Every finding on record at Broadview Health and Rehabilitation Center

Based on record review and interviews, the facility failed to honor resident choices for one (#2) of three residents reviewed for self-determination out of five sample residents. Specifically, the facility failed to provide bathing for Resident #2 per her preference. Findings include: I. Facility policy and procedure The Promoting/Maintaining Resident Self-Determination policy, undated, was provided by the nursing home administrator (NHA) on 2/24/25 at 4:16 p.m. It read in pertinent part, It is the practice of this facility to protect and promote resident rights by facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. All staff members involved in providing care to residents will promote and facilitate resident self-determination. It is the residents' right to determine what, if anything, they would prefer to do or not to do each day in accordance with physician orders and resident's abilities. Each resident has the right to choose their schedules (including sleeping, eating, bathing and waking times), consistent with their interests, assessments, and plans of care. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. The Resident Showers policy, undated, was provided by the NHA on 2/24/25 at 3:14 p.m. It read in pertinent part, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy. The CNA (certified nurse aide) will assess the skin for any changes while performing bathing and inform the nurse of any changes. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included enterocolitis due to clostridium difficile-recurrent (inflammation of the intestines and infection of the colon), heart failure, chronic obstructive pulmonary disease (progressive lung disease) and type 2 diabetes mellitus. The 2/10/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision or touching assistance with showers, sit to stand and chair to chair transfers. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interview Resident #2 was interviewed on 2/24/25 at 1:25 p.m. Resident #2 said she had been missing a lot of her showers/bathing. Resident #2 said the hospice staff never forgot to give her showers and gave her one every Wednesday. Resident #2 said however the CNAs at the facility had not given her regular showers and it made her feel like the staff did not care about her. Resident #2 said it made her mad that the facility staff tried to offer her a shower one time at midnight and that woke her up. Resident #2 said a shower at 9:00 p.m. would be nice and help her to relax before bedtime. Resident #2 said the facility had not provided her a shower the whole month of February 2025. Resident #2 said she felt better and cleaner when she got a shower. Resident #2 said she felt dirty when she did not get regular showers. She said she wanted regular and consistent showers. Resident #2 said she was not used to not having regular showers. She said when she lived at home she could have a shower every day if she wanted and was tired of being treated like this. Resident #2 said having a shower twice a week would be the minimum for her. C. Record review A review of Resident #2's activity of daily living (ADL) care plan, initiated 9/2/24, did not address the resident's specific shower/bathing preferences or needs. The hospice care plan, initiated 10/25/24, did not reveal the plan for shower/bathing assistance. Resident #2's bathing shower task records were reviewed from 1/1/25 to 2/24/25. The records revealed the resident preferred to receive a shower twice per week on Wednesday and Saturday in the morning. The bathing task records further revealed the following: According to review of Resident #2's bathing task records from 1/1/25 to 1/31/25, the resident received a shower on 1/8/25, 1/11/25, 1/15/25 and 1/29/25. The resident received a sponge bath on 1/22/25. The hospice records revealed Resident #2 received a tub bath on 1/8/25, 1/15/25, 1/22/25 and 1/29/25. -The resident received a total of five showers/baths out of nine opportunities. According to review of Resident #2's bathing task records from 2/1/25 to 2/24/25, the resident received no showers from the facility. The resident received one full body bath on 2/12/25. The hospice records revealed Resident #2 received a tub bath 2/5/25, 2/12/25 and 2/19/25. -The resident received a total of three baths out of seven opportunities. III. Staff interviews The director of nursing (DON) was interviewed on 2/24/25 at 11:10 a.m. The DON said she had worked at the facility for three years. The DON said the staff development coordinator had held a recent CNA training, on 2/11/25, regarding completing shower documentation in the EMR. The DON said the CNAs were trained to document completed showers under the shower task in the electronic medical record (EMR). The DON said the CNAs should document the type of shower and it should always be documented in the EMR. The DON said the facilities had a bath sheet at the nurse's station that indicated the showers schedule. The DON said the units were divided into two nurse managers and they should be auditing if the showers were completed. The DON said she also got an EMR dashboard alert if showers were not taken. The NHA and the clinical resource (CR) were interviewed on 2/24/25 at 2:07 p.m. The NHA reviewed the shower documentation and said it looked like there could have been a documentation issue by the CNAs because she thought the residents were getting their showers by looking at the bath sheets. The NHA said the bath sheets were not part of the resident's EMRs and the facility did not utilize paper charts. The NHA said she would look for documentation of the recent CNA education on documenting showers. The NHA acknowledged that the education did not appear to have been effective. The NHA said there was a documentation issue that needed to be addressed. The NHA said that the purpose of the shower sheets was to communicate the shower schedule. The NHA said the shower sheets were also used as a skin care check list and a communication tool between the CNAs and the nurses. The NHA said the CNAs should be documenting the showers in the EMR. -The CNA shower education documentation was not provided. The DON was interviewed again on 2/24/25 at 2:24 p.m. The DON said she would recommend a shower one or two times per week for cleanliness and to prevent skin breakdown. The DON said showers were also a good time for a skin assessment and if the CNA saw a skin issue they would notify the nurse. The DON said the shower bath sheets at the nurse's station had a body sketch so that the CNA could circle the location of any skin issues observed during the bathing. The DON said she could not remember what the instructions were to the CNAs during the education that was recently provided, except that it was related to documentation of showers. The DON said she was at the CNA education class but she was not the instructor. She said the instructors were the staff development coordinator and the infection preventionist. The DON said the lack of showers appeared to be a documentation issue. The DON said the shower preferences and needs should be on the care plan in order to share information on the residents' care. The DON said they updated Resident #2's care plan today (2/24/25). The NHA said she would complete a thorough shower audit and complete education on documentation on showers and education of the staff and review daily to see that charting/documentation was matching up. Licensed practical nurse (LPN) #1 was interviewed on 2/24/25 at 4:30 p.m. LPN #1 said showers should be given to the residents at least twice a week. LPN #1 said some of the refused showers but were asked three times and then the CNAs would write if they refused on the bath sheet and also document in the EMR. LPN #1 said the nurses could also chart in the progress notes if the resident refused and what they did to encourage them, the reason and look for a pattern. LPN #1 said regular showers were important to maintain good skin health, proper hygiene and infection control. CNA #1 was interviewed on 2/24/25 at 4:35 p.m. CNA #1 said had worked at the facility for one year. CNA #1 said residents got a shower about two times per week. CNA #1 said showers were important to prevent rashes and skin breakdown. CNA #1 said she wrote the showers down on the bath sheet and charted them in the EMR. CNA #1 said the bath sheet communicated with the nurse at the station in case they needed to do a skin assessment. CNA #1 said in the EMR she documented the type of shower the resident received, their transfer ability, and how much assistance the resident supplied.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#1) of three residents reviewed for quality of care out of eight sample residents. Specifically the facility failed to: -Assess and monitor Resident#1 after she developed eye drainage; and, -Ensure the facility's physician was aware Resident #1 had been diagnosed with clogged eye ducts and prescribed antibiotics for the condition by an outside provider. Findings include: I. Facility policy and procedure The Notification of Changes policy and procedure, dated 9/1/24, was provided by the nursing home administrator (NHA) on 12/18/24 at 4:30 p.m. It read in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. -The policy did not include any pertinent information regarding documentation and assessment that must be completed upon a change of resident's condition. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included osteoarthritis, rheumatoid arthritis and diabetes. The 7/28/24 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident required maximum assistance with activities of daily living (ADL). B. Record review The June 2024 medication administration record (MAR) revealed Resident #1 had the following physician's orders related to her eyes: Latanoprost Ophthalmic Emulsion 0.005% (percent). Instill one drop in both eyes at bedtime related to glaucoma, ordered 2/29/24. Tobrex Ophthalmic Solution (an antibiotic medication) 0.3%. Instill one drop in right eye three times a day for clogged duct for seven days, ordered 6/26/24. Warm compress to right eye four times a day for clogged duct, ordered 6/26/24 and discontinued 7/15/24. The progress note, dated 6/27/24 and written by the director of nursing (DON), documented that Resident #1 was taken out of the facility by her daughter the day before (6/26/24). Upon return to the facility, the daughter informed a nurse that the resident was prescribed an antibiotic for an eye infection by a physician from the walk-in clinic. She expressed concern that her mother had matted right eye drainage and the facility did not take any actions to address it. Another progress note dated 6/27/24 documented that the walk-in clinic's physician's order for antibiotic eyedrops was entered into Resident #1's electronic medical record (EMR) and the eye drops were administered to the resident. The progress note dated 6/29/24 documented that Resident #1 continued to receive eye drops to the right eye. The resident's eye was looking better and had less drainage noticed on the day shift. -Review of Resident #1's EMR revealed there was no documentation to indicate that the resident's right eye was assessed by nursing staff for drainage before 6/27/24. -Review of Resident #1's EMR revealed there was no documentation on 6/27/24 to indicate that the resident's right eye was assessed by nursing staff or the facility's physician after the resident's return from the walk-in clinic. -Further review of Resident #1's EMR revealed there was no documentation to indicate that the resident's primary physician was notified about the resident's right eye condition or that the resident had been prescribed an antibiotic eyedrop medication by an outside provider which was administered to the resident. III. Staff interviews Registered nurse (RN) #1 was interviewed on 12/18/24 at 1:30 p.m. RN #1 said she knew Resident #1 well and she remembered that the resident had an eye infection some time in the summer of 2024. She said she did not recall the details of the infection, but she did remember administering eye drops to the resident. She said drainage from the eye should be documented in the progress notes and the resident should have been assessed for a change of condition which included an assessment of the eye. RN #1 said family and the primary care physician should be notified when a resident had a change of condition. She said all medications that family brought into the facility should be reported to the physician and orders obtained before administering the medication to the resident. RN #2 was interviewed on 12/18/24 at 2:05 p.m. RN #2 said drainage from a resident's eye was considered to be a change of condition. He said the resident should be assessed and findings documented on the change of condition form. He said daily notes should document the condition of the eye. The DON was interviewed on 12/18/24 at 3:40 p.m. The DON said any changes in a resident's condition should be documented in a change of condition form. She said when Resident #1 started to experience drainage from her eye, she should have been assessed by a nurse who should have then documented in the progress notes the condition of her eye. She said she believed Resident #1's physician was contacted to inform him of the new orders from the walk-in clinic, however, she was not able to locate the note to confirm the physician was notified. The DON said she was not able to locate any additional nursing progress notes which indicated Resident #1's right eye drainage was assessed by the facility prior to 6/27/24 when the resident went to the walk-in clinic. She said if the resident started to experience drainage in the eye it should have been documented prior to 6/27/24.

Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for two (#7 and #3) of five residents reviewed for accident hazards out of eight sample residents. Specifically, the facility failed to repair the handicap-accessible door to the smoking patio in a timely manner and ensure the door functioned properly and was safe to use while it was broken for Resident #7 and Resident #3. Findings include: I. Facility policy and procedure The Fall Management System policy, revised November 2024, was received from the nursing home administrator (NHA) on 12/18/24 at 4:07 p.m. It read in pertinent part, It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The quality assessment and assurance (QAA) committee will analyze trends related to falls and will determine if further intervention is needed. II. Resident group interview and observations A group interview was conducted on the facility's smoking patio on 12/18/24 at 10:24 a.m. with four residents (#3, #4, #5 and #6) who were identified as interviewable by the facility and assessment. Resident #3 said the handicap button on the door to the smoking area was broken for months and the door would not open automatically during that time. Resident #3 said the door started working again a few weeks ago. Resident #3 said she repeatedly complained about the door to the staff at the facility, but the staff's response was only that they were still waiting for a part to fix it. Resident #3 said her knuckles were repeatedly scratched from trying to get through the smoking area door in her wheelchair and her knuckles were only just starting to heal. Resident #3 had multiple scabs along her knuckles that were in different stages of healing. Resident #3 and Resident #5 said Resident #7 fell out of his wheelchair because the door to the smoking patio was not opening automatically and had to be physically opened. Resident #3 and Resident #5 said that Resident #7 was not injured from the fall. Resident #4 and Resident #5 said they both had a difficult time getting in and out of the smoking area door in their wheelchairs when it was broken. Resident #6 said he had a difficult time getting into and out of the smoking area when the door was broken a few weeks prior. At 10:40 a.m. Resident #4 tried to leave the smoking area and re-enter the building. The handicap door repeatedly tried to close on the resident's wheelchair while Resident #4 was trying to navigate his wheelchair over the threshold of the door, despite the handicap button being pressed. Resident #3 said she needed to help Resident #4. Resident #3 proceeded to hold the door for Resident #4 as he grabbed both sides of the door frame so he could leverage his wheelchair up and over the door's threshold. III. Resident #7 A. Resident status Resident #7, age 77, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included arthritis, repeated falls, generalized muscle weakness and alcoholic polyneuropathy (a neurological disorder that occurs when peripheral nerves throughout the body malfunction simultaneously). The 9/17/24 minimum data assessment (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was dependent for most activities of daily living (ADL). B. Resident interview Resident #7 was interviewed on 12/18/24 at 2:05 p.m. Resident #7 said the door to the smoking area was broken for two weeks a while back. Resident #7 said he fell out of his wheelchair during the time the door was broken because he was trying to get in from the smoking area and could not get over the ledge of the threshold while trying to hold the door open himself. Resident #7 said he was not hurt during the fall. C. Record review A progress note, dated 10/23/24 at 10:20 p.m., revealed Resident #7 had a witnessed fall when coming in from the smoking patio. Resident #7 tried to open the door but found it too heavy. Resident #7 was helped back into his wheelchair by the nursing staff using a Hoyer lift. A progress note, dated 10/24/24 at 10:36 a.m., revealed the facility's interdisciplinary team (IDT) performed a fall review of Resident #7's 12/23/24 fall. The IDT team implemented an intervention to place a sign on the smoking patio door and educated Resident #7 on asking for assistance when going in and out of the smoking patio door. -However, the IDT note did not indicate that the handicap button on the smoking patio door was broken or identify when the door would be fixed. The fall committee IDT note, dated 10/24/24 at 10:39 a.m. revealed Resident #7 had a witnessed fall on 10/23/24 at 6:45 p.m. in the entryway of the smoking patio. Predisposing factors included that Resident #7 had been outside smoking and the handicap button to the door was not working properly. Resident #7 was attempting to come in from the smoking patio and was not able to manage the door by himself. The door hit the back of Resident #7's wheelchair and he slid out from his chair. Interventions included placing a sign on the smoking patio door asking residents to ask for assistance when going out or coming in from the smoking area until the door was repaired. -The note did not identify what the facility was doing to fix the door or identify where the facility was in the process of getting the door fixed. A progress note, dated 12/16/24 at 5:07 p.m., revealed Resident #7 had an unwitnessed fall. The nurse writing the note found Resident #7 lying on his back on the threshold to the smoking patio and did not see any signs of injury. The fall committee IDT note, dated 12/17/24 at 9:11 a.m., revealed Resident #7 had an unwitnessed fall on 12/16/24 at 4:42 p.m. coming back in from the smoking patio. Predisposing factors for Resident #7 included weakness and having a hard time getting back in from the smoking patio over the threshold. Resident #7 was coming into the facility from the smoking patio and having difficulty getting over the threshold of the door and fell out of his wheelchair. Interventions included having Resident #7 continue to work with therapy. -The note did not identify that the facility had assessed the threshold of the smoking patio door to identify if there were potential hazards with the threshold which could contribute to other potential falls for residents. IV. Resident #3 A. Resident status Resident #3, age 82, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included congestive heart failure, chronic respiratory failure, history of falling and generalized muscle weakness. The 10/8/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. B. Record review Wound assessment notes, dated 10/31/24, revealed Resident #3 had blisters to her left great toe, left medial ankle, left lateral ankle and left great toe, and abrasions to her left anterior knee, left anterior shin, and left proximal anterior shin. The abrasion to the left proximal anterior shin was acquired on 10/23/24 and the others were at least one month old at the time of assessment. The wound assessment notes revealed Resident #3 reported to the physician that she was having to use her left knee and left foot to open the door to the smoking patio because the door did not automatically open. The physician discussed with Resident #3 that she should have a staff member help her open the door to prevent further injury to her left knee and left toes. -The wound assessment notes did not reveal any abrasions identified on Resident #3's hands. Review of weekly skin assessments from 9/20/24 through 12/18/24 did not reveal any abrasions on Resident #3's hands. -However, Resident #3 had multiple scabs on her knuckles (see observation above). V. Staff interviews Hospitality aide (HA) #1 was interviewed on 12/18/24 at 2:18 p.m. HA #1 said she knew there was an issue with the smoking patio door a few weeks ago but that it was fixed now. HA #1 said the handicap button for the door was not working and the door was not closing all the way. Certified nurse aide (CNA) #1 was interviewed on 12/18/24 at 2:21 p.m. CNA #1 said she knew the smoking patio door was broken but it got fixed quickly. CNA #1 said she had not heard about any issues with the handicap button. -However, the handicap button on the smoking patio door was broken from 9/22/24 until 11/20/24 (see additional record review below). Licensed practical nurse (LPN) #1 was interviewed on 12/18/24 at 3:07 p.m. LPN #1 said Resident #7 fell on [DATE] at around 5:00 p.m. LPN #1 said Resident #7 fell at the threshold of the door to the smoking area. LPN #1 said Resident #7 was able to use his wheelchair to get to the door but could not push the door open. LPN #1 said the door to the smoking area was too heavy for wheelchair users to push open, but they could push the handicap button to open the door. LPN #1 said she had not heard of any issues with the handicap door mechanism. The maintenance supervisor (MS) was interviewed on 12/18/24 at 3:20 p.m. The MS said there was something wrong with the internal mechanisms of the motor for the smoking patio door so that the motor was not communicating with the handicap buttons inside and outside the door. He said the issue began in September 2024. The MS said the parts for the motor were on backorder so the vendor had to replace the whole motor. The MS said the issue with the smoking patio door was noticed on 9/24/24 and the door was repaired by the vendor on 11/20/24. The MS said the facility advised the residents to open the door to the smoking patio with caution while the handicap door motor was broken, as the door had some kickback to it. The director of nursing (DON) and the NHA were interviewed together on 12/18/24 at 3:42 p.m. The NHA said the handicap button on the smoking patio door stopped working but could not recall the date. The NHA said the vendor came out to repair it but did not have the proper parts. The NHA said the delay in getting the door repaired stemmed from having to get quotes to replace the whole handicap button. The NHA said, in the meantime, the staff in that section of the facility were there to help the residents open the door to the smoking area. The NHA said Resident #7 did have a fall during the time when the door was broken and another fall recently when the door was working. The NHA said the IDT team was looking to have a care conference with Resident #7 and his representative to see if the facility staff could hold the resident's cigarettes so he could remain an independent smoker but have a staff member aware of when he was going onto the patio. The NHA said she did not find Resident #7's second fall to be related to the door as the door was working at the time. The NHA and the DON said they had observed residents going in and out of the smoking patio but had not identified any issues with residents getting into and out of the smoking patio. The DON said residents in wheelchairs were able to hit the handicap button to open the door to the smoking patio. The DON said residents that were independent could push open the door, and those that were not physically able to open the door had staff to help them open the door to the smoking patio during the time the door was broken. The DON said Resident #7 did not have the physical ability to open the door to the smoking patio but the facility staff helped him open it. -However, Resident #7 sustained a fall on 10/23/24 related to the smoking patio door not working and documentation did not indicate staff had attempted to help the resident get through the door prior to the fall (see record review above). -Additionally, the facility failed to identify that Resident #7 did not have the physical ability to open the smoking patio door until after the resident's fall on 10/23/24. VI. Additional record review Additional documentation related to the handicap door for the smoking patio was provided by the NHA on 12/18/24 at 5:57 p.m. A handicap door repair timeline, signed by the NHA on 12/18/24, revealed the following: -On 9/22/24 the concern with the handicap door function was first reported; -On 9/23/24 the vendor was contacted; -On 9/24/24 the vendor came out to the facility to assess the door but the parts were no longer available for the unit that was installed and the unit needed to be replaced. An estimate was provided and work was scheduled to be completed; -On 10/9/24 the vendor canceled the replacement due to part and labor availability issues; -On 11/13/24 the vendor canceled the replacement due to labor availability issues; -On 11/18/24 the NHA called the vendor to confirm a repair date; and, -On 11/20/24 the vendor arrived and replaced the handicap button. -There was no documentation to indicate if the facility attempted to identify another vendor who could fix the door in a more timely manner when the initial vendor canceled the replacement of the door on two separate occasions. Additionally, a grievance form from Resident #7's representative, dated 11/13/24, revealed Resident #7's representative expressed frustration about the handicap accessibility button being broken for the smoking patio door. The response was that the NHA explained to the representative that the vendor would be out that week to perform the required maintenance to repair the door. -However, the smoking patio door was broken for almost two months before it was fixed.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in two of four medication carts and in one of one medication storage room. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; and, -Expired and discontinued medications were removed from the medication carts in a timely manner. Findings include: I. Professional references According to the manufacturer Sanofi Aventis US, How to Use Your Lantus Solostar Pen ([DATE]), retrieved on [DATE] from https://www.lantus.com/dam/jcr:817aed9c-a,d+[DATE]cd6-a6b3-d93d8aba629a/lantus-solostar-pen-guide.pdf, After 28 days, throw your opened Lantus pen away, even if it still has insulin in it. According to the manufacturer NovoNordisk, Taking Novolog-Insulin Aspart ([DATE]), retrieved on [DATE] from https://www.mynovoinsulin.com/insulin-products/novolog/taking-novolog.html, Storage after use - keep at room temperature or refrigerated up to 28 days. Dispose after 28 days, even if there is insulin left in the pen or vial. According to the manufacturer Biocon Biologics, Semglee, Insulin Glargine-yfgn (2023), retrieved on [DATE] from https://www.semglee.com/en/semglee-pen#:~:text=Don't%20use%20SEMGLEE%20after,after%20you%20first%20use%20it.&text=Don't%20reuse%20or%20share,get%20a%20serious%20infection%20yourself, Once you take Semglee out of cool storage, for use or as a spare, you can use it for up to 28 days. Do not use it after this time. According to the manufacturer [NAME] Lilly and Company, Humalog U-100 Insulin (February 2024), retrieved on [DATE] from https://www.humalog.com/u100, Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. According to the National Institutes of Health, Daily Med, Breyna ([DATE]), retrieved on [DATE] from https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=dc529fc4-bddb-,d+[DATE]-dc401f86166f, The inhaler should be discarded when the labeled number of inhalations have been used or within three months of removal from the foil pouch. According to the National Institutes of Health, Daily Med, Spiriva Respimat ([DATE]), retrieved on [DATE] from https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=7b656b14-fcaa-2741-f6f0-e0be48971c02, After assembly, the Spiriva Respimat inhaler should be discarded at the latest three months after first use, or when the locking mechanism is engaged, whichever comes first. According to the Food and Drug Administration, Aplisol-Tuberculin Purified Protein Derivative ([DATE]), retrieved on [DATE] from https://www.fda.gov/files/vaccines%2C%20blood%20%26%20biologics/published/Package-Insert---Aplisol.pdf, Vials in use for more than 30 days should be discarded. II. Facility policy and procedure The Storage of Drugs and Biologicals Policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 6:15 p.m. The policy read in pertinent part: Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. III. Observations and interviews On [DATE] at 11:09 a.m., the Aspen unit medication cart was observed with registered nurse (RN) #2. The following items were found: A used Insulin Glargine (Lantus) 100 units/milliliter (ml) pen was not labeled with the date it was opened. A used Insulin Aspart Flex Pen (NovoLog) 100 units/ml pen was not labeled with the date it was opened. A used Insulin Glargine-yfgn 100 units/ml pen was not labeled with the date it was opened. Two used Insulin Lispro (Humalog) 100 units/ml kwik pens were not labeled with the date they were opened. A used Budesonide and Formoterol Fumarate (Breyna) inhaler was not labeled with the date it was opened. A used Tiotropium Bromide (Spiriva Respimat) inhaler was not labeled with the date it was opened. A used container of Hydromorphone 1 milligram (mg)/ml with an expiration date of [DATE]. RN #2 said the insulin and inhalers should have been labeled with the date opened and the Hydromorphone discarded upon expiration. On [DATE] at 12:00 p.m., the Snowmass North unit medication cart was observed with licensed practical nurse (LPN) #2. The following items were found: A used Insulin Glargine (Lantus) 100 units/ml pen with a date opened label of [DATE]. The nurse said she did not know how long the insulin could be used before it needed to be discarded. -The insulin should have been discarded on [DATE], 28 days after opening. An opened package of Morphine 100 mg/five ml. LPN #2 said the resident used the medication when she was on hospice services and the order had since been discontinued. -The Morphine order had been discontinued on [DATE]. On [DATE] at 12:30 p.m., the Silver Key medication storage room was observed with LPN #3. The following items were found: An open vial of Tuberculin Purified Protein Derivative (Aplisol), Five TU/0.1 ml, with a house stock label dated [DATE]. -The package was not labeled with the date it was opened. -The medication should have been discarded 30 days after opening. An Insulin Levimir Flex Pen 100 units/ml with resident label attached. LPN #3 said the resident died a few weeks prior to the survey. She said the medication should have been discarded immediately after the resident died . On [DATE] at 3:25 p.m., two pill packages containing Bactrim medication were on top of the Snowmass medication cart. Certified nurses aide (CNA) #2, who was a certified medication tech, walked away from the cart. At 3:40 p.m., CNA #2 returned to the medication cart and the Bactrim pills remained on top of the cart. CNA #2 said the pills should have been locked in the cart and she proceeded to put them in the cart. IV. Staff interviews The director of nursing (DON) was interviewed on [DATE] at 11:25 a.m. She said insulin and inhalers should be labeled with the date when opened and she would expect the insulin to be discarded 28 days after opened. The DON was interviewed again on [DATE] at 3:46 p.m. She said discontinued medications should be removed from carts and storage within 48 hours.

Based on record review and interviews, the facility failed to ensure one (#51) of one resident reviewed for abuse out of 22 sample residents was kept free from abuse. Specifically, the facility failed to keep Resident #51 free from sexual abuse by Resident #6. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 2/12/24-2/15/24, resulting in the deficiency being cited as past noncompliance with a correction date 11/3/23. I. Facility policy and procedure The Abuse Policy, dated 5/3/23, was received by the nursing home administrator (NHA) on 2/13/24 at 11:09 a.m. It read in pertinent parts: Purpose: Communities does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Intent: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Standards: Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Identification of abuse shall be the responsibility of every employee. Definitions: Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Also, verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through use of technology. Sexual abuse- is non-consensual sexual contact of any type with a resident. Willful-means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. Common Area-is expanded to recognize the inclusion of living rooms or other similar areas where residents gather. Person-centered care means to focus on the resident as the loss of control and support the resident in making their own choices; having control over their daily lives. II. Investigation report of sexual abuse involving Resident #51 and Resident #6 on 11/1/23 based on record review and interviews (see below). On 11/1/23 Resident #51 who had a diagnosis of dementia and used a wheelchair for mobility and Resident #6 who was cognitively intact and ambulated (walk) independently with use of walker were participating in a scheduled movie night activity at the facility, in the dining room across from the kitchen. Two staff members, a dietary aide (DA) and a cook (CK) were leaving the kitchen around 8:00 p.m. to clock out for the day and saw Resident #6 touching Resident #51 inappropriately. On 11/1/23 at 8:03 p.m. the activities assistant (AA) reported an incident of inappropriate touching to the NHA. The AA, who facilitated the movie activity, reported leaving the dining room to escort another resident to their room. Upon returning to the dining room, the AA was approached by the CK who provided information of witnessing inappropriate touching. The AA said he was gone from the dining room for maybe a minute. The AA reported returning to the dining room and seeing Resident #51 and Resident #6 face to face holding each other's hands. Resident #51 informed the AA she had known Resident #6 a long time. The AA reported not seeing any inappropriate touching between Residents #51 and #6, not seeing Resident #51's clothes disheveled and not seeing Resident #51 upset. Resident #51 was laughing while being escorted from the dining room by the AA. On 11/2/23, time not indicated, the DA was interviewed by the NHA and reported Resident #6 had lifted Resident #51's breast out of her shirt and was kissing her breast and touching her face. The DA told the CK to look at the interaction and instructed the CK to report to nursing that Resident #6 was touching the breast of Resident #51. The DA did not intervene. On 11/2/23, time not indicated, the CK was interviewed by the NHA and reported walking to the time clock with the DA and being told by the DA to look at Resident #51 and Resident #6. The CK reported seeing Resident #6 standing over Resident #51 and Resident #6 had his hand inside her jacket on top of her shirt in the chest area. The CK reported she had not seen Resident #51's breast exposed, being kissed or her face being touched by Resident #51. The CK said she was not sure what was going on but it seemed weird. She did not intervene. She said she told a certified nurse aide (CNA) and returned to the dining room and the AA had returned and was informed of what she had witnessed. The investigation report included two interviews with Resident #51 and one interview with Resident #6. Resident #6 was interviewed by the NHA on 11/2/23 at 8:30 a.m. Resident #6 was noted as having a brief interview for mental status (BIMS) score of zero out of 15. She was asked if she was touched inappropriately or if she was scared of anyone at the facility. Resident #6 was unable to answer, made funny faces at the NHA and laughed which was noted to be her baseline. On 11/2/23 at 9:15 a.m. Resident #51 was interviewed by the social services assistant (SSA) and said he remembered asking the AA for a banana and was instructed to ask the kitchen staff. Resident #51 said he did not remember having any interactions with other residents. On 11/3/23, time not indicated, Resident #51 was interviewed again by the SSA and said he remembered hugging a female resident who had always been very nice to him since he was admitted there. III. Facility actions On 11/1/23 at 8:03 p.m. the NHA was informed of a witnessed allegation of inappropriate touching by the AA. Staff was instructed to begin one-to-one supervision of Resident #51. One-to-one supervision was concluded on 11/22/23. On 11/2/23 at 8:00 a.m. the facility made notifications to families, the director of nursing (DON), police, adult protective services (APS), ombudsman, health department and continued with the investigation. On 11/2/23 the activities director (AD) and AA were educated on ensuring there was always a staff member present during group activities for supervision of the residents and asking other departments to assist as needed in transporting residents to and from activities to ensure the safety of all residents, an all staff education was conducted on 11/3/23. On 11/2/23 dietary staff were educated on types of abuse to include what to do if witnessing or knowing of an instance of allegation of abuse. Instruction specified ensuring the victim was safe by removing them from the situation. The AA, the DA and the CK previously received abuse and dementia training on 10/17/23. On 11/3/23 Resident #6's care plan was updated to include increasing supervision when in group activities. On 11/3/23 Resident #51's care plan was updated to include him being supervised while in groups with females and assisting Resident #51 back to his room first to prevent leaving him unattended, especially with other female residents and the initiation of a behavior contract (see below). The 11/3/23 behavioral contract revealed Resident #51 would not enter another resident's room without their knowledge and permission, would not attempt to kiss another resident, would not invade another resident's personal space, would not hug another resident without their consent, would not inappropriately grab at another resident, would not put his hands on other residents without their verbal consent, would follow the request from staff when they redirected him if he was displaying inappropriate behaviors and violating the contract may result in a 30 day involuntary discharge notice from the facility. Resident #51 was informed the contract was being written based on staff observations and he had the right to disagree with the observations and the contract was written to keep himself and other residents safe and he was able to direct questions about the contract to administration or social services. On 11/6/23 the facility concluded the investigation and sexual abuse was substantiated. IV. Resident #51 A. Resident status Resident #51, age 72, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and aphasia (loss of ability to understand or express speech). The 12/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required substantial to maximum assistance with bathing, toileting and transferring B. Record review The 11/2/23 skin check revealed no skin issues were identified for Resident #51, nor was pain identified verbally or non-verbally, following the incident with Resident #6 on 11/1/23. The cognitive function care plan, initiated on 10/15/18 and revised on 10/17/22, revealed Resident #51 had impaired cognitive function and impaired thought processes related to a stroke. It indicated the resident would be able to communicate basic needs, in her own way, on a daily basis through the review date. Pertinent interventions included asking yes/no questions in order to determine the residents needs, providing cuing reorienting and supervising as needed. The communication care plan, initiated on 10/15/18 and updated 1/30/24, revealed Resident #51 had a communication problem related to having a stroke and she would call out [NAME] as a way of communication when wanting something. It indicated the resident would be able to make her needs known by answering simple yes/no questions on a daily basis. Pertinent interventions included allowing adequate time to respond, repeating as necessary, not rushing communication, requesting clarification from the resident to ensure understanding, facing the resident when speaking, making eye contact, asking yes/no questions if appropriate and using simple, brief, consistent words/cues. The activities care plan, initiated 10/10/22 and updated 11/3/23, revealed Resident #51 received biweekly one to one visits, she was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. She preferred spending time in her room watching television, listening to music, snacking or napping; she participated in activities involving food, drink, and movie nights as tolerated. It indicated the resident would express satisfaction with the type of activities and her level of activity involvement when asked through the review date. Pertinent interventions included escorting and assisting the resident to and from activities and increasing supervision of the resident while in groups. V. Resident #6 A. Resident status Resident #6, age 81, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), low back pain and diabetes. The 1/16/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required setup or clean up assistance with bathing, toileting and transferring. B. Resident interview Resident #6 was interviewed on 2/12/24 at 1:42 p.m. He said he had lived at the facility for many years, attended activities and was the resident council president at one time. He said he stayed in his room now and kept himself busy with activities and people could visit with him if they wanted. He said he did not attend activities anymore because he was accused of touching someone. He said he missed family who were close and hugged a lot but he could not show affection at the facility like he did at home. C. Record review The behaviors care plan, initiated 1/27/2020 and updated 11/7/23, revealed Resident #6 exhibited inappropriate social behaviors, wandering into other resident rooms at odd hours and often saying exactly what he was thinking regardless of social context clues. The resident liked to hug others with or without their consent, and, at times, made sexually inappropriate gestures towards females. A behavior contract was initiated with the resident on 11/3/23 for inappropriate behavior. It indicated the resident's inappropriate behavioral symptoms would be minimized through staff interventions by the next review date. Interventions included being alert for triggers of undesirable behavior, involving the resident's family as needed, modifying the resident's environment to minimize episodes, redirecting the resident as needed, reminding the resident and intervening as appropriate not to enter another resident's room without permission, invading personal space, hugging or touching another resident without permission, supervising the resident while in groups with females and assisting the resident back to his room first when in supervised groups. The 11/3/23 progress note indicated a conversation was had with Resident #51 regarding an observation made during an evening group activity that he may have displayed inappropriate behaviors towards a female resident. It revealed Resident #51 had a history of inappropriate behaviors towards others. A behavior contract was initiated and reviewed with Resident #51 by the social services director (SSD) to ensure the safety of Resident #51 and other residents at the facility moving forward. Resident #51 verbalized understanding of the contract and stated he was just going to keep to himself informing the SSD he came from South Texas and would hug everyone all the time as he knew them but understood how this could be perceived as inappropriate in a facility setting. VI. Staff interviews The DA was interviewed on 2/14/24 at 11:15 a.m. The DA said she was walking past the dining room where residents were watching a movie to clock out around 8:00 p.m. on 11/1/23 with the CK. She said she saw Resident #51 standing over Resident #6 with one hand on her face near her mouth and his other hand was down her shirt touching her breast like he was trying to lift it out of her shirt. She said she saw this in passing and she did not approach or intervene but told the CK to tell a nurse what was happening. The AD was interviewed on 2/14/24 at 11:47 a.m. The AD said she had worked at the facility for a year and a half and the 11/1/23 incident was the first allegation of inappropriate touching Resident #51 had been involved in that she knew of. The AA was interviewed on 2/14/24 at 11:57 a.m. The AA said he was present in the dining room for the duration of the movie on 11/1/23. He said Resident #51 and Resident #6 had not been sitting near one another or had any interaction during the movie. He said he escorted a resident to her room when the movie ended and was stopped in the hallway by CK when he was returning to the dining room to assist other residents. He said he was gone from the dining room for one minute, two minutes at the most. He said the CK informed him Resident #51 was seen touching Resident #6 inappropriately. The AA said he arrived in the dining room and saw Resident #51 and Resident #6 face to face holding hands as if shaking each other's hands. He said he approached the two residents and assisted Resident #51 to the nursing station and reported the allegation made by the CK to the NHA. The CK was interviewed on 2/14/24 at 3:00 p.m. She said she was exiting the kitchen to clock out with the DA. She said she saw Resident #51 standing in front of Resident #6 and his hands were inside her jacket and on top of her shirt near her chest. She said she did not see Resident #51 touching the breasts of Resident #6. She said she did not intervene but thought the closeness of the residents' proximity and the advancement of Resident #6's dementia could be problematic and went to inform nursing to keep an eye on them. The CK said she ran into the AA as he was returning to the dining room and informed him of what she saw and also informed Resident #6's nurse. The SSD was interviewed on 2/14/24 at 1:00 p.m. She said Resident #51 was care planned for inappropriate behaviors by a previous social services director. She said the behaviors included making sexually inappropriate comments, hugging people without asking first and poor personal boundaries. She said she had not witnessed these behaviors. The SSD and NHA were interviewed together on 2/14/24 at 1:30 p.m. The NHA said she was made aware of allegations of inappropriate touching on 11/1/23 at 8:03 p.m. by the AA and initiated an investigation. The NHA said Resident #51 was placed on immediate one-to-one supervision and Resident #6 was assessed for injury and monitored for any mood or behavioral changes through weekly skin checks and daily staff interactions. The NHA said Resident #51 remained on one-to-one supervision until 11/22/23 to establish a daily pattern and determine the need for continued supervision and monitoring. She said Resident #51 had not established a pattern of inappropriate behavior and engaged in activities in his room. The NHA said she attempted to contact Resident #6's responsible party without success and the daughter of Resident #51 had been contacted by herself and the resident. The NHA said the police and APS were notified. She said staff received abuse training to include types of abuse and what to do if abuse was witnessed and how to appropriately report events on 11/2/23. The NHA said, based on staff interviews, the facility substantiated the sexual abuse. The SSD said the care plans for both Resident #51 and Resident #6 had been updated to reflect the need for additional supervision while in groups and Resident #51 had entered into a behavioral contract (see above). The APS worker assigned to the sexual abuse case was interviewed on 2/15/24 at 4:00 p.m. She said the case was closed on her end as she felt the facility was able to continue providing the care needs for Resident #51 and the facility had put measures in place to prevent further occurrences.

