences.Review of the facility's policy, titled, PRN Medication Policy, reviewed 04/2026, revealed documentation would be provided in the resident's medical record to show adequate indications for a medication's use. Further, the policy advised that, when administering a PRN medication, staff must document the reason why the resident needed the medication, the time of administration, and an evaluation of the effectiveness of the medication.Review of R18's undated Resident Face Sheet revealed the facility admitted her on 06/02/2022 with diagnoses including but not limited to cerebral infarction, neuralgia, and unspecified pain.Review of the comprehensive care plan for R18 revealed she was initially care-planned for pain on 09/19/2022 as being at risk for pain related to impaired mobility, gastroesophageal reflux disease, and osteoporosis. This problem also noted that R18 had neck pain. Interventions for the problem included, administer medications as ordered, and, [R18] prefers to have pain controlled by oral medication as prescribed per physician. Further review of R18's care plan revealed an additional problem for pain added on 04/27/2025 related to her cerebrovascular accident (CVA) and osteoporosis. The long-term goal, with target date of 06/05/2026, stated, will not have complication related to opioid use and listed interventions included medications / treatments as ordered, as well as reviewing pain as needed.Review of R18's Medication Administration Record (MAR), dated, 03/01/2026 - 03/31/2026, revealed four (4) documented administrations of Hydrocodone-Acetaminophen 5-325 milligram tablets, complete with pain assessments before and after administration. Per the MAR, R18 could receive the medication every 8 hours as needed for pain. Review of the Medication Monitoring / Control Record for this medication revealed 17 tablets were removed for R18 from 03/01/2026 - 03/31/2026. Documentation of 13 PRN doses were missing from the MAR, including a pain assessment and reevaluation of R18's pain before and after administering the medication.Review of R18's MAR, dated, 04/01/2026 - 04/30/2026, revealed two (2) documented administrations of Hydrocodone-Acetaminophen 5-325 milligram tablets, complete with pain assessments before and after administration. Review of the Medication Monitoring / Control Record for this medication revealed 10 tablets were removed for R18 from 04/01/2026 - 04/30/2026. Documentation of eight (8) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R18's pain before and after administering the medication.Review of R4's undated Resident Face Sheet revealed the facility admitted her on 08/17/2019 with diagnoses including but not limited to diastolic heart failure, wedge compression fracture of T11-T12 vertebra, and unspecified pain.Review of the comprehensive care plan for R4 revealed she was initially care-planned for potential pain on 11/02/2022 related to age, decreased mobility, restless leg syndrome (RLS), and muscle spasms. Interventions included administering medications as ordered. Further review of the care plan revealed an additional pain problem added on 04/27/2025, stating, [R4] is receiving opioid related to decreased mobility, RLS, and muscle spasms. The long-term goal, with target date of 06/16/2026, stated, [R4] will not have complication related to opioid use and interventions included medications / treatments as ordered, as well as reviewing pain as needed.Review of R4's MAR, dated, 03/01/2026 - 03/31/2026, revealed one (1) documented administration of Tramadol 50 mg. Per the MAR, this medication could be administered every six (6) hours as needed for pain. Review of the Medication Monitoring / Control Record for this medication revealed 9 tablets were removed for R4 from 03/01/2026 - 03/31/2026. Documentation of 8 PRN doses were missing from the MAR, including a pain assessment and reevaluation of R4's pain before and after administering the medication.Review of R4's MAR, dated, 04/01/2026 - 04/30/2026, revealed one (1) documented administration of Tramadol 50 mg. Review of the Medication Monitoring / Control Record for this medication revealed six (6) tablets were removed for R4 from 04/01/2026 - 04/30/2026. Documentation of five (5) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R4's pain before and after administering the medication.Review of R4's MAR, dated, 05/01/2026 - 05/31/2026, revealed no documented administrations of Tramadol 50 mg. Review of the Medication Monitoring / Control Record for this medication revealed seven (7) tablets were removed for R4 from 05/01/2026 - 05/31/2026. Documentation of seven (7) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R4's pain before and after administering the medication.Review of R16's undated Resident Face Sheet revealed the facility admitted her on 07/02/2020 with diagnoses including but not limited to cerebrovascular disease, Alzheimer's Disease with late onset, and idiopathic neuropathy.Review of the comprehensive care plan for R16 revealed she was initially care-planned for pain on 11/14/2022 related to history of hip fracture, decreased range of motion, arthritis, and weakness. Interventions included administering medications as ordered, as well as evaluating the effectiveness of pain interventions. Further review of the care plan revealed an additional pain problem added on 04/27/2025, stating, [R16] is receiving opioid medication related to CVA and muscle weakness. The long-term goal, with target date of 07/13/2026, stated, [R16] will not have complication related opioid use and interventions included medications / treatments as ordered, as well as reviewing pain as needed.Review of R16's MAR, dated, 04/01/2026 - 04/30/2026, revealed no documented administration of Hydrocodone-Acetaminophen 5-325 milligram tablets. Per the MAR, this medication was ordered to be administered every six (6) hours as needed for pain. Review of the Medication Monitoring / Control Record for this medication revealed five (5) tablets were removed for R16 from 04/01/2026 - 04/30/2026. Documentation of five (5) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R16's pain before and after administering the medication.Review of R16's MAR, dated, 05/01/2026 - 05/31/2026, revealed one (1) documented administration of Hydrocodone-Acetaminophen 5-325 milligram tablets. Review of the Medication Monitoring / Control Record for this medication revealed nine (9) tablets were removed for R16 from 05/01/2026 - 05/31/2026. Documentation of eight (8) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R16's pain before and after administering the medication.Review of R8's undated Resident Face Sheet revealed the facility admitted her on 01/20/2025 with diagnoses including but not limited to Type 2 Diabetes Mellitus with hyperglycemia, unspecified myalgia, and acquired absence of the left foot and right great toe.Review of the comprehensive care plan for R8 revealed she was initially care-planned for acute pain on 01/21/2025 related to amputation of right great toe. Interventions included administering medications as ordered, as well as a resident preference for Hydrocodone-Acetaminophen. Further review of the care plan revealed an additional pain problem added on 04/27/2025, stating, [R8] is receiving opioid related to acquired absences of right great toe. The long-term goal, with target date of 07/08/2026, stated, [R8] will not have complication related opioid use and interventions included medications / treatments as ordered, as well as reviewing pain as needed.Review of R8's Medication Administration Record (MAR), dated, 03/01/2026 - 03/31/2026, revealed no documented administrations of Hydrocodone-Acetaminophen 7.5-325 milligram tablets. Per the MAR, R8 could receive the medication every 8 hours as needed for pain. Review of the Medication Monitoring / Control Record for this medication revealed five (5) tablets were removed for R8 from 03/01/2026 - 03/31/2026. Documentation of five (5) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R8's pain before and after administering the medication.Review of R8's MAR, dated, 04/01/2026 - 04/30/2026, revealed four (4) documented administrations of Hydrocodone-Acetaminophen 7.5-325 milligram tablets, complete with pain assessments before and after administration. Review of the Medication Monitoring / Control Record for this medication revealed 16 tablets were removed for R8 from 04/01/2026 - 04/30/2026. Documentation of 14 PRN doses were missing from the MAR, including a pain assessment and reevaluation of R8's pain before and after administering the medication.Review of R8's MAR, dated, 05/01/2026 - 05/31/2026, revealed no documented administration of Hydrocodone-Acetaminophen 7.5-325 milligram tablets. Review of the Medication Monitoring / Control Record for this medication revealed seven (7) tablets were removed for R8 from 05/01/2026 - 05/31/2026. Documentation of seven (7) PRN doses were missing from the MAR, including a pain assessment and reevaluation of R8's pain before and after administering the medication.During an interview with Licensed Practical Nurse (LPN)1 on 05/28/2026 at 4:10 PM, she stated that she was aware that medications, including PRNs, are supposed to be documented. Additionally, she stated she realized she needed to be more diligent about her documentation and that she became lazy about it over time. She further stated that it would be possible to double down on someone's medication if it is not documented properly.During an interview with Certified Medication Technician (CMT)4 on 05/28/2026 at 11:10 AM, she stated if a PRN pain medication is needed, she notified the nurse to do an assessment and once they did their part, she took out the medication and documented it in the MAR. She further stated that the documentation of administration is not complete unless it was on the MAR. Additionally, she stated, if a narcotic is given but not documented in the MAR, it could lead to a potential overdose, medication reaction, or death if the same medication is unknowingly administered too soon.During an interview with LPN3 on 05/29/2026 at 11:20 AM, she stated, if an administered narcotic is not documented in the MAR it could lead to drug overdoses because the MAR prevented someone from giving the medication too soon.During an interview with the DON on 05/29/2026 at 3:40 PM, she stated that she did not perform audits of PRN medications specifically, only scheduled medications, and was unaware if the consulting pharmacy performed narcotic audits. She stated that due to the concerns brought forward by the State Survey Agency, she started the process of making sure every narcotic signed out was then documented on the MAR. She further stated that she would be responsible for doing those audits on an ongoing basis because it was her expectation for all medication administrations, including PRNs, to be documented accurately in the MAR.During an interview with the Administrator on 05/29/2026 at 4:15 PM, she stated there will be audits moving forward on PRN narcotic documentation to compare the Controlled Substance Records to the MARs. Additionally, she stated that the facility would provide education about ensuring that staff documented all medications in the MAR. She stated, her expectation was for all medication administrations to be documented in the MAR, including PRN pain medications.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure all staff properly adhered to infection control and personal protective equipment (PPE) regulations in accordance with professional standards for one of four sampled residents (Resident (R) 1) for enhanced barrier isolation. Observation on 04/08/2026 revealed a staff member entered a R1's room, who was on enhanced barrier precautions and performed direct resident care without donning the appropriate PPE. The findings include: Review of facility's policy titled, Infection Prevention and Control Program, last revision date 01/20/2026, revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Further review of the policy revealed 16. Staff Education: A. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function. B. All staff shall demonstrate competence in relevant infection control practices. C. Direct care staff shall demonstrate competence in resident care procedures established by our facility Review of Resident (R) 1's Resident Face Sheet in the facility's electronic health record revealed the facility admitted R1 on 03/23/2026 with diagnoses of acute osteomyelitis, renal abscess, and perinephric abscess requiring intravenous antibiotic per physician order. Review of R1's Care Plan revealed she was on enhanced barrier precautions related to intravenous access. An intervention listed on the care plan included isolation per medical doctor's order on 03/31/2026. Review of R1's Resident Physician Orders revealed wound care was ordered on 04/03/2026 and was to be completed twice daily. The wound care order directed staff to cleanse the spine area with normal saline or wound cleanser, pat dry, to skin prep surrounding tissue or peri-wound and cover with sterile dressing with adhesive border. Additionally, an order dated 03/23/2026 directed staff to observe the IV site routinely for signs and symptoms of infiltration or extravasation, every shift. Observation on 04/08/2026 at 11:15 AM revealed Resident (R)1 did not have signage outside her doorway to indicate she was on enhanced barrier precautions. Additionally, during observation of R1's wound care treatment performed by the Assistant Director of Nursing (ADON), a PPE gown was not donned prior to performing R1's wound care treatment. During an interview on 04/10/2026 at 12:28 PM, the ADON stated she completely forgot to don a PPE gown prior to performing R1's wound care During an interview with Director of Nursing (DON) on 04/08/2026 at 2:00 PM she stated the precaution signs hung outside resident rooms are hung with tape and R1's must have fallen off. In a follow-up interview on 04/10/2026 at 11:48 AM with DON, she stated her expectation was for staff to adhere to infection control signage for enhanced barrier protection and to follow the policy. During an interview with Administrator on 04/10/2026 at 12:34 PM, she stated her expectations was for staff to follow infection control signage and to adhere to the precautions prior to entering a resident's room. She continued that a risk of not following precautions could lead to a resident developing a possible infection.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications with expired or post discard dates were not available for resident use for one of four sampled residents (Resident (R) 1). Observation on 04/08/2026 revealed an intravenous (IV) antibiotic (Meropenem) container hanging on an IV pole in R1's room labeled with directions to discard the medication after 03/03/2026.The findings include: Review of the facility's policy titled, Medication Storage last revision date of 02/01/2026, revealed A. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. The policy failed to include directions for staff on how to appropriately address medications past their discard date. Review of R1's Resident Face Sheet found in facility's electronic medical record revealed the facility admitted the resident on 03/23/2026 with diagnoses of acute osteomyelitis, renal abscess, and perinephric abscess. Observation on 04/08/2026 at 11:15 AM, revealed a full unadministered IV antibiotic, Meropenem, 1gram/100mililiters of normal saline container was hanging on an IV pole in R1's room. The label included a discard date with directions to discard after 03/03/2026. Review of R1's Physician Order Report dated 04/08/2026 revealed she had the antibiotic Meropenem 1 gram to be reconstituted in 100 milliliters of normal saline, to be given every 8 hours until 04/22/2026, prescribed for acute osteomyelitis. Review of Resident Progress Notes dated 04/08/2026 at 2:05 PM revealed the facility Nurse Practitioner documented R1's Peripheral Inserted Central Catheter (PICC) would not flush and staff were unable to administer the antibiotic during night shift on 04/08/2026. Continued review revealed day shift staff inserted a new peripheral intravenous catheter to administer IV medications. During an interview with Licensed Practical Nurse, LPN1 on 04/08/2026 at 1:34 PM, she stated during the nightshift on 04/08/2026, prior to attempting to flush and determine the patency of R1's PICC to administer IV medications, she set up the antibiotic Meropenem for R1. LPN1 stated she did not notice that the label on the Meropenem included a discard date of 03/03/2026. She stated when she was unable to flush the PICC, she left the antibiotic on the IV pole and notified the provider that she was unable to administer R1's scheduled antibiotic. She stated she would have double checked the medication label prior to administering. Further, LPN1 stated she usually worked on another unit and the expired medication should not have been in medication room for her to obtain. LPN1 continued that unit managers and charge nurses are supposed to go through products in the medication room to ensure there are no expired medications or products. LPN1 stated she received education on the five rights to medication administration. During an interview with Director of Nursing, (DON) on 04/08/2026 at 2:00 PM, she stated a licensed nurse should go through the medication rooms daily to ensure there are no expired medications or products. The DON stated that it does not seem to be working, but she expected staff to perform double checks of label information prior to medication administration. During an interview with Administrator on 04/10/2026 at 12:34 PM, she stated her expectations of adhering to proper medication storage was for staff to be mindful of expiration dates, check before administering, send expired medications back to pharmacy or dispose of them. The Administrator continued that nurses on the floor or unit managers are to ensure that medications are not expired in the medication rooms. She stated she is not sure how often that should be done. The Administrator continued that there was a risk of a medication error if an expired medication was administered.

Based on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents sampled for wound care out of the total sample of 20, (Resident (R)2 and R6). The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised on 02/02/2025, revealed it was the facility's policy for hand hygiene to be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's policy titled, Wound Care-Dressing Change, reviewed 03/24/2025, revealed it was the facility's policy to clean the bedside table with facility approved cleaning wipes and use a clean barrier to establish a clean field on resident's overbed table for placement of (wound care) supplies. Continued review of the policy revealed staff providing wound care were to remove their gloves and wash and dry hands thoroughly after removing the dirty (wound) dressing. Further policy review revealed staff were to apply clean gloves before cleansing the wound and remove those gloves and wash and dry hands thoroughly after cleansing the wound. Additional review of the policy revealed it was the facility's policy for staff to put on clean gloves before applying the clean dressing. 1). Review of the Face Sheet for R6 revealed the facility admitted the resident on 07/17/2025, with diagnoses that included unspecified dementia, neuromuscular dysfunction of bladder, chronic kidney disease, and essential hypertension. Review of the admission MDS Assessment, with an ARD of 07/23/2025, revealed the facility assessed R6 as having a BIMS score of 6 out of 15, indicating the resident had moderate cognitive impairment. Observation of R6's wound care on 09/09/2025 at 1:55 PM, revealed the wound care nurse failed to clean or disinfect the bedside table as per policy, before placing the clean dressing change supplies on it and removing the dirty dressing from the resident's left heel. Continued observation revealed the wound care nurse also failed to clean or disinfect her hands after removing the dirty dressing from the wound on R6's left heel and did not change her gloves or sanitize hands before applying the clean dressing. 2). Review of the Face Sheet for R2 revealed the facility admitted the resident on 03/18/2025, with diagnoses that included unspecified dementia, metabolic encephalopathy, pressure ulcer of left hip, unstageable, and other obstructive and reflux uropathy. Review of the Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/25/2025, revealed the facility assessed R2 as having a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating the resident had severe cognitive impairment. Observation of R2's wound care on 09/09/2025 at 2:05 PM, revealed the wound care nurse failed to clean or disinfect the bedside table prior to placing the clean dressing change supplies on it. In addition, observation revealed the wound care nurse failed to change her gloves or sanitize her hands after removing the dirty dressing from the wound on R2's right buttock and before applying the new dressing to the wound. During interview with the wound care nurse on 09/10/2025 at 11:00 AM, she stated she knew what she had done wrong during the dressing changes for R2 and R6, as soon as she did it. She said she knew she should have taken her gloves off after removing the dirty dressing, washed her hands, and put on a new pair of gloves before applying the clean dressings. The wound care nurse reported she also should have cleaned and sanitized the bedside tables prior to placing the clean drape and supplies on the bedside tables. She further stated a negative outcome of not changing one's gloves and sanitizing hands during dressing changes was the spread of infections and worsening of the residents' wounds. In interview on 09/10/2025 at 2:55 PM, the Director of Nursing (DON), who was also the facility's Infection Preventionist, stated the wound care nurse was new to her position and had only been doing the residents' wound care for two weeks now. She said she expected staff to follow their training and experience when performing the resident's wound care. The DON/IP her expectations also included for staff performing wound care to make sure there was a clean barrier between the bedside table and clean supplies. She reported she also expected staff providing wound care to perform hand hygiene and change their gloves after removing dirty dressing, after cleansing wounds, and before applying clean dressings. The DON/IP explained the wound care nurse received on-spot education and had been assigned lessons about wound care. She said the facility had a skills fair annually and they would be focusing more on infection prevention and were working on having the skills fairs more often. The DON/IP further stated negative outcomes of not cleaning and disinfecting the bedside table that wound care supplies were placed on and not performing hand hygiene after removing dirty dressing, was the risk of infection, spreading of infection, and deterioration of the residents' wound. During interview with the facility's Administrator on 09/12/2025 at 4:20 PM, she stated her expectations was for staff to follow wound care orders and follow the facility's infection control training as nurses and licensed professionals when providing residents' wound care.

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 93 of the facility's 93 residents who consumed food from the kitchen. The findings include: Review of the facility policy titled, Food Storage, revised 10/2019, revealed the Dining Service Director/Cook(s) were to ensure all food items were stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation on 09/09/2025 at 10:15 AM, with the Dietary Manager (DM) revealed her hairnet receded approximately three inches above the hairline exposing uncovered hair on both sides of her head above her ears and in the front above her forehead. Continued observation of the kitchen, of refrigerator, 1 revealed a container of strawberries covered with mold. Observation revealed two heads of lettuce stored in a plastic bag that was opened, uncovered, and undated. Observation of freezer 1 revealed a box of French toast sticks and a box of chicken patties stored in their original container which had uncovered flap, and inside a plastic container that was not covered exposing the food to air. Continued observation of freezer 1 revealed a freezer storage bag which contained 3 sausages that was not sealed, and the sausages were covered with ice crystals. Further observation of the kitchen area revealed an area beside the stove and fryer that was covered with a thick film of splattered grease and other debris on the floor, the wall, and sides of the appliances and pipes that extended from the wall into the floor and back into the wall. Additionally, observation revealed an area between the stove and fryer that was covered with a layer of splattered grease and other debris that was on the floor and the wall. During further observation of the kitchen, on 09/10/2025 at 10:30 AM, the DM was observed still wearing her hairnet as in the previous observation, exposing approximately 3 inches of hair. Additionally, observation revealed the areas previously observed to have been splattered with grease remained soiled. In interview with Dietary Aide (DA) 1, on 09/12/2025 at 9:44 AM, she stated when storing food items in the refrigerator or freezer staff should date, seal and cover the food items to prevent contamination. The DA said she did not know why that had not been done for the food observed in the refrigerator and freezer. She reported however, the person doing that had not followed food storage guidelines. DM 1 explained if staff were not following the facility's policy and procedures food could spoil, resident's might complain about the taste of the food or they could get sick. She stated all dietary staff were responsible for cleaning the kitchen and their assigned areas. The DM said cooks were responsible for cleaning the grease splatter around the fryer and stove, and most of the cleaning in that area was completed weekly. She reported grease splatter near the stove or fryer could cause a fire. DM 1 further stated she would not feel good about serving food to the residents from a soiled kitchen. Additionally, she stated she did not know why the cleaning had not been done. In interview with [NAME] (C) 1, on 09/12/2025 at 9:53 AM, she stated she had worked for the facility for about nine and a half years. She said for food items stored in the refrigerator or freezer, when finished with them, she would place it back in its original container or a new container if needed. C 1 explained she would then label and date the food items with the opened date, secure the plastic package, twist the top and put a rubber band on it to ensure it was covered. She reported there was no reason that kitchen staff should not be storing food items properly. C 1 stated every kitchen staff should be following the facility's policy and procedures. She said if food items were not being stored properly, they could become freezer burnt, and the food could possibly make the residents sick. C 1 explained she would never serve anything she would not eat herself. She stated, in regard to cleaning the kitchen, that had occurred every shift, and the cooks were responsible for cleaning the areas around the stove. C 1 reported the fryer and the grease splatters should be cleaned up every day as the buildup of grease that close to the stove and fryer could be a fire hazard. She further stated there was no reason the cleaning had not been being done and they had just not done it. In interview with the DM, on 09/12/2025 at 10:02 AM, she stated kitchen staff had cleaned the sides of the fryer, back of the stove, and floor, but the pipe would be the responsibility of maintenance. She said the floor, and surrounding area were to be done once a week and when the fryer was changed, and the task had just been overlooked and had not gotten done. The DM reported there was a potential for a fire hazard, and moving forward disciplinary action would be taken if that cleaning had not been done as required. She said the expectations for kitchen staff were for them to follow the facility's procedures to keep the kitchen area clean, free of grease, and other debris, and staff had everything necessary to ensure that was being done. The DM stated in regard to food storage and food safety kitchen staff should be using the first in first out (FIFO) method and ensure storage procedures were followed to include covering and/or resealing and labeling and dating those food items. She explained if staff were not following those procedures, the food could be past its expiration, contaminated and could potentially cause food borne illness or other sickness for the residents. Additionally, she stated her expectations for all kitchen staff was for all hair to be pulled back and secured with a hairnet at all times. She further stated that would prevent hair from falling into food that could cause potential cross contamination and sickness. In interview with the Administrator, on 09/12/2025 at 4:30 PM, she stated she had not previously believed food that was freezer burnt would make the residents sick. She said however, she expected dietary staff to follow the facility's policy for food storage to prevent contamination. The Administrator reported she expected all staff to wear their hairnets properly to ensure all hair was covered so that hair would not get into the resident's food. She stated she had not thought grease that was splattered all over the floor, walls, pipes, and appliances in the kitchen would be a hazard for the residents. The Administrator further stated however, there could be a potential for a grease fire if that area was not cleaned thoroughly and regularly.

