Every finding on record at Eagle Pointe Healthcare Center

Based on observation, staff interview, the facility failed to ensure that baking pans were stored in a sanitary manner by stacking them while still wet (wet nesting) and dishes were free from dired substances and stored clean. This practice has the potential to contaminate food-contact surfaces and cause foodborne illness. This failed practice had the potential to affect more than a minimal number of residents residing in the facility. The facility census was 119 12:50 PM observed the following issues in the kitchen:Pans were being stacked this is called Wet Nesting Plates, saucers, and coffee pots were on the clean side and were still dirty1:00 PM and interview with Dietary [NAME] # 142 Confirmed the pans were stacked wet by stating ok and also confirmed the plates and coffee pots were dirty stating i'm only one person i'll take care of it.

Based on Record review, observation, and Staff interview, the facility failed to ensure meals were served at a consistant time. This failed practice had the potentioal to affect a minimal number of residents residing in the long term care facility. Facility Census: 119Findings Include:Record review completed on 09/22/25 at 1:00 PM revealed the meal delivery time started at 5:00 PM on the Memory care unit an observation on 09/22/25 at 5:00 PM, the time dinner was posted to be served on Memory Care Unit, Further observations on the memory care dining room revealed residents being really agitated and restless before dinner arrived at 5:21 PM. twenty one minutes after the meal was posted to be served.An interview on 09/22/25 at 5:25 PM with an anonymous Nurse Aide Staff member stated they are normally late, and have been much later than this in the past. Confirming trays are being served past time of service posted. Record reviews completed on thirty three trayline meal service time records showed that eight (8) out of the thirty three were documented to be served at least thirty minutes or later past the posted service time for Dinner.

Based on observation and staff interview, the facility failed to ensure food was served at an appetizing temperature. This was a random opportunity for discovery. This failure had the potential to affect more than a limited number of residents. Facility Census: 108. Findings included: a) Food temperatures On 07/07/2025 at 01:15 PM, a lunch tray was tested by Regional Dietary Manager #151. This test tray was the last tray to be served on D Hall. The trays were on the hall at 01:05 PM. The following temperatures were obtained: -Bruschetta chicken - 125.1 degrees Fahrenheit -Buttered noodles - 112.0 degrees Fahrenheit -Broccoli - 102.9 degrees Fahrenheit The Regional Dietary Manager #151 confirmed the temperatures for the buttered noodles and broccoli were below the standard.

Based on facility documentation, staff interview and Operation Policy, the facility failed to have a certified Infection Preventionist (IP) attend and participate in the Quality Assessment and Assurance (QAA) meetings that worked at least part time in the facility and have all members attend, This failed practice had the potential to affect all residents residing at the facility. Facility Census: 108. Findings included: Record review of the facility's policy titled, QAPI Quality Assurance performance Improvement Plan (QAPI), with effective date 10/01/2017, found: - The QAPI committee will include the: Executive Director, Director of Nursing, Medical Director, Infection Preventionist, three other staff members and other state required attendees. -Monthly the QAPI committee will meet with all members of the committee present and review any open performance improvement plans, facility audits, or data collected since the last meeting. a) QAA Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no IP attended the meeting from the October 2024 - December 2024 quarter. -Meeting on 10/11/24, four members attended, the Executive Director, Director of Nursing, Medical Director and one other member. The DON signed both DON and Infection preventionist (IP) -Meeting on 11/08/24, four members attended, the Executive Director, Director of Nursing, Medical Director and one other member. The DON signed both DON and Infection preventionist (IP) -Meeting on 12/13/24, four members attended, the Executive Director, Director of Nursing, Medical Director and one other member. The DON signed both DON and Infection preventionist (IP) During an Interview 07/08/24 at 10:38 AM, the Executive Director verified the facility could not produce evidence the DON was officially certified as an IP and had been working in that role byond her 40 hours a week as the facility's DON. The Executive Director verified all required members did not attend the QAPI meetings. No other information was provided prior to the end of the survey on 07/08/25.

Based on facility record review and interview, the facility failed to explain the Binding Arbitration Agreement accurately and in a form and manner residents or Resident Representatives could understand. This had the potential to affect all residents or Residents Representatives that sign a Binding Arbitration Agreement. Facility Censes: 108. Findings included: a) Binding Arbitration Agreement A facility record review of the found 81 Residents or Resident Representatives signed and accepted the Binding Arbitration Agreement. 15 Residents or Residents Representatives signed and declined the Binding Arbitration Agreement. During an interview, on 07/01/25 at 1:18 PM, the Back-Up admission Coordinator was unable to explain the Binding Arbitration Agreement accurately. She stated that she was unsure who chose the Arbitrators and that the Resident or Representatives could take their issues to a court of law if they did not like the outcome of the Arbitration. When the admission Coordinator was asked questions about the Binding Arbitration Agreement, she was unable to explain. The admission Coordinator at this time stated that Residents don't usually ask questions about the form. She stated that she would need to better familiarize herself with the Agreement.

Based on observation, staff interview and record review, the facility failed to store food in accordance with professional standards for food service safety. The failed practice had the potential to affect more than a limited number of resident's. Facility Census: 108. Findings included: a) Food Storage The facility's policy and procedure for Food Storage: Dry Foods stated, 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. The facility's policy and procedure for Food Storage: Cold Foods stated, 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. On 06/30/25 at 11:10 AM during the Kitchen Investigation, the following items were found: -Three pitchers of drinks in the dining room, judged to be punch, lemonade and tea were not labeled or dated and not on ice. -No lock on employee refrigerator in the Main Dining Room. -Sysco Dry Milk - opened with no opened date. -Mission Flour Tortillas - opened and no use by date. -Rice Krispies and Corn Flakes - opened, not labeled or dated. -Hamburger Buns - opened with no open or use by date. -Sunbeam sandwich bread - opened with no open or use by date. -Ground Turkey - no open date. -Sliced Deli Ham in a metal container - opened, not sealed and no use by date. -Worcestershire Sauce - used by date 06/14/2025. -BBQ Sauce - opened 06/03/2025 with no use by date. -Italian Dressing - opened 06/2025 with no use by date. -Marzetti [NAME] Slaw Dressing - opened with no use by date. -Croissants with large hole in the corner of the package. The Assistant Dietary Manager confirmed items were to be discarded seven (7) days after opening. Items were confirmed by Regional Dietary Manager #152 and Account Manager. On 06/30/25 at 1:00 PM, the Cottage's (dementia unit) refrigerator/freezer was investigated. Items found included: -Wholesome Farms Vanilla Ice Cream - opened with no use by date. -Electrolit - opened with no open date. -Peanut butter and jelly sandwiches - no use by date for two (2) sandwiches. -Four (4) sandwiches - not labeled and no use by date. -Sandwiches not properly sealed - in a bag with no closure/seal. -Styrofoam container with plastic fork coming out the side with a red substance on the outside of the container - not labeled or dated. The items were confirmed by Nursing Assistant (NA) #22. The NA stated, I will date .seven (7) days right? and Dietary was here this morning. On 07/01/2025 at 9:45 AM, the East Nourishment Pantry was investigated. Items found included: -Farmer Brothers Coffee - opened, not sealed and not dated. -Basket of snacks - no open or use by date - oatmeal cakes, Quaker Chewy Bars - Peanut butter flavor. -Thick It - no use by date on individual packets. -Great Value Vanilla Ice Cream Sandwiches - no use by date. -Toaster Grills - use by date 06/16/25. Licensed Practical Nurse (LPN) #87 confirmed the items at 10:01 AM and stated, I don't know if dietary has the box. - referring to the thickener. On 07/01/25 10:05 AM, the North Nourishment Pantry was investigated. Items found included: -[NAME] Dean Bacon Breakfast Bowl - dated 06/17-06/23. -Ocean Spray CranGrape juice - opened with no use by date. -Smart Balance individual butter packages -9 (nine) - not dated. -Individual Lay's Classic Chips - opened, not sealed and not dated. -Rice Krispies Treats- two (2) packages - not dated. -Farmer Brothers Coffee - opened and not dated. -Individual packages of Swiss Miss No Sugar Added hot chocolate - not dated. Licensed Practical Nurse (LPN) #73 confirmed the items at 10:15 AM and stated, I'm gonna get all that out. On 07/01/25 at 11:55 AM, food serving and preparation utensils were observed in drawers with handles not facing the same direction. The Assistant Dietary Manager confirmed and stated, yes .same way.

Based on record review, observation, resident interview, and staff interview, the facility failed to ensure the menus were followed for Residents #64 and Resident #2. This was a random opportunity for discovery. This failured practice had the potential to affect more than a limited number of residents. Resident Identifiers: #2 and #64. Facility Census: 108. Findings included: a) Menus On 06/30/25 at 12:45 PM, Resident #2 was served a hot dog on a flat piece of bread with no condiments. The resident tray card stated, ALL BEEF HOT DOG on a BUN - 1 SANDWICH Mustard - 1 PKT. (packet). Nursing Assistant (NA) #22 reported the resident eats a hot dog almost every day. NA #22 confirmed the hot dog was on a piece of sandwich bread and resident was not given a condiment. During an observation of lunch service on 06/30/25 at approximately 1:11 PM, Resident #64 was unhappy with the meal served to him. He stated that he had ordered a hot dog. He received a hot dog placed on a slice of bread and cheese. He asked the person serving him, Where is the hot dog bun? The aide stated that they had run out of hot dog buns. The resident was unhappy that the meal did not meet his expectations. The Assistant Director of Nursing (ADON) who was present stated that she would check to find out why they did not have hot dog buns.

Based on observation, resident interview, and staff interview, the facility failed to ensure that residents could exercise their right to file a grievance, including the right to file an anonymous grievance. This was a random opportunity for discovery. Facility Census: 108 Findings Included: a) Grievance During an observation on 07/02/25 at 12:04 PM, it was noted that grievance forms were not readily available to residents. Further investigation revealed that grievance forms were kept at the nurses' station. During an interview with Resident #83, the resident stated that she was aware of the grievance policy. Upon being asked how a grievance could be filed, the resident stated that she would ask a staff member for a grievance form. Resident stated that once completed, the grievance form could be dropped off at the Social Worker's office. During an interview with the Director of Social Services (DSS) #76, the facility's designated grievance officer, she stated that if it was a family grievance, they would usually come to her. However, if a resident had a grievance, she stated that the resident would either come to speak to her or file a written grievance and drop it off in the box outside her office. Upon being asked where a resident could obtain a grievance form, DSS #76 stated that the forms were available at the nurses' station on each hallway. During an interview with the Administrator and Regional Director of Clinical Operations (RDCO) #157, on 07/02/25 at approximately 12:20 PM, they confirmed that the grievance forms were not readily available and could not be filed anonymously.

Based on record review and staff interview, the facility failed to ensure that the medical record was complete for a Physician Orders for Scope of Treatment (POST) form with no signature for Resident #87. This failed practice was true for one (1) of 28 residents reviewed in the Long-Term Care Survey Process. Resident Identifier: #87. Facility Census: 108. Findings included: a) Resident #87 On 06/30/25 at 09:02 PM, Resident #87's POST form was reviewed by the state surveyor. Verbal Consent was given on 04/16/2025 by the resident's legal representative, however a signed consent was not obtained by the facility. There was no evidence in the medical record to reveal the facility had attempted to follow-up with resident's legal representative to obtain a written signature. On 07/01/2025 at approximately 11:35 AM, the Interim Director of Nursing stated that they were mailing out the POST form today to be signed.

Based on observation and staff interview, the facility failed to maintain bed remote controls in a safe operating condition. This is true for one (1) of five (5) resident beds reviewed. Facility census:108. Findings included: a) room [ROOM NUMBER]B During an interview on 07/01/25 at approximately 2:55 PM, Employee #32. was asked if they were aware of any issues with any exposed electrical wiring. The employee replied, You mean like bed remotes? Yes. One is located in room [ROOM NUMBER]B. On 07/01/25 at approximately 3:10 PM, Surveyor observed electrical tape on the bed control remote on resident bed 123B. On 07/02/25 at approximately 7:53 AM, an interview with the facility Maintenance Director verified that the bed control remote for bed 123 B had electrical tape on the remote. This finding was also acknowledged by the Administrator upon exit on 07/08/25 at approximately 1:00 PM.

Based on interviews, observations, and record reviews, the facility failed to ensure that staff adhered to infection control protocols while caring for residents classified as requiring Enhanced Barrier Precautions (EBP). Staff failed to wear Personal Protective Equipment (PPE) as specified by the EBP guidelines posted outside the resident's room. This was a random opportunity for discovery. Resident Identifier: #105. Facility Census: 108. Findings Included: a) Resident #105 During an interview on 07/01/25 at approximately 9:40 AM, the resident stated that she had a Foley catheter. Resident was alert, oriented, and had a Brief Interview for Mental Status (BIMS) score of 8. She stated that she had the catheter because she did not have control of her bladder. The resident was under Enhanced [NAME] Precautions, and the notice posted outside Resident #105's room stated the following: ENHANCED BARRIER PRECAUTIONS EVERYONE MUST: -Clean their hands, including before entering and when leaving the room PROVIDERS AND STAFF MUST ALSO: -Wear gloves and a gown for the following High-Contact Resident Care Activities: -Dressing -Bathing/Showering -Transferring -Changing Linens -Providing Hygiene -Changing briefs or assisting with toileting -Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: any skin opening requiring a dressing A review of the physician's orders revealed the following, Foley cath care every shift and PRN (as needed) with soap and water. Secure straps if applicable, document output every shift. Provide anchoring device, privacy bag, and position privacy bag correctly. During an observation of catheter care on 07/07/25 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #90 and Nursing Assistant (NA) #107 performed catheter care on Resident #105. LPN #90 and NA #107 entered the resident's room, donned gloves, but did not don gowns. They pulled the curtains around the resident's bed, and then proceeded to lower the resident's bed. LPN #90 then assisted NA #107 to roll the resident so that her brief could be removed. NA #107 then brought in soap and water and towels and began to clean the resident's perineum, discarding the soiled towels into a soiled linen bag prepared for the purpose. NA #107 then began to clean the catheter, starting from the point nearest to the meatus and wiping, moving away. All soiled towels were discarded into the soiled linen bag. Once the catheter had been cleaned, they informed the resident that they would be putting a clean brief on her. LPN #90 and NA #107 then proceeded to put a clean brief on the resident, still without changing gloves or donning a gown. Upon completion of the care, they pulled the resident up in bed and made her comfortable. They removed the soiled linen bag from the room. Unit Manager (UM) #64 was notified of the failure to follow EBP protocols on 07/07/25 at approximately 3:00 PM. UM #64 confirmed that EBP protocols required that the specified Personal Protective Equipment (PPE) should be donned before care was provided to residents. UM #64 stated that she would begin education and training immediately.

Based on record review and staff interview, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifier: #371. Facility census: 108.Findings Included:a) Resident #371A facility record review revealed the following details: -Resident #371 was discharged following the end of their Medicare Part A Skilled -On the Minimum Data Set (MDS) Discharge assessment for Resident #371, with an Assessment Reference Date (ARD) of May 22, 2025, Section A (Identification Information) was marked Planned.-There was no evidence that a NOMNC had been issued to the resident prior skilled services ending. During an interview on 07/01/25 at 12:42 PM, the Social Worker Designee #82 verified the NOMNC was not given to Resident #371 or their representative.