Based on record review and interviews, the facility failed manage the pain of three (#15, #36 and #12) of five residents out of 22 sample residents in a manner consistent with professional standards of practice Specifically, the facility failed to ensure residents consistently received scheduled pain medications on time. Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 2/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Right time- administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. II. Facility policy and procedure The Pain Management Policy, revised May 2023, was provided by the nursing home administrator (NHA) on 2/15/24 at 6:15 p.m. It read, in pertinent part: Acceptable (tolerable) pain control is defined by the resident. Around the clock dosing for continuous pain, whether it be chronic or acute, is the key to effective pain management. III. Resident #15 A. Resident status Resident #15, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included kidney disease, diabetes, skin cancer and fibromyalgia. The 11/28/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment revealed the resident had frequent pain and was on a scheduled pain regimen. B. Record review Resident #15's February 2024 CPO included physician orders for the following pain medications: Oxycodone 5 milligrams (mg), two times daily (scheduled for 12:00 p.m. and 8:00 p.m.). MS Contin (Morphine extended release) 15 mg, three times daily (scheduled for 8:00 a.m., 4:00 p.m., and 12:00 a.m.). Acetaminophen 650 mg, four times daily (scheduled for 8:00 a.m., 12:00 p.m., 4:00 p.m. and 12:00 a.m.) Resident #15's medication administration record (MAR) documentation was reviewed from 1/1/24 through 2/14/24 with the following findings: Oxycodone: 20 of 90 medication administrations (22.2%) were given more than one hour past the scheduled time. MS Contin: 23 of 137 medication administrations (16.7%) were given more than one hour past the scheduled time. Acetaminophen: 22 of 163 medication administrations (13.5%) were given more than one hour past the scheduled time. C. Resident interview Resident #15 was interviewed on 2/12/24 at 12:12 p.m. She said her medications were sometimes late. She said she had pain medications scheduled at 4:00 p.m. given to her at 6:00 p.m. and pain medications scheduled for 12:00 a.m. given to her at 3:00 a.m. She said it was not acceptable because she took narcotics and needed to receive them as scheduled to minimize her pain. IV. Resident #36 A. Resident status Resident #36, age less than 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included diabetes, neuropathy (nerve damage), liver disease and urinary obstruction. The 11/30/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment revealed the resident had occasional pain. B. Record review Resident #36's February 2024 CPO included a physician's order for the following pain medication: Methocarbamol 500 mg, two times daily (scheduled for 8:00 a.m. and 8:00 p.m.) Resident #36's MAR documentation was reviewed from 1/1/24 through 2/14/24 with the following findings: Methocarbamol: 25 of 91 medication administrations (27%) were given more than one hour past the scheduled time. C. Resident interview Resident #36 was interviewed on 2/12/24 at 1:52 p.m. She said the nurses did not always give her pain medication on time. V. Resident #12 A. Resident status Resident #12, age greater than 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included cervical (neck) disc degeneration, heart disease, chronic obstructive pulmonary (lung) disease, and neuropathy (nerve damage). The 11/29/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident had frequent pain and was on a scheduled pain regimen. B. Record review Resident #12's February 2024 CPO included a physician's order for the following pain medication: Oxycodone 5 mg, two times daily (scheduled for 8:00 a.m. and 8:00 p.m.). Resident #12's MAR documentation was reviewed from 2/8/24 (the date the pain medication was started) through 2/15/24 with the following findings: Oxycodone: Three of 14 medication administrations (21%) were given more than one hour past the scheduled time. C. Resident interview Resident #12 was interviewed on 2/12/24 at 8:52 a.m. She said the facility had given her pain medication later than the time it was supposed to be administered to her. VI. Staff interviews Registered nurse (RN) #2 was interviewed on 2/14/24 at 2:35 p.m. She said she had some residents tell her they were not receiving their pain medications on time during the night. Licensed practical nurse (LPN) #1 was interviewed on 2/15/24 at 2:52 p.m. She said the acceptable time period to give scheduled medications was up to one hour before and one hour after the scheduled time of the medication. The director of nursing (DON) was interviewed on 2/15/24 at 3:30 p.m. She said nursing staff should give scheduled medications up to one hour before and one hour after the scheduled time. She said the facility used a lot of agency nurses and many of them were new nurses. She said this delayed the medication administration.

Based on observations, interviews and record review, the facility failed to ensure one (#47) of one resident out of 22 sample residents received the proper treatment and assistive devices to maintain hearing. .Specifically, the facility failed to: -Obtain an order for ear wax drops in order for the audiologist to perform a hearing test for Resident #47; and, -Obtain a follow-up appointment with the audiologist to address Resident #47's concerns with his hearing ability. Findings include: I. Facility policy and procedure The Ancillary Services policy and procedure, dated 11/4/13, was received by the nursing home administrator (NHA) on 2/14/24 at 4:40 p.m. It read in pertinent part: Purpose: Ancillary services, including, but not limited to, dental, vision, audiology and podiatry will be provided to the resident per state and federal regulatory guidelines at the resident/responsible family member's request and as needed. Policy: Any resident needing or requesting ancillary services such as dental, vision, audiology and podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice. Procedure: Social Services/Designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. All orders for the treatment of the resident's ancillary services must be in writing and the resident's attending physician must be made aware of any treatments or medications ordered by an ancillary service provider. II. Resident #47 A. Resident status Resident #47, age 81, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included unspecified hearing loss. The 1/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. He was dependent on staff for assistance with bathing, toileting, and transferring. B. Observation and interview Resident #47 was interviewed in his room on 2/12/24 at 11:42 a.m. The resident said he was hard of hearing and the facility was not helping to improve his hearing. Resident #47 said he was seen by the hearing doctor (audiologist) months ago but had too much wax in his ears. He said he should have been seen again but never had another appointment. Resident #47 said he enjoyed watching television in his room but either had to sit so close to the television he could not see the picture but hear the sound or lie down in bed and see the picture but not hear the sound. He said he was bothered by this. Resident #47 said he did not have hearing aids and wanted a pair. C. Record review: The communication care plan, initiated on 6/19/20 and revised on 1/18/24, revealed Resident #47 was hard of hearing but did not wear hearing aids. It indicated the resident would effectively communicate his needs through the next review date. Pertinent intervention included consulting audiology. The 4/6/23 audiology patient visit note revealed Resident #47's hearing test was not completed related to occluding cerumen, bilaterally (both ear canals were blocked with earwax). It revealed the audiologist was unable to remove the wax and recommended Resident #47 receive ear drops with irrigation for seven consecutive days right before the next scheduled appointment and for facility to schedule a second attempt at a hearing test. The 7/19/23 audiology patient visit note revealed Resident #47 had not received ear wax drops and a test would be attempted at a future visit. -There was no documentation in Resident #47's electronic medical record (EMR) to indicate the facility had obtained a physician's order for ear wax drops after the 4/6/23 or the 7/19/23 audiology visits. -There was no documentation in the resident's EMR that indicated the resident had been scheduled for another audiology appointment following the 7/19/23 appointment. C. Staff interviews The social services director (SSD) was interviewed on 2/14/24 at 9:00 a.m. She said when the audiologist was finished seeing patients the patient visit notes were given to social services. The SSD said if a medication recommendation was made, the information was given to the resident's nurse who would discuss the recommendation with the doctor so an order could be obtained. The SSD was interviewed again on 2/14/24 at 2:00 p.m. The SSD said the recommendation made by the audiologist on 4/6/23 for Resident #47 to receive ear wax drops with irrigation had not been communicated to the nursing department by social services, nor had the recommendation been communicated after the second visit on 7/19/23. The SSD said she had spoken to Resident #47 at 11:30 a.m. on 2/14/24 (after the concern was brought to the facility's attention). She said he reported difficulty in hearing and was in agreement to schedule an audiology appointment. The NHA was interviewed on 2/14/24 at 3:00 p.m. The NHA said when the audiologist was finished seeing residents and had written their visit notes, copies of the notes went to the social services department. She said it was social services' responsibility to review the notes and disburse information to the appropriate disciplines for follow up. She said if there was a recommendation from the audiologist for ear wax being removed prior to an exam happening nursing should have been informed so they could have contacted the physician to review and initiate the appropriate order. The NHA said she would work with nursing and social services to achieve completion of an ear exam to include the order for ear wax drops prior to exam for Resident #47.

Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one Resident (#1) out of three residents reviewed for blood sugar managements out of a total sample of six residents. Resident #1, who had a diagnosis of diabetes and was on diabetic medication, did not have his blood glucose levels consistently monitored by the facility. Resident #1 was sent to the hospital on 10/18/23 when he was lethargic with a diagnosis of hyperglycemia. For three days, 10/25/23 to 10/27/23, Resident #1 had high blood glucose readings above 300 milligrams per deciliter (mg/dl), with normal being 70-130 mg/dl. The facility staff failed to monitor the resident for signs and symptoms of high glucose levels. Two weeks later, on 11/2/23, the resident was sent to the hospital with hyperglycemia. Findings include: I. Professional reference The Mayo clinic Hyperglycemia in Diabetes, revised on August 2022, retrieved on 11/30/23 at https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631, read in pertinent part, For many people who have diabetes, the American Diabetes Association generally recommends the following target blood sugar levels: Between 80 and 130 mg/dL before meals Less than 180 mg/dL two hours after meals. If the blood sugar level is 240 mg/dL or above, use a urine ketones test kit. If the urine test is positive, the body may have started making the changes that can lead to diabetic ketoacidosis. It's important to treat hyperglycemia (high blood sugar level). If it's not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it's not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart. Symptoms of hyperglycemia develop slowly over several days or weeks. The longer blood sugar levels stay high, the more serious symptoms may become. If hyperglycemia isn't treated, it can cause toxic acids, called ketones, to build up in the blood and urine. This condition is called ketoacidosis. Symptoms include: fruity-smelling breath, dry mouth, abdominal pain, nausea and vomiting, shortness of breath, confusion, and loss of consciousness. II. Facility policy and procedures The Diabetic Management policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 11/29/23. The policy read: Diabetic Management involves both preventative measures and treatment of complications. From admission, the interdisciplinary team works together to implement a plan of care to minimize complications. Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure orders are received and are accurately related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow in communicating with the physician. To ensure appropriate nutritional orders are in place (enteral nutrition, diet, supplements, snacks). To ensure preventative skin care measures are in place. To ensure monitoring for signs and symptoms of hyperglycemia or hypoglycemia episodes. Routine Care: Blood glucose values are taken per the physician order. Antidiabetic agents (insulin or oral antidiabetic agents) are administered per physician order. Sliding Scale insulin is administered per physician orders. Diabetic foot care is provided during daily routine care. Residents are monitored for signs and symptoms of complications. Any identified complication is reported timely to the physician. III. Resident status Resident #1, age 90, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included diabetes, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), aortic aneurysm (an excessive enlargement of an artery), emphysema (damage of lung tissue) and Alzheimer's dementia. The 11/14/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required substantial/maximal assistance with meals and was dependent on staff for other activities of daily living (ADLs). IV. Record Review The care plan for diabetes, initiated on 4/26/23 and revised on 11/13/23, revealed the resident had diabetes. Interventions included to check skin routinely, administer medication as ordered by physician, monitor and document any signs of hypo or hyperglycemia. -Resident #1's care plan did not mention specific treatment that the resident was receiving for diabetes. The medical administration record (MAR) for November 2023 revealed the resident was receiving the following medication: Glipizide 5 milligrams (mg), one tablet every day for diabetes; and, Fasting blood sugars to be taken as needed for signs and symptoms of hypoglycemia and hyperglycemia, if blood sugar is 70 mg/dl or below or 400 mg/dl or above, call a physician. The order was initiated on 4/26/23. -Resident #1's fasting blood sugar levels were not checked (the MAR was not signed) as needed in October and November 2023. A. hospitalization on [DATE] On 10/12/23, a nurse progress note documented the resident was lethargic. His vital signs were within normal limits. -The blood glucose level was not checked at the time. On 10/15/23 a nurse progress note documented that the resident refused all meals and was sleeping and would not fully wake up. -The blood glucose level was not checked at the time. On 10/17/ 23 the resident was assessed by nurse practitioner (NP) #1 due to nursing report decreased verbalizations, increased time in bed, decreased meal intake. At the time of the visit NP #1 documented patient with no verbal response or interactions with provider or staff. The note read resident's diabetes was managed with oral medication and blood sugars were no longer monitored. Regarding fatigue, it was documented: Frail elderly gentleman, with history of recurrent pneumonia. Persistent fatigue most likely secondary to advanced age. -The blood glucose level was not checked at that time of the visit. On 10/18/23 at 6:06 p.m. a nurse progress note documented resident having increased lethargy, abnormal lung sounds, and decreased level of consciousness. Provider on call was contacted, chest x-ray and labs were ordered. -The note did not include the resident's vital signs and blood sugar levels. -At 8:48 p.m. the resident was assessed by a next shift nurse who documented the resident's vital signs within normal limits and blood sugar of 500 mg/dl. Resident's family requested hospitalization . The emergency medical technician's report documented the resident was unconscious in bed, minimally responsive to pain. Resident #1's family was on scene and requested transport to the hospital. The hospital admission summary dated 10/18/23 revealed the chief complaint was altered mental status.The primary reason for admission was encephalopathy (damage or disease that affects the brain). The resident was unresponsive and was reacting only to painful stimuli. He was admitted to the intensive care unit and started on sliding scale insulin. During the hospital stay the resident was diagnosed with sepsis (life threatening complication from infection), encephalopathy and hyperglycemia (high blood sugar) and acute kidney insufficiency with dehydration. On 10/25/23 the resident was discharged back to the nursing facility. Discharge orders did not include any changes to the diabetes treatment. The resident started back on Glipizide, an oral medication for diabetes. -Upon readmission blood sugar checks were not initiated. B. hospitalization on [DATE] At the time of admission to the nursing facility on 10/25/23 the resident was alert and oriented. The progress note on 10/25/23 documented that the resident's daughter requested blood sugar checks to be initiated for the resident. The on call provider was contacted by the nursing staff and blood sugar checks were initiated four times a day for two days. -The order did not specify when and if a physician should be contacted. According to the October 2023 MAR, the resident's blood sugars were consistently above normal range: On 10/25/23 the blood sugar was 232 mg/dl; On 10/26/23 it was 238, 276, 378, 382 mg/dl; and, On 10/27/23 it was 294, 390 and 365 mg/dl. On 10/27/23 blood sugar checks were discontinued. -The review of progress notes from 10/25/23 to 10/27/23 revealed no evidence that abnormal blood sugar levels were reported to the physician. A progress note on 10/30/23 documented patient very sleepy today, was too tired to eat breakfast. Lunch he ate but needed to be woken up continuously throughout the meal. On 10/31/23 the resident was assessed by NP #1. The note mentioned that the resident's diabetes was managed with Glipizide and daily blood sugars were no longer monitored. -There was no mention regarding the resident's elevated blood sugars between 10/25/23 and 10/27/23. At the time of the assessment, the resident's blood sugar was not checked. The nurse progress note on 10/31/23 documented nursing staff reached out to NP #1 to report that the resident was not getting up and non arousable for meals. NP #1's response was she would reach out to the family to discuss further options. On 11/1/23 the resident was assessed by NP #1. The note mentioned the resident's diabetes was managed with Glipizide and daily blood sugars were no longer monitored and persistent fatigue most likely secondary to advanced age. The interdisciplinary team (IDT) note on 11/2/23 documented the resident was reviewed due to recent hospitalization on [DATE]. The fasting blood sugar levels for the resident were running between 100 and 400 mg/dl and he was no longer on blood sugar checks per doctor's order. On 11/2/23 at 2:15 the nurse progress note revealed EMTs (emergency medical technicians) are here to transfer the resident to the emergency room . The transfer was related to altered mental status and hyperglycemia (increased blood sugar). Resident's blood sugar level was documented by EMTs as 590 mg/dl. The hospital admission note dated 11/2/23 read: Patient presents with worsening generalized weakness, hyperglycemia and increased oxygen requirement. He feels somewhat short of breath but denies chest pain. He has rhonchorous (abnormal) lung sounds. Remainder of his exam is only significant for clinical dehydration. He is hyperglycemic without evidence of DKA (diabetic ketoacidosis). He does have an acute kidney injury, likely from dehydration. Chest x-ray does not show significant infiltrate. He has received intravenous (IV) insulin and IV fluids. He has continued pneumonia with elevated lactate, hyperglycemia without DKA and dehydration with an acute kidney injury. I feel that his elevated lactate is more due to his dehydration and hyperglycemia. I do not feel that he is septic. He is not tachycardic (fast heart rate) and not febrile (fever). Resident #1 came back to the nursing facility on 11/8/23, after six days of hospitalization . He was started on sliding scale insulin and blood sugar checks. V. Staff interviews NP #1 was interviewed on 11/29/23 at approximately 1:00 p.m. She said she could not recall in detail- Resident's #1 hospitalization s for the last couple of months. She reviewed her notes and did not locate any information regarding Resident#1's blood sugar levels between 10/25/23 and 10/27/23. She said she did not review the October 2023 MAR and was not aware that the resident's blood sugar levels were high at that time. Licensed practical nurse (LPN) #2 was interviewed on 11/29/23 at 2:30 p.m. She said signs and symptoms of high blood sugar included thirst and changes in level of consciousness. She said residents who were diabetic, but not on insulin, should always be monitored for signs and symptoms of high blood sugar. She said blood sugar levels in the range of 300 mg/dl should be reported to the physician as it was an abnormally high level. Registered nurse (RN) #1 was interviewed on 11/29/23 at 2:50 p.m. He said Resident #1 had an as needed order for blood sugar checks to be completed. He said the order read the physician should only be notified if blood sugar levels were above 400 mg/dl. The director of nursing (DON) was interviewed in the presence of the nursing home administrator (NHA) on 11/29/23 at 3:45 p.m. She said the facility's policy and procedures for diabetes management did not define when to contact the physician. She said it was up to physicians to place an order and specify when they should be contacted. She said the nursing staff followed facility protocol and physician orders. She said Resident #1's order read to notify physicians only if blood sugar levels were below 70 mg/dl or above 400 mg/dl. VI. Facility follow-up On 11/29/23 the facility submitted a letter signed by a primary care physician (PCP) for Resident #1. The letter read: On the dates of October 25, 26 and 27, 2023, regarding (Resident #1), the nurses followed proper protocol and standing orders for reporting blood sugars with the parameters of calling MD for blood sugar less than 70 or greater than 400. -However, Resident #1 was hospitalized for hyperglycemia on 10/18/23 and two weeks later was hospitalized on [DATE] due to the facility's failure to continue to monitor the resident's blood glucose levels.

Based record review and interviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (#3) of six out of six sample residents. Specifically, the facility staff failed to investigate an unwitnessed fall that Resident #3 said it occurred in her room that resulted in bruising. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 3/8/23 to 3/14/23, resulting in the deficiency being cited as past noncompliance with a correction date of 3/6/23. There were no additional issues identified with resident falls. I. Facility policies and procedures The Fall Management policy, revised January 2023, was provided by the nursing home administrator (NHA) on 3/9/23 at 10:14 a.m. The policy revealed the facility assisted each resident in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, assistive devices and/or functional programs; as appropriate, to minimize the risk for falls. The interdisciplinary team (IDT) evaluated each resident's fall risks and a care plan was developed with implementation, based on this evaluation, with ongoing review. A fall was described as an event in which an individual unintentionally came to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (a resident pushes another resident). The event might be witnessed, reported, or presumed when a resident was found on the floor or ground, and could occur anywhere. When a fall occurred, the resident would be assessed for injury by a nurse. The nurse would enter the event information into risk management. complete a post fall assessment and initiate the Interdisciplinary Post Fall Review UDA (used defined assessment). The nurse would communicate the resident's fall to the attending physician, the resident's representative and documents in the medical record. The nurse would communicate the resident's fall to the IDT and initiate interventions to reduce the potential of additional falls. The IDT would review all resident falls within 24-72 hours to evaluate circumstances and probable cause for the fall. The resident's care plan would be reviewed and/or revised as indicated. Fall trending and analysis information would be reported to the Quality Assurance and Performance Improvement (QAPI) Committee. In the event a resident had a fall and it was determined they hit their head (the fall was witnessed, it was obvious there was a head injury, or the patient could verbalize they hit their head), or it could not be determined if they hit their head ( the fall was unwitnessed or the resident could not verbalize if they hit their head), the nurse would initiate the following actions: all items that were listed under Fall Event above are completed and neurological assessments would be completed and documented per instructions. II. Performance improvement project (PIP)/facility's actions The PIP for falls, initiated on 2/20/23, was provided by the NHA on 3/9/23 at 10:14 a.m. The opportunity for improvement revealed the facility staff were to review falls in a timely manner, conduct registered nurse (RN) assessments, neurological assessments, post fall assessments and have immediate interventions in place. The IDT would review the fall within 24-72 hours for recommendations and care plan updates. The PIP also revealed that residents' care plans were vague and not resident specific. The specific, measurable, achievable, relevant and time bound (SMART) goal was for all falls there would be a situation, background, assessment and recommendation (SBAR), RN assessment, neurological assessments if the resident's head was involved or the resident had an unwitnessed fall including falls that were reported by the resident, post fall assessment, Morse Fall Scale, IDT review and progress note within 24-72 hours, and a care plan update. Care plans would be comprehensive and include resident specific interventions as appropriate. The PIP root cause was staff turnover and the high use of agency staffing. PIP obstacles were staff education and the high changeover of staff. The projected outcome for the PIP was for all falls to be reviewed in a timely manner, RN assessments, neurological assessments, post fall assessments and immediate interventions would be in place to keep residents safe. The IDT would review falls within 24-72 hours with care plans updated and further recommendations. -Start date of 2/21/23: Audit of all residents with falls in the last 60 days to ensure RN assessments, neurological assessments, post fall assessments, immediate interventions, IDT review and care plan revisions have been completed. Actual completion date was 2/24/23. -Start date of 2/27/23: Audit of all new admissions in the last 90 days to ensure preventative fall measures were in place and a Morse Fall Scale was completed. Actual completion date was 3/3/23. -Start date of 2/27/23: Audit of all residents at risk for falls for comprehensive care plan for fall prevention. Care plans would include risk act factors such as seizures. Actual completion date was 3/6/23. -Start date of 2/21/23: Educate IDT to review all falls within 24-72 hours that must include complete SBAR, RN assessment, post fall review, Morse Fall Scale, immediate new intervention by a licensed nurse, IDT note of review, new recommendations, and care plans updated. Actual completion date was 2/21/23. -Start date of 2/21/23: Educate licensed nurses to complete SBAR, RN assessment, neurological assessments if the resident's head was involvement, or an unwitnessed including falls reported by residents, Morse Fall Scale, and implement immediate new intervention until IDT reviewed for further recommendations, such as a licensed nurse could implement, increased rounding, ensuring call lights in reach, add mat to floor, educating the resident, pacing sign to use call light etc. Actual completion date was 2/28/23. -Start date of 2/21/23: educate licensed nurses to implement fall precautions for new admission at risk. Preadmission, review referral information for fall risk, implement fall plan on arrival. Actual completion date was 2/28/23. -Start date of 2/21/23: Falls protocol in agency book. Actual completion date was 3/2/23. -Start date of 2/21/23: Evaluate effectiveness in monthly QAPI (quality assurance and performace improvement) Meeting. Nurse managers will do daily checks for RN assessments, neurological assessments, post fall assessments and immediate interventions for all current resident and future admission falls. Target date to be determined; status ongoing. -Start date of 2/21/23: Modify Action Items in monthly QAPI meeting based on effectiveness. Target date to be determined; status ongoing. III. Resident #3 A. Resident status Resident #3, age 59, was admitted on [DATE] and was discharged on [DATE] to another facility. According to the January 2023 computerized physician orders, pertinent diagnoses included altered mental status, metabolic encephalopathy (problem in the brain), muscle weakness, repeated falls, epilepsy, conversion disorder with seizures or convulsions. The 1/6/23 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview of mental status (BIMS) score of 11 out of 15. The resident did not have any behaviors. The resident required staff supervision for bed mobility, transfers, dressing, eating, toileting, and personal hygiene. B. Record review The care plan for falls related to gait, balance problems, and unaware of safety needs was initiated on 2/20/23. The interventions were for staff to anticipate and meet the resident's needs; ensure the resident's call light was within reach, and encourage the resident to use the call light for assistance as needed. Staff were to respond promptly for all requests for assistance and follow the facility fall protocols. -This care plan did not include that staff were to monitor resident's skin for excessive bruising. The plan also did not include that the resident would fall and would not tell staff that she had fallen in a timely manner. The care plan for an actual fall with related poor balance and unsteady gait was initiated on 2/20/23. Some of the interventions were to continue to work with therapy on balance and strengthening. Therapy would continue to work with the resident for safe functional ability. Staff would complete neurological assessments per protocol and physician orders. -The plan also did not include that the resident would fall and would not tell staff that she had fallen in a timely manner. A Weekly Head to Toe Skin Check, dated 12/30/22 at 3:50 p.m., was performed by the director of nursing (DON). The skin check revealed new and existing bruises to the right shoulder measuring 1.5 centimeters (cm) by 1.0 cm; left buttock measuring 5 cm: right trochanter measuring 18 cm by 3 cm; and left knee (no measurements). The left buttock was circular in size and the left knee bruise was very faded. The bruise to the left arm was fading and was approximately 5 cm by 2 cm. The bruise to the right shoulder was fading and old. An Evaluation and Management encounter note dated 12/30/22 by a nurse practitioner (NP) revealed the DON reported that the resident had a bruise on her hip with some pain. The resident tended to bump into things and had an unsteady gait. The resident did have a history of falling, was a poor historian and was very forgetful. The resident had repeated (two) falls since her admission and now had some bruising and pain on the hip. The resident did not remember how the bruising occurred. The resident answered questions to the best of her ability; but she was repetitive in answers, had poor safety awareness and wandered with the use of a walker. The NP wrote she was unsure of the resident's ability to give accurate information due to conflicting statements she made. The assessment and plan revealed the resident had repeated falls. The resident was to continue with physical/occupational therapies and safety measures per facility protocol. The resident had a history of falling and had some bruising on the hip. The NP ordered x-rays to evaluate the hip and monitor for improvement. This encounter was electronically signed on 1/12/23 at 9:59 p.m. The physician order dated 12/30/22 at 4:01 p.m., revealed to obtain a right hip x-ray due to the resident's complaint of pain and bruising. The SBAR dated 12/30/22 at 5:06 p.m., revealed the resident had a bruise to the right hip starting on 12/30/22. A right hip x-ray was to be taken as ordered. The resident was unsteady on her feet and tremulous (shaking). The resident bumped into walls and other things. The resident's daughter said the resident frequently fell at home. The daughter believed the resident might have fallen or bumped into something like a door or her walker. A nurse note by a licensed practical nurse (LPN) dated 12/31/22 at 12:51 p.m., revealed the resident's skin was assessed. The resident had bruises that had already been reported and no new bruising was observed. Staff would continue to monitor and educate the resident to walk slower and try not to bump into things. A Morse Fall Scale assessment was completed on 1/1/23 at 6:00 p.m. The assessment revealed the resident had a score of 80 or was a high fall risk. The resident had a history of falling and required a cane or walker for ambulation. The resident exhibited a weak gait and was forgetful of her own safety limits. An Acute Visit note dated 1/4/23 by a NP revealed the 1/12/23 x-rays of the right hip revealed no acute fractures, dislocations or osseous abnormalities. The resident appeared to be weight bearing without limping or wincing. The resident has not had any seizures since her admission. The resident had repeated falls, was to continue with physical/occupational therapies and safety measures per facility protocol. The resident had a history of falling and had some bruising on the hip. The NP ordered x-rays of the hip to evaluate, reviewed the results with the resident and nursing: there were no acute findings. The resident was to continue therapies and monitored for improvement. This was electronically signed 1/12/23 at 10:20 p.m. A progress note dated 1/5/23 at 9:42 p.m., by the assistant director of nursing (ADON) revealed IDT reviewed the risk plans of care for the resident. The resident was alert with confusion. The resident was a high risk for falls with a score of 80 and had two falls since admission. The resident had no current skin issues. The SBAR dated 1/8/23 at 6:00 p.m., by the DON revealed bruising to the resident's pubic area that started on 1/8/23. The resident reported that she fell out of bed and this was the cause of the bruise. The resident was a frequent faller, wandered about the facility, and kept her room door closed. The resident was able to get up from the floor by herself. Staff were to monitor the resident's whereabouts and attempt to keep the resident's room door open to frequently observe the resident. The resident had a bruise to the right hip and lateral. The bruise was scattered and appeared to be blood that traveled from the hip. The bruising to the hip was almost healed. The bruise was observed with a certified nurse aide (CNA) and the resident's daughter. Nurse note dated 1/8/23 at 6:10 p.m., by registered nurse (RN) #1, revealed the resident's daughter was in the facility and called this nurse to the resident's room due to a large purple bruise with swelling to the resident's pubic bone area. The CNAs told her that the resident had a shower yesterday and the bruise was not present. The resident said the bruise occurred when she fell out of her bed the other day. The resident said a doctor had come in and checked her out. The resident was adamant that she fell out of bed. The nurse manager on call was notified. Physician's order dated 1/9/23 at 2:03 p.m., revealed to obtain an x-ray of the resident's pelvis related to pain and bruising. Nurse note dated 1/10/23 at 8:54 a.m., by the DON revealed the pelvic x-ray done 1/9/23 was negative for fracture. -Review of the resident's record did not reveal a fall investigation when the resident had indicated she had fallen on 1/8/23. Evaluation and management note dated 1/10/23 by NP revealed the resident had a reduction in cognition, increased confusion, wandering and a reduction in activities of daily living. Resident had a recent bruise on a hip and did not remember how it occurred. The assessment and plan revealed the resident had baseline cognitive deficits that were consistent with likely underlying dementia. Due to the resident's wandering, falls and poor safety awareness; the resident would qualify for a secure dementia care unit for her safety. This note was electronically signed 1/12/23 at 11:04 p.m. On 1/11/23 at 4:15 a.m., the resident was on 15-minute checks that ended on 1/18/23 at 7:44 a.m. A Weekly Head to Toe Skin check dated 1/13/23 at 6:04 p.m., by the DON revealed existing bruises, bruising to the right hip and the bruise was flowing downward toward the symphysis pubis. The groin and right trochanter (hip) had no measurements and was noted as old bruises. Nurse note dated 1/22/23 at 1:31 p.m. by RN #1 revealed the resident complained of being dizzy, had slow speech and was unable to sit upright or stand. The resident's pupils were equal and reactive. The resident had equal hand grips. The resident said she tried to get up during the night, fell backward and hit her head on the wall. No bruising was noted. This was the first time the resident had mentioned she had a fall last night. The resident said she had not told any staff about the fall. While this writer was on the to a physician, the resident's daughter came out of the resident's room and complained the resident had right arm numbness and appeared to have a left facial droop. The physician ordered the resident to be sent to the emergency department by ambulance for evaluation. A call was placed to 911 and the resident left the facility at 1:00 p.m. The daughter accompanied the resident. The ADON was notified. Hospital Encounter Notes dated 1/22/23 1:27 p.m., revealed the resident had neurological disorders of dementia, altered mental status and a seizure disorder. The notes revealed negative x-rays for the pelvis and bilateral femurs. The resident had significant bruising over the thighs and hips. The resident had tenderness with palpation of the right hip and pubic symphysis on exam with known ecchymosis to the pelvic prior to admission. The resident's abdomen was soft and non-distended, and moderately tender to palpation at the suprapubic region with overlying ecchymosis. The resident was tender to palpation to the pubic symphysis, right hip with no lower extremity edema, non-tender and symmetrical. There was ecchymosis (discoloration due to bleeding typically a bruise) to the introits (entrance) in a ring like fashion without any superior tracking to the bruise at the pelvic bone. When asked about the pelvic bruising the resident's daughter she said the resident fell . IV. Additional fall documents The NHA provided a typed/signed document dated 1/8/23 (not timed) that was not included in the resident's medical record. The document revealed the NHA had interviewed the resident regarding the bruise to the pubic area and the resident said it was the result of her falling out of bed. The resident said she fell out of bed last night or the night before. The resident said she was not fearful or scared of any staff or residents. She said she was not injured by anyone and that she liked residing in the facility. The resident had no changes in mood or behavior. The resident consistently said pubic bruise was caused by her falling out of bed. The NHA wrote that the resident's daughter said her mother had a history of falling and getting herself up from off the floor. The daughter said when she took care of her mother at home, she would fall and not say anything, bruising would be observed and then the resident would say that she had fallen. The NHA wrote that the daughter said she felt this pubic bruising was from a fall out of the bed. The interventions were to monitor the residents' whereabouts, encourage the resident to keep her room door open so she can be observed for falls (resident liked to keep the door closed). The conclusion revealed the resident had a history of falls where she had gotten herself up and not reported the fall. There was no allegation of abuse made by the resident toward another person, the resident consistently said she fell out of bed, which caused the bruising. The resident had no change in mood or behavior that was observed by staff or the resident's daughter. There was no suspicion of abuse to the resident. Staff would continue to monitor the resident. The DON provided a typed document regarding interventions for falls and bruising for this resident dated 3/14/23 at 10:14 a.m. The document revealed the resident's metal bed edges were padded with foam on 1/8/23. The resident was placed on 15-minute checks from 1/11/23 to 1/18/23. The resident was encouraged to keep her room door open in order to allow staff to observe. The resident's room was close to the nurse's station. The staff performed frequent staff rounding to ensure the resident was safe. The staff encouraged the resident to use a walker at all times in and out of her room. The resident was encouraged to slow down when ambulating in order to pay attention to where she was going. The staff performed care in pairs with the resident. Therapy staff worked with the resident for strengthening, balance, gait and transfers. V. Staff interviews CNA #1 was interviewed on 3/13/23 at 3:22 p.m. She said the resident's daughter came to the facility (Wednesday) and she was asked to accompany the daughter into the resident's room because she wanted to show her something. She said herself, the resident and the resident's daughter went into the bathroom and the resident pulled down her pants. The resident had new bruising to the pubic area that was dark purple and black red in color. The area was slightly swollen. The CNA said the resident said she did not know how this happened but she thought she had fallen. She said the resident did have an old bruise to her right hip and it was yellow in color. She said on the Saturday prior to this Wednesday, the pubic bruise was not there. She said the resident did not make any statements that she had been hit/abused nor that she was afraid of any staff or residents. The CNA said the resident was not cognitive enough to make her own decisions. She said the resident called her by the name of an old high school friend and not by her real name. She said the resident sometimes got angry at CNAs that she did not like and did not want them to provide care to her. She said the resident always bumped into things and this also occurred when she used her walker. She said the resident probably had falls, especially in her room, that she did let anyone know had occurred. She said some of the interventions to help prevent falls for this resident were to encourage her to keep the door to her room open, have her sit near the nurse's station, use her walker at all times during ambulation (sometimes she forgot), foam piping (noodles) on the metal frame of the bed, and the use of a soft fabric recliner in her room. She said the daughter told her that the resident bruised easily. Licensed practical nurse (LPN) #1 was interviewed on 3/13/23 at 3:38 p.m. She said she saw the bruise on the resident's right hip on a Monday. She said the bruise looked new and purple. She said the pubic bruise was not on the previous skin check. She said she did a skin check on the following Monday (one week later) and there was a bruise to the pubic area (purple and starting to change colors). She said she was not told how it occurred. She said it might have been blood draining from the other bruises to this area. She said all of the other bruises were fading. She said the resident consistently ran into things. She said the resident was fast and impulsive in her actions. She said the resident did not say any staff or residents had hit her. She said for interventions the staff encouraged her to keep the door to her room open. She said at times the resident liked to keep the door closed. The staff also encouraged her to keep using her walker, walk slower, stay close to the nurse's station and the facility placed foam noodles on the bedframe and footboard. She said if the resident fell , she might or might not tell the staff. She said the daughter told her that the resident bruised easily. RN #1 was interviewed on 3/14/23 at 8:16 a.m. She said the daughter found the bruise and called her into the resident's room. She said the resident had a bruise on the pubic bone and it was dark purple and the area did not appear to be swollen. She said the hip bruise was fading and had a yellow-green color. She said the resident said she fell off the bed and was unable to remember when this occurred. She said the resident did not make any statements that anyone had hurt her. She said there was a CNA that she did not like and made statements at times that this CNA hit her (the facility had conducted two separate abuse investigations when the resident made two separate statements about this CNA and both of them were unsubstantiated). She said the resident would often make statements that were not true. She said the resident had the ability to get herself up from off the floor and often bumped into stuff. She said some of the fall interventions for this resident were to remind the resident to use her front wheeled walker (she forgot at times), encourage the resident to keep her room door open, encourage the resident not to sit on the floor (she liked to sit on the floor) and implement 15-minute checks as necessary. She said the resident liked to stand up at the foot of the bed, retrieve items from her dresser, and then lean forward (bent at the pubic area, over the footboard) as she placed the items on the bed. She said this might have caused the pubic bruise. The account manager (AM) was interviewed on 3/14/23 at 11:55 a.m. She said she was the resident's ambassador (advocate) and spoke with the resident almost on a daily basis. She said to her knowledge the resident had never mentioned any staff or resident was abusive to her. She said the resident never mentioned that she had any bruising. She said the resident was off balance at times when she walked and at times did not use her walker. She said the resident did not tell her if/or when she fell . The social services director (SSD) and the social services assistant (SSA) were interviewed on 3/14/23 at 12:06 p.m. They said they talked with the resident almost daily when passing down the hallways. They said the resident never mentioned anything about any staff or residents abusing her. They said the resident never mentioned anything regarding bruising. They said the resident did have a few falls in the facility. They said the resident used a front wheeled walker with a seat. They said when they observed the resident, she was always using the walker. They said the resident walked briskly and was focused on her walking and not her surroundings. They said when they talked with the resident's daughter, she never mentioned anything about falls or bruising. The NHA was interviewed on 3/14/23 at 9:00 a.m. He said there were no concern or complaint forms from the resident or the family regarding abuse, bruising (especially in the pubic area) or falls. He said neither the hospital nor the police had contacted him regarding abuse or bruising of the resident. He said the facility had completed two investigations regarding the resident's allegation of staff hitting her. He said for each allegation, there were two staff members present (care in pairs), no evidence of abuse and both were unsubstantiated. He said the resident did have a bruise to the pubic area and had made a statement that she had fallen. The NHA said the resident had the ability to get herself up from the floor without staff assistance. The NHA said there were no care plans for the bruising, bumping into walls (things) nor about telling staff she had fallen in a timely manner after a fall. On 3/14/23 at 1:10 p.m., an interview was conducted with the NHA, DON, director of clinical Services (DCS) and the director of operations (DOO). The DON said the bruising to the pubic area was scattered and not one large bruise. The DON said there were no measurements of the bruising due to the scattering. The DON said there was no large bruise to this area and the area was not swollen. The DON said the daughter brought the bruise to the pubic area to the attention of RN #1. The DON said she observed the bruising to the pubic area and then wrote the SBAR. The DON said the resident told her that she fell out of bed and this was the cause of the bruise. The DON said the resident had dementia and did not say when she fell out of bed. The DON said the RN that wrote the note on 1/8/23 at 6:10 p.m., did not specify the time she and the daughter went into the room and this might be the reason her SBAR was timed before the nurse note. The DSC agreed there was no documentation in the NP notes of bruising in the pubic area. The DCS said the resident's multiple bruises were measured on the Weekly Head to Toe Skin Check dated 12/30/22 at 3:50 p.m., by the DON in the presence of the resident's daughter. The DCS said there were additional skin checks that were completed on the resident, however there were no additional measurements for those bruises. The DCS said there was no documentation that the bruises worsened. The DCS said that there was no clinical rationale to keep measuring the bruises. The DCS said it was believed that the bruising was due to the resident bumping into things. The DCS said it was thought that the bruising of the hip had traveled to the pubic area. The DCS said the facility had ruled out abuse by interviewing the resident and no investigation had been conducted. The DCS said the resident was not fearful and had no concerns with staff. The DCS said since there was no investigation, the Ombudsman nor the police had been contacted. The DCS said since the resident told them how the pubic bruise had occurred from a fall out of bed, they did not consider it a bruise of unknown origin. The DCS said after the resident said she had fallen out of bed, the facility did not do a post fall assessment of the resident, neurological assessments, complete a SBAR of the fall, complete Morse Fall Scale, IDT review nor complete an incident report. The DCS said the facility had developed a performance improvement project (PIP) for falls. The DCS said there were no specific care plans for the resident walking into things or for not telling staff of her falls in a timely manner. The DCS said the resident was at risk for falls and this statement encompassed the safety concerns for the resident. The DCS said the resident's forgetfulness encompassed the resident not telling staff of her falling in a timely manner. The DCS said the was impulsive and the resident's fall interventions were to encourage the resident to walk slower in the facility, place foam padding on the metal bed rails, encourage the resident to keep her room door open, encourage her to use her walker in her room, encourage the resident to use her walker in the hallways, have the resident's room close to the nurse's station, have physical/occupational therapies, frequent staff rounding and placed the resident on 15-minute checks for seven days. The DCS said the daughter had told the facility that the resident had fallen at home, gotten herself up from the floor and did not tell her about the fall at that time. The DCS said the resident's fall interventions were not listed on her care plans and this was part of the PIP.