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 90 of the facility's 94 residents who consumed food from the kitchen. Observation during the initial kitchen tour revealed numerous food items in the reach-in cooler not labeled or dated. In addition, continued observation of the kitchen revealed [NAME] 2 failed to have a beard covering in place. Further observation revealed [NAME] 2 failed to utilize utensils when serving food, using his gloved hands and not changing gloves. The findings include: Review of the facility's policy titled, Food Preparation and Service, undated, revealed, Culinary service employees shall prepare and serve food in a manner that complies with safe food handling practices. Per policy review, food preparation staff were to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Continued review revealed bare hand contact with food was prohibited, and gloves must be worn when handling food directly. Further review revealed gloves could also become contaminated and/or soiled and must be changed between tasks, as disposable gloves were single use items and should be discarded after each use. Additionally policy review revealed dietary staff should wear hair restraints, hairnet, hat, and beard restraint, so that hair did not contact food. Review of the facility's policy titled,Leftovers, undated, revealed leftovers were to be properly handled and used or discarded as appropriate. Continued review revealed leftovers were to be covered, labeled, dated and stored appropriately and immediately after the end of the meal service. Policy review revealed leftovers were to be used within three days or discarded. Observation with the Head Cook, during the initial tour of the kitchen on 09/17/2024 at 7:10 AM, of the reach-in cooler revealed 6 bowls of fruit, not labeled or dated; a large container of leftover chili dated 07/15/2024; and 3 peanut butter and jelly sandwiches, 2 cheese sandwiches, and 2 bowls of chicken soup not labeled or dated. In addition, observation of the reach-in cooler further revealed a box of bacon opened with strips of bacon not covered. Interview with the Head [NAME] on 09/17/2024 at 7:10 AM, during observation, she stated all leftover items should have been labeled and dated when stored in the coolers. She stated staff were aware of that information. The Head [NAME] further stated the coolers and walk-in were checked on a daily basis by herself and the Dietary Manager (DM). Observation on 09/17/2024 at 1:39 PM, and on 09/18/2024 at 11:15 AM, of a male cook, revealed he had facial hair with no beard covering in place. Observation on 09/18/2024 at 11:15 AM, during the kitchen tray line observation, [NAME] 2 was observed handling serving utensils and food items with gloved hands. Per observation, [NAME] 2 failed to use utensils when placing the following items on plates: cornbread, chicken strips, hamburger patties, mechanical soft meat, pickles and onions. Continued observation revealed [NAME] 2 failed to change his gloves between tasks, as per facility policy. Further observation revealed the Dietary Manager reminded [NAME] 2 twice to utilize serving utensils; however, the [NAME] continued to use his gloved hands. Additionally, observation revealed [NAME] 2 had facial hair with no covering in place over the hair. Telephonic (Phone) attempts were made to interview the Cook; however, they were unsuccessful. In interview with a Regional Certified Dietary Manager (CDM) on 09/20/2024 at 5:11 PM, he stated he expected foods to be labeled and dated with what the product was when it was made and the expiration date, before the food was placed in the coolers. He stated the Dietary Manager was responsible for ensuring that occurred; however, all staff were trained on that information. The Regional CDM stated facial hair depended on the length of the hair. He said a full beard required a facial covering, but a day or two of growth without shaving would depend on the length of the hair. The Regional CDM stated it was not appropriate or common practice for the [NAME] to use gloved hands to distribute foods. He stated the [NAME] should have used serving utensils to serve all foods. The Regional CDM further stated there was a potential for cross-contamination of foods when handled with gloves. In interview with the Director of Nursing (DON) on 09/20/2024 at 5:47 PM, she stated she had been the DON since 2022. The DON stated she was not sure what the dietary policy was on facial hair being covered. She stated past a certain length it should probably be covered. The DON stated she expected the [NAME] to use serving utensils when serving food. She stated there would be a potential for cross contamination of the food if gloved hands were used. The DON further stated she expected kitchen staff to follow their dietary polices and procedures related to food storage. During interview with the Administrator on 09/20/2024 at 7:00 PM, she stated the dietary department was a contract company and had their own policies. She stated she expected the dietary staff to follow their policies and ensure all items placed in the coolers were labeled and dated. The Administrator further stated she expected staff to use serving utensils when serving food and for facial hair to be covered.

Based on interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 30 sampled residents, (Resident (R)83). R83 experienced significant weight loss; however, the facility failed to notify the Physician of the resident's significant weight loss and failed to follow recommendations from the Registered Dietician (RD). The findings include: Review of the facility's policy titled, Weight Assessment/Monitoring, dated 01/01/2021 and revised 02/20/2024, revealed the multidisciplinary team was to strive to prevent, monitor, and intervene for undesirable weight loss of facility residents. Review of R83's Face Sheet revealed the facility admitted the resident on 11/29/2023, with diagnoses that included acute kidney failure, disorientation, and weakness. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 08/06/2024, revealed the facility assessed R83 to have a Brief Interview for Mental Status (BIMS) score of seven out of 15, indicating the resident was severely cognitively impaired. Review of an email from the Registered Dietician (RD) to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), dated 08/20/2024 at 2:54 PM, revealed she recommended R83 be weighed once a week for four weeks. Review of R83's Electronic Medical Record (EMR) revealed no documented evidence the Physician was notified and an order obtained for weekly weights as per the RD's recommendation. Review of R83's vital results documentation revealed on 07/09/2024, the resident weighed 163.8 pounds and on 08/02/2024, the resident weighed 154 pounds which was a 5.98 % weight loss in a 24 day time period. Even though the RD recommended weekly weights be obtained for R83 for four weeks on 08/20/2024, continued review revealed no documented evidence the resident was weighed again until 09/11/2024. Further review revealed on 09/11/2024, R83's weight noted an additional weight loss of 3.8 pounds, as the resident's weight was noted as 150.2 pounds. During an interview with the RD on 09/19/2024 at 9:37 AM, she stated her recommendations were communicated to the ADON and DON via an email. The RD stated on 08/20/2024, she notified the ADON and DON to add weekly weights for R83 due to the resident's significant weight loss. She further stated she expected the Physician to be notified of her recommendations. During an interview with R83's Physician on 09/19/2024 at 6:40 PM, she stated weekly weights was a standing order and she expected the standing orders to be completed. She stated even though weekly weights were a standing order, she wanted to be notified of the RD's recommendations, so she could review R83's chart. During interview with the Central Supply/Certified Nursing Assistant (CNA) on 09/20/2024 at 10:55 AM, she stated she was responsible for weighing all residents. She stated the ADON or DON provided her with a list of all residents needing to be weighed. The Central Supply/CNA stated R83 had a history of weight loss, but was currently on monthly weights as the resident had not had any weight loss recently to her knowledge. During interview with the ADON on 09/20/2024 at 3:00 PM, she stated once the RD reviewed a resident's weight, she emailed her (ADON) and the DON with her recommendations. The ADON stated she then notified the Physician and obtained orders, which she entered into the resident's EMR. She stated she verbally communicated the Physician's Orders to staff. The ADON stated they should have followed up on the RD's recommendations, and R83 should have had a progress note documenting that the Physician had been notified of the resident's weight loss with any new orders given. She further stated, there was no documentation of that information in R83's record indicating that had been done During interview with the DON on 09/19/2024 at 3:29 PM, she stated she was unable to locate any documentation that the Physician had been notified of the RD's recommendations for R83 on 08/20/2024, nor of an order entered for the weekly weights to be completed. She stated it was her's or the ADON's responsibility to ensure the Physician had been notified, orders obtained, and related documentation entered in the resident's record. The DON stated she expected staff to operate within their clinical scope of practice. She further stated she expected the residents' Physicians be notified with orders obtained and weights documented as ordered; however, was not sure why that was not done for obtaining R83's weekly weights. The DON additionally stated however, she did not see that any of that had been completed for R83. During interview with the Administrator on 09/20/2024 at 3:25 PM, she stated she expected all staff to work within their scope of practice, including the ADON and DON, who failed to do that. The Administrator stated if the RD recommended R83 have weekly weights obtained, she expected staff to notify the Physician and obtain an order for the weekly weights. She further stated staff should have done whatever the RD and/or Physician wanted done.

Based on observation, interview, record review, and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of infections, for 1 of 30 sampled residents, (Resident (R)41). Observation revealed Certified Medication Aide (CMA) 2 administered R41's ophthalmic eye drops without wearing gloves. The findings include: Review of the facility's policy titled, Specific Medication Administration Procedures, dated 05/2022, revealed the purpose of the policy was for administering ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner. Continued review revealed examination gloves were to be utilized to administer the eye drops. Further review revealed the procedure required staff to perform hand hygiene, put on examination gloves, and with a gloved finger gently pull down the lower eyelid to form a pouch while instructing the resident to look up and instill the prescribed number of drops into the pouch near the outer corner of the eye. Review of R41's Face Sheet revealed the facility admitted the resident on 11/30/2020, with diagnoses to include: hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting right dominant side, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure with hypoxia. Review of R41's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 06/12/2024, revealed the facility assessed R41 to have a Brief Interview for Mental Status (BIMS) score of a 14 out of 15, indicating the resident was cognitively intact. Observation on 09/17/2024 at 8:45 AM, of medication (med) pass on Wing 200, revealed CMA 2 was providing medications for R41. Record review revealed R41 was prescribed Olopatadine HCl 0.2 % Solution and was to receive one drop in each eye once daily. Continued observation revealed CMA 2 had long fingernails, and did not don gloves prior to or when administering the ophthalmic eye drops to R41. Further observation revealed CMA 2 opened R41's top and bottom eyelids using her thumb and forefinger to administer the eye drops with no gloves on. In interview with CMA 2 on 09/20/2024 at 3:04 PM, she stated she was aware that when administering ophthalmic eye drops she was to clean and sanitize her hands and then shake the eye drops before using. She stated sometimes R41 held her eyes open while she had administered the resident's eye drops. CMA 2 stated during the observation she realized her error, and yes, she should have worn gloves to administer R41's eye drop solution. She further stated she was aware there was a potential for harm for residents if gloves were not utilized including cross-contamination and/or infection. Additionally, she stated she had received training when hired regarding eye drop administration which included using gloves. In interview with CMA 15 on 09/20/2024 at 3:06 PM, she stated she was aware that when administering ophthalmic eye drops in a resident's eyes, staff should wash their hands, use gloves, and have a gauze pad or tissue for the excess fluid. CMA 15 stated she was also aware that not wearing gloves could potentially cause germs to be spread or cause an infection. She further stated she used a new glove for each eye when administering eye drops. In interview with Unit Manager (UM) 1 on 09/20/2024 at 3:30 PM, she stated the process for administering ophthalmic eye drops required staff to sanitize their hands and don gloves and have a tissue ready when administering eye drops into a resident's eyes. She stated she provided the tissue for residents to wipe off any excess solution. The UM stated if she had observed a CMA providing eye drops without wearing gloves she would have stopped the staff member and provided education on following the policy and procedure correctly. She further stated education and training on administering eye drops was a requirement in all schools, but staff had also received instruction when hired at the facility. In interview with the Director of Nursing (DON) on 09/20/2024 at 3:50 PM, she stated her expectations for CMA's administering ophthalmic eye drops was for them to follow facility policy and procedure, work within their scope of practice, and utilize their training regarding eye drop administration. She stated all CMA's received on the floor orientation when hired. The DON stated there was always a risk of infection if staff were not wearing gloves as required per the facility's eye drop administration policy as with any other medication administration. She further stated if staff were observed administering eye drops without gloves, that would be a teachable moment to ensure it did not happen again. In interview with the Administrator on 09/20/2024 at 4:30 PM, she stated her expectations for CMA's was for them to work within their scope of practice and follow facility policy and procedures when administering ophthalmic eye drops to residents. She stated she was not familiar with the facility's policy on eye drop administration, but had access to that policy if necessary. She further stated she did not believe residents were at risk for potential harm if CMA's were administering ophthalmic eye drops to residents eyes without wearing gloves.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure interventions were in place to prevent a resident from developing a pressure injury for 1 of 30 sampled residents, (Resident (R)99). On 05/11/2022, 13 days following admission to the facility, Resident 99 developed a facility acquired suspected deep tissue injury (SDTI) to the right heel. The findings include: Review of the facility's policy titled, Pressure Injury, Prevention, and Management, revised 08/30/2022, revealed, the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable . Per policy review, the facility was also committed to providing treatment and services to heal a pressure ulcer/injury, prevent infection and development of additional pressure ulcers/injuries. Continued review revealed after completing a thorough assessment/evaluation, the interdisciplinary team (IDT) was to develop a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. Policy review revealed the interventions were to be based on specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment. Further review revealed evidence-based interventions for prevention were to be implemented for all residents assessed as at risk or who had a pressure injury present. Additionally, policy review revealed the interventions were to be documented on the resident's care plan and communicated to all relevant staff. Review of R99's electronic health record (EHR) Admission Record revealed the facility admitted the resident on 04/28/2022 with diagnoses to include Alzheimer's Disease, altered mental status, unspecified and opioid dependence with withdrawal. Review of the facility's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed R99 to have a Brief Interview for Mental Status (BIMS) score of 00 of 15, indicating the resident had severe cognitive impairment. Review of the MDS Section M revealed the facility assessed R99 as at risk for developing pressure ulcers/injuries and as not having unhealed pressure ulcers on admission. Review of R99's Comprehensive Care Plan initiated on 05/11/2022, 13 days after admission, revealed the facility had developed a focus problem that noted the resident had an actual impairment to skin integrity related to fragile skin and weakness. Continued review revealed the interventions included: encouraging good nutrition and hydration in order to promote healthy skin, dated 05/11/2022; wheelchair cushion and pressure reducing mattress to the resident's bed, dated 05/11/2022; and wound care as ordered, dated 06/29/2022, which was R99's date of discharge. Review of a daily skilled note for R99 dated 05/12/2022 at 4:25 PM, for skin integrity, revealed, No changes in skin integrity noted. Continues with deep tissue injury to right heel. Continued review revealed R99 does stomp foot and hold firmly when trying to transfer in the bed and wheelchair. Further review revealed it was noted R99 was Constantly taking socks and shoes off and manipulating footrest while trying to get up and walk. However, further review of R99's care plan revealed no documented evidence of interventions to address the resident constantly taking off her shoes and socks, manipulating the wheelchair footrest, and constantly trying to get up and walk. Review of the Progress Note for R99 dated 05/13/2022 at 4:03 PM, signed by the Assistant Director of Nursing (ADON) revealed the ADON documented, new wound care orders received for wound to right heel. Daughter made aware. Review of the Progress Note from the wound care provider dated 05/13/2022, revealed R99 had a facility acquired right heel deep tissue injury. Per review of the Note, there was a large deep tissue injury to R99's right heel. Continued review revealed it appeared the patient rested her heels over the edge of her wheelchair, likely to have caused the injury. Further review revealed the wound care provider noted, Recommend skin prep every shift and continue with protective booties. Review of the wound care Nurse Practitioner's (NP's) initial wound evaluation documentation dated 05/13/2022, revealed R99 had a facility acquired pressure ulcer, Suspected Deep Tissue Injury (SDTI) with an onset date of 05/11/2022 to the right heel. Continued review revealed the area measured 4.04 centimeters (cm) x 3.09 cm and skin prep was ordered. Further review revealed recommendations included: pressure reduction and offloading; ensuring compliance with the turning protocol; elevating the resident's legs regularly; and use of a wedge or foam cushion for offloading (pressure). Review of the wound consult documentation dated 05/18/2022, revealed R99 had a SDTI to the right heel, acquired in house which measured 2.36 cm x 2.23 cm. Continued review revealed Betadine was ordered to the area. Additionally review revealed recommendations that included: pressure reduction and offloading; ensuring compliance with the turning protocol; elevation of the resident's legs regularly; and using a wedge or foam cushion for offloading (pressure). Review of the wound consult documentation dated 05/25/2022, revealed R99 had a SDTI to the right heel which measured 4.19 x 4.95 cm and Betadine was continued as the treatment. Review of the wound consult documentation dated 06/01/2022, revealed R99 had a right heel SDTI that measured 4.69 cm x 3.84 cm, with Betadine continued as the treatment. Review of the wound consult documentation dated 06/08/2022, revealed R99 had a SDTI to the right heel that measured 3.64 cm x 3.51 cm. Review of the wound consult documentation dated 06/15/2022, revealed R99 had a right heel SDTI measuring 2.98 cm x 3.52 cm and was noted as improving. Further review revealed to cleanse (the SDTI) with wound cleanser and apply Betadine. Review of the wound consult note dated 06/22/2022, revealed suspected DTI to right heel, measures 4.76 cm x 4.80 cm, area is improving. Continued review revealed For the most part the wound appears healed. The outer edges still appear dark. Further review of the note revealed Recommend skin prep instead of Betadine as it may be discoloring the skin. Review of the progress note dated 06/27/2022 at 8:00 PM, documented by the ADON, for R99 revealed, area to back of right heel had ruptured. Further review revealed a new order to cleanse and apply comfort foam daily, and R99's daughter made aware. Review of the progress note dated 06/29/2022 at 3:00 PM, signed by the Director of Nursing (DON), revealed weekly observation of (R99's) pressure ulcer injury and light amount of serous drainage noted. Further review revealed the wound progress was worsening, and the Physician had been notified for need of a treatment change for the wound. In interview with R99's Family Member (FM) on 09/19/2024 at 8:40 PM, she stated she worked as a Certified Nurse Aide and had [AGE] years of experience. She stated R99 admitted to the facility to receive therapy services and had planned to return home. The FM stated she was made aware R99 had a pressure injury to the right heel about 2 weeks after the resident was admitted there. She stated she had not been aware of any specific interventions being used prior to that for R99's right heel. Per the FM in interview, she had requested the facility to keep heel boots on R99 and that had been a challenge. She stated R99 seldom had the heel boots on when she visited and she visited daily. The FM stated she observed R99's right heel on 06/09/2022, and observed a very dark area to the right heel. She stated she visited the facility on 06/27/2022 and saw blood on R99's right heel bandage, and she informed the ADON who explained to her that the area on the resident's right heel had busted. In continued interview, the FM stated the ADON told her the area of R99's right foot was healed and all the dead skin would come off and new skin would be there. She stated she told the ADON however, R99's heel did not look right. The FM stated when she arrived to the facility on [DATE] to take R99 home and there was blood on the bandage again she asked for it to be changed before they left. She stated the nurse cleaning the area on R99's right foot said the dressing on the area had not been changed for the day. The FM further stated she went to speak to the DON and learned that the wound clinic nurse had not seen R99 as the resident was being discharged home. In interview with the ADON on 09/20/2024 at 3:00 PM, she stated she had been the ADON for approximately two months, but had been employed at the facility for about three years. She stated she provided care for R99 and recalled the resident developed a deep tissue injury (DTI) to the right heel. The ADON stated when R99 was moved to her hall the resident already had the DTI and had heel boots. Per the ADON's interview, R99 also had a heel elevator (a foam protector that wrapped around the ankle area to elevate the heel off of the bed) and a regular (not specialized) pressure reducing wheel chair cushion implemented. She stated she could not speak to any other interventions R99 had while a resident. Per the ADON in interview, she recalled the wound on R99's right heel had been a DTI, which became a blistered area. She stated she had been working on 06/27/2022 when the blister on R99's right heel ruptured. The ADON further stated the area had been leaking bloody drainage, and she informed the Nurse Practitioner (NP) and applied a foam dressing to the area. During interview with the DON on 09/20/2024 at 5:47 PM, she stated she recalled R99 developed a SDTI shortly after admission to the facility. She stated R99 had been followed by the wound care clinic. The DON stated she was unable to recall any interventions in place prior to R99 developing the SDTI area. The DON stated a care plan had been developed after the area was discovered. The DON further stated heel boots were added but she was not sure if any other interventions had been initiated. In interview with the Administrator on 9/20/2024 at 7:00 PM, she stated she had been the Administrator since 02/2024 and this was her first job as Administrator since graduating last May. She stated she was not familiar with R99, but the MDS Nurse was responsible for residents' care plans. Per the Administrator's interview, she was not familiar with the MDS process or the care area assessments that indicated R99 had been at risk for skin impairment on admission or that a care plan was to be initiated. She stated she expected a resident's care plan to be developed as required. The Administrator stated all residents had interventions in place such as turn and repositioning. She further stated she was not sure, when asked how the direct care givers knew what interventions to provide for a resident.