Based on interview, observation and record review, the Facility failed to ensure that resident was free from physical restraints that unnecessarily inhibited resident's freedom of movement or activity. Resident Identifier: #4. Facility Census: 108 Findings Included: a) Resident #4 During an interview on 07/01/25, at approximately 9:30 AM, the resident stated that she was not allowed to use her wheelchair. Resident #4 indicated a wheelchair parked near her bed and said, That is my wheelchair, and I don't know why they won't allow me to use it. The resident also mentioned that she used to move around in her chair before coming to the facility. The resident mentioned that the facility would not allow her to use her wheelchair, so she requested an alternative chair. She stated that the Director of Physical Therapy (#155) provided her with another chair. The resident pointed to a Broda chair in the room and said, I can't move that chair because my feet don't work. The resident expressed the importance of being able to move in her wheelchair using her arms, as she is unable to stand or use her lower limbs. She mentioned that she has been at the facility for just over a year and, during that time, she has had to either stay in bed or sit in the Broda chair. Resident's spouse, who shares the room with her, said, She is fine and can use her arms to move a wheelchair. I don't understand why they won't let her! A review of Resident #4's records revealed the following physician's orders: - A 02/27/2025 order directed, Resident is medically unable to go on therapeutic outings r/t impaired mobility/contractures. -A 03/6/2024 order directed, May go out on pass with or without meds. -A 07/31/2024 order directed, OK to keep home wheelchair (with) cushion and leg rests in room. -A 07/31/2024 order directed, Mechanical lift for transfers. May leave yellow sling under resident when OOB (out of bed) due to repositioning difficulty and comfort. - A 06/25/2024 order directed, Broda chair with dycem above and below cushion, with footboard. A record review, completed on 07/01/25 at 11:25 AM, revealed the results of a Functional Assessment, dated 04/24/2025, which stated Resident #4 was totally dependent on two (2) helpers in order to transfer from bed to chair or from chair to bed. During an interview with DPT #155, on 07/01/25 at 12:45 PM, he provided the following details of Resident #4's occupational therapy (OT) for the period 08/26/24 to 09/06/24. -The treatment objective was for the resident to achieve her previous level of functioning (PLOF) -Patient's goal: Get this going again. -Assessment noted that the resident stated that she wants to be able to propel a wheelchair regardless of how much time she spends out of bed (OOB) monthly Further review of the provided occupational therapy documentation revealed the following: A note dated 08/28/24 which stated, Worked on a positioning in a standard wheelchair with resident sliding out of wheelchair times two within 20 minutes of being up in chair. Educated on the benefits of continuing to use Broda chair for safety while out of bed with focus on setting resident up with appropriate setting device upon discharge of therapy. Resident worked on wheelchair mobility with SBA (standby-by assist) with sliding out during tasks with focus on increasing independence within facility upon discharge of therapy. A note dated 08/29/24 which stated, Pt (patient) educated in the importance of sitting upright in a chair system in order to play bingo (pt likes this activity). To go out of her room such as sit on the porch to enjoy some fresh air/sunshine. Pt educated that the w/c tried yesterday pt was sliding off and hence unsafe. Pt educated in importance of Broda midline w/s Broda pedal. Pt agreeable to sit in Broda pedal. Pt hoyer lifted by CNA (nurse aide) from bed to Broda pedal. Pt sat in Broda pedal w/c chair positioning system for 2+ hours today. Pt seated upright with both feet not touching the floor at this time. Pt unable to use feet at this time to self propel with her feet. Pt alert, cooperative and agreeable to participate in skilled OT services today. Another note dated 09/06/24 stated, Pt (patient) unable to get OOB (out of bed) for OT tx (treatment) this date d/t (due to) weakness/illness. Mx (multiple) trials of a pedal Broda chair were incorporated into pt's prior OT tx sessions when she was of good health. W/c (wheelchair) seating system updated this date to a Pedal Broda chair with Midline Broda chair being d/c'd (discontinued) per pt's request. Assessed pt's knowledge of the pedal chair and it's features. Pt able to recall mx features and their benefit. Staff education on seating system change this date and aware of need for chair adjustment for pt when OOB. A further interview with DPT #155 on 07/02/25, at 1:15 PM, revealed that subsequent evaluations indicated Resident #4 was unable to use her feet to move her Broda chair. DPT #155 assessed the resident for a Broda chair with larger wheels that she could propel using her arms. He stated that around February 2025, he submitted a requisition for this chair, which would enable the resident to move independently throughout the facility. However, DPT #155 noted that he had not yet received authorization to procure the Broda chair. During an interview with the Administrator on 07/01/25 at approximately 1:30 PM, the Administrator stated that he would check on the status of the requisition. At approximately 10:40 AM on 07/02/25, the Regional Director of Operations (RDO) submitted a copy of a sales quote. He stated that the facility had approved the purchase of the Broda chair. A review of the sales quote revealed that the quote had been requested by DPT #155 on 02/04/25. The sales quote stated, A SIGNATURE AT THE BOTTOM WILL INDICATE ACCEPTANCE OF THIS QUOTE. The quote had been signed and approved on 07/02/25 by the Administrator. During a walk-through of the 300 Hallway, on 07/02/25 at approximately 11:35 AM, Resident #4 was observed sitting in a Broda chair. Resident immediately stated, Did you hear? I am getting that chair! Resident #4 further stated that she had been told that she would have to sit in the chair for at least two hours. She stated, I'll sit here for four hours if necessary! The resident's husband appeared very pleased and stated, Now she will be able to move around and not have to stay in bed all the time! During an interview with DPT #155, he stated that he had received approval to purchase the Broda chair. He stated, Now that I have approval, I want to make sure I get the chair that is suitable for her.

Based on medical record review and staff interview, the facility failed to update the care plan to reflect a change in diet status. This was a random opportunity for discovery. Resident identifier: #82. Facility census: 108. Findings included: a) Inaccurate Care Plan Resident #82's diet order stated, NPO Diet, NPO texture, NPO consistency for Diet type. The resident's care plan stated: 1) Lid on coffee/hot beverage Date initiated: 06/09/2025 2) Staff to offer nutrition/hydration during checks Date initiated 03/07/2023 3) Patient may be fed pureed foods by caregivers or family as snacks are requested Date initiated 07/06/2023 On 07/01/2025 at 02:30 PM, the Director of Nursing confirmed the inaccurate care plan and stated, She hasn't eaten anything. Corporate Registered Nurse #153 stated, We have a care plan problem.

Based on staff interview and record review, the facility failed to ensure patient centered rehabilitative services were provided for Resident #82. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: #82. Facility Census: 108. Findings included: a) Resident #82 Resident #82 had four (4) plus rehospitalizations per the Minimum Data Set (MDS) and was initially admitted on [DATE]. Speech Therapy (ST) had not screened the patient during her facility stay or upon re-admission to the facility for changes in condition following a hospitalization. The Director of Rehabilitation Services (DOR) stated, Occupational Therapy (OT) and Physical Therapy (PT) usually come from the hospital with orders and the ST need identified by nursing or other therapies. The DOR stated he didn't have speech in the building for awhile. However, interdisciplinary screens had been completed with no ST recommendations by PT and OT. The facility's screening policy and procedure stated, screens should be completed for the following reason: Admission/ re-admission for any discipline not ordered and A screen is used to identify if a change has occurred with a patient. The change may be an improvement, a decline, or a risk that something may happen without therapy intervention. A ST evaluation was completed on 06/20/2023. A ST discharge was completed on 08/03/2023. NPO (nothing by mouth) recommended. Patient to remain NPO but it has been discussed with staff and family re: pleasure feeding. Recommend small bites/sips, sitting upright during PO trials, alternate food/liquid, and ensure bolus is fully consumed before presenting another bolus. A Flexible Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallow Study (MBSS) were not indicated on the ST evaluation. On 07/01/25 at 01:15 PM, the Interim Director of Nursing reported there were no instrumental studies (FEES or MBSS) completed for Resident #82 at the hospital or at the facility. Resident #82's diet order stated, NPO Diet NPO texture, NPO consistency for Diet type. The resident's care plan stated: -Lid on coffee/hot beverage Date initiated: 06/09/2025 -Staff to offer nutrition/hydration during checks Date initiated 03/07/2023 -Patient may be fed pureed foods by caregivers or family as snacks are requested Date initiated 07/06/2023 The resident's current NPO order reflects a change in condition from the care plan which documents PO intake with pureed food and no liquid consistency indicated. Discharge from 08/03/2023 recommended: alternate food/liquid. On 07/01/2025 at 02:30 PM, the Director of Nursing confirmed the inaccurate care plan and stated, She hasn't eaten anything.

Based on record review and interview, the facility delayed necessary medical treatment, potentially impacting a resident's health and safety, by failing to address the resident's ongoing complaints of shortness of breath, progressive weight gain, and increasing edema over a period of two weeks. Resident Identifier: Resident #115. Facility Census:109. Findings included: a) Resident #115 A closed record review of Resident #115's records was performed on 11/18/24 at approximately 11:15 AM. Record review revealed that Resident #115 was (age and gender) diagnosed with Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), seizures, and hypertension. During the record review, the facility did not notify the physician of the resident's weight gain of over 12 pounds in two months. Additionally, the facility failed to obtain orders from the physician to address this weight gain. Furthermore, the facility did not inform the physician about the resident's +3 pitting edema. This is evidenced by the following notes and documentation: Record review revealed a nursing note 10/23/24 at 10:42 PM by Licensed Practical Nurse (LPN) #87, which stated: Resident refuses to allow staff to shower her due to the extent of pain that she is in. States that feet, legs, shoulders and arms hurt, that she had been up half the night from her feet hurting. Nursing medicated resident per her requests. Resident states, I want to wait till tomorrow. A follow up visit by the Nurse Practitioner (NP) #131 on 10/24/24 at 1:00 PM noted that: [Resident] is being seen for an acute visit today. She is a (age and gender) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. She states that she is having increased pain to her left shoulder and neck. Nursing staff states she has been refusing baths due to being in too much pain. She has been taking Flexeril at bedtime, which does help the pain and enables her to sleep. No redness or warmth or swelling noted to affected joint. VS WNL; afebrile. Will increase Flexeril to three times a day. Another nursing note on 10/26/224 at 2:48 PM by LPN #130 stated: Resident sitting in WC in room at this time. Resident feet/ankles/legs have edema, pitting 3+. Resident is noted to be on 80mg of Lasix and con't to drink several drinks at a time as well as not elevating feet throughout the day. This nurse educated that she needed to elevate her feet d/t swelling. Resident stated, I should, maybe I'll lay down later and put them up. Records reveal that resident #115 was examined by NP #131 on 11/1/24 at 1:00PM. NP #131 noted the following: Date of Service: 11/01/2024 Chief Complaint / Nature of Presenting Problem: Acute visit History of Present Illness: [Resident] is being seen for an acute visit today. She is a (age and gender) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. Staff has noted increased swelling, redness, warmth and pain to BLE. She is sitting up in her wheelchair today on exam; she has been resisting recommendations to go back to bed and keep her legs elevated. She does have clear serous fluid seeping from BLE. Afebrile; VS WNL. Will start cephalexin QID for cellulitis. Medication List: Cephalexin, Cephalexin Oral Capsule 500 MG, Give 1 capsule by mouth four times a day for cellulitis for 7 Days, 500MG, ACTIVE, 10/30/2024 to 11/6/2024 Hydrocodone-Acetaminophen, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG, Give 1 tablet by mouth three times a day for pain, 5-325MG, ACTIVE, 10/29/2024 Cyclobenzaprine HCl, Cyclobenzaprine HCl Oral Tablet 10 MG, Give 1 tablet by mouth three times a day for muscle pain, 10MG, ACTIVE, 10/24/2024 Albuterol Sulfate, ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, 2 puff inhale orally every 4 hours as needed for cough, COVID, congestion, 108 (90 Base) MCG/ACT, ACTIVE, 9/11/2024 Throat Lozenges, Throat Lozenges Mouth/Throat Lozenge, Give 1 unit by mouth every 2 hours as needed for sore throat, ACTIVE, 9/11/2024 Fluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 MCG/DOSE, 1 inhalation inhale orally every 12 hours for asthma rinse and spit, 250-50MCG/DOSE, ACTIVE, 9/2/2024 Albuterol Sulfate, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, 2 puff inhale orally every 6 hours as needed for asthma rinse and spit, 108 (90 Base) MCG/ACT, ACTIVE, 9/2/2024 Omeprazole 20 MG Capsule delayed release, Give 1 capsule by mouth in the morning for GERD, 20MG, ACTIVE, 8/31/2024 Furosemide, Furosemide Oral Tablet 80 MG, Give 1 tablet by mouth one time a day for edema, 80MG, ACTIVE, 8/31/2024 Lisinopril, Lisinopril Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for HTN, 5MG, ACTIVE, 8/31/2024 Aripiprazole, Abilify Oral Tablet 10MG, Give 1 tablet by mouth one time a day for schizophrenia, 10MG, ACTIVE, 8/31/2024 Potassium Chloride ER Tablet Extended Release 10 MEQ, Give 1 tablet by mouth one time a day for supplement, 10MEQ, ACTIVE, 8/31/2024 Cholecalciferol, Cholecalciferol Oral Tablet 125 MCG (5000 UT), Give 1 tablet by mouth one time a day for supplement, 125 MCG (5000 UT), ACTIVE, 8/31/2024 Aspirin, Aspirin 81 Oral Tablet Chewable 81 MG, Give 1 tablet by mouth one time a day for prophylaxis to be on hold 9/21 through 9/27for EGD and colonoscopy, 81MG, ACTIVE, 8/31/2024 Duloxetine HCl, Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG, Give 1 capsule by mouth one time a day for depression, 60MG, ACTIVE, 8/31/2024 Levothyroxine Sodium, Levothyroxine Sodium Oral Tablet 75 MCG, Give 1 tablet by mouth in the morning for hypothyroidism, 75MCG, ACTIVE, 8/31/2024 Lamotrigine, lamotrigine Oral Tablet 150 MG, Give 1 tablet by mouth two times a day for seizures, 150MG, ACTIVE, 8/30/2024 Metoprolol Tartrate, Metoprolol Tartrate Oral Tablet 50 MG, Give 1 tablet by mouth two times a day for HTN, 50MG, ACTIVE, 8/30/2024 Apixaban, Apixaban Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for circulation on hold 9/23/24 through 9/27/24 for EGD and colonoscopy, 5MG,ACTIVE, 8/30/2024 Buspirone HCl, buspirone HCl Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for anxiety, 5MG, ACTIVE, 8/30/2024 Docusate Sodium, Docusate Sodium Oral Tablet 100 MG, Give 1 tablet by mouth two times a day for constipation, 100MG, ACTIVE, 8/30/2024 Atorvastatin Calcium 40 MG Tablet, Give 1 tablet by mouth at bedtime for cholesterol, 40MG, ACTIVE, 8/30/2024 Lorazepam, Ativan Oral Tablet 0.5 MG, Give 1 tablet by mouth every 12 hours as needed for anxiety for 6 Months, 0.5MG, ACTIVE, 8/30/2024 to 2/28/2025 ***reviewed Allergy List: No known medication allergies. Past Medical History: Seizures Hyperlipidemia, CHF, Hypothyroidism, HTN, COPD, Dementia/ MDD, Insomnia, RLS CAD, Angina, A fib, Asthma, GERD, Hiatal Hernia, IBS/Constipation, OA, Anemia and Morbid Obesity. Past Surgical History: History of surgery (11/08/2021), right ankle Arthroplasty of right shoulder (05/03/2017) Miscellaneous operations fibrous mass (benign) excision from the Right hand first webspace. Cardiac catheterization, Total knee replacement bilateral, Cholecystectomy, Removal of gallstones from liver, Hysterectomy, Surgical repair of prolapsed uterus, Defibrillator, Bilateral TKD, Social History: Lives alone at home Family History: heart disease diabetes hypertension Review of Systems General: Appetite is satisfactory. No significant weight change. No fever, chills, or sweats reported. Respiratory: No dyspnea, cough or wheezing. Cardiovascular: No chest pain, tightness or palpitations. Gastrointestinal: No abdominal pain, nausea, vomiting, or change in bowel habits. Skin/Breast: +BLE redness/warmth/weeping suspect cellulitis Vital Signs/Constitutional Weight: 354.4 pounds; 9/16/2024 1:39:00 PM; Height: 64 inches; 9/6/2024 10:00:00 AM; Pulse: 76 BPM; 11/1/2024 10:20:19 AM; Blood Pressure: 136/76; 11/1/2024 10:20:19 AM; O2 Saturation: 96 Room Air; 10/18/2024 11:47:00 AM; Temperature: 98.1 Fahrenheit; 11/1/2024 10:20:19 AM; Respiratory Rate: 17 Breaths per minute; 10/18/2024 11:47:00 AM; BMI: 60.8; Pain Level: 5; 11/1/2024 10:20:40 AM; Blood Sugar: 120 mg/dL; 11/1/2024 4:57:28 AM; Physical Exam General: This patient is well developed and in no acute distress. Appears pleasant and cooperative. Answers questions appropriately. Respiratory: Lungs diminished throughout Normal respiratory effort. Cardiovascular: Regular rhythm; no murmurs, rubs, or [NAME]. Skin: BLE red, warm, weeping skin. Painful to touch. Appears to be cellulitis. Diagnosis and Assessment Assessment: CPT Codes: 99308 (1 unit) ICD Codes: L03.119: Cellulitis of lower extremity, unspecified laterality Start cephalexin QID Monitor for s/s of worsening infection R46.0: Poor hygiene Refusing bathing Educated patient on importance of regular bathing and possible increase risk of infections if not bathing regularly Increase Flexeril to three times daily to help with pain so patient is more willing to get a bath. E66.01: Morbid (severe) obesity due to excess calories BMI is now 53.6. Continue to monitor meal intake, BMI and weights. Continue on Monaro injection every week. Plan: Time spent 20 minutes ***** Document e-signed by [NP #131] on [DATE] 11:38AM EDT ***** Signed Date: 11/01/2024 10:38:41 AM NP #131 noted that the resident's bilateral lower extremities (BLE) were red, warm, and weeping a clear serous fluid. However, NP #131 did not document, or address, the +3 pitting edema that LPN #130 documented on 10/26/24. A nursing note by LPN #68 on 11/3/24 at 4:37 PM stated the following: Continues on ATB for cellulitis. BLE remain reddened and edematous. Resident states legs are seeping but staff has not observed any drainage. Asking if she should go to the hospital or not. Discussed with resident that NP and MD aware of cellulitis and this is why she is on ATB but if she chose to be sent out that we could notify MD. Resident then states she does not wish to go. On 11/20/24 at approximately 10:30 AM, LPN #80 stated that she had not noticed any exudate, or any fluid weeping from Resident #115's lower extremities at any time. On 11/19/24, at approximately 9:25 AM, an ongoing review of Resident #115's chart revealed that the resident had experienced a weight gain of 12.4 lbs. over the last two months. 11/4/24 at 1:17 PM 370.4 Lbs. 10/2/24 at 11:22 AM 366.2 Lbs. 10/01/24 at 9:04 AM 363.8 Lbs. 09/25/24 at 3:12 PM 356.8 Lbs. 09/16/24 at 1:39 PM 354.4 Lbs. 09/11/24 at 9:23 AM 356.8 Lbs. 09/05/24 at 4:14 PM 356.2 Lbs. 09/04/24 at 11:23 AM 358.0 Lbs. An admission dietary nutritional assessment on 09/03/24 at 1:34 PM noted the resident's weight as evidenced by the following note: (age) A&O (gender) from another SNF; known from that SNF. Diet regular diabetic diet, sugar sub, regular texture, feeds self, intakes 76-100%. No PIs. Admit wt. 369.8# (8/31)consistent w/previous SNF w/near significant gain x90-180d r/t excess kcalories w/between meal snacks/food related activities & good & adequate meal intakes. BMI=very severely obese. Further gain not desired but will depend on extra foods consumed. Weight gain should not occur w/intake of meals alone. Diet appropriate w/DM & adequate An assessment note by NP #131 on 11/04/24 at approximately 12:00 AM stated the following: Date of Service: 11/04/2024 Visit Type: Acute Chief Complaint / Nature of Presenting Problem: Acute visit History of Present Illness. [Resident] is being seen for an acute visit today. She is a (age and gender) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. Staff has noted increased swelling, redness, warmth and pain to BLE. She is sitting up in her wheelchair today on exam; she has been resisting recommendations to go back to bed and keep her legs elevated. Afebrile; VS WNL. Continues on cephalexin QID for cellulitis of BLE. Staff does report that she has been having increased/breakthrough pain in the early morning before her Norco is due; pain is in her left shoulder. Will add a once every 24 hours additional PRN dose of Norco. . Appetite is satisfactory. No significant weight change . Weight: 370.4 pounds; 11/4/2024 1:17:00 PM; .This patient is well developed and in no acute distress. Appears pleasant and cooperative. Answers questions appropriately. Respiratory: Lungs diminished throughout Normal respiratory effort. Time spent 20 minutes Signed Date: 11/07/2024 9:31:11 AM A review of resident's care plan on 11/19/24 at approximately 1:20 PM revealed the following: Observe for s/sx of elevated blood pressure: headache, altered vision, confusion, disorientation, lethargy, nausea/vomiting, irritability, seizure activity, dyspnea, edema. Report any abnormal findings to medical provider, resident / resident representative. Date Initiated: 09/10/2024 Revision on: 11/19/2024 Another encounter note by NP #131 on 11/08/2024 At 12:00 AM stated: Date of Service: 11/08/2024 Visit Type: Follow Up Transition of Care: No transition occurred. Details: This is a copy of a signed encounter note documented in GEHRIMED. Chief Complaint / Nature of Presenting Problem: Acute visit History of Present Illness: [Resident] is being seen for an acute visit today. She is a (age and gender) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. She reports she is feeling short of breath. She is sitting up in her wheelchair today on exam; she has been resisting recommendations to go back to bed and keep her legs elevated. Afebrile; VS WNL. Continues on cephalexin QID for cellulitis of BLE. .Appetite is satisfactory. No significant weight change. No fever, chills, or sweats reported. Respiratory: No dyspnea, cough or wheezing. Cardiovascular: No chest pain, tightness or palpitations. Gastrointestinal: No abdominal pain, nausea, vomiting, or change in bowel habits. Vital Signs/Constitutional Weight: 370.4 pounds; 11/4/2024 1:17:00 PM; This patient is well developed and in no acute distress. Appears pleasant and cooperative. Answers questions appropriately. Respiratory: Lungs diminished throughout Normal respiratory effort. Cardiovascular: Regular rhythm; no murmurs, rubs, or [NAME]. Gastrointestinal: The abdomen is soft and non-tender. There is no guarding or rigidity. Bowel sounds are present. There are no palpable masses. Continue to monitor meal intake, BMI and weights. J44.9: Chronic obstructive pulmonary disease, unspecified Reports shortness of breath Will get CXR and labs Spo2 currently 98% on room air Continue Advair Continue PRN albuterol sulfate Continue to monitor for s/s of any respiratory distress. I50.9: Heart failure, unspecified Report shortness of breath Will get chest x-ray and labs SPO2 98% on air currently Continue to monitor for acute exacerbations. Continue with Lasix. Monitor O2 sat and lung sounds Plan: Time spent 20 minutes ***** Document e-signed by NP #131 on [DATE] 11:22AM EST ***** Signed Date: 11/13/2024 at 11:22:47 AM A nursing note by LPN #130 on 11/08/24 at 1:28 PM stated: Resident called this nurse into room. Stated she was SOB. All vitals WNL, 02 was 98 RA. PRN inhaler was taken to resident. NP notified and observed. Orders for CXR, as well as a BNP, BMP. Will monitor. During an interview with the Director of Nursing (DON) on 11/19/24 at approximately 2:00 PM, the DON produced a copy of the x-ray results, which revealed that the resident's lungs were clear. An order on 11/08/2024 at 2:11 PM by NP #131 and was entered by LPN #130 Lasix Oral Tablet 20 MG (Furosemide) Give 20 mg by mouth one time a day for edema for 3 Days Give with 80mg to = 100mg total Record review revealed the following orders by NP #131. On 11/08/24 at 2:46 PM entered by LPN #130 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for asthma rinse and spit PRN Administration was: Effective Another order on 11/10/24 at 9:26 PM, entered by LPN #88 Ativan Oral Tablet 0.5 MG Give 1 tablet by mouth every 12 hours as needed for anxiety for 6 Months PRN Administration was: Effective Further record review revealed a progress note dated 11/11/24 at 10:11 AM by LPN #80 which stated: Appt with Dr (physician name) cancelled this morning due to transportation not being able to take her. This nurse called and cancelled her appt. This nurse spoke with resident in regards to rescheduling. Resident stated she needed to call and speak to her sister. Resident had this nurse speak to sister and sister states she will call and reschedule her appt with Dr. (physician name) herself and provide her own transportation for the resident. A follow up note by LPN # 80 on 11/11/24 at 3:20 PM stated: Resident outside in parking lot with her sister and Physical Therapist. Resident unable to get into personal vehicle. [Sister] was on the phone when this nurse walked outside. [Sister] had called 911 to have resident transported to her appt with Dr (physician name). This nurse explained that they could not transport her to her Dr appt. [Sister] states if she can't go to her Dr appt she wants her taken to ER to be evaluated for shortness of breath. Time of examination residents' oxygen was 99% and heart rate was 79. Resident was requesting that she go to the ER just to be checked out. Residents' sister had already called 911. This nurse spoke to facility NP #131 who ordered for resident to be sent to ER. Acute transfer letter, Transfer or Discharge Notice, Profile, Medication sheet, Post form and Capacity paper work sent to with resident. Report called to (name) ER. Records showed an order by NP #131 on 11/11/24 at 3:20 PM which stated: Send resident to (name) ER for shortness of breath one time only for 1 Day During an interview with the Director of Nursing (DON) on 11/19/24, at approximately 3:00 PM, the DON stated that the resident's transportation was canceled because she was attempting to visit her primary care provider. The facility did not encourage this visit, as they had their own Medical Director and Nurse Practitioners available to address the resident's needs. However, a review of the records revealed that the facility's Medical Director (MD) #132 had issued an order for the resident to see her primary care physician. This order was documented on November 8, 2024, at 11:32 AM by MD #132. Appt with Dr Med (Name) @ 10:30AM, (facility address), (name of ambulance service) to p/u @ 9:45AM On Monday, November 11, 2024 one time only for appt for 1 Day need to be in wheelchair under 32 in for w/c van. During an interview with LPN #80 on 11/20/24, at approximately 10:30 AM, LPN #80 stated that when she contacted transportation, she was informed that no arrangements had been made for the resident to visit her physician. LPN #80 also indicated that she was unaware of the order from MD #132. Record review revealed that Resident #155 was admitted to the hospital with a diagnosis of weight gain, edema, and congestive heart failure (CHF). As evidenced by the follow-up nursing note dated 11/11/24 at 9:18 PM by LPN #78 which stated:: called local hospital for status update resident being admitted for weight gain, edema, CHF. no room number at this time.