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to maintain nurse unit refrigerators used for resident snacks and nourishment on three of three nurse units with proper temperatures to prevent foodborne illness, and without accurate temperature logs or cleaning. These failures had the potential to cause foodborne illness among residents who eat food prepared in the facility's kitchen and stored in the unit refrigerators. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/Reg_BOH_RetailFoodRegulations.pdf, read in pertinent part, Ready-to-Eat, Potentially Hazardous Food (Time/Temperature Control for Safety Food) served in facilities providing food to highly susceptible populations shall adhere to the following date marking requirements: Refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 F (farenheit) or less for a maximum of 7 days. Cleaning, frequency and restrictions. Physical facilities shall be cleaned as often as necessary to keep them clean. Equipment, food-contact surfaces, nonfood-contact surfaces, and utensils shall be clean to sight and touch. Nonfood-contact surfaces shall be cleaned at a frequency necessary to preclude accumulation of soil residues. II. Facility policies and procedures The Food Storage: Cold Foods policy and procedure, revised April 2018, was provided by the nursing home administrator (NHA) on 11/16/22 at 9:30 a.m. It read in pertinent part, All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. All perishable foods will be maintained at a temperature of 41 degrees F (fahrenheit) or below, except during necessary periods of preparation and service. Freezer temperatures will be maintained at a temperature of 0 degrees F or below. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. All foods will be stored and wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. The Cleaning and Sanitizing Dietary Operations policy and procedure, undated, was provided by the dietary district manager (DDM) on 11/17/22 at 11:00 a.m. It read in pertinent part, Purpose: To educate all new hires and current employees on the importance of and proper method for cleaning and sanitizing to ensure safety for all staff and residents. Resident safety in a healthcare environment is a top priority. Cleaning and sanitizing properly is one of the most important things we continually do in our kitchens to prevent harm. -See facility follow up for in-service on cleaning and sanitizing snack refrigerators. III. Refrigerators on nursing units A. Observations and staff interviews On 11/15/22 at 10:52 a.m. the nurse unit resident nourishment refrigerators were observed. -Aspen unit: There were staff and resident snacks located in the same unit refrigerator and freezer. There was no cleaning documentation or log. The temperature log posted for November 2022 read 38 degrees F for the refrigerator. There was no documentation of the freezer temperature. The staff lunches located in the nurse unit refrigerator were not dated or labeled, there was a lasagna lunch in a tupperware. Some staff drinks were labeled with names but no date. Licensed practical nurse (LPN) #2 said she was not sure who was responsible for cleaning the refrigerator, maybe the housekeeping department or certified nurse aides (CNAs). In the freezer there was a large blue therapy ice pack, LPN #2 said it was used for pain management, but the resident had been discharged . LPN #2 took it out of the freezer and said she would return it to the therapy department. There were about 25 mini ice packs stored in a box in the refrigerator. LPN #2 did not know why they were there and said they had come with the insulin. There was an opened pack of four frozen waffles not labeled or dated, a frozen milkshake not labeled or dated. The refrigerator and freezer were not clean with various food stains and crumbs with blotches and spots of dried food and drink. -Silver key unit: Registered nurse (RN) # 2 said it was the responsibility of the dietary department to clean the refrigerators. There was no cleaning documentation or log. The temperature log for November 2022 read 39 degrees F, there was no documentation of the freezer temperature. In the freezer there was a bag of opened brussel sprouts and a bag of broccoli, not dated or labeled. There were four ice cream cups that were sticky when picked up. There was one sandwich in the refrigerator for residents labeled 11/14/22 and pudding cups labeled 11/13-11/17/22. There was a lunch not labeled or dated. The refrigerator and freezer were not clean with various food stains and drips of a pink/red color and blotches and spots of dried food and drink. At 11:46 a.m. the dietary supervisor (DS) said that resident snacks were sent to the nursing unit refrigerators one time per day between 3:00-4:00 p.m. Resident snacks include fortified pudding, cheese sandwiches and peanut butter and jelly sandwiches. The DS said that no staff were assigned to clean the nurse unit refrigerators/freezers although sometimes he or other staff would clean it. The DS said the nurse unit refrigerator/freezer temperature logs were completed by the certified nurse aides (CNAs) or the DS. At 2:02 p.m. the nurse unit resident nourishment refrigerators were observed. -North unit: There was a note on the refrigerator reading that it will be cleaned on Fridays, however there was no cleaning log or documentation that it had been completed. The refrigerator and freezer were dirty with various spills, stains, stickiness, and a wet ring under the opened pickle jar. The director of nursing (DON) observed and acknowledged the unclean/unsanitized condition. The DON said she did not know who was responsible for cleaning the refrigerator/freezer. The DON observed multiple undated and unlabeled foods in the freezer and refrigerator and threw them out. The DON observed the staff lunch box and removed it and said staff should not have food in the nurse unit refrigerator. The DON said she did not know the approved cleaning/sanitization process for cleaning the refrigerator/freezer. The DON saw the temperature log that said to keep the refrigerator between 36-46 degrees F and said she was not sure of the correct safe temperature for perishable foods. -Silver Key unit: The DON observed various foods not labeled or dated in the refrigerator and in the freezer an opened unlabeled, undated bag of brussel sprouts. The temperature log did not record the freezer temperature and the thermometer inside read 38 degrees F. The DON said she would check if the thermometer was broken or if the freezer needed to be adjusted. The DON removed an old salad from the refrigerator that was not labeled or dated. -Aspen unit: The DON observed four staff drinks on the door, a V8 drink, iced teas, and soda not dated. In the freezer, the DON observed the opened pack of four waffles not labeled or dated, a milkshake not labeled or dated and four frozen dinners not labeled or dated. The DON said the frozen dinners may belong to a residents, however LPN #2 said she thought that residents may have been discharged . The DON viewed the 25 mini ice packs and said there should be no ice packs in the freezer. LPN #2 showed her the large blue therapy ice pack that she removed from freezer earlier and the DON said it should not have been in the freezer and asked LPN #2 to return it to the therapy department. At 2:40 p.m. The DS acknowledged that the temperature log signage sheet was incorrect, it was posted on the refrigerators stating that nurse unit refrigerator temperatures should be kept between 36-46 degrees F. The DS said he would get that corrected and write the correct temperature range on the logs. The DS said he would create a cleaning log for the resident snack refrigerators. On 11/16/22 at 10:04 a.m. the DDM observed the inspection of the North nursing unit snack refrigerator and freezer. They appeared to have been cleaned although there was no documentation if it had or not. The DDM said she would provide the approved cleaning/sanitization procedure. Upon further inspection, there was a blue therapy ice pack in the freezer, the DDM said it should not be in there and removed it. The DDM observed five canned drinks in the refrigerator not labeled or dated and a staff reusable bottle, with a straw, full of liquid, not labeled or dated. The DDM removed the drinks. There was no freezer temperature log posted on the refrigerator, the DDM said she would get one. The DDM said she would put a sign on the refrigerator educating staff not to put their personal food/drink in the nourishment refrigerator and not to put ice packs in the freezer. B. Record review The Medication Room Refrigeration Temperature Log that was posted on the nurse unit refrigerators, was provided by the DDM on 11/16/22 at 10:45 a.m. It read in pertinent part, -The Silver Key nurse unit, November 2022, all refrigerator temperatures were documented to be below 41 degrees F. There was no documentation of the freezer temperatures. The bottom of the paper read that refrigerator temperatures should be kept between 36-46 degrees F. -The North nurse unit, November 2022, refrigerator temperatures were documented to be between 39 degrees F and 42 degrees F. The freezer temperatures were documented to be zero degrees F. The bottom of the paper read that refrigerator temperatures should be kept between 36-46 degrees F. -The Aspen unit nurse unit, November 2022, all refrigerator temperatures were documented to be 38 degrees F. There was no documentation of the freezer temperatures. The bottom of the paper read that refrigerator temperatures should be kept between 36-46 degrees F. C. Facility follow-up New refrigerator signage was posted, it was provided by the DDM on 11/16/22 at 10:46 a.m. It read, resident fridge is for resident food only and it must be labeled and dated prior to getting put in. Freezers is for resident food only. Ice packs cannot go in the freezer due to infection control due to food being stored in there. Thank you dietary. In-service documentation of staff in-service on snack refrigerators, dated 11/15/22 and 11/16/22, and signed by all staff members. On 11/17/22 at 11:00 a.m. the DDM provided documentation of a staff in-service on cleaning and sanitizing snack refrigerators, dated 11/16/22 and 11/17/22, and signed by six dietary staff members. -However, no cleaning log or other documentation system was provided that would demonstrate that the cleaning and sanitizing services would be completed. Updated Refrigerator and freezer temperature logs were provided by the DDS, they read in pertinent part, -Freezer temperature log, AM (morning) temp (temperature), PM (evening) temp, initials, and corrective action of temperature greater than zero degrees F. -Refrigerator temperature log, AM temp, PM temp, initials, and corrective action of temperature greater than 41 degrees F.

Based on record review and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one resident (#27) out of five sample residents reviewed for dignity out of 36 sample residents. The facility failed to treat the resident with dignity and respect by not addressing Resident #27's concerns through the grievance process. The facility failed to act upon a report from Resident #27 that the nursing home administrator (NHA) hurt her feelings by asking her to leave his office if she was there to complain, therefore the facility did not initiate the grievance process in order to provide timely follow-up and resolution. Due to the NHA not taking the resident's grievance, the resident stated she cried after what the NHA said to her about her concerns, was tearful during an interview during the survey, and stated she was afraid of retaliation when expressing her concerns. Findings include: I. Facility policy The Resident and Family Grievance policy, dated 10/1/22, was provided by the clinical nursing consultant (CNC) on 11/16/22 at 3:36 p.m. It read in pertinent part, It is the policy of the facility to support each resident's and family member's right to voice grievances without discrimination or reprisal. Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. The policy also stated that grievances may be voiced in the following forums: a. Verbal complaint to a staff member or grievance official b. A written complaint to a staff member or grievance official. c. A written complaint to an outside party. d. A verbal complaint during a resident or family council meeting. The Resident Dignity policy, undated, was provided by the facility on 11/17/22. It read, in pertinent part, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident individuality. The compliance guidelines also included: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 2. When interacting with a resident, pay attention to the resident as an individual. 3. Respond to requests for assistance in a timely manner. II. Resident #27 A. Resident status Resident #27, age 78, was admitted to the facility on [DATE]. According to the November 2022 computerized physician orders (CPO) diagnoses included, pneumonia, anxiety disorder, manic depression, asthma, chronic lung disease, and bipolar disorder. The 10/18/22 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for a mental status score of 11 out of 15. No behaviors or rejection of care were indicated. B. Resident interview Resident #27 was interviewed on 11/16/22 at 9:15 a.m. The resident said she went to the NHA's office about a month ago to discuss her concerns with him and the moment the NHA saw her, he said to her if you are here to complain then get out of my office. The resident said his statement made her sad and she immediately started crying. She said she went to the activity room and talked to an activity assistant. The resident said the activity assistant brought her to the director of nursing's (DON) office to tell her what the NHA had said. The resident said after reporting what the NHA had said, the DON responded to the resident that she was pretty sure the NHA was joking with her and he will never say something like that. The resident said she did not file a grievance as it would go to the same NHA she had the issue with. She said she told her sister who was her power of attorney (POA) about the incident. The resident said she had never gone back to talk to the NHA as he made her cry, which hurt her feelings. The resident was tearful during the interview and she said she was afraid of retaliation from the NHA. She said since the incident, no staff had talked to her about it and it was not resolved. C. Legal representative interview The legal representative was interviewed on the phone on 11/16/22 at 9:40 a.m. She said her sister mentioned to her about three to four weeks ago how the NHA had told her to get out of his office if she was there to complain about something. She said her sister was crying as she was sharing the story with her and she told her that she was afraid to tell anyone else for the fear of retaliation. She said her sister was a strong-willed woman who spoke her mind and got easily upset. She said she visited her sister every two weeks and her sister was overall positive about the nurses and aides that worked with her daily. D. Record review The comprehensive care plan with no revision date revealed the resident experienced trauma from past abuse by her husband. Interventions included continuing mental health counseling and therapy sessions. The resident did not report any triggers. In addition, the resident had bipolar disorder with reported episodes of feeling manic and difficulty concentrating. She displayed inappropriate behavior during manic episodes such as physical aggression or starting arguments. Interventions included administering medications, redirecting her behavior, and providing care in pairs. The care plan for anxiety revealed the resident had anxiety that manifested itself in repetitive questions and verbalizations of complaints and concerns. Interventions included actively listening to the resident's concerns and encouraging her to share feelings with trusted individuals. A review of the facility grievance concern forms for Resident #27 revealed no grievance forms were completed for the incident that occurred several weeks ago as the resident mentioned during her interview above. In addition, no written evidence of the investigation was provided by the facility after the resident's concerns were reported to NHA on 11/16/22 at 11:00 a.m. The resident's electronic medical record did not include notes from the resident's mental health professionals. Records were requested at the time of the survey and not received prior to the exit of the survey on 11/17/22. E. Staff interviews The activities assistant to whom Resident#27 initially reported the incident was no longer working in the facility and facility management stated they had no contact information for her. The DON was interviewed on 11/16/22 at approximately 10:02 a.m. She said she remembered that the resident came to her office crying a few weeks ago, however, she did not remember what the issue was about. She said the resident was complaining about something, she was upset, but I do not remember what it was. She usually complains about the food and I think she was upset about NHA on that day. She said the resident had a love-hate relationship with management therefore she did not follow up with her. The DON said she did not file a grievance report since she did not think it was a concerning issue. She said she would have filed a report about her concerns if she perceived it as relevant. She said even though the resident did approach her frequently with other concerns, she did not recall any previous incidents when the resident was crying while sharing her concerns. The NHA was interviewed together with the clinical nurse consultant (CNC) on 11/16/22 at approximately 11:00 a.m. He was notified about the resident's statement. The NHA said he remembered his conversation with the resident a couple of weeks ago and it was about her showers. He said the resident was at his office to complain about not getting her showers. The NHA said he told the resident that her records indicated she had been refusing her showers. The NHA said he told the resident he could not help her if she had been refusing care and had come to complain to him. He said he did not complete a grievance form because the resident often came to his office to complain about many things. The CNC said the administrator would be suspended until the investigation for these allegations was completed. She said the grievance form should be completed depending on what the resident shared. She said if the resident was crying and she told the DON about her concerns the facility should have completed a grievance form and investigated it. She did not comment if the grievance should have been completed based on what was shared with her and NHA at the moment. The resident's mental health counselor was contacted over the phone on 11/16/22 at 11:32 a.m. The call was not returned at the time of the survey. On 11/16/22 at 1:28 p.m. the CNC provided the follow-up on the investigation in the presence of the director of operations (DOO), the regional therapy manager (RTM), and NHA #2. The CNC said Resident #27 was interviewed by the RTM and NHA #2. The RTM said during her interview with the resident, the resident shared that she went to the NHA's office to complain about the staffing, and NHA was rude and hurt her feelings. The resident said to her that her concerns were not being followed. NHA #2 said he conducted a follow-up interview with Resident #27, and the resident did say she was afraid that the NHA could turn residents and staff against her. The resident said, this was her fear and she talked to her mental health provider today about it. He said that she shared that she loves all the staff except NHA, and missed the previous administrator. She said as a resolution she wants an apology from NHA about his behavior. NHA #2 said the resident's request for an apology has not been discussed with the NHA and the decision was not made yet on how the facility would proceed. The DOO said she interviewed the DON on 11/16/22. The DON shared that Resident #27 came to her office to report a staffing concern. She said the DON reviewed the staffing and reassured the resident that the facility had enough staff to meet her needs. She said she did not think she needed to complete a grievance form about staffing concerns as all concerns were reviewed with the resident at that time. The DOO said, at this point, we do not think that there is an area of abuse. She said the facility will involve the ombudsman to facilitate communication with the resident. The CNC stated that social services were not involved in the investigation since the resident's concerns were addressed by the DON at the time when she expressed them. The CNC said the above interviews with Resident #27 were not documented on paper, but the facility could provide the written results of the investigation later. The social services director (SSD) was interviewed in the presence of a social services assistant (SSA) on 11/17/22 at 11:03 a.m. The SSA stated she was communicating with the resident daily and knew the resident well. She said the resident had a bipolar disorder that contributed to her cycles of worrying and tearfulness. She said once a month the resident worked with a mental health therapist, and a mental health counselor came to see her weekly. She said she was involved in the grievance process if the grievance was related to the social services department. She said she was not aware of any current grievances from the resident. She said the last grievance from the resident was several months old and it was about her bed. The SSD stated she was not aware of any current ongoing grievance concerns for the resident. She said the social services department was investigating grievances related to social services, but the NHA was ultimately responsible for ensuring all grievances were resolved. The NHA was interviewed a second time in the presence of DON on 11/17/22 at 2:23 p.m. He said he was responsible for the grievance process. He said he reviewed grievances that were investigated by corresponding departments and made sure they were resolved. He said he disagreed with the findings of the survey and believed Resident #27 was treated with respect and dignity in the facility. He said Resident #27's concerns were resolved by the DON at the time of their initial encounter. The DON who was present during the interview stated she never said that Resident #27 mentioned the NHA's name to her or that the resident was crying because of the NHA's behavior. She said she did not recall the details of the incident at all. -However, the DON's initial statement on 11/16/22 at 10:02 a.m. and the statement by the DOO (see above) details were recalled from the interaction with Resident #27. F. Facility follow-up At the time of the exit on 11/29/22 and 24 hours after the exit, the facility did not submit any written evidence that Resident #27's concerns were properly documented on the grievance form, investigated, and resolved to her satisfaction.

Based on interviews and record review, the facility failed to ensure that one (#71) out of five sample residents reviewed for grievances out of 36 sample residents were provided prompt efforts by the facility to ensure all grievances were followed up on and resolved promptly and appropriately. Specifically, the facility failed to follow up on Resident #71's concerns promptly, which were brought forward to staff members. Findings include: I. Facility policy and procedure The Resident and Family Grievances policy, revised 10/1/22, was provided by the clinical nurse consultant (CNC) on 11/16/22 at 3:36 p.m. It read in pertinent part, Grievances may be voiced in the following forums: -Verbal complaint to a staff member or grievance official. -Written complaint to a staff member or grievance official written complaint to an outside party. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family to complete the form, and take immediate actions needed to prevent further potential violations of any resident right. In accordance with the resident ' s right to obtain a written decision regarding his or her grievance, the grievance official will issue a written decision on the grievance to the resident at the conclusion of the investigation. The written decision will include at a minimum: the date the grievance was received, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident ' s concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, the date the written decision was issued. The facility will make prompt efforts to resolve grievances. ' Prompt efforts to resolve ' include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. II. Resident #71 status Resident #71, age 57, was admitted to the facility on [DATE]. According to the October 2022 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis (chronic damage) of the liver and nerve damage. The 10/4/22 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. The resident required only supervision and set up assistance with activities of daily living (ADLs) including transfers and locomotion on and off the unit. III. Resident interview Resident #71 was interviewed on 11/21/22 at 11:35 a.m. He stated the facility had run out of cold cereal he requested for breakfast and was told the cereal was on the truck yet to be delivered. He said he ordered macaroni and cheese and received a substitute item, and had ordered a chef salad and there was no lettuce to make the salad. He stated he has taken his concerns to the director of nursing (DON) and nursing home administrator (NHA). The resident said he found the repeated food issues aggravating and insulting. He stated he filed a complaint regarding the kitchen, and he spoke to someone he thought was the dietary supervisor (DS). He said in November 2022 a staff person was supposed to come visit him to discuss food concerns and they did not. IV. Record review The 3/23/22 progress notes revealed Resident #71 was irritated and upset over the facility ' s food. The 7/5/22 progress notes revealed Resident #71 was not pleased with the kitchen ' s recent meals. The 10/5/22 progress notes revealed Resident #71 went down to the kitchen and started yelling about his food. The 10/6/22 progress notes revealed Resident #71 was agitated, cussing about the food. Resident #71 went to the kitchen and started shaking his fist at the kitchen staff, yelling about his cereal. The 10/10/22 ResidentConcern form/action/outcome/resolution was provided by the social services director (SSD) on 11/16/22 at 2:00 p.m. She confirmed this was the only grievance for Resident #71. A compliant incident documentation was attached to the resident concern form that revealed Resident #71 called a compliance hotline on 10/6/22. A description of the alleged incident read in pertinent part, The caller, Resident #71 was a resident at the facility. The caller stated that due to a serious COVID outbreak, the food has not been edible. The temperature was not good and they do not have basics like butter. V. Staff interviews The SSD and social services assistant (SSA) were interviewed on 11/16/22 at 2:00 p.m. The SSD stated anyone could fill out a grievance form, and residents could fill it out themselves if they were able to. She said a staff member could fill out a grievance for a resident and there were orange grievance forms available in the front hallway right by the DON ' s office. She said residents have stopped by the social services office and the social services staff have filled out a grievance form for the resident if needed. The SSA stated she also filled out a grievance for a resident when a resident came to their office. The SSA stated she spoke to Resident #71 about the grievance forms, and told him he could fill out the form himself but acknowledged Resident #71 still continued to write his concerns on his meal tickets. She stated she spoke to him more than three months ago. She stated Resident #71 did go to the kitchen to talk to the dietary staff. The SSD stated the initial compliance call initiated by Resident #71 contained a concern about being out of menu items but she was not aware of a resolution provided. The dietary district manager (DDM) was interviewed on 11/16/22 at 3:00 p.m. She stated she had met with Resident #71 and was going to meet with him again that week. She stated not all concerns escalated to her. She said if there were menu items the facility was out of, the dietary department could complete an order or go to the store to acquire the needed product. She stated she was aware Resident #71 was writing his food concerns on meal tickets from previous meals. The NHA was interviewed on 11/17/22 at 10:45 a.m. He stated the resolution for the menu items the facility was out of was not on this particular grievance form. The NHA stated he told staff if they were aware of an issue then they should write a grievance form.

Based on observations, record review, and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#27) of five residents reviewed for oxygen therapy out of 36 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Resident #27. Findings include: I. Facility policy The Oxygen Administration policy, revised on 10/1/22, was provided by the director of nursing (DON) on 11/16/22 at 3:20 p.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen will be administered under orders of a physician. The policy explanation and compliance guidelines documented that the resident's care plan shall identify the interventions for oxygen therapy, based on the resident's assessment and physician's orders, such as but not limited to: a. The type of oxygen delivery system. b. When to administer, such as continuous or intermittent, and/or when to discontinue. II. Resident #27 A. Resident status Resident #27, age 78, was admitted to the facility on [DATE]. According to the November 2021 computerized physician orders (CPO) diagnoses included pneumonia, anxiety disorder, manic depression, asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disease. The 10/18/22 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for a mental status score of eleven out of 15. The MDS coded the resident with oxygen therapy. B. Observations On 11/14/22 at 10:36 a.m. Resident #27 was in her room, sitting in her wheelchair watching television. The resident was wearing a nasal cannula connected to her portable oxygen concentrator which was not turned on. The resident was not receiving oxygen. On 11/15/22 at 9:22 a.m. Resident #27 was in her room, she was wearing a nasal cannula that was connected to the concentrator set to three liters. An observation on the same day at 4:00 p.m. revealed the resident was still on three liters of oxygen. On 11/16/22 at 9:00 a.m., the resident was observed in her room. The oxygen concentrator was set to three liters per minute. C. Record review The November 2022 CPO documented a physician order for continuous oxygen therapy at four liters per minute (LPM) via nasal cannula. The care plan for oxygen, last revised on 10/12/22, identified the resident had a respiratory illness (COPD), repeated pneumonia, and bronchiectasis. Pertinent interventions included continuously administering oxygen at four (LPM) via nasal cannula or as per physician orders. III. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 11/14/22 at 10:46 a.m. She said the resident should be on four liters of oxygen flow per minute, however, she confirmed the resident's portable oxygen tank was not turned on even though the cannula was in her nose. Licensed practical nurse (LPN) #1 was interviewed on 11/16/22 at 3:00 p.m. She said the physician's order for Resident #27 was four liters per minute continuously and there was no order to taper with the oxygen level. LPN #1 said the resident oxygen should be at four liters, however, she confirmed it was set at three and a half liters per minute which was contrary to the physician's order. The director of nursing (DON) was interviewed on 11/17/22 at 2:23 p.m. She said oxygen should be administered as ordered by the physician. She said oxygen flow should be set up by nurses when a resident was transferred from a portable oxygen tank to a room concentrator.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of four units. Specifically, the facility failed to provide peri care and skin assessment to Resident #74 in a sanitary manner. Findings include: I. Peri care and skin assessment observations Licensed practical nurse (LPN) #3 was observed completing skin assessment and peri care for Resident #74 on 11/16/22 at 4:14 a.m. with assistance from certified nursing aide (CNA) #4. LPN #3 applied clean gloves, positioned the resident on his back and assessed his legs. She pulled off his socks to look at the heels, and put his socks back on. Without changing her gloves she removed the resident's brief and discarded it into the trash. She attempted to clean the resident's penis with peri wipes. The resident had a sensitive area at the tip of his penis with a mild bright red discharge. After the resident communicated to her his discomfort, she obtained a wash cloth soaked in soap and water and continued to clean the resident's perineum. After she completed the cleaning she placed used wash cloth stained with blood on top of the resident's daily chronicle page on top of his table. Without changing gloves, she put a clean brief on the resident and continued to assess his skin on the back, chest and his arms. CNA #4 assisted the nurse with repositioning resident and applying a clean brief. After completing skin assessment LPN #3 and CNA #4 repositioned the resident in bed. LPN #3 was still wearing the same gloves that she put on prior to providing peri care. She repositioned the resident's pillow, blanket and placed the call light at his bedside. She picked up the wash cloth off the daily chronicles and pushed the table closer to the resident. She collected trash and passed the trash bag with soiled wash cloth on top of it to the CNA #4. CNA #4 took the trash and unbagged washcloth to the soiled linen room. LPN #3 removed her gloves, returned to the resident's table and tossed away daily chronicles into the trash. She did not clean the resident's table. She exited the room and sanitized her hands. After exiting the resident's room, CNA #4 discarded trash and removed her gloves. She did not wash or sanitize her hands. She returned to the resident's room, grabbed his pitcher and refilled it with ice and water. After she exited the room, she sanitized her hands. II. Staff interview LPN #3 was interviewed on 11/16/22 at 4:30 p.m. She said she should have changed her gloves after touching the resident's feet, and after cleaning the resident, and she should have washed her hands after changing gloves and she forgot to do so. She said used washcloth should have been placed in a plastic bag, instead of on the resident's personal items on his table. CNA #4 was interviewed on 11/16/22 at 4:35 p.m. She said she should have removed her gloves after she applied a clean brief to the resident. She said she should have washed her hands after she removed the gloves before refilling the pitcher with water. The director of nursing (DON) was interviewed on 11/17/22 at 2:10 p.m. She said gloves should be changed after touching a resident's feet and after providing peri care. She said hands must be washed or sanitized prior to the application of clean gloves. She said the resident's table was not an appropriate place to set the soiled wash cloth, it should have been placed in a plastic bag and taken to a soiled linen room. She said she would provide education to all nurses to make sure they were following proper infection control techniques during peri care and skin assessments.

Based on interviews and record review, the facility failed to ensure residents on two out of three units had the right to a dignified existence. Specifically, the facility failed to ensure: -Residents experienced a dignified living experience by answering the call lights timely according to the previous three months of resident council meeting minutes reviewed with no facility response or action; -Resident #4 experienced a dignified living experience by answering the call lights timely; and, -Resident #1 had access to her call light to call for assistance when needed. Findings include: I. Facility policy and procedure The Call Light: Accessibility and Timely Response policy, undated, was received from the nursing home administrator (NHA) on 4/12/22 at 12:30 p.m. The policy documented in pertinent part, The Resident and Family Grievances policy, undated, was received from the NHA on 4/12/22 at 12:30 p.m. The policy documented in pertinent part, Grievances may be voiced in the following forums .Verbal complaints during resident or family council meetings .The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Take any immediate actions needed to prevent further potential violations of any resident right .Forward the grievance form to the Grievance Official as soon as practicable. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. Prompt efforts include acknowledgment of complaint/grievances and actively working toward a resolution of that complaint/grievance . The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances .In accordance with the resident's right to obtain a written decision regarding his or her grievance,the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: The date the grievance was received.The steps taken to investigate the grievance. A summary of the pertinent findings or conclusions regarding the resident's concern(s). A statement as to whether the grievance was confirmed or not confirmed.Any corrective action taken or to be taken by the facility as a result of the grievance. The date the written decision was issued. II. Record review and interviews The January, February and March 2022, Resident Council Meeting agenda and notes were received from the NHA on 4/11/22 at 11:00 a.m. The 1/26/22 resident council notes documented in pertinent part-Old business, call lights not being answered, audits done. New Business, call light issues due to staff being on Aspen still. There were 17 residents from two of three units documented in attendance. Attached to the council minutes was a Resident Council Concern follow up form. The form documented in pertinent part, the nurses and certified nurse aides (CNAs) still hanging out at Aspen nursing station so they aren't answering old Silver Keys lights timely. The action taken was staff education provided and call light audits. The 2/23/22 resident council notes documented in pertinent part-Old business, call light issues, New Business, call lights aren't being answered during meals. There were seven residents documented in attendance. There was a Resident Council Concern/Feedback Form attached to the minutes dated 2/23/22. The form documented an area for the concern, the forwarding of the concern, resolution, follow up, and review with the resident council. However, the form was blank. The 3/30/22 resident council notes documented in pertinent part, Old business there was nothing documented. New business, call lights not being answered timely. There were eleven residents documented in attendance. There was a Resident Council Concern/Feedback Form attached to the minutes dated 3/30/22. -There was no documentation related to facility action for the concern with call lights not being answered timely. On 4/11/22 at 4:00 p.m., follow-up documentation related to the resident concerns regarding call lights for January to March 2022 were requested from the NHA. Additionally, the audits and staff education documented on the concern form on 1/26/22 were requested. The NHA was interviewed on 4/12/22 at 9:43 a.m. He said he had no documentation of the audits or staff education documents for the January concerns as resident council He said we didn't do the audits and education we said we would in January 2022. Additionally, he said there was no documented follow-up to the call light concerns reported at resident council in February and March of 2022, and there should have been. The NHA said the activity director should have completed a concern form for February and March of 2022. The NHA said he had done some interviews with residents last night, 4/11/22, after follow-up to the resident concerns had been requested from the surveyor. He said the resident's did not have issues with call light timeliness. III. Resident #4 A. Resident status Resident #3, age less than 70, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/7/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required extensive two person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She was always incontinet of bowel and bladder. B. Resident interview Resident #3 was interviewed on 4/12/22 at 10:02 a.m. in the hallway of the North unit. She said on the weekend there was a long delay in getting call lights answered. She said it could be 25 minutes or longer due to staffing .they are short staffed. Resident #3 said it was usually when she needed to be changed or assisted back to bed from her electric wheelchair. She said it could be frustrating. IV. Resident #1 A. Resident status Resident #1, age 90, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She required extensive two person assistance with bed mobility and personal hygiene.Transfers did not occur during the assessment period. She required extensive one person assistance dressing, and was totally dependent on one staff person for toileting. The assessment documented Resident #1 was on hospice care. B. Observation and interview On 4/12/22 at 9:50 a.m., Resident #1 was observed in her room, in bed, on the North unit. She asked for her blinds to be opened. Her call light was on the floor under her bed. On 4/12/22 at 10:05 a.m., Resident #1 was observed in bed with her eyes closed. Her call light was still under her bed. On 4/12/22 at 10:10 a.m., Resident #1 was observed in bed with the DON. Her eyes were still closed. The DON said Resident #1 was capable of using her call light. The DON said she had answered it herself many times. She said the call light should be within the residents reach. The DON bent down and retrieved the call light from the floor and clipped it to the bedding within the residents' reach. She said the resident would not have been able to call for help if she needed it. She would have to wait until staff checked on her. V. Additional observations and interview On 4//12/22 at 10:15 a.m, two female residents were observed in their room on the North unit. Both residents were seated in wheelchairs. Their call lights were in a top dresser drawer behind each of them and out of their reach. On 4/12/22 at 10:20 a.m., the DON observed the two female residents. One resident was now in the bathroom. The other female resident remained in her wheelchair, with the call light in the dresser behind her. The DON said the call light was not within the residents' reach and should be. VI. Follow-up during survey On 4/12/22 at 9;10 a.m., the NHA provided a quality assurance performance improvement (QAPI) document dated 4/11/22. The form documented in pertinent part, call light response times were brought up as an issue in previous resident councils, but are no longer an issue. The concern has been resolved. Will continue to monitor call light response times with resident interviews and five random audits twice per week for two months to ensure and maintain compliance. Attached to the QAPI was a list of 28 resident names. The title was Call light Audit, dated 4/11/22. The questions asked were not documented on the audit. Next to one resident name, the response was, not always, but sometimes it takes 15-20 minutes. A blank audit tool was attached to the QAPI, titled Call Light Audit Tool. The form documented If a call light is on for longer than 15 minutes, stop audit, intervene and identify why the call light could not be answered in a timely manner. Additionally, a resident interview during the survey revealed concerns with current call light response times greater than 25 minutes.

Based on record review, and interviews, the facility failed to notify the physician when required, for two (#3 and #1) of three residents reviewed out of 12 sample residents. Specifically, the facility failed to notify the physician when medications were unavailable for administration per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy and procedure The Medication Errors policy, undated, was received from the NHA on 4/12/22 at 12:30 p.m. The policy documented in pertinent part, the facility shall ensure medications will be administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Examples include, but are not limited to, medication omission .If a medication error occurs .the nurse assesses and examines the resident's condition and notifies the physician or health care provider as soon as possible. II. Resident #3 A. Resident status Resident #3, age 76, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/18/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of six out of 15. He required extensive two person assistance with transfers and toileting. He required extensive one person assistance with bed mobility, dressing and personal hygiene. The assessment documented Resident #3 had a [CONDITION(S)], received insulin injections, and was on scheduled pain medication. B. Record review The March 2022 and April 2022 nursing progress notes documented the following in pertinent part, -On 3/22/22 at 7:37 a.m., [MEDICATION(S)] Tablet 150 MG, Give 150 mg by mouth two times a day for [CONDITION(S)]. Medication has been reordered, awaiting script from pharmacy nurse called on 03/21/22 for a new script. There was no documentation the physician was notified on 3/22/22 that the anti [CONDITION(S)] medication was unavailable for administration that day. There was no documentation in the nurse's notes that the resident was monitored for [CONDITION(S)] activity related to the missed dose. -On 3/22/22 at 7:13 p.m., [MEDICATION(S)] Tablet 150 MG, Give 150 mg by mouth two times a day for [CONDITION(S)]. Medication has been reordered, per pharmacy will be delivered on 3/23/22. Not available in STAT safe. There was no documentation the physician was notified that the anti [CONDITION(S)] medication was unavailable. There was no documentation in the nurses notes that the resident was monitored for [CONDITION(S)] activity related to the missed dose. -On 4/10/22 at 9:02 a.m., [MEDICATION(S)] [MEDICATION(S)] insulin, inject 15 units subcutaneously one time a day related to type two diabetes mellitus, not available on cart. There was no documentation the physician was notified that the resident did not receive the ordered insulin. -On 4/11/22 at 7:31 a.m., during the survey, [MEDICATION(S)] Tablet Extended Release 15 MG, Give 15 mg by mouth two times a day related to pain, medication not available on cart; waiting for pharmacy to deliver. There was no documentation that the physician was notified that the [MEDICATION(S)] was not administered as ordered. -On 4/11/22 at 3:00 p.m., the nurse notes were reviewed again after the surveyor notified the facility of the omitted pain medication at 2:00 p.m.There was a new nurses note dated 4/11/22 at 7:37 a.m. The note documented, During beginning of shift report, on coming (day) nurse was instructed by the night nurse; pt's [MEDICATION(S)] is not available on the cart. Night nurse reports, she called the pharmacy for reorder but was instructed, they will need a signed script from the physician to refill the med order. Night nurse reports, she spoke with the physician and, physician verbalized, he will call the pharmacy for order. -However, this note was not in the progress notes prior to 2:00 p.m. on 4/11/22 or before being notified of the concern. C. Interviews Licensed practical nurse (LPN) #1 was interviewed on 4/11/22 at 1:50 p.m. She said medications should be reordered when we get to the last blue column on the medication card. She said if the medication was not available the nurse should call the pharmacy, and the physician for an order to hold, or a different order. She said the nurse should document the notifications in the nursing progress notes. The DON, NHA and regional clinical director (RCD) were interviewed on 4/11/22 at 2:00 p.m. The DON said Resident #3 would be at risk for [CONDITION(S)] activity, pain and [CONDITION(S)] with the missed doses of medications. She said the nurse should have called the pharmacy, notified the physician for orders, and documented this in the nursing progress notes. The RCD was interviewed again on 4/11/22 at 3:00 p.m. He said the nurse was administering the [MEDICATION(S)] now. The RCD looked at his laptop and said Resident #3 had his insulin today, but he did not have it yesterday according to the nurses notes and MAR. He said regarding the [MEDICATION(S)], antiseizure medication and missed doses, there is not a lot I can say. The RCD said there was no documentation the physician was notified, and there should have been. III. Resident #1 A. Resident status Resident #1, age 90, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She required extensive two person assistance with bed mobility and personal hygiene.Transfers did not occur during the assessment period. She required extensive one person assistance dressing, and was totally dependent on one staff person for toileting. The assessment documented Resident #1 was on hospice care. B. Record review The March 2022 and April 2022 nursing progress notes documented the following in pertinent part, -On 3/22/22 at 10:08 p.m., the nurse's notes documented, [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression, medication not available, reordered. -On 3/23/22 at 7:29 p.m., the nurse's notes documented, [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression, med not available. On order. -On 3/25/22 at 3:47 a.m., the nurse's notes documented, [MEDICATION(S)] Tablet 0.5 MG Give 0.5 mg by mouth every 8 hours for anxiety . Medication is not available. -On 4/4/22 at 8:46 a.m., the nurse's notes documented, [MEDICATION(S)] Suspension 50 MCG 2 spray in both nostrils one time a day for congestion, med not available on cart. -There was no documentation in the nursing progress notes, the physician was notified of the medications that had not been administered as ordered. C. Interview The RCD was interviewed again on 4/11/22 at 3:00 p.m. The RCD looked at his laptop and said there was no documentation the physician was notified of the omitted medications.