Based on observation, interview, record review and review of facility polity, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 2 of 30 sampled residents (Resident (R)23 and R99). 1. The facility admitted R99 on 04/28/2022, and on 05/04/2024 assessed R99 as being at risk for developing pressure injuries. However the facility failed to develop a care plan for at risk for impaired skin integrity or risk for developing pressure injuries. On 05/11/2024, R99 developed a suspected deep tissue injury (SDTI) to the right heel. 2. The facility admitted R23 with diagnoses of schizophrenia, bipolar disorder, depression, and anxiety. However, the facility failed to develop and implement a care plan to address R23's psychiatric diagnoses. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 02/2024, revealed it was the facility's policy to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, physical, mental, and psychosocial needs. Continued review revealed the care plan process was to include an assessment of the resident's strengths and needs and was to incorporate the resident's personal and cultural preferences in developing the goals of care. Additionally, all Care Area Assessments (CAAs) triggered by the Minimum Data Set (MDS) Assessment were to be considered in the development of the care plan. Further review revealed the facility's rationale for deciding whether to proceed with care planning was to be documented in the residents' clinical records. 1. Review of the facility's policy titled, Pressure Injury, Prevention, and Management, revised on 08/30/2022 revealed interventions were to be based on specific factors identified in a resident's risk assessment, skin assessment, and any pressure injury assessment. Further review revealed evidence-based interventions for prevention were to be implemented for all residents assessed as at risk or who had a pressure injury present. Additionally, policy review revealed interventions were to be documented on the resident's care plan and communicated to all relevant staff. Review of R99's electronic health record (EHR) Admission Record revealed the facility admitted the resident on 04/28/2022, with diagnoses that included: altered mental status, opioid dependence with withdrawal, and Alzheimer's Disease with late onset. Review of R99's Admission MDS assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 00 of 15, which indicated R99 was severely cognitively impaired. Review of the MDS Section M revealed the facility assessed R99 as at risk for developing pressure ulcers/injuries and not to have unhealed pressure ulcers on admission. Review of the Admission MDS Care Area Assessment (CAA) worksheet for pressure ulcer injury dated 05/04/2022, revealed R99 was at risk for and had potential for pressure ulcer/injury. Continued review revealed the risk factors included: decreased mobility, incontinence, altered mental status, and Alzheimer's Disease. Per review, for the question, Care plan considerations would be addressed on the care plan, the facility answered Yes. However, review of R99's EHR revealed no documented evidence the facility developed and implemented a care plan for R99's assessed risk for developing pressure ulcers. Review of R99's care plan revealed a skin integrity care plan was not developed until 05/11/2024, after the resident developed an in-house pressure injury to the right heel. Review of the Comprehensive Care Plan initiated on 05/11/2022, for R99 revealed a focus problem noting the resident had an actual impairment to skin integrity related to fragile skin and weakness. Continued review revealed interventions which included: a pressure reducing mattress to R99's bed, dated 05/11/2024; encouraging good nutrition and hydration in order to promote healthy skin, dated 05/11/2022; pressure reducing mattress to bed, dated 05/11/2022; and wound care as ordered, dated 06/29/2022. Review of the facility's initial wound evaluation dated 05/13/2022, revealed R99 had a facility acquired pressure ulcer, Suspected Deep Tissue Injury (SDTI) with an onset date of 05/11/2022 to the right heel. Per review, the SDTI area measured 4.04 centimeters (cm) x 3.09 cm. Continued review revealed skin prep was ordered, and pressure reduction and offloading were recommended. In addition, recommendations were also noted for ensuring R99's compliance with the turning protocol; using a wedge or foam cushion for offloading (pressure); and elevating the resident's legs regularly. Review of the Progress Note documented by the wound care provider dated 05/13/2022, revealed, R99 had a facility acquired right heel deep tissue injury. (DTI). Continued review of the Note revealed there was a large deep tissue injury to R99's right heel. Further review revealed it appeared the resident rested her heels over the edge of her wheelchair which was likely to cause the injury. In addition, the wound care provider recommended skin prep to the DTI every shift and to continue with the protective booties. interview on 09/18/2024 at 1:18 PM, MDS Nurse 1 stated she and MDS Nurse 2 were responsible for completing the residents' comprehensive care plans. She stated the baseline care plans were initiated by the admitting nurse. MDS Nurse 1 stated she would expect the care plan to have been initiated if a resident had a problem or was at risk for having a problem. She stated the care plan should be developed/revised with interventions as needed. In interview on 09/20/2024 at 10:40 AM, the Unit Manager (UM) stated the admitting nurse was responsible for the developing residents' baseline care plans on admission. The UM stated the MDS Nurse was responsible for updating the care plan. She stated she expected all residents to have a skin integrity care plan. In interview on 09/20/2024 at 10:46 AM, MDS Nurse 2 stated she was responsible for residents' care plans. She stated if she was made aware of a new concern for a resident she updated their care plan. In interview on 09/20/2024 at 3:00 PM, the Assistant Director of Nursing (ADON) stated R99 should have had a baseline care plan developed on admission that addressed the resident's skin integrity. In interview on 09/20/2024 at 5:47 PM, the Director of Nursing (DON) stated she recalled R99 developed a SDTI shortly after admission. She stated R99 had been followed by the wound care clinic after developing the SDTI. The DON stated she was unable to recall any interventions in place for R99 prior to developing the SDTI area. She stated a care plan had been developed for R99 after the SDTI area was discovered. The DON stated she expected care plans to be developed and implemented for all residents. She stated the admitting nurse was responsible for developing residents' baseline care plan and she expected those to be completed on admission. Per the DON heel boots were added as an intervention for R99; however, she was not sure if any other interventions had been initiated. According to the DON, heel boots should have been on the Certified Nursing Assistants (CNA) care guide and on the resident's care plan. She further stated she was not familiar with the MDS Assessment process, but R99 should have had a care plan for skin integrity. In interview on 9/20/2024 at 7:00 PM, the Administrator stated she was not familiar with R99, but the MDS Nurse was responsible for developing residents' care plans. The Administrator stated residents' baseline care plans should be completed within 48 hours of admission. The Administrator stated she would expect the care plan to be developed as required. She stated all residents had interventions in place such as turning and repositioning. 2. Review of R23's EHR Admission Record revealed the facility admitted the resident on 10/26/2022, with diagnoses of anxiety, depression, bipolar disorder unspecified, and schizophrenia unspecified. Review of R23's History and Physical, documentation from an acute psychiatric (psych) hospital stay, dated 09/24/2022, revealed the facility admitted the resident to the acute psych hospital in February 2022. Review of the Admission MDS assessment dated [DATE] for R23, of section A 1500, Preadmission Screening and Resident Review (PASRR) revealed no was the answer to the question, Has the resident been evaluated by Level 2 PASRR and determined to have a serious mental illness, and or mental retardation or a related condition? Review of Section I of the Admission MDS, for Active Diagnosis, the facility documented R23's primary medical condition was schizophrenia. Review of the Quarterly MDS assessment dated [DATE] for R23, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, which indicated R23 was intact cognitively. Review of R23's Comprehensive Care Plan (CCP) dated 10/29/2022, revealed no documented evidence of care plans developed or implemented related to the resident's diagnoses of schizophrenia, bipolar disorder, depression or anxiety. Review of the CCP focus problem, Psychotropic Drug Use dated 02/02/2023, revealed R23 had depression, insomnia, and tremor. Further review revealed the interventions included, administering medications as ordered and to evaluate, record, report effectiveness, and any adverse side effects. Review of the CCP focus problem, Psychotropic Drug Use dated 11/01/2022, revealed R23 was at risk for adverse consequences related to receiving psychotropic medications and to the resident's bipolar and schizophrenia diagnoses. Per review, the interventions dated 11/01/2022 included: reviewing for continued need at least quarterly; quantitively and objectively documenting R23's behavior. Continued review revealed the interventions also included consulting, reviewing, monitoring R23's behavior and response to medication, attempting to give the lowest dose possible, and attempting a gradual dose reduction if not contraindicated. Further review revealed an intervention added for staff to listen when R23 was upset and reassure the resident she was safe. Review of the CCP focus problem, Behaviorial Symptoms dated 12/06/2022, revealed R23 resisted care such as dressing changes, incontinent care, showers, and removal of facial hair at times. Continued review revealed the interventions dated 12/06/2022, included actively involve R23 in care, express willingness to adjust regimen, administer medications as ordered, and monitor and record effectiveness and report adverse side effects. Continued review revealed the interventions also included: allowing R23 to choose options; explaining the disease process and consequences of all of the therapy, medication and care; maintaining a common environment and approach to the resident; and obtaining a psych consult or psychosocial therapy. Further review revealed when R23 began to resist care, stop and try later, do not force the resident to do a task, an intervention dated 01/01/2023. In addition, review of the care plan revealed the interventions encompassed redirecting R23 when the resident made false allegations an intervention dated 01/24/2023, and personal care to be completed with at least two staff assist. In interview on 09/20/2024 at 10:48 AM, the Licensed Clinical Social Worker (LCSW) stated she saw R23 on a weekly basis and the resident's mood was up and down. She stated overall though R23 was doing well. The LCSW further stated she was not aware of any current episodes of behaviors that R23 was having. In interview on 9/20/2024 at 7:00 PM, the Administrator stated she was not sure if R23 should have a care plan (for her psych diagnoses) because care plans varied from person to person. She stated she was unsure if R23 should have a care plan for psychosocial concerns; however, thought R23's diagnoses should have been on the care plan.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents received a Level II Preadmission Screening and Resident Review (PASRR) referral based on the positive Level 1 PASRR screening results for 1 of 2 residents sampled for Level II PASRR out of the total sample of 30 residents (Resident #23 (R23)). The facility assessed R23 to have a positive Level I PASRR screen on admission on 10/26/2022, related to her diagnoses and psychiatric (psych) stay. Based on the positive Level I PASRR, R23 required a Level II Screening related to diagnoses of schizophrenia and bipolar disorder. However, the facility failed to ensure R23 received a Level II PASRR evaluation as required. The findings include: Review of the facility's policy, Resident Assessment-Coordination with PASRR Program, revised 03/14/2023, revealed, the facility coordinated assessment with the Pre Admission Screening and Resident Review (PASRR) program under Medicaid. Per policy review, the PASRR assessment was to ensure individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs. Continued review revealed all applicants to the facility were to be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state Medicaid rules for screening. Policy review revealed a positive Level I screen necessitated an in-depth evaluation, known as PASRR Level II, of the individual by the state-designated authority. Further review revealed the PASRR Level II assessment must be conducted prior to admission to a nursing facility. Additional review of the facility's policy revealed the PASRR Level II evaluation should be placed in the resident's Electronic Health Record (EHR). Review of R23's Face Sheet revealed the facility admitted the resident on 10/26/2022, with diagnoses that included schizophrenia unspecified, bipolar disorder unspecified, anxiety, and depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R23, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This score indicated R23 was cognitively intact. Review of the Admission MDS assessment dated [DATE], Section A 1500, Pre Admission Screening and Resident Review, read as follows, Has the resident been evaluated by Level 2 PASRR and determined to have a serious mental illness, and or mental retardation or a related condition. Further MDS review revealed the Pre Admission Screening question was answered No. Review of Section I of the MDS, Active Diagnosis, revealed the facility documented R23's primary medical condition was schizophrenia. Review of R23's Level I PASRR documentation dated 10/28/2022, revealed a positive screening had been identified. However, further review revealed no documented evidence the facility had referred R23 for the required Level II PASRR assessment. In interview with the Social Services Director (SSD) on 09/08/2024 at 11:19 AM, she stated R23 had not met all three criteria for a Level II PASRR evaluation, and therefore was not referred for that screening. When the State Survey Agency (SSA) Surveyor asked her R23 could not have a change after being hospitalized in the psych hospital for eight months, the SSD had no response to the question. During an interview with the Director of Nursing (DON) on 09/20/2024 at 5:47 PM, she stated a PASRR Level 2 assessment was not completed for R23, as the resident had not met the criteria in all three categories as stated in the regulation. Per the DON, when the referral came for R23's admission to the facility, she did an onsite visit with the resident at the psychiatric (psych) hospital. She stated she did not recall seeing any recommendations from the psych hospital when R23 was discharged . She stated R23 had her initial visit with psych services in January 2023, and the resident had not exhibited any behaviors since being admitted to the facility. In interview with the Administrator on 9/20/2024 at 7:00 PM, she stated a Level 1 PASRR review was required prior to a resident's admission to the facility. She stated a Level I would trigger if a Level II (PASRR) was to be completed. Per the Administrator, the State system did not trigger a Level II (PASRR) evaluation. She stated she was not sure exactly what would trigger a Level 2 (PASRR assessment). The Administrator stated she did not think that R23 triggered for a Level II even though she had diagnoses of schizophrenia, bipolar, depression and anxiety and was admitted to the facility following an eight month inpatient stay at an acute psychiatric hospital.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure its grievance policy was followed to ensure prompt resolution of all residents' grievances and completion of such grievances for 2 of 30 sampled residents (Residents (R6 and R73)). The findings include: Review of the facility's policy titled, Resident and Family Grievances, revised 03/14/2024, revealed the facility was to support each resident's and family member's right to voice grievances without fear of discrimination or reprisal. The policy stated the (facility's) grievance official was responsible for overseeing the grievance process; receiving and tracking grievances through to the conclusion. Continued review revealed the staff member receiving a grievance was to record the nature and specifics of the grievance on the designated grievance form and forward the form to the grievance official as soon as practicable. Per policy review, the written decision was to include, at a minimum: the date the grievance was received; steps taken to investigate the grievance; and a summary of pertinent findings or conclusions. Further review revealed the written decision was also to include: a statement as to whether the grievance was confirmed or not confirmed; any corrective action taken; and the date the written decision was issued. In addition, the policy revealed all grievances were to be maintained for a period of no less than three years from the issuance of the grievance decision. 1. Review of R73's Face Sheet revealed the facility admitted the resident on 08/10/2023, with diagnoses that included anemia, coronary artery disease (CAD), heart failure, and diabetes mellitus. Review of R73's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 08/14/2024, revealed the facility assessed R73 to have a Brief Interview for Mental Status (BIMS) score of a 15 out of 15. This score indicated R73 was cognitively intact. Review of the facility's document titled, Grievance Form, dated 09/19/2024, revealed the document concerned R73's report of lost clothing. Continued review revealed R73 was, missing red shorts about three weeks now; however, the grievance date was noted it occurred on 09/10/2024 or 09/11/2024. Further review revealed the Form had not been completed to include who the staff member was investigating the grievance or who was completing the form, and there was no signature documented by the grievance official. In interview, during the Resident Council Meeting, on 09/18/2024 at 2:08 PM, R73 stated he had clothing that had been missing for some time. He stated he was missing a pair of shorts and two shirts ever since those items were taken to the laundry. R73 stated those clothing items still not been returned to him. He stated the facility had told him if they could not find his missing items they would be replaced; however, the resident stated he still had not received the missing items' replacement. In interview with the Social Services Director (SSD), on 09/19/2024 at 10:50 AM, she stated she was the facility's grievance official. The SSD stated she had a folder outside her door and made residents aware they could complete a grievance form with their concerns and place it back in the folder or slide it under her door. She stated or the residents could talk with her about their concerns if they preferred. The SSD stated the process depended on the grievance, as not all grievances were documented due to real-time resolutions. She stated if they could resolve the resident's concern right away they would not document that information on a grievance form. Per the SSD in interview however, if a resident's concern required a more thorough investigation that information would generally be documented which also included any Resident Council concerns. She stated anything that was determined to be valid would be addressed immediately. The SSD stated on admission families were asked to put residents' names on their clothing when it was brought into the facility. She further stated if there were concerns with lost clothing and those items were not found, the facility replaced those missing items. 47798 2. Review R6's Face Sheet revealed the facility admitted the resident on 05/06/2016, with diagnoses that included: anxiety disorder, morbid obesity (severe) due to excess calories, and chronic obstructive pulmonary disease (COPD). Review of R6's Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 08/02/2024, revealed the facility assessed R6 to have a BIMS' score of a 14 out of 15, which indicated the resident had intact cognition. Review of the facility's grievance log dated 03/01/2024 through 09/01/2024, revealed no documented evidence of grievances noted for R6. In interview with R6 and Family Member (FM) 9 on 09/17/2024 at 11:06 AM, they stated they were unsure of what a grievance form was. R6 stated he had reported several missing items of clothing (to the Administrator) that had been sent to laundry and not returned. The resident stated he called the new girl (Administrator) that was now in charge if he had any complaints. R6 and FM 9 stated they had not received any communication after the complaints about the missing clothing had been made. In interview with the Administrator on 09/18/2024 at 10:00 AM, she stated she had been in her position for seven months. R6 and FM 9 both had access to her personal cellular (cell) phone and called her with any issue they might have. She stated she just takes care of the problem right then. The Administrator stated she did not document any of the telephone calls from R6 or RM 9, nor the problems they had reported or whether they were resolved. She stated she was not familiar with the facility's grievance policy or what it said; however, she did not feel like her process was incorrect. The Administrator stated she thought the way she handled R6's concerns was adequate. She stated she could only provide the time and date of the telephone calls from her telephone. During an interview with the SSD on 09/20/2024 at 9:18 AM, she stated she was responsible for all grievances and followup. The SSD stated R6 had no documented evidence of any grievances on file. She stated R6 and FM 9 called the Administrator's (personal) cell phone directly and the resident's concerns were handled in real time (right then) by the Administrator. The SSD further stated the Administrator had not communicated any of R6's problems with her. She additionally stated she felt like the Administrator handling R6's concerns/problems in real time was sufficient. In an additional interview with the Administrator on 09/20/2024 at 3:00 PM, she stated R6 had never voiced any concerns regarding missing clothing. The Administrator stated she did not know what the facility's grievance policy stated because she had not read it word for word. She stated she was unable to say if she had been following the facility's grievance policy and would have to read the policy word for word. The Administrator stated she felt like as long as residents' concerns were addressed it did not matter what the facility's policy stated. In addition, she stated it did not matter if residents' concerns and the resolution of them was documented.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure each resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and the resident had a right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 30 sampled residents (Resident #6 (R6)). The findings include: Review of the facility's policy titled, Resident Self Determination and Participation, dated 02/22/2024, revealed the facility was to promote and facilitate a resident's right to self-determination through support of the resident's choice. Further review revealed a resident had the right to make choices about aspects of his or her life that were significant to the resident. Review of R6's Face Sheet for revealed the facility admitted the resident on 05/06/2016, with diagnoses that included chronic obstructive pulmonary disease (COPD), anxiety disorder, and morbid obesity (severe), due to excess calories. Review of R6's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 08/02/2024, revealed the facility assessed R6 to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15. This score indicated the resident was cognitively intact. Review of R6's comprehensive care plan revealed the facility care planned the resident for Activities of Daily Living (ADL), dated 11/21/2022. Continued review of the ADL care plan revealed the interventions included when bathing or showering R6 was to have a maximum assist of two staff twice weekly and as necessary. Review of the facility's bath/shower schedule documentation revealed from 05/26/2024 through 09/16/2024, R6 received partial to full bedbaths. The shower record noted R6 was to receive showers on day shift; however, over the past four months the resident only received a bed bath/partial bed bath five times on night shift. Further review revealed no documented evidence R6 received a shower during that timeframe. During an interview with R6 on 09/17/2024 at 6:00 AM, he stated he would like to take a shower, but he did not think he could fit on the shower bed any longer due to his size. R6 stated he would like to be taken into the shower, have his hair washed, and just let the water run over him. He stated he had voiced his concern about bathing to the new girl (Administrator). R6 stated he had been told he could not have showers because he could no longer fit on the shower bed/table. He further stated it had been a long time since he had been able to take a shower and that made him feel sad. During an interview with Certified Nursing Assistant (CNA) 8 on 09/19/2024 at 10:30 AM, she stated she thought R6 received his baths on the night shift. She stated she had provided care of R6 and he refused his bedbaths often, and told her he had already washed up. CNA8 stated she did not think R6 would fit on the shower bed. She stated she did not think there was any other option for R6 in order for him to be able to take a shower. During an interview with the Assistant Director of Nursing (ADON) on 09/20/2024 at 3:00 PM, she stated residents were given a choice if they wanted a shower or a bed bath. She stated she did not know who was responsible for assessing residents to know their bathing/showering preferences. The ADON stated R6 preferred to have a bed bath. She further stated the facility had bariatric shower equipment that could be utilized for morbidly obese residents. During an interview with the Director of Nursing (DON) on 09/19/2024 at 3:29 PM, she stated R6 was scheduled for baths or showers twice a week. The DON stated R6 had received showers previously using the shower bed; however, he had gained weight and no longer fit on the bed. She stated she thought R6 preferred bed baths and was unaware R6 wanted to take a shower. The DON stated residents should be given a choice and staff should give the resident their preference, a bath or shower. During an interview with the Administrator on 09/20/2024 at 3:00 PM, she stated the facility did not have a set way to assess a resident's preferences, to include their bathing preference. The Administrator stated she thought R6 wanted a bed bath. She stated the facility had a bariatric shower chair that was available to give R6 a shower if he chose to have one. The Administrator stated staff should just ask the resident whether they wanted a bath or shower and just do what they preferred.

Based on observation, interview, and review of the facility's policy, and the Centers for Disease Control and Prevention (CDC) guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases. Observation on 10/21/2021 at 1:57 PM, revealed Certified Nursing Assistant (CNA) #2 walked down 200 Hall with her mask below her nose. Observation on 10/21/2021 at 2:24 PM, revealed Registered Nurse (RN) #1 provided surgical wound care to Resident #6's right lower leg without her face mask donned over her nose. Further, RN #1 failed to perform hand hygiene after removing the soiled dressing prior to cleaning the surgical wound. The findings include: Review of the facility document titled, Guidelines for all masks and other Personal Protective Equipment, (PPE), revised 04/01/2021, revealed, all long-term care facility personnel should wear a medical grade facemask while they were in the facility for their entire shift except when clocked out for lunch. Review of facility policy titled, Wound Care, Steps in Procedure, dated October 2010, revealed that when removing soiled dressing, staff were to pull glove over dressing and discard into appropriate receptacle. Further, staff were to wash and dry their hands thoroughly. Observation, on 10/21/2021 at 1:57 PM, revealed Certified Nursing Assistant (CNA) #2 walked down 200 Hall with her mask below their nose. Interview with CNA #2, on 10/21/2021 at 1:57 PM, revealed face masks should always be worn. She further revealed face mask should cover the mouth and nose because of COVID. Observation, on 10/21/2021 at 2:24 PM, revealed Registered Nurse (RN) #1 provided surgical wound care to Resident #6's right lower leg with her face mask below her nose. Further observation revealed RN #1 performed hand hygiene after removing the soiled dressing and prior to cleaning the surgical wound. Additionally, RN #1's face mask was observed below her nose while she continuously touched her mask. Interview with RN #1, on 10/21/2021 at 3:03 PM, revealed the facility policy on wearing face mask was a face mask was to be on, always covering your nose and mouth in a resident care area. She further revealed goggles were a preference only and not required. She revealed the masks stopped the spread of COVID. Continued interview with RN #1 revealed she should have performed hand hygiene after removing the soiled dressing from Resident #6's wound. Interview with Director of Nursing (DON), on 10/26/2021 at 4:28 PM, revealed she expected staff to wear all appropriate PPE (personal protective equipment) properly, per the Centers for Disease Control and Prevention (CDC) guidelines and facility policy. The DON stated this was important to prevent the spread of infectious diseases such as COVID-19. Interview with the Administrator, on 10/26/2021 at 4:59 PM, revealed she expected staff to follow infection control guidelines to decrease the potential spread of infection.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify one (1) of three (3) sampled resident's responsible party of a significant change in condition when the resident refused to participate in physical therapy for six (6) days (Resident #1). The findings include: Review of facility policy titled, Change in a Resident's Condition or Status, last revised December 2016, revealed unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Closed record review revealed the facility admitted Resident #1 on 03/25/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the record revealed Resident #1 was discharged from the facility on 04/11/2020. Review of Physical Therapy Notes dated 04/03/2020, 04/06-04/10/2020, revealed therapy staff documented Resident #1 had refused to participate in physical therapy. Review of the Nurse's Notes dated 04/03/2020-04/10/2020, revealed no documented evidence Resident #1's Responsible Party was notified of the resident's refusal to participate in physical therapy. Interview with Resident #1's responsible party on 09/10/2020 at 10:20 AM, revealed Resident #1 was admitted from the hospital to the facility to get stronger with the help of therapy. She stated she had called the facility multiple times to check on Resident #1 and was told by staff Resident #1 was doing well. She further stated Resident #1 had been discharged on [DATE] because staff stated he/she was not participating in physical therapy. Resident #1's responsible party stated she had been told the resident was doing well. Interview with Physical Therapist Assistant (PTA) #1 on 09/11/2020 at 1:35 PM, revealed Resident #1 refused therapy more often than not. He stated therapy makes nursing staff aware of the refusals. PTA #1 stated if a resident consistently refuses therapy it is difficult to evaluate the resident's progress. Interview with Licensed Practical Nurse (LPN) #1, on 09/15/2020 at 3:06 PM, revealed she vaguely remembered Resident #1. She stated therapy was good about making nursing staff aware if a resident refused therapy. LPN #1 further revealed if a resident refuses care such as therapy the resident's responsible party should be made aware and the notification is documented in the nurses notes. Interview with the Director of Nursing (DON), on 09/14/2020 at 9:50 AM, revealed she expected nursing staff to notify the resident's responsible party of multiple consistent refusals of care, therapy, treatments, or medications that may impact the resident's quality of life. She further stated nursing should make the notifications of such refusals and document it in the nurses notes.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify one (1) of one (1) sampled resident's responsible party of a significant change in condition when the resident was identified to have an unstagable pressure area to the coccyx (Resident #1). The findings include: Review of facility policy titled, Change in a Resident's Condition or Status, last revised December 2016, revealed unless otherwise instructed by the resident, a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Record review revealed the facility admitted Resident #1 on 12/09/19 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 01/17/2020 revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was not interviewable. Further review revealed the resident was hosptalized on [DATE] and remained out of the facility. Review of a Nurses Note, dated 12/27/19 at 6:15 AM, revealed, wounds found by staff on resident's scrotum and coccyx. Left message for facility Nurse Practitioner. Further review of the Nurse's Notes revealed on 12/27/19 at 5:00 PM, an order was received to cleanse with wound cleaner, apply [MEDICATION NAME], and cover with [MEDICATION NAME]. However, further review of the Nurse's Notes revealed there was no documented evidence Resident #1's family members were made aware of the pressure wound, per facility policy. Review of Admission/New Onset/Weekly Wound Analysis sheet, dated 12/27/19 revealed a wound to the coccyx was initially identified on 12/09/19; however, interview with Licensed Practical Nurse (LPN) #1, on 02/11/2020 at 3:09 PM, revealed she admitted Resident #1 and at that time the resident had redness to the coccyx and there were no open areas. Further review of the Analysis sheet revealed the wound was identified as unstageable on 12/27/19 and was two point four (2.4) centimeters (cm) by two (2) cm, ninety percent (90%) brown with wound edges defined. The periwound color was normal and the skin temperature was warm. There was no periwound [MEDICAL CONDITION] noted. Interview with Resident #1's daughters, on 02/11/2020 at 10:12 AM, revealed the facility did not notify them when the resident developed a pressure area. Interview with Licensed Practical Nurse (LPN) #3, on 02/12/2020 at 12:58 PM, revealed she did not call the family because it was her understanding the Nurse Practitioner had already talked with the family as the wound was not new. Interview with the Director of Nursing (DON), on 02/12/2020 at 10:02 AM, revealed when the resident came, the area on the coccyx was not open but was red. She stated she was the Unit Manager when the opened wound was identified on 12/27/19. She further revealed the nurse should have notified the family when the new wound was identified, but she did not know whether the family was notified or not.