Based on observation and Interviews, the facility failed to ensure that resident's rooms and common areas were maintained at a comfortable temperature. Resident Room Identifiers: room [ROOM NUMBER], #205 and TV room. Facility Census: 109. Findings included: During a walk-through of the locked Alzheimer's unit on 11/19/24 at approximately 9:30 AM, Resident #35 in room [ROOM NUMBER] was observed on his bed, tightly bundled up in a blanket. Investigation revealed the P-tac unit was set to 67 degrees Fahrenheit. Resident did not respond to questions. Further observation revealed that the P-tac unit in room [ROOM NUMBER] was set to 65 degrees Fahrenheit. During an interview with the Director of Plant Maintenance (DPM) #30 at approximately 9:45 AM, a temperature check was requested. The DPM used an ambient air thermometer to check the temperature of room [ROOM NUMBER], and room [ROOM NUMBER]. The DPM confirmed that the ambient air temperature of room [ROOM NUMBER] was observed to be approximately 67 degrees Fahrenheit. The DPM then proceeded to check the temperature of room [ROOM NUMBER]. The ambient air temperature of room [ROOM NUMBER] was observed to be approximately 72 degrees Fahrenheit. The DPM was also requested to check the temperature of the TV Room. The DPM confirmed that the temperature of the TV room was recorded to be 67 degrees Fahrenheit. Resident #5 was observed on 11/19/24 at approximately 9:45 AM, walking down the hallway, stating I am feeling cold to LPN #113. LPN #113 stated come with me, I'll get you a blanket.