Based on observations, interviews and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for three of three licensed nurses reviewed. Specifically, the facility failed to ensure licensed nurses received competency reviews for medication management. Cross-reference: F760 the facility failed to ensure Residents (#1, #2 and #3) were free from significant medication errors. F580 the facility failed to notify the physician of significant medications that were not administered per orders. I. Facility policy and procedure The Competency Evaluation policy, undated, was received from the regional clinical director (RCD) on 4/12/22 at 2:02 p.m. The policy documented in pertinent part, It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of the facility residents .Initial competency is evaluated during the orientation process. An employee remains in orientation until all competencies are verified .subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance. II. Record review On 4/12/22 at 12:30 p.m., competency reviews related to medication administration and management were requested for a sample of licensed practical nurses, (LPN) #1, #2, and #3, from the nursing home administrator (NHA) due to significant medication errors reviewed. No competency records were received for review by the end of the survey on 4/12/22. III. Interviews The director of nursing (DON) was interviewed on 4/12/22 at 1:40 p.m. with the NHA and RCD. The DON said the facility had no records of any competency reviews for the licensed nurses in the last year. The DON said the competencies for medication administration should be done annually, and as needed if a concern was identified. The DON said she had been at the facility for one month, and she would plan to do the nursing staff competencies. Certified nurse aide with medication aide authority (CNA-Med) #1 was interviewed on 4/12/22 at 1:55 p.m. She said she administered medication to residents. CMT #1 said she had never had a competency evaluation for medication administration. She said she had not had anyone at the facility observe her administer medications. Registered Nurse (RN) #1 was interviewed on 4/12/22 at 2:02 p.m. She said she had been at the facility for nine months. She said she had not had a competency check for medication administration since she was hired. IV. Follow-up No further documentation was provided.

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for two (#3 and #1) out of three residents reviewed out of four sample residents. Specifically, the facility failed to ensure: -Narcotic pain medication (MS-[MEDICATION(S)], [MEDICATION(S)]), Insulin ([MEDICATION(S)]), and anti [CONDITION(S)] medication ([MEDICATION(S)]) were available and administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Antianxiety medication ([MEDICATION(S)]), antidepressant medication ([MEDICATION(S)]), and allergy nasal spray ([MEDICATION(S)]) was available and administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Cross-reference: F726-the facility failed to ensure licensed nurses were evaluated for medication administration competencies. F580-the facility failed to notify the physician of significant medications that were not administered per orders. Findings include: I. Facility policy and procedure The Medication Administration policy, undated, as received from the director of nursing (DON) on 4/11/22 at 3:16 p.m. The policy documented in pertinent part, Medications are administered by licensed nurses .as ordered by the physician .administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. The Medication Reordering policy, undated, was received form the nursing home administrator (NHA) on 4/12/22 at 10:13 a.m. The policy documented in pertinent part, Each time a nurse is administering medications and observes six or less dose left .that nurse will reorder the medication .The nurse assigned to each medication cart will perform a medication match every Thursday night. The Medication Errors policy, undated, was received from the NHA on 4/12/22 at 12:30 p.m. The policy documented in pertinent part, the facility shall ensure medications will be administered according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Examples include, but are not limited to, medication omission. Medication administration observations will be conducted periodically to evaluate facility medication administration practices. II. Resident #3 A. Resident status Resident #3, age 76, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/18/22 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of six out of 15. He required extensive two person assistance with transfers and toileting. He required extensive one person assistance with bed mobility, dressing and personal hygiene. The assessment documented Resident #3 had a [CONDITION(S)] disorder, received insulin injections, and was on scheduled pain medication. B. Record review The March 2022 MAR was reviewed on 4/11/22. On 3/22/22 at 8:00 a.m. and 8:00 p.m., the MAR documented [MEDICATION(S)] Tablet 150 MG, Give 150 mg by mouth two times a day for [CONDITION(S)] disorder, the number 9 see progress notes. The April 2022 CPO documented the following orders in pertinent part, -MS ([MEDICATION(S)]) [MEDICATION(S)] Tablet Extended Release 15 MG (milligrams) ([MEDICATION(S)] ER). Give 15 mg by mouth two times per day, for pain, dated 1/25/2018; -[MEDICATION(S)] [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (milliliters)(Insulin Detemir). Inject 15 units subcutaneously daily, for diabetes mellitus, dated 1/20/21; -[MEDICATION(S)] Tablet 150 MG ([MEDICATION(S)]). Give 150 mg by mouth two times a day for [CONDITION(S)] disorder, dated 1/15/2019. The April 2022 medication administration record (MAR) was reviewed on 4/11/22. On 4/10/22 at 8:00 a.m. the MAR documented for the dose of [MEDICATION(S)] [MEDICATION(S)] Solution Pen-injector 100 UNIT/ML (Insulin Detemir) the number 9 see progress notes. On 4/11/22 at 8:00 a.m. the MAR documented for the dose of MS [MEDICATION(S)] Tablet Extended Release 15 MG (milligram) the Number 9 see progress notes. The March 2022 and April 2022 nursing progress notes documented the following in pertinent part, -On 3/22/22 at 7:37 a.m., [MEDICATION(S)] Tablet 150 MG, Give 150 mg by mouth two times a day for [CONDITION(S)] disorder. Medication has been reordered, awaiting script from pharmacy nurse called on 03/21/22 for a new script. There was no documentation the physician was notified on 3/22/22 that the anti [CONDITION(S)] medication was unavailable for administration that day. There was no documentation in the nurses notes that the resident was monitored for [CONDITION(S)] activity related to the missed dose. -On 3/22/22 at 7:13 p.m., [MEDICATION(S)] Tablet 150 MG, Give 150 mg by mouth two times a day for [CONDITION(S)] disorder. Medication has been reordered, per pharmacy will be delivered on 3/23/22. Not available in STAT safe. There was no documentation the physician was notified that the anti [CONDITION(S)] medication was unavailable. There was no documentation in the nurses notes that the resident was monitored for [CONDITION(S)] activity related to the missed dose. -On 4/10/22 at 9:02 a.m., [MEDICATION(S)] [MEDICATION(S)] insulin, inject 15 units subcutaneously one time a day related to type two diabetes mellitus, not available on cart. There was no documentation the physician was notified that the resident did not receive the ordered insulin. -On 4/11/22 at 7:31 a.m., during the survey, MS [MEDICATION(S)] Tablet Extended Release 15 MG, Give 15 mg by mouth two times a day related to pain, medication not available on cart; waiting for pharmacy to deliver. ] -There was no documentation that the physician was notified that the [MEDICATION(S)] was not administered as ordered. Cross-reference F580 -On 4/11/22 at 3:00 p.m., the nurse notes were reviewed again after the surveyor notified the facility of the omitted pain medication at 2:00 p.m. There was a new nurses note dated 4/11/22 at 7:37 a.m. The note documented, During beginning of shift report, on coming (day) nurse was instructed by the night nurse; pt's MS [MEDICATION(S)] is not available on the cart. Night nurse reports, she called the pharmacy for reorder but was instructed, they will need a signed script from the physician to refill the med order. Night nurse reports, she spoke with the physician and, physician verbalized, he will call the pharmacy for order. -However, this note was not in the progress notes prior to 2:00 p.m. on 4/11/22 or before being notified of the concern. -There was no note from the night nurse regarding her conversation with the physician, or plan for the resident's pain due to the medication not being available. There was no no nurses note regarding the omitted MS [MEDICATION(S)] until the facility was notified by the surveyor. C. Interviews Licensed practical nurse (LPN) #1 was interviewed on 4/11/22 at 1:50 p.m. She said medications should be reordered when we get to the last blue column on the medication card. She said if the medication was not available the nurse should call the pharmacy, and the physician for an order to hold, or a different order. She said the nurse should document the notifications in the nursing progress notes. The DON, NHA and regional clinical director (RCD) were interviewed on 4/11/22 at 2:00 p.m. The NHA said the facility had identified an issue with medications being unavailable last Friday 4/8/22, and had started a performance improvement plan (PIP). The DON said she was not at the facility on 4/8/22, and was not aware of the PIP. The DON said the nurses are responsible for reordering the medication. She said there was no double check system or monitoring program to ensure the medication was reordered. She said the nurses passing meds are responsible for ensuring they reorder medications. They should reorder medication when they had a week's supply left. The DON said Resident #3 would be at risk for [CONDITION(S)] activity, pain and [CONDITION(S)] with the missed doses of medications. She said the nurse should have called the pharmacy, notified the physician for orders, and documented this in the nursing progress notes. The DON said the problem was we use a lot of agency. She said sometimes it was an issue of not reordering timely, and sometimes she thought it was a pharmacy issue. However, she did not specify what the pharmacy issue was. The RCD was present for the interview. He said the facility had done a PIP, and started education, but said there were current issues with significant medication not being administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON was interviewed again on 4/11/22 at 2:50 p.m. She said the MS [MEDICATION(S)] was available in the facilities emergency medication kit. She said the agency nurses don't pay attention to these things. The DON said we do an orientation with them, but she did not know if there was a checklist of items reviewed with the agency staff or if medication recording and the emergency medication kit was part of the orientation. The RCD was interviewed again on 4/11/22 at 3:00 p.m. He said the nurse had just written the note dated 4/11/22 at 7:37 a.m. this afternoon for Resident #3, after the facility was notified by the surveyor of the omitted MS [MEDICATION(S)]. He said the night nurse was coming into the facility to make a note in the chart. Additionally, the RCD said the MS [MEDICATION(S)] was in the facility's emergency medication kit. He said the nurse had it in her hand now, and was going to give it to the resident. However, the dose was almost seven hours overdue. The RCD said he had spoken to the resident who said his pain was two out of 10. The RCD looked at his laptop and said Resident #3 had his insulin today, but he did not have it yesterday according to the nurses notes and MAR. He said regarding the [MEDICATION(S)], antiseizure medication and missed doses, there is not a lot I can say. The facility registered pharmacist (RPh) was interviewed on 4/11/22 at 5:09 p.m. via telephone. The RPh said the facility received two deliveries per day. One delivery left the pharmacy at 11:00 a.m. and one left the pharmacy at 10:00 p.m. She said the facility received the medications four to five hours later. The RPh said stat deliveries can be made to the facility from a local pharmacy the facility's pharmacy contracts with. She said, or the medication can be sent from the facility pharmacy via courier. The RPh said it usually takes two to four hours to get stat medications. She said the [MEDICATION(S)] anti [CONDITION(S)] medication as not ordered for Resident #3 until 3/22/22 (when the facility was already out of medication) according to her records. She said the [MEDICATION(S)] insulin was refilled on 3/21/22, and the facility should have had enough for 28 days, and was not due to be refilled until 4/12/22. She said the MS [MEDICATION(S)] was available in the facility emergency kit. She said the provider gave a three day refill order on 4/7/22, and provided a new script on 4/11/22. III. Resident #1 A. Resident status Resident #1, age 90, was admitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/8/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She required extensive two person assistance with bed mobility and personal hygiene. Transfers did not occur during the assessment period. She required extensive one person assistance dressing, and was totally dependent on one staff person for toileting. The assessment documented Resident #1 was on hospice care. B. Record review The March 2022 MAR was reviewed on 4/11/22. On 3/22/22 and 3/23/22 for the 8:00 p.m. doses, the MAR documented [MEDICATION(S)] 5 MG give one time per day for depression, the number 9 see progress notes. On 3/25/22, all doses of [MEDICATION(S)] were signed off the MAR as given. However, the nurse's notes documented on 3/25/22 at 3:47 a.m., the medication was not available. The March 2022 and April 2022 nursing progress notes documented the following in pertinent part, -On 4/4/22 at 8:46 a.m., the nurse's notes documented, [MEDICATION(S)] Propionate Suspension 50 MCG 2 spray in both nostrils one time a day for congestion, med not available on cart. -On 3/25/22 at 3:47 a.m., the nurse's notes documented, [MEDICATION(S)] Tablet 0.5 MG Give 0.5 mg by mouth every 8 hours for anxiety . Medication is not available. -On 3/23/22 at 7:29 p.m., the nurse's notes documented, [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression, med not available. On order. -On 3/22/22 at 10:08 p.m., the nurse's notes documented, [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth one time a day for Depression, medication not available, reordered. There was no documentation in the progress the physician was notified of the medications that had not been administered as ordered. The April 2022 CPO documented the following orders in pertinent part, -[MEDICATION(S)] Tablet 0.5MG, Give 0.5 mg by mouth every eight hours for anxiety; - [MEDICATION(S)] OxalateTablet 5 MG, Give 1 tablet by mouth one time a day for depression; and, -[MEDICATION(S)] Propionate Suspension 50 MCG (micrograms), two sprays in both nostrils one time a day for congestion. The April 2022 medication administration record (MAR) was reviewed on 4/11/22. On 4/4/22 at 8:00 a.m., the MAR documented for the dose of [MEDICATION(S)] Propionate Suspension 50 MCG (micrograms), the number 9 see progress notes. There was no documentation in the progress the physician was notified of the medications that had not been administered as ordered. C. Interviews The RPh was interviewed on 4/11/22 at 5:09 via telephone. She said [MEDICATION(S)] is over the counter medication and something the facility should have in their central supply, it was not sent by the pharmacy. She said the [MEDICATION(S)] was not reordered by the facility until 3/22/22 (when the facility was already out of the medication). Additionally, she said the [MEDICATION(S)] was available in the facility emergency kit. VI. Facility follow- up On 4/11/22 at 1:50 p.m. The NHA provided a PIP titled Unavailable Medications, dated 4/8/22. The PIP documented the opportunity for improvement was the need to re-educate staff on ordering medications and following up on meds that have been ordered and not received yet. Education on what to do if medications are not available. -There were no dates on when the education would be completed, the PIP did not address agency staff. The PIP did not address how the actions would be monitored or what follow up would be done. On 4/12/22 at 10:00 A.M., during the survey, and after the concern had been discussed with the NHA and DON, the NHA provided an updated PIP. The PIP then documented, update 4/11/22, daily monitoring of meds not available, daily monitoring of calling MD and documentation of such for meds not available, and immediate action will be taken such as putting med on hold, getting med elsewhere such as another pharmacy, or substitute per MD order. An inservice, titled Medication Availability. undated, was provided by the NHA on 4/12/22. -The inservice did not indicate who provided the education. The inservice documented in pertinent part, When receiving new physician orders, please ensure the pharmacy receives the fill request immediately. Check to see if the medication is available in the facility emergency kit/StatSafe for timely administration and if medication is not in there, order the medication STAT to ensure medication is received prior to administration time. When re-ordering medication, ensure this occurs when the resident has a seven day supply left to prevent the medication from running out. If you receive a refill too soon request or prior authorization request please communicate this to the nurse management team to ensure timely delivery of medication. If a medication is unavailable, notify the DON, pharmacy and contact the MD to get alternate orders if able until the medication arrives. If a medication is unavailable, check to see if the medication is available to pull from, the e-kit/Stat Safe until the medication arrives. Document all efforts in PCC (Point Click Care). Medication variance should be completed for missed doses. There were 10 signatures between 4/6/22 and 4/11/22. The NHA and DON were interviewed on 4/12/22 at 10:30 a.m. The NHA said the facility had no documentation of orientation of agency (contract) licensed nurses, Cross- reference F726. He said the facility had started orientation documentation last night with the agency nurses who were at the facility, after he had been asked for the orientation documentation. The NHA provided an orientation checklist dated 4/11/22 for licensed practical nurse (LPN) #3 and LPN #4. The orientation checklist titled Agency Personnel/Contractors Checklist, documented reviewed items were, medication times, medication administration and storage, MAR and treatment administration (TAR) documentation. -It did not document medication ordering or reordering, or the facility's emergency medication kit despite the DON's concern that the omission of medications was due to the use of agency licensed nurses. The DON said the facility should have done a risk management document related to the mediation errors of omission, including notifying the physician and resident representative if applicable. She said this had not been done. The DON was interviewed again on 4/12/22 at 1:40 p.m. with the NHA and RCD. The DON said the facility had no records of competency reviews for any of the licensed nurses in the last year regarding medication management, what to do if medications are not available during medication administration or notification of the physician. Cross-reference F726

Based on observations, record review and interview, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#1) of six residents reviewed for quality of care of seven sample residents. Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was administered sliding scale insulin based on his blood sugar levels that were checked by the nurses prior to administration. On 2/3/22 at 8:35 a.m. Resident #1 developed continuous high blood sugar (BS), and increased respiration. The facility failed to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's condition continued to deteriorate and at 7:14 p.m. (eleven hours after he developed a change of condition), when the resident was sent to the emergency room (ER) for acute [CONDITION(S)] due to COVID-19, acute on chronic renal failure, diabetic ketoacidosis, and septic shock. He subsequently passed away at the hospital shortly after being admitted . Findings include: I. Facility policies and procedures The Blood Glucose Monitoring policy, dated 2021, was provided on 2/16/22 at 2:23 p.m. by the regional nurse consultant (RNC). The policy read in pertinent part, it is the policy of this facility to perform blood glucose monitoring to the diabetic residents as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Notification of Changes policy, dated 2021, was provided on 2/16/22 at 2:23 p.m. by the RNC. The policy read in pertinent part, the facility must consult with the resident's physician when there is a change requiring such notification, circumstances requiring notification include a significant change in the resident's physical condition including life-threating conditions or clinical complications. II. Professional reference Diabetic Ketoacidosis, the Centers for Disease Control and Prevention (CDC), dated 3/25/21, retrieved 3/1/22 from https://www.cdc.gov/diabetes/basics/diabetic-ketoacidosis.html#:~:text=Diabetic%20ketoacidosis%20(DKA)%20is%20a,cells%20for%20use%20as%20energy, read in pertinent part, Diabetic Ketoacidosis (DKA) is a serious complication of diabetes that can be life-threatening. DKA is most common with people who have type I diabetes, but can also occur in people with type II diabetes. DKA develops when the body does not have enough insulin to allow blood sugar into the cells for use as energy. Instead, the liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in the body. Very high blood sugar and low insulin levels lead to DKA. If left untreated, severe symptoms can appear such as fast, deep breathing. III. Resident #1 A. Resident status Resident #1, age 61, was admitted on [DATE], and discharged to acute care hospital on 2/3/22. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance for bed mobility, toileting and activities of daily living (ADLs). B. Record review 1. Resident status on admission The admission data collection on 7/22/2020 revealed the resident had a BS reading of 160. The nursing daily skilled charting on 7/23/2020 revealed the resident had a BS reading of 160. The care plan dated 7/22/2020 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included observe and document for effectiveness of diabetes medication as ordered by the physician and the use of injectables to control BS. The most recent physician note document on 1/13/22 read that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . He is slowly declining into a place where it is hard to tell if he is depressed or demented. He is still aphasic and has a very flat affect but I am told he was like this before his stroke by family. He is confused and refuses to communicate. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] According to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] < (less than) 70 or > (greater than) or = to 400, call provider. Additionally, the resident had the following insulin order: inject insulin as per sliding scale: if BS is 201-250, give four units of insulin; if BS is 251-300, give six units; if BS is 301-350 give eight units; if BS is 351-400 give 10 units, if BS above 400, give 12 units of insulin. Notify the provider if BS remains above 400 after 30 minutes. IV. Change of condition Resident #1 developed high blood sugar levels and high respirations on 2/3/22. On 2/3/22 resident developed elevated blood sugar levels of 514 at 8:35 a.m. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Insulin was administered per sliding scale. -There was no documented progress note by the nurse that the physician was notified about BS of 514 at 8:35 a.m., and no additional check the resident's BS in 30 minutes (as indicated by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's blood sugar was checked according to the scheduled order at 11:51 a.m. and was 510. The resident was administered insulin per sliding scale. -However, there were no documented progress notes that physician was contacted to report BS above 400 and Resident#1's BS was not rechecked in 30 minutes (cross-reference F580). The resident's blood sugar was checked according to the scheduled order at 3:39 p.m., the blood sugar was 472. Insulin was administered per sliding scale. -There were no documented progress notes that physician was notified about BS of 472, and no evidence that Resident #1's BS was re-checked in 30 minutes per physician order. The physician was not appropriately notified and the blood sugar was not rechecked (cross-reference F580). In addition, the resident had developed increased respirations on 2/3/22 at 1:39 p.m. The documented respirations were 28 breaths per minute (with norm being 12-16 breaths per minute), which was a symptom of diabetic ketoacidosis (DKA). According to the progress note on 2/3/22 at 2:05 p.m., (six hours after initial reading of BS above 400) the PCP was notified of increased BS, low oxygen saturation (O2) of 83% and a low grade fever of 99.1. The physician ordered two liters of oxygen via nasal cannula and 650mg (milligrams) Tylenol. -The note did not mention the resident's increased respirations. There were no additional nurses notes on what actions were taken and what recommendations from the physician were received regarding the resident's condition until 7:14 p.m. At 7:14 p.m., nurses note read: resident was transferred via stretcher to the ER (emergency room ) due to change in status, as a result of labored breathing, temperature 102.3, blood pressure 162/93, oxygen in the low 70's with 4 liters of oxygen. -The resident's power of attorney was not notified of the resident's condition until he was being sent to the emergency room for evaluation (cross-reference F580). According to the ER note on 2/3/22, the resident was admitted at 7:19 p.m. The resident's admitted diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the ER note dated 2/3/22, at 8:57 p.m.,power of attorney (POA) sister arrived to the bedside, understands that patient will not likely survive the night despite full resuscitative measures, sister would like to withdraw care, time of death was 9:05 p.m. IV. Staff interviews The primary care physician (PCP) was interviewed on 2/14/22 at 2:56 p.m. The PCP was unsure why the resident passed away. He did not recall if he was contacted about his blood sugars that day. He stated the resident had started to decline and he was not eating and that might be why the blood sugars were high. He stated he was not notified about the high blood sugars of 514, 510, 472 on 2/3/22. He said he should have been notified of BS over 400 and the blood sugars should have been rechecked in 30 minutes after the insulin was administered. He said he could have addressed the resident's BS over 400 if he was notified; he said sustained high blood sugars caused dehydration. Licensed practical nurse (LPN) #3 was interviewed on 2/14/22 at 4:30 p.m. She said if residents were on a sliding scale, she would check blood sugar with a glucometer and follow the sliding scale directions. When the BS was above 400 or below 70, she would notify the physician. She said the PCP was also the medical director (for this resident) and he was easy to get ahold of. She said she would report the blood sugar and make a nurse's note. She said she believed the night shift calibrated the glucometers every night but was unsure as she was an agency licensed nurse. LPN #4 was interviewed on 2/14/22 at 5:00 p.m. LPN#4 said for residents who were on a sliding scale insulin, she would review the order for the sliding scale parameters. If over 400 she would call the doctor, ask for any orders and report the high blood sugar. She said the glucometers were calibrated every night. She said she would notify the physician who wrote the order if the blood sugar was out of parameter. She said she could also look in the binder at the nurses'station to get the physician's number and follow the prompts. She said she would call the doctor, report the blood sugar and ask for orders. She said she documented in the progress notes that she called the doctor and note if any new orders were given. LPN #1 was interviewed on 2/15/22 at 11:00 a.m. LPN #1 said she had training on insulin management recently, and signed the in-service form. She was unable to recall the date of training, stated a month ago. LPN #4 was interviewed via telephone on 2/15/22 at 2:45 p.m. She said she worked with Resident #1 occasionally. He was nonverbal most of the time, he was a brittle diabetic and he had severe kidney issues. He was alert and generally was able to answer questions at times asked of him. He would feed himself most of the time. The LPN #4 said she had worked with him on 2/3/22. She said she had not checked his blood sugar (BS). She said BS was checked by the certified nurse aide with medication authority (CNA/MA). The CNA/MA then informed LPN #4 of the results. She said she then administered the sliding scale insulin which was 12 units. She stated she notified the PCP about the blood sugars. The LPN #4 said that morning his oxygen (O2) was a little low, the PCP ordered 2 liters per minute (LPM) of O2. Resident #1 refused to stay within his diabetic meals, he ate snacks and drank Coke. She stated she reviewed the amount of units of insulin to administer, for the sliding scale, per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident went to the emergency room three hours after her shift and he was stable at the end of her shift. She stated the resident was mumbling when she left, he was drinking fluid and receiving assistance with eating. She said she was overseeing the CNAMAs. She said she oversaw the CNAs with medication authority occasionally when there were no RNs in the building. The DON was in the building during the day when Resident #1 was sent to the emergency room . She stated the CNAs with medication authority's scope of practice was that they could not take physician orders, assess residents, give injection medications and check blood sugars. She stated she did call the physician for BS over 400, which was a standard protocol if additional insulin was given. She said if she was working with CNAs with medication authority she would call the physician to report the insulin given. She stated she did not recall if she made notes when she called the PCP that day. She stated she did not think she made a nursing note every single time the resident was given additional insulin. The PCP was interviewed a second time on 2/15/22 at 4:30 p.m. He said it was brought to his attention that he was notified about the resident's condition in general via text messages (see under facility follow-up). His response to the notification read ok. He said that he probably decided at that point that no additional interventions needed since the resident received his scheduled dose of insulin per sliding scale, therefore he did not reply to the message. He did not recall if he called the facility and spoke to the nurse. V. Facility follow-up provided during the survey On 2/14/22 at 6:15 p.m. the facility provided an investigation of the events that took place on 2/3/22. The investigation included: A disciplinary action for LPN #2 for failure to re-check Resident #1's BS and notify the physician of the BS out of parameters. The disciplinary action was dated 2/14/22 and signed by LPN #2, the nursing home administrator (NHA), and the staff development coordinator (SDC). Blood glucose audits were conducted by the assistant director of nursing (ADON) on 2/14/22 at 6:00 p.m. The audits consisted of each resident who had BS checks, the current medical order, whether or not the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quality assurance and performance improvement (QAPI) meeting was held on 2/14/22 with the NHA, RNC, and the ADON. The QAPI meeting identified the employees who were responsible for ongoing management of change of condition and physician notification for residents. Educational in-service training was provided to all staff on duty on 2/14/22 and would be provided to all upcoming staff on 2/15/22. The topic of training was titled: Diabetes and insulin and blood sugar education. Sign-in sheets were signed by all employees who received the in-service training on 2/14/22 and 2/15/22. On 2/15/22 at 4:20 p.m. RNC provided a print screen of text messages that she stated were communication between LPN #4 and PCP. The text message on 2/3/22 at at 9:36 a.m.read that Resident #1 was not feeling well at all.No specific information given. The physician's response was ok.At 9:38 a.m. the message read that Resident #1's BS reading was high after 18 units of insulin were given per sliding scale. Resident #1 ate very little and LPN #4 was asking if any additional insulin should be given. There were no additional messages from the physician.

Based on record review, and interviews, the facility failed to notify the resident representative when there was a significant change in the resident's condition for one (#1), of three residents reviewed out of seven sample residents. Specifically, the facility failed to notify the the power of attorney (POA) of Resident #1 after a change of condition of the resident's health status. Cross-reference F684 (Quality of Care). I. Facility policy and procedures The Notification of Changes policy dated 2021, was provided on 2/16/22 at 2:23 p.m. by the regional nurse consultant. The policy read in pertinent part, the facility must promptly notify the resident's representative when there is a change requiring such notification, circumstances requiring notification include a significant change in the resident's physical condition including life-threatening conditions or clinical complications. II. Resident #1 A. Resident status Resident #1, age 61, was admitted on [DATE], and discharged to acute care hospital on 2/3/22. According to the February 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required extensive assistance for bed mobility, toileting and activities of daily living (ADL's). B. Record review Review of the resident's profile sheet on 2/14/22, indicated the resident had a power of attorney (POA). The POA listed was the resident's sister. III. The resident's POA being notified of his change of condition A. Record review On 2/3/22 the resident had a change of condition in which he had increased blood sugars, a low grade fever, increased respirations, new oxygen orders for low oxygen saturations and was minimally eating or drinking (cross-reference F684 for Quality of Care). -There were no nursing notes that the resident's POA was notified about the resident's change of condition until he was sent to the emergency room (see interview below). B. The resident's POA interview The resident's POA was interviewed on 2/14/22 at 3:42 p.m. She said she was not notified about the resident's condition until late in the evening on 2/3/22. She said she received a call from the nurse who told her that her brother was sent to the emergency room for evaluation because he had slight labored breathing and inconclusive COVID tests. She said she arrived at the emergency room (ER) within 15 minutes of their call, and the resident was in grave condition. She said she felt that the nursing home did not keep her informed of the resident's condition throughout the day as he was not doing well when she got to the ER. She said she had not been notified of his condition at all that day until he was being transferred to the hospital. V. Staff interviews The assistant director of nursing (ADON) was interviewed on 2/16/22 at 12:30 p.m. The ADON said any changes in a resident's condition should be reported to the primary care physician and resident's responsible party. She reviewed Resident#1's record and stated she was not able to locate any notes indicating that the family was notified. The DON was not available for the interview.