Based on interview, record review, review of Pharmacy Facsimile (fax) information and receipts, and facility policy review, it was determined the facility failed to provide routine drugs for five (5) of five (5) sampled residents (Resident #1, #2, #3, #4, and #5). On 12/12/19, the facility's Pharmacy failed to ensure Resident #1's medications were available in a timely manner. The resident's physician's orders [REDACTED]. In addition, the resident's narcotic pain medication ([MEDICATION NAME]) was not received until 12/13/19 at 11:25 AM. Resident #1 was crying, agitated, and unable to focus due to the pain and the resident's dependence on the medication due to long term use. In addition, Residents #2, #3, #4, and #5's medication was not received from pharmacy in a timely manner. The findings include: Review of the Pharmacy Service Agreement with Polaris Pharmacy Service of North Carolina, dated 11/15/19, revealed the pharmacy will provide products and services in a prompt and timely manner. Delivery Schedule: The pharmacy agrees to deliver to the facility any prescriptions and supplies unless the failure is a result of circumstances and conditions beyond its control. Emergency Drug Service: The Pharmacy will provide any product needed on an emergency basis in a prompt and timely manner. In the event the pharmacy cannot furnish an ordered medication on a prompt and timely basis, the pharmacy will make arrangements with another pharmacy supplier in a community local to the facility to provide such services to the facility. The pharmacy will notify the facility of any such arrangement in a reasonably prompt manner. 1. Record review revealed the facility admitted Resident #1 on 12/12/19 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Orders and facility Physician order [REDACTED]. Review of the December 2019 Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. The medication was not available due to the medication not being delivered from the Pharmacy. Review of the Pharmacy Fax information revealed the Pharmacy received the orders on 12/12/19 at 2:25 PM CST. Review of the Pharmacy Packing Slip revealed it was not printed until 12/12/19 at 8:57 PM CST and Resident #1's medications were not delivered until 12/13/19. In addition, review of the Nurse's Notes dated 12/12/19 and 12/13/19, further review of the MAR, and interviews with Licensed Practical Nurse (LPN) #1 on 01/09/2020 at 11:45 AM and LPN #2 on 01/07/2020 at 8:30 AM revealed Resident #1 was in pain on admission (12/12/19 before 2:30 PM) and did not receive any narcotic pain medication due to the resident's medication not being received from the pharmacy. At 8:00 PM, the Nurse Practitioner ordered a one time dose from the facility Emergency Drug Kit (EDK) and it was administered. The EDK contained extra medication but it does not contain all medications. At 12:00 midnight, the resident's pain returned; however, the narcotic pain medication still had not arrived. At approximately 4:30 AM, the resident's [MEDICATION NAME] and [MEDICATION NAME] were delivered and administered which gave some pain relief; however, the PRN [MEDICATION NAME] was not received. The resident remained in pain until 12/13/19 at approximately 11:25 AM when the Administrator obtained the medication from a local pharmacy. 2. Record review revealed the facility admitted Resident #2 on 11/29/19 with [DIAGNOSES REDACTED]. Review of the Admission Physician order [REDACTED].(sq) at bed time, and Humalog (insulin) kwikpen 100 units sliding scale. Review of the November 2019 MAR indicated [REDACTED]. Further review also revealed no documented evidence the resident received Tresiba 200 units/ml, 5 units sub q at 9:00 PM on 11/29/19. Review of the Pharmacy Fax information revealed the Pharmacy received the orders on 11/29/19 at 7:33 PM (CST). However, review of the Pharmacy Packing Slips revealed all of Resident #2's medications except the Humalog were not delivered to the facility until 11/30/19 at 10:35 PM; and, the Humalog was not delivered until 12/01/10 at 4:45 PM. Interview with LPN #3 on 01/07/2020 at 2:20 PM revealed they used Resident #2's medications from home until the resident's medication arrived from the pharmacy. 3. Record review revealed the facility admitted Resident #3 on 12/12/19 with [DIAGNOSES REDACTED]. Review of the Admission Physician order [REDACTED]. daily for UTI, [MEDICATION NAME] 2 mg daily start 12/14/19 [MEDICAL CONDITION], [MEDICATION NAME] 10 mg TID for Hypertension (HTN), Losartin 50 mg daily for HTN, Carvedilol 12.5 mg BID for HTN, [MEDICATION NAME] 120 mg daily for HTN, [MEDICATION NAME] 20 mg daisy fluid retention, Nebulizer [MEDICATION NAME] 3 ml every two (2) hours for shortness of breath (SOB) PRN, Potassium Chloride extended release (ER) 10 meq daily for [DIAGNOSES REDACTED], [MEDICATION NAME] 10 mg daily for urinary incontinence, and Calcitrol 0.25 mcg daily. Review of Resident #3's December 2019 and January 2020 MAR's revealed he/she did not receive his/her 1:00 PM and 6:00 PM doses of [MEDICATION NAME] 10 mg, and 6:00 PM dose of Carvedilol 12/5 mg; on 12/12/19. Further review revealed the resident also did not receive his/her 9:00 AM and 6:00 PM doses of [MEDICATION NAME] 10 mg, 6:00 PM dose of Carvedilol 12/5 mg, and 9:00 AM doses of [MEDICATION NAME] 100 mg, [MEDICATION NAME] 20 mg, Potassium Chloride 10 meq, and [MEDICATION NAME] 10 mg; on 12/13/19. Review of the Pharmacy Packing slip revealed Resident #3's medication was not sent out from the Pharmacy in North Carolina until 12/13/19 after 10:00 AM. 4. Record review revealed the facility admitted Resident #4 on 12/27/19 with [DIAGNOSES REDACTED]. Review of the Admission Physician Orders, dated 12/27/19 revealed to administer Aspirin (anti-[MEDICAL CONDITION]) 325 every day, [MEDICATION NAME] 400 mg BID for [MEDICAL CONDITION], Aclidinium for [MEDICAL CONDITION], [MEDICATION NAME] one puff inhaled every 4 hours as needed for [MEDICAL CONDITION], Atorvastatin (lowers cholesterol) 80 mg at bedtime, [MEDICATION NAME] (anti-[MEDICAL CONDITION]) two puffs inhaled BID, [MEDICATION NAME] (lowers risk [MEDICAL CONDITION] stroke) 75 mg every day, [MEDICATION NAME] (anti-acid) 40 mg every day, [MEDICATION NAME] (lowers cholesterol) 200 mg daily at bedtime, [MEDICATION NAME] (narcotic pain med) 7.5 mg/325 mg three times a day (TID), [MEDICATION NAME] (nerve pain) 800 mg four times a day (QID), [MEDICATION NAME] ([MEDICAL CONDITION] arthritis) 200 mg BID, [MEDICATION NAME] (antidepressant) 30 mg at HS, [MEDICATION NAME] (steroid) 10 mg daily, [MEDICATION NAME] (anti depressant) 200 mg daily, [MEDICATION NAME] Spirivia ([MEDICATION NAME]) 15 mcg (one cap) inhale daily. Review of Resident #4's December 2019 MAR indicated [REDACTED]. and [MEDICATION NAME] 30 mg at 9:00 PM, on 12/27/19; and [MEDICATION NAME] 800 mg at 6:00 PM on 12/27/19; at 12:00 AM, 6:00 AM, 12:00 noon, and 6:00 PM on 12/28/19, and from 12:00 AM on 12/29/19 through 12/31/19 (sixteen {16} doses). Further review of the back of the MAR indicated [REDACTED]. Review of a Pharmacy email revealed Resident #1's Physician order [REDACTED]. Review of the Pharmacy Packing Slips revealed Resident #4's medication was not filled by the Pharmacy in North Carolina until 12/27/19 at approximately 10:00 PM and the packing slip did not include the [MEDICATION NAME]. 5. Record review revealed the facility readmitted Resident #5 on 01/07/2020 at 4:00 PM with [DIAGNOSES REDACTED]. Review of Resident #5's Admission Physician order [REDACTED]. Review of Resident #5's January 2020 MAR indicated [REDACTED]. Review of the Local Pharmacy Receipts revealed the order for Cepahalexin was not filled until 01/08/2020 at 9:49 AM. Interviews on 01/07/2020 with Registered Nurse (RN) #1 at 9:58 AM, LPN #3 at 2:20 PM, on 01/08/20 with LPN #4 at 6:55 AM, LPN #5 at 7:30 AM, and on 01/09/19 with LPN #1 at 11:45 AM revealed medication is not available due to not receiving the medication from the pharmacy in a timely manner. The licensed staff stated the medications are sent from the pharmacy in North Carolina or from a pharmacy as far as two (2) hours away. The staff further revealed they obtain the medications that are available in the EDK; however, not all medication are available in the EDK. Interview with the Facility Nurse Practitioner on 01/09/19 at 11:10 PM revealed there has been a huge problem with receiving medication from the pharmacy in a timely manner. She stated she hopes with the state survey agency and the Pharmacy staff being there to try to figure out the failure, the situation will improve. She stated she thinks they are on the right track. Interview with Pharmacy Manager for Polaris on 01/08/19 at 12:07 PM revealed she was in the building to try to determine what was causing the medication not to be filled and delivered in a timely manner. She stated she was still doing her investigation and had not come to any conclusions yet. Interview with the Administrator on 01/07/2020 at 12:45 PM revealed she had identified the failure was the lack of securing a back up pharmacy to be able to receive medication in a timely manner. She stated the facility Pharmacy was in North Carolina and was not using local pharmacies to ensure medication was delivered within a timely manner. She revealed the facility was working with the pharmacy to to put actions in place to try to ensure all residents medications would be delivered to the facility in a timely manner. She stated they were still identifying medications were not being delivered timely but there had been an improvement. She stated pharmacy was in the building now trying to identify where the failures are.

Based on interview, record review, review of pharmacy receipts and packing information, and facility policy review, it was determined the facility failed to ensure pain management was provided to one (1) of five (5) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE] prior to 2:25 PM with [MEDICATION NAME] (nerve pain), [MEDICATION NAME] (narcotic for chronic pain), and [MEDICATION NAME] (muscle spasms) due to Severe Arthritis, [MEDICAL CONDITION] Arthritis, [MEDICAL CONDITION] Disc Disease, and [MEDICAL CONDITION]. The resident was in pain; however, the facility failed to ensure the resident's pain medication was available to control his/her pain. The resident did not receive his/her [MEDICATION NAME] for nerve pain at 2:00 PM and 9:00 PM on 12/12/19, as ordered. The nurse obtained an order for [REDACTED]. The resident's pain continued. The resident's [MEDICATION NAME] and [MEDICATION NAME] were delivered by pharmacy on 12/13/19 at 4:30 AM, which were administered by the nurse without an order to administer at that time, to get the resident some relief from the pain. The resident had some pain relief; however the resident's [MEDICATION NAME] was not received until 12/13/19 at 11:25 AM. Resident #1 was crying, agitated, and unable to focus due to the pain; and, the resident's dependence on the medication due to long term use. In addition, licensed staff failed to assess the resident's pain to include where located and severity; and how effective the pain medication was after administered, per facility policy. The findings include: Review of the facility's policy titled Pain Assessment and Management last revised March 2015, revealed pain management is a multidisciplinary care process that includes the following: Assessing the potential for pain; Effectively recognizing the presence of pain; Identifying the characteristics of pain, Addressing the underlying causes of the pain; Developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain; Monitoring for the effectiveness of interventions; and Modifying approaches as necessary. Further review of the policy revealed a comprehensive pain assessment should be conducted on admission and when there is onset of new pain or worsening of existing pain. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. Record review revealed the facility admitted Resident #1 on 12/12/19 with [DIAGNOSES REDACTED]. Further review of Resident #1's record revealed there was no documented evidence an Admission Pain assessment was conducted on 12/12/19 on the 7:00 AM through 7:00 PM shift, per facility policy. Interview with Licensed Practical Nurse (LPN) #2 on 01/07/2020 at 8:30 AM revealed he completed a pain assessment on day shift for Resident #1 on 12/12/19 prior to 7:00 PM and the resident stated his/her pain was eight (8) out of ten (10) on a pain scale of 1-10 with 10 being the worst. He stated the resident was complaining of back pain, and the resident's daughter was a nurse and had concerns because the resident's medications had not been received. He further revealed he was in orientation at that time and he did not recall what was done. Review of the Hospital Discharge Orders and facility physician's orders [REDACTED]. Review of the Pharmacy Fax information revealed the Pharmacy (in North Carolina) received the orders on 12/12/19 at 2:25 PM CST. Review of Resident #1's Baseline Care Plan for pain, dated 12/12/19, revealed a goal for pain will be at acceptable or below resident's stated acceptable level. Further review revealed interventions to evaluate resident pain level, administer pain medication as ordered, provide comfort measures, and observe for non-verbal indicators of pain such as facial grimaces and moans. Review of Nurse's Notes, dated 12/12/19 revealed there was no documentation of the resident's admission or condition until 7:00 PM. Licensed Practical Nurse (LPN) #1 documented she received report from the off going shift and a call was placed to the facility's pharmacy requesting the resident's narcotics (pain medication) be sent from the back-up Pharmacy and the Pharmacy stated the narcotics would be sent. However, there was no assessment documented that described if the resident was in pain, where the pain was, and the severity of the pain, per facility policy. Review of Resident 1's December 2019 Medication Administration Record (MAR) revealed there was no documented evidence the resident received his/her 9:00 PM dose of [MEDICATION NAME] on 12/12/19 at 9:00 PM or, the as needed [MEDICATION NAME] and [MEDICATION NAME] on 12/12/19 from 7 AM - 7 PM. Review of the Nurse Practitioner's (NP) Assessment, dated 12/12/19 at 10:09 PM revealed Resident #1 was in severe pain, agitated due to pain, and his/her thought processes were disordered due to pain. The Nurse Practitioner ordered a one (1) time dose of two (2) 5/325 mg [MEDICATION NAME] to be given now (approximately 7:55 PM), from the EDK (contains a supply of medications that can be used in case medications are needed). Further review of the assessment revealed the Pharmacy was sending the medication from the back up pharmacy within the next four (4) hours. Review of Nurse's Notes, dated 12/12/19 at 7:55 PM, revealed LPN #1 received a one time order for [MEDICATION NAME] 5/325 mg- two (2) tabs (to be given from the Emergency Drug Kit {EDK}) and the narcotic script and order were faxed to Pharmacy. The Pharmacy called for a control number and stated it would take fifteen (15) minutes for them to receive the fax and they would call back with authorization. At 8:25 AM, the pharmacy called back with an authorization number and the medication was obtained from the EKG and administered to the resident. Review of Resident #1's December 2019 Medication Administration Record (MAR) revealed there was no documented evidence the Now dose of [MEDICATION NAME] was given on 12/12/19 at 8:25 PM. In addition, further review of the MAR and Nurse's Notes dated 12/12/19 revealed there was no documented evidence the resident's pain was assessed to determine the effectiveness of the now dose of [MEDICATION NAME], per facility policy. Review of Nurse's Note, dated 12/12/19 at midnight (four {4} hours after received one time dose of pain medication and last spoke to Pharmacy), revealed LPN #1 placed another call to the pharmacy to inquire about Resident #1's medications as the medications had still not been received. The Pharmacist assured LPN #1 he would call the local back up pharmacy to inquire about the medication. A Nurse's Note dated 12/13/19 at 2:00 AM, revealed LPN #1 received a call from pharmacy stating someone was coming to the facility to pick up the hard script so the medications could be delivered from the back up pharmacy; however, there were no hard scripts only faxed copies from the hospital. A call was placed to the on call physician who was unable to write an order for [REDACTED].#1 tried to contact the Nurse Practitioner by phone with no answer. Further review revealed Resident #1 was in much pain; however, there was no description of where the pain was, or the severity of the pain per facility policy. Review of Nurse's Note, dated 12/13/19 at 4:30 AM, revealed three (3) 600 mg tablets of [MEDICATION NAME] were received from the back up pharmacy; however, there was no [MEDICATION NAME] received. The nurse administered one (1) [MEDICATION NAME] PRN and one (1) [MEDICATION NAME] due to the resident crying and complaints of headache. The resident's blood pressure was 219/98 mm/Hg. Further review of this Nurse's Note, revealed the resident asked the nurse to sit with him/her for a while and the nurse applied a cold compress to the resident's forehead and neck and administered two (2) 325 mg of Tylenol even though there was no order. The nurse sat with the resident for approximately thirty (30) minutes trying to get the resident to relax. The resident had not been asleep that night. Review of the December 2019 MAR revealed the resident's [MEDICATION NAME] and [MEDICATION NAME] were administered on 12/13/19 at 4:40 AM; however, further review of the MAR and Nurse Notes revealed there was no pain assessment conducted to determine the effectiveness of the pain medication and there was no further documentation about the resident's pain or need for pain medication. Further review of the Nurse's Notes revealed there was no further documentation of the resident's condition and pain for the rest of the day. However, review of the NP assessment dated [DATE] revealed Resident #1 was in severe pain and had not received his/her pain medication from pharmacy the previous night as expected. She wrote a script for a three (3) day supply of [MEDICATION NAME] and [MEDICATION NAME] to be picked up at local pharmacy this AM. Further review of the assessment revealed she visited resident later in day after he/she had pain relief and the resident was pleasant and apologetic for his/her behavior while in pain. She assured him/her everyone understood. Review of a Pharmacy Receipt dated 12/13/19 at 11:27 AM revealed one (1) dose of [MEDICATION NAME] 10/325 mg was received by the facility from the local pharmacy. Further review of the December 2019 MAR revealed there was no documented evidence the resident received this pain medication. Further review of the MAR and Nurse's Note dated 12/13/19 revealed there was no documented evidence the resident's pain was assessed prior to the administration of the pain medication, or after, to determine the resident's pain level or effectiveness of the medication, per facility policy. Interview with LPN #3 (travel nurse who worked on 12/12/19 and 12/13/19 (day shift) by phone, on 01/07/2020 at 9:25 AM, revealed the only thing she recalled was there were problems with getting the resident's pain medication. She stated the resident's orders were sent to pharmacy but it took forever for the medications to arrive at the facility. Interview with LPN #1 (travel nurse), on 01/09/2020 at 11:45 AM revealed when she arrived at work at approximately 7:00 PM on 12/12/19, she was told Resident #1 was a new admission and the resident was in a lot of pain, but the resident's pain medication had not been delivered yet. She stated she called the pharmacy and spoke to them and they stated they would get it delivered from the back up pharmacy. She stated when the medication did not arrive, she spoke to the Nurse Practitioner and she wrote an order for [REDACTED]. She stated the pharmacy called back a little while later with the authorization number and she obtained the medication and administered it. She stated the resident was in quite a lot of pain and the pain was in his/her back. She revealed the resident was anxious, crying, and his/her expression was strained, and voice was cracking. She further revealed a little bit later the resident showed relief and calmed down and she assured the resident his/her pain medication was coming from the back-up pharmacy. Further interview with LPN #1 revealed she could see after a while Resident #1's pain medication was starting to wear off and by 2:00 AM, the resident's pain was getting really bad again with him/her getting very agitated and showing the same symptoms as before. She stated around that time, the resident's [MEDICATION NAME] and [MEDICATION NAME] came in, so since the resident had not received his/her 9:00 PM dose of [MEDICATION NAME] on 12/12/19, she went ahead and gave her a dose with the PRN [MEDICATION NAME]. LPN #1 stated the resident showed some relief but she knew the pain was not going to be tolerable if she was not able to get the resident's narcotic medication. She stated she told the day shift nurse when she arrived that her first priority needed to be to get this resident's pain medication. She stated she did not document an assessment of the resident's pain before and after the pain medications were given but there was no doubt the resident's pain was a ten (10) on a pain scale of one to ten (1-10) with 10 being the most severe pain. She also stated she did not document the now dose of [MEDICATION NAME] on the MAR but she was so tied up with caring for the resident trying everything she could to relieve some of his/her pain she did not get it documented. She stated it was horrible and she never felt so helpless. Interview with Certified Nurse Aide (CNA) #1 on 01/08/2020 at 11:20 AM revealed Resident #1 was up most of the night in pain and was crying at times during the night of 12/12/19. She stated the resident kept pushing the call light and asking if his/her medications had come in yet or if they had heard anything about his/her medications. She stated she saw the nurse doing everything she could making phone calls trying to get medication delivered. She stated the resident did seem to relax a little after receiving some of the medication that came in but the medication was not the narcotic pain medication and she was still in pain. Interviews on 01/07/2020 with Registered Nurse (RN) #1 at 9:58 AM, LPN #2 at 8:30 AM, LPN #3 at 2:20 PM, and on 01/08/2020 with LPN #4 at 6:55 AM, and LPN #5 at 7:30 AM, and on 01/09/19 with LPN #1 at 11:45 AM revealed licensed staff were supposed to assess the resident's pain to identify where the pain was, and the severity of the pain using a pain scale of one to ten (1-10) with ten (10) being the worse pain. The licensed staff stated the assessment should be done prior to administering pain medication and after to determine the effectiveness of the medication. The licensed staff further revealed the assessment should be recorded on the back of the MAR or the nursing notes. Interview with the NP on 01/09/2020 at 11:10 AM revealed Resident #1 was admitted on Friday (12/12/19) but she did not see him/her until around 8:00 PM. She stated Resident #1 was in a lot of pain and his/her medication had not been delivered yet. She revealed she ordered a one time dose of a narcotic medication contained in the facility's EDK to get the resident pain relief as the medication was supposed to be delivered. She stated the next morning the medication still had not been delivered and the resident was in severe distress, agitated, and in pain. She stated she wrote another script and the Administrator went and obtained the medication from the local pharmacy. She further revealed Resident #1 was in severe pain and was not only reacting to the pain but the resident was also physiologically dependent on the medication due to long term use. Interview with the Administrator on 01/07/20 at 12:45 PM and review of a written statement by the Administrator dated 01/09/2020 revealed she was notified Resident #1 was in pain on 12/13/19 and the resident's pain medications had not been received. She stated she assessed the resident to be in minimal pain but was starting to feel pain again. She revealed she had the Nurse Practitioner write a script and she went and picked up the pain medication from a local pharmacy. She stated she identified the failure was the lack of securing a back up pharmacy to be able to receive medication in a timely manner. She stated the facility's Pharmacy was in North Carolina and they were not using local pharmacies to ensure medication was delivered within a timely manner. She also stated the licensed staff should have completed pain assessments and assessed the severity of the pain before and after the medication was given to determine its effectiveness, per facility policy.