Based on record review and interview, a resident's necessary medical treatment was delayed due to a lack of ongoing clinical assessment and identification of changes in condition by the facility. This failure resulted in the resident being admitted to the hospital for edema and congestive heart failure. Resident Identifier: Resident #115. Facility Census: 109. Findings included: a) Resident #115 A closed record review of Resident #115's records was performed on 11/18/24 at approximately 11:15 AM. Record review revealed that Resident #115 was a (age and gender) diagnosed with Dementia, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), seizures, and hypertension. Record review on 11/19/24 at approximately 10:00 AM revealed a nursing note dated 10/26/224 at 2:48 PM by LPN #130, which stated: Resident sitting in WC in room at this time. Resident feet/ankles/legs have edema, pitting 3+. Resident is noted to be on 80mg of Lasix and can't to drink several drinks at a time as well as not elevating feet throughout the day. This nurse educated that she needed to elevate her feet d/t swelling. Resident stated, I should, maybe I'll lay down later and put them up. Further record review revealed that Resident #115 was examined by Nurse Practitioner (NP) #131 on 11/1/24 at 1:00 PM, and NP #131 had noted that the resident's bilateral lower extremities (BLE) red, warm, weeping skin. Painful to touch. Appears to be cellulitis. as evidenced by the following note: Date of Service: 11/01/2024 Chief Complaint / Nature of Presenting Problem: Acute visit History of Present Illness: [Resident] is being seen for an acute visit today. She is a (age and gender) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. The staff has noted increased swelling, redness, warmth, and pain to BLE. She is sitting up in her wheelchair today on exam; she has been resisting recommendations to go back to bed and keep her legs elevated. She does have clear serous fluid seeping from BLE. Afebrile; VS WNL. Will start cephalexin QID for cellulitis. Medication List: Cephalexin, Cephalexin Oral Capsule 500 MG, Give 1 capsule by mouth four times a day for cellulitis for 7 Days, 500MG, ACTIVE, 10/30/2024 to 11/6/2024 Hydrocodone-Acetaminophen, Hydrocodone-Acetaminophen Oral Tablet 5-325 MG, Give 1 tablet by mouth three times a day for pain, 5-325MG, ACTIVE, 10/29/2024 Cyclobenzaprine HCl, Cyclobenzaprine HCl Oral Tablet 10 MG, Give 1 tablet by mouth three times a day for muscle pain, 10MG, ACTIVE, 10/24/2024 Albuterol Sulfate, ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, 2 puff inhale orally every 4 hours as needed for cough, COVID, congestion, 108 (90 Base) MCG/ACT, ACTIVE, 9/11/2024 Throat Lozenges, Throat Lozenges Mouth/Throat Lozenge, Give 1 unit by mouth every 2 hours as needed for sore throat, ACTIVE, 9/11/2024 Fluticasone-Salmeterol Aerosol Powder Breath Activated 250-50 MCG/DOSE, 1 inhalation inhale orally every 12 hours for asthma rinse and spit, 250-50MCG/DOSE, ACTIVE, 9/2/2024 Albuterol Sulfate, Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT, 2 puff inhale orally every 6 hours as needed for asthma rinse and spit, 108 (90 Base) MCG/ACT, ACTIVE, 9/2/2024 Omeprazole 20 MG Capsule delayed release, Give 1 capsule by mouth in the morning for GERD, 20MG, ACTIVE, 8/31/2024 Furosemide, Furosemide Oral Tablet 80 MG, Give 1 tablet by mouth one time a day for edema, 80MG, ACTIVE, 8/31/2024 Lisinopril, Lisinopril Oral Tablet 5 MG, Give 1 tablet by mouth one time a day for HTN, 5MG, ACTIVE, 8/31/2024 Aripiprazole, Abilify Oral Tablet 10MG, Give 1 tablet by mouth one time a day for schizophrenia, 10MG, ACTIVE, 8/31/2024 Potassium Chloride ER Tablet Extended Release 10 MEQ, Give 1 tablet by mouth one time a day for supplement, 10MEQ, ACTIVE, 8/31/2024 Cholecalciferol, Cholecalciferol Oral Tablet 125 MCG (5000 UT), Give 1 tablet by mouth one time a day for supplement, 125 MCG (5000 UT), ACTIVE, 8/31/2024 Aspirin, Aspirin 81 Oral Tablet Chewable 81 MG, Give 1 tablet by mouth one time a day for prophylaxis to be on hold 9/21 through 9/27for EGD and colonoscopy, 81MG, ACTIVE, 8/31/2024 Duloxetine HCl, Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG, Give 1 capsule by mouth one time a day for depression, 60MG, ACTIVE, 8/31/2024 Levothyroxine Sodium, Levothyroxine Sodium Oral Tablet 75 MCG, Give 1 tablet by mouth in the morning for hypothyroidism, 75MCG, ACTIVE, 8/31/2024 Lamotrigine, lamotrigine Oral Tablet 150 MG, Give 1 tablet by mouth two times a day for seizures, 150MG, ACTIVE, 8/30/2024 Metoprolol Tartrate, Metoprolol Tartrate Oral Tablet 50 MG, Give 1 tablet by mouth two times a day for HTN, 50MG, ACTIVE, 8/30/2024 Apixaban, Apixaban Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for circulation on hold 9/23/24 through 9/27/24 for EGD and colonoscopy, 5MG,ACTIVE, 8/30/2024 Buspirone HCl, buspirone HCl Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for anxiety, 5MG, ACTIVE, 8/30/2024 Docusate Sodium, Docusate Sodium Oral Tablet 100 MG, Give 1 tablet by mouth two times a day for constipation, 100MG, ACTIVE, 8/30/2024 Atorvastatin Calcium 40 MG Tablet, Give 1 tablet by mouth at bedtime for cholesterol, 40MG, ACTIVE, 8/30/2024 Lorazepam, Ativan Oral Tablet 0.5 MG, Give 1 tablet by mouth every 12 hours as needed for anxiety for 6 Months, 0.5MG, ACTIVE, 8/30/2024 to 2/28/2025 ***reviewed Allergy List: No known medication allergies. Past Medical History: Seizures, Hyperlipidemia, CHF, Hypothyroidism, HTN, COPD, Dementia/ MDD, Insomnia, RLS CAD, Angina, A fib , Asthma, GERD, Hiatal Hernia, IBS/Constipation, OA, Anemia, Morbid Obesity Past Surgical History: History of surgery (11/08/2021), right ankle Arthroplasty of right shoulder (05/03/2017 Miscellaneous operations fibrous mass (benign) excision from the Right hand first webspace. Cardiac catheterization, Total knee replacement bilateral, Cholecystectomy, Removal of gallstones from liver, Hysterectomy, Surgical repair of prolapsed uterus, Defibrillator, Bilateral TKD Social History: Lives alone at home Family History: heart disease diabetes hypertension Review of Systems General: Appetite is satisfactory. No significant weight change. No fever, chills, or sweats reported. Respiratory: No dyspnea, cough or wheezing. Cardiovascular: No chest pain, tightness or palpitations. Gastrointestinal: No abdominal pain, nausea, vomiting, or change in bowel habits. Skin/Breast: +BLE redness/warmth/weeping suspect cellulitis Vital Signs/Constitutional Weight: 354.4 pounds; 9/16/2024 1:39:00 PM; Height: 64 inches; 9/6/2024 10:00:00 AM; Pulse: 76 BPM; 11/1/2024 10:20:19 AM; Blood Pressure: 136/76; 11/1/2024 10:20:19 AM; O2 Saturation: 96 Room Air; 10/18/2024 11:47:00 AM; Temperature: 98.1 Fahrenheit; 11/1/2024 10:20:19 AM; Respiratory Rate: 17 Breaths per minute; 10/18/2024 11:47:00 AM; BMI: 60.8; Pain Level: 5; 11/1/2024 10:20:40 AM; Blood Sugar: 120 mg/dL; 11/1/2024 4:57:28 AM; Physical Exam General: This patient is well developed and in no acute distress. Appears pleasant and cooperative. Answers questions appropriately. Respiratory: Lungs diminished throughout Normal respiratory effort. Cardiovascular: Regular rhythm; no murmurs, rubs, or [NAME]. Skin: BLE red, warm, weeping skin. Painful to touch. Appears to be cellulitis. Diagnosis and Assessment Assessment: CPT Codes: 99308 (1 unit) ICD Codes: L03.119: Cellulitis of lower extremity, unspecified laterality Start cephalexin QID Monitor for s/s of worsening infection R46.0: Poor hygiene Refusing bathing Educated patient on importance of regular bathing and possible increase risk of infections if not bathing regularly Increase Flexeril to three times daily to help with pain so patient is more willing to get a bath. E66.01: Morbid (severe) obesity due to excess calories BMI is now 53.6. Continue to monitor meal intake, BMI and weights. Continue on Mounjaro injection every week. Plan: Time spent 20 minutes ***** Document e-signed by [NP #131] on [DATE] 11:38AM EDT ***** Signed Date: 11/01/2024 10:38:41 AM While NP #131 noted that the resident's bilateral lower extremities (BLE) were red, warm, and weeping a clear serous fluid, NP #131 did not document or address the +3 pitting edema documented by LPN #130 on 10/26/24. In addition, NP #131 incorrectly noted the resident's most recent weight as 353.4 pounds (lbs). Record review on 11/19/24 at approximately 9:25 AM of Resident #115's chart revealed that the resident's weight on 10/02/24 had been 366.2 lbs. The resident had experienced a weight gain of 12.4 lbs. from 09/04/24 to 11/04/24. 11/4/24 at 1:17 PM 370.4 Lbs. 10/2/24 at 11:22 AM 366.2 Lbs. 10/01/24 at 9:04 AM 363.8 Lbs. 09/25/24 at 3:12 PM 356.8 Lbs. 09/16/24 at 1:39 PM 354.4 Lbs. 09/11/24 at 9:23 AM 356.8 Lbs. 09/05/24 at 4:14 PM 356.2 Lbs. 09/04/24 at 11:23 AM 358.0 Lbs. While NP #131 had documented on 11/01/24 at 1:00 PM that Resident #115's bilateral lower extremities (BLE) were red, warm, weeping skin. Painful to touch. Appears to be cellulitis. A nursing note by LPN #68 on 11/3/24 at 4:37 PM stated the following: Continues on ATB for cellulitis. BLE remain reddened and edematous. Resident states legs are seeping but staff has not observed any drainage. Asking if she should go to the hospital or not. Discussed with resident that NP and MD aware of cellulitis and this is why she is on ATB but if she chose to be sent out that we could notify MD. Resident then states she does not wish to go. A follow-up assessment by NP #131 on 11/04/24 at approximately 12:00 AM, while now noting the resident's current weight of 370.4 lbs., stated that Resident #115's Appetite is satisfactory. No significant weight change, and that Lungs diminished throughout Normal respiratory effort . Date of Service: 11/04/2024 Visit Type: Acute Chief Complaint / Nature of Presenting Problem: Acute visit History of Present Illness. [Resident] is being seen for an acute visit today. She is a (age and sex) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. Staff has noted increased swelling, redness, warmth and pain to BLE. She is sitting up in her wheelchair today on exam; she has been resisting recommendations to go back to bed and keep her legs elevated. Afebrile; VS WNL. Continues on cephalexin QID for cellulitis of BLE. Staff does report that she has been having increased/breakthrough pain in the early morning before her Norco is due; pain is in her left shoulder. Will add a once every 24 hours additional PRN dose of Norco. . Appetite is satisfactory. No significant weight change . Weight: 370.4 pounds; 11/4/2024 1:17:00 PM; .This patient is well developed and in no acute distress. Appears pleasant and cooperative. Answers questions appropriately. Respiratory: Lungs diminished throughout Normal respiratory effort. Time spent 20 minutes ***** Document e-signed by NP #131 on [DATE] 9:31AM EST ***** Signed Date: 11/07/2024 9:31:11 AM A review of resident's care plan on 11/19/24 at approximately 1:20 PM revealed the following: Observe for s/sx of elevated blood pressure: headache, altered vision, confusion, disorientation, lethargy, nausea / vomiting, irritability, seizure activity, dyspnea, edema. Report any abnormal findings to medical provider, resident / resident representative. Date Initiated: 09/10/2024 Revision on: 11/19/2024 Another encounter note by NP #131 on 11/08/2024 At 12:00 AM stated: Chief Complaint / Nature of Presenting Problem: Acute visit History of Present Illness: [Resident] is being seen for an acute visit today. She is a (age and gender) with Seizures, Hyperlipidemia, CHF, HTN, hypothyroidism, COPD, dementia, MDD. She reports she is feeling short of breath. She is sitting up in her wheelchair today on exam; she has been resisting recommendations to go back to bed and keep her legs elevated. Afebrile; VS WNL. Continues on cephalexin QID for cellulitis of BLE. .Appetite is satisfactory. No significant weight change. No fever, chills, or sweats reported. Respiratory: No dyspnea, cough or wheezing. Cardiovascular: No chest pain, tightness or palpitations. Gastrointestinal: No abdominal pain, nausea, vomiting, or change in bowel habits. Vital Signs/Constitutional Weight: 370.4 pounds; 11/4/2024 1:17:00 PM; This patient is well developed and in no acute distress. Appears pleasant and cooperative. Answers questions appropriately. Respiratory: Lungs diminished throughout Normal respiratory effort. Cardiovascular: Regular rhythm; no murmurs, rubs, or [NAME]. Gastrointestinal: The abdomen is soft and non-tender. There is no guarding or rigidity. Bowel sounds are present. There are no palpable masses. Continue to monitor meal intake, BMI and weights. J44.9: Chronic obstructive pulmonary disease, unspecified Reports shortness of breath Will get CXR and labs Spo2 currently 98% on room air Continue Advair Continue PRN albuterol sulfate Continue to monitor for s/s of any respiratory distress. I50.9: Heart failure, unspecified Report shortness of breath Will get chest x-ray and labs SPO2 98% on air currently Continue to monitor for acute exacerbations. Continue with Lasix. Monitor O2 sat and lung sounds Plan: Time spent 20 minutes ***** Document e-signed by NP #131 on [DATE] 11:22AM EST ***** Signed Date: 11/13/2024 11:22:47 AM Another nursing note by LPN # 130 on 11/08/24 at 1:28 PM stated that: Resident called this nurse into room. Stated she was SOB. All vitals WNL, 02 was 98 RA. PRN inhaler was taken to resident. NP notified and observed. Orders for CXR, as well as a BNP, BMP. Will monitor. During an interview with the DON on 11/19/24 at approximately 2:00 PM, the DON produced a copy of the x-ray results, which revealed that the resident's lungs were clear. Upon being contacted by the facility, on 11/08/2024 at 2:11 PM, NP #131 ordered: Lasix Oral Tablet 20 MG (Furosemide) Give 20 mg by mouth one time a day for edema for 3 Days Give with 80mg to = 100mg total This order was entered by LPN #130. Record review revealed that the following orders were prescribed by NP #131 on 11/08/24 at 2:46 PM, and entered by LPN #130 Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours as needed for asthma rinse and spit PRN Administration was: Effective NP #131 had prescribed another order on 11/10/24 at 9:26 PM, which was entered by LPN #88 Ativan Oral Tablet 0.5 MG Give 1 tablet by mouth every 12 hours as needed for anxiety for 6 Months PRN Administration was: Effective Further record review revealed a progress note dated 11/11/24 at 10:11 AM by LPN #80 which stated: Appt with Dr (name) cancelled this morning due to transportation not being able to take her. This nurse called and cancelled her appt. This nurse spoke with resident in regards to rescheduling. Resident stated she needed to call and speak to her sister. Resident had this nurse speak to sister and sister states she will call and reschedule her appt with Dr. (name) herself and provide her own transportation for the resident. A follow-up note by LPN # 80 on 11/11/24 at 3:20 PM stated: Resident outside in parking lot with her sister and Physical therapist. Resident unable to get into personal vehicle. [Sister] was on the phone when this nurse walked outside. [Sister] had called 911 to have resident transported to her appt with Dr [NAME]. This nurse explained that they could not transport her to her Dr appt. [Sister] states if she can't go to her Dr appt she wants her taken to ER to be evaluated for shortness of breath. Time of examination residents' oxygen was 99% and heart rate was 79. Resident was requesting that she go to the ER just to be checked out. Residents' sister had already called 911. This nurse spoke to facility NP #131 who ordered for resident to be sent to ER. Acute transfer letter, Transfer or Discharge Notice, Profile, Medication sheet, Post form and Capacity paper work sent to with resident. Report called to (named) ER. Records showed an order by NP #131 on 11/11/24 at 3:20 PM which stated: Send resident to (named) ER for shortness of breath one time only for 1 Day. During an interview with the DON on 11/19/24 at approximately 3:00 PM, the DON stated that resident's transportation was canceled because the resident was attempting to visit her primary care provider, and the facility did not encourage this because the facility had their own house Medical Director, and Nurse Practitioners, that could attend to the resident's needs. Record review, however, revealed that the facility's Medical Director (MD) #132, had written an order for the resident to visit her primary care physician as evidenced by the following order dated:11/08/24 at 11:32 AM by Medical Director (MD) #132 Appt with Dr (name) @ 10:30AM, (ambulance service name) to p/u @ 9:45AM On Monday, November 11, 2024 one time only for appt for 1 Day need to be in wheelchair under 32 in for w/c van During an interview with LPN #80 on 11/20/24 at approximately 10:30 AM, LPN #80 stated that when she contacted transportation, she had been notified that no transportation had been arranged for resident to visit her physician. LPN stated that she had no knowledge of the order by MD #132. A follow-up nursing note on 11/11/24 at 9:18 PM by LPN #78 stated: Called (hospital name) for status update resident being admitted for weight gain, edema, CHF. no room number at this time Record review and interviews make it evident that the facility failed to notify the physician of the resident's weight gain of over 12 pounds (lbs.) in two months, failed to obtain orders from the physician to address the weight gain, failed to notify the physician of the residents +3 pitting edema, as evidenced by the nursing and progress notes, and in addition, failed to follow a physician's order to transport resident to resident's primary care physician

Based on record review, staff interview, and observation the facility failed to provide palatable, attractive, and appetizing food. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 109. Findings included: a) Meals During a complaint investigation for Residents not being served nutritious and palatable meals found Resident Council Minutes: June 2024 - Concerning the meat is tough, residents not receiving substitutions and eggs not being cooked correctly. No response noted. - Meals do not match the menu. Response We are working to have more consistent offering. We are good as long as the meal matches the tray ticket. August 2024 - Meals are late. Response from the Administrator that meals will be late for various reasons. He encouraged the residents to ask for a snack. October 2024 - Rolls were flat and potatoes were cold. Response education to on temperature of food and presentation of food was given to dietary staff. - Meals are coming late. No response at this time. Review of greivance forms found: -06/03/24 - Roast Beef was to hard to chew. Resolution -Cooking it in a different way -06/10/24 - Time of meals are usually late, meat, fish and eggs are over cooked and tough. Resolution- Posted meal times are times meal starting to be served but not all floors/residents/ can recieve meals at exact times. Staff educated on keeping meals on schedule. On 11/19/24 a test tray was obtained from the Kitchen, Menu stated Salisbury steak, sliced glazed carrots, egg noodles, buttered dinner roll/bread, spiced peaches. -Carrots were palatable, no glaze present. -Egg Noodles, has a mushy consistency, and not appetizing to taste. -Bread- no rolls. On 11/19/24 an observation of the Dining room [ROOM NUMBER]:24 PM found Residents served mashed potatoes in place of egg noodles . During an interview on 11/19/24 at about 12:38 PM the Administrator stated the kitchen did not prepare enough egg noodles. He stated that they were preparing more at this time. On 11/19/24 around 2:15 PM the recipe was reviewed for the egg noodles. During an interview on 11/19/24 at about 2:30 PM the Administrator verified the issues with the noon meal. He stated that the kitchen staff just didn't prepare the rolls, and didn't follow the recipe for the egg noodles, they steamed the noodles instead of boiling them.

Based on record review, staff interview, and observation the facility failed to provide palatable, attractive, and appetizing food at a scheduled time. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 109. Findings included: a) Meal times During a complaint investigation for Residents not being served meals on time meals found Resident Council Minutes: August 2024 -Meals are late. Response from the Administrator that meals will be late for various reasons. He encouraged the residents to ask for a snack. October 2024 -Rolls were flat and potatoes were cold. Response education to on temperature of food and presentation of food was given to dietary staff. - Meals are coming late. No response at this time. Review of grievance forms found: -06/10/24 - Time of meals are usually late, meat, fish and eggs are over cooked and tough. Resolution- Posted mealtimes are times meal starting to be served but not all floors /residents/ can receive meals at exact times. Staff educated on keeping meals on schedule. During an interview on 11/19/24 at about 12:30 PM with Interviews were conducted with staff throughout the survey process with, Nurse Aide (NA) #49, NA # NA #5, Licensed Practical Nurse (LPN) #68, voiced concerns about mealtimes being so late and not on a scheduled time. An observation of the facility found no mealtimes posted. During an interview on 11/19/24 at about 2:30 PM the Administrator verified that mealtimes were not posted, and they have had some issues with consistency in meal time. He also stated that they just recently changed the times the meal carts come out.

