Every finding on record at Burton Health Care Center

Based on record review, facility Self-Reported Incident review, facility policy and procedure review and interview the facility failed to ensure Temporary Nurse Aide (TNA) #369 was immediately removed from the facility once an allegation of resident abuse involving the TNA was made. This affected one resident (#222) and had the potential to affect 32 additional residents (#1, #7, #9, #10, #12, #13, #15, #18, #21, #30, #34, #30, #36, #40, #43, #44, #45, #47, #49, #51, #55, #56, #58, #59, #61, #62, #66, #67, #71, #231, #232 and #234) residing on the unit where TNA #369 worked. The facility census was 70. Findings include: Record review revealed Resident #222 was admitted to the facility on [DATE] for a respite stay and then transitioned to long term care placement on 08/24/22. Resident #222 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a facility Self-Reported Incident (SRI), tracking number 0, dated 08/13/22 revealed an allegation of abuse involving Resident #222 was reported to the State agency. As a result of the investigation/the SRI noted the facility unsubstantiated the incident with no physical or emotional injury identified to Resident #222. TNA #369 denied the incident that was reported by State tested Nursing Assistant (STNA) #358 and the facility found no evidence the resident recalled the incident or sustained any physical injury as a result of the incident. Review of the five day Minimum Date Set (MDS) 3.0 assessment, dated 08/17/22 revealed Resident #222 was severely cognitively impaired with physical and verbal behaviors directed toward others, continuous disorganized thinking, rejection of care, wandering and required extensive assist of two staff for most activities of daily living. A plan of care, dated 08/24/22 revealed the facility had developed plans related to limited physical mobility and behavior problems related to combative, aggressive behavior during hands on care. The care plan noted gentle redirection ineffective on most occasions. On 08/31/22 at 4:35 P.M. interview with State tested Nursing Assistant (STNA) #358 revealed she was working with TNA #369 on the night of 08/12/22. The STNA revealed as the two of them tried to assist Resident #222 with going to bed at approximately 11:30 P.M., the resident grabbed her (STNA #358) shirt and would not let go. TNA #369 then slapped the resident's hand repeatedly, harder than she needed to, telling him to let go. STNA #358 reported she had the situation under control and got the resident to release her shirt by talking to him. STNA #358 revealed she reported the incident to the nurse working the unit, Registered Nurse (RN) #378, who was an agency nurse. However, the STNA revealed the nurse did not report the incident to any of the administrative staff and TNA #369 continued to work her whole shift, the TNA was not removed from the facility. On 08/31/22 at 4:49 P.M. interview with the Licensed Practical Nurse (LPN), who was the STNA supervisor revealed she received a phone call from STNA #358 on 08/13/22 at approximately 10:20 A.M. notifying her of the alleged abuse involving Resident #222. The LPN revealed she immediately called and spoke with the Director of Nursing (DON) who began an investigation. She verified TNA #369 was not removed from the facility after the incident and continued to work her full shift. On 08/31/22 at 4:58 P.M. an attempt to reach RN #378, the agency nurse who was working at the time of the incident was unsuccessful as the phone number provided was no longer in service. On 09/01/22 at 8:05 A.M. interview with the Administrator verified TNA #369 should have been sent home immediately when the incident was reported by STNA #358 and that RN #378 should have known to contact Administration with a report of alleged abuse at the time it occurred. Review of the punch detail for hours worked by TNA #360 for August 2022 revealed the TNA worked from 6:00 P.M. on 08/12/22 to 6:30 A.M. on 08/13/22. The facility identified 32 additional residents, #1, #7, #9, #10, #12, #13, #15, #18, #21, #30, #34, #30, #36, #40, #43, #44, #45, #47, #49, #51, #55, #56, #58, #59, #61, #62, #66, #67, #71, #231, #232 and #234 residing on the unit where TNA #369 worked on 08/12/22 to 08/13/22. Review of the Resident Abuse Prevention Practices policy, dated September 2019 revealed staff received training which included understanding behaviors of residents which may increase abuse and neglect and reporting any suspected abuse.

Based on interview and record review the facility failed to ensure the physician was notified when Resident #224 missed five doses of her muscle relaxant and for Resident #56's elevated blood sugars. This affected two residents (Resident #56 and #224) out of two residents reviewed for physician notification of change in condition. The facility census was 70. Findings included: 1. Review of the medical record for Resident #56 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 02/07/22 revealed Resident #56 had diabetes. Interventions included medications as ordered, monitor blood sugar per order, monitor, document and record any signs of [CONDITION(S)] including increased thirst, increased appetite, frequent urination, weight loss, fatigue, dry skin, and if breath smells fruity. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 11:00 A.M. and 4:00 P.M. The sliding scale revealed if Resident #56's blood sugar was from 150 to 200 she was to receive two units, from 201 to 250 she was to receive four units, from 251 to 300 she was to receive six units, from 351 to 400 she was to receive 10 units, and 401 and above she was to receive 10 units and the nurse was to call the physician. She also had an order to receive [MEDICATION(S)] insulin solution 10 units SQ at bedtime. Review of nursing notes dated 07/01/22 to 08/29/22 for Resident #56 revealed there was no documentation Primary Care Physician (PCP) #900 was notified on 07/24/22 when Resident #56's blood sugar was 533 and she had refused her routine insulin that was ordered at bedtime. The nursing notes revealed there no documentation that PCP #900 was notified when Resident #56's blood sugar was 450 on 08/13/22 at 4:00 P.M. even though the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing notes also revealed no documentation on 08/28/22 at bedtime that PCP #900 was notified when her blood sugar was 543. Review of July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It was also documented per the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. Resident #56's blood glucose level was checked per Registered Nurse (RN) #340 and was documented as 450. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/28/22 upon bedtime Resident #56's blood sugar was checked per LPN #308 and was 543. Resident #56 received [MEDICATION(S)] 10 units SQ per her routine physician order. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #56 had impaired cognition. She received seven days of insulin during the assessment period. Interview on 08/31/22 at 4:27 P.M. and on 09/01/22 at 8:34 A.M. with the Director of Nursing verified there was no documentation PCP #900 was notified on 07/24/22 at bedtime, 08/13/22 at 4:00 P.M. and 08/28/22 at bedtime when Resident #56's blood sugar was elevated. He verified Resident #56 had a sliding scale order that revealed the nurse was to contact the physician if above 400 and on 08/13/22 at 4:00 P.M. Resident #56's blood sugar was 450. He verified on 07/24/22 at bedtime Resident #56's blood sugar was 533 and she had refused her insulin that was ordered at the same time and on 08/28/22 at bedtime her blood sugar was 543 and revealed he would have expected anytime a resident's blood sugar was above 500 that the nurse would contact the physician as he stated, best practice. Review of facility policy labeled, Change in Condition dated May 2020 revealed the facility would inform the resident and consult with the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status and/ or a need to alter treatment significantly. The policy revealed any sudden or marked change in blood glucose level including below 70 and/ or above or below baseline levels that the nurse was to check the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of medical record for Resident #224 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 12:00 P.M. and 6:00 P.M. and on 08/28/22 at 12:00 A.M. and 6:00 A.M. She missed a total of five doses. Review of admission/ readmission screener dated 08/17/22 and completed per Licensed Practical Nurse (LPN) #308 revealed Resident #224 had pain and it was a five on a pain scale of zero to ten. The assessment revealed she had pain due to the fractures and intermittent sharp shooting throbbing pain that increased with movement and was alleviated with rest. Review of care plan dated 08/21/22 revealed Resident #224 was on pain medication due to fractures in her back, right wrist, [CONDITION(S)], and muscle spasms. Interventions included administer medications as ordered and monitor and document side effects and effectiveness. Review of nursing note dated 08/28/22 at 3:25 P.M. and completed by LPN #329 revealed Resident #224 was out of her [MEDICATION(S)] since 08/26/22 which caused Resident #224 great distress. LPN #329 revealed she had faxed pharmacy 08/27/22 when she discovered Resident #224 needed a refill and the medication was not sent per the pharmacy which again stressed Resident #224 out. LPN #329 assured Resident #224 that she would contact pharmacy and see if they could bring the medication today, 08/28/22. The nursing note revealed the medication was delivered and LPN #329 administered Resident #224 [MEDICATION(S)] immediately which appeared to satisfy her. The nursing note did not include any documentation the Primary Care Physician #900 was notified regarding Resident #224 not having the [MEDICATION(S)] available and of the Resident stating it was causing her great distress Review of Medicare five-day Minimum Data Set (MDS) dated [DATE] was in progress. Interview on 08/29/22 at 3:25 P.M. and on 08/31/22 08:58 A.M. with Resident #224 revealed she recently had a miserable day as the facility did not have her [MEDICATION(S)] for a couple days and that when she does not take that medication her muscle spasms intensify. She revealed the facility just kept saying they were calling pharmacy for the medication but then still never had the medication. She revealed it was just frustrating as when she knows what medications finally help with the muscle spasms and then the facility did not have, or the facility did not call the physician for maybe another medication to be given with her pain medication to help with the muscle spasms. She revealed she was able to take other as needed medications that she had ordered for the pain that had helped with the pain but not he muscle spasms. Interview on 09/01/22 at 8:44 A.M. with the Director of Nursing revealed he was not aware of the incident where Resident #224 missed five doses and of the nursing note that was documented as Resident #224 was in great distress. He revealed LPN #329 should have contacted the physician regarding the missed doses and see if the physician wanted any other medication that could have been potentially in the starter kit. He revealed Resident #224 had received as needed medications including [MEDICATION(S)] 5-325 milligram on 08/27/22 and 08/28/22 and the medication was documented as effective for her pain. Review of facility policy labeled, Pain Management dated January 2016 revealed the facility would manage a resident's pain to the extent as possible in order to help attain is or her highest practicable level of wellbeing. The policy revealed if a resident had ineffective pain management the facility would re-assess the pain, including determination of underlying cause if possible, and notify the resident's physician. Review of facility policy labeled, Change in Condition dated May 2020 revealed the facility would inform the resident and consult with the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status and/ or a need to alter treatment significantly. The policy revealed any sudden or marked change in blood glucose level including below 70 and/ or above or below baseline levels that the nurse was to check the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed any change in resident status that required a potential change to ordered medication and treatment such as resident refusals, and unavailability of ordered medications the physician would be notified. This deficiency substantiates Complaint Number OH 092.