Based on interview, record review, facility policy review, and hospital record review, it was determined the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of twenty-one (21) sampled residents (Resident #43). On 07/02/18, the licensed nurse failed to ensure the batteries were changed on Resident #43's quick release alarming seatbelt. On 07/21/18, the resident stood up from the wheelchair without the alarm sounding. The resident fell and sustained a Left [MEDICAL CONDITION]. The resident had surgery on 07/23/18. The findings include: Review of facility policy titled, Incident/Accident, last revised 11/28/16, revealed it is the policy of the facility to provide a safe and hazard free environment as is possible. The incident/accident reporting and investigative process is part of the facility's ongoing quality assessment/assurance program. Incidents, accidents or injury of unknown origin will be investigated and appropriate interventions taken as needed. Record review revealed Resident #43 was initially admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment, dated 06/24/18, revealed the facility assessed Resident #43's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review revealed the resident utilized a trunk restraint daily and required extensive assistance with one (1) assist with ADLs, Review of Comprehensive Care Plan for falls, at risk for related to Alzheimer's, antipsychiatric medications, incontinence, impaired communication, and impaired safety and balance dated 01/29/18 with interventions for a quick release safety belt to wheelchair alarm and review of the Comprehensive Care Plan for Potential for Decline related to seatbelt use for safety dated 01/29/18 with interventions to utilized quick release safety belt to wheelchair alarm and observe for proper placement PRN (as needed). Review of Hendrich II Fall Risk Model revealed Resident #43 was assessed on 06/24/18 with a fall score of ten (10) signifying the resident was a high risk for falls. Review of Resident #43's Physician order [REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed Resident #43 had a quick release alarming seatbelt to wheelchair related to unaware of safety needs and to change batteries on the first Monday of each month. However, further review revealed there was no initials to indicate the the alarm batteries were checked on 07/02/18 (first Monday) or any time after that through 07/21/18. Review of a facility Abbreviated Fall Investigation provided to surveyor revealed Resident #43 fell on [DATE] at 2:00 PM. Resident #43 was found sitting in front of wheelchair on floor in room with seatbelt in place after recent incontinent care. The batteries to belt alarm were not functioning properly and resident had attempted to ambulate self after incontinent care and fell in front of wheelchair. Review of Hospital Records dated 07/24/18 revealed Resident #43 suffered a fall at skilled nursing facility (SNF) and was diagnosed with [REDACTED]. The resident's Post-Operative [DIAGNOSES REDACTED]. Review of Resident #43's Physician order [REDACTED]. Review of Resident #43's physician telephone order with date of 07/23/18 revealed to administer [MEDICATION NAME] 7.5/325 mg. every (4) four hours for pain and to discontinue Aspirin 81 mg and give Aspirin 325 mg twice a day. Review of Resident #43's Physician order [REDACTED]. Review of 07/25/18 Medication Administration Record [REDACTED]. Interview (Post Survey) with Licensed Practical Nurse (LPN) #6 on 09/19/18 at 8:50 PM revealed she could not say if she had been responsible for changing the batteries, but did know batteries were to be replaced on Mondays. LPN #6 stated the hall was split and she could not recall. Interview with the Director of Nursing (DON), on 09/06/18 at 12:46 PM and 2:02 PM revealed the nurse (LPN #6) did not check the batteries and it was on the TARS to check the batteries the first Monday of every month. The facility implemented the following actions to correct the deficient practice: 1. Resident #1's seatbelt alarm battery was replaced on 07/21/18. 2. LPN #6 (staff who did not change batteries on 07/21/18) was given a verbal warning because she did not change the quick release alarming seat belt batteries per physician orders. 3. On 07/23/18-08/01/18, the Unit Manager (UM) #2 with ADON and a former UM did 100% audit of alarms to ensure battery changes were completed and if not batteries to alarms were replaced. 4. On 07/23/18, all licensed nurses were inserviced by Unit Manager #2 and ADON, on pressure alarms, clip alarms, seatbelt alarms, and any other alarm batteries should be changed monthly and signed off on the TARS. In addition, the placement and function of the alarms are to be checked every shift and signed off on the TAR. 5. Abbreviated Quality Assurance conducts daily meetings to check the TAR's for residents with alarms to ensure the batteries are changed every month and the alarms are checked for placement and function every shift. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of alarm audit revealed alarm batteries for Resident #43 was changed on 07//21/18. 2. Review of Termination Document revealed LPN #6 had been given a verbal warning on 07/25/18 related to not following physician orders. Interview with LPN #6 on 09/19/18 at 8:50 PM revealed she did not remember getting a verbal warning for not following physician orders [REDACTED]. 3. Review of alarm audit revealed batteries were checked and changed on 07/23/18, 07/24/18, and 08/01/18 for all residents that utilized a device with batteries. Interview with Unit Manager #2 on 09/18/18 at 2:08 PM revealed she does not recall the date the audit was done but the unit managers did the audit on all the floors to ensure the batteries were changed. She stated it would have been the first Monday after the fall. Interview with the DON on 09/18/19 at 1:49 PM revealed a 100% audit of the alarms was done the day of the fall (07/21/18) by the unit managers and the Assistant Director of Nursing (ADON); however, the ADON is out of town on vacation and one of the UM is no longer employed. 4. Review of the Inservice Record dated 07/23/18 at 11:00 AM revealed the inservice consisted of pressure alarm, clip alarm, seatbelt, and any other alarm batteries to be changed monthly and signed on the Treatment Administration Record (TAR's). There placement and function is to be checked every shift and signed on the TAR. The inservice was signed by Unit Manager #2, with signatures by Certified Nursing Aides and all Licensed Staff. Review of the Inservice Record of Licensed Practical Nurse (LPN) #6 revealed she was inserviced on all pressure alarm, clip alarm, seatbelt, and any other alarm batteries to be changed monthly and signed on the TAR. There placement and function is to be checked every shift. Interviews on 09/18/18 with LPN #5 at 2:48 PM, and LPN #7 at 2:34 PM revealed whoever is on the floor signs the TAR's when they change the batteries. Interview on 09/19/18 at 8:00 AM with DON revealed Licensed Practical Nurse (LPN) #6 received 1:1 education and was given a verbal warning for not following physician orders [REDACTED].#43. Interview with Unit Manager (UM) #2 on 09/18/18 at 2:08 PM revealed she developed the education for the alarms and had been the one that had provided the 1:1 education with LPN #6 related to the alarms and the ADON and another Unit Manager had helped with inservicing the rest of the licensed staff. Interview with DON on 09/06/18 at 12:46 PM revealed all the licensed nurses and some of the CNAs were educated after the fall. Interview with the DON, on 09/18/19 at 1:49 PM revealed the ADON is responsible for educating the staff most of the time and was responsible for the education of the licensed staff related to the alarms/checking the batteries/and the function, monitoring and signing off on the treatment administration record (TAR's) for the alarms. 5. Interview on 09/18/18 at 1:49 PM with Director of Nursing (DON) revealed the battery changes, checking function and placement of the alarms are on each individual TAR. She stated AQA looks at the TAR every single day in the AQA meeting. She revealed all of nursing management (ADON, UM, DON and charge nurses) attend that as well now. Interview on 09/18/18 at 2:08 PM with Unit Manager (UM) #2 revealed there was no monitoring form but the UM have started looking at the TARS for holes (to ensure the batteries and the alarms are being checked and signed off). UM #2 stated they were checking to ensure the batteries have been actually changed and signed off. She revealed she was involved in the daily AQA and they check over the TAR's to ensure they are complete and were completed daily.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of twenty-one (21) sampled residents (Resident #43). The facility revised Resident #43's care plan to use an alarming Quick Release Safety Belt. However, the care plan was not revised to include interventions to address the use of batteries with the belt (check function, expiration date of battery, and/or change alarm batteries). On 07/21/18, Resident #43 fell from his/her wheelchair and fractured his/her left hip requiring hospitalization and surgery to the left hip. The facility determined the resident's belt did not alarm due to the batteries not working. and the licensed staff not changing the battery on the first of the month. In addition, Resident #43 returned from the hospital with orders for pain medication due to [MEDICAL CONDITION]. However, the facility failed to revise the care plan to include the medications. The findings include: Review of the facility's policy titled, Care Plans, last revised 11/20/17, revealed residents will have a person-centered plan of care that supports the resident's assessed needs. Care plan approaches will be communicated to staff for use in providing directions for care; and will be reviewed and revised when requested by resident and/or indicated, based on residents' response to the plan of care. Record review revealed the facility admitted Resident #43 on 12/02/16 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS) assessment, dated 06/24/18, revealed the facility assessed Resident #43's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review revealed the resident utilized a trunk restraint daily and required extensive assistance with one (1) assist with Activities of Daily Living (ADL's). Review of Comprehensive Care Plan for at risk for falls related to Alzheimer's, antipsychiatric medications, incontinence, impaired communication, and impaired safety and balance and potential for decline related to seatbelt use for safety dated 01/29/18 revealed interventions for a quick release safety belt to wheelchair alarm and observe for proper placement PRN (as needed). Review of Resident #43's Physician order [REDACTED]. However, further review of the the Comprehensive Care Plan dated 01/29/18 revealed there was no documented evidence the care plan was revised to include interventions to address the wheelchair alarm's use of batteries or the need to change batteries (check function, expiration date of battery, and/or change alarm batteries). Review of the fall investigation revealed on 07/21/18, Resident #43 was discovered sitting on the floor in front of his/her wheelchair in his/her room. The facility determined that the batteries to the belt alarm were not properly functioning. Review of Hospital Records dated 07/24/18 revealed Resident #43 suffered a fall at a skilled nursing facility (SNF) and was diagnosed with [REDACTED]. The resident's Post-Operative [DIAGNOSES REDACTED]. In addition, review of Physician order [REDACTED]. Review of Comprehensive Care Plan for Potential for pain related to kidney disease and Osteoporoses dated 07/23/18 revealed an intervention for meds (medications) per MD (Physician's) order with line crossed through it and initialed with no date noted; however, there were no interventions added to address the 07/25/18 order for Tylenol 1000 mg PO daily for pain, Tylenol 325 mg tablet give (2) two tablets (650) mg by mouth every (4) four hours (Q4H) as needed (PRN) for pain or temperature > 100.4, [MEDICATION NAME] 7.5/325 mg. every (4) four hours PRN for pain of hip. Interview with the Minimum Data Set (MDS) Coordinator on 09/06/18 at approximately 3:08 PM revealed the MDS Coordinator was responsible for ensuring that interventions were on the care plans; and, that they checked the care plans daily to ensure physician orders [REDACTED]. Interview (Post Survey) with the Director of Nursing (DON) on 10/03/18 at 11:30 AM revealed nurses add the Physician order [REDACTED]. She stated in addition, new Physician order [REDACTED].

Based on interview, record review and facility policy review, it was determined the facility failed to review or revise a Comprehensive Care Plan for one (1) of fifteen (15) sampled residents (Resident #11). The findings include: Review of the facility's policy titled, Comprehensive Care Plan Policy, last revised 04/03/13, revealed it was the facility policy for residents to have a plan of care for assessed needs and the care plan should be developed based on assessed needs. Further review revealed care plan approaches will be communicated to staff for use in providing direction for care and the plan of care will be reviewed and revised when indicated, based on the resident's response. Record review revealed the facility admitted Resident #11 on 09/29/15 with diagnoses, which included [MEDICAL CONDITION], Diabetes Mellitus, Type II, and Generalized Pain. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/16/16, revealed the facility assessed Resident #11's cognition as intact with a Brief Interview of Mental Status (BIMS) score of twelve (12) indicating the resident was interviewable. Further review of the MDS Assessment, dated 05/16/16, revealed the facility assessed the resident to require extensive assistance of two (2) for bed mobility, personal hygiene and toilet use, which was defined as how the resident used the toilet room, commode, bedpan, or urinal; transferred on and off the toilet; cleansed self after elimination; changed pad and adjusted clothes. Review of the resident's Comprehensive Care Plan for Self-Care Deficit and Altered Elimination, dated 12/29/15 and last revised 06/10/16, and the Nurse Aide Data Sheet, undated, revealed the resident required the assistance of two (2) staff for transfers with a mechanical lift; the assistance of one (1) for bathing, showers, hygiene and elimination; and to utilize fracture pan or bed pan with one (1) staff member, even though the facility assessed the resident as requiring the extensive assistance of two (2) staff for bed mobility, personal hygiene and toilet use. Review of Nursing Notes, dated 05/22/16 at 8:00 PM, and phone interview with Licensed Practical Nurse (LPN) #3, on 06/16/16 at 3:50 PM, revealed Resident #11 was being changed and was placed on his/her left side with the right leg crossed over the left leg and the resident's knees came over the edge of the mattress. He/she started to fall from the bed and was eased to the floor. The resident then complained of right shoulder pain. Review of Mobile Services X-Ray results, dated 05/23/16, revealed there was an anterior dislocation of the right humeral head. Interview with Resident #11, on 06/16/16 at 10:45 AM, revealed, That one man was in my room changing my brief and got me to close to the edge of the mattress and down I went. The resident further stated, Now the nurses are saying that they need two (2) to help me all the time and it should have been like that to begin with. Interview with the Minimum Data Set (MDS) Coordinator, on 06/16/16 at 5:00 PM, revealed the MDS assessment should drive the resident's Comprehensive Plan of Care development and if the resident's condition changes between assessments, nursing can update the plan of care. She stated she expected the residents' care plans to be up to date and to reflect the resident's current care status. She revealed she would not expect the resident's plan of care to be different from the MDS assessment and when she looked at Resident #11's plan of care, it did not reflect the coding on the current MDS assessment or the previous assessment that was completed on 03/10/16. Interview with the Director of Nursing (DON), on 06/16/16 at 6:00 PM, revealed it was her expectation that staff followed the Nurse Aide Data Sheet and the resident's plan of care when providing care, and she was not aware the resident's plan of care did not match the MDS assessment. She stated the Admission Nurses completed the Interim Care Plan upon admission, and the MDS Coordinator completed the Comprehensive Plan of Care after the assessment was completed. She further stated the MDS Coordinator was responsible for checking the plan of care to ensure it matched the MDS assessment. Interview with the Administrator, on 06/16/16 at 1:00 PM, revealed through the facility's investigation the resident was able to assist with turning, so they felt like the resident slid out of the bed. The Administrator stated they updated the resident Nurse Aide Care Plan to reflect the assistance of two (2) for bed mobility on 05/23/16.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for two (2) of fifteen (15) sampled residents (Resident #4 and Resident #11) and one (1) unsampled resident (Resident A). The facility assessed Resident #11 as requiring extensive assistance of two (2) persons for bed mobility, toilet use and personal hygiene; however, review of the resident's Comprehensive Plan of Care and the Nurse Aide Data Sheet revealed the resident required physical assistance of one (1) for bed mobility, toileting assistance, and hygiene. On 05/22/16, Certified Nurse Aide (CNA) #2 was providing incontinent care for Resident #11 without the adequate supervision of two (2) staff and when CNA #2 repositioned the resident to his/her left side, the resident turned over and slid off the side of the bed. Resident #11 sustained a right shoulder dislocation. In addition, observations revealed Unsampled Resident A and Resident #4 were observed to have medication at bedside. The findings include: Review of the facility's Incident/Accident Policy, last revised 02/07/13, revealed it was the policy of the facility to provide a safe and hazard free environment as is possible. Further review revealed incidents, accidents, or injury of unknown origin will be investigated and appropriate interventions taken as needed. 1. Record review revealed the facility admitted Resident #11 on 09/29/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/16/16, revealed the facility assessed Resident #11's cognition as intact with a Brief Interview of Mental Status (BIMS) score of twelve (12) indicating the resident was interviewable. Further review of the MDS assessment, dated 05/16/16, revealed the facility assessed the resident as requiring extensive assistance of two (2) for bed mobility and toilet use which was defined as how the resident used the toilet room, commode, bedpan, or urinal; transferred on and off the toilet; cleansed self after elimination; changed pad and adjusted clothes. Review of Resident #11's Comprehensive Care Plan for Self-Care Deficit and Alteration in Elimination, last revised 06/10/16, revealed the resident required extensive assistance with bed mobility, and toileting. Interventions included to provide staff assistance of one (1) for bed mobility, incontinent care with one (1) staff member, and to utilize fracture pan or bed pan with one (1) staff member. Further review revealed documentation, dated 05/18/16, that the resident required extensive assistance with activities of daily living (ADL), continue the plan of care. Review of the Nurse Aide Data Sheet (for the Certified Nurse Aides {CNAs}), undated, revealed the resident required the physical assist of one (1) for bed mobility, bathing, bedpan and incontinent care. Review of Nursing Notes, dated 05/22/16 at 8:00 PM, revealed Resident #11 was being changed and was placed on his/her left side with the right leg crossed over the left leg and the resident's knees came over the edge of the mattress and he/she started to fall from the bed and was eased to the floor. The resident was evaluated for pain prior to being transferred back into bed and the resident complained of right shoulder pain; however, there were no obvious deformities of the shoulder. The physician was notified and an order was obtained to place the resident's right arm in a sling and to get mobile services to x-ray the shoulder on 05/23/16. Interview with Resident #11, on 06/16/16 at 10:45 AM, revealed, That one man was in my room changing my brief and got me to close to the edge of the mattress and down I went. The resident further stated, Now the nurses are saying that they need two (2) to help me all the time and it should have been like that to begin with. Interview with CNA #2 , on 06/16/16 at 7:20 PM, revealed he was providing incontinent care for Resident #11 and when he turned him/her over to the left side, the resident was holding on the side rail for assistance and his/her legs slid off the bed onto the floor. He further revealed the resident did not let go of the top bed rail and his/her knees and legs were on the floor; and then he lowered the resident to the floor and placed a pillow under his/her head for comfort, and immediately got the nurse for assistance. He further revealed the resident was care planned as a two (2) assist for transfers and one (1) assist for personal care. Phone interview with Licensed Practical Nurse (LPN) #3, on 06/16/16 at 7:10 PM, revealed she was completing a medication pass on the resident's hallway, and was outside the resident's door at the time of the fall. She further revealed CNA #2 came out of the room and stated he needed assistance because the resident was in the floor beside the bed. She further revealed she was not aware what the resident's plan of care indicated for transfer or incontinent care, and her main concern was to assess the resident for injury, and get the resident out of the floor safely and back in bed. She further revealed the resident did not want to go to the emergency room the night of the fall, and the resident's medical provider was notified. Orders were received to place a sling on the resident's right arm and get mobile services to do an x-ray the next day. Review of Mobile Services X-Ray results, dated 05/23/16, revealed there was an anterior dislocation of the right humeral head. The resident's physician was notified of the results on 05/23/16 at 10:34 AM, and an order was obtained to send to the emergency room for further evaluation. Interview with the Unit Manager, on 06/16/16 at 7:00 PM, revealed the resident was sent to the emergency room for evaluation and treatment after the physician was notified of the mobile x-ray results on 05/23/16, and the resident returned with new orders to continue the sling for comfort, physical therapy to evaluate and treat. She further revealed Resident #11's spouse declined any surgical intervention to repair the dislocated shoulder at this time and the resident had limited range of motion in that shoulder, previously, due to an old injury and the resident decided to use pillows for support when in bed and wears the sling when out of bed in chair. Interview with the Minimum Data Set (MDS) Coordinator, on 06/16/16 at 5:00 PM, revealed she expected the residents' care plans to be up to date and reflect the residents' current care status. She stated she would not expect the resident's plan of care to be different than the MDS assessment. She further revealed she did not know why the care plan and the assessment did not match but was in the process of completing an update and she realized the assessment and the resident's plan of care did not match when we ask for a copy and she reviewed the information prior to printing. Interview with the Director of Nursing (DON), on 06/16/16 at 6:00 PM, revealed she expected the staff to follow the Nurse Aide Data Sheet and the resident's plan of care when providing care, and she was not aware the resident's plan of care did not match the MDS assessment. She stated the MDS Coordinator was responsible for checking the plan of care to ensure it matches the MDS assessment. Interview with the Administrator, on 06/16/16 at 1:00 PM, revealed through the facility's investigation, the resident was able to assist with turning and they felt like the resident slid out of bed. She further revealed, the resident's care plan and Nurse Aide Care Plan indicated the resident to be one (1) assist for care, and they failed to see that the CNA did anything wrong at the time of the incident. She stated they updated the resident Nurse Aide Care Plan to reflect the assistance of two (2) for bed mobility on 05/23/16 and completed an assessment for the safe use of a low air loss mattress. The resident did not qualify for the mattress after the fall and the mattress was also changed on 05/23/16. 2. Record review revealed the facility admitted Unsampled Resident A on 07/14/03 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 05/29/16, revealed the facility assessed Unsampled Resident A's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Observation of Unsampled Resident A, on 06/16/16 at 8:40 AM, revealed the resident was lying in bed with eyes open with his/her bedside table at bedside with a medicine cup with twelve (12) medications in the cup. The medications which were present in the medicine cup were as follows: Norco (narcotic pain) 7.5/325 milligrams (mg), Invokana (antidiabetic) 100 mg, Januvia (antidiabetic) 100 mg, Klor-Con M20 (potassium supplement), Metformin HCL (antidiabetic) 1000 MG, Amlodipine-Benaze (anti-angina)10-40 mg, Aspirin (anti-inflammatory) 81 mg, Furosemide ((Diuretic) 20 mg, Gabapentin (anti-seizure) 600 mg, Metoprolol Tart (antihypertensive) 50 mg, Tamsulosin HCL (for Benign Prostatic Hyperplasia) 0.4 mg and Zetia (treats high cholesterol) 10 mg. Interview with Licensed Practical Nurse (LPN) #1, on 06/16/16 at 8:50 AM, revealed she was Unsampled Resident A's Medication Nurse and responsible for the administration of his/her medication. LPN #1 stated she took the resident's medication to him/her at approximately 8:20 AM and thought the resident had taken the medication after she had handed the medicine cup with twelve (12) medications in it. LPN #1 revealed she handed the resident the medication cup and while it was still in the resident's hand, she left the room. LPN #1 stated this was not her normal practice and she always waits to ensure a resident takes their medication prior to leaving the room. She also stated this was unacceptable and in hindsight, she should have ensured the resident had taken the medication prior to leaving the room. Interview with Unsampled Resident A, on 06/16/16 at 9:15 AM, revealed LPN #1 left his/her room prior to him/her taking the medications. Unsampled Resident A stated this was the first time he/she could recall a nurse leaving the room prior to him/her taking his/her medications. Interview with the Unit Manager, on 06/16/16 at 10:00 AM, revealed it is not acceptable for a nurse to leave a resident's room prior to ensuring the resident took the medication that was prescribed by the physician. She stated this was a potential hazard because the facility had resident's who were mobile and wandered that could have potentially gotten the medication that was left at Unsampled Resident A's bedside. 3. Record review revealed the facility admitted Resident #4 on 02/18/16 with diagnoses, which included Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, [DIAGNOSES REDACTED], and Pressure Ulcer to the Left Buttock. Review of the Significant Change MDS assessment, dated 04/13/16, revealed the facility assessed Resident #4's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of physician's orders [REDACTED]. Observation of Resident #4, on 06/14/16 at 8:24 AM, 11:12 AM, and 1:44 PM, and on 06/15/16 at 9:04 AM and 3:35 PM, revealed Ventolin HCF inhaler with aero chamber connected and Duoneb in nebulizer machine laying on the nightstand. Observation of Resident #4, on 06/15/16 at 4:05 PM, revealed the resident opened Duoneb and placed into nebulizer chamber and self-administered the medication via inhalation. Further observation revealed there were three (3) ampules of Duoneb in the nebulizer storage area. Interview with Resident #4, on 06/16/16 at 1:40 PM, revealed he/she does his/her own nebulizer treatments. He/she stated the nurse brought two (2) packs of nebulizer vials to him/her last night. Observation at this time revealed twelve (12) Duoneb ampules in the nebulizer storage on the nightstand along with the Albuterol inhaler with aero spacer attached. Interview with LPN #6, on 06/16/16 at 2:32 PM, revealed Resident #4 has been self-administering nebulizer treatment for [REDACTED]. Interview with the DON, on 06/16/16 at 10:20 AM and 6:47 PM, revealed she expected if medications are left in the room for self-administration, there should be a lock box. She stated it was also unacceptable practice to leave a resident's room prior to ensuring the resident had taken the medications. She revealed this was a potential hazard as the facility had wandering residents on the unit who possibly could have wandered into the resident's room and gotten the medications that were left at bedside. Further interview with the facility DON, revealed there were fifteen (15) wandering residents in the entire facility.