Based on record review, staff interview, visitor interview and resident interview the facility failed to provide Resident #19 with a reasonable accommodation of need that suited her preference for locomotion. Resident #19 had a motorized wheelchair that she had used for ten (10) years. The facility felt she was not safe to operate it anymore and took the batteries from the chair therefore disabling it. This left the feeling depressed and trapped as she had used this chair to travel throughout the facility. She suffered psychological harm due to this. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Resident identifier: #19. Facility Census: 110. Findings included: a) Resident #19 On 05/23/23 at 3:51 PM it was brought to the attention of the survey team by a concerned visitor at the facility that Resident #19 had her motorized wheelchair batteries taken away from her several months ago and the facility would not return her batteries to her nor would they allow her to use her motorized wheelchair for mobility. The visitor indicated this had been Resident #19's only form of mobility since her admission to facility which was [AGE] years ago. A review of Resident #19's medical record beginning at 4:00 PM on 05/23/23 found Resident #19 was admitted to the facility on [DATE] at which time she used a motorized wheelchair for mobility to assist her in getting around the facility and for getting around in her room. Further review of the medical record found on 10/24/22 there was a physician order entered into the record discontinuing the use of the motorized wheelchair for Resident#19. An interview with Resident #19 at 3:37 PM on 05/24/23 revealed the following: When asked why she was no longer able to use her motorized wheelchair Resident #19 stated, A while ago I was down by the nurses' station in my wheelchair. The Med (Medication) cart was there and in the way. There was a gentleman who had his feet out blocking my way. Another woman was behind me and kept pushing on my wheelchair. I was afraid she was going to break my chair by pushing on it. I asked him to move his feet three times and he did not, so I ran over them. I did not have any other choice because the woman kept pushing on my chair and I did not want her to break my chair. Resident #19 continued to state that later that evening they took her battery and had not given it back since. When asked how losing her ability to use her motorized wheelchair made her feel she stated, I feel like I am trapped and have been in jail. The resident said, Nine (9) months is a long enough punishment for what I did don't you think. When it first happened, I was sad and now I am just angry because I cannot go like I was able to then. She further stated, They told me they would take me to all the activities, but they don't, there is not enough staff to get me there. She also stated, Physical Therapy asked me to give them my chair so someone else could use it, but it's my chair and I want to use it. The facility presented an incident report dated 10/22/22 for Resident #471, this incident indicated Resident #19 ran over Resident #471's feet with her motorized wheelchair. The incident report indicated Resident #19 was not paying attention while driving her motorized wheelchair as the cause of this accident. However, Resident #19's account of the incident does not indicate she was not paying attention. Her recount of the incident demonstrates there were several extenuating circumstances such as the medication cart being parked in the way, the resident being asked to move his feet and did not, and the other female resident who was continually pushing on the back of her wheelchair. The resident felt she made the only decision available to her because no staff was present to assist with eliminating any of the factors inhibiting her ability to pass by the area safely. The following pertinent information was obtained from Resident #471's medical record: A nurses note dated 10/22/22 at 7:17 PM which read as follows, This nurse informed by staff that resident of (room Number of Resident #19) ran over (First and Last Name of Resident #471) feet with motorized wheelchair. Resident stated both feet when asked by this nurse. Upon Assessment. No Redness, bruising, or swelling noted. Right Hallux began bleeding during assessment. This toe already had a band aid treatment in place. Right Hallux cleaned and new Band-Aid applied. Resident currently propelling self with legs down the hallway in wheelchair. Denies pain at present. Physician and Wife/POA notified. Additional note in Resident #471's record dated 10/23/22 at 6:28 PM read as follows, Results from X-ray of feet received. No acute fracture or dislocation. Findings consistent with gout. Resident #471's diagnosis included, Vascular Dementia with behavioral disturbance, lack of coordination, and anxiety disorder. On 05/24/23 at 10:33 am an interview with Occupational Therapist (OT) #172, confirmed Resident #19 was no longer allowed to use her motorized wheelchair. He stated they did evaluations on all residents who have a motorized wheelchair and the first thing they look at is decision making capacity. He stated if a resident loses capacity, they no longer can make right decisions. He stated there was also one (1) incident where the resident ran over someone's toes, and it coincided with the resident's annual assessment. He stated her scores on her cognitive tests had decreased so he referred her to the psychologist to evaluate her capacity. The Mental Health Nurse Practitioner evaluated the resident the following day on 10/14/22 and noted no issues with the resident using her motorized wheelchair nor any cognitive issues which would impair Resident #19's ability to make medical decisions. When asked if the reason Resident #19 was no longer allowed to use her motorized wheelchair was because she lost capacity to make medical decisions? OT #172 stated, Yes that is the main reason. Resident #19's medical record contained a Physician's Determination of Capacity indicating Resident #19 lacked capacity to make medical decisions. This capacity statement was dated 11/07/22. This was completed two (2) weeks after Resident #19's batteries were taken from her, and only three (3) weeks after the evaluation by the Mental Health Nurse Practitioner which noted no concerns related Resident #19's decision making ability. OT #172 was asked to provide copies of the cognitive tests he performed on Resident #19 which he spoke of during his interview. A review of these test found the following information (Please note all tests were performed prior to the incident which took place on 10/24/22): - Brief Interview of Mental Status (BIMS) : Score 13 of 15. This score indicates Intact Cognitive response. (Please note a review of the OT discharge summary for the dates of service from 09/28/22 - 10/13/22 indicated Resident #19's baseline score on the BIMS was 13 of 15 on 09/28/22 (which was one (1) month prior to Resident #19 being told she could no longer use her motorized wheelchair.) - Brief Cognitive Assessment Tool (BCAT): Score 33 of 50. This score indicates mild dementia. (This score was noted on 10/13/22) - Saint [NAME] University Mental Status Exam (SLUMS): 14 of 30. This score indicates dementia. (This score was also noted on 10/13/22). During an interview with the Nursing Home Administrator (NHA) at 4:05 PM on 05/24/23 he stated, If a resident does not have decision making ability (Capacity to make medical decisions) they are not able to use a powered wheelchair because they cannot make safe decisions. That is how it has always been in this building; I just went along with it. I think there are other instances of her being unsafe I'll bring you the documentation. At the conclusion of the survey on 05/30/23 at 3:45 PM the NHA had not provided any further documentation to confirm Resident #19 had any other instances in her motorized wheelchair which made her unsafe to operate it other than the incident on 10/24/22. A further review of the medical record was completed on 05/24/23 and the following information was found: a nursing progress note dated 10/25/22 at 3:45 PM which read as follows, Spoke with friends of resident at residents request regarding her wheelchair that is motorized not being authorized for her use at this time due to safety concerns. (First and last name of Two (2) friends) contacted and returned the phone calls with social worker. Explained situation of resident running over other residents and bumping into doorways and walls and things in hallways and room with her power chair and the safety concerns this presents to others and herself. Informed resident would be evaluated by therapy and psychology at this time for her ability to use her chair safely. Further review of the medical record did not reflect any assessments or evaluations for the use of a manual wheelchair. An interview with Social Worker #82, who has been employed at the facility since 09/23/13, at 11:22 am on 05/25/23 regarding this note found she was the Social Worker who had spoken with Resident #19's friends. When asked what other residents Resident #19 run over she had stated, I know she ran over the one resident's toes. She was unable to provide any documentation of any other instances when Resident #19 ran over other residents. When asked if she could remember a time the resident had run over any other residents she could not. When asked when the incidents occurred where she ran into doorways and walls and other things in the hallways the Social Worker was unable to recall any of these incidents specifically. She was asked to provide documentation from the medical record to support this statement and at of the time of exit on 05/30/23 at 3:45 PM no further documentation to support these statements was provided. The psychologist did assess Resident #19 at the request of the facility following the incident on 10/24/23, and the following is his note related to his assessment completed on 10/28/22, Patient is an [AGE] year old female for examination due to her demonstrated inability to perform carious tasks such as safely operating her motorized wheelchair. The patient was seen in her room at the above long term care facility and the nature and extent of this examination was presented to her. She stated that she understood the purpose of this examination and voiced no objections. Patient stated that she was ready to actively participate and appeared to offer information freely. At the end patient stated that she did her best on each question and the results were presented to her shortly after the examination. Patient was administered the Neurobehavioral Cognitive Status Examination (COGNISTAT) for the purpose of today's examination. This standardized assessment instrument measures various cognitive abilities across 11 different ability domains. Regarding level of consciousness, orientation, and attention patient scored in the average range of abilities. Patient also scored in the average range of abilities on tasks comprehension. On tasks of naming and repetition, patient's scores were in the mildly impaired range, while tasks calculations and judgment were in the moderately impaired range. Lastly, tasks that required constructional abilities, memory and reasoning were in the severely impaired range. From these scores it appears that this patient lacks the basic understanding or ability to fully appreciate the impact or consequences of some of her actions or behaviors. Additionally, patient appeared quite focused on the issue of being able to operate her motorized wheelchair without any regard for the safety of those around her. Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities, and friendships she has without this device. These and other issues will be addressed during upcoming psychotherapy sessions. Thank you for the opportunity to serve this resident. As always, please do not hesitate to contact me with and questions or concerns. The NHA, OT #172 and Social Worker #82 was asked during their interviews if this psychologist ever actually watched this resident drive her motorized wheelchair, they all three (3) said he did not he only did the cognitive portion in which he stated it appeared she did not have the ability to safely operate her motorized wheelchair. Resident #19 voiced her concerns to the psychologist about not having her independence with her motorized wheel chair and how this was going to affect her ability to participate in the events in the facility she enjoyed as evidenced by the psychologist's statement from his report which read, Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities and friendships she has without this device. The facility claimed they transport the resident to all desired activities, but Resident #19's medical record does not support this claim. The following progress notes were written by Activities Leader (AL) #17. The first note is prior to the resident losing her ability to drive her motorized wheelchair and the second note is after. The notes read as follow: -- Note dated 10/07/22 at 9:26 am, (this was just 17 days before Resident #19 lost her privileges to operate her motorized wheelchair): (First and Last Name of Resident #19) is reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports independently via her motorized wheelchair. (First name of Resident #19) eats all her meals in her room due to Covid- 19 and social distancing. (First name of Resident #19) has a cell phone and is familiar with using it. (First name of Resident #19) enjoys sleeping in, snacking, watching television, listening to Elvis [NAME], doing her make up, her nails, spending time with pets and time outdoors when it is warm. (First name of Resident #19) enjoys using social media, especially Facebook. (First name of Resident #19) enjoys attending church services and meeting with the facility chaplain. (First name of Resident #19) enjoys playing bingo with staff assistance. (First name of Resident #19) enjoys food related activities, musical performances, parties and social events, pet therapies, seasonable activities, some games and observing some crafts. (First name of Resident #19) enjoys using her tablet to shop online. (First name of Resident #19) checks on the facility fish tank daily, she enjoys watching the fish and making sure they eaten. (First name of Resident #19) has friends at the facility and will occasionally visit their rooms and chat. (First name of Resident #19) enjoys going on outings when able. Activities staff will continue to encourage (First name of Resident #19) to participate in activities of her choosing both in and out of her room. Activities staff will continue to offer supplies for independent self-directed activities. Care plan has been reviewed and updated. -- Note dated 12/27/22 at 11:18 am (this is two (2) months after Resident #19 was no longer allowed to use her motorized wheelchair) : (First and last name of Resident #19) reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports via wheelchair with assistance from staff. (First name of Resident #19) recently lost the use of her wheelchair battery and has participated in activities far less. (First name of Resident #19) no longer visits friends throughout the facility due to her lack of independent mobility. (First name of Resident #19) will mostly stay in her room, watch television, and listen to music. (First name of Resident #19) eats all her meals in her room due to covid 19 and social distancing. (First name of Resident #19) visits the facility chaplain. (First name of Resident #19) enjoys having her hair done and nails painted. (First name of Resident #19) enjoys using her tablet to browse social media and online shop. Activities staff will continue to offer supplies for independent self-directed activities and continue to invite and encourage group activity participation. Care plan has been updated. The psychologist also indicated he would address these concerns with the resident in upcoming psychotherapy sessions. The social worker also stated she had referred the resident to the psychologist for psychotherapy sessions. A review of the record found the resident was not seen by the psychologist until 02/23/23 which was four (4) months after the initial evaluation determining she could no longer use her motorized wheelchair. During this visit the psychologist stated he was seeing the patient for depression. He again evaluated the patient's ability to safely operate her motorized wheelchair. He noted the following in regard to this evaluation: The patient responded that the current year was 2024, was unable to complete tasks of concentration, comprehension and attention. She could not recall three items after a brief interference. In summary, this patient was unable to successfully complete basic cognitive functions. Subsequently, she would likely lack the necessary cognitive and physical skills to safely operate her motorized wheelchair throughout the building, especially in areas where other elderly residents were walking with walkers etc. Also, in this note the psychologist indicated he would see the patient for psychotherapy and would see her everyone (1) to three (3) weeks for three (3) months. This was noted on 02/23/23. On 05/25/23 Social worker #82 confirmed the psychologist had not seen the resident since 02/23/23. Further review of the medical record found Resident #19 was discharged from Occupational Therapy on 10/13/22. The discharge recommendations and status on this report written by OT #172 read as follows: Discharge recommendations: PT (patient) dc (discontinued) from OT Tx(treatment) 10/13/22. PT demonstrated MOD I (Modified Independent) with power w/c (wheelchair) propulsion. COG (cognitive ) assessments at time of d/c BCAT 33 Slums 14/30 KT 18/21 showed cognitive impairment, discussed findings with social services. Social Services possibly refer for capacity assessment. Also contained in the medical record was a Comprehensive Psychiatric Evaluation which was completed the day after her discharge from OT on 10/14/22 at 2:00 PM by a Mental Health Nurse Practitioner who works with the psychologist who has completed the above-mentioned psychological evaluations. This assessment contained the following pertinent information: . Patient was a fair Historian.She was pleasant and cooperative. Orientated to person, time, situation and place. Her speech is slightly unclear with normal volume and slow rate. Her affect was reactive, congruent, and appropriate. Thought process is tangential. No psychosis noted. (first name of Resident #19) concentration is good. Psychomotor activity was noted as fidgeting. Patient is non ambulatory and uses automated wheelchair. Her recent remote memory is good. Her insight and judgement is adequate On 05/25/23 at approximately 11:15 AM when the NHA and Social Worker #82 in separate interviews, was asked what happened between 10/13/22 and 10/14/22 until 10/24/22 they both referred to the incident involving Resident #471. When asked if they had asked Resident #19 why she had run over the other residents toes they remained silent. They both again reiterated the resident was no longer capacitated so she could not use the motorized wheelchair. A review of the Resident #19's minimum data sets found the following information: -- An annual with an assessment reference date (ARD) of 7/14/22 (the assessment prior to losing the use of her motorized vehicle) found Section G00110 E.(Locomotion on unit) was coded with a 0 to indicate Resident #19 was independent with this Activity of Daily Living (ADL). And section G00110 F. Locomotion off unit was coded with a 0 to indicate the resident was independent with ADL. -- A quarterly with an ARD of 12/26/22 (The assessment following the loss of her motorized wheelchair) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. Section G00110 F. (Locomotion off unit) was coded with a 3 to indicate the resident was and extensive assist with this ADL and she could no longer perform it without the assistance of staff. -- A quarterly with an ARD of 03/16/23 (The most recent assessment) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. In an interview with the NHA on 05/25/23 at 11:08 AM the NHA stated, We made the decision based on the information we had, and we stand by that decision as being a right decision. He stated there was past incidents, but they were not documented. When asked what the incidents were, he was unable to verbally describe any other incidents other than the one which occurred on 10/24/22. When asked if there were any other incident reports involving Resident #19 and her motorized wheelchair he stated there was not. When asked if he knew how Resident #19 felt about this decision he stated, We know she is not happy about it. At the conclusion of the survey on 05/30/23 at 3:45 PM no further information was provided related to Resident #19 no longer being able to use her motorized wheelchair.