Based on record review, facility Self-Reported Incident (SRI) review and interview the facility failed to prevent the misappropriation of medications for Resident #58 and Resident #122. This affected two residents (#58 and #122) of two residents reviewed for misappropriation of medication. The facility census was 70. Findings Include: Review of the medical record for Resident #58 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #58 had intact cognition. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the closed medical record for Resident #122 revealed an admitted [DATE]. Resident #122 expired on [DATE]. Resident #122 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed Resident #122 had impaired cognition. Record review revealed during his stay, Resident #122 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility SRI, tracking number 8, dated [DATE] revealed the facility was informed by a local enforcement agency on [DATE] that medications had been taken from the facility. The SRI revealed the husband of Alleged Perpetrator (AP) #500 (facility employee) was observed with medication cards in their home for residents (#58 and #122) who resided in the facility where AP #500 currently worked and contacted the agency. The agency contacted the facility and the medication cards were returned to the facility on [DATE] and subsequently destroyed by the facility. Review of the returned medication cards by the facility revealed two empty cards of 30 tablets of [MEDICATION(S)] (muscle relaxer) four milligrams (mg) and one card with three remaining tablets. There were three cards of 30 tablets of [MEDICATION(S)] (anticonvulsant/pain) 300 mg that were empty as well. The medication cards were labeled for Resident #58 and Resident #122. A facility investigation revealed the medication cards were for medications that had been previously discontinued for Resident #58 and #122. At the time the medications were discontinued, they should have been returned to the pharmacy. However, it was concluded that AP #500 had instead taken them. On [DATE] at 4:43 P.M. interview with Corporate Quality Assurance Nurse (QAN) and the Director of Nursing (DON) revealed the facility received a call from local enforcement informing them they had found medications belonging to facility residents in the home of a facility employee. QAN revealed the medications taken by the employee were medications that were being sent back to the pharmacy. Following the incident, the QAN revealed all medication carts were reviewed and all residents were interviewed with no additional concerns identified.

Based on record review, observation and interview, the facility failed to ensure medications were administered at the time they were prepared per professional standards. This affected two residents (Resident #16 and #17) of six Residents reviewed for medication administration. The facility census was 70. Finding included: Review of Licensed Practical Nurse (LPN) #320's personnel file revealed a date of hire of 06/28/13. There was no education and/ or disciplinary action revealed in her file regarding the concern of preparing medications in advance or leaving medications in rooms unattended. 1. Review of medical record for Resident #17 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of person-centered plan of care dated 07/31/20 revealed there was nothing in her care plan regarding Resident #17 having a preference that she received her medication at the same time as Resident #16. Review of annual Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had intact cognition. 2. Review of medical record for Resident #16 revealed an admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of person-centered plan of care dated 02/10/22 revealed there was nothing in her care plan regarding Resident #16 having a preference that she received her medications at the same time as Resident #17. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had intact cognition. Observation on 08/30/22 at 8:20 A.M. revealed LPN #320 had two medications cups unlabeled sitting on her medication cart that contained nine tablets and/ or capsules in the one cup and 12 tablets in the other. Interview on 08/30/22 at 8:20 A.M. with LPN #320 revealed she knew she was not supposed to but that she prepared Resident #16 and Resident #17's medications at the same time, and then goes into their room and gives both residents their medications at the same time. She revealed that she did it this way because both residents, Residents #16 and #17 requested that she gives their medications at the same time. Observation on 08/30/22 at 8:29 A.M. with LPN #320 verified the one cup contained nine tablets and/ or capsules for Resident #17 that included: [MEDICATION(S)] 100 mg (milligram) tablet for gout, [MEDICATION(S)] 25 mg tablet half tablet to equal 12.5 mg tablet for hypertension, [MEDICATION(S)] 2000 units tablet for vitamin D deficiency, potassium 20 milliequivalent (meq) tablet for low potassium, [MEDICATION(S)] 100 mg tablet for vitamin B deficiency, [MEDICATION(S)] 20 mg half tablet to equal 10 mg for hypertension, Vitamin B 12 1000 (microgram) mcg tablet, lactobacillus one capsule for health maintenance, and [MEDICATION(S)] (vitamin B 6) 50 mg tablet. LPN #320 then administered Resident #17 her medications. Observation on 08/30/22 at 8:36 A.M. with LPN #320 verified the other cup contained twelve tablets for Resident #16 that included: two tablets of [MEDICATION(S)] 1 mg for [MEDICATION(S)] deficiency, [MEDICATION(S)] 400 mg tablet as a supplement, [MEDICATION(S)] delayed release 40 mg tablet for GERD, potassium chloride extended release 20 meq tablet, vitamin B 12 2500mcq tablet, vitamin D 3 25 mcg tablet, [MEDICATION(S)] 100 mg tablet for depression, [MEDICATION(S)] 750 mg tablet for convulsions, [MEDICATION(S)] 25 mg tablet for hypertension, [MEDICATION(S)] 10 mg half tablet to equal 5 mg for muscle spasms, and [MEDICATION(S)] 300 mg tablet for pain. LPN #320 then administered Resident #16 her medications. Interview on 08/31/22 at 8:38 A.M. with LPN #320 verified she should not have prepared Resident #16 and Resident #17's medications at the same time as she stated, I should give one at a time as that is how mistakes can happen. Interview on 08/30/22 at 9:09 A.M. with State tested Nursing Assistant (STNA) #304 revealed she had witnessed on several occasions nurses preparing medications in advance. She revealed she had seen several agency nurses and LPN #320 prepare residents medications by putting resident's medications into separate medication cups and placing initials on the cups. She revealed the nurses would have the medication cups lined up on the medication cart. She revealed she was concerned as she had witnessed residents attempting to grab the medication cups off the medication carts. She revealed she felt LPN #320 pre-poured the medications every time she worked. She also revealed LPN #320 would place the medication cups in the residents' rooms without observing the residents take their medications as she found several cups with medication still in the cups in residents' rooms when LPN #320 worked. She revealed she had brought up the concerns to management including the Director of Nursing. Interview on 08/30/22 at 9:12 A.M. with STNA #331 revealed she had witnessed nurses pre-pouring medications as they have multiple medication cups lined up across their medication cart. She revealed she had witnessed LPN #320 pre-pour medications multiple times as well as she revealed some agency nurses. She revealed she had found medication cups in residents' rooms with medication in the cup as the nurses including LPN #320 did not ensure that the resident took their medications. She revealed she had brought the Director of Nursing the medication cups with the medication inside the cup anytime she found cups of medication in a resident's room and that she had reported the nurses pre-pouring medications. She revealed the nurses including LPN #320 continued to pre-pour and leave medication in resident's rooms after she had reported the concern. Interview on 08/31/22 at 8:24 A.M. with Director of Nursing revealed staff had reported to him multiple occasions regarding nurses including LPN #320 pre-pouring medications. He revealed he had educated LPN #320 verbally but did not have anything in writing regarding the education that he had given LPN #320. He revealed the last time he had educated LPN #320 was approximately one month ago and that he had stated to LPN #320 that preparing medication in advance was an unacceptable practice at the facility and that she was to administer one resident at a time their medications. He revealed no residents to his knowledge had a preference of receiving their medications at the same time and that medications should be prepared one resident at a time for all residents including Resident #16 and Resident #17. Interview on 08/31/22 at 3:46 P.M. with Resident #17 revealed she did not have a preference of when she got her medications including any preference that she had to receive her medication at the same time as her roommate, Resident #16. Interview on 08/31/22 at 3:50 P.M. with Resident #16 revealed she did not have a preference of when she got her medications including any preference that she had to receive her medication at the same time as her roommate, Resident #17. Review of pharmacy manual that included undated policy labeled, Preparation for Medication Administration revealed medication were to be administered at the time they were prepared, and medications were not to be pre-poured. This deficiency substantiates Complaint Number OH 092 and Complaint Number OH 605.

Based on observation, record review and interview the facility failed to accurately document the intakes of nutritional supplements as ordered by the physician for four of four residents reviewed for nutrition (Resident #10, Resident #22, Resident #40 and Resident #55). The facility census was 69. Findings include: 1. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 08/23/19 indicated the resident was at risk for weight loss. She had a physician's orders [REDACTED]. Review of documentation for the intakes of the supplements from 08/20/19 through 09/17/19 revealed the supplements were only documented for two meals on 08/20/19, 08/22/19, 08/23/19, 08/24/19, 08/29/19, 08/31/19, 09/01/19, 09/02/19, 09/03/19, 09/08/19, 9/10/19, 09/11/19, 09/14/19, 09/15/19 and 09/17/19 and for only one meal on 09/09/19. This concern was verified with Registered Dietician/Licensed Dietician (RDLD) #100 on 09/18/19 at 12:35 P.M. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The care plan dated 06/20/19 indicated the resident was at risk for weight loss. Dietary notes dated 08/16/19 indicated the resident had a significant weight loss of 4.64 percent for one month and had variable meal intakes. The resident had a physician order [REDACTED]. Review of documentation for the intakes of the supplement from 09/01/19 through 09/17/19 revealed the supplements were only documented one time on 09/02/19, 09/04/19, 09/05/19, 09/06/19, 09/08/19, 09/10/19, 09/11/19, 09/12/19 and 09/17/19 and were not documented at all on 09/01/19, 09/03/19, 09/07/19, 09/13/19, 09/14/19 and 09/15/19. This concern was verified with RDLD #100 on 09/18/19 at 12:40 P.M. 3. Record review for Resident #40 revealed she was admitted to facility on 01/10/11 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. State tested Nursing Assistants (STNAs) to record percentage consumed in plan of care (P[NAME]) with meal documentation. This start date of this order was 07/27/19. Observation on 09/18/19 at 12:09 P.M. during tray line service revealed the house supplement being placed on the lunch tray for Resident #40. The staff who delivered the tray, opened and poured the contents into a cup. The house supplement was delivered to her. Observation on 09/19/19 at 12:28 PM revealed Resident #40 in the dining room. She had a cup on her tray with the house supplement, some of which had been consumed. Review of nutrition tracking for Resident #40, from 08/20/19 through 09/17/19, revealed the house supplement was not offered on six days; 08/23/19, 08/25/19, 08/31/19, 09/01/19, 09/08/19, and 09/16/19. Interview on 09/19/19 at 12:35 P.M. with Registered Nurse (RN) #105 confirmed Resident #40 was documented as not receiving the supplements. He confirmed the kitchen rarely runs out of nutritional supplements and there is always an alternative to be given. 4. Clinical record review for Resident #55 revealed she was admitted to facility on 12/10/18 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. STNAs were to record percentage consumed in the plan of care (P[NAME]) with meal documentation. The start date was 05/30/19. Observation on 09/18/19 at 12:35 P.M. during tray line service revealed the nutritious juice was placed on the lunch tray for Resident #55. Observation on 09/19/19 at 12:54 P.M. revealed Resident #55 in her room during lunch. She had a full cup on her tray with the nutritious juice. None had been consumed. Review of nutrition tracking for Resident #55, from 08/20/19 through 09/17/19, revealed the nutritious juice was not offered one of three times for eight days; 08/25/19, 08/26/19, 08/27/19, 09/03/19, 09/06/19, 09/07/19, 09/13/19, and 09/15/19. It was not offered for two of three times for four days; 08/20/19, 09/01/19, 09/14/19, and 09/16/19. Interview on 09/19/19 at 12:35 P.M. with RN #105 confirmed Resident #55's supplements were not documented as provided. He confirmed the kitchen rarely runs out of nutritional supplements and there is always an alternative to be given.