Based on observations, record review and interviews, the facility failed to ensure resident care was consistent with professional standards of practice, to prevent avoidable pressure ulcers for one (#5) of four residents reviewed out of seven sample residents. The facility failed to ensure Resident #5 who was admitted without pressure ulcers and dependent on staff for mobility, transfers and care did not sustain a pressure ulcer/ deep tissue injury (DTI). The facilities failures to implement a person centered care plan with appropriate interventions, monitor and carry out the interventions, document accurately and consistently in the pressure ulcer forms and Skin Weekly Non-pressure Condition Records, transcribe physician orders for heel protective booties and follow physician orders contributed to Resident # 5 sustaining an in house acquired stage 4 pressure injury with an infection to the left great toe. (see-The Skin Weekly Non-Pressure Condition Record dated 7/24/2020) Furthermore, the facility failed to document the pressure ulcer and provide the pressure reducing bed device (air mattress) in the resident's minimum (MDS) data set [DATE], and conduct a pressure ulcer assessment from 7/13/2020 through 7/23/2020. Findings include: I. Facility policies and procedures The Skin Management policy, revised July 2017, was provided by the nursing home administrator (NHA) on 8/3/2020 at 4:24 p.m. The policy revealed residents were to receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise would be identified, assessed and provided treatment to promote healing, prevent infection and prevent new ulcers from developing. Ongoing monitoring and evaluation would be provided for optimal resident outcomes. -A pressure ulcer was defined as any [MEDICAL CONDITION] caused by unrelieved pressure resulting in damage to underlying tissue. Pressure ulcers were usually over bony prominences and were staged to determine the degree of tissue damage observed. -Suspected deep tissue injury was an intact or non-intact skin with a localized area of persistent non-blanchable deep, red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. This wound resulted from intense and/or prolonged pressure and shearing forces at the bone-muscle interface. This area may be preceded by tissue which was firm, mushy, boggy, or warmer/cooler as compared to adjacent tissue. The wound may evolve rapidly to reveal the actual extent of the tissue injury . If any necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures were visible, this would indicate a full thickness pressure ulcer (unstageable stage three or stage four). -Unstageable wound was a full-thickness skin and tissue loss where the extent of the tissue damage within the ulcer cannot be confirmed, because the depth was obscured by slough or eschar. Unstageable wounds might be covered with yellow, tan, gray, green or brown slough. -If a new pressure ulcer was identified, either upon admission, readmission or during the resident's stay, it would be assessed and documented on the weekly Pressure Ulcer Record. -A Weekly Skin Check assessment would be completed in the resident's record using the Head to Toe Skin Check. -A Situation, Background, Assessment, Recommendation (SBAR) Communication Form and a Progress Note would be completed. A new physician's order would be obtained for a new incidence of compromised skin integrity. -A nurse would initiate treatments, interventions, care plans and the appropriate skin documentation records in a timely manner according to practice guidelines. -Pressure ulcers would be measured and staged in accordance with the practice guidelines. The Comprehensive Care Plan policy, revised November 2017, was provided by the NHA on 8/3/2020 at 4:26 p.m. The policy revealed, the facility would develop a comprehensive person centered care plan that identified each resident's medical, nursing, mental and psychosocial needs within seven days after completion of a comprehensive assessment. The plan would be developed with the resident or the resident's representative. The plan would reflect the resident's goals, wishes and preferences. The plan would include measurable objectives and timetables agreed to by the resident to meet such objectives. -The purpose was to provide an effective and person centered care for each resident. -(4b) Interventions would be developed to meet both short and long term resident goals, to prevent avoidable decline in function or functional levels and to attempt to manage risk factors. -(5) The care plan would be reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change of condition. -(9) Interventions specify the frequency of the provided services. II. Resident status Resident #5, age 95, was admitted on [DATE]. According to the August 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 6/7/2020 minimum data set (MDS) assessment revealed the resident had moderate impairment in cognition with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, and personal hygiene. The resident was at risk for the development of pressure ulcers/injuries. The resident utilized a pressure reducing bed device and utilized hospice services. The MDS did not reveal the resident had a pressure ulcer at a stage one or higher. III. Resident observations On 7/30/2020 at 12:55 p.m., the resident laid on a regular mattress with the head of the bed elevated. The resident had covers pull to her chest. -At 1:53 p.m., the resident laid on a regular mattress with the covers pulled to her chest. Licensed practical nurse (LPN) #1 accompanied the surveyor and removed the covers off of the resident's feet. The resident was not wearing any heel protection booties, her heels were not floated and touched the mattress. The bandage on the resident's great toe area was dated 7/29/2020. IV. Wound dressing observation and interview On 7/30/2020 at 3:18 p.m., the resident laid on a regular mattress and was not wearing heel protection booties on either foot. Her heels were not floated and they touched the mattress. The LPN #1 said the resident did have a pair of heel protection booties, but they were soiled and she sent them to the laundry. She said the resident did not have a second set of booties. -Another method to offload the residents heels was not appropriate to relieve pressure from her feet and the pillow that was placed by staff at this time was positioned under the residents knees. LPN #1 said the wound dressing was changed daily and the resident had been followed by a wound clinic. She said due to the resident's decline, the resident was not followed by the clinic at this time. She said the wound resulted from a bad bunion on the resident's left foot. LPN #1 said the wound was measured each Friday with a nurse practitioner and the measurements were sent to her primary care physician and to hospice. LPN #1 removed the bandage dated 7/29/2020 and cleaned the wound with a spray wound cleanser. The wound appeared to be black in color with no visible open area in the middle and drainage. She then applied silver alginate to the wound bed and covered it with a dry dressing. V. Record review The Care Plan (CP) initiated on 3/23/2020 for the potential for impaired skin integrity had interventions to refer to the skin care team as needed, ensure the proper positioning with each encounter, turn/reposition as needed to decrease pressure, complete skin checks weekly per the facility protocol, document findings, provide wound care/preventative skin care per physician orders, observe wound healing and notify the physician of changes in the wound or emerging wounds. -The CP did not mention the resident had a pressure ulcer on her left great toe (bunion) or specific interventions for the resolution of the pressure ulcer. -The preventative interventions initiated on 7/1/2020 and revised on 7/31/2020 included an air mattress and soft floating booties. The Wound Care Clinic (WCC) progress note by a Nurse Practitioner (NP) dated 4/24/2020 revealed the resident received a telemedicine visit. The information was obtained from the resident, caregiver and the clinical record. The resident had a deep tissue injury (DTI) on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The initial wound encounter measurements were 2.5 centimeters (cm) length by 3.0 cm width with no measurable depth. The area of the wound was 7.5 square cm. The wound was 100% [MEDICATION NAME]. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The WCC progress note by a NP dated 5/1/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 0.5 cm length by 1.0 cm width with no measurable depth. The area of the wound was 0.5 square cm. There was no drainage and the wound was 100% [MEDICATION NAME]. There was no change in the wound progression. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. There was no WCC progress note for 5/8/2020 for the wound to the left great toe being assessed weekly. The WCC progress not by a NP dated 5/15/2020 revealed the information was obtained from the resident, caregiver and chart. The resident verbally gave consent to receive telemedicine services. The pressure ulcer received a status of not healed. The subsequently wound measurements of 0.5 cm length by 0.5 cm width with no measurable depth. The wound had an area measurement of 0.3 square cm. The wound was 100% [MEDICATION NAME] with no change noted in the wound progression. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The WCC progress not by the NP dated 5/22/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 0.5 cm length by 0.6 cm width with no measurable depth. The area of the wound was 0.3 square cm. There was no drainage and the wound was 100% [MEDICATION NAME]. There was no change in the wound progression. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The WCC progress note by a NP dated 5/29/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 1.5 cm length by 1.2 cm width with no measurable depth. The area of the wound was 1.8 square cm. There was no drainage and the wound was 100% [MEDICATION NAME]. There was no change in the wound progression. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The Braden Scale for Predicting Pressure Sore Risk dated 6/1/2020 at 9:26 a.m., revealed a score of 13 or moderate risk. The resident's sensory perception was slightly limited in response to verbal commands. The resident could not always communicate discomfort or the need to be turned related to the possibility of sensory impairment which limited the ability to feel pain or discomfort in one or two extremities. The resident was confined to the bed and was completely immoble. The resident did not make even the slightest changes in body or extremity position without assistance. The resident's meal intake was adequate. The resident had the potential problem of friction and shear. The resident moved feebly or required minimum assistance. During a move the skin probably slid to some extent against sheets, chairs, restraints or other devices. The resident maintained a relatively good position in a chair or the bed most of the time, but occasionally slid down. The WCC progress note by a NP dated 6/5/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 0.8 cm length by 1.2 cm width with no measurable depth. The area of the wound was 0.96 square cm. There was no drainage. There was no change in the wound progression. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The WCC progress note by a NP dated 6/12/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 0.5 cm length by 1.0 cm width with no measurable depth. The area of the wound was 0.5 square cm. There was no drainage and the wound was 100% [MEDICATION NAME]. The wound was improving. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The WCC progress note by a NP dated 6/19/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 1.5 cm length by 0.9 cm width with no measurable depth. The area of the wound was 0.27 square cm. There was no drainage and the wound was 100% [MEDICATION NAME]. The wound was improving. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The WCC progress note by a NP dated 6/26/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 0.3 cm length by 0.9 cm width with no measurable depth. The area of the wound was 0.27 square cm. There was no drainage and the wound was 100% [MEDICATION NAME]. There was no change in the wound progression. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. The Treatment Administration Record (TAR) dated 7/1/2020 revealed the resident received four ounces of house supplement twice a day for wound healing. The resident had 62 opportunities to consume the supplement for the month. The resident consumed 0% a total of 19 times, 25% a total of 3 times, 50% a total of 7 times, 75% a total of 1 time, 100% a total of 30 times and not documented a total of 2 times. The Skin Weekly Non-Pressure Condition Record dated 7/3/2020 revealed an assessment of the great toe with an onset date of 4/24/2020. The resident had a DTI measuring 1.0 cm length by 1.5 width by 0.1 depth. The periwound was red and the wound bed was dark. There was a small amount of serosanguineous (blood and clear yellow liquid) drainage. The specialty interventions were air mattress and floating boots. The physician was notified. The WCC progress note by a NP dated 7/10/2020 revealed the information was obtained from the resident, caregiver and the clinical record. The resident was seen today for a follow up and management of the resident's wound. The resident had a DTI on the left great toe, persistent with a non-blanchable deep red, maroon or purple discoloration pressure ulcer and received a status of not healed. The subsequent wound encounter measurements were 2.5 cm length by 4.0 cm width with no measurable depth. The area of the wound was 10.0 square cm. There was no drainage and the wound was 100% slough. The wound was deteriorating. The periwound skin texture was normal, the periwound skin moisture was normal and the periwound skin color was normal. The resident reported a wound pain level of 0 out of 10. A review of the resident's physician orders revealed the following: -7/11/2020: cleanse the left great toe with a wound cleanser, apply silver alginate to the wound bed and cover with a dry dressing. -7/31/2020: apply Santyl Ointment 250 unit/gram to the left great toe topically every day shift. This was related to an unspecified open wound of the left great toe without damage to the nail. -7/31/2020: cleanse the left great toe with a wound cleanser, apply Santyl to the wound bed, and cover with a dry dressing on every day shift. The Skin Weekly Non-Pressure Condition Record dated 7/12/2020 revealed an assessment of the great toe with an onset date of 4/24/2020. The resident had a DTI measuring 2.5 cm length by 4.0 cm width by 0.1 cm depth. The wound was not staged. The peri-wound was macerated (soft and breaking down of skin due to prolonged exposure to moisture) and red. The wound bed was 100% slough (dead tissue cream or yellow in color) with moderate drainage and visible muscle and bone to the left great toe. There was moderate serosanguineous drainage. Specialty interventions were air mattress and floating booties. The wound had deteriorated. The physician was notified. -The resident's clinical record did not contain a Skin Weekly Non-Pressure Condition Record or a WCC progress note by the NP from 7/13/2020 through 7/23/2020. The Skin Weekly Non-Pressure Condition Record dated 7/24/2020 revealed an assessment of the great toe with an onset date of 4/24/2020. The resident had a DTI measuring 4.0 cm length by 5.0 cm width by 0.3 cm deep. The wound was a stage 4 pressure ulcer (full thickness skin loss with exposed muscle, tendon or bone). The wound bed was 80% beefy red granulation and 20% slough. The peri-wound was pink and non-blanchable. The wound has increased in size and depth. There was moderate purulent (milky in color and possibly due to infection) drainage with visible bone. There was an increase in drainage. The physician was notified on 7/24/2020. Specialty interventions were air mattress and floating booties. The Skin Weekly Non-Pressure Condition Record dated 7/31/2020 revealed an assessment of the great toe with an onset date of 4/24/2020. The resident had a DTI measuring 3.8 cm length by 3.0 wide with no depth. The wound was a stage 3 pressure ulcer. The area was 50% slough and 50% granulation. The wound had moderate green purulent drainage with no odor. The wound bed appeared red and yellow. The positioning intervention was to float the heels. The wound had decreased in diameter and had an increase of healthy beefy red granulation. The physician was notified on 7/31/2020. -This indicated the resident had the ability to heal even though she was receiving hospice services. DTI was avoidable and treatable. The resident's Meal Percentage Intake (MPI) records were provided by the director of nursing (DON) on 8/5/2020 at 10:34 a.m. The records revealed: -The resident had 90 meal opportunities from 6/1/2020 through 6/30/2020. The resident consumed 0-25% a total of 7 times, 26-50% a total of 8 times, 51-75% a total of 17 times, 76-100% a total of 42 times and not documented 16 times. -The resident had 93 meals opportunities from 7/1/2020 through 7/31/2020. The resident consumed 0-25% a total of 15 times, 26-50% a total of 16 times, 51-75% a total of 14 times, 76-100% a total of 37 times and not documented 11 times. VI. Interviews The DON was interviewed on 8/3/2020 at 9:15 a.m. She said the resident was on hospice services when she was admitted to the facility on [DATE]. She said the resident did not have a pressure ulcer to her left great toe area when admitted . She said the great toe pressure ulcer was facility acquired on 4/24/2020. She said this pressure ulcer was staged at a 4. She said wound measurements were conducted by LPN #1 and the NP. She said if the NP was not in the facility the wound measurements were conducted by the LPN #1 via telemedicine with the NP. She said the resident had leveled out from her recent decline that started the second week of July 2020. She said the resident's family and physician were notified about the resident's condition. She said hospice called each week to check on the resident. The DON said the wound had improved, but now it was some worse because the resident stopped eating for about one week and declined to the point that end of life services was considered. She said the resident had an admission weight of 131 pounds and she had a weight of 127 pounds on 7/31/2020 and 8/3/2020. She said the resident averaged eating 25 to 50% of her meals. She said she usually ate one large daily meal and then ate smaller meals for the other two daily meals. She said the resident was provided a dietary supplement twice a day between meals. She said sometimes the resident drank the supplement and sometimes she refused. The DON said the wound had improved some on the 7/31/2020 assessment and the resident would be placed back on wound rounds by the service provider NP every Friday. She said the resident's family and physician were notified weekly on the wound assessments. The DON said the resident was on a regular mattress and there was no physician order for [REDACTED]. -However, the left great toe pressure ulcer had never healed since development on 4/24/2020 (see above). The DON said the resident did not have a physician's order for bilateral heel protection booties. She said the resident did have booties and on 7/30/2020, they were sent to the laundry. She said a second pair of booties were provided to the resident on 7/31/2020. She said the resident should have the booties on while in bed and with the heels floated. LPN #2 was interviewed on 8/3/2020 at 11:15 a.m. She said hospice ordered an air mattress and it was delivered to the facility on [DATE]. She said previously the resident was on a regular mattress. She said the resident had a pressure ulcer on her left great toe area. She said the resident was unable to use the call light, staff checked and repositioned her every two hours. She said the resident sometimes did not eat much and slept a lot. She said the resident utilized bilateral booties while the resident was in bed The DON was interviewed with the NHA in attendance a second time on 8/3/2020 at 3:00 p.m. She said the resident had bilateral boggy heels with stage 2 pressure ulcers on admission. She said the heel ulcers resolved quickly. She said the pressure ulcer on the resident's left big toe (bunion) started on 4/24/2020 as a DTI with a red or purple color. She said the skin opened on 7/3/2020 and was a stage II or III. She said as of 7/30/2020, the pressure ulcer was covered with slough and the wound bed was not visible, it should be staged as a IV. She said she did not know how the wound started. She said she thought it was more due to the internal pressure that pressed the tissue on the bone. The DON said the resident's co-morbidities included [MEDICAL CONDITION], left side [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] with a pacemaker, [MEDICAL CONDITION], and dementia. She said [MEDICATION NAME] (diuretic) was the only medication the resident was administered that might prevent wound healing. The DON said the pressure ulcer was not documented on the MDS dated [DATE] because the skin assessment was documented on a non-pressure skin form and it should have been documented on a pressure ulcer form. She said it should have always been documented as the pressure ulcer. The DON said there was no physician's order for bilateral booties on the computerized physician orders (CPO) dated 8/1/2020. She said an order had been written for the booties but it was not transcribed onto the monthly CPOs. She said a new physician order for [REDACTED]. She said since there was no order on the CPO for the booties, the TAR would not have a place to document the monitoring of the booties. The DON said hospice provided an air mattress on 8/1/2020. She said previously the resident had not been on an air mattress. She said staff were to float the residents heels when in bed so that they did not touch the mattress. The DON said there was no care plan for the resident's left great toe (bunion) pressure ulcer. She said a care plan should have been developed by the wound nurse, LPN #1. She said the plan should have included the location of the pressure ulcer and the resident specific interventions such as an air mattress and bilateral booties. The DON said there were no laboratory results for this resident. She said no laboratory tests had been ordered by her physician. She said the physician ordered specific laboratory tests on 7/31/2020. The DON said the resident's pressure ulcer wound was monitored during daily wound dressing changes and on the weekly wound assessment. If any changes were observed in the wound, the resident's provider would be notified. The weekly wound assessment was conducted in conjunction with the NP either in person or by telemedicine. The DON said the resident was unable to use the call light and staff went into the room every two hours to reposition the resident, if the resident allowed. The hospice nurse practitioner (HNP) was interviewed via a conference call with the NHA and DON on 8/3/2020 at 4:00 p.m. She said the resident had a wound on her left great toe (bunion) area. She said the wound started on 4/24/2020 as a DTI that was not measurable at this time. The HNP said the wound became a pressure ulcer on 7/3/2020 when it opened and had some depth. She said she did not stage the ulcer on this date. She said she did not know how the DTI started. She said the resident did have a little contracture in her feet, multiple comorbidities, and a variable nutritional status, which could promote the development of a wound. The HNP said on 7/10/2020 the resident was deteriorating and was not engaging with staff. The pressure ulcer was unstageable. She said on 7/30/2020 via telemedicine, the pressure ulcer was unstageable and contained slough. She said since the wound bed was covered with slough, it was unknown what was under the slough. The HNP said the resident's primary care physician (PCP) could review her notes in the computerized clinical record and write orders as necessary. She said the resident's PCP had not contacted her. VII. Observations and follow-up 8/3/2020 On 8/3/2020 at 11:15 a.m., the resident laid on an air mattress. She had covers pulled to her chest. LPN #2 accompanied the surveyor and removed the covers off of the resident's feet. The resident had heel protection booties on both her feet and the heels were floated off of the mattress. The following physician orders were subsequently added: -8/3/2020: heel protection booties applied to both feet while in bed on every shift for skin treatment and prevention. -8/3/2020: monitor specialty air mattress for proper function on every shift and as needed for mattress function. -8/3/2020: monitor the left great toe and surrounding area for pain, maceration, increased warmth, swelling, drainage, or other abnormalities on every shift for skin treatment and prevention. Document all observed abnormalities or changes noted in progress notes and alert the physician.

Based on observations, record review and interviews, the facility failed to manage pain for four (#10, #1, #2 and #11) of six residents reviewed of 12 sample residents in a manner consistent with professional standards of practice and the residents' goals and preferences. The facility failed to ensure nursing staff followed professional standards for pain management for Residents #10, #2, #1 and #11 by not addressing the residents' continued complaints of pain after pain medication was administered. Additionally, the facility failed to ensure Residents #2 and #11 had pain medications available from the pharmacy to administer when needed. These failures caused the residents to experience prolonged severe pain. Findings include: I. Facility policy and procedure The Pain Management policy, last revised (MONTH) (YEAR), was provided by the nursing home administrator (NHA) on 5/31/19 at 4:05 p.m. It revealed in pertinent part, Pain is subjective and is what the resident says it is, existing when and where the resident says it does. The licensed nurse screens for pain during various interactions and scheduled evaluations. Interventions should be focused on approaches that help to control the resident's level of pain, whether it is by managing pain by the use of pain medications or other non-pharmacological approaches. Evaluation of pain, implementation of interventions, monitoring of the residents response to those interventions, and communicating with the care team regarding pain management strategies are important components of successful pain management system. II. Resident #10 A. Resident status Resident #10, age less than 65, was admitted to the facility on [DATE] on hospice services. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 4/24/19 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was taking scheduled and as needed (PRN) pain medications for complaints of frequent pain. B. Resident observation and interview Resident #10 was interviewed on 6/5/19 at 2:47 p.m. She was sitting crossed legged on her bed rocking back and forth, wringing her hands and she was tearful. She said she was in pain and pointed to her low back and across her abdomen. She was unable to describe or rate her pain, saying, I just don't know, over and over. C. Staff interview Registered nurse (RN) #1 was interviewed on 5/31/19 at 2:50 p.m. She said the resident usually was unable to describe or report her pain. She said she knew the resident was in pain when she was holding her stomach and moaning. She said she used the faces scale to determine what level of pain the resident was in. The RN said she did not like to give the resident her PRN [MEDICATION NAME] unless she thought she really needed it because she did not want to over sedate her. She said she offered the resident a snack and drink or to lie down as non-pharmacological interventions. She said the resident's anxiety and confusion had gotten worse in the last couple of weeks and that's why hospice changed her anti-anxiety medication to every four hours which also seemed to help with her pain. She said she did not know what the resident's pain goal was. She said when the resident first came she used the 0-10 pain scale to evaluate the resident's pain but recently the resident had had more difficulty rating her pain so she started using the Wong-Baker scale (a scale using facial expressions for different levels of pain). D. Record review 1. Care plan The care plan, initiated on 4/22/19, revealed the resident had acute pain related [MEDICAL CONDITION] [DIAGNOSES REDACTED]. -Evaluate the effectiveness of pain interventions. Review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; -Notify physician if interventions were unsuccessful or if current complaint was a significant change from resident's past experience of pain; and -Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician/hospice immediately if there is breakthrough pain. 2. Pain evaluation According to the most recent pain evaluation, dated 4/18/19, the resident had frequent pain related to [MEDICAL CONDITION]. She had taken routine and PRN pain medications and non-pharmacological interventions for her pain. The location of the pain was generalized and described as aching, although the resident had difficulty describing her pain. She did not have a history of hurting or pain. The numeric pain rating scale was: 0 no pain, 1-3 mild pain, 4-5 moderate pain, 6-7 severe pain, 8-9 very severe pain, and 10 worst possible pain. The resident was able to verbalize her pain, rating her pain a six (severe pain) out of 10 at the time of the assessment. She rated her pain a 10 (worst pain possible) at its worst and a two (mild pain) at its best. The resident's goal and plan for managing her pain would be to report her pain level at or below three (mild) out of 10 with the use of pharmacological and non-pharmacological interventions. 3. Computerized physician orders According to the (MONTH) 2019 CPO, orders included: -[MEDICATION NAME] 4 mg, give 4 mg by mouth every one hour as needed for pain, written 4/21/19; -[MEDICATION NAME] 10 mg, give 2.5 tablets (25 mg) by mouth every eight hours, written 5/8/19; -[MEDICATION NAME] 1 mg, give 1.5 mg by mouth every four hours, written 5/8/19; and -Pain: observe every shift, if present, complete pain flow sheet and treat, trying non pharmacological interventions prior to medicating if appropriate. Document in a progress note. 4. Progress note According the orders-administration notes for 4/21/19 at 1:46 a.m., the resident was to receive [MEDICATION NAME] 4 mg for complaint of severe pain all over. Her pain was re-evaluated at 4:02 p.m. and she rated her pain five out of 10. Review of the Controlled Drug Administration Record for the resident's [MEDICATION NAME] revealed on 4/21/19 at 1:46 a.m. only one 2 mg tablet was given instead of two 2 mg tablets to equal the prescribed dose of 4 mg. 5. Medication administration records (MARs) a. (MONTH) 2019 According to (MONTH) 2019 MAR the resident received [MEDICATION NAME] 4 mg 49 times, from 5/1/19 through 5/31/19, where she reported her pain was very severe or the worst pain (8-10 on the pain scale). When the pain was reevaluated the resident reported on 17 occasions her pain remained very severe or the worst pain and on eight occasions her pain was severe. Furthermore, there were not any documented attempts at non-pharmacological interventions to minimize the resident's pain. b. (MONTH) 2019 According to (MONTH) 2019 MAR the resident received [MEDICATION NAME] 4 mg six times, from 6/1/19 through 6/4/19, where she reported her pain was very severe or the worst pain (8-10 on the pain scale). When the pain was reevaluated the resident reported on four occasions her pain remained severe or very severe. Furthermore, there were not any documented attempts at non-pharmacological interventions to minimize the resident's pain. III. Resident #2 A. Resident status Resident #2, age 68, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 4/3/19 MDS assessment, the resident had no cognitive impairment with a BIMS score of 14 out of 15. The resident received PRN pain medications and non-medication interventions. Her pain was frequent, limiting day to day activities, and was rated four out of 10. B. Record review 1. Pain evaluation According to the 3/28/19 pain evaluation, the resident had pain from [MEDICAL CONDITION] and right total knee replacement, described as stabbing, aching and soreness. She received PRN pain medications and non-medication interventions for pain. Her pain was frequent and limited her day-to-day activities. The resident rated her pain a two (mild pain) at the time of the assessment. She rated her pain 10 (worst possible pain) at its worst and one (mild pain) at its best. The resident's goal for managing her pain would be to report her pain level at or below three (mild) out of 10. Non-pharmacological interventions that assisted to relieve the pain were rest, positioning and ice/cold pack.The care plan, initiated 3/30/19, revealed the resident had acute and chronic pain related to bilateral [MEDICAL CONDITION] and right total knee replacement. The only intervention listed was to notify the physician if interventions were unsuccessful or if current complaint was a significant change from the resident's past experience of pain. 2. Computerized physician orders According to the (MONTH) 2019 CPO, orders included: -[MEDICATION NAME] give 650 mg by mouth every eight hours as needed for pain; -[MEDICATION NAME] 5mg, give one tablet by mouth every four hours as needed for pain and two tablets by mouth every four hours as needed for severe pain; -Apply ice to affected area (right knee) or use polar ice unit (45-50 degrees) PRN; and -Pain - observe every shift, if present, complete pain flow sheet and treat, trying non pharmacological interventions prior to medicating if appropriate. Document in a progress note. 3. Medication administration records a. (MONTH) 2019 According to (MONTH) 2019 MAR the resident received [MEDICATION NAME] 5 mg six times, from 3/28/19 through 3/31/19, where she reported her pain was very severe or the worst pain (8-10 on the pain scale). When the pain was reevaluated the resident reported on two occasions her pain remained severe or very severe. Furthermore, there were not any documented attempts at non-pharmacological interventions to minimize the resident's pain. B. (MONTH) 2019 According to (MONTH) 2019 MAR the resident received [MEDICATION NAME] 5 mg six times, from 3/28/19 through 3/31/19, where she reported her pain was severe, very severe or the worst pain (8-10 on the pain scale). When the pain was reevaluated the resident reported on two occasions her pain remained severe or very severe. Furthermore, there were not any documented attempts at non-pharmacological interventions to minimize the resident's pain. IV. Resident #1 A. Resident status Resident #1 age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 3/13/19 MDS assessment, the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident received scheduled and PRN pain medications but no non-medication interventions. Her pain was occasional rated two out of 10. B. Record review 1. Progress notes According to the 3/7/19 nursing note the resident arrived via facility bus from home at 6:38 p.m. The resident had a right foot fracture. According to the 3/8/19 nursing note the registered nurse (RN) was called into the resident's room by the licensed practical nurse (LPN) at 3:45 a.m. The resident was upset she could not get her [MEDICATION NAME]. The LPN explained to the resident that he was working on getting a prescription for the pharmacy so they could get her pain medication. The resident became upset and called 911. The ambulance crew was in the room when the RN arrived and the LPN was on the phone with the pharmacy. The emergency medical technician (EMT) explained to the resident about the process of getting the medication and that it would not be worth a trip to the emergency room (ER) at this time as they would most likely not do much for her. The LPN had already given the resident 800 mg of [MEDICATION NAME] per on call order and staff would be able to get the [MEDICATION NAME] before they could even get her in the ambulance. She finally agreed not to go to the ER. The nurse explained the process of getting the medication to her. The authorization code was obtained and the [MEDICATION NAME] was given at 3:55 a.m. The nurse explained to the resident that they had more and that her next dose would be available at about 8:00 a.m. When the nurse left the room the resident was sitting on the bed holding her head in her hands. 2. Pain evaluation According to the 3/7/19 pain evaluation, the resident had pain related to a right ankle fracture. She had taken routine and PRN pain medications and non-medication interventions for her pain. The location of the pain was to the right ankle joint and described as throbbing and aching. Her pain was frequent and interfered with her sleep. The resident was able to verbalize her pain, rating it a four (moderate pain) out of 10 at the time of the assessment. She rated her pain an eight (very severe pain) at its worst and a zero (no pain) at its best. The resident's goal for managing her pain would be to report her pain level at a zero (no pain) out of 10 with the use of pharmacological and non-pharmacological interventions. Non-pharmacological interventions that assisted to relieve the resident's pain were positioning and elevation. 3. Care plan The care plan, initiated 3/11/19, revealed the resident had acute and chronic pain related to a broken foot and was at risk for addiction, constipation and ADL decline and falls related to the use of narcotics to help manage her pain. Interventions included: -Attempt to identify the root cause of pain; -Offer non-pharmacological interventions for complaint of pain such as repositioning, back to bed/out of bed, elevation of extremities, ice pack, topical modalities, back rubs; and -Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. 4. Computerized physician orders According to the (MONTH) 2019 CPO, orders included: -[MEDICATION NAME] 5-325 mg, give one tablet by mouth every four hours as needed for moderate pain and two tablets by mouth every four hours as needed for severe pain; -[MEDICATION NAME] give 5 mg by mouth every eight hours as needed for muscle spasms; -[MEDICATION NAME] 75 mg, give one capsule by mouth two times a day; and -Pain - observe every shift, if present, complete pain flow sheet and treat, trying non pharmacological interventions prior to medicating if appropriate. Document in a progress note. 5. Medication administration records a. (MONTH) 2019 According to the (MONTH) 2019 MAR, the resident did not receive her scheduled [MEDICATION NAME] on 3/7/19 at 8:00 p.m., 3/8/19 at 8:00 a.m. and 8:00 p.m., 3/25/19 at 8:00 p.m., 3/26/19 at 8:00 p.m. and 3/27/19 at 8:00 a.m. and 8:00 p.m. due to the medication not being available from the pharmacy (cross reference F755). The 8:00 a.m. dose on 3/26/19 was documented as being administered even though the medication was not available to be given. According to the (MONTH) 2019 medication administration record (MAR) and orders-administration note on 3/7/19, the resident received [MEDICATION NAME] 5-325 mg two tablets at 3:55 a.m. for pain rated 10 out of 10, more than nine hours after she had been admitted to the facility. The resident's pain was re-evaluated at 5:36 a.m. and she rated her pain a seven out of 10. The resident did not receive any non-pharmacological pain interventions for her increased pain. At 11:39 a.m., the resident received [MEDICATION NAME] 5-325 mg one tablet for pain she continued to rate seven out of 10, instead of two tablets ordered for severe pain. According to the (MONTH) 2019 MAR and orders-administration notes on 3/11/19 at 10:55 a.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for pain rated nine out of 10 for continued pain to [DEVICE] site and right ankle. Her pain was re-evaluated at 12:09 p.m. She said it was better but continued to rate her pain five out of 10. At 7:45 p.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for pain she continued to rate five out of 10. The resident did not receive any non-pharmacological pain interventions during this time period. According to the (MONTH) 2019 MAR and orders-administration notes on 3/13/19 at 4:00 a.m., the resident received [MEDICATION NAME] 5/325 mg one tablet for abdominal pain rated eight out of 10 instead of two tablets ordered for severe pain. According to the (MONTH) 2019 MAR and orders-administration notes on 3/18/19 at 7:31 a.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe pain rated nine out of 10. Her pain was re-evaluated at 8:31 a.m. and she rated her pain four out of 10. At 10:30 a.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe abdominal pain rated five out of 10. No re-evaluation was documented after this dose, however she did receive more [MEDICATION NAME] 5/325 mg, two tablets at 2:06 p.m. for pain rated eight out of 10. Her pain was re-evaluated at 3:05 p.m. She rated her pain four out of 10. At 6:30 p.m., she received [MEDICATION NAME] 5/325 mg two tablets for severe abdominal pain rated six out of 10. The resident did not receive any non-pharmacological pain interventions during this time period. According to the (MONTH) 2019 MAR and orders-administration notes on 3/21/19, at 5:36 a.m. and 5:00 p.m., the resident received [MEDICATION NAME] 5/325 mg one tablet for pain rated seven out of 10 instead of two tablets ordered for severe pain. According to the (MONTH) 2019 MAR and orders-administration notes on 3/25/19 at 7:19 p.m., the resident received [MEDICATION NAME] 5/325 mg one tablet for moderate abdominal pain rated seven out of 10 instead of two tablets ordered for severe pain. The resident's [MEDICATION NAME] 75 mg was not available and on order from the pharmacy. Her pain was not re-evaluated until 3/26/19 at 1:20 a.m. after she had already received [MEDICATION NAME] 5/325 mg two tablets for severe abdominal pain rated seven out of 10. The resident did not receive any non-pharmacological pain interventions during this time period. According to the (MONTH) 2019 MAR and orders-administration notes on 3/26/19 at 1:48 p.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe body pain rated eight out of 10. Her pain was re-evaluated at 2:51 p.m. and she rated her pain four out of 10. At 8:18 p.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe abdominal pain rated seven out of 10. The resident's [MEDICATION NAME] was not available and on order from the pharmacy. The resident did not receive any non-pharmacological pain interventions during this time period. According to the (MONTH) 2019 MAR and orders-administration notes on 3/28/19 at 1:05 a.m., the resident received [MEDICATION NAME] 5/325 one tablet for right foot pain rated seven out of 10 instead of two tablets ordered for severe pain. b. (MONTH) 2019 According to the (MONTH) 2019 MAR and orders-administration noted on 4/1/19 at 5:02 a.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe leg pain rated seven out of 10. Her pain was re-evaluated at 6:02 a.m. and she rated her pain four out of 10. At 9:06 a.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe right leg pain rated eight out of 10. Her pain was re-evaluated at 10:06 a.m. and she rated her pain four out of 10. At 1:45 p.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe right leg pain rated eight out of 10. The resident did not receive any non-pharmacological pain interventions during this time period. According to the (MONTH) 2019 MAR and orders-administration notes on 4/2/19 at 12:47 p.m., the resident received [MEDICATION NAME] 5/325 mg two tablets for severe right leg pain rated eight out of 10. Her pain was re-evaluated at 1:47 p.m. and she rated her pain four out of 10. At 7:11 p.m., the resident received [MEDICATION NAME] 5/325 mg one tablet for pain rated seven out of 10. The resident did not receive any non-pharmacological pain interventions during this time period. According to the (MONTH) 2019 MAR and orders-administration notes on 4/3/19, at 7:11 a.m., the resident received [MEDICATION NAME] 5/325 mg one tablet for right foot pain rated seven out of 10 instead of two tablets ordered for severe pain. V. Staff interviews The director of nursing (DON) was interviewed on 5/31/19 at 3:30 p.m. She said a pain assessment was done on every resident when they were admitted . This assessment included what the resident's pain goals were. She said resident's pain should be assessed every shift and before any pain medication was given. If the resident did not receive pain relief from the medication, the physician should be notified. She said the nurses should be using the 0-10 numeric rating scale for all residents except those with cognitive issues. For residents with confusion or dementia, the nurses should use the Wong-Baker Scale. She said severe pain was anything the resident rated above a six out of 10. LPN #3 was interviewed on 6/5/19 at 11:38 a.m. She said if a resident's pain was not relieved after giving pain medication, a different pain medication should be offered if they had an order for [REDACTED]. She said there were always three nurses in the facility and the nurses could access the emergency kit with another nurse at any time as long as they had authorization from the pharmacy. She said medications including narcotics should be ordered from the pharmacy when the resident still had three or four days of pills left to ensure they did not run out. RN #1 was interviewed again on 6/6/19 at 1:08 p.m. She said when she gave a PRN pain medication, she would re-evaluate the resident approximately an hour later. If they continued to complain of pain, she would offer non-pharmacological interventions or another type of pain medication if the resident had orders for it. If the resident did not have any other pain medications ordered to be given and it was too soon for more of the same pain medication to be given, the physician needed to be contacted for further orders. She said if a pain medication was not available, she would notify the physician and the pharmacy and keep bugging them frequently until they responded and she was able to get the medication she needed from the emergency kit. VI. Resident #11's status Resident #11, age less than 60, was admitted on [DATE]. According to the (MONTH) 2019 CPO, pertinent [DIAGNOSES REDACTED]. The 4/15/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident was on a scheduled pain medication regimen, received PRN pain medication, and did not receive non-medication intervention for pain. The resident occasionally had pain that did not affect his sleep or day-to-day activities, and the pain was rated at 4 out of 10. The resident required supervision with setup help only for activities of daily living (ADLs). A. Resident interview Resident #11 was interviewed on 6/6/19 at 10:42 a.m. The resident said he had chronic pain in his legs and back, and acute pain from a rotator cuff tear to the right shoulder. He said because he was a paraplegic, he used his arms for all transferring which made the pain worse. Resident #11 said his chronic pain depended on the day and the weather. He rated his current pain as a 5 out of 10, and would like his pain to be at least a three. He said the worst his pain got was a 10 and the best was a 3. Resident #11 said he understood the limitations the physician had with prescribing narcotic medications, but there were times when his pain medication was not available for the nurses to give. He said on the night of 6/2/19, he went over 12 hours without any pain medication because it was not available. Resident #11 said the nurses told him it was because there had to be two nurses to remove the medication from the emergency kit (e-kit) and there was not another one available until the next shift, so he had to wait. He said he missed his 7:00 p.m., 11:00 p.m., and 3:00 a.m. doses of immediate-release [MEDICATION NAME]. He said no staff asked him about his pain goals or what non-pharmacological interventions might work for him, and no non-pharmacological interventions were ever offered to him. B. Record review The 4/9/19 pain assessment revealed the resident had pain related to [MEDICAL CONDITION], a tear or rupture of the right rotator cuff, and chronic pain. The assessment revealed the resident's pain ranged from zero to eight, and his goal for pain was hurts a little bit/mild pain. The resident's pain was relieved by rest, positioning, and scheduled and PRN pain medications. The pain care plan, last revised 4/19/19, read the resident had chronic pain related to back injuries and previous surgeries. The resident's goal was to have pain managed to the greatest extent possible so it did not affect day-to-day activities. The intervention listed was to notify the physician if interventions were unsuccessful or if current complaint is a significant change from resident's past experience of pain. The resident received occupational therapy in (MONTH) and (MONTH) 2019 for pain management for his left shoulder. The (MONTH) 2019 CPO revealed the following physician orders: -[MEDICATION NAME], 10 mg every four hours related to pain in left shoulder, effective 5/31/19 -[MEDICATION NAME], 600 mg by mouth every eight hours as needed for pain in left shoulder and lower back, effective 5/14/19 -Pain goal of zero. Implement one of the following interventions prior to administration of pain medication: 1. Repositioning 2. Redirection 3. Snack 4. Massage Document yes, no or refused as needed, effective 6/2/19 and discontinued 6/6/19 -Observe for pain every shift. If pain present, complete pain flow sheet and treat trying nonpharmacologic interventions prior to medicating if appropriate. Document in the progress notes, effective 4/9/19 The (MONTH) 2019 medication administration record (MAR) revealed: -The [MEDICATION NAME] 10 mg was not administered on 6/2/19 at 8:00 p.m. and 6/3/19 at 12:00 a.m. and 4:00 a.m. A pain level was not documented at these administration times. The resident was administered the [MEDICATION NAME] on 6/2/19 at 4:00 p.m., pain level of 5 out of 10, and 6/3/19 at 8:00 a.m., pain level of 9 out of 10. -600 mg [MEDICATION NAME] was not documented as administered on 6/2/19 or 6/3/19. -No nonpharmacological interventions were documented on 6/2/19 or 6/3/19. -Pain was documented on 6/2/19 at 6:00 p.m. at 9 out of 10, and on 6/3/19 at 6:00 a.m. at 6 out of 10. The 10mg [MEDICATION NAME] was signed out on the narcotic medication count record on 6/2/19 at 4:00 a.m. and 6/3/19 at 8:00 a.m. The Pain/Vitals Log was reviewed on 6/2/19 at 10:48 p.m. The resident's pain was rated as a 9 out of 10 on the pain scale. Nursing progress notes on 6/2/19 and 6/3/19 were reviewed. The progress notes revealed: -On 6/2/19 at 7:50 p.m., the order for [MEDICATION NAME] 10 mg was awaiting delivery from the pharmacy. -On 6/2/19 at 11:36 p.m., the order for [MEDICATION NAME] 10 mg was awaiting a stat (immediate) order to remove the medication from the medication dispenser. -On 6/3/19 at 1:45 a.m., the resident had no noted changes in behavior at this time, will continue to monitor, continues to use every four hour pain medication for shoulder pain. -On 6/3/19 at 5:27 a.m., the order for [MEDICATION NAME] 10 mg was awaiting pharmacy delivery. -There were no progress notes discussing the resident's elevated pain levels, non-pharmacological interventions implemented to treat the resident's pain, or attempts to contact the pharmacy or physician regarding the resident's pain or the availability of the pain medications. The Request for Removal of Schedule II Medication from Contingency Supply form, dated 6/3/19 (per interviews below, this form was completed on 6/2/19), documented the physician was contacted at 11:50 p.m. for authorization to remove the medication from the medication dispenser. The pharmacy delivery slip revealed the order for 10 mg [MEDICATION NAME] was placed on 6/2/19, but did not specify the time, and delivered on 6/3/19 at 11:20 a.m. The resident missed three doses of the pain medication and experienced an increase in pain level during this time of waiting for the medication to be delivered to the facility. VII. Staff interviews The medical director (MD) was interviewed on 6/6/19 at 11:42 a.m. The MD said if the resident was in pain, they should be treated with their scheduled and as needed pain medications. He said nonpharmacological interventions, such as walking, repositioning or topical agents could also be effective. He said if the resident was not relieved of pain, the physician should be contacted to see what other interventions could be implemented. The MD said he did not have any issues with residents at the facility receiving pain medications and was not familiar with the situation regarding Resident #11. He said his expectation would be for nursing to document any interventions attempted. The pharmacy consultant (PC) was interviewed on 6/6/19 at 12:30 p.m. The PC said the physician should be notified immediately if a medication was not available. She said the physician would place the medication on hold or find a replacement until the supply arrived. The PC said if the medication was available in the medication dispenser, the facility could send a request to the pharmacy to remove the medication from the emergency supply, and the physician would need to be notified that this request was made. There would need to be a second nurse to access the dispenser to retrieve the medications, but this should not happen if there were two nurses working. The director of nursing (DON) was interviewed on 6/6/19 at 2:00 p.m. The DON said she was not aware of Resident #11 missing his pain medication on the night of 6/2/19 and she was not notified of this. The DON said she should have been notified and if there was not a second nurse to open the dispenser, she could have been called in at any time of the night to come in. She said there were two nurses scheduled that night to work to open the dispenser. The DON said the nurses had received education the weekend of 6/1/19 on pain management, implementing non-pharmacological interventions and documentation, and would be re-educating nurses on the above mentioned topics. Licensed practical nurse (LPN) #2 was interviewed on 6/6/19 at 2:28 p.m. LPN #2 said her shift had started at 6:00 p.m. She said the resident was scheduled to receive the medication at 8:00 p.m. She said she heard in report from the previous shift that the pharmacy had been contacted but had not yet delivered the medication. She said they should have arrived at 5:00 p.m. on 6/2/19. LPN #2 said she called the on-call pharmacy and on-call physician later that shift (around 11:00 p.m.) so she could get authorization to get into the medication dispenser. She said she had also contacted the pharmacy at 3:30 p.m. but had not heard anything. LPN #2 said she did not get access into the medication dispenser until 6/3/19 at 5:15 a.m. and then the resident was administered his pain medication immediately (on the MAR this was documented at 8:00 a.m.). LPN #2 said she offered him other medications and non-pharmacological interventions but he only wanted his [MEDICATION NAME]. She said the resident always said his pain was a 9 out of 10, and he set an alarm to get his scheduled pain medications. LPN #2 said herself and the certified nurse aides (CNAs) on duty that shift had checked on him hourly and he was sleeping soundly and had not complained about pain until he came out of his room around 5:00 a.m. She said she did not think there was any concern for him not to have received his pain medications. VIII. Facility follow-up A new pain assessment for Resident #11 was completed on 6/6/19. The 6/6/19 pain assessment determined the resident had pain to his lower back, bilateral thighs, left bicep, rotator cuff, and left clavicle. The resident had pain almost constantly that affected his sleep and day-to-day activities. The resident's pain ranged fro