Based on record review, staff interview, visitor interview, and resident interview the facility failed to ensure Resident #19 was free from abuse. Resident #19 had a motorized wheelchair that she had used for ten (10) years. The facility felt she was not safe to operate it anymore and took the batteries from the chair therefore disabling it. This left the feeling depressed and trapped as she had used this chair to travel throughout the facility and attend activities. She suffered psychological harm due to this. This was true for one (1) of four (4) residents reviewed for the care area of abuse. Resident identifier: #19. Facility Census: 110. Findings included: a) Resident #19 On 05/23/23 at 3:51 PM it was brought to the attention of the survey team by a concerned visitor at the facility that Resident #19 had her motorized wheelchair batteries taken away from her several months ago and the facility would not return her batteries to her nor would they allow her to use her motorized wheelchair for mobility. The visitor indicated this had been Resident #19's only form of mobility since her admission to facility which was [AGE] years ago. A review of Resident #19's medical record beginning at 4:00 PM on 05/23/23 found Resident #19 was admitted to the facility on [DATE] at which time she used a motorized wheelchair for mobility to assist her in getting around the facility and for getting around in her room. Further review of the medical record found on 10/24/22 there was a physician order entered into the record discontinuing the use of the motorized wheelchair for Resident#19. An interview with Resident #19 at 3:37 PM on 05/24/23 revealed the following: When asked why she was no longer able to use her motorized wheelchair Resident #19 stated, A while ago I was down by the nurses' station in my wheelchair. The Med (Medication) cart was there and in the way. There was a gentleman who had his feet out blocking my way. Another woman was behind me and kept pushing on my wheelchair. I was afraid she was going to break my chair by pushing on it. I asked him to move his feet three times and he did not, so I ran over them. I did not have any other choice because the woman kept pushing on my chair and I did not want her to break my chair. Resident #19 continued to state that later that evening they took her battery and had not given it back since. When asked how losing her ability to use her motorized wheelchair made her feel she stated, I feel like I am trapped and have been in jail. The resident said, Nine (9) months is a long enough punishment for what I did don't you think. When it first happened, I was sad and now I am just angry because I cannot go like I was able to then. She further stated, They told me they would take me to all the activities, but they don't, there is not enough staff to get me there. She also stated, Physical Therapy asked me to give them my chair so someone else could use it, but it's my chair and I want to use it. The facility presented an incident report dated 10/22/22 for Resident #471, this incident indicated Resident #19 ran over Resident #471's feet with her motorized wheelchair. The incident report indicated Resident #19 was not paying attention while driving her motorized wheelchair as the cause of this accident. However, Resident #19's account of the incident does not indicate she was not paying attention. Her recount of the incident demonstrates there were several extenuating circumstances such as the medication cart being parked in the way, the resident being asked to move his feet and did not, and the other female resident who was continually pushing on the back of her wheelchair. The resident felt she made the only decision available to her because no staff was present to assist with eliminating any of the factors inhibiting her ability to pass by the area safely. The following pertinent information was obtained from Resident #471's medical record: A nurses note dated 10/22/22 at 7:17 PM which read as follows, This nurse informed by staff that resident of (room Number of Resident #19) ran over (First and Last Name of Resident #471) feet with motorized wheelchair. Resident stated both feet when asked by this nurse. Upon Assessment. No Redness, bruising, or swelling noted. Right Hallux began bleeding during assessment. This toe already had a band aid treatment in place. Right Hallux cleaned and new Band-Aid applied. Resident currently propelling self with legs down the hallway in wheelchair. Denies pain at present. Physician and Wife/POA notified. Additional note in Resident #471's record dated 10/23/22 at 6:28 PM read as follows, Results from X-ray of feet received. No acute fracture or dislocation. Findings consistent with gout. Resident #471's diagnosis included, Vascular Dementia with behavioral disturbance, lack of coordination, and anxiety disorder. On 05/24/23 at 10:33 am an interview with Occupational Therapist (OT) #172, confirmed Resident #19 was no longer allowed to use her motorized wheelchair. He stated they did evaluations on all residents who have a motorized wheelchair and the first thing they look at is decision making capacity. He stated if a resident loses capacity, they no longer can make right decisions. He stated there was also one (1) incident where the resident ran over someone's toes, and it coincided with the resident's annual assessment. He stated her scores on her cognitive tests had decreased so he referred her to the psychologist to evaluate her capacity. The Mental Health Nurse Practitioner evaluated the resident the following day on 10/14/22 and noted no issues with the resident using her motorized wheelchair nor any cognitive issues which would impair Resident #19's ability to make medical decisions. When asked if the reason Resident #19 was no longer allowed to use her motorized wheelchair was because she lost capacity to make medical decisions? OT #172 stated, Yes that is the main reason. Resident #19's medical record contained a Physician's Determination of Capacity indicating Resident #19 lacked capacity to make medical decisions. This capacity statement was dated 11/07/22. This was completed two (2) weeks after Resident #19's batteries were taken from her, and only three (3) weeks after the evaluation by the Mental Health Nurse Practitioner which noted no concerns related Resident #19's decision making ability. OT #172 was asked to provide copies of the cognitive tests he performed on Resident #19 which he spoke of during his interview. A review of these test found the following information (Please note all tests were performed prior to the incident which took place on 10/24/22): - Brief Interview of Mental Status (BIMS) : Score 13 of 15. This score indicates Intact Cognitive response. (Please note a review of the OT discharge summary for the dates of service from 09/28/22 - 10/13/22 indicated Resident #19's baseline score on the BIMS was 13 of 15 on 09/28/22 (which was one (1) month prior to Resident #19 being told she could no longer use her motorized wheelchair.) - Brief Cognitive Assessment Tool (BCAT): Score 33 of 50. This score indicates mild dementia. (This score was noted on 10/13/22) - Saint [NAME] University Mental Status Exam (SLUMS): 14 of 30. This score indicates dementia. (This score was also noted on 10/13/22). During an interview with the Nursing Home Administrator (NHA) at 4:05 PM on 05/24/23 he stated, If a resident does not have decision making ability (Capacity to make medical decisions) they are not able to use a powered wheelchair because they cannot make safe decisions. That is how it has always been in this building; I just went along with it. I think there are other instances of her being unsafe I'll bring you the documentation. At the conclusion of the survey on 05/30/23 at 3:45 PM the NHA had not provided any further documentation to confirm Resident #19 had any other instances in her motorized wheelchair which made her unsafe to operate it other than the incident on 10/24/22. A further review of the medical record was completed on 05/24/23 and the following information was found: a nursing progress note dated 10/25/22 at 3:45 PM which read as follows, Spoke with friends of resident at residents request regarding her wheelchair that is motorized not being authorized for her use at this time due to safety concerns. (First and last name of Two (2) friends) contacted and returned the phone calls with social worker. Explained situation of resident running over other residents and bumping into doorways and walls and things in hallways and room with her power chair and the safety concerns this presents to others and herself. Informed resident would be evaluated by therapy and psychology at this time for her ability to use her chair safely. Further review of the medical record did not reflect any assessments or evaluations for the use of a manual wheelchair. An interview with Social Worker #82, who has been employed at the facility since 09/23/13, at 11:22 am on 05/25/23 regarding this note found she was the Social Worker who had spoken with Resident #19's friends. When asked what other residents Resident #19 run over she had stated, I know she ran over the one resident's toes. She was unable to provide any documentation of any other instances when Resident #19 ran over other residents. When asked if she could remember a time the resident had run over any other residents she could not. When asked when the incidents occurred where she ran into doorways and walls and other things in the hallways the Social Worker was unable to recall any of these incidents specifically. She was asked to provide documentation from the medical record to support this statement and at of the time of exit on 05/30/23 at 3:45 PM no further documentation to support these statements was provided. The psychologist did assess Resident #19 at the request of the facility following the incident on 10/24/23, and the following is his note related to his assessment completed on 10/28/22, Patient is an [AGE] year old female for examination due to her demonstrated inability to perform carious tasks such as safely operating her motorized wheelchair. The patient was seen in her room at the above long term care facility and the nature and extent of this examination was presented to her. She stated that she understood the purpose of this examination and voiced no objections. Patient stated that she was ready to actively participate and appeared to offer information freely. At the end patient stated that she did her best on each question and the results were presented to her shortly after the examination. Patient was administered the Neurobehavioral Cognitive Status Examination (COGNISTAT) for the purpose of today's examination. This standardized assessment instrument measures various cognitive abilities across 11 different ability domains. Regarding level of consciousness, orientation, and attention patient scored in the average range of abilities. Patient also scored in the average range of abilities on tasks comprehension. On tasks of naming and repetition, patient's scores were in the mildly impaired range, while tasks calculations and judgment were in the moderately impaired range. Lastly, tasks that required constructional abilities, memory and reasoning were in the severely impaired range. From these scores it appears that this patient lacks the basic understanding or ability to fully appreciate the impact or consequences of some of her actions or behaviors. Additionally, patient appeared quite focused on the issue of being able to operate her motorized wheelchair without any regard for the safety of those around her. Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities, and friendships she has without this device. These and other issues will be addressed during upcoming psychotherapy sessions. Thank you for the opportunity to serve this resident. As always, please do not hesitate to contact me with and questions or concerns. The NHA, OT #172 and Social Worker #82 was asked during their interviews if this psychologist ever actually watched this resident drive her motorized wheelchair, they all three (3) said he did not he only did the cognitive portion in which he stated it appeared she did not have the ability to safely operate her motorized wheelchair. Resident #19 voiced her concerns to the psychologist about not having her independence with her motorized wheel chair and how this was going to affect her ability to participate in the events in the facility she enjoyed as evidenced by the psychologist's statement from his report which read, Patient voiced no appreciation for her own physical deficits in relation to the safe operation of her motorized wheelchair and how she could still enjoy the events, activities and friendships she has without this device. The facility claimed they transport the resident to all desired activities, but Resident #19's medical record does not support this claim. The following progress notes were written by Activities Leader (AL) #17. The first note is prior to the resident losing her ability to drive her motorized wheelchair and the second note is after. The notes read as follow: -- Note dated 10/07/22 at 9:26 am, (this was just 17 days before Resident #19 lost her privileges to operate her motorized wheelchair): (First and Last Name of Resident #19) is reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports independently via her motorized wheelchair. (First name of Resident #19) eats all her meals in her room due to Covid- 19 and social distancing. (First name of Resident #19) has a cell phone and is familiar with using it. (First name of Resident #19) enjoys sleeping in, snacking, watching television, listening to Elvis [NAME], doing her make up, her nails, spending time with pets and time outdoors when it is warm. (First name of Resident #19) enjoys using social media, especially Facebook. (First name of Resident #19) enjoys attending church services and meeting with the facility chaplain. (First name of Resident #19) enjoys playing bingo with staff assistance. (First name of Resident #19) enjoys food related activities, musical performances, parties and social events, pet therapies, seasonable activities, some games and observing some crafts. (First name of Resident #19) enjoys using her tablet to shop online. (First name of Resident #19) checks on the facility fish tank daily, she enjoys watching the fish and making sure they eaten. (First name of Resident #19) has friends at the facility and will occasionally visit their rooms and chat. (First name of Resident #19) enjoys going on outings when able. Activities staff will continue to encourage (First name of Resident #19) to participate in activities of her choosing both in and out of her room. Activities staff will continue to offer supplies for independent self-directed activities. Care plan has been reviewed and updated. -- Note dated 12/27/22 at 11:18 am (this is two (2) months after Resident #19 was no longer allowed to use her motorized wheelchair) : (First and last name of Resident #19) reviewed for a quarterly review. (First name of Resident #19) can communicate her needs and preferences to activities staff. (First name of Resident #19) transports via wheelchair with assistance from staff. (First name of Resident #19) recently lost the use of her wheelchair battery and has participated in activities far less. (First name of Resident #19) no longer visits friends throughout the facility due to her lack of independent mobility. (First name of Resident #19) will mostly stay in her room, watch television, and listen to music. (First name of Resident #19) eats all her meals in her room due to covid 19 and social distancing. (First name of Resident #19) visits the facility chaplain. (First name of Resident #19) enjoys having her hair done and nails painted. (First name of Resident #19) enjoys using her tablet to browse social media and online shop. Activities staff will continue to offer supplies for independent self-directed activities and continue to invite and encourage group activity participation. Care plan has been updated. The psychologist also indicated he would address these concerns with the resident in upcoming psychotherapy sessions. The social worker also stated she had referred the resident to the psychologist for psychotherapy sessions. A review of the record found the resident was not seen by the psychologist until 02/23/23 which was four (4) months after the initial evaluation determining she could no longer use her motorized wheelchair. During this visit the psychologist stated he was seeing the patient for depression. He again evaluated the patient's ability to safely operate her motorized wheelchair. He noted the following in regard to this evaluation: The patient responded that the current year was 2024, was unable to complete tasks of concentration, comprehension and attention. She could not recall three items after a brief interference. In summary, this patient was unable to successfully complete basic cognitive functions. Subsequently, she would likely lack the necessary cognitive and physical skills to safely operate her motorized wheelchair throughout the building, especially in areas where other elderly residents were walking with walkers etc. Also, in this note the psychologist indicated he would see the patient for psychotherapy and would see her everyone (1) to three (3) weeks for three (3) months. This was noted on 02/23/23. On 05/25/23 Social worker #82 confirmed the psychologist had not seen the resident since 02/23/23. Further review of the medical record found Resident #19 was discharged from Occupational Therapy on 10/13/22. The discharge recommendations and status on this report written by OT #172 read as follows: Discharge recommendations: PT (patient) dc (discontinued) from OT Tx(treatment) 10/13/22. PT demonstrated MOD I (Modified Independent) with power w/c (wheelchair) propulsion. COG (cognitive ) assessments at time of d/c BCAT 33 Slums 14/30 KT 18/21 showed cognitive impairment, discussed findings with social services. Social Services possibly refer for capacity assessment. Also contained in the medical record was a Comprehensive Psychiatric Evaluation which was completed the day after her discharge from OT on 10/14/22 at 2:00 PM by a Mental Health Nurse Practitioner who works with the psychologist who has completed the above-mentioned psychological evaluations. This assessment contained the following pertinent information: . Patient was a fair Historian.She was pleasant and cooperative. Orientated to person, time, situation and place. Her speech is slightly unclear with normal volume and slow rate. Her affect was reactive, congruent, and appropriate. Thought process is tangential. No psychosis noted. (first name of Resident #19) concentration is good. Psychomotor activity was noted as fidgeting. Patient is non ambulatory and uses automated wheelchair. Her recent remote memory is good. Her insight and judgement is adequate On 05/25/23 at approximately 11:15 AM when the NHA and Social Worker #82 in separate interviews, was asked what happened between 10/13/22 and 10/14/22 until 10/24/22 they both referred to the incident involving Resident #471. When asked if they had asked Resident #19 why she had run over the other residents toes they remained silent. They both again reiterated the resident was no longer capacitated so she could not use the motorized wheelchair. A review of the Resident #19's minimum data sets found the following information: -- An annual with an assessment reference date (ARD) of 7/14/22 (the assessment prior to losing the use of her motorized vehicle) found Section G00110 E.(Locomotion on unit) was coded with a 0 to indicate Resident #19 was independent with this Activity of Daily Living (ADL). And section G00110 F. Locomotion off unit was coded with a 0 to indicate the resident was independent with ADL. -- A quarterly with an ARD of 12/26/22 (The assessment following the loss of her motorized wheelchair) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. Section G00110 F. (Locomotion off unit) was coded with a 3 to indicate the resident was and extensive assist with this ADL and she could no longer perform it without the assistance of staff. -- A quarterly with an ARD of 03/16/23 (The most recent assessment) found Section G00110 E. (Locomotion on unit) was coded with a 3 to indicate Resident #19 was an extensive assist with this ADL and she could no longer perform it without the assistance of the staff. In an interview with the NHA on 05/25/23 at 11:08 AM the NHA stated, We made the decision based on the information we had, and we stand by that decision as being a right decision. He stated there was past incidents, but they were not documented. When asked what the incidents were, he was unable to verbally describe any other incidents other than the one which occurred on 10/24/22. When asked if there were any other incident reports involving Resident #19 and her motorized wheelchair he stated there was not. When asked if he knew how Resident #19 felt about this decision he stated, We know she is not happy about it. At the conclusion of the survey on 05/30/23 at 3:45 PM no further information was provided related to Resident #19 no longer being able to use her motorized wheelchair.

Based on record review, staff interview, and policy review, the facility failed to provide an environment free from accident hazards over which it had control. A resident fell from a hoyer lift during a transfer resulting in multiple fractures, hospitalization , and death. This practice was considered to be at harm level and affected one (1) of eight (8) residents reviewed for falls during the Long Term Care Survey Process (LTCSP). The facility failed to ensure the resident was properly positioned in the hoyer lift and failed follow protocols for rolling the lift slowly from the bed. As a result the resident fell from the hoyer lift to the floor suffering harm with a femur fracture, ankle fracture and [MEDICAL CONDITION]. The harm the resident suffered required emergency surgeries for both fractures. The resident died at the hospital 5 days later at the hospital. Resident identifier: #358. Facility census: 112. Findings included: a) Resident #358-Record Review A review of the Resident's physician orders, on [DATE] at 10:00 AM, revealed the order Resident to have mechanical lift with 2 assist with an order date of [DATE]. A review of the Resident's Care Plan, on [DATE] at 10:25 AM, revealed the resident has the potential for injury from history of falls and confusion with the intervention of the assistance of two with transfers via mechanical lift. The care plan was revised and dated [DATE]. A review of the facility's investigation records, on [DATE] at 12:00 PM, for the [DATE] fall, revealed Nurse Aides (NA) #141 and #142, were both present with the Resident at the time of the fall. Witness statements from NA #141, dated [DATE] and [DATE], revealed NA #142 was using the lift and NA #141 was guiding the Resident's legs while attempting a transfer from the bed to the chair. NA #141 stated NA #142 was backing the lift out from under the bed when the Resident slid out sling from the front on her head. NA #141 stated the Resident is stiff and her buttocks does not go down into the lift like other residents. NA #141 stated she was not sure if the lift was stuck on something under the bed. Further review of the facility's investigative records for the [DATE] fall, on [DATE] at 12:15 PM, revealed a witness statement from NA #142 dated [DATE]. NA#142 stated during the transfer with the hoyer lift she tugged on the lift due to the legs were stuck on something under the bed. When that occurred the resident's weight shifted and she slid out of the top part of the sling. NA #142 grabbed the resident's head but could not stop the fall due to the weight. Further review of the medical record, on [DATE] at 1:15 PM, revealed the Resident was taken to an acute care hospital for emergency services, on [DATE], where they determined she had suffered a Femur fracture, an ankle fracture, and a [MEDICAL CONDITION] from the fall. The Resident had emergency surgery for [REDACTED]. b) Interview An interview with the Director of Nursing (DON), on [DATE] at 7:35 AM, revealed the Resident had fallen on [DATE] and sustained a Femur fracture, ankle fracture, and a head injury during a transfer with a hoyer lift from the bed to the chair. The DON stated the Resident expired at the hospital a few days later and never returned to the facility. The DON stated the Resident came out of the top of the sling of the hoyer and fell to the floor hitting several parts of her body on the bed and the lift. The DON verified that her investigation revealed that NA #141 stated that the resident's bottom wasn't fully in the sling like other residents and that NA #142 had tugged on the lift trying to free it causing the resident's weight to shift. The DON stated NA #142 stated the lift was stuck on something under the bed. The DON verified the transfer should have been stopped if the lift was stuck on something or if the resident was not fully in the sling. The DON stated her staff had verbalized to her that the sling was applied correctly and the lift was later inspected for any issues which was found not to have any. The DON stated both NA #141 and #142 had been trained on the lift and clinically validated before and after the accident. The DON stated neither NA#141 or #142 no longer work at the facility. The DON stated I can see how this fall could be considered neglect. The DON further stated she is still unsure what fully happened. c) Policy Review The facility's Clinical Validation for Mechanical Lifts Checklist that is used for orientation, identified needs, and annual reviews, was reviewed on [DATE]. The checklist instructs the staff to roll the lift slowly away from the bed. The facility failed to ensure the resident was properly positioned in the hoyer lift and failed follow protocols for rolling the lift slowly from the bed. As a result the resident fell from the hoyer lift to the floor suffering harm with a femur fracture, ankle fracture and [MEDICAL CONDITION]. The harm the resident suffered required emergency surgeries for both fractures. The resident died at the hospital 5 days later at the hospital.