Based on medical record review, resident and staff interviews, review of the American Diabetes Association guidelines, Med Scape.com (internet-based medication reference) and review of facility policies, the facility failed to ensure necessary care and services were provided for one resident (Resident #56) related to consistent monitoring of blood sugars and meal intakes, administration of insulin as ordered and notification of the physician for significantly low or high blood sugars. This resulted in Immediate Jeopardy when Resident #56 was found lethargic and diaphoretic, with a critically low blood sugar level of 31 milligrams per deciliter (mg/dL). The nurse failed to ensure the resident's physician was notified. This resulted in actual harm when two additional episodes of symptomatic [DIAGNOSES REDACTED] (low blood sugar) occurred with subsequent hospitalization of the resident. The facility identified 16 residents having diabetes and requiring blood sugar monitoring (Residents #1, #2, #4, #12, #17, #19, #26, #38, #40, #46, #47, #50, #56, #213, #262 and #315). The facility census was 66. On 07/26/18 at 2:10 P.M., the Administrator, Director of Nursing (DON) and Corporate Registered Nurse (RN) #108 were notified Immediate Jeopardy began on 05/17/18 at 12:10 A.M. when Resident #56 was found lethargic and diaphoretic with a blood sugar of 31. One dose of [MEDICATION NAME] (an injection used to treat low blood sugar) was given and at 12:25 A.M. the blood sugar was 50. The resident remained lethargic and diaphoretic and a second [MEDICATION NAME] injection was given. At 12:50 A.M. the resident's blood sugar was 92. There was no evidence the resident's physician was notified of the critically low blood sugar and the need for treatment with two doses of [MEDICATION NAME]. The Immediate Jeopardy was removed 07/27/18 when the facility implemented the following corrective actions: * On 07/26/18 at 3:15 P.M., Resident #56 and 15 residents with a [DIAGNOSES REDACTED].#1, #2, #4, #12, #17, #19, #26, #38, #40, #46, #47, #50, #213, #262 and #315) who received insulin or required blood sugar monitoring, were reviewed for accuracy and completion of blood sugar checks and/or administration of insulin by the DON, Clinical Director Registered Nurse (RN) #131 and RN #108. * On 07/26/18, the DON and Medical Doctor (MD) #128 clarified existing orders for administration of [MEDICATION NAME] for Resident #56 and established new guidelines/parameters pertaining to notification of the physician of hypoglycemic (low blood sugar) episodes. * On 07/26/18, the DON established a new Medication Administration Record [REDACTED]. The new MAR indicated [REDACTED]. * On 07/26/18 at 3:15 P.M., the MARs for the other 15 residents ordered insulin or blood sugar checks were reviewed by RN #108 and changed for clarity if needed. * On 07/26/18 at 3:15 P.M., the Medical Director, MD #129 was notified of the concerns by the DON and the concerns were introduced to the Quality Assurance (QA) committee. * On 07/26/18, new communication tools were created by the DON to facilitate improved communication between the facility, the [MEDICAL TREATMENT] center and the workshop attended by the resident regarding checking blood sugars and meal intakes for Resident #56. The new communication form for the workshop was sent with Resident #56 on 07/27/18 and the new communication form for the [MEDICAL TREATMENT] center would go with the resident to [MEDICAL TREATMENT] on 07/28/18. No other insulin dependent residents attended either workshop or [MEDICAL TREATMENT]. * On 07/26/18 at 3:45 P.M., all licensed nurses (ten RNs and 12 Licensed Practical Nurses (LPN) were in-serviced on Resident #56's complex diabetic issues and changes in communication forms for [MEDICAL TREATMENT] and workshop. They were also educated on the need to record all dietary intakes, ordered blood sugar checks and all insulin administration, for all diabetic residents. Nurses were also educated on notification of change and when to contact physicians to communicate changes. This education was completed by the DON, RN #131, and Corporate Nurse, RN #127. All licensed nurses were in serviced, either in person or by phone. Staff who were educated by phone would receive written materials prior to their first worked shift. * On 07/26/18 at 4:00 P.M., all 22 state tested nursing assistants (STNA) were educated on consistent documentation of meal intakes by the STNA coordinator (STNA #133). All STNAs were in serviced, either in person or by phone. Staff who were educated by phone would receive written materials prior to their first worked shift. * On 07/27/18, all 15 residents who were diagnosed with [REDACTED].#108. * On 07/27/18 at 6:00 A.M., all licensed nurses were educated on documentation, including documentation of blood sugars, insulin administration and meal intakes. They were also educated on signs and symptoms of low and elevated blood sugar and the new communication tools for workshop and the [MEDICAL TREATMENT] center attended by Resident #56. This education was completed by the DON, RN #127 and RN #131. All nurses were educated either in person or by phone. Staff who were educated by phone would receive written materials prior to their first worked shift. * On 07/27/18 at 8:30 A.M., the DON communicated to the [MEDICAL TREATMENT] center and workshop attended by Resident #56 the need to educate their nurses on the new communication tools and the need to complete the forms daily when the resident attended their facility. * On 07/27/18 at 6:00 A.M., STNA #133 in serviced nursing assistants on the signs and symptoms of low and elevated blood sugar. All STNAs were in serviced, either in person or by phone. Staff who were educated by phone would receive written materials prior to their first worked shift. * On 07/27/18, daily audits of residents with insulin orders and blood sugar checks were started to ensure accurate and consistent recording of blood sugar results, insulin administration, meal intakes, need for [MEDICATION NAME] or instant glucose and physician notification of change of condition for diabetic residents. The audits were completed by the DON, RN #131 and RN #108 and would be completed daily for 30 days. * After 30 days, the audits would be reviewed by the QA committee with the need and frequency of on-going audits determined. * On 07/27/18, between 12:30 P.M. and 2:00 P.M., blood sugars for seven current diabetic residents (Residents #2, #12, #17, #40, #46, #56 and #315) were reviewed for the 7:30 A.M. and 11:30 A.M. checks and confirmed the facility was monitoring the blood sugars and providing the required notifications and treatments as ordered. * Interviews on 07/27/18 between 12:30 P.M. and 2:00 P.M., with LPN #109, #111 and #112 and RN #113, verified education by the facility on notification of changes in condition by a licensed nurse and proper procedures regarding documentation of blood sugars, meal intakes and insulin administration. All staff were able to correctly verbalize knowledge of the communication changes regarding Resident #56 related to the [MEDICAL TREATMENT] center and workshop. * Interviews on 07/27/18 between 12:30 P.M. and 2:00 P.M. with STNA #114, #115, #116, #117, #118 and #119 revealed they had received education on documentation of meal intakes and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. * On 07/30/18, the facility policy for Change of Condition was updated by Corporate Nurse, RN #130 to include blood sugar levels below 70 mg/dL or above or below baseline levels as a marked change that would require appropriate care, documentation and physician notification. * On 07/30/18, a facility policy for Assessment for Changes in Blood Glucose Levels was developed by RN #130 to incorporate previous policies. * On 07/30/18, education began for all licensed nurses regarding the new change of condition policy and policy for assessment in changes in blood glucose levels. The education would be conducted by the DON and RN #127. Although the Immediate Jeopardy was removed, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Record review revealed Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] revealed the resident was cognitively intact, but did exhibit verbal behaviors, including yelling, threatening or cursing at others. He required limited to extensive assistance of one staff member for all activities of daily living. Review of Resident #56's diabetes care plan, revised 06/27/18, revealed the resident was at risk for low and elevated blood sugars and was non-compliant with his diet and medication regimen. The goal was for the resident to be free from unstable blood sugars. Interventions included monitoring for signs and symptoms of unstable blood sugars such as tremors, shaking, confusion, headache, irritability, hunger, nausea, clammy or pale skin and sweating. Symptoms would be reported to the physician. Oral medications and insulin would be administered, blood sugars checked, and meal intakes monitored as ordered. Supplements and substitutes would be offered to ensure adequate intake for dinner and a snack was to be provided at bedtime. Resident #56 was seen by his endocrinologist (a physician who treats diabetes) on 11/29/17 and also in (MONTH) (YEAR). His insulin was reviewed and adjusted. A social service note dated 03/19/18 indicated the resident's father (his guardian) was aware of the resident's medical condition, expected decline and blood sugar fluctuations. Review of physician's orders revealed on 03/17/18, Resident #56 was ordered a routine dose of seven units of [MEDICATION NAME]100 units/milliliter (a long acting insulin) every evening at 8:00 P.M. His blood sugar was to be checked every day at 5:00 A.M. with no orders for insulin at that time. Resident #56 was to have his blood sugar checked daily at 7:00 A.M., 11:00 A.M. and 6:00 P.M. (before meals) and receive [MEDICATION NAME] (fast acting insulin) based on the results of the blood sugar check and on the percentage of food that he ate at the meal. If his blood sugar was over 500, the physician was to be notified. Resident #56's blood sugar was also to be checked two hours after the resident finished eating (10:00 A.M., 2:00 P.M. and 8:00 P.M.) as well as 2:00 A.M. Based on the blood sugar result, the resident would receive coverage with [MEDICATION NAME] insulin. Other orders dated 03/17/18 revealed the nurse was to verify the percentage of all meal intakes including calling the [MEDICAL TREATMENT] center and workshop for meal intake information while at their facility. The staff was to ensure Resident #56 got his snack at bedtime. Resident #56 had an order dated 03/17/18 for [MEDICATION NAME] (used to treat symptoms of severe low blood sugar) by injection if the blood sugar was less than 50 and the resident was unresponsive. The blood sugar was to be rechecked in 15-20 minutes after giving [MEDICATION NAME] and the physician was to be notified if it was ineffective. An order dated 04/06/18 revealed if the blood sugar was less than 50 and the resident was responsive, one tube of instant glucose (a concentrated sugar in gel form that can be given by mouth to increase the blood sugar) should be administered. The blood sugar should be rechecked 15-30 minutes after the instant glucose and the physician notified if it was ineffective. Review of physician progress notes [REDACTED].#128, on 04/09/18. The note repeated his orders for insulin, both routine and sliding scale (a varied dose of insulin ordered based on blood sugar levels, often called coverage) and did not indicate any concerns related to blood sugar levels Review of nursing notes on 04/02/18, 04/06/18, 05/06/18 and 05/10/18 revealed Resident #56 had low blood sugars and received either a dose of instant glucose or [MEDICATION NAME]. His blood sugar responded to the medications and increased to normal levels. Review of the Medication Administration Record [REDACTED].M. was not marked, only initialed, with no indication of the blood sugar level or any insulin given. Nurses notes dated 05/17/18 revealed Resident #56 was found lethargic, diaphoretic, opening eyes. His blood sugar was 31. One dose of [MEDICATION NAME] was given at 12:10 A.M. Resident #56's blood sugar was rechecked at 12:25 A.M. and was 50. The resident remained lethargic and diaphoretic. A second [MEDICATION NAME] injection was given. The resident was then awake, able to answer questions, was oriented to himself and surroundings and was drinking juice. His blood sugar was 92. A note on 05/17/18 at 1:30 A.M. indicated Resident #56 was resting in bed, was alert and oriented and his blood sugar was 108. There was no indication the resident's physician was notified of the low blood sugars and need for two doses of [MEDICATION NAME]. On 07/25/18 at 4:20 P.M. phone interview with LPN #110 revealed she provided care to Resident #56 on the night of 05/17/18. She was notified Resident #56 was not responsive and administered [MEDICATION NAME] after checking his blood sugar. She verified the order for [MEDICATION NAME] indicated the physician should be notified if the dose was ineffective but stated she knew Resident #56 and administered the second dose of [MEDICATION NAME] using nursing judgment. She verified she did not notify the physician because the blood sugar was going up. She stated she would have only called the physician if the resident had not responded at all after 15 minutes. She did verify the order indicated to call the physician and did not specify the [MEDICATION NAME] should be repeated. Review of the nursing notes for 05/17/18 through 05/23/18 did not reveal any documentation regarding notification of the physician or other concerns related to Resident #56's blood sugar. Review of the MAR indicated [REDACTED].M. Resident #56's blood sugar was 234, and at 7:00 A.M. it was 199 with no evidence of meal intake or of any insulin administration. On 05/23/18 at 6:00 P.M. the blood sugar was 144. There was no indication of how much Resident #56 ate, of any recheck or any insulin administration. His blood sugar at 8:00 P.M. was 184 and no insulin was needed. Interview with LPN #126 on 07/30/18 at 4:35 P.M. revealed she was the nurse who checked Resident #56's blood sugar on 05/23/18 at 7:00 A.M. (199) and at 6:00 P.M. (144). She verified the record did not indicate if he ate his meals or required insulin coverage. She stated it was difficult to monitor the resident's intake, as he sometimes ate things he got out of the vending machine rather than what was on his tray. She could not remember if she'd given the resident any insulin on 05/23/18. Review of the MAR for 05/23/18 revealed the resident received [MEDICATION NAME] at 11:20 P.M. for a blood sugar of 26. Nurses' medication notes indicated his blood sugar increased to 33, instant glucose was given, and the blood sugar increased to 77 at 11:45 P.M. The note then indicated the resident was given another dose of [MEDICATION NAME] at that time. There were no nursing notes or other assessment found regarding the condition of the resident when he was found with the low blood sugar on 05/23/18 at 11:20 P.M. Interview with the DON on 07/25/18 at 1:40 P.M. revealed LPN #121, who gave the [MEDICATION NAME] on 05/23/18, no longer worked at the facility. The DON verified there was no information about why the resident received another dose of [MEDICATION NAME] at 11:45 P.M. when his blood sugar was 77. A phone call to LPN #121 on 07/25/18 at 3:57 P.M. was not answered. Phone interview with STNA #123 on 07/30/18 at 4:30 P.M. revealed she worked the night shift on 05/23/18. Around 11:15 P.M. she found Resident #56 in his room, cold and clammy and slumped in his chair. She called his name and shook his arm but he did not respond. She called for LPN #121, who gave him at least one shot and something from a tube, and he finally started to respond. She did not know if the physician had been notified. Review of nursing notes revealed no entries between 05/20/18 and 05/26/18. Review of the MAR indicated [REDACTED].M. was 368, and at 7:00 A.M. it was 522. There was no evidence of the resident's meal intake, any insulin administration or that the physician was notified. Review of the MAR for 05/27/18 revealed a blood sugar recorded in the 11:00 A.M. space in the MAR, but was marked as 2:00 P.M. The note indicated the resident's blood sugar was 258 with three units of insulin administered. There was no indication of the resident's meal intake. On 07/25/18 at 1:40 P.M. the DON verified the documentation on 05/27/18 for 11:00 and/or 2:00 P.M. was unclear regarding the time the insulin dose was administered. She verified the insulin was administered in error if it was given as a result of the blood sugar check at 2:00 P.M. She also verified if the insulin was given correctly after the resident did not eat lunch, there was no evidence the resident's blood sugar was checked at 2:00 P.M. as ordered. Nursing notes dated 05/27/18 at 4:00 P.M. revealed LPN #109 was called to the shower room for a change in Resident #56's condition. The resident's blood sugar was 20, he was unresponsive, and [MEDICATION NAME] was given. His blood sugar was rechecked and read lo (less than 20 mg/dL) and 911 was called. The physician was notified and a second injection of [MEDICATION NAME] was given. Emergency medical services (EMS) arrived, and Resident #56 was stabilized. The resident was transferred to the local emergency room and admitted with a [DIAGNOSES REDACTED]. On 07/26/18 at 12:00 P.M. interview with STNA #120 revealed on 05/27/18 she was assisting Resident #56 with his shower and was waiting behind the curtain, when she heard the shower head fall to the floor. When the resident did not pick it up or call for assistance, she looked around the curtain and saw the resident was unresponsive. She put the call light on, yelled for help, and the nurse arrived quickly. On 07/26/18 at 8:40 A.M. interview with LPN #109 revealed she was working on 05/27/18. Another nurse was assigned to Resident #56, but she was called to the unit when the resident became unresponsive in the shower. His blood sugar when checked read 20. LPN #109 gave the resident a [MEDICATION NAME] injection and when the blood sugar did not improve and read lo, she called the physician and EMS. LPN #109 then gave a second injection of [MEDICATION NAME]. By the time EMS arrived, the resident was more responsive and able to answer questions. Review of the notes from the hospital history and physical dated 05//27/18 revealed Resident #56 was admitted on [DATE] after he was found to be hypoglycemic (low blood sugar) at 55. The notes indicated Resident #56 was given [MEDICATION NAME], which increased the blood sugar to 74 and the only meal the resident had that day was breakfast. Resident #56 was admitted for further evaluation and treatment of [REDACTED]. He returned to the facility on [DATE] with his long acting night time insulin dose of [MEDICATION NAME] changed to a morning dose. Review of Resident #56's record revealed no further hypoglycemic episodes from 05/29/18 through 07/27/18. On 07/26/18 at 8:01 A.M. Resident #56 was observed sitting at the bedside with his breakfast in front of him. He had asked staff to bring him some hot water for tea and was waiting for the hot water before eating his breakfast which included a donut, a piece of sausage, and some other unidentified items in bowls. He was pleasant and stated he was excited to go to workshop that day, because he liked the work he did there. When asked, he admitted his blood sugar could be low at times. When asked if felt different when his blood sugar was low, he said he started to get a headache and would cuss at the staff. He stated he also got double vision. He remembered going to the hospital after his blood sugar was low in the shower, referring to 05/27/18 and verified he understood it was important to eat his meals to maintain his blood sugar. An interview with the resident's physician, MD #128 on 07/26/18 at 9:20 A.M. revealed the resident's orders had been changed in (MONTH) (YEAR) after review and input from the endocrinologist. The resident been hospitalized for [REDACTED]. He verified the resident had hypoglycemic episodes in the past and had received instant glucose or [MEDICATION NAME] injections on 04/02/18, 04/06/18, 05/06/18 and 05/10/18. However, on those dates the resident had responded to one dose of the medication and he would not have expected to be notified of those episodes. MD #128 stated he was unaware Resident #56's low blood sugar episodes on 05/17/18 and 05/23/18. He checked his phone and verified he had not received phone calls from the facility on those dates at times that would indicate he had been notified. MD #128 verified his orders indicated he should have been notified when the resident did not respond to one dose of the instant glucose or the [MEDICATION NAME] on 05/17/18 or 05/23/18. MD #128 also verified the resident's blood sugar was over 500 on 05/27/18 at 7:00 A.M. and he should have been notified of this level as ordered to provide guidance on the amount of insulin to be administered. He stated if he had been aware of the resident's hypoglycemic episodes, he would have checked for the next scheduled appointment with the resident's endocrinologist to possibly explore changes in the resident's insulin dosing. MD #128 verified the blood sugars, meal intakes and insulin administration prior to the hypoglycemic episodes revealed incomplete monitoring of meal intakes and corresponding insulin coverage, as well as lack of documentation of symptoms experienced by the resident when his blood sugars were low. MD #128 verified blood sugars should remain as stable as possible. Large fluctuations in blood sugar levels should be avoided, and hypoglycemic episodes could lead to serious medical complications, including death. Review of the facility policy on Change of Condition, dated (MONTH) (YEAR), revealed the resident's physician should be notified when the resident experiences a change in condition and that an assessment of symptoms, treatments, the physician orders and notifications should be documented. Changes of condition included any sudden or marked change in vital signs, behavior (including lethargy) or level of consciousness. Review of the facility policy for Blood Glucose Monitoring, dated (MONTH) (YEAR), did not include specific guidelines for levels of blood sugars. The policy indicated blood glucose levels for residents with diabetes vary, depending on food intake, insulin dose and exercise, and target glucose levels should be established by the resident's attending physician. Review of the facility policy on Percentage of Foods Consumed, dated (MONTH) 2010, revealed nursing staff would record the percentage of meals consumed by each resident after each meal. According to current medical professional references (www. Medscape.com), blood glucose should be maintained at near-normal levels. The recommended fasting blood sugar of pre-prandial (before meal) should be within levels of 90-130 mg/dL. According to the American Diabetes Association (www.diabetes.org<http://www.diabetes.org>), older and frail adults are at increased risk for [DIAGNOSES REDACTED]. Some of the effecting factors include impaired renal function, slower hormonal metabolism and gastrointestinal absorption, polypharmacy, as well as variable oral intake and activity levels. Therefore, the risk for [DIAGNOSES REDACTED] is paramount in establishing the treatment goals for diabetes among patients in long-term care and skilled nursing facilities. Severe and/or persistent [MEDICAL CONDITION] can increase the risks for dehydration, urinary incontinence, falls and electrolyte imbalances. treatment of [REDACTED]. Glycemic control among facility residents is recommended as pre-meal target glucose levels of 80-130 mg/dL and post-meal glucose level of less than 180 mg/dL.