Based on record review and interviews, the facility failed to provide appropriate pharmaceutical services to meet the needs of six (#1, #2, #10, #11 #4 and #9) of six residents reviewed of 12 sample residents. Specifically, the facility failed to: -Ensure staff kept accurate and legible records of controlled medications for all facility residents; -Ensure nursing staff documented accurately in the residents' record when a controlled medication was given for Residents #1, #2, #10, #11, #4 and #9; -Ensure medications were ordered and received timely for Residents #1 and #11; and -Establish a system for the facility to accurately reconcile controlled medications using acceptable standards of practice. The facility failed to have a system to ensure pain medications were being ordered and delivered timely from the pharmacy and were being administered appropriately to the resident's according to physician orders. This failure caused residents to have prolonged increased pain. Cross-reference F684 highest practicable resident well-being, and F697 pain management. Findings include: I. Facility policy and procedure The Inventory Control of Controlled Substances policy, last revised 1/1/13, was provided by the nursing home administrator (NHA) on 5/31/19 at 4:05 p.m. It revealed in pertinent part, Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results. The facility should: -Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and remove medications that have completed or discontinued from the inventory; -Reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification/Shift Count Sheet; -Routinely reconcile the number of doses remaining in the package to the number of remaining doses record on the Controlled Substance Verification/ Shift Count Sheet, to the medication administration record (MAR). -Ensure staff immediately report suspected theft or loss of controlled substances to their supervisor/manager for appropriate documentation, investigation and timely follow-up. A facility representative should regularly check the inventory records to reconcile inventory. Facility should regularly reconcile: -Current and discontinued inventory of controlled substances to the log used in the facility's controlled medication inventory system; -Current inventory to the controlled medication declining inventory record and to the residents MAR; and -Unused controlled substances held in storage awaiting destruction to the declining inventory record. II. Resident #1 status Resident #1, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 3/13/19 minimum data set (MDS) assessment, the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident received scheduled and as needed (PRN) pain medications but no non-medication interventions. Her pain was occasional, rated two out of 10. Record review According to the (MONTH) 2019 CPO, orders included: -[MEDICATION NAME] 5-325 mg, give one tablet by mouth every four hours as needed for moderate pain and two tablets by mouth every four hours as needed for severe pain; and -[MEDICATION NAME] 75 mg, give one capsule by mouth two times a day. Comparison of the (MONTH) 2019 medication administration record (MAR) and the Controlled Drug Administration records (narcotic sheets) revealed one tablet of [MEDICATION NAME] 5/325 was signed out on the narcotic sheet but was not documented as being administered on the MAR on the following dates: -3/9/19 at 1:20 p.m.; and -3/31/19 at 8:00 p.m. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed two tablets of [MEDICATION NAME] 5/325 were signed out on the narcotic sheet but were not documented as being administered on the MAR on the following dates: -3/8/19 at 8:00 a.m.; -3/9/19 at 8:00 p.m.; -3/11/19 at 3:45 p.m.; -3/13/19 at 8:30 a.m., 1:30 p.m., 6:00 p.m. and 10:00 p.m. -3/14/19 at 6:00 a.m.; -3/15/19 at 2:00 a.m., 7:50 a.m. and 8:00 p.m.; -3/16/19 at 5:30 p.m. and 8:00 p.m.; -3/17/19 at 1:00 p.m. and 8:00 p.m.; -3/19/19 at 8:00 p.m.; -3/20/19 at 6:00 a.m.; -3/22/19 at 5:00 a.m. and at either 1:45 p.m. or 3:45 p.m. (writing was unclear). -3/24/19 at 10:30 a.m. and 3:00 p.m.; -3/26/19 at 9:00 a.m.; -3/27/19 at 1:00 p.m.; and -3/29/19 at 8:00 a.m. and 8:00 p.m. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed two tablets of [MEDICATION NAME] 5/325 mg were signed out on the narcotic sheet but only one tablet was signed out as being administered on the MAR on the following dates: -3/8/19 at 12:00 p.m. and 8:00 p.m.; -3/13/19 at 4:00 a.m.; -3/16/19 at 1:30 a.m.; -3/21/19 at 5:00 p.m.; -3/25/19 at 7:15 p.m.; -3/27/19 at 8:00 a.m.; and -3/28/19 at 1:00 a.m. -According to the Controlled Drug Administration Record on 3/21/19 at 12:00 p.m. the amount given had the number one written in the space with the number two written over it. The amount left had the number 24 written in the space with the number 23 written over it. According to the (MONTH) 2019 MAR, the resident only received one tablet of [MEDICATION NAME] 5/325 mg. Review of the Controlled Drug Administration Record (narcotic sheet) revealed the totals in the amount left column were incorrect. On 3/22/19 at 3:45 p.m. 13 tablets were in the amount left column. After two tablets of [MEDICATION NAME] 5/325 mg were given at 8:00 p.m. the number of tablets in the amount left column was 12 instead of 11. On 3/23/19 at 12:41 a.m. two more tablets of [MEDICATION NAME] 5/325 mg were signed out and the number of tablets in the amount left column was 10 instead of nine. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed the following: -On 4/2/19 at 8:16 a.m. and 4:00 p.m. two tablets of [MEDICATION NAME] 5/325 mg were signed out but the MAR only had two tablets of [MEDICATION NAME] 5/325 mg documented as being administered at 12:47 p.m.; and -On 4/3/19 at 1:00 a.m. two tablets of [MEDICATION NAME] 5/325 mg were signed out but were not documented as being administered on the MAR, and at 7:00 a.m. two tablets of [MEDICATION NAME] 5/325 mg were signed out but only one tablet was documented as being administered on the MAR. Medication availability According to the (MONTH) 2019 MAR, the resident did not receive her scheduled [MEDICATION NAME] on 3/7/19 at 8:00 p.m., 3/8/19 at 8:00 a.m. and 8:00 p.m., 3/25/19 at 8:00 p.m., 3/26/19 at 8:00 p.m. and 3/27/19 at 8:00 a.m. and 8:00 p.m. due to the medication not being available from the pharmacy. The 8:00 a.m. dose on 3/26/19 was documented as being administered even though the medication was not available to be given. III. Resident #2 status Resident #2, age 68, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 4/3/19 MDS assessment the resident had no cognitive impairment with a BIMS score of 14 out of 15. The resident received as needed (PRN) pain medications and non-medication interventions. Her pain was frequent, limiting day to day activities and was rated four out of 10. Record review According to the (MONTH) 2019 CPO, orders included [MEDICATION NAME] 5 mg give one tablet by mouth every four hours as needed for pain and two tablets by mouth every four hours as needed for severe pain. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed two tablets of [MEDICATION NAME] 5 mg were signed out but were not documented as being administered on the MAR on the following days: -3/29/19 at 2:56 p.m.; and -3/31/10 at 3:56 p.m. and 7:00 p.m. According to the (MONTH) 2019 MAR, the resident received [MEDICATION NAME] 5 mg two tablets 12 times in April. The Controlled Drug Administration Records for the resident's [MEDICATION NAME] from 4/1/19 through 4/5/19 were requested from the facility and were not received. The NHA reported on 6/6/19 that the records were not available (see interview below). IV. Resident #10 status Resident #10, age less than 65, admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 4/24/19 MDS assessment, the resident had no cognitive impairment with a BIMS score of 14 out of 15. The resident was taking scheduled and as needed (PRN) pain medications for complaints of frequent pain. Record review According to the (MONTH) 2019 CPO, orders included: -[MEDICATION NAME] 4 mg give 4 mg by mouth every one hour as needed for pain; -[MEDICATION NAME] 10 mg give 2.5 tablets (25 mg) by mouth every eight hours; and -[MEDICATION NAME] 1 mg give 1.5 mg by mouth every four hours. The facility was requested to provide all the Controlled Drug Administration Record's for the resident's [MEDICATION NAME] from the time of admission. A record was provided for [MEDICATION NAME] 5 mg from 4/18/19-4/21/19 for eight tablets. No record was provided for the 20 mg [MEDICATION NAME] tablets that were supposed to be administered with the 5 mg for the same time period. Review of the Controlled Drug Administration Record for the Resident's [MEDICATION NAME] 10 mg from 4/20/19 at 8:05 p.m. to 5/1/19 at 2:30 p.m. revealed the record had 11 out of 30 entries in the amount remaining column that were scribbled through and the amount changed. Further review of the record revealed the following: -On 4/21/19 at 5:15 a.m. the number of tablets in the amount remaining column was 116 tablets. -At 2:00 p.m. the nurse signed out three 10 mg tablets, however the number of tablets in the amount remaining column was 112 tablets when it actually should have been 113 tablets. -On 4/21/19 at 9:30 p.m. the nurse signed out two and a half 10 mg tablets and the number of tablets in the amount remaining column was 109.5 tablets (this amount had been written on top of a different illegible amount). It actually should have been 111.5 tablets. -On 4/22/19 at 6:52 a.m. two and a half tablets were signed out and the number of tablets in the amount remaining column was 107 tablets when it actually should have been 108 tablets. At an undocumented time, two tablets were signed out and the number of tablets in the amount remaining was 105 when it should have been 106. At 7:30 p.m. two and a half tablets were signed out and the number of tablets in the amount remaining column was 102.5 tablets when it actually should have been 103.5 tablets. -On 4/23/19 at 6:00 a.m. two and a half tablets were signed out and the number of tablets in the amount remaining column was 100 tablets when it actually should have been 101 tablets. At 2:00 p.m. two and a half tablets were signed out and the number of tablets in the amount remaining column was 99.5 tablets but was then written over to change the number to 98.5 tablets making the count correct at that time. -On 4/29/19 at an undocumented time, two and a half tablets were signed out and the number of tablets in the amount remaining column was 48.5 tablets. At 2:00 p.m. two and a half tablets were signed out and the amount in the remaining column was 45.5 tablets when it should have been 46 tablets. At 8:00 p.m. two and a half tablets were signed out and the amount in the remaining column was 43 when it actually should have been 43.5 tablets. -On 4/30/19 at 5:00 a.m. two and a half tablets were signed out and number of tablets in the amount remaining column was 40.5 tablets when it actually should have been 41 tablets. -On 5/1/19 at 2:30 p.m. two and a half tablets were signed out and the number of tablets in the amount remaining column was 38 tablets when it actually should have been 38.5 tablets. This was the last entry on this document. On the continuing record the amount carried over was 38 tablets. The above errors were not identified during shift change when reconciliation of the narcotics was supposed to occur to verify the correct amount of medications available match the Controlled Drug Administration Record. According to the Controlled Drug Administration Record for the resident's [MEDICATION NAME] dated from 5/4/19 to 5/15/19, 35 tablets were documented as the amount left on the last entry of the record. No Record was provided by the facility for the resident's [MEDICATION NAME] remaining 35 tablets or for any doses administered from 5/16/19 through 5/20/19. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed two tablets of [MEDICATION NAME] 2 mg were signed out but were not documented as being administered on the MAR on the following dates: -4/20/19 at 1:30 p.m. and 5:30 p.m.; -4/21/19 at 12:00 p.m. and 3:00 p.m.; -4/25/19, at 9:00 a.m. and 11:00 a.m.; -4/26/19, at 11:30 a.m.; -4/29/19, at 2:00 a.m. and 12:30 p.m.; and -4/30/19, at 1:00 a.m. and 2:30 p.m. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed two tablets were signed out at 12:43 p.m. but were documented as being administered at 2:46 p.m. on the MAR. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed the following: two tablets of [MEDICATION NAME] 2 mg were signed out but were not documented as being administered on the MAR on the following dates: -5/1/19 at 9:00 a.m. and 4:00 p.m.; -5/2/19 at 5:09 a.m.; -5/3/19 at 2:45 p.m.; -5/4/19 at 11:04 a.m.; -5/5/19 at 8:00 a.m. and 3:00 p.m.; -5/6/19 at 11:20 p.m.; -5/10/19 at 4:58 p.m., 8:52 p.m. and 11:48 p.m. and -5/14/19 at 8:00 a.m. and 2:00 p.m. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed the following: one tablet of [MEDICATION NAME] 4 mg was signed out but was not documented as being administered on the MAR on the following dates: -5/17/19 at 7:30 a.m., 10:05 a.m., 1:15 p.m., and 4:00 p.m.; -5/18/19 at 1:00 p.m. and 2:05 p.m.; -5/19/19 at 8:30 a.m. and at 4:00 p.m.; -5/22/19 at 3:45 p.m.; -5/28/19 at 12:00 p.m. and 4:00 p.m.; -5/29/19 at 11:00 a.m., 12:00 p.m., and 4:30 p.m.; and -5/31/19 at 8:00 a.m. Comparison of the (MONTH) 2019 MAR and the Controlled Drug Administration records (narcotic sheets) revealed the following: one tablet of [MEDICATION NAME] 4 mg was signed out but was not documented as being administered on the MAR on the following dates: -6/1/19 at 10:30 p.m.; -6/2/19 at 12:00 p.m.; and -6/3/19 at 2:15 a.m. Review of the Controlled Drug Administration Record for the resident's [MEDICATION NAME] 2 mg from 5/8/19-5/16/19, revealed six tablets were documented as the amount left on the last entry of the record. No Controlled Drug Administration Record was provided by the facility for the remaining six tablets. Review of the Controlled Drug Administration Record for the resident's [MEDICATION NAME] 4 mg from 5/17/19-5/23/19 revealed two tablets of [MEDICATION NAME] 4 mg was signed out on the following days: -5/20/19 at 1:29 a.m. and 6:12 p.m.; -5/21/19 at 12:57 a.m. and 6:42 p.m.; and -5/22/19 at 12:20 a.m. when only one tablet should have been signed out and administered. Medication error reports for the above errors was requested from the facility. The NHA reported on 6/6/19 that no reports were available (see interview below). V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/5/19 at 11:38 a.m. She said when a narcotic medication was given, it should be signed out on the narcotic sheet and on the MAR at the time it was administered. She said the narcotics were counted at the change of every shift. If there was a discrepancy in the count that could not be accounted for, management should be notified. She said she has seen other nurses cross off their signature on the narcotic sheet if the count was incorrect to make it correct oftentimes meaning the resident did not get the medication they were supposed to. She said it would be considered a medication error and should be reported to the director of nursing (DON) by the person making the error. She said she did not feel it was her responsibility to bring the medication error to the attention of the DON if it was not her error. Registered nurse #1 was interviewed on 6/6/19 at 1:08 p.m. She said if a medication was signed out on the narcotic count sheet by mistake, it should have a single line crossed through it with the person's initials and a small note indicating why the dose was being crossed off. She said if the dose was crossed off because it was not given it was considered a medication error and should be reported to the DON and the physician. She said anytime a medication was given it should be documented on the MAR but especially if it was a narcotic. She said it was important to keep track of the time a narcotic was given so that the next dose administered was not given too soon. She said when a resident arrived and was admitted to the facility, their medication should be ordered immediately so they would arrive on the next delivery. She said some medications could be obtained through the emergency kit or Omni-cell if needed before the pharmacy delivery. She said medications should be re-ordered several days prior to the last dose being administered to ensure they did not run out of the medication. The nursing home administrator (NHA) was interviewed on 6/6/19 at 10:00 a.m. He said the facility was unable to locate all of the controlled drug administration records requested. He said the facility had a possible drug diversion problem a few months back but it was unsubstantiated. He said he did not know if a reconciliation had been done on all of the narcotics. The DON was interviewed on 6/6/19 at 2:00 p.m. She said if a narcotic was signed out on the narcotic count sheet by mistake, it needed to have one line drawn through it with the person's initials. She said if the count was incorrect during narcotic count during shift change due to a routine medication being signed off that wasn't actually given, it was a medication error and a report should be completed and the physician notified. She said it was the responsibility of both the off-going nurse and the on-coming nurse to make sure appropriate measures are taken after a medication error is discovered. She said a reconciliation of the controlled substances in the building had not been done. She said medical records reviewed them for discrepancies. The medical records assistant (MRA) was interviewed on 6/6/19 at 2:25 p.m. She said when she picked up the Controlled Drug Administration Records, she did not review the records and would just put them in the resident's file. She said she would not even know what she was looking for if she was to look for discrepancies. VI. Resident #11's status Resident #11, age less than 60, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 4/15/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment revealed the resident was on scheduled pain medication regimen, received as needed pain medication, and did not receive non-medication intervention for pain. The resident occasionally had pain that did not affect his sleep or day-to-day activities, and the pain level was rated at 4 out of 10. The resident required supervision with setup help only for activities of daily living (ADLs). Record review [MEDICATION NAME] The (MONTH) and (MONTH) 2019 CPOs included orders for: -[MEDICATION NAME] sulfate 30 milligram (mg) one tablet two times a day effective 5/3/19 and discontinued 5/17/19. -[MEDICATION NAME] sulfate 15 mg one tablet two times a day effective 5/17/19 and discontinued 5/22/19. -[MEDICATION NAME] sulfate 15 mg one tablet one time a day effective 5/22/19 and discontinued 5/31/19. Review of the (MONTH) and (MONTH) 2019 medication administration record (MAR) and 5/1/19 to 6/5/19 narcotic medication count record revealed discrepancy between how many tablets were signed out from the narcotic record and what was administered to the resident. -The 5/3/19 to 5/10/19 [MEDICATION NAME] sulfate 30 mg narcotic record was requested, but could not be located by the facility. The medication was documented as administered to the resident on the MAR seven times from 5/3/19 to 5/10/19. -5/13/19 three tablets of 30 mg [MEDICATION NAME] were signed out on the narcotic record, two tablets were documented as administered to the resident on the MAR. -5/14/19 one tablet of 30 mg [MEDICATION NAME] was signed out on the narcotic record, two tablets were documented as administered to the resident on the MAR. -5/17/19 two tablets of 30 mg [MEDICATION NAME] were signed out on the narcotic record, one tablet was documented as administered to the resident on the MAR. -5/25/19 two tablets of 15 mg [MEDICATION NAME] were signed out on the narcotic record, one tablet was documented as administered to the resident on the MAR. -The 15 mg [MEDICATION NAME] was last documented as administered to the resident on the MAR on 5/30/19 and the order was discontinued on 5/31/19. The narcotic record revealed the 15 mg [MEDICATION NAME] was signed out on 5/31/19, 6/1/19 and 6/2/19. [MEDICATION NAME] The (MONTH) and (MONTH) 2019 CPOs included orders for: -30 mg [MEDICATION NAME] extended release, one tablet every 12 hours for pain, effective 4/19/19 and discontinued 5/13/19. -5 mg [MEDICATION NAME] one tablet every six hours as needed for pain, effective 4/9/19 and discontinued 5/22/19. -5 mg [MEDICATION NAME], give one tablet for pain level 6-8 and two tablets for pain level 9-10, every four hours, effective 5/17/19 and discontinued 5/22/19. -10 mg [MEDICATION NAME], one tablet every four hours as needed for pain, effective 5/22/19 and discontinued 5/31/19. -10 mg [MEDICATION NAME], one tablet every four hours, effective 5/31/19. Review of the (MONTH) and (MONTH) 2019 MAR including the 5/1/19 to 6/5/19 narcotic medication count records which revealed discrepancies between how many tablets were signed out from the narcotic record and what was administered to the resident. -5/1/19, 5/7/19, 5/8/19 and 5/16/19, three tablets of 5 mg [MEDICATION NAME] signed out each day on the narcotic record, one tablet was documented as administered to the resident on the MAR each day. -5/2/19, 5/4/19, 5/10/19, 5/13/19 and 5/15/19, three tablets of 5 mg [MEDICATION NAME] signed out each day on the narcotic record, two tablets were documented as administered to the resident on the MAR each day. -5/3/19, 5/6/19 and 5/11/19, four tablets of 5 mg [MEDICATION NAME] signed out on the narcotic record each day, two tablets were documented as administered to the resident on the MAR each day. -5/9/19, three tablets of 5 mg [MEDICATION NAME] signed out on the narcotic record, zero tablets were documented as administered to the resident on the MAR. -5/13/19, 30 mg [MEDICATION NAME] was documented as administered to the resident on the MAR, however was not signed out on the narcotic record. -5/17/19, four tablets of 5 mg [MEDICATION NAME] signed out on the narcotic record, three tablets were documented as administered to the resident on the MAR. -5/19/19, there was one 5 mg [MEDICATION NAME] signed out on the narcotic record that did not match with the medication administration times on the MAR. -5/20/19, there were three medication doses at 12:00 a.m., 8:00 a.m., 12:00 p.m. that were not signed out on the narcotic record but were documented as administered to the resident on the MAR. -5/22/19, the resident was documented as receiving one or two 5 mg [MEDICATION NAME] tablets at 12:00 a.m. and 4:00 a.m.; the medication order was dependent on pain level and the MAR did not indicate how many tablets were administered, see F684 Quality of Care, for failure to follow physician orders; and one 10 mg [MEDICATION NAME] tablet at 12:25 p.m. and 4:36 p.m. The narcotic record revealed ten 5 mg [MEDICATION NAME] tablets were signed out and one 10mg [MEDICATION NAME] tablet was signed out on 5/22/19. -5/23/19, there were four 10 mg [MEDICATION NAME] tablets and two 5 mg [MEDICATION NAME] tablets signed out on the narcotic record, and the resident was documented as receiving four 10 mg [MEDICATION NAME] tablets on the MAR. -5/24/19, there were six 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and four tablets were documented as administered to the resident on the MAR. -5/25/19, there were seven 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and three tablets were documented as administered to the resident on the MAR. -5/26/19, there were five 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and two tablets were documented as administered to the resident on the MAR. -5/27/19, there were six 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and two tablets were documented as administered to the resident on the MAR. -5/28/19, there were five 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and six tablets documented as administered to the resident on the MAR. -5/29/19, and 5/30/19 there were five 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and four tablets documented as administered to the resident on the MAR. -5/31/19, there were six 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and three tablets documented as administered to the resident on the MAR. -6/1/19, there were five 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and six tablets documented as administered to the resident on the MAR. -6/2/19, there were two 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and five tablets documented as administered to the resident on the MAR. -6/3/19, there were three 10 mg [MEDICATION NAME] tablets signed out on the narcotic record, and four tablets documented as administered to the resident on the MAR. [MEDICATION NAME] (a controlled-substance used to treat [MEDICAL CONDITION]) The (MONTH) 2019 CPO included orders for: -[MEDICATION NAME] extended release, one 12.5 mg tablet as needed for sleep, effective 4/9/19 and discontinued 5/14/19. -[MEDICATION NAME] extended release, one 12.5 mg tablet at nighttime, effective 5/14/19. Review of the (MONTH) 2019 MAR and narcotic medication count record revealed discrepancy between how many tablets were signed out from the narcotic record and what was administered to the resident. -5/2/19, 5/4/19, 5/5/19, 5/8/19, 5/9/19 and 5/12/19 one [MEDICATION NAME] tablet signed out each day but not documented as administered to the resident each day on the MAR. -5/10/19 one [MEDICATION NAME] tablet documented as administered to the resident on the MAR but not signed out on the narcotic record. -5/11/19 two [MEDICATION NAME] tablets signed out in the narcotic record, none administered on the MAR. VII. Resident #4's status Resident #4, age 69, was admitted on [DATE]. According to the (MONTH) 2019 CPO, pertinent [DIAGNOSES REDACTED]. The 5/24/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The MDS assessment revealed the resident was on a scheduled pain medication regimen, received as needed pain medication, and did not receive non-medication intervention for pain. The resident occasionally had pain that did not affect her sleep or day-to-day activities, and the pain was rated a seven out of ten. The resident required extensive assistance with two person assist for ADLs. Record review The (MONTH) and (MONTH) 2019 CPOs included orders for: -[MEDICATION NAME] 5 mg, one tablet at bedtime effective 1/17/19 and discontinued 5/9/19. -[MEDICATION NAME] 5 mg, two tablets at bedtime effective 5/7/19. -[MEDICATION NAME] 5 mg, one tablet every six hours as needed effective 3/1/19 and discontinued 5/7/19. -[MEDICATION NAME] 5 mg, two tablets every four hours as needed effective 5/7/19. Review of the (MONTH) and (MONTH) 2019 MAR and 5/1/19 to 6/5/19 narcotic medication count record revealed discrepancy between how many tablets were signed out from the narcotic record and what was administered to the resident. -5/1/19 and 5/5/19 two [MEDICATION NAME] tablets signed out on narcotic record each day, one tablet documented as administered to the resident per the MAR each day -5/7/19 three [MEDICATION NAME] tablets signed out on the narcotic record, two tablets documented as administered to the resident per the MAR -5/11/19 and 5/15/19 four [MEDICATION NAME] tablets signed out on the narcotic record each day, two tablets documented as administered to the resident per the MAR each day -5/17/19 and 5/27/19 one [MEDICATION NAME] tablet signed out on the narcotic record each day, two tablets documented as administered to the resident on the MAR each day (the resident's order as above was for two tablets). VIII. Resident #9's status Resident #9, age less than 60, was admitted on [DATE]. According to the (MONTH) 2019 CPO, pertinent [DIAGNOSES REDACTED]. The 5/7/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident was on a scheduled pain medication regimen, received as needed pain medication, and did not receive non-medication intervention for pain. The resident frequently had pain that did not affect his sleep or day-to-day activities, and the pain was rated a four out of ten. The resident required supervision with setup help only for ADLs. Record review The (MONTH) 2019 CPO included an order for [REDACTED]. Review of the (MONTH) 2019 MAR and 5/1/19 to 5/26/19 narcotic medication count record revealed discrepancy between how many tablets were signed out from the narcotic record and what was administered to the resident. -5/1/19 three [MEDICATION NAME] tablets signed out on the narcotic record, zero tablets documented as administered to the resident per the MAR -5/2/19, 5/3/19 and 5/5/19 three [MEDICATION NAME] tablets signed out on the narcotic record each day, two tablets documented as administered to the resident per the MAR each day -5/7/19 three [MEDICATION NAME] tablets signed out on the narcotic record, one tablet documented as administered to the resident per the MAR. -5/8/19 three [MEDICATION NAME] tablets signed out on the narcotic record, zero tablets documented as administered to the resident per the MAR. -5/9/19 three [MEDICATION NAME] tablets signed out on the narcotic record, two tablets documented as administered to the resident per the MAR. -5/12/19 three [MEDICATION NAME] tablets signed out on the narcotic record, one tablet documented as administered to the resident per the MAR. -5/13/19 two [MEDICATION NAME] tablets signed out on the narcotic record, one tablet documented as administered to the resident per the MAR. -5/15/19 three [MEDICATION NAME] tablets signed out on the narcotic record, one tablet documented as administered to the resident per the MAR. -5/16/19 two [MEDICATION NAME] tablets signed out on the narcotic record, three tablets documented as administered to the resident per the MAR. -5/17/19 three [MEDICATION NAME] tablets signed out on the narcotic record, one tablet documented as administered to the resident per the MAR. -One [MEDICATION NAME] tablet signed out between the dates 5/18/19 and 5/19/19

Based on record review and interviews, the facility failed to ensure four (#10, #1, #12 and #11) of six residents reviewed of 12 sample residents received treatment and care in accordance with professional standards of practice, which caused the potential for adverse medication effects, unnecessary pain and inability to appropriately assess and treat the residents' medical conditions. Specifically, the facility: -Failed to ensure pain medication was given as ordered by the physician to prevent unnecessary prolonged pain for Resident #10; -Failed to ensure routine pain medication was given as ordered by the physician to prevent unnecessary pain and transfer to the emergency room for Resident #1; -Failed to ensure staff administered Resident #12's scheduled [MEDICATION NAME] as ordered (cross reference F755); -Failed to obtain a wound culture as ordered by the physician for Resident #1; and -Failed to ensure one narcotic pain reliever had been completed before starting another narcotic pain reliever for Resident #11 as ordered by the physician. Findings include: I. Resident #10 status Resident #10, age less than 65, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. According to the 4/24/19 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was taking scheduled and as needed (PRN) pain medications for complaints of frequent pain. Record review According to the 4/18/19 pain evaluation, the resident had frequent pain related to [MEDICAL CONDITION]. She had taken routine and PRN pain medications and non-medication interventions for her pain. The location of the pain was generalized and described as aching, although the resident had difficulty describing her pain. She did not have a history of hurting or pain. The numeric pain rating scale: 0 no pain, 1-3 mild pain, 4-5 moderate pain, 6-7 severe pain, 8-9 very severe pain, and 10 worst possible pain. The resident was able to verbalize her pain rating; her pain level was six (severe pain) out of 10 at the time of the assessment. She rated her pain a 10 (worst pain possible) at its worst and a two (mild pain) at its best. The resident's goal and plan for managing her pain were to report her pain level at or below three (mild) out of 10 with the use of pharmacological and non-pharmacological interventions. The care plan, initiated on 4/22/19, revealed the resident had acute pain related [MEDICAL CONDITION] [DIAGNOSES REDACTED]. -Evaluate the effectiveness of pain interventions and review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; -Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain; -Observe resident closely for signs of pain administer pain medications as ordered, and notify physician/hospice immediately if there is breakthrough pain. According to the May/June 2019 CPO, orders included: -[MEDICATION NAME] 4 mg (milligrams) give 4 mg by mouth every one hour as needed for pain; -[MEDICATION NAME] 10 mg give 2.5 tablets (25 mg) by mouth every eight hours; -[MEDICATION NAME] 1 mg give 1.5 mg by mouth every four hours; and -Pain - observe every shift, if present, complete pain flow sheet and treat, trying non pharmacological interventions prior to medicating if appropriate. Document in a progress note. [MEDICATION NAME] According to the Controlled Drug Administration Records for the resident's [MEDICATION NAME], on 5/28/19, [MEDICATION NAME] 5 mg was signed out as being administered at 6:00 a.m. (even though it was documented as not being given). At 2:00 p.m., [MEDICATION NAME] 20 mg was signed out as being administered instead of the ordered 25 mg. According to the (MONTH) 2019 MAR, the resident's pain level at 2:00 p.m. when she received the [MEDICATION NAME] 20 mg on 5/28/19 was rated eight out of 10. Since the resident had not received the appropriate amounts of her scheduled [MEDICATION NAME] that day or her scheduled [MEDICATION NAME], the resident then required two doses of her as needed (PRN) pain medication [MEDICATION NAME] 4 mg at 7:40 p.m. for pain rated nine out of 10 and again at 9:44 p.m. for pain rated seven out of 10. Medication error reports were requested from the facility for both the [MEDICATION NAME] and the [MEDICATION NAME] . The NHA reported no reports had been completed. [MEDICATION NAME] According to the (MONTH) 2019 medication administration record (MAR), the resident received her as needed (PRN) pain medication [MEDICATION NAME] 4 mg on 5/20/19 at 1:29 a.m., 6:12 p.m.; on 5/21/19 at 12:57 a.m., 6:42 p.m.; and on 5/22/19 at 12:20 a.m. According to the Controlled Drug Administration Record, the resident received two tablets of the [MEDICATION NAME] 4 mg instead of only one tablet as ordered by the physician on the above dates and times. Medication error reports were requested from the facility for the above medication errors. The nursing home administrator (NHA) reported that no medication error reports had been completed. [MEDICATION NAME] According to the (MONTH) 2019 MAR the resident was scheduled to receive her scheduled [MEDICATION NAME] at 6:00 a.m., 2:00 p.m. and 10:00 p.m. and her scheduled [MEDICATION NAME] at 12:00 a.m., 4:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. On 5/28/19, the MAR was coded 8 (indicating to see progress notes) for the resident's 12:00 a.m. and 4:00 a.m. doses of [MEDICATION NAME] and her 6:00 a.m. dose of [MEDICATION NAME]. The 5/27/19 orders-administration notes documented at 11:24 p.m. the resident was lying quietly with eyes closed so the 5/28/19 12:00 a.m. [MEDICATION NAME] was held. According to the 5/28/19 orders-administration notes, at 4:07 a.m., 5:11 a.m. and 5:14 a.m. the resident was sleeping so the nurse decided not to wake her and let her sleep, and if the resident was in pain she would get up and tell the nurse. II. Resident #1 status Resident #1, age less than 65, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 3/13/19 MDS assessment the resident had no cognitive impairment with a BIMS score of 13 out of 15. The resident received scheduled and as needed (PRN) pain medications but no non-medication interventions. Her pain was occasional, rated two out of 10. Record review Medication error The care plan, initiated 3/11/19, revealed the resident had acute and chronic pain related to a broken foot and was at risk for addiction, constipation and activities of daily living (ADL) decline and falls related to the use of narcotics to help manage her pain. Interventions included: -Attempt to identify the root cause of pain; -Offer non-pharmacological interventions for complaint of pain such as repositioning, back to bed/out of bed, elevation of extremities, ice pack, topical modalities, back rubs; and -Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. According to the (MONTH) 2019 CPO, orders included: -[MEDICATION NAME] 5-325 mg, give one tablet by mouth every four hours as needed for moderate pain and two tablets by mouth every four hours as needed for severe pain; -[MEDICATION NAME] 75 mg, give one capsule by mouth two times a day; and -Pain - observe every shift, if present, complete pain flow sheet and treat, trying non pharmacological interventions prior to medicating if appropriate. Document in a progress note. According to the (MONTH) 2019 MAR, the resident received her [MEDICATION NAME] 75 mg on 4/3/19 at 8:00 p.m.; however according to the Controlled Drug Administration Record, the dose was signed off at 8:00 p.m. but then crossed out indicating it had not been administered. There were no initials indicating which nurse crossed out the information. According to the (MONTH) 2019 MAR and orders-administration notes, on 4/3/19, the resident then required [MEDICATION NAME] 5/325 mg two tablets at 9:35 p.m. for severe pain rated 10 out of 10. The resident stated her feeding tube site burned like she was stuck with a hot poker. The resident was subsequently sent out to the emergency roiagnom on [DATE] at 12:35 a.m. for complaint of stomach pain not relieved by PRN [MEDICATION NAME]. Wound culture The care plan, last revised on 3/27/19, revealed the resident had potential/actual impairment to skin integrity of the foot related to surgery and had a gastrostomy (feeding tube) site. Interventions included: -Monitor dressing to ensure it is intact and adhering; and -Observe site for redness, swelling, increasing drainage, and pain. According to the (MONTH) 2019 CPO for admission, the resident had orders for a culture to the wound, one time only for infection. The order did not specify where the wound was, however the resident also had an order for [REDACTED]. The culture was needed to ensure the resident was receiving the correct antibiotic for the infection she had. Review of the record revealed the order did not get placed on the treatment administration record (TAR) and the results of the culture could not be located in the resident's record. The laboratory results for the culture were requested from the facility. The staff development coordinator (SDC) reported on 6/19/19 that the culture had not been obtained and sent. See interview below. III. Resident #12 status Resident #12, age less than 65, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. According to the 4/5/19 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of nine out of 15. [DIAGNOSES REDACTED]. Record review The care plan, last revised 4/25/19, revealed the resident had an anxiety disorder and required the use of antianxiety medication. His anxiety was marked by repetitive statements or verbalizations; anxious complaints or concerns, pained or worried facial expressions and repetitive movements. He exhibited increased restlessness that could result in injury. Interventions included: -Observe for medication effectiveness and document appropriately; -Observe for potential side effects of medication administered; -Periodic reviews of medications by interdisciplinary team (IDT) to determine potential dose reductions, and -Review drug regime and possible interactions with the physician and IDT. According to the (MONTH) 2019 CPO, the resident had orders for [MEDICATION NAME] 0.5 mg, give one tablet by mouth three times a day for anxiety related to depression. According to the (MONTH) and (MONTH) 2019 MARs, the [MEDICATION NAME] was scheduled to be given at 8:00 a.m., eight hours later at 4:00 p.m. and then four hours later at 8:00 p.m. The resident had not missed any doses of the medication. According to the Controlled Drug Administration Record for the resident's [MEDICATION NAME] 0.5 mg, the resident received the medication earlier than the scheduled times on the MAR on the following dates: -On 4/29, 5/5, 5/6, 5/20, 5/25, 5/26, and 5/27/19, the 8:00 p.m. dose was signed out at 6:30 p.m., only two and a half hours after receiving a dose at 4:00 p.m.; and -On 5/31/19 the 8:00 a.m., the dose was signed out at 6:52 a.m. According to the Controlled Drug Administration Record, on 5/29/19, [MEDICATION NAME] 0.5 mg one tablet was signed out at 4:00 p.m., then it was scribbled out indicating the medication was not given. On 6/3/19, [MEDICATION NAME] 0.5 mg one tablet was signed out at 7:00 p.m., then it was scribbled out indicating the medication was not given. There were no initials indicating which nurse crossed out the information. IV. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/5/19 at 11:38 a.m. She said when she came to work the previous day, 6/4/19, and did narcotic count with the off-going nurse, the count was incorrect for Resident #12's [MEDICATION NAME]. The narcotic count sheet (Controlled Drug Administration Record) indicated there were 12 tablets left but the card actually had 13 tablets. She said the off-going nurse said oops and crossed it off, making the narcotic count correct. The LPN said the [MEDICATION NAME] was ordered routinely and the nurse crossing the dose off probably meant she did not give the medication, making it a medication error. She said it was the previous nurse's medication error and she was responsible for reporting it to the director of nursing (DON). She said she did not feel it was her responsibility to bring the medication error to the attention of the DON. Registered nurse (RN) #1 was interviewed on 6/6/19 at 1:08 p.m. She said if a medication was signed out on the narcotic count sheet by mistake, it should have a single line crossed through it with the person's initials and a small note indicating why the dose was being crossed off. She said if the dose was crossed off because it was not given, it was considered a medication error and should be reported to the DON and the physician. She said if the resident was taking routine pain medication around the clock, the resident should be offered pain medication when it was due. If the resident was sleeping at the time the medication was due, the nurse should reattempt to give the medication if it was within the allowed time. She said Resident #10 needed to have her pain medication and anti-anxiety medication routinely around the clock to control and manage her pain and anxiety. The DON was interviewed on 6/6/19 at 2:00 p.m. She said if a narcotic was signed out on the narcotic count sheet by mistake, it needed to have one line drawn through it with the person's initials. She said if a routine medication was signed out on the narcotic sheet but not actually given, it would be considered a medication error. A medication error report should be completed and the physician notified. She said it was the responsibility of both the off-going nurse and the on-coming nurse to make sure appropriate measures were taken after a medication error was discovered. The staff development coordinator (SDC) was interviewed on 6/19/19 at 12:35 p.m. She said any time an order came in for a lab or diagnostic test, she would put the order into the computer and have it come up on the treatment administration record (TAR) for the nurse to sign off on. She said when the lab results came in, the nurse would note the results with the date, time and initials and then put it in the file for the physician to review. Once the physician reviewed the lab and signed off on it, it was placed in the medical records basket to be filed in the resident's record. She reported she was unable to find the results of Resident #1's wound culture and she said it was not done. V. Resident #11's status Resident #11, age less than 60, was admitted on [DATE]. According to the (MONTH) 2019 CPO, pertinent [DIAGNOSES REDACTED]. The 4/15/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident was on a scheduled pain medication regimen, received PRN pain medication, and did not receive non-medication interventions for pain. The resident occasionally had pain that did not affect his sleep or day-to-day activities, and the pain was rated at 4 out of 10. The resident required supervision with setup help only for ADLs. Record review The (MONTH) 2019 CPO revealed orders for: -30 milligram (mg) of extended release [MEDICATION NAME] every 12 hours for pain, effective 4/19/19 and discontinued 5/13/19. -30 mg of [MEDICATION NAME] sulfate twice a day for lower back pain, effective 5/3/19 and discontinued 5/17/19. This order read to be used when 30 mg oxy(contin) is completed. -5 mg [MEDICATION NAME] every four hours, one tablet if pain level was 6 to 8 out of 10, two tablets if pain level was 9 to 10 out of 10, effective 5/17/19 and discontinued 5/22/19 The (MONTH) 2019 MAR revealed the resident received both the 30 mg [MEDICATION NAME] and 30 mg [MEDICATION NAME], despite the order reading to use [MEDICATION NAME] when [MEDICATION NAME] was completed. The MAR revealed the resident received: -30 mg [MEDICATION NAME] once daily on 5/4/19, 5/11/19 and 5/13/19 and twice daily from 5/5/19 to 5/10/19; and -30 mg [MEDICATION NAME] sulfate once daily from 5/4/19 to 5/7/19 and twice daily on 5/8/19, 5/12/19 and 5/13/19. The nursing electronic MAR notes for 5/4/19, 5/5/19, 5/6/19 and 5/10/19 documented the resident's supply of [MEDICATION NAME] had not yet exhausted. The (MONTH) 2019 MAR also revealed the 5 mg [MEDICATION NAME] was not administered according to the resident's pain levels as ordered by the physician. -On 5/17/19, the narcotic medication count record was signed out for two 5 mg [MEDICATION NAME] tablets. The MAR did not indicate how many tablets were administered but indicated the resident received medication for a pain level of 8 out of 10 at 8:00 p.m. The resident should have received one tablet for a pain level of 8, per the physician's orders [REDACTED].>-On 5/18/19, the resident had pain levels of 8 out of 10 at 12:00 a.m. and 6 out of 10 at 4:00 p.m., and the narcotic record was signed out for two 5 mg [MEDICATION NAME] tablets corresponding with these medication pass times. The MAR did not indicate how many tablets were administered. The resident should have received one tablet for pain levels of 6 and 8 out of 10, per the physician's orders [REDACTED].>-On 5/20/19, the resident had a pain level of 5 out of 10 at 4:00 p.m. The narcotic record was signed out for two 5 mg [MEDICATION NAME] tablets at that time, the MAR did not indicate how many tablets were administered. The medication order did not mention what dose to administer for pain levels of 5 out of 10. -On 5/21/19, the resident had pain levels of 6 out of 10 at 8:00 a.m., 12:00 p.m. and 4:00 p.m. The narcotic record was signed out for two 5 mg [MEDICATION NAME] tablets corresponding with the medication pass times. The MAR did not indicate how many tablets were administered. The resident should have received one tablet for a pain level of 6 out 10, per the physician's orders [REDACTED].>-On 5/22/19, the resident had pain levels of 6 out of 10 at 12:00 a.m. and 8 out of 10 at 4:00 a.m. The narcotic record was signed out for two 5 mg [MEDICATION NAME] tablets corresponding with the medication pass times. The MAR did not indicate how many tablets were administered. The resident should have received one tablet for pain levels of 6 and 8 out of 10, per the physician's orders [REDACTED].>Nursing progress notes from 5/1/19 to 6/1/19 did not mention any adverse reactions related to the medications administered by not following physician orders. VI. Staff interviews The director of nursing (DON) was interviewed in the presence of the nursing home administrator (NHA) on 6/6/19 at 1:00 p.m. The DON said nurses should follow physician orders [REDACTED]. She said if there was confusion the nursing staff should have contacted her or the physician for clarification. She said the resident had not suffered any adverse effects of receiving medications incorrectly. The DON said she was not aware of these medication errors. The nurse practitioner (NP) was interviewed in the presence of the primary care physician (PCP) on 6/17/19 at 12:42 p.m. The NP said she would not confirm that the resident received both the [MEDICATION NAME] and [MEDICATION NAME] at the same time while reviewing the resident's medical records. She said the [MEDICATION NAME] should not have been administered together with the extended release [MEDICATION NAME].