Based on staff interview, record review, and policy review, the facility failed to ensure a resident was free from neglect. A resident fell from a hoyer lift during a transfer resulting in multiple fractures, hospitalization , and death. This practice was considered to be at harm level and affected one (1) of eight (8) residents reviewed for falls during the Long Term Care Survey Process (LTCSP). The facility failed to ensure the resident was properly positioned in the hoyer lift and failed follow protocols for rolling the lift slowly from the bed. As a result the resident fell from the hoyer lift to the floor suffering harm with a femur fracture, ankle fracture and [MEDICAL CONDITION]. The harm the resident suffered required emergency surgeries for both fractures. The resident died at the hospital 5 days later at the hospital. Resident identifier: #358 Facility census: 112. Findings included: a) Resident #358-Record Review A review of the Resident's medical record, on [DATE] at 9:30 AM, revealed the Resident was admitted to the facility on [DATE] with Dementia, [MEDICAL CONDITION], and multiple contractures. A review of the Resident's physician orders, on [DATE] at 10:00 AM, revealed the order Resident to have mechanical lift with 2 assist with an order date of [DATE]. A review of the Resident's Care Plan, on [DATE] at 10:25 AM, revealed the resident has the potential for injury from history of falls and confusion with the intervention of the assistance of two with transfers via mechanical lift. The care plan was revised and dated [DATE]. A review of the Resident's Progress Notes, on [DATE] at 11:10 AM, revealed a note from Licensed Practical Nurse (LPN) #140 dated [DATE], concerning a fall that occurred on [DATE] during a transfer from the bed to a chair using a hoyer lift. The note stated Certified Nursing Assistant (CNA) came to get this nurse for emergency incident. As this nurse entered the room the resident was lying on the floor. Resident was on her right side with head lying on left leg of hoyer lift. This nurse observed injury to right orbital. Laceration noted. CNA then notified this nurse to observe residents foot. This nurse observed left foot displaced over right side of the hoyer lift leg. Skeletal deformity observed to left ankle. This nurse then observed blood on the floor under area foot was resting. Notified 911 for transfer. A review of the facility's investigation records, on [DATE] at 12:00 PM, for the [DATE] fall, revealed Nurse Aides (NA) #141 and #142, were both present with the Resident at the time of the fall. Witness statements from NA #141, dated [DATE] and [DATE], revealed NA #142 was using the lift and NA #141 was guiding the Resident's legs while attempting a transfer from the bed to the chair. NA #141 stated NA #142 was backing the lift out from under the bed when the Resident slid out sling from the front on her head. NA #141 stated the Resident is stiff and her buttocks does not go down into the lift like other residents. NA #141 stated she was not sure if the lift was stuck on something under the bed. Further review of the facility's investigative records for the [DATE] fall, on [DATE] at 12:15 PM, revealed a witness statement from NA #142 dated [DATE]. NA#142 stated during the transfer with the hoyer lift she tugged on the lift due to the legs were stuck on something under the bed. When that occurred the resident's weight shifted and she slid out of the top part of the sling. NA #142 grabbed the resident's head but could not stop the fall due to the weight. Further review of the medical record, on [DATE] at 1:15 PM, revealed the Resident was taken to an acute care hospital for emergency services, on [DATE], where they determined she had suffered a Femur fracture, an ankle fracture, and a [MEDICAL CONDITION] from the fall. The Resident had emergency surgery for [REDACTED]. b) Interview An interview with the Director of Nursing (DON), on [DATE] at 7:35 AM, revealed the Resident had fallen on [DATE] and sustained a Femur fracture, ankle fracture, and a head injury during a transfer with a hoyer lift from the bed to the chair. The DON stated the Resident expired at the hospital a few days later and never returned to the facility. The DON stated she was called on [DATE] concerning the fall but could not determine what fully caused it until a complete investigation had been completed. The DON stated the Resident came out of the top of the sling of the hoyer and fell to the floor hitting several parts of her body on the bed and the lift. The DON verified that her investigation revealed that NA #141 stated that the resident's bottom wasn't fully in the sling like other residents and that NA #142 had tugged on the lift trying to free it causing the resident's weight to shift. The DON stated NA #142 stated the lift was stuck on something under the bed. The DON verified the transfer should have been stopped if the lift was stuck on something or if the resident was not fully in the sling. The DON stated her staff had verbalized to her that the sling was applied correctly and the lift was later inspected for any issues which was found not to have any. The DON stated both NA #141 and #142 had been trained on the lift and clinically validated before and after the accident. The DON stated neither NA#141 or #142 no longer work at the facility. The DON stated I can see how this fall could be considered neglect. The DON further stated she is still unsure what fully happened. c) Policy Review The facility's Clinical Validation for Mechanical Lifts Checklist that is used for orientation, identified needs, and annual reviews, was reviewed on [DATE]. The checklist instructs the staff to roll the lift slowly away from the bed. A review of the facility policy titled Abuse, Neglect and Exploitation, on [DATE], revealed the policy stated Neglect means failure of the center, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy was dated [DATE]. The facility failed to ensure the resident was properly positioned in the hoyer lift and failed follow protocols for rolling the lift slowly from the bed. As a result the resident fell from the hoyer lift to the floor suffering harm with a femur fracture, ankle fracture and [MEDICAL CONDITION]. The harm the resident suffered required emergency surgeries for both fractures. The resident died at the hospital 5 days later at the hospital.

Based on resident interview, staff interview, and record review the facility failed to ensure medications were available and the facility failed to, in coordination with the licensed pharmacist, provide for a system of medication records that enabled periodic accurate reconciliation and accounting for all controlled medications, prompt identification of loss or potential diversion of controlled medications and determination of the extent of loss or potential diversion of controlled medications. This was true for two (2) of four (4) residents reviewed for care area of pain during the annual Long Term Care Survey Process (LTCSP). For Residents #91 and 86, the facility failed to ensure prn pain medications were ordered and available from the pharmacy and also prn pain medication was signed as administered on the Control Medication Utilization Record and not recorded on the Medication Administration Record. Resident identifiers: #91 and #86. Facility census: 108. Findings included: a) Resident #91 1. Review of Resident #91's medical record at 9:15 a.m. on 08/08/18 found this [AGE] year-old male was admitted to the facility on [DATE]. According to the discharge summary from a local hospital, the resident was treated for end-stage [CONDITION(S)] ([CONDITION(S)]) on hemodialysis on Mondays, Wednesdays and Fridays, who was treated for his bilateral chronic lower extremity [CONDITION(S)] secondary to [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)]) and was on chronic [MEDICATION(S)] treatment. Persistent chronic bilateral metatarsal polymicrobial [CONDITION(S)] with gangrenous left foot infection requiring an amputation of left below the knee on 07/09/18. Additionally, diagnosis of Diabetes Mellitus (DM) with diabetic [CONDITION(S)], [CONDITION(S)] (CHF) and [CONDITION(S)], [CONDITION(S)] joint disease (DJD) and two (2) infected ([CONDITION(S)]) on the bottom of right foot. Review of the admission Minimum Data Set (MDS) showed a Brief Mental exam with a score of 13; which a score of 13- 15 indicates the resident is cognitively intact. Review of Physician orders found the following medication ordered for pain: [MEDICATION(S)] 15 milligrams (mg) daily for treatment of DJD, [MEDICATION(S)] 600 mg three times daily for treatment of diabetic [CONDITION(S)] and [MEDICATION(S)] 10 mg every four hours as needed (PRN) for pain. Further review of the medical records found Medication Administration Record (MAR) for period time from July 16, 2018 (date of admission) and August 9, 2018 found from 12 am to 7 am, the resident had requested the prn [MEDICATION(S)] one (1) to two (2) times each night since admission on 07/16/18. Review of the progress notes written by Employee #51, registered nurse (RN) found Resident #91 signed himself out at 11:15 AM on 08/08/18 to run errands and visit with friends and would return later in the evening. On 08/08/18 at 7:37 PM, written by RN #51, the resident complained of pain 8/10 (reported on a numerical score from 0 being no pain and 10 being the worse pain) and was given [MEDICATION(S)] 10 mg now. At 10:12 PM on 08/08/18 documented the resident's oxycondone was effective due to resident resting with eyes closed. On 08/08/18 at 11:42 PM note read . Resident was out of facility (OOF) for some time today upon return the resident stated that he had fallen while OOF. This nurse did a pain and skin assessment; no further injuries were found. Resident stated to this nurse he did hurt but it was his normal hurt nothing extra and he requested a prn pain pill which was administered at 7:37 pm. Progress note on 08/09/18 at 9:00 AM written by Employee #5 RN read, Spoke with (Name of Pharmacy concerning [MEDICATION(S)]. The pharmacy stated, the resident has refills remaining on script however Medicaid has filled the maximum for this script. MD (medical doctor) notified. Requested (Name of Pharmacy) to send the medication stat from local pharmacy. Spoke with resident concerning situation. States he does not need additional medication now. At 9:14 AM on 08/09/18 by #5 RN read, . Scheduled pain medication administered ([MEDICATION(S)] and [MEDICATION(S)]). At 10:05 AM on 08/09/18 a progress note written by Employee # 107 RN read, I asked the resident if he was doing okay and how his pain was. Resident stated he was still in pain, and asked about his prn pain medication. I explained to resident we were still waiting on pharmacy to bring them to us and as soon as the medication gets here, we will administer the pain med. At 10:30 AM on 08/09/18 this surveyor knocked on resident's door and asked if I could come in. He stated, I would prefer you not right now my stump is hurting bad. I asked if he had told the nurse he stated, Yes. During this conversation, I observed resident to be rubbing his left thigh and facial grimacing and moaning and appeared to be angry. This surveyor on 08/09/18 at approximately 10:40 AM went to the nurse's station and inquired about Resident #91's pain medication. I was informed they were awaiting the pharmacy to deliver the [MEDICATION(S)]. The last dose available from his supply was given at 7:37 PM on 08/08/18. I was also informed his routine medication had been given at 9:14 AM. This surveyor then went to the Director of Nursing (DON) on 08/09/18 at approximately 10:50 AM to inquire if Resident #91's pain medication. She said she would check on it. Progress note written by the DON on 08/09/18 at 11:09 AM read, Notified (Name of Physician) regarding resident's pain received an order for 5 mg [MEDICATION(S)] 2 tablets to be given x1 until supply arrives. Notified pharmacy with script and form for authorization to release medication from Omni cell. Awaiting phone call from pharmacy. Discussed arrival of medication from pharmacy driver was notified it will be here at 12:30 PM. Review of the facility's Omni cell (an automated dispensing cabinets and systems efficiently manage, store, and dispense medications for healthcare facilities) inventory revealed it contained six (6) [MEDICATION(S)] 5 mg tablets. Resident #91 was administered the last dose of his [MEDICATION(S)] at 7:37 PM and went till 08/09/18 at 11:30 AM, although the medication ([MEDICATION(S)]) was available in the Omni cell. This was a lapse of 17 hours and resulted in Resident #91 experiencing actual harm with severe pain. No further information provided. 2. Review of the Control Medication Utilization Record and the Medication Administration Record (MAR) found on the following dates the medication [MEDICATION(S)] was signed out on the Control Medication Utilization Record but were note placed on the MAR as administered: --08/01/18 at 5:00 AM --08/01/18 at 8:30 AM --08/01/18 at 9:40 PM --08/03/18 at 5:20 AM --08/05/18 at 3:00 PM Interview with the Director of Nursing on 08/09/10 at 1:00 pm, revealed she was unaware as to why the nurses had signed out the [MEDICATION(S)] but was not placed on the MAR as administered. She was unable to determine if a drug diversion had occurred or not. b) An interview with Resident #86, on 08/06/18, at 4:40 PM, revealed that this resident experienced pain in her legs and feet. Resident #86 further stated she had medications ordered but did not always get them. Review of the medical record on 08/08/18, revealed that pain medications were not available to administer medications as prescribed by the physician. According to the admission orders, dated 06/22/18, '[MEDICATION(S)] 50 mg Give 1 capsule three times a day for neuropathic pain and [MEDICATION(S)]-Acetaminophen tablet 5-325 mg Give 1 tablet by mouth every 6 hours as needed for pain had been ordered. A review of the Controlled Medication Utilization Record, the [MEDICATION(S)] was not received until 06/24/18 and the [MEDICATION(S)] was not received until 06/25/18. The medical record contained a progress note , dated 06/23/18, at 09:04 AM , noting Resident #86 complained of severe pain all over. It was documented that plain Tylenol ordered for temperature over 101 was given and [MEDICATION(S)] was not available. Further review of the Controlled Medication Utilization Records revealed the following discrepancies: On 7/14/18, facility staff signed out four times for [MEDICATION(S)]-Acetaminaphen 5-325 mg tablet for a physician's order for [MEDICATION(S)]-Acetaminaphen 5-325 mg to be administered every eight hours. The Medication Administration Record for 07/14/18 verified the medication had been administered three times on this date and not four. An interview with RN#21, on 08/09/18, at 2:16 PM, revealed that sign out indicated that Resident #86 received an extra dose on this date and was not administered in accordance with physicians . It was further stated by RN #21 that staff should have completed a medication error on this occurrence but none was found. On 07/26/18, the Controlled Medication Utilization Record indicated staff had signed out for one [MEDICATION(S)]-Acetaminaphen 5-325 mg, however, the Medication Administration Record for this date indicated that Resident #86 had been medicated for pain on two occasions. An interview, on 08/09/18, at 2:55 PM, with RN #21 verified that the sign out did not match what was documented as given and these issues would be reported to pharmacy.