Based on observation, record review, and interview the facility failed to provide appropriate staff supervision for one resident (Resident #39) during toileting, resulting in a fall. Actual harm occurred when Resident #39 fell to the floor when she attempted to self-transfer off the toilet without staff supervision. Resident #39 was sent to the hospital and diagnosed with [REDACTED]. The facility census was 66. Findings include: Review of Resident #39's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment and required extensive assistance of two staff for transfers and toileting. Review of Resident #39's plan of care revealed the resident was at risk for falls due to her dementia [DIAGNOSES REDACTED]. Review of nurses' notes revealed on 06/05/18 Resident #39 was found on the bathroom floor face down on her left side with a nosebleed. Resident #39 was sent to the hospital on [DATE] for a computed tomography (CT) scan of her head due to her [MEDICATION NAME] (blood thinning medication) use. Resident #39 returned to the facility on [DATE] and was sent back to the hospital after increased right leg and ankle swelling. X-rays and hospital records on 06/06/18 indicated an acute [MEDICAL CONDITION] fibula. A review of the facility fall investigation from the 06/05/18 incident revealed Resident #39 was using the toilet with her wheelchair and sonic alarm pushed away from the doorway. Resident #39 attempted to self-transfer off the toilet, and was found on the floor on her left side. The investigation verified Resident #39 was unattended on the toilet when she fell and indicated State tested Nurse Aide (STNA) #102 and STNA #106 witnessed the fall. Observations on 07/23/18 at 3:11 P.M., 07/23/18 at 4:11 P.M., 07/24/18 at 3:02 P.M. and 07/25/18 at 11:32 A.M. revealed Resident #39 laying down in bed. The resident was only observed to be up in her wheelchair for meals, which was observed on 07/24/18 at 12:34 P.M., 07/25/18 at 12:43 P.M. and 07/26/18 at 8:54 A.M. Interview with the representative of Resident #39 on 07/23/18 at 5:13 P.M. revealed Resident #39 fell and had a fracture since staff were not in the bathroom with her. The representative stated Resident #39 was up in her wheelchair frequently before the fracture but now was in bed often as she was a hassle for staff to get up now. Interview on 07/25/18 at 11:35 A.M. with Licensed Practical Nurse (LPN) #101 revealed she was the nurse on duty at the time of Resident #39's fall. LPN #101 verified staff should have been supervising Resident #39 when she was in the bathroom. Interview on 07/25/18 at 4:47 P.M. with STNA #102 revealed she was working when Resident #39 fell . STNA #102 reported STNA #106 and STNA #107 put Resident #39 on the toilet. STNA #102 also reported STNA #107 told STNA #106 (Resident #39) will ring (the bell) when she is done before leaving the resident's room. STNA #102 shared Resident #39 was not able to comprehend using her call light to indicate she was done using the toilet, and reiterated staff were not to leave a resident alone on the toilet if they required a chair alarm. Interview on 07/27/18 at 10:32 A.M. with the Director of Nursing (DON) verified any resident with an alarm should not be left unsupervised in the bathroom. The DON acknowledged the facility policy should have had further guidance regarding residents with alarms. Review of the facility policy, Assessment, Fall Prevention, and Fall Protocol, revised (MONTH) (YEAR), was silent to any supervision guidelines for residents requiring alarms on assistive devices.