Based on observations, record review, and interviews, the facility discharged on e (#1) of three sample residents to the community without evidence of discharge planning and without appropriate and adequate supports in place to ensure a safe transition from the facility to the community. Specifically, the facility discharged resident #1 to an independent living facility where the resident no longer had an apartment. The resident was left in the lobby, where he experienced a change of condition that lead to a prolonged hospitalization . The findings include: I. Facility policy and procedure A copy of the facility's Transfer and Discharge Procedure dated 10/2017 was provided by the nursing home administrator (NHA) on 12/27/17 at 5:45 p.m. According to the policy, Transfer and discharge procedure(s) must provide sufficient preparation and orientation of the resident to ensure a safe, orderly transfer or discharge from the facility. II. Resident #1 Resident #1, age 52, was admitted on [DATE], readmitted on [DATE] after a hospitalization due to the [MEDICAL CONDITION], and discharged from the facility on 10/6/17. According to the 10/17 computerized physician orders [REDACTED]. According to the 9/29/17 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. Resident #1 required maximum assistance of one person with transfers and toilet use. He used a wheelchair for ambulation. A. Resident status on admission According to the pre-admission and resident review (PASRR) level one, dated 8/28/17, the resident had a [MEDICAL CONDITION] disorder, cognitive impairment, delusions/hallucinations, altercations and aggressive behaviors. According to the PASRR level two, the resident was in need of nursing facility level of services. He had a history of [REDACTED]. Staff were advised to be aware of that and to focus on grounding techniques. Resident #1 did not wish to participate in any specialized activity. Occupational therapy for living skills and physical therapy for general strength were recommended. It is unlikely he would be able to live independently, but maybe an assisted living facility would be appropriate in the future .Client does not have a neurologist and needs to have one as soon as possible . B. Resident status after admission Record review revealed hospitalization for [MEDICAL CONDITION] activity and readmission with purported aggressive behavior, followed by a 30 day involuntary discharge notice. Physician notes revealed the resident had a poor rehab potential, demonstrated an inability to take care of himself, and was not capable of understanding or acting on his rights. 1. According to the physician progress notes [REDACTED]. Patient has [MEDICAL CONDITION] disorder, is on multiple agents for this due to frequency of [MEDICAL CONDITION]. Was recently hospitalized for [REDACTED]. 2. A communication form and progress note, dated 9/16/17, revealed the resident had a verbal and physical altercation with another resident in the dining room. Resident had a disagreement over the condiment and later pushed female resident against the wall. An interview with resident #1 was not included in the investigation. 3. A nursing note dated 9/17/17 and a note on 9/18/17 read, resident stayed in room most of this shift, no behaviors (noted). 4. A letter of involuntary discharge, signed by NHA, was issued to the resident on 9/18/17. In pertinent part it read, .You continue to jeopardize your own health and health and safety of all residents and staff by violating facility policies governing resident behavior. Your physical abuse of other residents will not be tolerated and is unacceptable. This letter is notification that you will be discharged from this facility on October 18, 2017. A progress note by the NHA dated 9/21/17 confirmed the NHA had issued a 30 day involuntary discharge notice related to the resident's inappropriate behavior. 5. A care plan, initiated 9/18/17 and revised 9/19/17, identified the resident had a [DIAGNOSES REDACTED]. Keep in mind that this aggression may not be fully behavioral but is instead a result of his [MEDICAL CONDITION] (Resident) may have hallucinations while experiencing [MEDICAL CONDITION] . Staff should remain calm and present with calm behaviors when dealing with (resident) while he is belligerent. Confrontations and interactions should be minimized when he is agitated. 6. A physician progress notes [REDACTED]. The note read the resident had a history of [REDACTED]. According to the computerized physician orders [REDACTED]. 7. A physician progress notes [REDACTED]. According to nursing, no new issues are apparent patient being quite somnolent . The treatment plan included to continue current therapy. According to the computerized physician orders [REDACTED]. 8. A care plan initiated on 10/4/17 (two days prior to discharge), identified the resident had an actual fall with no injury due to poor balance. Interventions included to continue work with therapy to increase strength and balance. However, record review revealed the resident was discharged from occupational and physical therapy 10/6/17 (day of actual discharge from the facility) due to noncompliance. 9. According to the social services note, dated 10/5/17, when the social services director (SSD) went into the resident's room to discuss his discharge, He (resident) suddenly became sleepy and could not sign his notice . Resident has been acting more and more non-responsive since then and it appears to be a behavior as the last time resident was scheduled to discharge, he refused his home eval(uation) and became more aggressive . C. Failure to prepare the resident for discharge and ensure a safe transition to the community 1. Lack of planning for resident discharge 10/6/17 Although aware from the PASRR level two that the resident was unlikely to be able to live independently, aware from the physician progress notes [REDACTED].#1 demonstrated an inability to take care of himself, was not capable of understanding and acting upon his rights, and aware as recently as 10/3/17 that the physician's plan was to continue current treatment, record review revealed the facility involuntarily discharged the resident 10/6/17 to an independent living facility where the resident no longer had an apartment. There was no evidence of discharge planning in the resident's record to ensure appropriate and adequate supports were in place for resident #1's safe transition from the facility to the community. Rather, record review revealed the facility knew the independent living facility to which the resident was discharged was not available to resident #1. This knowledge was confirmed in staff interviews. Nonetheless, facility staff left the resident in the lobby of the independent living facility. Specifically: Record review: An email dated 10/3/17 (three days prior to discharge) from the SSD to the ombudsman read in pertinent part: (Resident) was issued the 30-day on September 18th. He went out to the hospital and we sent a copy of the 30-day to the (hospital) in the hopes they would honor it It was not honored and we readmitted him. He has chosen to not appeal the notice, so I am proceeding with the safest discharge possible, considering the circumstances The plan is to send him (resident) back to (independent living facility). The issue now is (daughter of resident's wife) apparently called (independent living facility) yesterday and gave them a 30-day (notice of lease termination), but (daughter hasn't) given us any sort of indication that they intend to keep them (resident and his wife) here (at the facility) long-term. I don't think (daughter) knows that (resident #1) was issued a 30-day from us . Another email dated 10/5/17 (one day prior to discharge) from the SSD notified the ombudsman resident #1 was returning home to an independent living facility. . he is acting behavioral again just as he did last time we tried to discharge him . In the event that he refuses to go home and goes back to the hospital we will probably not re-admit him because of the 30-day . Record review revealed no further notes by social services regarding follow up with the resident's family member or the independent living facility. Interviews: A facility employee whose primary duty was to take residents to doctor's appointments (driver) was interviewed on 12/27/17 at 9:30 a.m. -The driver said on 10/6/17, he was asked by a staff member to help resident #1 move to the independent living facility. He said resident #1 was very quiet, he was not happy about leaving. He did not want to leave. The driver said the resident would not talk to him during the entire ride. -Upon arrival at the independent living facility, he wheeled the resident into the lobby and asked for a wheelchair to transfer the resident. He said a person who was in the lobby told him the resident did not live there any longer. He said the person brought the wheelchair and he helped the resident transfer into it. The driver said he then left the independent living facility. -The driver said he was accompanied by a social worker who handled the conversation with the front desk. He said he was not involved in the conversation but when he returned to the facility, he told the SSD the details about of the transfer and that front desk at the independent living facility did not want to accept the resident. The SSD was interviewed on 12/27/17 at 10:45 a.m. -She said she recalled the resident and she remembered the resident had some behavior problems that made other residents uncomfortable. She said resident #1 had several altercations with other residents and had a history of [REDACTED]. She believed the resident's behavior was intentional and was not triggered by his medical diagnosis. -She confirmed the resident received a notice of involuntary discharge based on his behavior following an altercation with another resident. She said that decision was made by NHA and her role was to find a good place for the resident. -She said she felt comfortable about the discharge because the resident had a chance to appeal but he did not and because he told her he wanted to go home. She believed the resident was cognitively capable of understanding the legal paperwork she presented to him. She said she was communicating with the ombudsman and case worker for the resident; however, the discharge planning was mainly completed by her assistant. -She confirmed the facility driver told her the front desk staff at the independent living facility refused to accept the resident and had stated to him that the resident no longer had an apartment there. SSD agreed that such statement would require a follow up, but she did not contact an independent living facility to clarify why resident was not admitted or find out what would or did happen next to the resident. -She said the person who was with the driver on 10/6/17 during resident's transfer was not a social worker but a certified nurse aide (CNA) who usually worked nights. She did not know why CNA was accompanying resident during the transfer. The SSD was interviewed again at 5:01 p.m. the same day. She confirmed she knew the resident's wife's daughter had requested termination of the lease on the resident's apartment in the independent living facility. However, she said the resident was discharged to the independent living facility anyway because, per her understanding, the resident's name was on the lease and he had the right to be there. The Social services assistant was interviewed over the phone on 12/27/17 at 12:15 p.m. -She, too, said resident #1 was discharged from the facility due to aggressive behaviors. She said her part in his discharge was to facilitate the conversation with independent living facility. -She recalled two different conversations with the manager at the independent living facility whose name she could not recall. She said their first conversation was about a month prior to discharge when she confirmed with the manager that the resident's apartment was available and the resident's name was on the lease. Their second conversation was about a week prior to the discharge; she said she spoke with the same person and communicated that resident #1 would be discharged with home health services. -She said two days prior to the discharge, she called the resident's physician and got a discharge order from him. She said it was part of social services tasks to obtain the physician's orders [REDACTED]. She said he did meet with agency staff (home care agency) and he said he liked them, but by his demeanor, I could tell he did not want to go. See above; there was no documentation in the social service notes regarding conversations with the independent living facility manager. 2. Lack of appropriate and adequate supports for a safe transition Interviews indicated it was not safe to discharge the resident on 10/6/17 due to his long history of [MEDICAL CONDITION] per his wife, his disorientation and confusion per the manager at the independent living facility, and the physician assistant's determination resident #1 would not be a candidate for a discharge until his [MEDICAL CONDITION] were under control and he progressed with physical and occupational therapy. Resident #1's wife was interviewed on 12/27/17 at 11:21 a.m. She said she and resident #1 had lived at independent living facility for a number of years but she now required a different level of care. -She said resident #1 originally stayed in the apartment by himself after she left, but later he was admitted to the hospital due to his frequent [MEDICAL CONDITION] and an inability to take care of himself. She said he has grand mal [MEDICAL CONDITION] and falls on the floor every time the [MEDICAL CONDITION] comes, and after that, he has a tendency to walk away or run away to some unknown place. She said resident #1 has had this condition for a long time and is not able to take care for himself and live independently due to his [MEDICAL CONDITION]. -She confirmed she gave her daughter permission to cancel the lease for the independent living apartment as no one was living there. The manager at the independent living facility was interviewed over the phone on 12/27/17 at 2:34 p.m. She said she did not recall having a conversation with anyone from nursing facility regarding resident #1's return to his apartment at the independent living facility. -She said she received one call from nursing facility staff and the only question the staff member asked was if resident was up to date on his payment for the apartment. She clarified that resident #1 had been residing at the independent living facility with his wife who was the primary applicant; she said resident #1 by himself would not qualify to live in independent living facility as he was younger than 55. She said as a primary applicant, the resident's wife had the right to discontinue the rent. She confirmed the resident's wife's daughter was listed as a financial power of attorney and acted on that behalf. -She said on 10/6/17, resident #1 was brought to the lobby by a driver and left there. She said the receptionist at that time explained to the driver that resident #1 no longer had an apartment in the building. She said the receptionist reported to her resident #1 was disoriented, confused and could not answer any questions. She said her staff explained to the driver that the resident appeared in need of medical and nursing attention and they have no nurses at the independent living facility. She said driver walked away and left the resident in the lobby. Staff at independent living facility contacted emergency medical services (EMS) as the resident did not appear well; he could not communicate or move. Resident's physician was on vacation during this investigation and therefore was unable to be reached for comment. The physician's physician assistant (PA) was interviewed on 12/27/17 at 1:30 p.m. -He said resident #1 was followed by the physician and he was not very familiar with him. He reviewed the physician's notes and stated the resident was admitted to the facility on [DATE] due to [MEDICAL CONDITION] with strong [MEDICAL CONDITION] that prior to admission had led to a spinal injury. -He said resident #1 was in the facility for rehabilitation and he required physical and occupational therapy. He said the resident was on several anticonvulsants and was not always complaint with care. Upon further review of documentation, he said he could not locate a discharge summary/note by the physician regarding this resident's discharge. He said the last note by the physician was not a discharge note. -The PA said based on the record review, resident #1 would not be a candidate for a discharge until his [MEDICAL CONDITION] were under control; only after that and with a neurologist consultation and progress with physical and occupation therapy, would the resident be considered for discharge. -He said based on the resident's medical diagnoses, resident #1 would not be a good candidate for an independent living facility. He said the resident should have been assessed by the physician in person and should not have been discharged over the phone. D. Resident harm According to EMS records, dated 10/6/17, on EMS's arrival at the independent living facility, resident #1 had an altered level on consciousness, was lethargic with slurred speech. The resident had an episode of vomiting and three [MEDICATION NAME]es were found on his back; one of the patches was a day old and the others were undated. The resident was transported to the hospital. According to the hospital summary, dated 10/6/17, resident was admitted to the hospital on [DATE] with chief complaint of altered mental status and decreased responsiveness. The resident was unable to provide any history of his own and was unable to care for himself. Further review of hospital records revealed the resident was discharged from the hospital 29 days later, on 11/4/17. He was admitted to different nursing facility. The physician discharge note read, .The patient was thought to be postical (state of consciousness after an epileptic [MEDICAL CONDITION]) secondary to his sedating meds including [MEDICATION NAME]es, which were found on him . His mentation improved back to baseline. There were multiple concerns about patient's safety and social situation. Ultimately, patient's son was proxy and placement was found . in skilled nursing facility. E. Administration and therapy interviews The director of nursing (DON) was interviewed on 12/27/17 at 5:15 p.m. He said resident #1 was discharged from the facility as he was medically cleared by the physician and by the therapy department. He was able to recall the resident had some behavioral issues, but was unable to describe any specific behaviors or incidents. He said the floor nurse was responsible for obtaining a discharge order from the physician. He said he did not recall any concerns with the resident upon discharge. The NHA was interviewed on 12/27/17 at 5:30 p.m. He said resident #1 was admitted for short term rehabilitation and he wanted to go back home. -He said he learned the resident was in the hospital from hospital social services who contacted him. He said he expected staff would report to him if concerns were identified during the discharge. He said there had been a miscommunication with independent living facility. -He clarified that at the time of discharge, resident #1 was with a facility driver and security guard, not CNA or social services assistant as it was reported previously. (The security guard was not available for the interview as he no longer was employed by the facility.) -He confirmed the resident was issued a 30 day notice of involuntary discharge due to behaviors, but said the resident was not discharged on that basis. He said resident was discharged as he reached his full potential and was discharged from therapy and nursing services. However, interviews with the facility occupational therapist (OT) and physical therapist (PT) on 12/27/17 at 3:32 p.m. and 4:50 p.m., respectively indicated the resident's therapy discharge summaries were not accurate. Both stated that although the resident's record showed he was discharged from therapies due to noncompliance, the resident did not refuse therapy sessions. -The OT said the resident was progressing well and improving with dressing, transferring and bathroom use, but he had poor safety awareness, was impulsive and needed supervision. The PT said some days the resident was very cooperative and involved in therapy and other days he would have low energy. -Review of service log for physical and occupational therapy revealed the resident refused only one session of occupational therapy on 9/8/17. He did not skip any sessions of physical therapy except for two occasions when he was out of the building.

Based on record review and interviews, the facility failed to consult with the resident's physician and notify the legal representative for one (#5) out of five sampled residents. Specifically the facility failed to call the physician or legal representative when resident #5 reported pain, difficulty breathing and a blood sugar registering high. The resident continued to have difficulty breathing and agitation throughout the night and in the morning was found void of vital signs: she was subsequently pronounced deceased with the cause being identified as [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The findings include: 1. Resident Status Resident #5, age 55, was originally admitted to the facility on [DATE], discharged ,[DATE] and then was readmitted to the facility on [DATE]. According to the face sheet, the resident's [DIAGNOSES REDACTED]. The resident did not have a minimum data set (MDS) assessment or a brief interview for mental status (BIMS) due to the brevity of her most recent admission. 2. Record Review a. Hospital Discharge Records A review of hospital discharge records, dated [DATE] at 1:44 p.m., revealed the resident was admitted to the hospital for infectious teno[DIAGNOSES REDACTED] (an inflammation of the fluid filled sheath that surrounds a tendon) of the right wrist, acute blood loss [MEDICAL CONDITION] and brittle type 1 diabetes. The resident was transferred to the facility for care of her PICC (peripherally inserted central catheter) and IV (intravenous) antibiotics. The resident was noted to have requested cardiopulmonary resuscitation in the event of [MEDICAL CONDITION]. b. admission orders [REDACTED] A review of admission orders [REDACTED]. c. Nursing notes All nursing notes that were available in the resident record are noted below. -A nursing admission assessment note, dated [DATE] at 11:30 p.m., documented the following: Resident admitted to (facility) to room (#) arrived at 1700 (5:00 p.m.) via (facility) bus. Resident in bed sleeping. Has a PICC line to left arm. Coccyx intact. Has drsg (dressing) to R (right) arm. Will continue to monitor. The note did not indicate whether the physician was called, or if the medications had been verified. -A nursing note, dated [DATE](no time of entry), documented the resident's BS (blood sugar check) as: Glucometer read Hi 600+. (Physician) on call ordered no new orders d/t (due to) refusing to eat. The note did not indicate from which physician the nurse had received the order, and there was no supporting telephone order available in the resident record. -A nursing note, dated [DATE] at 11:00 p.m., documented, Resident appears to be very confused, lethargic, and restless. C/o (complains of) pain, using only the word pain. Resident unable to verbalize pain level or give origin of pain. Medication give as ordered. Resident is unable to make needs known. Unable to use call light- will continue to monitor. -Another nursing note, dated [DATE] at 1:40 a.m., read, Resident appears to be having labored breathing. Resident is mouth breathing and very restless. Resident is combative and restless. Resident refuses to allow staff to remove dentures. Resident refuses to allow staff to administer medication or check blood glucose. DON (director of nursing) contacted about resident's condition. O2 placed on resident to attempt to relieve labored breathing via NC (nasal cannula) on 2L. Resident monitored frequently throughout remainder of shift. Resident is unable to verbalize needs. -The final nursing note was written on [DATE] at 12:00 p.m. by the DON. It noted, (At 7:00 a.m.) (staff name) was in room and res (resident) was breathing and sleeping. (At 7:40 a.m.) Nurse came in room to administer AM meds and found res to not be breathing. Nurse called code. Compressions started (at 7:43 a.m.) switching nurses Q2min (every two minutes). 911 called EMTs (emergency medical technicians) arrived (at 7:50 a.m.) and assumed care. Family (name) spouse, first attempted to call (at 7:55 a.m.) no answer and no available voicemail. Attempted contact again with res's phone. (Spouse) answered (at 8:00 a.m.). Notified of res current position. EMT called on call Dr and pronounced time of death (at 8:04 a.m.). (Spouse) called again (at 8:22 a.m.) to notify of passing. (At 8:37 a.m.) coroner notified and wants to talk with next of kin. (At 9:40 a.m.) family arrived and wanted res cleaned up and moved. All tubing removed except line in leg and (left) arm. Family notified mortuary of choice. Mortuary here (at 10:40 a.m.). Family and mortuary left (at 11:25 a.m.). Order wrote/confirmed (physician name) to pronounce death release remains to mortuary of choice. d. Telephone Orders A review of telephone orders (TOs) revealed only one order for the resident was written on [DATE] at 8:04 a.m. which noted, (Physician) EMT called pronounced death- absent vs (vital signs). May release remains to family mortuary of choice. e. Care Plans A review of the comprehensive care plan, initiated on the resident's previous stay at the facility, had not been updated. Previous goals and approaches were used for the resident's most recent stay in October. The care plans did not indicate a problem with or include any interventions for behaviors or refusals of care. The comprehensive care plan did identify heart failure, respiratory issues and hypo/[MEDICAL CONDITION] as areas of concern. The care plan for heart failure identified related issues such as increased shortness of breath, unrelieved or new chest pain, wheezing or chest tightness, increased dizziness or complaints of being light headed. No approaches were identified for heart failure. The care plan for respiratory risk noted the resident had [MEDICAL CONDITIONS] and interventions indicated staff should notify the physician of any change in status. The care plan for hypo/[MEDICAL CONDITION] directed staff to call the physician for blood sugars below 60 and above 400 and to observe for signs and symptoms of hypo/[MEDICAL CONDITION]. f. Death certificate The resident's death certificate listed the cause of death as acute [MEDICAL CONDITION] infarction. 2. Interviews a. An interview with licensed practical nurse (LPN) #1, the staff who documented the resident's care on the night of [DATE] and the early morning of [DATE] (see nursing notes above), was conducted on [DATE] at 12:30 p.m. The LPN stated she had been the nurse responsible for the resident's care on the night in question and she did recall the resident. When she came onto the shift, the LPN was given report the resident had been noncompliant and agitated. The LPN said the resident continued to be agitated and noncompliant throughout the shift as the resident became, more and more worked up. The LPN stated the resident appeared to have labored breathing secondary to her agitation and as a result the LPN had called the DON (see nursing note from 1:40 a.m. above). The DON recommended she administer oxygen. The resident did not have an order for [REDACTED]. The LPN stated she was so focused on the resident's labored breathing that she did not call the physician. She was aware of the complications of heart failure. The LPN was not present when the resident was found in [MEDICAL CONDITION]. b. An interview with the DON was conducted on [DATE] at 12:19 p.m. The DON had cared for the resident on [DATE] during the day and could recall the resident was agitated. The DON stated she was called late at night by LPN #1 because the resident had labored breathing. She directed the LPN to administer oxygen to the resident; however, she was not aware if the resident had an order for [REDACTED]. After review of the closed record from the initial stay in June, 2015 the DON could not find a care plan or assessment indicating the resident had frequent refusal of care or behaviors. c. An interview with the spouse on [DATE] at 2:00 p.m. revealed the resident was admitted for a short 30 day stay for maintenance of her PICC line. He went to see his wife the day after her admission and she was acting strange and seemed agitated with his questions. He left her to rest and wanted to talk to a nurse but could not find one in his wife's hall. He went home and the next day as he was driving to work at approximately 7:30 a.m. he received a call from the head nurse (DON) from his wife's phone. He did not understand what she was saying initially but then, the DON said the EMTs were working on his wife and he should get down there. A few minutes later the facility called and said that his wife had not made it. He had not received any calls from the facility prior to that morning. d. An interview with the resident's physician on [DATE] at 3:48 p.m. revealed she had not received a call regarding the resident on [DATE]-[DATE]. Her physician group had no record of receiving a call to verify admission orders [REDACTED]. The only call that was documented, and that she had received, was regarding notification the resident had passed away.