Based on record review, interview and facility policy review it was determined the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for four (4) of six (6) sampled residents (Resident #1, #2, #4, and #5). Review of the April 2016 Medication Administration Records (MARS) for Resident #1, Resident #2, Resident #4, and Resident #5, revealed forty-six (46) blanks/omissions were noted related to accu-checks and or insulin administration having been left blank on the MARS with no licensed staff initials signifying these were completed. The facility's failure to ensure the clinical record was maintained in accordance with accepted professional standards and practices that were complete and accurately documented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/29/16 and determined to exist on 04/15/16. The facility was notified of the Immediate Jeopardy on 04/29/16. An acceptable Allegation of Compliance (AoC) was received on 05/05/16 alleging the removal of the Immediate Jeopardy on 05/05/16. The State Survey Agency validated, on 05/09/16, the Immediate Jeopardy was removed on 05/05/16, as alleged. The scope and severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Documentation Standards, last revised 01/02/14, revealed it is the policy of the facility that documentation will reflect medical presence, team approach, and clinical decision making to promote quality of care. The policy further states: entries should be legible, signed, dated and timed by the author and charting should contain pertinent information about the resident. 1. Record review revealed the facility admitted Resident #1 on 03/17/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/23/16, revealed the facility assessed Resident #1's cognition as severely impaired and this resident was unable to participate in the Brief Interview for Mental Status (BIMS) due to the impaired cognition. This indicated the resident was not interviewable. Review of the April 2016 MARS revealed Resident #1 had nine (9) blanks for scheduled insulin to be given and also had eight (8) blanks for accu-checks to be performed. Review of Resident #1's April 2016 MAR revealed the resident's accu-check results for 04/15/16 at 6:00 AM was four-hundred thirty six (436) mg/dl, but the MAR was not initialed as the insulin having been given at 6:00 AM as ordered by Resident #1's Physician. Further review revealed the scheduled accu-check for 04/15/16 at 8:00 PM, and 04/16/16 at 6:00 AM and 8:00 PM were left blank on the MAR and the scheduled insulin for those times was also left blank with no licensed staff initials. Review of the 100 Hall's accu-check flow sheet revealed the accu-check completed on 04/17/16 at 6:00 AM was five-hundred seventeen (517) mg/dl. There was documented evidence the resident's insulin had been administered. Review of Resident #1's hospital admission to Intensive Care Unit (ICU) orders, dated 04/17/16 at 6:42 PM, revealed Resident #1 was admitted to ICU with [DIAGNOSES REDACTED]. 2. Record review revealed the facility admitted Resident #2 on 03/25/15 with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS Assessment, dated 03/16/16, revealed the facility assessed Resident #2 to have a BIMS score of fourteen (14) which indicated his/her cognition was intact and interviewable. Review of the April 2016 MARS revealed Resident #2 had ten (10) blanks for accu-checks with sliding scale insulin to be administered and two (2) blanks for scheduled routine insulin to be administered. Interview with Resident #2 on 04/28/16 at 4:20 PM, revealed he/she did not recall staff forgetting to perform accu-checks or administer insulin as per his/her physician's orders [REDACTED]. 3. Record review revealed the facility admitted Resident #4 on 08/15/16 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #4 with a BIMS score of fifteen (15) which indicated his/her cognition was intact and interviewable. Review of the April 2016 MARS revealed Resident #4 had nine (9) blanks for accu-checks with sliding scale insulin to be administered. Interview with Resident #4 on 04/29/16 at 3:20 PM, revealed he/she did not recall remembering an instance when staff had forgotten to perform accu-checks or administer insulin as per his/her physician's orders [REDACTED]. 4. Record review revealed the facility admitted Resident #5 on 05/12/15 with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS Assessment, dated 03/30/16, revealed the facility assessed Resident #5 for a BIMS score of four (4) indicating this resident had impaired cognition and was not interviewable. Review of the April 2016 MARS revealed Resident #5 had eight (8) blanks for accu-checks with sliding scale insulin to be administered. Interview with LPN #1 on 04/28/16 at 03:45 PM, revealed she knew she was expected to initial the MARS whenever she performed an accu-check or administered insulin. She further stated it was not acceptable to leave blanks on the MARS and sometimes she may have forgotten to initial the MARS, but she had performed the accu-check and administered insulin if it was due during her shift. Interview with LPN #2 on 04/29/16 at 11:03 AM, revealed she knew she was expected to initial the MARS whenever she performed an accu-check or administered insulin. She further stated it was not acceptable to leave blanks on the MARS. Interview with LPN #3 on 04/28/16 at 1:20 PM, revealed she expected all licensed staff to initial the MARS any time they administered medications, performed a treatment or accu-check for a resident. She also stated it was not acceptable to leave blanks on the MARS, and if a resident refused something, the licensed staff was to still initial the spot, circle their initials, and chart the resident refused. Interview with LPN #4 on 04/29/16 at 4:20 PM, revealed he was expected to initial the MARS if he performed an accu-check or administered any medication to a resident. He stated it was not acceptable to leave any blanks on the MAR. Interview with LPN #5 on 04/28/16 at 1:20 PM, revealed she expected all licensed staff to initial the MARS any time they performed an accu-check or administered insulin to a resident. She stated even if a resident refused something the licensed staff was to initial the spot on the MAR, then circle their initials and chart if it was refused or withheld or why it was not administered or performed. Interview with Registered Nurse (RN) #1 on 04/29/16 at 3:50 PM, revealed she was expected to ensure she initialed the MARS anytime she administered any medication such as insulin and anytime she performed an accu-check, and it was not acceptable to leave blanks. Interview with the Director of Nursing (DON) on 04/28/16 at 3:35 PM, revealed she expected licensed staff to initial the MAR for every accu-check performed and every insulin administered and not to leave any blanks on the MARS. She stated it was not acceptable for licensed staff to leave blanks on the MARS. Interview with the Administrator on 04/29/16 at 8:40 AM, revealed she expected there to be no blanks/omissions on the MARS as it was unacceptable to have omissions on the MARS. She stated even if a medication, accu-check or insulin was refused or withheld the licensed staff would still need to initial the MAR and circle their initials, which indicated it was not administered or performed, and then chart the reason why the medication, accu-check or insulin was not being performed or administered. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 was suspended and taken off the schedule on 04/18/16 pending the facility's investigation. LPN #1 was terminated by the facility on 04/26/16. 2. LPN #2 was suspended and taken off the schedule on 04/19/16 pending the facility's investigation; and, after the facility's investigation, LPN #2 was given a disciplinary action of a Final Written Performance Correction on 04/23/16. 3. On 04/29/16, the facility began auditing accu-checks every shift to ensure all accu-checks had been completed, any sliding scale insulin that was required had been administered, and any accu-check results outside the physician's orders [REDACTED]. 4. On 04/29/16, education for all shifts was initiated by the DON with licensed nurses regarding omissions on the Medication Administration Records (MARS); notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of Twenty-four (24) Hour Report Logs regarding the need to have documentation on the logs related to any significant changes in a resident's condition; and that any new orders for a resident needed to be documented on the log. Education was completed with licensed nurses on 05/02/16. 5. On 05/04/16, education for all shifts was initiated by the DON with licensed nurses regarding diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. All licensed nurses will be educated before their next shift worked and any licensed staff who was on leave of absence, or who works as needed (PRN) will be educated prior to returning to work. 6. On 05/04/16, education for all shifts was initiated by the DON with Nurse Aides regarding the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. Education to be completed with all Nurse Aides prior to their next shift worked. 7. On 04/30/16, the facility did a one-hundred (100%) percent audit of residents with [DIAGNOSES REDACTED]. The facility found no issues through their audits. 8. On 04/30/16, the facility implemented a system for all residents with accu-check orders to have his/her diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, all residents with Diabetes had a copy of their Diabetic care plan placed in front of their diabetic MAR; and, Diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. 9. A Quality Assurance (QA) Meeting was held on 05/04/16, with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehabilitation (Rehab) Program Manager and Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Payroll Director, Medical Records (MR) Coordinator and the Medical Director (MD). During the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three (3) weeks then monthly for three (3) months: the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that is outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with LPN #1 on 04/28/16 at 3:45 PM, revealed the facility had informed her of the suspension starting on 04/18/16, pending the facility's investigation related to Resident #1 and after the facility's investigation the facility informed her of the job termination on 04/26/16. Review of LPN #1's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/18/16 pending the investigation and after the investigation LPN #1 was terminated on 04/26/16. 2. Interview with LPN #2 on 04/29/16 at 11:03 AM, revealed the facility had informed her of the suspension starting on 04/19/16 pending the facility's investigation related to Resident #1 and after the facility's investigation she was informed of the disciplinary action. On 04/23/16, the facility provided her a final written notice. Review of LPN #2's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/19/16 pending the facility's investigation and after the investigation, LPN #2 was given a disciplinary action of a final written notice on 04/23/16. 3. Interview with the Administrator on 05/09/16 at 10:10 AM, revealed the facility did perform audits on 04/29/16. The audit paperwork was reviewed and did show the auditing of accu-checks every shift to ensure all accu-checks had been completed; any sliding scale insulin that was required had been administered, and when any accu-check results were outside of the physician ordered parameters, or significant changes in condition, had a physician notification. 4. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed training was initiated on 04/29/16. Licensed staff was inserviced on omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident. The education was completed with licensed nurses on 05/02/16. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked a shift recently, had been notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. On 05/09/16, a copy of the letter sent to this PRN nurse was reviewed. Interviews on 05/09/16 with Registered Nurse (RN) #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN/UM #5 at 11:38 AM, revealed they received the inservice training in regards to omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition/ the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident needed to be documented on the Log. 5. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training regarding education about diabetes; the signs and symptoms of hypo/[MEDICAL CONDITION] ( low and high blood sugar); and, care of residents with diabetes, revealed the DON did initiate this training on 05/04/16 for all shifts for licensed nurses. All licensed nurses were educated prior to their next shift worked. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked recently. This nurse was notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. Interviews on 05/09/16 with RN #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN UM #5 at 11:38 AM, revealed they all stated they received the inservice training in regards to: education about diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. 6. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed the SRNAs were trained on the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. The DON did initiate the inservice on 05/04/16. Education was to be completed with all SRNAs prior to their next shift worked. Review of the facility's employee listing compared to the inservice sign in logs, revealed three (3) PRN SRNAs, who were PRN staff, who had not worked recently were not listed on the inservice sign in logs, but the facility had notified them by phone. The DON stated these three (3) SRNAs had not returned the facility's call, but they were on a list of being unable to work until the training had been completed. The DON further stated these three (3) SRNAs would also be notified by letter on 05/09/16. Interviews on 05/09/16 with SRNA #4 at 11:40 AM, SRNA #5 at 11:45 AM, SRNA #6 at 11:48 AM, SRNA #7 at 11:50 AM, SRNA #8 at 12:03 PM, and SRNA #9 at 12:07 PM, revealed they all stated they had received the training related to the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to report any of those signs and symptoms to a licensed nurse. 7. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16, the facility did perform a one-hundred (100) percent audit of residents with a [DIAGNOSES REDACTED]. The facility found no issues through their audits. The surveyor observed all completed audits. 8. Review of all MARS on 05/09/16 at 8:30 AM, revealed all residents who had accu-check orders had their diabetic MAR placed under a separate tab in the MARS and all diabetic residents had a copy of their diabetic care plan placed in front of their diabetic MAR. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16 the facility implemented, as a facility standard, all residents who had accu-check orders had their diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, a copy of all resident's with Diabetes had a copy of their diabetic care plan placed in front of their diabetic MAR and diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. Review of a new facility admission packet on 05/09/16 at 2:38 PM, revealed the admission packet had a diabetic care plan in place as part of the admission packet. 9. Interview with the Administrator on 05/09/16 at 10:10 AM, and review of the QA sign in log dated 05/04/16, revealed a QA meeting was held on 05/04/16 with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehab Program Manager, Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Medical Records (MR) Coordinator and the Medical Director (MD). Review of the QA log and information, revealed during the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three weeks then monthly for three (3) months. They would be monitoring for the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that was outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. Review of the Monitoring Sheets for 05/04/16 through 05/09/16, revealed the above monitoring was completed daily and turned into the Administrator.

Based on interview, record review, and review of the facility's policy, and the emergency room (ER) records, it was determined the facility failed to ensure one (1) of six (6) sampled residents' (Resident #1) physician was notified when there was a change in condition and a potential need to alter treatment. On 04/15/16 at 6:00 AM, Resident #1 had an elevated accu-check of four-hundred and thirty-six (436) milligrams per deciliter (mg/dl) (normal 70 to 100 mg/dl); and, an elevated accu-check on 04/17/16 at 6:00 AM of five-hundred and seventeen (517) mg/dl. In addition, on 04/17/16 at 9:00 AM, Resident #1 was lethargic and unable to be aroused to take his/her scheduled medication. Licensed staff failed to notify the Physician of the resident's elevated blood sugars and increased lethargy. On 04/17/16 at 1:30 PM, Resident #1 was found unresponsive with increased respirations and pulse; and with blush nailbeds and fingertips. Resident #1 was sent to the emergency room (ER). Resident #1 was hospitalized for [REDACTED]. The facility's failure to notify the Physician with a resident's significant change in condition/need to alter treatment has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/29/16 and determined to exist on 04/15/16. The facility was notified of the Immediate Jeopardy on 04/29/16. An acceptable Allegation of Compliance (AoC) was received on 05/05/16 alleging the removal of the Immediate Jeopardy on 05/05/16. The State Survey Agency (SSA) validated, on 05/09/16, the Immediate Jeopardy was removed on 05/05/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, 'Notification Requirements, last revised 05/22/12, revealed the facility should notify the resident's attending Physician and representative when a resident has had a significant change in physical, mental or psychosocial status and when there is a need to alter resident's treatment significantly. Record review revealed the facility admitted Resident #1 on 03/17/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/23/16, revealed the facility assessed Resident #1's cognition as severely impaired. Resident #1 was unable to participate in the Brief Interview for Mental Status (BIMS) due to the impaired cognition. This resident was not interviewable. Review of Resident #1's Medication Administration Record (MAR) for April 2016, revealed Resident #1 had an accu-check on 04/15/16 at 6:00 AM with a result of four-hundred thirty-six (436) mg/dl; and review of the 100 Hall's accu-check flow sheet revealed the accu-check completed on 04/17/16 at 6:00 AM was five-hundred seventeen (517) mg/dl. However, review of Resident #1's Nurses' Notes, revealed there was no documented evidence the Physician was notified of the resident's elevated accu-check results on 04/15/16 at 6:00 AM and on 04/17/16 at 6:00 AM. Interview with Licensed Practical Nurse (LPN) #1, on 04/28/16 at 3:45 PM, revealed she did not notify the Physician of Resident #1's accu-check results on 04/15/16 at 6:00 and on 04/17/16 at 6:00 AM. She stated in hindsight, she should have used better judgment and she should have notified the Physician on 04/15/16 and 04/17/16 of the results of the accu-checks. Interview with State Registered Nurse Aide (SRNA) #1, on 04/28/16 at 1:45 PM, and LPN 2, on 04/29/16 at 11:03 AM, revealed on 04/17/16, before and after breakfast, Resident #1 was acting more sleepy than normal and did not eat his/her breakfast. Further interview revealed LPN #2 checked Resident #1's vital signs and they were within normal limits. However, review of the Nurses' Notes revealed there was no documented evidence the Physician was notified of the resident's change in condition. Interview with LPN #2, on 04/29/16 at 11:03 AM, revealed when she went to administer Resident #1's 9:00 AM medications on 04/17/16, she was unable to wake Resident #1 up enough to give his/her medication. She stated she withheld Resident #1's medication, but she did not call the Physician to make him aware of the resident's change in condition and the possible need to alter treatment. LPN #2 stated at approximately 1:30 PM, Resident #1 was found unresponsive, with rapid respirations, decreased oxygen levels, and his/her fingertips were blue. She stated she should have used better judgment and notified the Physician after she could not arouse Resident #1 to take his/her scheduled medications at 9:00 AM on 04/17/16. In addition, she stated if she had notified the Physician after she was unable to arouse Resident #1, it may have prevented Resident #1 from getting to the point he/she needed to be sent out to the ER. Review of Resident #1's physician's orders [REDACTED].#1 to the ER related to decreased responsiveness. Review of the ER Records, revealed an ER Focus Assessment, dated 04/17/16 at 3:03 PM, which noted Resident #1 had [MEDICAL CONDITION](elevated pulse rate) and shallow labored breathing. Further review revealed, at 3:34 PM, it was noted Resident #1's blood sugar at that time was six-hundred sixty (660) mg/dl. Review of Hospital admission orders [REDACTED]. Resident #1 was admitted to ICU with [DIAGNOSES REDACTED]. Further review of the hospital records revealed Resident #1 was hospitalized from [DATE] through 04/22/16. Interview with the Director of Nursing (DON), on 04/28/16 at 3:35 PM, revealed she would have expected LPN #1 to notify Resident #1's Physician after the elevated accu-check results on 04/15/16 and 04/17/16 at 6:00 AM. She stated she would have expected LPN #2 to have notified Resident #1's Physician after staff reported Resident #1 was not acting like his/her normal self at breakfast time; after LPN #2 was unable to wake Resident #1 to administer his/her scheduled medications on 04/17/16; and, anytime a resident had a change in condition. Interview with the Administrator, on 04/29/16 at 8:40 AM, revealed she expected staff to follow the facility's policies. She stated she would have expected LPN #1 to have notified Resident #1's Physician after she obtained the elevated accu-check results on 04/15/16 and 04/17/16. She also stated she would have expected LPN #2 to have notified Resident #1's Physician after staff reported to LPN #2 that Resident #1 was not acting like his/her normal self and after LPN #2 was unable to wake Resident #1 to administer his/her scheduled medications to him/her. Interview with the Regional Nurse, on 04/28/16 at 3:30 PM, revealed the facility had no specific policy in regards to accu-check results parameters as to when to notify the Physician with a low or high accu-check result. However, she stated the standard for licensed staff to notify the Physician would have been with any accu-check results below sixty (60) mg/dl or above four-hundred (400) mg/dl. Interview with Resident #1's Physician, on 04/28/16 at 2:40 PM, revealed he would have expected to be notified on 04/15/16 at 6:00 AM, when Resident #1's accu-check results were four-hundred thirty six (436) mg/dl and on 04/17/16 at 6:00 AM when the accu-check result was five-hundred seventeen (517) mg/dl. He stated he expected to have been notified on 04/17/16 when staff found Resident #1 at breakfast and at 9:00 AM during the medication pass when the resident was noted with increased lethargy and staff was not able to arouse him/her. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 was suspended and taken off the schedule on 04/18/16 pending the facility's investigation. LPN #1 was terminated by the facility on 04/26/16. 2. LPN #2 was suspended and taken off the schedule on 04/19/16 pending the facility's investigation; and, after the facility's investigation, LPN #2 was given a disciplinary action of a Final Written Performance Correction on 04/23/16. 3. On 04/29/16, the facility began auditing accu-checks every shift to ensure all accu-checks had been completed, any sliding scale insulin that was required had been administered, and any accu-check results outside the physician's orders [REDACTED]. 4. On 04/29/16, education for all shifts was initiated by the DON with licensed nurses regarding omissions on the Medication Administration Records (MARS); notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of Twenty-four (24) Hour Report Logs regarding the need to have documentation on the logs related to any significant changes in a resident's condition; and that any new orders for a resident needed to be documented on the log. Education was completed with licensed nurses on 05/02/16. 5. On 05/04/16, education for all shifts was initiated by the DON with licensed nurses regarding diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. All licensed nurses will be educated before their next shift worked and any licensed staff who was on leave of absence, or who works as needed (PRN) will be educated prior to returning to work. 6. On 05/04/16, education for all shifts was initiated by the DON with Nurse Aides regarding the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. Education to be completed with all Nurse Aides prior to their next shift worked. 7. On 04/30/16, the facility did a one-hundred (100%) percent audit of residents with [DIAGNOSES REDACTED]. The facility found no issues through their audits. 8. On 04/30/16, the facility implemented a system for all residents with accu-check orders to have his/her diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, all residents with Diabetes had a copy of their Diabetic care plan placed in front of their diabetic MAR; and, Diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. 9. A Quality Assurance (QA) Meeting was held on 05/04/16, with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehabilitation (Rehab) Program Manager and Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Payroll Director, Medical Records (MR) Coordinator and the Medical Director (MD). During the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three (3) weeks then monthly for three (3) months: the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that is outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with LPN #1 on 04/28/16 at 3:45 PM, revealed the facility had informed her of the suspension starting on 04/18/16, pending the facility's investigation related to Resident #1 and after the facility's investigation the facility informed her of the job termination on 04/26/16. Review of LPN #1's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/18/16 pending the investigation and after the investigation LPN #1 was terminated on 04/26/16. 2. Interview with LPN #2 on 04/29/16 at 11:03 AM, revealed the facility had informed her of the suspension starting on 04/19/16 pending the facility's investigation related to Resident #1 and after the facility's investigation she was informed of the disciplinary action. On 04/23/16, the facility provided her a final written notice. Review of LPN #2's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/19/16 pending the facility's investigation and after the investigation, LPN #2 was given a disciplinary action of a final written notice on 04/23/16. 3. Interview with the Administrator on 05/09/16 at 10:10 AM, revealed the facility did perform audits on 04/29/16. The audit paperwork was reviewed and did show the auditing of accu-checks every shift to ensure all accu-checks had been completed; any sliding scale insulin that was required had been administered, and when any accu-check results were outside of the physician ordered parameters, or significant changes in condition, had a physician notification. 4. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed training was initiated on 04/29/16. Licensed staff was inserviced on omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident. The education was completed with licensed nurses on 05/02/16. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked a shift recently, had been notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. On 05/09/16, a copy of the letter sent to this PRN nurse was reviewed. Interviews on 05/09/16 with Registered Nurse (RN) #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN/UM #5 at 11:38 AM, revealed they received the inservice training in regards to omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition/ the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident needed to be documented on the Log. 5. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training regarding education about diabetes; the signs and symptoms of hypo/[MEDICAL CONDITION] ( low and high blood sugar); and, care of residents with diabetes, revealed the DON did initiate this training on 05/04/16 for all shifts for licensed nurses. All licensed nurses were educated prior to their next shift worked. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked recently. This nurse was notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. Interviews on 05/09/16 with RN #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN UM #5 at 11:38 AM, revealed they all stated they received the inservice training in regards to: education about diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. 6. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed the SRNAs were trained on the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. The DON did initiate the inservice on 05/04/16. Education was to be completed with all SRNAs prior to their next shift worked. Review of the facility's employee listing compared to the inservice sign in logs, revealed three (3) PRN SRNAs, who were PRN staff, who had not worked recently were not listed on the inservice sign in logs, but the facility had notified them by phone. The DON stated these three (3) SRNAs had not returned the facility's call, but they were on a list of being unable to work until the training had been completed. The DON further stated these three (3) SRNAs would also be notified by letter on 05/09/16. Interviews on 05/09/16 with SRNA #4 at 11:40 AM, SRNA #5 at 11:45 AM, SRNA #6 at 11:48 AM, SRNA #7 at 11:50 AM, SRNA #8 at 12:03 PM, and SRNA #9 at 12:07 PM, revealed they all stated they had received the training related to the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to report any of those signs and symptoms to a licensed nurse. 7. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16, the facility did perform a one-hundred (100) percent audit of residents with a [DIAGNOSES REDACTED]. The facility found no issues through their audits. The surveyor observed all completed audits. 8. Review of all MARS on 05/09/16 at 8:30 AM, revealed all residents who had accu-check orders had their diabetic MAR placed under a separate tab in the MARS and all diabetic residents had a copy of their diabetic care plan placed in front of their diabetic MAR. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16 the facility implemented, as a facility standard, all residents who had accu-check orders had their diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, a copy of all resident's with Diabetes had a copy of their diabetic care plan placed in front of their diabetic MAR and diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. Review of a new facility admission packet on 05/09/16 at 2:38 PM, revealed the admission packet had a diabetic care plan in place as part of the admission packet. 9. Interview with the Administrator on 05/09/16 at 10:10 AM, and review of the QA sign in log dated 05/04/16, revealed a QA meeting was held on 05/04/16 with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehab Program Manager, Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Medical Records (MR) Coordinator and the Medical Director (MD). Review of the QA log and information, revealed during the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three weeks then monthly for three (3) months. They would be monitoring for the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that was outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. Review of the Monitoring Sheets for 05/04/16 through 05/09/16, revealed the above monitoring was completed daily and turned into the Administrator.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure care was provided in accordance with the written plan of care for one (1) of six (6) sampled residents (Resident #1). Resident #1 was care planned for staff to observe for any signs and symptoms of hypo/[MEDICAL CONDITION] (low or high blood sugar), to notify the Physician with any decline in health or with significant changes and to conduct accu-check per physician's orders [REDACTED].#1 was identified as having elevated accu-checks of 436 milligrams per deciliter {mg/dl}(normal 70 to 100 mg/dl) and 517 mg/dl, respectively; however, the Physician was not notified per the care plan. In addition, on 04/17/16 at 9:00 AM, staff identified Resident #1 was lethargic and unable to take his/her medication. However, licensed staff failed to identify Resident #1 had symptoms of [MEDICAL CONDITION], failed to conduct as needed accu-checks; and, failed to notify the Physician of the resident's change in condition per the resident's care plan. On 04/17/16 at 1:30 PM, Resident #1 was found unresponsive, had increased pulse and respirations, and bluish colored fingernail beds and fingertips. Resident #1 was hospitalized for [REDACTED]. The facility's failure to follow the interventions on the resident's care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 04/29/16 and determined to exist on 04/15/16. The facility was notified of the Immediate Jeopardy on 04/29/16. An acceptable Allegation of Compliance (AoC) was received on 05/05/16 alleging the removal of the Immediate Jeopardy on 05/05/16. The State Survey Agency validated, on 05/09/16, the Immediate Jeopardy was removed on 05/05/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, Comprehensive Care Plans, last revised 04/03/13, revealed it is the facility's policy that residents will have a plan of care for assessed needs. It also stated, a care plan will be developed based on assessed needs, care plan approaches will be communicated to staff for use in providing direction for care and the plan of care will be reviewed and revised when indicated, based on resident's response. Record review revealed the facility admitted Resident #1 on 03/17/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility determined Resident #1 was unable to be assessed for a Brief Interview for Mental Status (BIMS) score due to impaired cognition. Review of Resident #1's Comprehensive Care Plan for Diabetes, dated 04/04/16, revealed staff should observe Resident #1 for any signs and symptoms of hypo/[MEDICAL CONDITION], notify the Physician PRN of any decline in health or with any significant changes and do accu-checks per physician's orders [REDACTED]. Review of Resident #1's April 2016 physician's orders [REDACTED]. Review of Resident #1's April 2016 Medication Administration Record (MAR) and review of the Hall 100 Accu-check flowsheet revealed the resident's accu-check results for 04/15/16 at 6:00 AM was four-hundred thirty six (436) mg/dl; and, on 04/17/16 at 6:00 AM, it was five-hundred seventeen (517) mg/dl. However, review of the Nurses' Notes revealed there was no documented evidence the care plan was followed with Physician notification of a significant change, per the care plan. Interview with Licensed Practical Nurse (LPN) #1 on 04/28/16 at 3:45 PM, revealed she failed to notify Resident #1's Physician after she performed an accu-check on Resident #1 on 04/15/16 at 6:00 AM with results of four-hundred thirty six (436) mg/dl and on 04/17/16 at 6:00 AM with results of five-hundred seventeen (517) mg/dl. She stated she administered the resident's long acting insulin, but in hindsight she should have used better judgment and should have notified the Physician on 04/15/16 and on 04/17/16 at 6:00 AM. She also stated if she had called the Physician after the initial increased accu-check results from 6:00 AM on 04/15/16, Resident #1 may not have gotten as sick as he/she did when he/she had to be sent out to the emergency room (ER) on 04/17/16. She further stated the residents' care plans were supposed to be followed by the staff, but she was often too busy to look at care plans. Interview with State Registered Nurse Aide (SRNA) #1 on 04/28/16 at 1:45 PM, and LPN #2, on 04/29/16 at 11:03 AM, revealed SRNA #1 notified LPN #2 on 04/17/16 before and after breakfast that the resident was more sleepy acting than usual and did not eat breakfast. LPN #2 checked Resident #1's vital signs and they were in normal limits. However, LPN #1 stated at approximately 9:00 AM, she attempted to administer Resident #1's medications, but she was unable to wake the resident up enough to get him/her to take his/her medication. She stated she withheld Resident #1's medication, but she did not conduct an accu-check per the care plan, even though the resident was showing symptoms of [MEDICAL CONDITION]. LPN #1 stated this was the first time she had provided care for this resident and she did not know the resident was a diabetic. She also stated she did not notify the Physician of the resident's increased lethargy and the withholding of the scheduled medication, per the care plan. SRNA #1 and LPN #2 further stated at approximately 1:30 PM, Resident #1 was found with increased respirations, decreased oxygen levels and his/her fingertips were bluish. LPN #2 stated Resident #1's Advanced Practice Registered Nurse (APRN) was notified of the resident's unresponsiveness and overall condition and orders were given for Resident #1 to be sent to the ER for evaluation due to being unresponsive. LPN #2 stated she should have followed the resident's care plans. Review of Resident #1's physician's orders [REDACTED].#1 to the ER related to decreased responsiveness. Review of an ER Focus Assessment revealed on 04/17/16 at 3:03 PM, Resident #1 had an elevated pulse rate and shallow labored breathing; and, at 3:34 PM, Resident #1's blood sugar was six-hundred sixty (660) mg/dl. Review of the Hospital Admission to the Intensive Care Unit (ICU) orders, dated 04/17/16 at 6:42 PM, revealed Resident #1 was being admitted to ICU with diagnoses, which included Diabetic Ketoacidosis, Altered Level of Consciousness, Interstitial Pneumonia,[MEDICAL CONDITION], and [MEDICAL CONDITION]. Further review of the hospital records revealed Resident #1 was discharged from the hospital on [DATE]. Interview with Director of Nursing (DON) on 04/28/16 at 3:35 PM, revealed she expected all staff to use the care plans and follow the care plans. Interview with the Administrator on 04/29/16 at 8:40 AM, revealed she expected staff to follow the facility policies and to follow the care plans. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 was suspended and taken off the schedule on 04/18/16 pending the facility's investigation. LPN #1 was terminated by the facility on 04/26/16. 2. LPN #2 was suspended and taken off the schedule on 04/19/16 pending the facility's investigation; and, after the facility's investigation, LPN #2 was given a disciplinary action of a Final Written Performance Correction on 04/23/16. 3. On 04/29/16, the facility began auditing accu-checks every shift to ensure all accu-checks had been completed, any sliding scale insulin that was required had been administered, and any accu-check results outside the physician's orders [REDACTED]. 4. On 04/29/16, education for all shifts was initiated by the DON with licensed nurses regarding omissions on the Medication Administration Records (MARS); notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of Twenty-four (24) Hour Report Logs regarding the need to have documentation on the logs related to any significant changes in a resident's condition; and that any new orders for a resident needed to be documented on the log. Education was completed with licensed nurses on 05/02/16. 5. On 05/04/16, education for all shifts was initiated by the DON with licensed nurses regarding diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. All licensed nurses will be educated before their next shift worked and any licensed staff who was on leave of absence, or who works as needed (PRN) will be educated prior to returning to work. 6. On 05/04/16, education for all shifts was initiated by the DON with Nurse Aides regarding the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. Education to be completed with all Nurse Aides prior to their next shift worked. 7. On 04/30/16, the facility did a one-hundred (100%) percent audit of residents with [DIAGNOSES REDACTED]. The facility found no issues through their audits. 8. On 04/30/16, the facility implemented a system for all residents with accu-check orders to have his/her diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, all residents with Diabetes had a copy of their Diabetic care plan placed in front of their diabetic MAR; and, Diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. 9. A Quality Assurance (QA) Meeting was held on 05/04/16, with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehabilitation (Rehab) Program Manager and Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Payroll Director, Medical Records (MR) Coordinator and the Medical Director (MD). During the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three (3) weeks then monthly for three (3) months: the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that is outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with LPN #1 on 04/28/16 at 3:45 PM, revealed the facility had informed her of the suspension starting on 04/18/16, pending the facility's investigation related to Resident #1 and after the facility's investigation the facility informed her of the job termination on 04/26/16. Review of LPN #1's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/18/16 pending the investigation and after the investigation LPN #1 was terminated on 04/26/16. 2. Interview with LPN #2 on 04/29/16 at 11:03 AM, revealed the facility had informed her of the suspension starting on 04/19/16 pending the facility's investigation related to Resident #1 and after the facility's investigation she was informed of the disciplinary action. On 04/23/16, the facility provided her a final written notice. Review of LPN #2's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/19/16 pending the facility's investigation and after the investigation, LPN #2 was given a disciplinary action of a final written notice on 04/23/16. 3. Interview with the Administrator on 05/09/16 at 10:10 AM, revealed the facility did perform audits on 04/29/16. The audit paperwork was reviewed and did show the auditing of accu-checks every shift to ensure all accu-checks had been completed; any sliding scale insulin that was required had been administered, and when any accu-check results were outside of the physician ordered parameters, or significant changes in condition, had a physician notification. 4. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed training was initiated on 04/29/16. Licensed staff was inserviced on omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident. The education was completed with licensed nurses on 05/02/16. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked a shift recently, had been notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. On 05/09/16, a copy of the letter sent to this PRN nurse was reviewed. Interviews on 05/09/16 with Registered Nurse (RN) #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN/UM #5 at 11:38 AM, revealed they received the inservice training in regards to omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition/ the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident needed to be documented on the Log. 5. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training regarding education about diabetes; the signs and symptoms of hypo/[MEDICAL CONDITION] ( low and high blood sugar); and, care of residents with diabetes, revealed the DON did initiate this training on 05/04/16 for all shifts for licensed nurses. All licensed nurses were educated prior to their next shift worked. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked recently. This nurse was notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. Interviews on 05/09/16 with RN #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN UM #5 at 11:38 AM, revealed they all stated they received the inservice training in regards to: education about diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. 6. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed the SRNAs were trained on the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. The DON did initiate the inservice on 05/04/16. Education was to be completed with all SRNAs prior to their next shift worked. Review of the facility's employee listing compared to the inservice sign in logs, revealed three (3) PRN SRNAs, who were PRN staff, who had not worked recently were not listed on the inservice sign in logs, but the facility had notified them by phone. The DON stated these three (3) SRNAs had not returned the facility's call, but they were on a list of being unable to work until the training had been completed. The DON further stated these three (3) SRNAs would also be notified by letter on 05/09/16. Interviews on 05/09/16 with SRNA #4 at 11:40 AM, SRNA #5 at 11:45 AM, SRNA #6 at 11:48 AM, SRNA #7 at 11:50 AM, SRNA #8 at 12:03 PM, and SRNA #9 at 12:07 PM, revealed they all stated they had received the training related to the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to report any of those signs and symptoms to a licensed nurse. 7. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16, the facility did perform a one-hundred (100) percent audit of residents with a [DIAGNOSES REDACTED]. The facility found no issues through their audits. The surveyor observed all completed audits. 8. Review of all MARS on 05/09/16 at 8:30 AM, revealed all residents who had accu-check orders had their diabetic MAR placed under a separate tab in the MARS and all diabetic residents had a copy of their diabetic care plan placed in front of their diabetic MAR. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16 the facility implemented, as a facility standard, all residents who had accu-check orders had their diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, a copy of all resident's with Diabetes had a copy of their diabetic care plan placed in front of their diabetic MAR and diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. Review of a new facility admission packet on 05/09/16 at 2:38 PM, revealed the admission packet had a diabetic care plan in place as part of the admission packet. 9. Interview with the Administrator on 05/09/16 at 10:10 AM, and review of the QA sign in log dated 05/04/16, revealed a QA meeting was held on 05/04/16 with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehab Program Manager, Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Medical Records (MR) Coordinator and the Medical Director (MD). Review of the QA log and information, revealed during the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three weeks then monthly for three (3) months. They would be monitoring for the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that was outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. Review of the Monitoring Sheets for 05/04/16 through 05/09/16, revealed the above monitoring was completed daily and turned into the Administrator.