Based on interview and record review, the facility failed to ensure residents were receiving all of the restorative nursing services and care as documented in the resident's records. This effected three Residents (#2, #27, and #46)of three residents reviewed for restorative nursing care. The facility census was 66. Finding include 1. Review of the medical record for the Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #2 was cognitively intact and required limited assistance with bed mobility, transfers, and personal hygiene. He required extensive assistance with dressing and toilet use. He used a wheelchair and needed assistance with bathing. Review of assessment for restorative nursing care dated 07/03/18 revealed Resident #2 was referred to the restorative nursing program through a therapy referral. Resident #2 had 50 to 100 percent range of motion to bilateral upper and lower extremities, and did not want to participate in a restorative program on weekends. The program for Resident #2 was active range of motion three to seven days per week for 15 to 20 minutes per day. Active range of motion exercises to bilateral upper extremities of all joints and planes using two pound barbell; two sets of 20 repetitions, and active range of motion exercises to bilateral lower extremities all planes using two pound weights for two sets of 20 repetitions. Also, Resident #2 required limited assistance of one staff for supervision for transfers and expressed fears of attempting to ambulate due to knees buckling. Resident #2 did not want to attempt an ambulation program. The program included transfers three to seven days per week for 15 to 20 minutes per day. Plan to prompt and assist resident to perform sit to stand transfers at bar, encourage resident to increase amount of time standing, and to cue for safety as needed. Reviews of restorative nursing documentation for (MONTH) (YEAR) reveals, on 07/04/18, 07/10/18, 07/11/18, 07/12/18, and 07/13/18, Resident #2 received 15 minutes of active range of motion exercises and prompts for transfers to stand for between three minutes and six minutes. No other evidence of restorative care was documented . Interview on 07/27/18 at 10:41 A.M. with Resident #2 revealed he had not been receiving any restorative nursing care for the past couple of weeks. Resident #2 stated he was told he had not been getting restorative care because of a lack of staffing at the facility. He stated he was told the restorative aids were working as floor aides, and they did not have time to provide him any restorative care. He stated he had only been provided with assistance with toileting and bathing. He had not had anyone to assist him with standing or range of motion exercises. He stated he transferred from chair to bed and back independently and performed most other tasks independently. He had not had any problems with his transfers since Easter time when he fell . He stated he would like to keep receiving restorative care because he was fearful of falling and can't visit his children because they cannot assist him in their homes. 2. Review of medical records for Resident #27 revealed, on 06/27/13, Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed Resident #27 was cognitively intact. She required supervision with walking in the corridor, and was independent with all other activities of daily living (ADL). Review of restorative nursing assessment dated [DATE] revealed Resident #27 required assistance with ambulation six to seven days per week for 15 to 20 minutes per day. The resident was to ambulate with a walker for greater than 300 feet. Review of restorative nursing documentation dated 05/21/18 revealed resident #27 was able to perform her own ADL with oversight and/or independently. Restorative nursing program plan included active range of motion six to seven days per week for 15 to 20 minutes per day using three pound weights to upper and lower extremities; and resident was to ambulate 300 feet with a walker and supervision. Documentation for (MONTH) (YEAR) reveals, on 07/01/18, 07/04/18, 07/10/18, 07/11/18, 07/12/18, and 07/13/18, Resident #27 received active range of motion exercises and assistance with walking. No other documentation was provided for the restorative program. Interview on 07/27/18 at 1:34 P.M. with Resident #27 revealed she had not been receiving any restorative nursing care for the past couple of weeks. She stated she was told there was no restorative nursing care because of a lack of staffing to provide the restorative care. She stated the restorative nurses usually walked her with her walker and were there to monitor her. She stated, recently, she has been walking independently, but fears she may have a [MEDICAL CONDITION] while walking and may fall. 3. Record review for Resident #46 revealed, on 06/06/18, Resident #46 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed moderate cognitive impairment. The resident required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of restorative nursing program evaluation dated 06/25/18 revealed therapy referral Resident #46 had 75 to 100 percent range of motion to bilateral upper and lower extremities. The plan included active range of motion six to seven days per week, 15 to 20 minutes per day. Active range of motion exercises to bilateral upper extremities all planes using two pound weights for 20 repetitions; active range of motion to bilateral lower extremities all planes using two pound weights, two sets of 20 repetitions. Documentation for (MONTH) (YEAR) reveals Resident #46 received restorative care on 07/01/18, 07/04/18, 07/10/18, 07/11/18, 07/12/18, 07/18/18, and 07/21/18. There was no documentation regarding other restorative care for the resident. On 07/27/18 at 11:00 A.M. Resident #46 declined to be interviewed. Interview on 07/23/18 at 10:45 A.M. with State tested Nurse Aid (STNA) #40 revealed, recently, she has been reassigned as a floor aid and was taken from her duties as a restorative aid due to staffing issues. She reported she helped residents, sometimes, with restorative care when she could, but it was not frequent due to staffing. She reported she was getting her showers and other aid tasks completed as a floor aid, but she had not been able to provide restorative care as often as she would have liked. Interviews on 07/25/18 at 8:27 A.M. and 5:00 P.M. and 07/27/18 at 8:15 A.M. with Restorative Nurse (RN) #22 revealed, for the past couple of weeks due to staffing problems, they had not been providing all of the restorative nursing services to the residents of the facility. She reported she had three aids who were trained to provide restorative care to residents, who were previously dedicated to restorative nursing, but the aids have been reassigned to floor nursing duties to cover staffing shortages from recent resignations. She stated some of the aides help the residents with their restorative programs during routine care, sometimes, and she, RN #22, helped out with the restorative care when she could, but it did not happen often. She stated the care provided by the aides during routine care was not being documented in the resident's records. Interview on 07/25/18 at 7:30 A.M. with the Director of Nursing (DON) revealed during the past several months they had been having issues with staffing at the facility. She stated she had several nurses and aides resign, and she had been having difficulty finding replacements for the lost staff. She reported they had made adjustments to their scheduling to meet the needs of the residents timely. She stated that through contract with a staffing agency, they were able to have sufficient staff to provide routine care to the residents. She admitted they had needed to take their restorative aides and incorporate them with their floor staff because of the staffing issues. She stated, other than floor care, none of their residents were receiving restorative nursing care. Interviews on 07/24/18 at 2:00 P.M. with two residents (Resident #10 and Resident #27) during resident group meeting, the residents reported there was enough staff to provide care for residents, but staff who were working were doing a lot of care. The residents reported they would like to see more staff on shifts, so staff who were working would not have to work so hard. This deficiency substantiates Complaint Number OH 066.