Based on observations and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for residents, including five of 49 sample residents (#48, #76, #81, #140, #50). Specifically, the facility failed to: -prevent resident #76, who utilized oxygen, from entering the smoking area during smoking times with open flames (lit cigarette); -ensure egresses in resident rooms were adequately monitored for elopement or intrusion; -ensure resident #48, who had a history of [REDACTED]. -ensure resident #81's transfer pole was at a safe distance from the resident's bed to prevent entrapment. The facility's failure to ensure oxygen was not in use in the smoking area created a situation of immediate jeopardy for serious harm. The findings included: I. Immediate Jeopardy On 05/17/12 at 9:00 a.m., observations revealed resident #76 sitting in the smoking area within one foot of female resident #50, smoking a lit cigarette. A second female resident sat approximately three feet in front of the resident, smoking a lit cigarette. In all there were seven residents in the smoking area with lit cigarettes (open flames). Resident #76 was observed using oxygen via a nasal cannula. Resident #76 stated his oxygen was on and in use. By observation, the needle of the oxygen tank was in the middle of the line range. The resident stated he did not smoke and he was just sitting with the other residents. Resident #76 stated he did not see the signs at the entrance door to the smoking area. One sign on the entrance door to the smoking area read, "Absolutely no oxygen or oxygen tubing allowed in this area." A second sign posted on the right wall adjacent to the entrance door read, "Remove oxygen before entering. No oxygen use beyond this point." Both signs were written in English. The resident was asked by the state surveyor to move from the fenced smoking area and to sit in the large patio area away from the residents with lit cigarettes. The resident ambulated by himself from the smoking area and sat in a chair over in the large patio area. Female resident #140 walked out of the smoking area onto the patio area while smoking a lit cigarette. Resident #140 paced around on the patio area near (approximately 6 feet) resident #76. During the entire observation period, a female staff member assigned to the smoking area did not ask resident #76 to leave the smoking area due to oxygen use, she did not stop resident #140 from leaving the smoking area with a lit cigarette and she did not stop resident #140 from walking in near resident #76 who was still using oxygen. The female staff member was observed handing out cigarettes to residents and lighting the cigarettes for the residents. The staff member lit the cigarette for resident #50, who was sitting within three feet of resident #76. In addition a Maintenance Assistant (MA) was observed disconnecting the hose from a propane tank, which was attached to a gas grill. The gas grill was stored in the smoking area. Resident #50 was sitting in a wheelchair adjacent to the gas grill smoking a lit cigarette when the propane tank hose was disconnected. The Director of Nursing (DON) was standing in the patio area at this time and turned to witness the MA remove the propane tank from the gas grill. The DON stated she had asked the MA to remove the gas grill from the smoking area and did not intend for him to disconnect the propane tank from the gas grill. On 05/17/12 at 9:10 a.m., the Activity Director (AD) stated resident #76 should not have been in the smoking area with oxygen on. The AD stated the large patio area was not considered part of the smoking area. The AD stated resident #76 had been educated previously not to be in the smoking area with his oxygen on. The AD stated resident #76 told her he could read the two English signs at the entrance door to the smoking area. On 5/17/12 at 9:15 a.m., the Director of Nursing (DON) stated resident #76 should not have been in the smoking area with his oxygen on. The DON stated she did not know the true boundaries of the smoking area. The DON stated the MA should not have disconnected the propane hose from the tank in the smoking area while residents were smoking. The DON agreed resident #50 was smoking (lit cigarette) in close proximity (three feet) of the gas grill when the propane hose was disconnected. On 5/17/12 at 9:25 a.m., the Maintenance Assistant (MA) stated he did disconnect the hose from the gas grill and the propane tank while a resident sat within three feet of the grill smoking a lit cigarette. The MA stated he did not know propane gas could escape from disconnecting the hose from the propane tank. The MA stated he did not smell any propane gas when he disconnected the hose from the propane tank. On 5/17/12 at 9:33 a.m., resident #50 stated it was not normal for resident #76 to be in the smoking area while residents are smoking. Resident #50 stated that normally the residents will catch him in the smoking area but did not catch him today. Resident #50 stated the boundaries of the smoking area were enclosed by a railed fence; however, some residents did smoke on the large patio area when it was sunny. Resident #50 said she had observed resident #76 sitting in the smoking area during smoking times with his oxygen in use. On 5/17/12 at 9:37 a.m., the Environmental Services Manager (ESD) stated the smoking area included the railed fenced in area and did not include the large cement patio area. On 5/17/12 at 10:32 a.m., the facility was notified that the observations in the smoking area (see above) created a situation of Immediate Jeopardy for serious harm. At 10:48 a.m., a conference regarding the Immediate Jeopardy was held with the Nursing Home Administrator (NHA), the Director of Nurses (DON) and the Regional Nurse Consultant (RNC). At this time, the NHA stated all smoking was supervised on the facility grounds and there was only one independent smoker that smoked out of the facility. On 5/17/12 at 11:15 a.m., observations of the smoking area did not document any residents or staff in the area. There was a fire blanket and a fire extinguisher attached to the wall. There were no signs stating where the location of the designated smoking area or where smoking was prohibited. A sign in Spanish was now attached to the wall. II. Plan to Remove Immediate Jeopardy On 5/17/12 at 5:20 p.m., the fourth draft of the facility's Plan of Correction to remove Immediate Jeopardy was presented. The plan documented in its entirety: -Kenton Manor respectively presents the following immediate plan for abatement of current alleged immediate jeopardy regarding safe smoking. The plan details: -Residents will be re-directed immediately by person supervising smoking area if they enter the designated smoking area with oxygen during a time when residents are smoking. Staff member assigned to supervise smoking area will remain in the smoking area until all cigarettes are extinguished. -Designated smoking area will be in courtyard and covered patio outside the door between dining areas and Aspen. Designated smoking area will be in the black fenced area only. A yellow line will be painted so staff can easily identify the safe boundary line for non-smokers with or without oxygen use. Maintenance Director will measure and establish and paint boundary 5/17/12. The area identified will be the black fenced in area with the additional patio area outlined in yellow. -Beginning day shift 5/17/12 staff who supervise smoking will be educated on supervision of residents while smoking in the designated smoking area. Staff who supervise residents' smoking area will not supervise area until education has been completed. Additional facility staff education will begin 5/17/12 and will continue during each upcoming shift until all staff have had the education. Staff will be re-educated on supervision of residents while in the designated smoking area as identified above to include risks of smoking near oxygen or flammable material. Staff will be re-educated on the risks of smoking near oxygen or other flammable material in one month then quarterly thereafter for one year. New employees will be educated upon hire during the initial orientation process. -The following education was provided to residents: Resident (#76) was re-educated on the risk of wearing oxygen near people smoking. Resident (#76) was re-educated on other areas to go outside away from smoking area. Resident (#76) was informed of smoking times to alleviate being around flammable material. Resident (#76) was educated by Unit Manager and Spanish Interpreter (Housekeeper) in English and Spanish on 5/17/12. Resident (#140) was informed and educated on 5/17/12 of the risks of smoking near oxygen including residents wearing oxygen and walking near oxygen sources. Residents (#76, #50 and #140)'s care plans have been updated to reflect risks of being near flammable materials while smoking is occurring. This will occur on 5/17/12. -Smoking times will be at 6:45 a.m., 9:00 a.m., 10:45 a.m., 1:00 p.m., 3:15 p.m., 4:45 p.m., 6:45 p.m. and 8:00 p.m. An assigned staff member will supervise smoking. -Spanish and English No Oxygen while smoking signs have been placed surrounding smoking area and will be visible to residents, staff, and visitors on 5/17/12. Signage states: No oxygen or oxygen tubing is permitted within 10 feet of a person smoking or designated smoking area. A second sign states absolutely no oxygen or oxygen tubing is allowed in this area and calls for the removal of oxygen before entering. -Newly admitted residents will be informed of the location of the smoking area and where oxygen is permitted and not permitted. Residents admitted to the facility will be assessed to determine whether they are safe or unsafe smokers upon admission. Residents will be educated regarding the facility smoking policy. Resident care plans will be updated, as necessary. -The facility smoking policy will be posted at each nurses' station in a binder that will also include the list of smokers who require supervision, residents who smoke and have a [DIAGNOSES REDACTED]. This will be completed on 5/17/12. -Portable oxygen tanks can be hung on a coat rack provided in the Aspen dining room across from the smoking area entrance. -BBQ grill with propane tank has been moved to another location away from smoking areas and propane not stored with grill on 5/17/12. -Maintenance Assistant will be re-educated by NHA/Designee on storage of BBQ grill and propane maintenance on 5/17/12. -Medical Director will be made aware of smoking policy and plan of correction as well as resident (#76's) compliance with wearing oxygen near residents who smoke on 5/17/12. -A designated supervisor will be assigned to monitor each smoking session to validate that the appropriate supervision is being conducted and policy followed beginning 4:45 p.m. 5/17/12 daily for 14 days then will be re-evaluated for continued compliance by IDT. On 5/17/12 at 5:30 p.m., after review of the above Plan of Correction, the facility administration was notified that the facility Plan of Correction had been accepted and the Immediate Jeopardy removed. On 5/29/12 at 11:04 a.m., observations revealed seven residents in smoking area. No residents were wearing oxygen tubing or had oxygen tanks in their possession. One staff member was standing in the smoking area and a second staff member was watching the residents through a window. On 5/29/12 at 1:00 p.m., observations revealed nine residents in smoking area. No residents were wearing oxygen tubing or had oxygen tanks in their possession. One staff member was standing in the smoking area and a second staff member was watching the residents through a window. Although immediate jeopardy was removed on 5/17/12, deficient practice remained at an E level. III. Facility Failures A. Smoking 1. Resident #76, age 71, was admitted to the facility on [DATE]. The Face Sheet documented the resident had [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], documented the resident had a BIMS (brief cognitive exam) score of 11, indicating he was moderately impaired. The resident was independent in all areas of activities of daily living (ADLs). The resident had no short or long-term memory problems. The resident usually understood verbal content and usually made himself understood to others in his ability to express ideas and wants. The resident had end stage renal disease. Care Plan Communication dated 2/29/12, documented the resident was able to speak English but preferred Spanish. 2. Observations 5/17/12 At 9:00 a.m., resident #76, using a four wheel walker, was observed in the smoking area. He was wearing oxygen (portable tank) and tubing; he was sitting within 12 inches of female resident #50, who was smoking. A staff member was present assisting other residents to light their cigarettes. There were seven residents in the smoking area. -A surveyor asked resident #76 to please leave the smoking area. An ambulatory resident #140 got up and walked out of the smoking area with her cigarette to the area where resident #76 had gone. Resident #140 walked around outside of the smoking area until she was done smoking. Staff did not redirect her to the patio where the other residents were smoking. -At approximately 9:04 a.m., resident #140 indicated that she walked around and smokes outside the patio area because she likes the sunshine and she doesn't want to be in the shade. -At approximately 9:07 a.m., the staff member responsible for supervising the smoking time/area was interviewed. She indicated that she had never been told that residents could not smoke off of the patio; she indicated that resident #140 always smoked out there. -At 9:09 a.m., the activity director (AD) was interviewed. She indicated that resident #76 had been educated several times about having his oxygen on while he was in the smoking area. -At approximately 9:11 a.m., the interim director of nursing (IDON) was interviewed. She indicated that the staff had been educated related to smoking policy and she believed that the fenced patio area was the only smoking area, not the area where resident #140 had been smoking. She indicated that she would see if she could get a clear definition on the smoking area. -At approximately 9:14 a.m., the AD indicated that resident #76 could read the signs related to smoking in English. -At 9:15 a.m., the maintenance assistant (MA) was observed removing a propane tank off of the grill (he disconnected the tank from the hose attached to the grill) approximately two feet from resident #50, who was still smoking. The IDON instructed the MA to put the tank back on the grill and wait until the residents had finished smoking and had left the smoking area. The propane tank was observed to have a flammable gas 2 sign on it. At 9:20 a.m. the grill was removed by the MA after the smoking area was empty. -At 9:25 a.m., the MA was interviewed. He indicated that he didn't know that removing the propane tank from the hose of the grill could be dangerous because it could leak gas when it was disconnected. He acknowledged that he removed the propane tank from the grill with a resident within three feet (or less) of the tank and that that resident was smoking. He indicted that he then reconnected the tank and waited until the residents all left the smoking area before he moved the grill. -At 9:35 a.m., resident #50 was interviewed. She said she saw resident #76 outside with his oxygen on. She said he comes out sometimes with his oxygen on. She indicated that he comes out less now that a resident that he use to visit quit smoking, but even then, he used to come out all the time with oxygen on. She stated, "We (residents) have reminded him to take it off or chase him out." She indicated that she felt bad that she had not said anything before 5/17/12. 3. Facility Response to Safety Concerns Observed 5/17/12 Nurses' Notes dated 5/17/12 at 2100 (9:00 p.m.) documented resident alert and able to make needs known: no problems. Care Plan Behavior Symptoms dated 5/17/12 documented resident has a history of non-compliance of wearing oxygen near smokers. Resident re-educated not to wear oxygen near smokers (see education form). Resident/Family Education Record dated 5/17/12 at 10:00 a.m., documented as previously educated gave verbal instruction to this resident that there is to be no oxygen tanks in the Smoking Area. Writer educated him on the potential of self harm and harm to his peers of potential suffocation, burns, combustion, fires or burns where oxygen is combined with a source of flame or fire i.e., when people are smoking. Resident stated understanding and agrees not to go out in court yard when peers are on smoke pass. He also stated understanding that are other locations to go outside to get fresh air or enjoy the outdoors i.e. out Aspen door or out door of the front lobby. Also gave resident a copy and educated him on smoking times so that he may go to other areas during times of smoke pass. Obtained a translator and educated the resident in Spanish. Resident states understand in Spanish and English. Nurses' Notes dated 5/20/12 at 9:15 a.m., documented resident reminded this morning again not to be outside in smoking area with oxygen tank on. This reminder was given only to re-enforce education. No further incidences noted since last incident on 5/17/12. B. Resident Room Egresses 1. Resident Elopement According to a 4/21/12 occurrence report, a resident wearing a wanderguard eloped from the building on 4/21/12 at approximately 7:15 a.m. The report detailed: "(Staff) assisted resident with AM ALDs (activities of daily living) and dressing. They reported completed cares around 0645. Res(ident) was found by staff at 0715. Res is at risk for elopement and wears a wander guard. Resident's wanderguard was replaced. The SDC (staff development coordinator) completed an audit of all residents with wanderguards and tested each for proper function. Every alarming door in the facility was checked and all function appropriately." The report did not make clear which door the resident eloped from the facility. 2. Observation An interview occurred with a resident located in room 23 on the north unit on 5/17/12 at 4:55 p.m. In room 23, a door leading to the outside of the building was noted on the western half of the room. Further observation revealed two doors were present. One of the doors was a solid wood door, which was open. The second door was a glass screen door, which was shut. After the interview, the screen door was opened and upon exiting room 23, a concrete porch was observed spanning outside of the facility. The street was approximately 50 feet away. Leading a few hundred feet south of this street was a four lane road with heavy traffic. After exiting room 23, four egresses in total were observed in rooms 19, 21, 23, and 25. The wood door and the glass screen doors were shut in the three other rooms, as seen from outside of the facility. The screen doors were opened to room 21 and 25 and showed neither of the wood doors were locked. The wood door was locked in room 19. Further exploration of the facility revealed four egresses opening to the back side of the building and an alley way in rooms 18, 20, 22, and 24. The screen and wood doors in these rooms were shut; however, the wood doors in rooms 18 and 20 were unlocked. Four more rooms with egresses opening to the front of the building and the street were located in rooms 27, 29, 31, and 33. The screen and wood doors in these rooms were shut; however, the wood doors in rooms 27, 31, and 33 were unlocked. The 12 rooms with egresses to the outside of the building did not have wanderguard detectors placed on them, deeming the wanderguards ineffective if a resident eloped from one of the rooms. Additionally, a potential was created undetected access into the building. 3. Record Review A list of residents requiring wanderguards due to their confusion or elopement potential was requested and received on 5/17/12 at 7:45 p.m. Of the residents with wanderguards, three resided in rooms with egresses to the outside in rooms 20, 22, and 27. Both rooms 20 and 27 were observed with the wooden doors unlocked. The resident in room 27 was the resident who eloped on 4/21/12. 4. Staff Interview On 5/17/12 at 5:42 p.m., the certified nurse aide (CNA) was asked if there was a system in place to ensure the doors in the residents' rooms were locked. She said, "When I work I always make sure they are locked but I am not sure there's a protocol." On 5/17/12 at 6:40 p.m., a north unit manager was asked if there was a system in place to ensure the doors in the residents' rooms were locked. She said, "I think the night shift locks the doors. They come in at 10:00 p.m." On 5/17/12 at 6:45 p.m., a CNA in the dining room was asked if there was a system in place to ensure the doors in the residents' rooms were locked. She said, "We lock the doors and keep them locked unless the residents are independent and open them." On 5/17/12 at 6:47 p.m., a licensed practical nurse (LPN) in the dining room was asked if there was a system in place to ensure the doors in the residents' rooms were locked. She said, "Oh, I'm not sure." On 5/17/12 at 7:13 p.m., an interview about resident room egresses was conducted with the NHA, DON, and regional clinical director (RCD). The NHA said, "In general, they should be locked and checked. The night staff is responsible for that. The nurses are supposed to be responsible for checking the front door and the back door." When asked about the resident in room 27 and his elopement, the NHA was doubtful the resident eloped from the door in his room. She said, "He is very familiar with the facility and he does wander. He propels himself around the facility and the situation was that he was waiting from breakfast and he moved himself into the lobby. He thought he was going to dinner by going out those doors." The NHA and RCD stated, to their knowledge, no resident had ever eloped from the egresses in the rooms and individuals had never come in undetected. When asked how the facility intended to ensure residents with wanderguards did not elope through the egresses, the NHA said they would come up with a plan. At 7:58 p.m., the NHA said, "We have decided to bolt the doors shut tonight." She said they planned to brainstorm the matter and would follow-up. On 5/21/12 at 4:15 p.m., the NHA said that the 12 resident rooms that had exit doors to the front and the back had double passage locks on them. She described a double passage lock as a dead bolt that required a key to enter or exit. She said a system has been implemented and if a resident wants the wood door in their room open, they are to ask a nurse who carries the key to the double passage lock. She added the door could only be opened when the resident was in the room and it was to be locked once the resident left the room. When asked how this would address residents potentially eloping from the building through an open, unalarmed door, the RCD said, "Staff were educated over the weekend of the protocol. If they walk by one of the rooms and the room is empty, they are to alert the nurse so she can lock the door. We also asked the residents if they see someone trying to get out the door to put on their call light so we can take care of it. It's an extra set of eyes." The RCD said residents with egresses in their rooms received education about the new policy. 5. Facility Follow-up The NHA provided the protocol in writing on 5/21/12: "Protocol for Resident Rooms with Doors to Outside: Currently there are 12 rooms that have doors which exit to the outside. The doors are in resident rooms 18, 20, 22, 24, 19, 21, 23, 25 on North and rooms 27, 29, 31, and 33 on Silver Key. The doors have double passage locks which require a key for exit and entrance. The North and Silver Key nurse will have a key on the nurses key ring. The combo cart nurse will be responsible from 6 a.m. - 10 p.m. The Silver Key and North night shift nurse will be responsible during the hours of 10 p.m. - 6 a.m. The doors are to remain locked at all times unless the resident requests otherwise (residents with wanderguards are to have doors locked at all times). If residents request their door to be opened, ask the nurse to open the door for the resident and alert the nursing staff that the door is open. If a resident leaves their room for any reason the door will be locked. If a resident door is open, the nursing staff will check during rounds. Remind the resident with the door opened to alert staff if someone attempts to exit the door. The evening North nurse will make a round at the end of his/her shift to validate all doors are locked. Staff who observe a door open without a resident in the room are to report such to the nurse. The NHA and maintenance director have backup keys." Resident education was provided to the residents with egresses in their rooms on 5/20/12 and included: "Double passage door lock on your door. Nurse has the key to your door. If you would like your door opened, just tell a staff member and the nurse will unlock for you. We would like the door to remain locked when not in your room. You may let a staff member know if someone tries to leave through your door." C. Choking 1. Resident #48, according to the face sheet, was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the 1/6/12 quarterly minimum data set (MDS), the resident had clear comprehension and was able to be understood. She had a short and long-term memory impairment. Her ability to make decisions regarding tasks of daily life was moderately impaired. The resident did not exhibit inappropriate behaviors. She was independent with eating and required only setup assistance. According to the speech therapy care plan dated 2/16/12, the resident had a problem with dysphagia. Goals included: Demonstrate safe swallowing techniques with 90% acceptance, tolerate least restrictive diet, demonstrate no signs/symptoms of aspiration, care plan to reduce aspiration risk. Approaches included: -Dysphagia therapy 1. Progress diet as tolerated 2. Compensatory strategies According to the non-compliance care plan dated 2/29/12, the resident had the potential to be non-compliant related to behaviors and moods, cognitive impairment, and personal choice. In pertinent part, the resident was non-compliant with recommended diet textures and ate beef jerky snacks against recommendations. Approaches included: -Explain why treatment/care is necessary. -Try to ascertain why resident is refusing. -Explain potential outcome of refused treatment. -Staff to encourage (resident) to seek assistance with activities of daily living ... -Encourage (resident) to comply with doctor ordered plan of care. -Continue to educate resident as she will allow regarding diet/swallow risks. 2. First Choking Episode According to the nurse's documentation, the resident had a choking incident requiring intervention on 2/13/12. -2/13/12: "This nurse in DR (dining room) on lunch duty when it was noted res(ident) was patting self on the back and then more forcefully pounding self on the chest. When this nurse asked x 2 if resident was choking she vigorously shook head yes - noted no air movement from mouth or nose. With res seated in DR performed Heimlich x 2 on second thrust a piece of turkey flew out of res mouth to the floor. Res able to catch (breath). This nurse stayed with her until CNA retrieved WC (wheelchair) and res taken to her unit. -2/14/12 IDT review of choking incident from 2/13/12 - S/T (speech therapy) orders to evaluate diet appropriateness of texture. Correct diet served at time of occurrence and all protocols followed appropriately. Resident had no adverse after effects or apparent injuries. According to the incident/accident report dated 2/13/12: Incident/Injury Type: Choking Incident Findings: "This nurse in DR (dining room) with resident when resident started patting self on back and then more forcefully on chest. Inquired x 2 if res(ident) was choking - res shook head yes - Heimlich done. Object removed - piece of turkey." Was initial treatment provided: "Heimlich by RN (registered nurse) in DR. Action: The action section was left blank. 3. Speech Therapy Course The resident was evaluated for speech therapy and opened to case load on 2/16/12. According to the speech therapy evaluation: Prior Level of Function: "Pt (patient) is a long term resident here at Kenton Manor. Per pt, she is experiencing a gradual decline overall over the past few mos. Complicated medical hx (history) w/ various aspiration indications, PNA (pneumonia) asthma, seizure dx (diagnosis), tremors, and bipolar/schizophrenia." Reason for Referral: "Pt "choked" on a food item a couple of days ago." Long term goals: "Pt to tolerate least restrictive diet textures without overt s/sx (signs or symptoms) of aspiration complications." Short term goals: "Pt to tolerate regular diet textures w/o overt s/sx of asp complications." Additional comments: "Pt presents with a functional swallow with low asp(iration) risk. However, pt would benefit from SSS (safe swallowing strategies) to decrease overall mastication time. Pt with prolonged mastication over 2 minutes, however is refusing decrease in diet text(ure)." The resident was discharged from speech therapy on 3/2/12. The therapy notes showed: Status at the End of Therapy Program: "Pt tolerates least restrictive diet textures w/o overt s/sx of aspiration complications - reg(ular)/thin liquid." Discharge Summary: "Pt presents with a functional swallow with low aspiration risk and uses SSS independently." Additionally, on 3/2/12, a physician's telephone order was documented by the speech therapist calling to, "Downgrade to puree fruits and veggies, con't (continue) all previous diet recommendations per Pt's request." 4. Second Choking Episode According to the nurse's documentation, the resident had a second choking incident, requiring intervention, on 3/6/12, four days after being discharged from speech therapy. -3/6/12: Res noted to be choking in DR. This nurse could not hear air movement. Res did not respond to verbal commands. Heimlich thrusts x 6. Res coughed up a round unchewed carrot slice. Able to verbalize after that. This nurse stayed with resident and assisted to room...PA informed of incident. Speech eval(uation) re-ordered. According to the incident/accident report dated 3/6/12: Incident/Injury Type: Choking Incident Findings: "Resident noted to be choking at noon meal - unable to pass air. Heimlich done x 6 thrusts. Coughed out a round carrot slice." Was initial treatment provided: "VS (vital signs) taken - assisted to room." Action: The action section was left blank. 5. Facility Response -The resident was not reopened on the speech therapy caseload following the second choking incident. However, the resident received education on the risk associated with diet textures on 3/9/12. "Pt provided education/information verbally with regards to dysphagia management and risk of choking with current diet textures. Given incident of recent choking, explained to patient the least restrictive diet textures with minimal risk of aspiration complications would be pureed diet textures. Pt verbalized understanding and stated she would like her fruit/veggies pureed. Spoke with dietary manager. Will make appropriate adjustments. PT (resident) not currently on SLP (speech therapist) caseload. SLP eval(uation) prior and deemed pt with low asp risk, however, pt continues to present with intermittent choking events." -After a short hospitalization , the resident was seen by the speech therapist on 5/17/12. The therapy note documented: "Would you leave me alone, I don't choke any more ZX

Based on record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being for six (#22, #26, #44, #48, #58 and #145) of 49 sample residents. Specifically: -The facility failed to ensure resident #145's pain was managed. The resident cried out in pain when staff attempted to reposition him. Staff continued to reposition the resident notwithstanding his distress, and did not intervene to seek pain relief for the resident. (Cross-reference F226) -The facility failed to ensure resident #26 and #48's pain was assessed and monitored. -The facility failed to ensure resident #22 and #145's bowel movements were monitored and interventions initiated and documented. -The facility failed to ensure residents #44 and #58 had thorough skin assessments. The findings include: I. Expectations A. Reference According to Delaune and Ladner, "Fundamentals of Nursing, Standards and Practice," 1998, page 237, "nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm." B. Facility Policy On 5/24/12 at 2:42 p.m., the Director of Nurses (DON) provided the facility policy on Physician Orders OP4 0104.00 (9/2011). The policy documented, in pertinent part, Physician Orders are obtained to provide clear direction regarding the care of the resident. On a regular basis (often 30 days, or as required by State law), the current set of physician orders was printed for the attending physician to review and renew with signature. The physician was to review and sign the orders at the time of the physician's visit. II. Facility Failures A. Pain 1. Resident #145, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], revealed no information in any of the sections except the initial page. Information from the care plans revealed the resident could usually understand and was sometimes understood. He needed total assist with all activities of daily living. He had pain in his legs and a pressure ulcer on the ankle. a. Pain Review of physician orders revealed the resident had the following orders for pain: -[MEDICATION NAME] 10 mg routinely -[MEDICATION NAME] PRN (as needed) The care plan for pain, dated 5/4/12, noted actual pain due to acute ischemia on left leg and left ankle ulcer. The approaches were: Administer [MEDICATION NAME], implement pain management flow sheet. Observe resident for signs and symptoms of pain each shift and as needed. Medicate prior to treatments and therapy. On 5/16/12 at 11:45 a.m., the resident was observed in the dining room. The resident's brows were furrowed and he was clenching his teeth. The resident was sitting in his wheelchair with his left leg slightly bent at the knee so that his heel was resting on the seat of wheelchair. A certified nurse aide (CNA) approached the resident and began to manipulate the resident's knee so his legs would fit under the table. The resident began screaming loudly in pain and said, "What are you doing to me?" The CNA said, "I'll be gentle because I know it hurts." The CNA did not stop and seek nursing assistance, although there were two nurses standing outside the dining room. The nurses outside the dining room did not respond as the resident cried out. No assessment of the resident was conducted and no PRN pain medication was offered. Review of the Medication Administration Record (MAR) revealed the resident received [MEDICATION NAME] 10 mg at 11:00 a.m. (No effectiveness documented.) On 5/17/12, the resident was observed in the dining room at 8:32 a.m. He was receiving feeding assistance from a CNA. The resident looked at the CNA and said, "My leg hurts." The CNA responded, "Oh, your leg hurts?" and continued to assist the resident with eating. She did not inform the nurse about the resident's complaint of pain. The resident was not offered intervention for his pain. 2. Resident #26, age 59, was admitted to the facility on [DATE]. The Face Sheet documented the resident had [DIAGNOSES REDACTED]. Resident Status: -The Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 15, indicating he was cognitively intact. The resident was independent of Activities of Daily Living. The resident was independent for bathing functional status. The resident had pain presence, occasionally which in the past five days has limited his day to day activities due to the pain. The resident was documented as having rating his pain scale over the past five days as a 05 using the 0-10 pain scale. Resident's current weight was 302 pounds. The resident was expected to stay in the facility. -Physician's Note, dated 10/21/11, documented left lower leg pain with no [MEDICAL CONDITION]: pain was constant and remained stable. The pain was described as aching and burning. No documented injury to the leg was noted. The resident presented with worsening leg pain, thought to be due to [MEDICAL CONDITION] and was started on [MEDICATION NAME]. Resident had a [DIAGNOSES REDACTED]. The resident's [MEDICATION NAME] was increased to 600 mg (milligrams) by mouth three times a day for leg pain suspected to be due to [MEDICAL CONDITION]. -Nurse Note, dated 3/8/12, documented new orders for [MEDICATION NAME] ([MEDICATION NAME]): increase to 900 mg by mouth, three times a day. Care Plan: Care plan for Pain, dated 3/15/12, documented actual pain related to chronic disease process, neuropathic pain, [MEDICAL CONDITION], diabetic [MEDICAL CONDITION]: bilateral lower leg pain. Approaches listed were positioning/support, recreational therapy/activity programming, relaxation, education on healthy eating habits, administer medications as ordered, implement pain management flow sheet, observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other). Monitor each shift and as needed. Notify physician if interventions were not consistently effective. Orders: Physician's Order Sheet, dated 5/2012, documented the following pain medications: -[MEDICATION NAME] 300 mg 3 capsules total 900 mg by mouth, three times a day, -Regular Strength Tylenol 325 mg 2 capsules total 650 mg by mouth every 4 hours as needed, -Ancillary Note: ask the resident if he was having any pain or discomfort or assess the resident's non-verbal indicators using the Wong Baker faces pain rating scale, 0-10. If the resident has a routine pain medication, document after the routine has been given (11/19/09). Doctor's Progress Notes, dated 5/3/12, documented the resident reported his leg pain had improved with the [MEDICATION NAME]. Pain Evaluation, dated 5/12/12, documented pain related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. The evaluation documented at any time in the past five days had the resident: -been on scheduled pain management regimen: yes, -received as needed pain medications: no, -received non-medication intervention for pain: no, and -resident stated he had not had pain or hurting at any time in the last 5 days. Medication Administration: Medication Administration Record (MAR), dated 4/2012, documented [MEDICATION NAME] 300 mg 3 capsules total 900 mg by mouth, three times a day was administered as physician ordered. PRN (as needed) Pain Medication Administration Record, dated 4/2012 and 5/2012, for Regular Strength Tylenol 325 mg 2 capsules total 650 mg by mouth every 4 hours as needed did not document the resident was administered the medication either month. Pain Assessments: Treatment Administration Record (TAR), dated 4/2012, documented: ask the resident if he was having any pain or discomfort or assess the resident's non-verbal indicators using the Wong Baker faces pain rating scale 0-10. If the resident has routine pain medication, document after the routine has been given (11/19/09). The resident was to be assessed for pain on the 6a - 6p shift and on the 6p - 6a shift (twice a day). The TAR documented the resident was assessed for pain 5 days 4/1/12 through 4/5/12. A line was drawn across the documentation boxes and a hand written statement documented to see PRN (as needed) Pain Sheet. The PRN Pain Medication Administration Record 4/2012 did not document any physician ordered resident pain assessments from 4/6/12 through 4/31/12: a period of 25 days. The PRN Pain Medication Administration Record for 5/2012 did not document any physician ordered pain assessments were performed for the entire month. The TAR dated 5/2012 documented the resident was assessed for pain on the 6p-6a shift six (9th, 10th, 11th, 12th, 21st and 23rd) times: the resident did not have any pain levels (o). Interview: On 5/24/12 at 1:22 p.m., the Director of Nursing (DON) observed/agreed: -the PRN Pain Medication Administration Record dated 4/2012 did not document the resident was assessed for pain for a period of 25 days, -the PRN Pain Medication Administration Record dated 5/2012 did not document the resident was assessed for pain for the entire month, and -the TAR dated 5/2012 documented the resident was assessed for pain only six times. The DON stated it was her expectation nursing staff follow physician orders. The DON stated the resident should have been assessed for pain twice a day and he was not. On 5/24/12 at 2:25 p.m., the Aspen/Silver Key Unit Manager stated it was her expectation nursing staff follow physician orders. On 5/24/12 at 1:35 p.m., North Unit Manager stated it was her expectation nursing staff follow physician orders. On 5/24/12 at 1:42 p.m., the resident stated he received sufficient pain medications and he knew that he could get PRN Tylenol if he needed it. He stated the [MEDICATION NAME] was working well for him. On 5/24/12 at 2:52 p.m., the Nursing Home Administrator (NHA) stated it was her expectation nursing staff follow physician orders. 3. Resident #48, age 53, according to the face sheet, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent quarterly minimum data set (MDS), dated [DATE], showed the resident had clear comprehension and was able to understand. She had short- and long-term memory impairment. Her ability to make decisions regarding tasks of daily life was moderately impaired. The resident was documented to have occasional pain, which made it hard to sleep at night and limited her day to day activities. The resident received both scheduled and as needed (PRN) pain medications. The resident's pain care plan, dated 2/29/12, showed the resident had actual pain related to chronic disease process, bilateral lower [MEDICAL CONDITION], and left leg/knee pain. Approaches included: -Positioning/support. -Administer [MEDICATION NAME] as ordered. -Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other) every shift. -Notify physician if interventions are not consistently effective. -Medicate resident for pain prior to treatments and therapy, if indicated. -Encourage to elevate BLE (bilateral lower extremities). Resident Interview: On 5/21/12 at 11:29 a.m., the resident was asked if she experienced discomfort or pain, heaviness, or burning without relief. The resident said she was always in pain but added "I'm used to it." On a scale of one to ten, one being the least and ten being the most, the resident said the highest her pain got was a ten. She said after pain medicine, it went down to an eight. Record Review: According to the May 2012 computerized physician orders, the resident was to be assessed for pain. "Ask the resident if she is having any pain or discomfort or assess the resident's non-verbal indicators using the (faces) pain rating scale. If the resident has a routine pain medication, document after the routine has been given." A review of the resident's pain assessments showed the resident's pain was not assessed as ordered. The March 2012 medication administration record (MAR) and treatment administration record (TAR) were reviewed. The resident's pain was assessed for both the 6:00 a.m. and 6:00 p.m. shifts on 3/1/12. After 3/1/12, "See pain flow sheet" was written on the MAR. The pain flow sheet showed the resident's pain was only assessed on the days she received PRN pain medications, which was not on a daily basis. The April 2012 MAR and TAR were reviewed. The resident's pain was not assessed on the MAR and again, "See pain flow sheet," was written where the pain levels could be documented. The pain flow sheet showed the resident's pain was only assessed on the days she received PRN pain medications, which was not on a daily basis. The May 2012 MAR and TAR were reviewed. The resident's pain was assessed inconsistently on the MAR and again on the pain flow sheet, only when the resident received PRN pain medication. Staff Interview: On 5/29/12 at 10:10 a.m., the director of nursing (DON) stated she expected the resident's pain to be assessed and documented on the MAR every shift. She said the nurses were going to be reeducated as there was a misunderstanding when the pain flow sheets were implemented. B. Skin Assessment 1. Resident #44, age 82, according to the face sheet, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident's non-pressure ulcer skin impairment care plan, dated 4/24/12, showed the resident had potential for skin impairment related to co-morbid conditions and thin fragile skin. ,Approaches included: -Observe skin weekly and document findings as indicated. -Document observation of any non-pressure related skin impairments on facility non-pressure ulcer wound documentation form. -Observe for safety needs with transfer. Resident Observation: On 5/16/12 at 4:28 p.m., the resident was observed in his room sitting in his wheelchair. Bruising was noted to the resident's right and left hands. Record Review: --According to the May 2012 computerized physician orders, the resident was ordered to have head to toe skin assessments completed every Saturday. --The head to toe skin check record showed the resident's skin assessments were completed on Wednesdays during the 6:00 a.m. - 6:00 p.m. shift. The 5/9/12 skin assessment showed the resident's skin was intact and he was not documented to have have any bruising. The 5/16/12 skin assessment showed the resident's skin was intact and he was not documented to have any bruising. The 5/23/12 skin assessment showed the resident's skin was intact and he was not documented to have any bruising. Staff Interview: On 5/24/12 at approximately 5:15 p.m., the north unit manager (UM) was made aware of the bruising on the resident's hands. She said she would look into it. On 5/30/12 at 10:10 a.m., the director of nursing (DON) said she expected bruising to be noted on the skin assessment. She said if unexplained bruising was found, an incident report was to be completed. Facility Follow-up: --The nurse's notes were reviewed and a note acknowledging the bruising was made on 5/25/12. "This nurse noticed on R(ight) and left hand bruises. Right hand by thumb has a 2.5cm x 1cm above that bruises 1cm x 1cm. Will cont to monitor." --The incident report dated 5/24/12 showed: -Incident/Injury Type: Bruises R&L(eft) hand -Findings: This nurse noticed R hand bruises by thumb 2.5 cm (centimeter) x 2.5 cm above that 1 cm x 1 cm L hand sporadic bruising. Will cont(inue) to monitor. --The incident/accident investigation follow-up dated 5/24/12 showed: -Description of Incident/Accident: "This nurse noticed bruising to right and left (hand). Right hand has a bruise by thumb 2.5 cm x 1 cm. Left hand sporadic small bruising. -Summary of Investigation: Asked resident what happened. "They appear every now and then." -Recommendations/New Interventions: "Have resident wear protective stockings or longer sleeves. (Resident) states he has gotten discolorations all his life. They don't bother him and he denies any pain. He denies any injury by anyone." 2. Resident #58, age 86, was admitted to the facility on [DATE]. Review of the resident's face sheet revealed her [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS), dated [DATE], revealed the resident was unable to complete the Brief Interview Mental Status (MDS). During the interview the resident was unable to complete one or more questions for the interview. Review of the resident's Braden scale for predicting pressure sore risk, the resident scored 17 points. A score of 12 or less represents high risk for pressure sores. Observations: The resident was observed sitting in her room, on 5/21/12 at 8:39 a.m. A dark purple circular area was on the center of the resident's left cheek. The area looked like a raised bruise that measured approximately 9 cm X 6 cm in size. Record Review: Review of the record (nurses' notes, incident reports, bath records, skin assessments) revealed no documentation of the resident's area to the left cheek. The resident's last skin assessment was 5/25/12. The resident was on weekly skin assessments. The nurse documented weekly on resident's skin. Review of the last six months of weekly skin assessments revealed the area to the left cheek had not been addressed. Review of the facility policy for incident management was provided by the administrator on 5/29/12. The Skin Management, policy effective 2/2010, read under practice guidelines; "Newly admitted residents 1. Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale- for Predicting Press Sore Risk." The skin management policy further stated, "4. Residents admitted with skin impairments will have: a. appropriate interventions implemented to promote healing." 5. All other significant skin impairment: Non-pressure Skin Conditions should be placed on the resident's Treatment Record. Section 6 of the facility policy for Skin Management stated: "A Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or actual impairment, the interventions implemented to promote healing and prevent further breakdown. Note: Alterations or change in skin integrity, any break in the resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds etc, are to be recorded on the Head to Toe weekly skin check form. Review of the comprehensive care plan did not have the area to left cheek documented. The care plan titled non-pressure ulcer skin impairment, dated 2/23/12, had a potential for skin impairment. Actions taken after notification of bruising: During an interview with the director of nursing (DON), on 5/23/12 at 3:16 p.m., she stated "I would expect my staff to document the area on her cheek or care plan it somewhere especially since it was there when the resident was admitted ." The nurse consultant with the DON present on 5/23/12 at 3:20 p.m. notified the surveyor that "the area on her cheek is a [DIAGNOSES REDACTED], it was added to her care plan today." "The resident's daughter who is a registered nurse just informed me what the area was and that the resident had refused any treatment a few years ago. The resident's daughter, who had medical power of attorney, informed me she doesn't want any treatment for [REDACTED]." On 5/24/12 at approximately 11:00 a.m., the DON stated they could not find any documentation where the area to the cheek was addressed. The DON provided copy of the resident's care plan for non-pressure ulcer skin impairment. On 5/23/12, "history of [DIAGNOSES REDACTED] to face per daughter. No treatment at this time" was added to the resident's care plan. C. Bowel Management Reference: According to "Nursing Procedures and Protocols," (2003) by Lippencott Williams & Wilkins "Managing the Patient with Alteration in Bowel Function" pages 416-417: -Purpose: to provide treatment measures to effectively induce bowel movement and prevent future bowel alterations. -Nursing Interventions: monitor the patient's bowel frequency and habits, perform bowel assessments, encourage physical activity, encourage adequate fluid intake, review patient's current medication, monitor the patient for fecal impaction. -Assessment and Guidance: no bowel movement for several days, discomfort in abdominal region, full feeling with abdominal pressure, decreased appetite, needing to strain for a small amount of hard stool, abdominal distention, hard, dry small volume stool, abdominal area tender to palpate. -Documentation: record frequency and characteristics of all bowel movements, document any aids used for defecation, document abdominal assessment, and note signs and symptoms of altered bowel functioning. Facility Bowel and Bladder Procedure: -Bowel sheets will be pulled each morning by the Nurse Manager or designee. All nurses will follow thru with documentation and PRN (as needed) documentation in the Medication Administration Record (MAR). -The 6-2 nurses will give prune juice to residents on list in morning and begin acute charting with complete abdomen assessment. -The 2-10 nurses will follow-up with milk of magnesia or alternative laxative if no results are documented on day shift. Continue with acute charting including implementation of laxative and results if any. Document implementation of laxative and any results of PRN's given in MAR along with results. -The 10-6 nurses will follow-up with a suppository and rectal check if no results are documented on the 2-10 shifts. Complete the acute charting on all residents remaining on Bowel Monitoring sheet including abdomen assessments and rectal check results. Document any PRN's given in MAR along with the results. 1. Resident #22, age 94, was admitted to the facility on [DATE]. The Face Sheet documented the resident had the following Diagnoses: [REDACTED]. Record Review: Admission Evaluation for Bowel and Bladder Training, dated 2/10/12, documented resident with confused mental status requiring functional assist of two. Present bowel status was incontinent with a frequency pattern of once a day with a medium amount. Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS score of 99 indicating the exam was not completed. The resident was modified independent in cognitive skills for daily decision-making. The resident had short-term memory problems. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was frequently incontinent of both bowel and bladder. Care Plan - Bowel Elimination, dated 2/21/12, documented the resident had a potential for alteration in bowel function related to decreased mobility and medication influence. There were five approaches documented: encourage fluids unless contraindicated, encourage activity within ability, observe for bowel pattern to ensure adequate bowel elimination, administer medications as ordered and observe for side effects/effectiveness and dietician consult as indicated. Physician's Order Sheet, dated 3/2012, documented the resident utilized the following medications for constipation: Senna-S 8.6 mg - 50 mg tablet one tablet by mouth twice a day, and [MEDICATION NAME] 17 grams by mouth mix with 8 ounces of water or juice as needed. Resident Bowel and Bladder by Shift Chart documented the resident did not have a documented bowel movement from 2/21/12 shift 2 through 2/26/12 shift 2 a total of 16 shifts. In addition, the resident did not have a documented bowel movement from 2/27/12 shift 1 through 3/3/12 shift 2 a total of 17 shifts. Nurse Notes documented the following pertinent information: -2/27/12: 240 cc (cubic centimeters) prune juice administered to resident, bowel sounds active in all four quadrants and abdomen was soft and non-tender to touch, -3/1/12: 30 cc milk of magnesia administered to resident, no bowel movement in three days, -3/1/12: 120 cc of prune juice administered to resident, bowel sounds in all four quadrants with no distension noted, -3/2/12: 120 cc prune juice administered to resident, physician notified resident has had no bowel movement in five days, non-distended abdomen with bowel sounds in all four quadrants, resident denies abdomen discomfort, -3/2/12: 30 cc milk of magnesia administered to resident, bowel sounds distant hypoactive, -3/2/12: Ducolax suppository administered to resident for constipation, -3/3/12: [MEDICATION NAME] and prune juice administered to resident with no bowel movement this shift; bowel sounds hyperactive in all quadrants with soft non-tender abdomen. -3/3/12: [MEDICATION NAME] and milk of magnesia administered to resident at 7:00 p.m., with extra large bowel movement. Nurse Notes, dated 2/21/12 through 2/26/12 and 2/2712 through 3/3/12, did not document any rectal checks results as detailed on the facility's Bowel and Bladder Procedure form. Interview: On 5/23/12 at 4:23 p.m., the North Unit Manager (Licensed Practical Nurse) stated she believed the charting of bowel movements in the Care Tracker (CT) was accurate. She stated it was her expectation nursing staff document a resident's bowel movement in CT as soon as they could or at least by the end of the shift. -She stated nursing staff receive a bowel movement list of residents who have not had a bowel movement in three days or nine shifts. She stated after a resident has not had a bowel movement in nine shifts, the facility bowel movement protocol was initiated. She stated it was her expectation nurses chart the administered bowel intervention and the results of the intervention either in the nurses' notes or on the blue PRN (as needed) medication sheet. -She stated the night nurse printed out the residents with no bowel movements in nine shifts form for the following morning shift. She stated she also printed out her own copy of the form when she arrived at work each morning and attached the facility bowel movement protocol to the list of residents who had not had a bowel movement in nine shifts. She stated she also transcribed all the residents on her hall onto the bowel movement protocol form itself. She stated the no bowel movement form was discussed each day in the morning meeting. On 5/23/12 at 4:15 p.m., a Registered Nurse (RN) stated she thought the charting of bowel movements in the Care Tracker (CT) was accurate most of the time. She stated it was her expectation bowel movements be documented in CT as soon as they occur or at least by the end of the shift. On 5/23/12 at 4:17 p.m., CNA #1 stated the documentation she placed in CT was accurate and she hoped others documented accurately as well. She stated she documented bowel movements in CT as soon as possible or by the end of the shift. She stated she kept a list of residents in her pocket and marked on the paper list each time a resident had a bowel movement. She also stated at shift change she would discuss the residents who did not have bowel movements to the oncoming shift. On 5/24/12 at 1:47 p.m., CNA #2 stated she placed resident bowel movement documentation in CT as soon as possible after the event, several times during the day or at least by the end of the shift. On 5/24/12 at 1:50 p.m., CNA #3 stated for the most part the documentation in CT was accurate. She placed resident bowel movement documentation in CT as soon as possible or by the end of the shift. She stated the goal was to chart in CT as soon as you walk out of a resident's room. On 5/24/12 at 2:11 p.m., the Director of Nursing (DON) observed/agreed there was no documentation of bowel movements on the Resident Bowel and Bladder by Shift Chart, from 2/21/12 shift 2 through 2/26/12 shift 2 and from 2/27/12 shift 1 through 3/3/12 shift 2 for resident #22. The DON stated it was her expectation nursing staff place resident bowel movement documentation in CT as soon as possible or by the end of the shift. The DON stated it was her expectation the facility Bowel Movement protocol was followed by nursing staff. The DON stated that during each morning meeting, the residents who have not had a bowel movement in the last nine shifts are identified and discussed. The DON stated on the 10th shift, the facility Bowel Movement protocol begins. The DON stated it was her expectation nursing staff document the use of prn (as needed) bowel medications and document the results/effectiveness of the medications. On 5/24/12 at 2:25 p.m., the Aspen/Silver Key Unit Manager stated it was her expectation nursing staff document resident bowel movements accurately and timely in CT. She stated it was her expectation nursing staff document any administered prn bowel medications and the effectiveness of the provided intervention. She stated it was her expectation nursing staff follow the Bowel Movement protocol at the beginning of the 10th shift. On 5/24/12 at 2:52 p.m., the Nursing Home Administrator (NHA) stated it was her expectation nursing staff document the effectiveness of administered bowel management interventions. The NHA stated it was her expectation nursing staff document resident bowel movements accurately and timely in CT. The NHA stated it was her expectation nursing staff follow the facility Bowel Movement protocol starting on the 10th shift. On 5/24/12 at 2:05 p.m., the Director of Nursing (DON) stated it was her expectation nursing staff document administered prn bowel medications and document the results/effectiveness of medications. 2. Resident #145, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], revealed no information in any of the sections except the initial page. Information from the care plans revealed the resident could usually understand and was sometimes understood. He needed total assist with all activities of daily living. He had pain in his legs and a pressure ulcer on the ankle. Record Review: On the Pain Evaluation form dated 5/1/12 (date of admission), there was a note that the resident had no BM (bowel movement) in the past five days while the resident was hospitalized . Review of the Resident Bowel and Bladder Chart revealed the resident did not have a BM until 5/3/12; therefore, according to the documentation available to facility staff, the resident had gone seven days without a BM. Review of the Medication Administration Record (MAR) revealed the resident was given one dose of MOM on 5/2/12. There were no results documented. Review of the nurse's notes, dated 5/2/12, revealed no documentation of the administration of the Milk of Magnesia and no documentation of the lack of results. Review of the MAR revealed, on 5/3/12 (no time documented), a [MEDICATION NAME] suppository was administered. The results were a small BM. Review of the Resident Bowel and Bladder Chart also revealed that the resident had a small BM on 5/3/12. A nurses' note dated 5/3/12 on the 10-2 shift noted that the resident was incontinent of bowel. There was no mention of a suppository being given or when. Interview: On 5/24/12 at 11:30 p.m. the director of nurses and the regional registered n