Based on interview, record review, review of hospital records and review of the facility policy, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial wellbeing for one (1) of six (6) sampled residents (Resident #1). On 04/15/16 at 6:00 AM, Resident #1 had an elevated accu-check of four-hundred thirty-six (436) milligrams per deciliter (mg/dl) (normal 70 to 100 mg/dl) and an elevated accu-check on 04/17/16 at 6:00 AM of five-hundred seventeen (517) mg/dl. In addition, on 04/17/16 at 9:00 AM, Resident #1 was lethargic and unable to be aroused to take scheduled medication. The facility failed to assess the resident's accu-check results, consult the resident's physician, and to identify and assess for signs and symptoms of hypo/[MEDICAL CONDITION] (low or high blood sugar). Resident #1 was hospitalized for [REDACTED]. The facility's failure to provide the necessary care and services to a diabetic resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified, on 04/29/16 and determined to exist on 04/15/16. The facility was notified of the Immediate Jeopardy on 04/29/16. An acceptable Allegation of Compliance (AoC) was received on 05/05/16 alleging the removal of the Immediate Jeopardy on 05/05/16. The State Survey Agency validated, on 05/09/16, the Immediate Jeopardy was removed on 05/05/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy 'Notification Requirements', revised 05/22/12, revealed the facility should notify the resident's attending Physician and representative when a resident has had a significant change in physical, mental, or psychosocial status and when there is a need to alter resident's treatment significantly. Review of the facility's policy 'Comprehensive Care Plans', revised 04/13/13, revealed it is the facility's policy that residents will have a plan of care for assessed needs and care plan approaches will be communicated to staff for use in providing direction for care. Record review revealed the facility admitted Resident #1 on 03/17/16 with diagnoses, which included Diabetes Mellitus Type 2, [MEDICAL CONDITIONS] Disorder, Heart Failure, and Hypertension. Review of the Admission Minimum Data Set (MDS) Assessment, dated 03/23/16, revealed Resident #1 was unable to be assessed for a Brief Interview for Mental Status (BIMS) score due to impaired cognition. Review of Resident #1's Comprehensive Care Plan for Diabetes, dated 04/04/16, revealed staff should observe Resident #1 for any signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION], should notify the Physician PRN of any decline in health or with any significant changes and should conduct accu-checks, per Physician's orders. Review of Resident #1's April 2016 Physician's Orders revealed the resident had orders for accu-checks two (2) times per day, at 6:00 AM and 8:00 PM and to administer [MEDICATION NAME] (long-acting insulin) every morning and at bedtime. In addition, there was an order to obtain accu-checks as needed (PRN) for signs and symptoms of [DIAGNOSES REDACTED]/[MEDICAL CONDITION]. Review of Resident #1's April 2016 Medication Administration Record (MAR) revealed the resident's accu-check results for 04/15/16 at 6:00 AM was four-hundred thirty six (436) mg/dl, but the MAR was not initialed as the insulin having been given at 6:00 AM as ordered by Resident #1's Physician. Further review revealed the scheduled accu-check for 04/15/16 at 8:00 PM, and 04/16/16 at 6:00 AM and 8:00 PM were left blank on the MAR and the scheduled insulin for those times were also left blank with no licensed staff initials. Review of the 100 Hall's accu-check flowsheet revealed the accu-check completed on 04/17/16 at 6:00 AM was five-hundred seventeen (517) mg/dl. Review of the Nurses' Notes revealed there was no documented evidence the Physician was made aware of the resident's elevated blood sugars on 04/15/16 and 04/17/16. Interview with State Registered Nurse Aide (SRNA) #1 on 04/28/16 at 1:45 PM, revealed she informed Licensed Practical Nurse (LPN) #2 on 04/17/16 at breakfast time that Resident #1 was not acting like his/her normal self and was more sleepy acting than usual. LPN #2 went and checked Resident #1's vital signs. She stated when she went to check on the resident after breakfast she noticed Resident #1 was still sleepy acting and did not attempt to consume any of his/her breakfast and LPN #2 again checked on the resident. She revealed at approximately 1:30 PM, while checking on Resident #1 she noticed he/she was breathing very fast and his/her fingertips were bluish so she notified LPN #2 again. She stated LPN #2 and LPN #3 assessed Resident #1 and shortly after that Resident #1 was sent out to the emergency room (ER). However, review of the Nurses' Notes revealed there was no documented evidence of Resident #1's condition, that the resident was assessed for [MEDICAL CONDITION], or the Physician was notified until 04/17/16 at 1:45 PM. Review of the Nurses' Notes, revealed a Situation Background Assessment Recommendation (SBAR) Communication Form, dated 04/17/16 at 1:45 PM stating Resident #1 was unresponsive, had an increased pulse and respiration rate, and had purple tinged fingers and nail beds. Review of Resident #1's Physician's Orders, revealed an order dated 04/17/16 at 2:00 PM to send Resident #1 to the emergency room (ER) related to decreased responsiveness. Review of ER Records, revealed an ER Focus assessment dated [DATE] at 3:03 PM, which noted Resident #1 to have [MEDICAL CONDITION](elevated pulse rate) and shallow labored breathing. Further review revealed at 3:34 PM it was noted Resident #1's blood sugar at that time was six-hundred sixty (660) milligrams per deciliter (mg/dl). Review of the Intensive Care Unit (ICU) hospital's admission orders [REDACTED]. Review of ICU Insulin Drip Daily work Sheet dated 04/17/16 through 04/18/16, revealed Resident #1 received intravenous (IV) insulin starting at 7:00 PM on 04/17/16 through 7:00 AM on 04/18/16 to treat [MEDICAL CONDITION] (high blood sugar). Review of Resident #1's Physician's Hospital Progress Note dated 04/18/16 at 8:00 AM, revealed Resident #1 was still being assessed for Diabetic Ketoacidosis. Further review of the hospital records revealed Resident #1 was discharged from the hospital on [DATE]. Interview with LPN #1, on 04/28/16 at 3:45 PM, revealed she did not notify Resident #1's Physician of the accu-check results on 04/15/16 at 6:00 AM and on 04/17/16 at 6:00 AM. She stated she did no further assessment after performing the accu-checks and administering Resident #1's scheduled insulin. LPN #1 stated she left the facility prior to giving the oncoming day shift nurse a report on 04/17/16 because she forgot to do report. She also stated in hindsight she should have used better judgment and should have notified the Physician on 04/15/16 at 6:00 AM and on 04/17/16 at 6:00 AM. LPN #1 further stated she should have ensured that she gave the on-coming nurse shift report on 04/17/16 and if she had called the Physician after the initial increased accu-check on 04/15/16 at 6:00 AM, Resident #1 may not have gotten as sick as he/she did when he/she had to be sent out to theER on [DATE]. Interview with LPN #2, on 04/29/16 at 11:03 AM, revealed she was the day shift nurse who was responsible for Resident #1 on 04/17/16. She stated she was not given report for her section that day by the off-going night shift nurse. LPN #2 stated she did not report this to management at that time or attempt to ask for a report from another nurse who may have been familiar with her assigned section. She also stated she was not familiar with Resident #1 and had never cared for Resident #1 prior to 04/17/16. LPN #2 stated she was informed at breakfast time by SRNA #1 that Resident #1 did not seem like his/her normal self so went and checked on the resident. She stated she noted that Resident #1 was very sleepy acting but his/her vital signs were ok, so no further assessment or action was taken by her at that time. LPN #1 stated at approximately 9:00 AM on 04/17/16, she took Resident #1 his/her scheduled medications but was unable to wake the resident up enough to get him/her to take his/her medication. She stated she withheld Resident #1's medication and did not further assess Resident #1 or call the resident's Physician related to his/her lethargy and withholding the scheduled medication. She stated at approximately 1:30 PM on 04/17/16, SRNA #1 notified her Resident #1 had decreased oxygen levels, rapid respirations and bluish colored fingertips. LPN #1 stated she was not aware Resident #1 was a diabetic until she started looking at his/her chart after she observed the resident was unresponsive at 1:30 PM. During further interview with LPN #1, she stated she performed two (2) accu-checks on Resident #1 after learning he/she was diabetic and both results read 'High' which meant it was higher then what the facility's accu-check machine would read. She stated Resident #1's Advanced Practice Registered Nurse (APRN) was notified of the resident's unresponsiveness and overall condition and orders were given for Resident #1 to be sent to the ER for evaluation due to being unresponsive. LPN #1 further stated she should have used better judgment and notified the Physician and assessed Resident #1 better after she could not arouse the resident to take his/her scheduled medications at 9:00 AM on 04/17/16. She stated that if she would have notified the Physician after she was unable to arouse Resident #1 it may have prevented the resident from getting to the point he/she needed to be sent out to the ER. Interview with the Director of Nursing (DON) on 04/28/16 at 3:35 PM, revealed she would have expected LPN #1 to notify the Physician for Resident #1 after the Finger Stick Blood Sugar (FSBS) results on 04/15/16 at 06:00 AM with a result of four-hundred thirty six (436) mg/dl and also on 04/17/16 at 06:00 AM with the result of five-hundred seventeen (517) mg/dl. The DON stated she would have expected LPN #2 to have assessed Resident #1 further after she was unable to arouse the resident and notify the Physician of the resident's change in condition. She further stated she would expect licensed staff to notify the Physician anytime a resident had a change in condition. The DON stated she would expect licensed staff to ensure report was given and received by ongoing and oncoming shifts. Interview with Resident #1's Physician on 04/28/16 at 2:40 PM, revealed he would have expected to have been notified on 04/15/16 when Resident #1's FSBS results four-hundred thirty six (436) mg/dl and also on 04/17/16 when Resident #1's 6:00 AM FSBS results was five-hundred seventeen (517) mg/dl. He stated he expected to have been notified on 04/17/16 when staff found Resident #1 at breakfast; and, when staff found Resident #1 at 9:00 AM during the medication pass when the resident was noted to have increased lethargy and he/she was not able to be aroused. Interview with the Regional Nurse on 04/28/16 at 3:30 PM, revealed the facility did not have a policy or a procedure guiding staff when they should contact the Physician for elevated FSBS results. She stated she expected staff to notify a Physician with any FSBS results below 60 mg/dl and any results above 400 mg/dl if a particular resident did not have any parameters in place. Interview with the Administrator on 04/29/16 at 8:40 AM, revealed she expected staff to follow facility policies. She stated she would have expected LPN #1 to have notified Resident #1's Physician after the elevated FSBS results on 04/15/16 and on 04/17/16. She also stated she would have expected LPN #2 to have further assessed Resident #1 and notified Resident #1's Physician after staff had reported to LPN #2 that Resident #1 was not acting like his/her normal self and when LPN #2 was unable to awake Resident #1 to administer his/her scheduled medications. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. LPN #1 was suspended and taken off the schedule on 04/18/16 pending the facility's investigation. LPN #1 was terminated by the facility on 04/26/16. 2. LPN #2 was suspended and taken off the schedule on 04/19/16 pending the facility's investigation; and, after the facility's investigation, LPN #2 was given a disciplinary action of a Final Written Performance Correction on 04/23/16. 3. On 04/29/16, the facility began auditing accu-checks every shift to ensure all accu-checks had been completed, any sliding scale insulin that was required had been administered, and any accu-check results outside the Physician's ordered parameters or significant changes in condition had a Physician notification. 4. On 04/29/16, education for all shifts was initiated by the DON with licensed nurses regarding omissions on the Medication Administration Records (MARS); notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of Twenty-four (24) Hour Report Logs regarding the need to have documentation on the logs related to any significant changes in a resident's condition; and that any new orders for a resident needed to be documented on the log. Education was completed with licensed nurses on 05/02/16. 5. On 05/04/16, education for all shifts was initiated by the DON with licensed nurses regarding diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. All licensed nurses will be educated before their next shift worked and any licensed staff who was on leave of absence, or who works as needed (PRN) will be educated prior to returning to work. 6. On 05/04/16, education for all shifts was initiated by the DON with Nurse Aides regarding the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. Education to be completed with all Nurse Aides prior to their next shift worked. 7. On 04/30/16, the facility did a one-hundred (100%) percent audit of residents with [DIAGNOSES REDACTED]. The facility found no issues through their audits. 8. On 04/30/16, the facility implemented a system for all residents with accu-check orders to have his/her diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, all residents with Diabetes had a copy of their Diabetic care plan placed in front of their diabetic MAR; and, Diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. 9. A Quality Assurance (QA) Meeting was held on 05/04/16, with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehabilitation (Rehab) Program Manager and Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Payroll Director, Medical Records (MR) Coordinator and the Medical Director (MD). During the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three (3) weeks then monthly for three (3) months: the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that is outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with LPN #1 on 04/28/16 at 3:45 PM, revealed the facility had informed her of the suspension starting on 04/18/16, pending the facility's investigation related to Resident #1 and after the facility's investigation the facility informed her of the job termination on 04/26/16. Review of LPN #1's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/18/16 pending the investigation and after the investigation LPN #1 was terminated on 04/26/16. 2. Interview with LPN #2 on 04/29/16 at 11:03 AM, revealed the facility had informed her of the suspension starting on 04/19/16 pending the facility's investigation related to Resident #1 and after the facility's investigation she was informed of the disciplinary action. On 04/23/16, the facility provided her a final written notice. Review of LPN #2's personnel record, on 04/29/16 revealed she was suspended and taken off the schedule on 04/19/16 pending the facility's investigation and after the investigation, LPN #2 was given a disciplinary action of a final written notice on 04/23/16. 3. Interview with the Administrator on 05/09/16 at 10:10 AM, revealed the facility did perform audits on 04/29/16. The audit paperwork was reviewed and did show the auditing of accu-checks every shift to ensure all accu-checks had been completed; any sliding scale insulin that was required had been administered, and when any accu-check results were outside of the physician ordered parameters, or significant changes in condition, had a physician notification. 4. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed training was initiated on 04/29/16. Licensed staff was inserviced on omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition; the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident. The education was completed with licensed nurses on 05/02/16. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked a shift recently, had been notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. On 05/09/16, a copy of the letter sent to this PRN nurse was reviewed. Interviews on 05/09/16 with Registered Nurse (RN) #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN/UM #5 at 11:38 AM, revealed they received the inservice training in regards to omissions on the MARS; notification of the Physician when blood sugars were outside of the ordered parameters; when to notify the Physician of a resident's change in condition/ the use of the Twenty-four (24) Hour Report Logs regarding the need to have documentation on the Logs related to any significant changes in a resident's condition and any new orders for a resident needed to be documented on the Log. 5. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training regarding education about diabetes; the signs and symptoms of hypo/[MEDICAL CONDITION] ( low and high blood sugar); and, care of residents with diabetes, revealed the DON did initiate this training on 05/04/16 for all shifts for licensed nurses. All licensed nurses were educated prior to their next shift worked. Review of the employee listing compared to the inservice sign in sheets, revealed all licensed nurses participated in the education except one as needed (PRN) nurse, who had not worked recently. This nurse was notified by letter explaining he/she would need the inservice training prior to working a shift. The facility had not had a response from this PRN nurse. Interviews on 05/09/16 with RN #1 at 8:40 AM, RN #2 at 11:35 AM, LPN #3 at 8:48 AM, LPN #5 at 11:32 AM and LPN UM #5 at 11:38 AM, revealed they all stated they received the inservice training in regards to: education about diabetes and the signs and symptoms of hypo/[MEDICAL CONDITION] (low and high blood sugar) and care of residents with diabetes. 6. Interview with the DON on 05/09/16 at 1:45 PM, and review of the inservice education and sign in sheets for training revealed the SRNAs were trained on the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to notify the Licensed Nurse if a resident was observed with signs and symptoms of hypo/[MEDICAL CONDITION]. The DON did initiate the inservice on 05/04/16. Education was to be completed with all SRNAs prior to their next shift worked. Review of the facility's employee listing compared to the inservice sign in logs, revealed three (3) PRN SRNAs, who were PRN staff, who had not worked recently were not listed on the inservice sign in logs, but the facility had notified them by phone. The DON stated these three (3) SRNAs had not returned the facility's call, but they were on a list of being unable to work until the training had been completed. The DON further stated these three (3) SRNAs would also be notified by letter on 05/09/16. Interviews on 05/09/16 with SRNA #4 at 11:40 AM, SRNA #5 at 11:45 AM, SRNA #6 at 11:48 AM, SRNA #7 at 11:50 AM, SRNA #8 at 12:03 PM, and SRNA #9 at 12:07 PM, revealed they all stated they had received the training related to the signs and symptoms of hypo/[MEDICAL CONDITION] and the need to report any of those signs and symptoms to a licensed nurse. 7. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16, the facility did perform a one-hundred (100) percent audit of residents with a [DIAGNOSES REDACTED]. The facility found no issues through their audits. The surveyor observed all completed audits. 8. Review of all MARS on 05/09/16 at 8:30 AM, revealed all residents who had accu-check orders had their diabetic MAR placed under a separate tab in the MARS and all diabetic residents had a copy of their diabetic care plan placed in front of their diabetic MAR. Interview with the Administrator on 05/09/16 at 10:10 AM revealed, on 04/30/16 the facility implemented, as a facility standard, all residents who had accu-check orders had their diabetic MARS placed under a separate tab in the MARS, accu-check logs were discontinued by the facility, a copy of all resident's with Diabetes had a copy of their diabetic care plan placed in front of their diabetic MAR and diabetic care plans were added to the facility's admission packets to ensure these care plans were put in place immediately upon admission of a diabetic resident. Review of a new facility admission packet on 05/09/16 at 2:38 PM, revealed the admission packet had a diabetic care plan in place as part of the admission packet. 9. Interview with the Administrator on 05/09/16 at 10:10 AM, and review of the QA sign in log dated 05/04/16, revealed a QA meeting was held on 05/04/16 with the following staff: Administrator, Director of Nursing (DON), Unit Manager (UM), Rehab Program Manager, Minimum Data Set (MDS) Coordinators, Social Services Director (SSD), Admissions Coordinator, Dietary Manager (DM), Medical Records (MR) Coordinator and the Medical Director (MD). Review of the QA log and information, revealed during the QA meeting the facility implemented a plan that the Administrator, DON, UM, Rehab Program Manager and MDS Coordinators would monitor daily times twenty-one (21) days, then three (3) times a week for three (3) weeks, then one (1) time for three (3) weeks, then every other week for three weeks then monthly for three (3) months. They would be monitoring for the effectiveness and on-going compliance of their Allegation of Compliance (AoC) regarding ensuring all newly admitted residents who have orders for accu-checks have orders for parameters for blood sugars; ensuring any accu-check that was outside the ordered parameters have been reported to the physician; ensure any accu-check requiring sliding scale insulin coverage has had their insulin administered; ensure any diabetic resident who has had a significant change in condition had a physician notification; ensure any new admission with the [DIAGNOSES REDACTED]. The DON will bring the results of the monitoring and the findings to the monthly QA meeting monthly for six (6) months. Review of the Monitoring Sheets for 05/04/16 through 05/09/16, revealed the above monitoring was completed daily and turned into the Administrator.