Based on interviews and record reviews, the facility failed to have sufficient staffing available to provide restorative nursing services and care to residents of the facility. This effected three Residents (#2, #27, and #46) of three residents reviewed for restorative nursing care. The facility census was 66. Findings include 1. Review of the medical record for the Resident #2 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Minimum Data Set 3.0 ((MDS) dated [DATE] revealed Resident #2 was cognitively intact and required limited assistance with bed mobility, transfers, and personal hygiene. He required extensive assistance with dressing and toilet use. He used a wheelchair and needed assistance with bathing. Review of assessment for restorative nursing care dated 07/03/18 revealed Resident #2 was referred to the restorative nursing program through a therapy referral. Resident #2 had 50 to 100 percent range of motion to bilateral upper and lower extremities, and did not want to participate in a restorative program on weekends. The program for Resident #2 was active range of motion three to seven days per week for 15 to 20 minutes per day. Active range of motion exercises to bilateral upper extremities of all joints and planes using two pound barbell; two sets of 20 repetitions, and active range of motion exercises to bilateral lower extremities all planes using two pound weights for two sets of 20 repetitions. Also, Resident #2 required limited assistance of one staff for supervision for transfers and expressed fears of attempting to ambulate due to knees buckling. Resident #2 did not want to attempt an ambulation program. The program included transfers three to seven days per week for 15 to 20 minutes per day. Plan to prompt and assist resident to perform sit to stand transfers at bar, encourage resident to increase amount of time standing, and to cue for safety as needed. Reviews of restorative nursing documentation for (MONTH) (YEAR) reveals, on 07/04/18, 07/10/18, 07/11/18, 07/12/18, and 07/13/18, Resident #2 received 15 minutes of active range of motion exercises and prompts for transfers to stand for between three minutes and six minutes. No other evidence of restorative care was documented . Interview on 07/27/18 at 10:41 A.M. with Resident #2 revealed he had not been receiving any restorative nursing care for the past couple of weeks. Resident #2 stated he was told he had not been getting restorative care because of a lack of staffing at the facility. He stated he was told the restorative aids were working as floor aides, and they did not have time to provide him any restorative care. He stated he had only been provided with assistance with toileting and bathing. He had not had anyone to assist him with standing or range of motion exercises. He stated he transferred from chair to bed and back independently and performed most other tasks independently. He had not had any problems with his transfers since Easter time when he fell . He stated he would like to keep receiving restorative care because he was fearful of falling and can't visit his children because they cannot assist him in their homes. 2. Review of medical records for Resident #27 revealed, on 06/27/13, Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed Resident #27 was cognitively intact. She required supervision with walking in the corridor, and was independent with all other activities of daily living (ADL). Review of restorative nursing assessment dated [DATE] revealed Resident #27 required assistance with ambulation six to seven days per week for 15 to 20 minutes per day. The resident was to ambulate with a walker for greater than 300 feet. Review of restorative nursing documentation dated 05/21/18 revealed resident #27 was able to perform her own ADL with oversight and/or independently. Restorative nursing program plan included active range of motion six to seven days per week for 15 to 20 minutes per day using three pound weights to upper and lower extremities; and resident was to ambulate 300 feet with a walker and supervision. Documentation for (MONTH) (YEAR) reveals, on 07/01/18, 07/04/18, 07/10/18, 07/11/18, 07/12/18, and 07/13/18, Resident #27 received active range of motion exercises and assistance with walking. No other documentation was provided for the restorative program. Interview on 07/27/18 at 1:34 P.M. with Resident #27 revealed she had not been receiving any restorative nursing care for the past couple of weeks. She stated she was told there was no restorative nursing care because of a lack of staffing to provide the restorative care. She stated the restorative nurses usually walked her with her walker and were there to monitor her. She stated, recently, she has been walking independently, but fears she may have a [MEDICAL CONDITION] while walking and may fall. 3. Record review for Resident #46 revealed, on 06/06/18, Resident #46 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed moderate cognitive impairment. The resident required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of restorative nursing program evaluation dated 06/25/18 revealed therapy referral Resident #46 had 75 to 100 percent range of motion to bilateral upper and lower extremities. The plan included active range of motion six to seven days per week, 15 to 20 minutes per day. Active range of motion exercises to bilateral upper extremities all planes using two pound weights for 20 repetitions; active range of motion to bilateral lower extremities all planes using two pound weights, two sets of 20 repetitions. Documentation for (MONTH) (YEAR) reveals Resident #46 received restorative care on 07/01/18, 07/04/18, 07/10/18, 07/11/18, 07/12/18, 07/18/18, and 07/21/18. There was no documentation regarding other restorative care for the resident. On 07/27/18 at 11:00 A.M. Resident #46 declined to be interviewed. Interview on 07/23/18 at 10:45 A.M. with State tested Nurse Aid (STNA) #40 revealed, recently, she has been reassigned as a floor aid and was taken from her duties as a restorative aid due to staffing issues. She reported she helped residents, sometimes, with restorative care when she could, but it was not frequent due to staffing. She reported she was getting her showers and other aid tasks completed as a floor aid, but she had not been able to provide restorative care as often as she would have liked. Interviews on 07/25/18 at 8:27 A.M. and 5:00 P.M. and 07/27/18 at 8:15 A.M. with Restorative Nurse (RN) #22 revealed, for the past couple of weeks due to staffing problems, they had not been providing all of the restorative nursing services to the residents of the facility. She reported she had three aids who were trained to provide restorative care to residents, who were previously dedicated to restorative nursing, but the aids have been reassigned to floor nursing duties to cover staffing shortages from recent resignations. She stated some of the aides help the residents with their restorative programs during routine care, sometimes, and she, RN #22, helped out with the restorative care when she could, but it did not happen often. She stated the care provided by the aides during routine care was not being documented in the resident's records. Interview on 07/25/18 at 7:30 A.M. with the Director of Nursing (DON) revealed during the past several months they had been having issues with staffing at the facility. She stated she had several nurses and aides resign, and she had been having difficulty finding replacements for the lost staff. She reported they had made adjustments to their scheduling to meet the needs of the residents timely. She stated that through contract with a staffing agency, they were able to have sufficient staff to provide routine care to the residents. She admitted they had needed to take their restorative aides and incorporate them with their floor staff because of the staffing issues. She stated, other than floor care, none of their residents were receiving restorative nursing care. Interviews on 07/24/18 at 2:00 P.M. with two residents (Resident #10 and Resident #27) during resident group meeting, the residents reported there was enough staff to provide care for residents, but staff who were working were doing a lot of care. The residents reported they would like to see more staff on shifts, so staff who were working would not have to work so hard. This deficiency substantiates Complaint Number OH 066.

Based on interview and record review, the facility failed to ensure resident funds were conveyed after discharge or death as required. This affected Resident #'s 112, 113, and 115, three of five residents reviewed for resident funds at discharge (Resident #'s 112, 113, 114, 115 and 116). The census was 66. Findings include: 1. Review of the record of Resident #115 revealed he expired at the facility on [DATE]. Review of his resident account revealed he had a balance of $559.31 that was not returned to the state treasurer until a check was written on [DATE]. The business office manager (BOM) #99 verified on [DATE] at 3:20 P.M. that the funds should have been returned within 30 days. 2. Review of the record of Resident #113 revealed he transferred to another facility on [DATE]. Review of his resident account revealed he had a balance of $317.97 that was not returned to him until a check was written on [DATE]. Upon review of the account on [DATE], the resident still had a balance in the account of $1430.68. An interview with the BOM #99 on [DATE] at 3:20 P.M. revealed the money in the account was a payment from social security. She stated she had thought the amount would be recouped electronically from his account by social security and was waiting for that to occur. She also verified the resident did not receive his amount of personal funds within 30 days from his discharge on [DATE]. 3. Review of the record of Resident #112 revealed he was discharged to another facility on [DATE]. Review of his resident account on [DATE], the resident still had a balance of $5219.92. An interview with BOM #99 on [DATE] at 3:20 P.M. revealed the resident's account had not been settled because of questions concerning his actual payment to the facility. Review of notes kept with the account revealed the last attempt to clarify the payment was on [DATE]. An interview with BOM #99 on [DATE] at 11:55 A.M. revealed the account had been closed with a check for personal funds refund sent to Resident #112 for $247.92 on [DATE], and the balance of the account was used to settle his liability. BOM #99 verified the funds had not been returned to the resident within 30 days.

Based on record review, facility internal investigation review, and interview the facility failed to timely report an allegation of verbal abuse to the Administrator and to the State Agency (SA). This affected one resident (Resident #45) of three residents reviewed for abuse, neglect, and misappropriation. The census was 66. Findings include: Review of Resident #45's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #45's quarterly Minimum Data Set 3.0 (MDS) assessment indicated the resident was cognitively intact and independent with activities of daily living (ADL). No nurses' notes were available after 06/15/18 in Resident #45's medical record. Review of a facility internal investigation dated 07/06/18 revealed an allegation of verbal abuse was made on 07/02/18 that State tested Nursing Assistant (STNA) #104 used profanity towards Resident #45 back on 06/24/18. Review of the facility investigation revealed STNA #103 reported to STNA Supervisor #100 that on 06/24/18 Resident #45 had been reaching over the nurses' station when STNA #104 told the resident to ask for help. Resident #45 replied he did not ask for help, and STNA #104 replied now you're not getting s***. Resident #45 replied F*** you, to which STNA #104 replied F*** you too! Review of one witness statement, undated, from STNA #103 verified the incident occurred on 06/24/18, but had no further information regarding when the allegation was reported. The investigation stated a self-reported incident (SRI) was not completed, as the incident happened eight days prior to when the Administrator was notified, and it was too late to do so. Review of the facility's SRI's revealed no report of the alleged 06/24/18 incident was submitted to the SA. Interviews with STNA Supervisor #100 on 07/25/18 at 9:00 A.M. and 5:20 P.M. revealed STNA #103 did not report the allegation of verbal abuse timely as required. STNA Supervisor #100 stated she found out about the incident a few days after it happened from STNA #102 and then immediately called the Administrator to report an allegation of verbal abuse. STNA Supervisor #100 stated she had to text-message STNA #103 to get him to come to work and write a statement. Interview with STNA #102 on 07/25/18 at 4:47 P.M. revealed she heard about the incident with STNA #104 and Resident #45 a few days after it happened from STNA #103 and immediately reported this to STNA Supervisor #100. Interview with the Administrator on 07/25/18 at 11:05 A.M. verified the incident was not reported timely, and the SA was not notified as it was she felt it was too late to submit a SRI. The Administrator felt the incident was unacceptable but more of a customer service issue than abuse.

Based on record review and interview, the facility failed to fully investigate an allegation of verbal abuse for one resident (Resident #45) and an allegation of sexual abuse for one resident (Resident #56). This affected two of three residents reviewed for abuse, neglect, and misappropriation. The facility census was 66. Findings include: 1. Review of Resident #45's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Resident #45's quarterly Minimum Data Set 3.0 (MDS) assessment indicated the resident was cognitively intact and independent with activities of daily living (ADL). No nurses' notes were available after 06/15/18 in Resident #45's medical record. Review of a facility internal investigation dated 07/06/18 revealed an allegation of verbal abuse was made on 07/02/18. The allegation stated on 06/24/18 State tested Nursing Assistant (STNA) #104 used profanity towards Resident #45. One witness statement from STNA #103 was included; no additional staff or resident interviews were present. STNA #104 refused to come to the facility to provide a statement and was subsequently terminated on 07/06/18. Review of a witness statement, undated, from STNA #103 revealed on 06/24/18 Resident #45 had been reaching over the nurses' station when STNA #104 told the resident to ask for help. Resident #45 replied he did not ask for help, and STNA #104 replied now you're not getting s***. Resident #45 replied F*** you, to which STNA #104 replied F*** you too! The statement verified the incident occurred on 06/24/18, but had no further information regarding when the allegation was reported, to whom the allegation was reported, or if any other residents or staff had been aware of or affected by the incident. Interview with STNA #103 on 07/25/18 at 5:16 P.M. revealed the content of his statement was accurate and verified the incident occurred on 06/24/18. Interview with the Administrator on 07/25/18 at 11:05 A.M. verified no other residents or staff were questioned regarding the allegation of verbal abuse by STNA #104 during the facility's internal investigation. 2. Record review of Resident #56 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Minimum Date Set 3.0 ((MDS) dated [DATE] revealed Resident #56 the resident was cognitively intact. Review of Resident #56's nursing note dated 07/07/18 at 2:30 A.M. revealed Resident #56 was assisted to the toilet by staff at 12:00 A.M. STNAs tried to assist the resident from the toilet when Resident #56 cursed at the STNAs and yelled rape, rape. Resident #56 was difficult to transfer back to the wheelchair, and STNAs were unable to pull Resident #56's pants up due to refusing care. Resident #56 remained awake in a wheelchair and continued to refuse care from staff. Review of the behavioral problem care plan with a revision date of 06/27/18, revealed Resident #56 became easily annoyed, refusing care, yelling, swearing, or swinging at staff. Resident #56 had a history of [REDACTED]. Interview with the Director of Nursing (DON) on 07/25/18 at 2:48 P.M. stated that she was unaware of the incident on 07/07/18, as the incident was not reported or investigated. Interview with Licensed Practical Nurse (LPN) #110 on 07/25/18 at 4:19 P.M. stated she did not report the incident on 07/07/18 when Resident #56 yelled rape, because Resident #56 had many behaviors and had a history of [REDACTED]. Interview with the Administrator on 07/26/18 at 12:02 P.M. revealed she was obtaining witness statements from staff and investigating the incident that occurred on 07/07/18. Review of facility policy, undated, labeled Resident Abuse Prevention Practices revealed staff must report the suspicion of any incident to the administrator, director of nursing, or supervisor immediately, so a thorough investigation can be immediately initiated.

Based on interview and record review the facility failed to change Resident #12's suprapubic catheter as ordered by the physician. This affected one Resident (#12) out of five residents with catheters. The facility census is 66. Findings Include: Record review of Resident #12 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #12's physician order [REDACTED].#12 was to have her suprapubic catheter changed every month and as needed (PRN). Record review of Resident #12's treatment administration record (TAR) and nurse's notes for (MONTH) (YEAR) revealed Resident #12's suprapubic catheter was not documented as being changed for the month. Interview on 07/25/18 at 02:48 P.M. with the Director of Nursing (DON) verified Resident #12's suprapubic catheter is to be changed monthly, and for the month of (MONTH) (YEAR) Resident #12's catheter was not changed.

Based on record review, interview, and review of Medscape the facility failed to monitor the heart rate of Resident #56 prior to the administration of his cardiac medication as ordered by the physician. This affected one Resident (#56) of seven Residents (#9, #20, #24, #45, #50, #55, and #56) residents reviewed for unnecessary medications. The facility census was 66. Findings include: Record review of Resident #56 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #56's physician order [REDACTED]. Review of Medscape revealed [MEDICATION NAME] had an adverse effect of [MEDICAL CONDITION] listed. Review of Medication Administration Record's (MAR) from 05/2018 through 07/2018 revealed Resident #56 [MEDICATION NAME] was held on the following dates due to heart rate below 60: 05/14/18 for a heart rate of 59, 06/14/18 for heart rate of 58, 06/16/18 for heart rate of 57, and 07/07/18 for heart rate of 58. Review of MAR from 05/2018 through 07/2018 revealed Resident #56's heart rate was not obtained and documented prior to the administration of [MEDICATION NAME] on the following dates: 5/04/18, 5/19/18, 6/10/18, 7/03/18, 7/04/18, 7/06/18, 7/09/18, 7/13/18, 7/14/18, 7/16/18, 7/17/18, 7/18/18, 7/19/18, 7/21/18, 7/22/18, and 7/23/18. Interview on 07/27/18 at 10:32 A.M. with the Director of Nursing (DON) verified that the heart rate was not obtained prior to the administration of [MEDICATION NAME].

Based on record review and interview, the facility failed to ensure non-pharmacological interventions were attempted prior to the use of anti-anxiety or anti-psychotic medications. The facility also failed to ensure as needed anti-psychotic medications were reviewed by a physician every 14 days as required. This affected Resident #9, one of seven Residents (#9, #20, #24, #45, #50, #55, and #56) reviewed for unnecessary medications. The facility census was 66. Findings include: Review of the record revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed she was severely cognitively impaired, had little interest in doing things, was tired, and frequently had a poor appetite. She did not have behaviors and required extensive to total assist with all of her activities of daily living (ADL). Review of her care plan, dated 07/04/18 and updated through 10/16/18, for cognition revealed she was confused. Interventions revealed she was to have medications administered as ordered, keep the resident's routine consistent, and provide consistent care givers. Her care plan for [MEDICAL CONDITION] medications, with the same dates, revealed the medications were to be administered as ordered, discuss with the physician the need for the on-going use of the medication, and review behaviors and interventions as well as alternate therapies attempted and their effectiveness as per facility policy. Review of the resident's care plan for anxiety revealed that she would be monitored for target behaviors of trying to get up, and these would be documented per facility protocol, as well as administer the medications as ordered, and monitor for side effects and effectiveness. Review of the resident's target behavior/intervention tracking form revealed she had behaviors including tearfulness, anxiety, exit seeing, and restlessness. Intervention options on the form included redirection, one to one interventions, remove to low stimulation area, diversion techniques such as food, magazine or activity, and medication. The form indicated when medication was used, documentation should be included in the nursing notes. Review of the resident's orders dated 10/30/17 revealed she was ordered [MEDICATION NAME], an anti-anxiety medication, that could be administered up to four times a day as needed for restlessness, agitation, and anxiety. An order dated 10/31/17 revealed she was ordered [MEDICATION NAME], an anti-psychotic medication, that could be given as needed every four hours as needed for anxiety. Review of the resident's Medication Administration Record [REDACTED].M., 05/03/18 at 8:00 A.M., 05/16/18 at 8:30 P.M., 05/25/18 at 4:00 P.M. 06/17/18 at 9:00 P.M., 07/19/18 at 2:00 A.M., 07/19/18 at 9:00 P.M., and 07/20/18 at 5:30 P.M. Review of the medication administration records, nursing notes, and behavior tracking forms for (MONTH) and (MONTH) (YEAR) did not reveal evidence of non-pharmacological interventions attempted prior to the administration of these doses of [MEDICATION NAME]. There was no behavior tracking form for (MONTH) (YEAR). The resident also received 14 doses of [MEDICATION NAME] during (MONTH) (YEAR) and one dose on 06/24/18 at 3:30 A.M. The record did not contain evidence of of non-pharmacological interventions attempted prior to the administration of these doses of [MEDICATION NAME]. An interview with the resident on 07/26/18 at 3:30 P.M. revealed her in her chair. She was calm and pleasant, neatly groomed, but confused and unable to answer questions. These findings were verified with the Director of Nursing on 07/25/18 at 3:15 P.M. 2. Review of the record of Resident #9 revealed she was ordered [MEDICATION NAME], an anti-psychotic medication, that could be given as needed every four hours as needed for anxiety on 10/31/18. Review of the Medication Administration Record [REDACTED]. Review of the record did not reveal any recommendations regarding the [MEDICATION NAME] or reevaluation by the physician regarding the need for the anti-psychotic medication every 14 days as required. These findings were verified with the Director of Nursing on 07/25/18 at 3:15 P.M.