Based on observation, interview, record review, review of the facility's policy and procedures and hospital records it was determined the facility failed to provide care according to the resident's written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].#1 included interventions to administer pain medication as ordered by the physician; notify the physician if the medications were ineffective; assess Resident #1's level of pain and provide comfort measures such as positioning, music and massage; and, to administer "Biofreeze" topically to the resident's back as needed for back pain. Resident #1 began having increased pain on 02/04/15 and complained of pain for fifteen (15) days; however, there was no documented evidence the facility monitored the resident's pain or implemented the interventions from the Comprehensive Care Plan. On 02/18/15, Resident #1 had a Computed Tomography (CT) and it was discovered he/she had a L-1 burst fracture (fracture of lower spine) and was transferred to the hospital on [DATE] and diagnosed with [REDACTED]. Resident #1 was transferred back to the facility for palliative care and a consult for Hospice. The findings include: Review of the facility's policy and procedure titled, "Comprehensive Care Plans" last revised 04/03/13, revealed it was the facility's policy that each resident had a plan of care for assessed needs. Additional review revealed a care plan would be developed based on the resident's assessed needs. Care plan approaches will be communicate to staff for the use in providing direction for care. The plan of care would be reviewed and revised when indicated and based on the resident's response. Review of the facility's policy and procedure titled, "Pain Management", last revised 12/19/13, revealed the facility should manage a resident's pain in a manner that allowed the resident to attain or maintain their highest practicable level of physical, mental and psychosocial well-being. Further review revealed the residents would be evaluated for the presence of pain and the potential impact of pain on their activities of daily living. Based on the evaluation, the resident would receive an individualize pain management plan. Additional review revealed non-pharmacological interventions would be utilized as appropriate or per the resident's preference to address the factors influencing pain and as an intervention to alleviate the pain. Additionally, medication would be administered based on the evaluated level of pain and the effectiveness of the interventions implemented to manage the resident's pain. The resident's pain medication would be adjusted according to the resident's response. Record review revealed the facility admitted Resident #1 on 09/17/14, with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment, dated 09/24/14, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) indicating the resident was not interviewable. Further review revealed the facility had assessed Resident #1's pain presence as occurring occasionally and not interfering with sleep or activities. Review of a Comprehensive Care Plan, dated 10/01/14, revealed the facility assessed Resident #1 to have pain related to a surgical incision and he/she had a history of [REDACTED].#1's level of pain and provide comfort measures such as positioning, music and massage, encourage the resident to report pain before it became unbearable; and to administer "Biofreeze" (gel pain medication) topically to the resident's back as needed for pain. Review of a physician's orders [REDACTED]. [REDACTED]. Review of a Nurse's Note, dated 02/04/15 at 6:00 PM, (one (1) hour after the scheduled pain medication [MEDICATION NAME] was administered) revealed Resident #1 was crying and stating over and over, "My back hurts". Further review revealed Resident #1 was informed his/her pain medication had been administered and it needed time to take effect. The nurse documented Resident #1 was asked if he/she would like to lie down in bed and informed the resident that sitting in the wheel chair for long periods of time would make his/her back hurt. Further review of the Nurse's Notes revealed the resident stated he/she did not want to go to bed and then began repeating, "My leg hurts, my back is killing me, I didn't sleep good last night". The nurse reminded the resident again when his/her last pain medication was given and the resident was satisfied for a while; however, he/she began crying and whimpering again. The nurse documented she observed the resident cursing to his/her baby doll in the hallway over and over. Further review of the Nurse's Notes revealed no documented evidence that the Biofreeze was applied to alleviate the resident's pain. Review of the resident's February 2015 Medication Administration Record [REDACTED]. In addition, further review of the record revealed no documented evidence the facility provided comfort measures, or notified the physician of the resident's continued pain after his/her pain medication was administered. Review of Nurse's Notes, dated 02/06/15 at 1:00 PM, 02/07/15 at 5:00 PM and 02/08/15 at 1:00 PM revealed Resident #1 was noted to be crying and complaining of back pain; and, on 02/09/15 at 10:15 AM, he/she complained of headache and back pain. Further review of the Nurse's Note, dated 02/07/15 revealed the "as needed" Biofreeze was applied at that time and Resident #1 was repositioned with a pillow placed behind his/her back. However, there was no documented evidence the Biofreeze was effective. In addition, review of the Nurse's Notes, dated 02/06/15 and 02/08/15, revealed the facility was unable to locate the page of the February 2015 MAR indicated [REDACTED]. There was no documented evidence the physician was notified if the medications were ineffective, the resident's level of pain was assessed, or comfort measures such as positioning, music and massage were offered, per the care plan. Review of a Nurse's Note, dated 02/10/15 at 3:15 PM, (two (2) hours and fifteen (15) minutes after the scheduled pain medication was administered), revealed Resident #1 began to refuse care and refused to get out of bed to socialize. It was documented Resident #1 was noted to have behaviors of scratching and rubbing his/her legs which caused bleeding. The resident was noted to be grinding his/her teeth, crying, and pulling his/her own hair out. Further review of the Nurse's Note, revealed Resident #1 had received the scheduled pain medication as ordered by the physician at 1:00 PM; however, there was no documented evidence to show if the Biofreeze was applied. Further record review revealed there was no documented evidence of ongoing monitoring to ensure the effectiveness of the medication and that comfort measures were provided, as per plan of care. Review of a Nurse's Note, dated 02/11/15 at 11:00 AM, revealed the resident was noted with repeated episodes of calling out that his/her legs hurt. The resident propelled himself/herself up and down the hallway in his/her wheelchair grinding his/her teeth together and making crying sounds. Review of a Nurse's Note, dated 02/11/15 at 6:00 PM, revealed Resident #1 continued to state his/her back hurt. The Advanced Practice Registered Nurse was notified and a new order was received to send the resident to the hospital; however, the resident refused and the physician was made aware with no new orders received. Review of a physician's orders [REDACTED]. Review of a Nurse's Note, dated 02/14/15 at 6:40 PM, revealed Resident #1 refused to get out of bed and was curled up in a fetal position with the bed covers pulled up to his/her chin and refused to allow wound care. Resident #1 stated, "No, it hurts". Further review of the Nurse's Note revealed the "as needed" [MEDICATION NAME] was administered. However, there was no documented evidence Resident #1's level of pain and effectiveness of the medication was assessed, or that comfort measures such as positioning, music and massage were offered according to the care plan. Review of a Nurse's Note, dated 02/15/15 at 12:00 PM, revealed Resident #1 was up in his/her wheelchair crying and gnashing his/her teeth. Resident #1 was noted scratching at self and smeared blood along the hallway and the hand rails. In addition, Resident #1 screamed and used profanity. Resident #1 was taken to his/her room where his/her clothes and wound dressing were changed. Review of the February 2015 MAR indicated [REDACTED]. In addition, there was no documented evidence comfort measures were provided. Review of a Nurse's Note, dated 02/15/15 at 6:30 PM, revealed Resident #1 placed him/her self on the floor in the hallway and stated he/she was hurting. There was no documented evidence in the Nurse's Note or on the February 2015 MAR indicated [REDACTED]. Further review of the record revealed there was no documented evidence of continued monitoring to ensure the effectiveness of the resident's medication management and degree of pain relief, as stated in the resident's care plan. Review of a Nurse's Note, dated 02/18/15 at 9:00 AM, revealed repeated episodes of crying out that the resident's back hurt and Resident #1 was noted making crying sounds and grinding his/her teeth. Review of the February 2015 MAR, revealed the PRN [MEDICATION NAME] was administered on 02/18/15 at 2:30 PM; however the facility was unable to provide documented evidence the as needed Biofreeze had been administered or the facility monitored the effectiveness of the medication. Review of a physician's orders [REDACTED]. Review of the CT Scan Report, dated 02/19/15, revealed Resident #1 had a L-1 burst fracture (traumatic spinal injury in which a vertebra breaks from a high-energy axial load such as a car accident or fall from a great height) with significant subluxation (when one or more of the bones of spine move out of position and create pressure on or irritate spinal nerves). Review of a physician's orders [REDACTED]. Review of a physician's orders [REDACTED].#1 to local hospital. Review of a Hospital Discharge Summary dated 02/26/15, revealed Resident #1 was transferred to another hospital and diagnosed with [REDACTED]. Further review revealed Resident #1 would be transferred back to the facility with new orders for palliative care and a consult for Hospice. Interview with Wound Care Nurse, Licensed Practical Nurse (LPN #1) on 04/02/15 at 3:25 PM, revealed Resident #1 has chronic pain due to [MEDICAL CONDITION]. She further stated Resident #1's pain has gotten worse and the resident had become less active. She stated she was not usually Resident #1's primary nurse, but did see the resident when she provided his/her wound care treatments. Interview with Registered Nurse #1 (who documented the Nurse's Notes dated 02/05/15, 02/06/15, 02/07/15, and 02/08/15), on 04/08/15 at 11:50 AM, revealed Resident #1 had uncontrolled pain. She stated she did not apply the Biofreeze that was ordered as needed because the resident stated it did not help. She stated Resident #1 received a scheduled pain medication; however, it got to where it would not hold the resident over until time for the next dose was due. She stated she had provided back massages and repositioning which did relieve pain sometimes. Interview with Floor Nurse, LPN #2, on 04/06/15 at 8:30 AM, revealed Resident #1's pain had become worse since he/she was admitted to the facility. She further stated she would offer to reposition Resident #1; however, she did not recall offering music or massage to the resident per the care plan. Interview with Floor Nurse, LPN #3 on 04/16/15 at 11:20 AM, revealed Resident #1 had frequent complaints with back pain and had issues with back pain since admission. She stated the back pain got worse in February this year (2015). She stated she would administered the scheduled pain medication and offer to reposition Resident #1 and prop him/her up with pillows per the care plan. Interview with the Director of Nursing (DON), on 04/08/15 at 5:25 PM, revealed she expected the staff to follow the care plan. Interview with the Advance Practice Nurse Practitioner (APRN), on 04/08/15 at 9:48 AM, revealed the facility staff reported to her on occasions that Resident #1 continued to have pain. She stated she was hesitant to continue to increase the pain medication and stated she felt that it was important to identify the underlying cause of the continued pain and not just increase the medication. She further stated she was not aware Resident #1's pain was severe and uncontrolled; she stated she should have been notified. The APRN stated she expected the staff to continue to monitor for the effectiveness of the pain medication and to have provided comfort measures per the resident's Comprehensive Care Plan.

Based on observation, interview, record review and review of the facility's policy and procedures it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) sampled residents (Resident #1) related to pain management. The facility admitted Resident #1 on 09/17/14 with the [DIAGNOSES REDACTED].#1 began having increased pain on 02/04/15 and complained of pain for fifteen (15) days. However, there was no documented evidence the facility monitored the resident's pain or implemented the interventions from the residents' Comprehensive Care Plan. On 02/18/15, Resident #1 had a Computed Tomograpy (CT) and it was discovered he/she had a L-1 burst fracture (fracture of lower spine) and was transferred to the hospital on [DATE]. The findings include: Review of the facility's policy and procedure titled, "Pain Management", last revised 12/19/13, revealed the facility should manage a resident's pain in a manner that allowed the resident to attain or maintain their highest practicable level of physical, mental and psychosocial well-being. Further review revealed the residents would be evaluated for the presence of pain and the potential impact of pain on their activities of daily living. Further review revealed based on the evaluation, the resident would receive an individualize pain management plan. Additional review revealed non-pharmacological interventions would be utilized as appropriate or per resident's preference to address the factors influencing pain and as an intervention to alleviate the pain. Additionally, medication would be administered based on evaluated level of pain and the effectiveness of the interventions implemented to manage the resident's pain would be observed and adjusted according to the resident's response. Review of the facility's policy and procedure titled, "Comprehensive Care Plans" last revised 04/03/13, revealed it was the facility's policy that each resident had a plan of care for assessed needs. Additional review revealed a care plan would be developed based on the resident's assessed needs. Care plan approaches will be communicate to staff for the use in providing direction for care. The plan of care would be reviewed and revised when indicated and based on the resident's response. Record review revealed the facility admitted Resident #1 on 09/17/14, with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment, dated 09/24/14, revealed the facility assessed the cognition of Resident #1 as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Further review revealed the facility assessed that Resident#1's pain interfered with his/her sleep and occurred occasionally. Review of a Comprehensive Care Plan, dated 10/01/14, revealed Resident #1 was assessed to have pain related to a surgical incision and a history of complaints of pain. The interventions the facility had put in place included to administer medications as ordered by the physician and to notify the physician if the medications were ineffective. Additionally, the staff was to assess Resident #1's level of pain, provide comfort measures such as positioning, music and massage, encourage the resident to report pain before it became unbearable and administer "Biofreeze" (gel pain med) topically to the resident's back as needed for back pain. Review of a physician's orders [REDACTED].{Tylenol} 7.5/325 milligrams (mg), one (1) tablet, three (3) times a day (TID) at 9:00 AM, 1:00 PM and 5:00 PM; and on 01/28/15, an order to administer [MEDICATION NAME] (pain medication) 500 mg two (2) times daily (BID) for back pain. Review of a Nurse's Note, dated 02/04/15 at 6:00 PM, (one (1) hour after the scheduled pain medication was administered) revealed Resident #1 was crying and stating over and over, "My back hurts". Further documentation revealed Resident #1 was informed his/her pain medication had been administered and it needed time to take effect. The nurse documented Resident #1 was asked if she would like to lie down in bed and Registered Nurse (RN) #1 stated to the resident, "Sitting in the wheel chair for long periods of time would make your back hurt". The resident stated he/she did not want to go to bed and then began repeating "My leg hurts, my back is killing me, I didn't sleep good last night". The resident was again reminded about when his/her pain meds were given, and was satisfied for a while; however, he/she began crying and whimpering again. The resident was then observed cursing to his/her baby doll in hallway over and over. There was no documented evidence the facility assessed Resident #1's level of pain, provided comfort measures such as positioning, music and massage, or administered Biofreeze topically to back as needed for back pain. Review of a facility's "Pain Analysis", dated 02/06/15, revealed Resident #1's pain was assessed with [REDACTED]. Further review revealed the resident had decreased socialization and episodes of crying. Review of the February 2015 Medication Administration Record [REDACTED]. Review of Nurse's Notes, dated 02/06/15 at 1:00 PM, 02/07/15 at 5:00 PM, 02/08/15 at 1:00 PM, and 02/09/15 at 10:15 AM, revealed Resident #1 was noted to be crying and complaining of back pain. Further review of the Nurse's Note revealed no documented evidence the facility assessed Resident #1's level of pain and the effectiveness of the pain medication, or provided comfort measures such as positioning, music and massage, and administered Biofreeze topically to the resident's back as needed for pain. Interview with the MDS Coordinator, RN #2 on 04/08/15 at 8:35 AM, revealed she completed a Significant Change MDS assessment on Resident #1 related to his/her decline. She stated Resident #1 had increased back pain and just started to go down hill. She stated, "it was so sad to see him/her crumble". She revealed she completed the ancillary pain assessment on Resident #1 but did not notify the physician because she expected the resident's nurse to notify the physician. Review of a Nurse's Note, dated 02/10/15 at 3:15 PM, and on 02/11/15 at 11:00 AM and 6:00 PM revealed Resident #1 began to refuse care and refused to get out of bed to socialize. Resident #1 was noted to have behaviors of scratching and rubbing his/her legs which caused bleeding; grinding his/her teeth, crying, and pulling his/her own hair out. The physician was notified and discontinued the [MEDICATION NAME] 25 mg and [MEDICATION NAME] sprinkles; and added [MEDICATION NAME] 0.5 mg, and [MEDICATION NAME] 20 mg daily. In addition, an order was received to send resident to the hospital, however the resident refused. Review of a facility's "Pain Analysis", dated 02/13/15, revealed Resident #1 was assessed by the facility to have pain on the Numeric Pain Scale of nine (9) out of ten (10) and described as throbbing and the frequency and duration was constant and behaviors of rocking back and forth. Review of a physician's orders [REDACTED]. Interview with Wound Care Nurse, Licensed Practical Nurse (LPN #1) on 04/02/15 at 3:25 PM, revealed Resident #1 has chronic pain due to [MEDICAL CONDITION]. She further stated Resident #1's pain had gotten worse and she became less active. She stated she was not usually Resident #1's primary nurse but she did see her when she did her wound care treatments. LPN #1 stated she did complete the facility's "Pain Analysis" on 02/13/15 and stated this was done due to the increase in Resident #1's pain medication. LPN #1 stated Resident #1 was not able to comprehend the numerical value of a number related to rating the level of his/her pain. She further stated Resident #1 would look away if asked to rate his/her pain on the Faces Pain Scale. She stated Resident #1 would state it hurts real bad and that meant a nine (9) or a (ten) 10. Review of a Nurse's Notes, dated 02/14/15 at 6:40 PM, 02/15/15 at 12:00 noon and 6:30 PM, and on 02/18/15 at 9:00 AM revealed Resident #1 refused to get out of bed and curled up in a fetal position with the bed covers pulled up to his/her chin and refused to allow wound care stating "No, it hurts"; was up in his/her wheelchair crying and gnashing his/her teeth, scratching at self and smearing blood along the hallway and the hand rails; began to scream and use profanity and loosing hair due to pulling it out. Further review revealed there was no documented evidence of continued monitoring to ensure the effectiveness of pain medication was monitored and the degree of pain relief. In addition, there was no documented evidence comfort measures were provided such as music or massage, as per plan of care. Review of a physician's orders [REDACTED]. Review of the CT Scan Report, dated 02/19/15, revealed Resident #1 had a L-1 burst fracture (traumatic spinal injury in which a vertebra breaks from a high-energy axial load such as a car accident or fall from a great height) with significant subluxcation (when one or more of the bones of spine move out of position and create pressure on or irritate spinal nerves). Review of a physician's orders [REDACTED].#1 to Jennie Stewart Medical Center on 0/20/15. Interview with Registered Nurse (RN) #1, on 04/08/15 at 11:50 AM revealed she documented the Nurse's Notes on 02/05/15, 02/06/15, 02/07/15, and 02/08/15. RN #1 stated Resident #1 had uncontrolled pain. RN #1 revealed she did not apply the Biofreeze as ordered because the resident stated it did not help. She stated Resident #1 received a scheduled pain medication; however, it got to where it would not hold the resident over until time for the next dose was due. She stated she had provided back massages and repositioning which did relieve pain sometimes. She stated she was unsure if the resident had uncontrolled pain or increase in behaviors. Interview with Floor Nurse, LPN #2, on 04/06/15 at 8:30 AM, revealed Resident #1's pain had worsened since he/she was admitted to the facility. She further stated she would offer to reposition Resident #1, however did not recall offering music or massage to the him/her. She further stated Resident #1 received scheduled pain medication and she would only document an assessment if the medication administered was an as needed medication and if it was scheduled she would just sign it out on the MAR. Interview with Floor Nurse, LPN #3, on 04/16/15 at 11:20 AM, revealed Resident #1 had frequent complaints with back pain and had issues with back pain since admission. She stated the back pain got worse in February this year. She stated she would administered the scheduled pain medication and offer to reposition Resident #1 and prop him/her up with pillows. Interview with the Director of Nursing (DON), on 04/08/15 at 5:25 PM, revealed she expected the staff to follow the care plan. She further stated she expected the staff to complete the facility's Pain Analysis form or the Pain Analysis for for the Non-Communicative Resident when a Resident experienced a change in his/her pain level. Interview with the Licensed Counciling Psychologist, on 04/08/15 at 9:34 AM, revealed she received a referral for Resident #1 for a Psychiatric Consultation due to Resident #1's increased behaviors. She stated Resident #1 was having increased pain and that could have been the cause of the increased behaviors. She further stated she had seen Resident #1 in the past and stated she had been more outgoing before; however, now she felt the resident was more withdrawn. Interview with the Advance Practice Nurse Practitioner, on 04/08/15 at 9:48 AM, revealed facility staff reported to her on occasions that Resident #1 continued to have pain. She stated she was hesitant to continue to increase the pain medication and stated she thought it could possibly be related to psychiatric issues. She stated she felt that it was important to identify the underlying cause of the continued pain and not just increase the medication. She further stated she was not aware Resident #1's pain was severe and uncontrolled and stated she should have been notified. She stated she expected the staff to continue to monitor for the effectiveness of the pain medication and to have provided comfort measures per the Comprehensive Care Plan. Interview with the Physician, on 04/08/15 at 2:23 PM, revealed he was made aware of Resident #1's increased pain; however, he stated he could not recall the exact dates and times. He further stated he had changed the pain medication in the past; however he stated he wanted to identify the underlying cause of the continued pain.