Based on interview and record review, the facility failed to ensure medical records were complete and legible. This affected two (Residents #17 and #56) of eight (Residents #9, #17, #20, #24, #45, #50, #55, and #56) residents reviewed for medications. The facility census was 66 residents. Findings include: 1. Review of the record of Resident #17 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her Medication Administration Record [REDACTED]. Review of the area on the MAR indicated [REDACTED]. The areas appeared to have writing in them indicating the blood sugar level, units of insulin given if needed, site the insulin injection was provided, and the initials of the staff member. These entries were not readable as they were written over the pre-printed asterisks. An interview with the Director of Nursing (DON) on 07/27/18 at 2:00 P.M. confirmed it was not possible to read the MAR for Resident #17 to review her blood sugars levels and if she received the required coverage. 2. Review of the record of Resident #56 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his MAR for (MONTH) (YEAR) revealed he was ordered [MEDICATION NAME], a medication that affects pulse rate. The MAR indicated [REDACTED]. The resident's pulse was marked over the asterisks, below the initials of the nurse, and were difficult to read. The corporate nurse, Registered Nurse RN #108 verified on 07/31/18 at 3:50 P.M. that the pulse rates were not clearly written.

Based on record review and interview, the facility failed to investigate and resolve a grievance that was brought to the attention of facility staff. This finding affected two (Residents #8 and #40) of three residents reviewed for grievances. Findings include: 1. Review of Resident #8's Problem/Complaint Intake Form dated 05/09/17 indicated Resident #28 would sit in a corner on the C hall and would stick her foot out when the resident tried to go by. Resident #8 revealed the behavior usually happened at least once per day and the nurses were informed. Interview on 05/09/17 at 10:08 A.M. with Registered Nurse (RN) #20 indicated Resident #28 was observed by staff not letting residents pass by on the C hall at times. Interview on 05/09/17 at 10:10 A.M. with Licensed Practical Nurse (LPN) #21 confirmed Resident #8 voiced a grievance to the staff that Resident #28 would not let the resident pass by the nurses station on the C hall and the most recent grievance voiced by the resident was the previous week. LPN #21 confirmed Resident #8's grievance was not investigated and a plan was not implemented to resolve the grievance. Review of the facility Grievances policy dated 11/2016 indicated without discrimination or reprisal for voicing the grievances, prompt efforts by the facility would be furnished to resolve grievances the resident may have, including those with respect to the behavior of other residents. 2. Review of Resident #40's Problem/Complaint Intake Form dated 05/09/17 indicated an interview was completed with the resident who indicated staff left the resident's roommate in the doorway to block access to the resident's room. Resident #40 indicated this concern occurred daily. Interview on 05/09/17 at 9:44 A.M. with Licensed Practical Nurse (LPN) #22 revealed Resident #40 informed the facility that staff placed the resident's roommate in the doorway blocking the resident's access in and out of the room. Interview on 05/09/17 at 9:47 A.M. with State tested Nursing Assistant (STNA) #23 revealed Resident #40 voiced a grievance to the facility staff concerning the resident's roommate being left in the doorway and blocking the resident's entrance and exit to the resident's room. Interview on 05/09/17 at 9:50 A.M. with the Director of Nursing (DON) verified Resident #40's grievance was not investigated and a plan to resolve the grievance was not implemented. Review of the facility Grievances policy dated 11/2016 indicated without discrimination or reprisal for voicing the grievances, prompt efforts by the facility would be furnished to resolve grievances the resident may have, including those with respect to the behavior of other residents.

Based on record review and interview the facility failed to consistently implement care planned interventions to prevent a fall for Resident #23. This affected one out of three residents reviewed for falls in the facility. Findings include: Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #23's clinical record revealed on 09/05/16 her fall assessment indicated she had a high risk of falling. On 01/25/17 an assessment indicated she used a wheeled walker for ambulation and had an unsteady gait. A plan of care was initiated on 11/24/17 and revised on 01/07/17 to attempt to prevent Resident #23 from falling in the facility. Interventions on the plan of care included to place an alarm on Resident #23's bed at all times and in the recliner when out of bed Resident #23 sustained four falls from 01/07/17 to 04/21/17. A review of the summary report of a fall on 01/07/17 revealed she was found on the floor in her room. Resident #23 stated she was self transferring herself in the bathroom while attempting to fill her water cup. An additional intervention was initiated to attempt to prevent falls. The intervention included to place an alarm on her bed at all times and on the seat of her recliner when out of bed. On 03/11/17 the summary report indicated Resident #23 was seated in a recliner and while attempting to rise out of the chair she grabbed another resident's walker and tripped and fell to the floor. Resident #23 landed on her right side and while assisted up from the floor she complained of pain to her right shoulder. The report indicated there was no alarm on the seat of the recliner Resident #23 was using prior to the fall. A statement from Licensed Practical Nurse (LPN) #24 dated 03/11/17 indicated she was seated in the nursing station and was notified Resident #23 fell . LPN #24 assessed Resident #23 for injury and noted there was no alarm present on the seat of the recliner to alert staff of attempting to self transfer. Review of the facility policy and procedure titled Assessment, Fall Prevention and Fall Protocol dated 04/2011 revealed all residents were assessed upon admission to the facility for their risk of falls. Residents with a risk for falls had a plan of care developed with interventions implemented to attempt to prevent falls. If a fall occurred the staff were to assess the resident for injury, obtain vital signs, assess level of consciousness/orientation and document on the resident's clinical record. The physician, family/responsible party were notified. The nurse should document the fall on an incident report and forward to the Director of Nursing to investigate and implement additional interventions to prevent another fall.

Based on observation, interview and record review the facility failed to ensure Resident #55 received her dentures in a timely manner. This affected one out of two residents reviewed for obtaining dentures. Findings include: An observation and interview on [DATE] at 9:22 A.M. with Resident #55 revealed she had no upper teeth and only a few crooked lower teeth. When asked about her missing teeth Resident # 55 explained approximately a year ago she had her teeth pulled by a dentist and was still waiting for her dentures. Resident #55 stated the dentist had obtained impressions of her teeth last summer and was still waiting for them to be delivered. Resident #55 stated she had inquired about the delay in receiving her teeth and was told the facility was awaiting authorization through medicare/medicaid payer source. Resident #55 stated she was unhappy about the wait and felt a year was too long to wait to receive her dentures. Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #55's clinical record indicated social service progress notes dated [DATE] which indicated Resident #55 had multiple tooth extractions performed on [DATE]. On [DATE] the progress notes indicated Resident #55 was seen by the dentist and the dentist obtained impressions to make her dentures. On [DATE] dental progress notes indicated a wax cast denture mold was modified and adjusted to fit Resident #55's mouth dimensions and bite registration. On [DATE] the dental progress notes indicated the authorization for her dentures through her pay source had expired. The pre-authorization paperwork was completed. The dental note indicated Resident #55 was dissatisfied with the length of time waiting for her full upper and lower dentures. An interview with the Licensed Social Worker (LSW) on [DATE] at 2:33 P.M. revealed the facility was waiting for the dentist to deliver Resident #55's dentures. The LSW stated the dentist caring for Resident #55 was responsible for the delivery of the dentures and was unsure why Resident #55 had a lengthy wait for her dentures. The dentist visited the facility approximately once every six months and the LSW did not contact the dentist to ensure Resident #55's dentures were made/delivered in a timely manner. An interview on [DATE] at 12:00 P.M. with the Medical Assistant (MA) from the dental office revealed the dentures were a five step process. The MA stated Resident #55 had her final fitting for her permanent dentures during the ,[DATE] visit and was unsure why the dentures were not ready. Upon investigation of the reason of the long wait time, the MA stated after the final fitting, the dentures were sent to a laboratory to make the final permanent dentures. This usually took approximately four weeks. The MA could not explain the delay and added the dentist would make additional visits to the facility when the permanent dentures were received. During the routine visit to the facility on ,[DATE] Resident #55's paperwork for authorization for the payment of the dentures was obtained due to the prior authorization had expired and the paperwork was resubmitted. The authorization for payment took approximately four to six weeks and then the dentures would be sent to the laboratory to make them. The MA was unable to explain why the dentures were not sent to the laboratory to make her permanent dentures after the [DATE] visit and fitting. On [DATE] at 8:30 A.M. an interview with the Director of Nursing verified the above findings.

Based on record review and staff interview the facility failed to provide advance notification to two residents (Resident # 93 and Resident #10) of the discontinuation of skilled therapy services. This affected two residents (Resident #93 and #10) of three residents reviewed for Advance Beneficiary Notice of Non-coverage. Findings include: 1. Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received both physical therapy (PT) and occupational therapy (OT). The PT services ended 12/01/15 and the OT services ended 12/03/15. The reason for the discontinuation of the skilled therapy services was the resident plateaued due to achieving maximum potential with goals. Review of the Center for Medicare and Medicaid Services Form CMS-R-131, the Advance Beneficiary Notice of Non-coverage (ABN) revealed Resident #93's PT was cut on 12/01/15 and the OT was cut on 12/03/15. In addition to notification of discontinuation of services, the ABN also explained the resident's right to appeal the decision to discontinue the services and how to ask for an immediate appeal. The request for an appeal should be made as soon as possible, but no later than noon of the day before the effective end of services date indicated above. The form was signed by Resident #93 on 12/08/15, seven days after the end of PT and five days after the end of OT. On 03/17/16 at 10:30 A.M. the surveyor met with the business office manager (BOM), corporate nurse, director of nursing and facility administrator. The BOM verified the above information and stated that at the time of the discontinuation of services, Resident #93 resided in the facility. The BOM could have physically walked the form to the resident for notification and signature. On 03/17/16 at 11:00 A.M. the facility administrator stated that Resident #93 should have been notified prior to the discontinuation of skilled PT and OT services. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received PT and OT. The PT and OT services ended 01/27/16. Review of the ABN revealed Resident #10's PT and OT would end on 01/27/16 due to Resident #10 having plateaued due to achieving maximum potential with goals. In addition to notification of discontinuation of services, the ABN also explained the resident's right to appeal the decision to discontinue the services and how to ask for an immediate appeal. The request for an appeal should be made as soon as possible, but no later than noon of the day before the effective end of services date indicated above. The form was signed by Resident #10 on 01/29/16, two days after the end of PT and OT. On 03/17/16 at 10:30 A.M. the surveyor met with the business office manager (BOM), corporate nurse, director of nursing and facility administrator. The BOM verified the above information and stated that at the time of the discontinuation of services, Resident #10 resided in the facility. The BOM could have physically walked the form to the resident for notification and signature. On 03/17/16 at 11:00 A.M. the facility administrator stated that Resident #10 should have been notified prior to the discontinuation of skilled PT and OT services.