Based on resident interview, record review, staff interview. the facility failed to provide prompt pain management. This was true for four (4) of four (4) residents reviewed for care area of pain during the annual Long Term Care Survey Process (LTCSP). For Resident #91 the facility failed to provide as needed (prn) pain medication when the resident was experiencing severe pain in his left stump. From 11:30 p.m. on 08/08/18 until 11:30 am on 08/09/18 the facility failed to effectively treat Resident #91's pain when a treatment option was available to them. This failure caused Resident #91 to suffer severe pain for a prolonged period resulting in actual harm. For Resident #107 the facility failed to timely assess his prn pain medication to ensure the resident's pain was controlled which resulted in actual harm to this resident. For Resident #86's pain medication was not available for a period and the facility failed to document non-pharmalogical interventions were provided before the prn medication was administered and failed to timely assess the prn pain medication. Resident #48 prn pain medication was not administered as directed by the physician order, failed to timely follow up on the effect of the pain medication and no documentation non-pharmalogical interventions were attempted before administering the prn pain medication. Resident identifiers: #91, #107, #86 and #48. Facility census: 108. Findings included: a) Resident #91 Review of Resident #91's medical record at 9:15 a.m. on 08/08/18 found this [AGE] year-old male was admitted to the facility on [DATE]. According to the discharge summary from a local hospital, the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Persistent chronic bilateral metatarsal polymicrobial [CONDITION(S)] with gangrenous left foot infection requiring an amputation of left below the knee on 07/09/18. Additionally, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) showed a Brief Mental exam with a score of 13; which a score of 13- 15 indicates the resident is cognitively intact. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the medical records found Medication Administration Record (MAR) for period time from July 16, 2018 (date of admission) and August 9, 2018 found from 12 am to 7 am, the resident had requested the prn [MEDICATION(S)] one (1) to two (2) times each night since admission on 07/16/18. Review of the progress notes written by Employee #51, registered nurse (RN) found Resident #91 signed himself out at 11:15 AM on 08/08/18 to run errands and visit with friends and would return later in the evening. On 08/08/18 at 7:37 PM, written by RN #51, the resident complained of pain 8/10 (reported on a numerical score from 0 being no pain and 10 being the worse pain) and was given [MEDICATION(S)] 10 mg now. At 10:12 PM on 08/08/18 documented the resident's oxycondone was effective due to resident resting with eyes closed. On 08/08/18 at 11:42 PM note read . Resident was out of facility (OOF) for some time today upon return the resident stated that he had fallen while OOF. This nurse did a pain and skin assessment; no further injuries were found. Resident stated to this nurse he did hurt but it was his normal hurt nothing extra and he requested a prn pain pill which was administered at 7:37 pm. Progress note on 08/09/18 at 9:00 AM written by Employee #5 RN read, Spoke with (Name of Pharmacy concerning [MEDICATION(S)]. The pharmacy stated, the resident has refills remaining on script however Medicaid has filled the maximum for this script. MD (medical doctor) notified. Requested (Name of Pharmacy) to send the medication stat from local pharmacy. Spoke with resident concerning situation. States he does not need additional medication now. At 9:14 AM on 08/09/18 by #5 RN read, . Scheduled pain medication administered ([MEDICATION(S)] and [MEDICATION(S)]). At 10:05 AM on 08/09/18 a progress note written by Employee # 107 RN read, I asked the resident if he was doing okay and how his pain was. Resident stated he was still in pain, and asked about his prn pain medication. I explained to resident we were still waiting on pharmacy to bring them to us and as soon as the medication gets here, we will administer the pain med. At 10:30 AM on 08/09/18 this surveyor knocked on resident's door and asked if I could come in. He stated, I would prefer you not right now my stump is hurting bad. I asked if he had told the nurse he stated, Yes. During this conversation, I observed resident to be rubbing his left thigh and facial grimacing and moaning and appeared to be angry. This surveyor on 08/09/18 at approximately 10:40 AM went to the nurse's station and inquired about Resident #91's pain medication. I was informed they were awaiting the pharmacy to deliver the [MEDICATION(S)]. The last dose available from his supply was given at 7:37 PM on 08/08/18. I was also informed his routine medication had been given at 9:14 AM. This surveyor then went to the Director of Nursing (DON) on 08/09/18 at approximately 10:50 AM to inquire if Resident #91's pain medication. She said she would check on it. Progress note written by the DON on 08/09/18 at 11:09 AM read, Notified (Name of Physician) regarding resident's pain received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Notified pharmacy with script and form for authorization to release medication from Omni cell. Awaiting phone call from pharmacy. Discussed arrival of medication from pharmacy driver was notified it will be here at 12:30 PM. Review of the facility's Omni cell (an automated dispensing cabinets and systems efficiently manage, store, and dispense medications for healthcare facilities) inventory revealed it contained six (6) [MEDICATION(S)] 5 mg tablets. Resident #91 was administered the last dose of his [MEDICATION(S)] at 7:37 PM and went till 08/09/18 at 11:30 AM, although the medication ([MEDICATION(S)]) was available in the Omni cell. This was a lapse of 17 hours and resulted in Resident #91 experiencing actual harm with severe pain. No further information provided. b) Resident #107 An observation and interview with Resident #107 on 08/06/18 at 4:05 p.m. found him to be experiencing pain. When asked how he was doing Resident #107 stated, I am doing good except for my pain. He stated, today is the worst that it has been. He stated, I ask for medication but it takes a long time to get it, and sometimes it works and sometimes it doesn't. Resident was noted to be shifting his position in bed and grimacing. When asked what his pain level was he stated, It is a 7 right now. Resident #107 indicated that he has [CONDITION(S)] that had spread all over his body. He indicated, I hurt all over even my toes hurt. An interview with Licensed Practical Nurse (LPN) #32 at 4:15 p.m. on 08/06/18 indicated Resident #107 had received is scheduled pain medication at 9:00 a.m. and was due another scheduled dose at 9:00 p.m. She indicated the resident had an as needed order for [MEDICATION(S)] 10-325 milligrams every four (4) hours and he had it last at 12:04 p.m She stated, He has not asked for any since. She was advised of his pain and promptly went to his room and provided his pain medication. A review of Resident #107's care plan found the following focus statement related to pain management, Resident has frequent pain related to metastatic [CONDITION(S)]. He reports his tolerable pain level is a 5. This focus statement was initiated on 07/25/2018 and revised on 08/01/18. The goal associated with this focus statement read as follows, Resident's pain will be relieved within 1 hour of interventions as evidenced by no voiced complaints of pain i.e.:grimacing, frowning, crying, moaning, or guarding through next review. This goal had a target date of 10/22/18. Interventions related to this goal included: Assess for effectiveness of -medication, notify physician of unrelieved pain. A review of Resident #107's medical record at 2:00 p.m. on 08/07/18 found the following occasions when he was administered his PRN [MEDICATION(S)] 10-325 mg and the effectiveness of the medication was not assessed in a timely manner. On these occasions the medication was also found to be ineffective when assessed resulting in actual harm for Resident #107. -- Medication administered at 3:28 p.m. on 07/28/18 the effectiveness of the medication was not assessed until 9:07 p.m. at which time the medication was deemed ineffective and Resident #107's follow up pain score was assessed as a 6. -- Medication administered at 4:26 a.m. on 08/03/18 the effectiveness of the medication was not assessed until 7:46 a.m. at which time it was deemed ineffective with a follow up pain score of 10. -- Medication administered at 11:37 a.m. on 08/03/18 at 1:57 p.m. the effectiveness was assessed as effective even though the resident follow up pain score was a 6 which is higher than his acceptable level of pain. -- Medication administered at 3:07 p.m. on 08/07/18 the effectiveness was not evaluated until 9:07 p.m. at which time medication was deemed ineffective with the residents follow up pain score being a 7. On all four (4) occasions the effectiveness of the pain medication was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Director of Nursing at 3:54 p.m. on 08/08/18 found that as needed pain medication should have the effectiveness evaluated within 30 minutes to one (1) hour after administration of the medication. An interview with the facility's pain champion, Registered Nurse (RN) #118 at 9:14 a.m. on 08/09/18 found the effectiveness of as needed pain medication should be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated, This is how we determine if adequate pain control is achieved. The Above findings were reviewed with RN #118 and she agreed the effectiveness of the pain medication was not assessed timely. She agreed that when assessed the resident was still in pain and could have been in pain the entire time since the administration of the as needed pain medication. c) An interview with Resident #86, on 08/06/18, at 4:40 PM, revealed that this resident experienced pain in her legs and feet. Resident #86 further stated she had medications ordered but did not always get them when requested. A review of the care plan for Resident #86 revealed a problem relating to pain. The care plan did not address an acceptable level of pain the resident could tolerate. The care plan interventions were to administer medications as prescribed by the physician but did not contain resident specific interventions to medication such as the specific medication or side effects to monitor. The care plan did not address non-pharmacological measures to use to promote pain relief. An interview with CNA #8, on 08/08/18, at 11:20 AM revealed that she was not aware of any measures other than medicine that should be used to help control the pain for Resident #86. An interview with RN #128, on 08/08/18, at 11:30 AM, verified that interventions for Resident #86 were not specific to the care to be provided to Resident #86. Further review of the medical record on 08/08/18, revealed that pain medications were not available to administer medications as prescribed by the physician. According to the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Controlled Medication Utilization Record, the [MEDICATION(S)] was not documented as received by the facility until 06/24/18 and the [MEDICATION(S)] was not documented as received until 06/25/18. The medical record contained a progress note , dated 06/23/18, at 09:04 AM , noting Resident #86 complained of severe pain all over. It was documented that plain Tylenol ordered for temperature over 101 was given and [MEDICATION(S)] was unavailable. Further review of the Controlled Medication Utilization Records revealed the following discrepancies: On 7/14/18, facility staff signed out four times for [MEDICATION(S)]-Acetaminaphen 5-325 mg tablet for a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record for 07/14/18 verified the medication had been administered three times on this date and not four. An interview with RN#21, on 08/09/18, at 2:16 PM, revealed that sign out indicated that Resident #86 received an extra dose on this date and was not administered in accordance with physicians . It was further stated by RN #21 that staff should have completed a medication error on this occurrence but none was found. On 07/26/18, the Controlled Medication Utilization Record indicated staff had signed out for one [MEDICATION(S)]-Acetaminaphen 5-325 mg, however, the Medication Administration Record for this date indicated that Resident #86 had been medicated for pain on two occasions. An interview, on 08/09/18, at 2:55 PM, with RN #21 verified that the sign out did not match what was documented as given and these issues would be reported to pharmacy. On 08/09/18, the Pain MDS 3.0, dated 08/08/18, was reviewed . which revealed that Resident #86 had not received non-medication interventions for pain and day to day activities were limited because of pain. d) Resident #48 Record review on 08/07/18, found the resident was receiving the following medications for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Ibuprofen 400 mg. every 8 hours as needed (PRN). [MEDICATION(S)] HCI 10 mg, three times a day. Review of the medication administration record (MAR) for July, 2018, found the resident received the Ibuprofen on the following days: 7/8/18, 07/09/18, 07/07/18, 07/08/18, 07/11/18, 07/12/18, 07/14/18, 07/16/18, 07/18/18, 07/20/18, 07/21/18, 07/27/18, 07/28/18, 07/31/18. Review of the MAR for August, 2018, found the Ibuprofen was administered on the following days: 08/03/18 and 08/04/18. The resident received the [MEDICATION(S)] as directed, except the 10:00 p.m. dosage on 07/29/18. Review of the resident's care plan found the following focus/problem: Resident is at risk for pain due to pain from wound on his foot. The goal associated with the focus/problem is: Resident's pain will be relieved within 1 hour of interventions as evidence by no voiced complaints of pain or no signs/symptoms of pain i.e.: grimacing, frowning, crying, moaning or guarding through next review. Interventions included: Encourage resident to use relaxation techniques and/or diversional activity (music, television, conversation) as alternative methods of pain management. Monitor for effectiveness of pain relieving measures (non pharmacological or medication.) At 8:30 a.m. on 08/09/18 the director of nursing (DON) said the expectation of nursing staff is they will document the effectiveness of the pain medication within 1 hour after receipt. On 08/09/18 at 11:27 a.m. the DON, a Corporate Consultant Registered Nurse, RN #151, and the surveyor reviewed the nursing notes and the MAR and concluded the following times and dates when the pain medication was received and the effectiveness of the pain medication was not rated within 1 hours as directed by the care plan, the resident complained of pain and did not receive the physician ordered PRN pain medication. On 07/16/18, the resident received the Ibuprofen at 2:25 a.m., the follow up documentation regarding the effectiveness of the pain medication did no occur until 6:04 a.m. On 7/26/18, documentation in the nursing note noted the resident complained of pain at 7:32 p.m. and 7:44 p.m. The resident's last ibuprofen was administered on 07/21/18. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . ( The resident received [MEDICATION(S)] at 6:00 a.m. 2:00 p.m. and 10:00 p.m.) On 7/27/18, the resident received the Ibuprofen at 8:33 p.m., the effectiveness of the pain medication was not rated until 11:18 p.m. On 08/1/18 the Ibuprofen was administered at 2:17 a.m., the effectiveness of the medication was not rated until 4:02 a.m. On 08/3/18, Ibuprofen was administered at 1:00 a.m. the effectiveness of the medication was not rated. On 08/4/18, Ibuprofen was administered at 7:47 p.m. the pain was not rated until 9:24 p.m. At 3:27 p.m. on 08/09/18, The DON confirmed the nurses should have documented the non-pharmacological interventions used in addition to providing the PRN pain medication. The DON was unable to provide any documentation of the non-pharmacological interventions provided on any of the days in July or August when the pain medication was administered.

Part I Based on observation, resident interview, staff interview, review of the facility's policy for Bed Safety Assessment Guidelines, and review of the 03/10/06, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued by the United States Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health, it was determined the facility failed to ensure the resident environment, over which the facility had control, remained as free of accident hazards as possible. With the slight touch of a hand, half side rails on the beds of two (2) resident's, Resident #37 and Resident #63, were able to be tilted inward and outward, forward and backwards. When moved outward, the gap between the mattress and the side rails measured four (4) inches on Resident #37's bed and three (3) inches on Resident #63's bed, resulting in a potential for entrapment. Side rails on an additional nineteen (19) residents' beds were observed and found loose, allowing a slight touch of the hand to rock the rails forward and backwards and inward and outward. Interviews with facility staff, residents, and review of the bed safety assessments for two (2) residents (Residents #52 and #44) confirmed the facility was aware of the ill-fitting side rails. On 12/02/13 at 7:30 p.m. the loose side rails were discussed with the administrator and no further information was presented to verify the facility had assessed the situation or implemented a plan of action for correction. The administrator stated the facility would have work orders to verify the action taken when occurrences of loose rails were reported; however, this information was never presented. At 8:00 p.m. on 12/02/13, the administrator was informed of the ill-fitting side rails and the unsafe conditions present resulting in immediate jeopardy. An acceptable plan of correction was provided on 12/02/13 at 10:20 p.m. Observations of the corrective actions on 12/02/13 at 11:15 p.m. found the immediate jeopardy had been removed. At that time, the scope and severity of the citation was reduced from a "K" to an "E." Resident identifiers: #37, #63, #81, #20, #52, #27, #91, #16, #45, #88, #25, #128, #58, #167, #163, #82, #79, #106, #13, #44, and #11. Facility census: 130. Findings include: a) Resident #37 At 4:28 p.m. on 12/02/13, Resident #37 was observed in his bed in Room 335 - B with both half side rails in the up position. Both side rails were loose and able to be moved inward and outward and forward and backwards. Moving the rails outward created a four (4) inch gap between the rail and mattress. The resident stated the rails had been like this for a long time. b) Resident #63 At 5:25 p.m. on 12/01/13 observation of bed -A in room 335 revealed the resident was in bed with both half side rails raised. The rails were able to be moved inward and outward and forward and backwards. Moving the rails outward created a three (3) inch gap between the rail and the mattress. This resident stated he had told staff about the side rails on numerous occasions but the side rails had never been fixed. c) Residents #20, #52, #27, #91, #16, #81, #45, #88, #25, #128, #58, #167, #163, #82, #79, #106, #13, #44 and #11. At 5:30 p.m. on 12/02/13, a tour of the facility was conducted to evaluate the side rails on other residents' beds. Observation found the beds for Residents #20, #52, #27, #91, #16, #81, #45, #88, #25, #128, #58, #167, #163, #82, #79, #106, #13, #44 and #11 had half rails. The rails on each of these nineteen (19) additional beds were able to be moved inward and outward and forward and backwards with the slight touch of a hand. d) Interviews with facility employees 1. At 6:25 p.m., on 12/02/13 Employee #54, a register nurse supervisor, was interviewed. Employee #54 stated at times the rails get loose and they have to tighten them up. She stated she had never witnessed a rail that could not be tightened up. 2. Employee #67, the assistant director of nursing, was interviewed at 6:50 p.m. on 12/02/13. This employee verified Resident #63 had told staff his rails were loose and she stated staff had tightened the rails before. 3. An interview with Employee #61, a nursing assistant, at 6:45 p.m., on 12/05/13, verified she was aware of various side rails being loose but she believed the side rails had been tightened when discovered. 4. At 7:48 p.m. on 12/02/13, Employee #178, the maintenance director, was interviewed in Room #335, (occupied by Resident's #37 and #63). Employee #178 stated he was aware there were problems with the side rails being loose. He said the current process for monitoring and maintenance of the side rails was, "done by word of mouth." Employee #178 verified staff members verbally informed him when the rails were loose and he tightened them. He was unaware of how many times he had tightened the side rails because there was no formal record keeping process. On 12/02/13 at 7:48 p.m., Employee #178 demonstrated how he tightened the side rails by turning a knob attached to the side rail. This intervention was observed ineffective when demonstrated on Resident #63's bed. After Employee #178 turned the knob, the rails were still loose. Employee #178 stated the bed rails were not safe and he felt if pressure was applied to the rails they could easily break. He verified the rails were unable to be tightened to prevent injury. Observation revealed the turning of the knob did not prevent the rail from moving. Further observation with Employee #178 included a demonstration by the survey team which allowed the surveyor's hand and arm to easily fit between the side rails and the mattress. Employee #178 acknowledged the observation and again stated the rails were not safe. e) Resident #81 On 12/02/13 at approximately 7:30 p.m. Resident #81 was interviewed and stated the rails had been loose "forever." She said she had reported the situation to the nurse at least three (3) times and nothing had happened. f) Residents #52 and #44 The administrator and director of nursing (DON) provided bed safety assessments for the twenty-one (21) residents identified above at 7:00 p.m. on 12/02/13. A review of the assessments provided by the facility found the assessment for Resident #52 and Resident #44 each indicated the response to "latches on the bed rails are stable and will not fall when shaken," could not be completed. Hand written documentation on the pre-printed forms noted the rails were described as "loose." Further instructions on the bed safety assessment pre-printed form found, "Based on observation, check all applicable findings. Any items that are NOT checked indicate a potential safety issue to be addressed. Add any comments or discussion on the reverse side of this form." The facility had not listed any comments on the reverse side of the forms. g) Review of the guidelines for Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issues on 03/10/06 by the US Department of Health and Human Services, Food and Drug Administration and the Center for Devices and Radiological Health found the following guidelines to reduce entrapment: "We suggest that facilities and manufactures determine the level of risk for entrapment and take steps to mitigate the risk. Evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy to reduce entrapment..." "...Entrapment describes an event in which a patient/resident is caught, trapped or entangled in the space in or about the bed rail, mattress or hospital bed frame. Patient entrapments may result in deaths and serious injury..." "Reassessment may be appropriate when (1) there is reason to believe that some components are worn) e.g., rails wobble, rails have been damaged, mattresses are softer) and could cause increased spaces within the bed system...." According to the guidelines a resident's neck could become entrapped in a space of 2 3/8 inches. h) Review of the facility's policy for bed safety found the following: "...The facility shall complete a bed safety assessment upon admission and with any change in condition." "To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: 1. Review the gaps within the bed system are within the dimensions established by the FDA (Note the review shall consider situation that could be caused by the resident's weight, movement or bed position.); 2. Ensure that when bed system components are worn and need to be replaced, components meet manufactured specifications..." i) At 7:30 p.m. on 12/02/13, the facility administrator was unable to provide any documentation to verify the facility had assessed the use of side rails when they were aware the rails continued to require interventions, i.e. continual tightening by staff. No evidence was provided to verify the facility followed their policy for bed safety which referenced the 2006 guidelines for prevention of bed entrapment. j) At 8:00 p.m. on 12/02/13, the administrator was notified an immediate jeopardy situation existed due to the potential for entrapment related to the ill-fitting side rails. The administrator was advised of the above residents' beds observed with the loose fitting side rails He was further advised of the findings / interviews with facility staff, residents, and the information obtained from the bed safety assessment regarding Residents #52 and #44, as well as the observations of the bed rails made with Employee #178. k) At 8:30 p.m. on 12/02/13, the administrator presented the first plan of correction which did not provide adequate measures to provide immediate protection for residents identified to be in immediate jeopardy. The plan was not accepted because the administrator identified three (3) of the twenty-one (21) beds could not be repaired to eliminate the potential for entrapment. The administrator stated these residents would be placed on 30 minute checks. The survey team did not feel this was adequate as the potential for entrapment could occur at any given time. l) At 10:20 p.m. on 12/02/13 the administrator presented the second plan of correction which was accepted. The plan of correction included: 1. Identifying the beds that have side rails that are not appropriate. 2. Completion of new bed safety assessments on the 21 beds/residents identified. 3. Identify available beds in house not being currently used. Switch the available beds with those identified as not appropriate. 4. Any bed left with inappropriate side rails will have staff assigned to 1:1 observations to assure safety and security until replacement beds arrive Tuesday; Assignments for 1:1 observations include the following rooms: 31 b, 345 b, and 350 b. 5. There is potential for this to affect other residents. The facility will reassess all residents using the bed safety assessments to make sure they are not affected by this alleged deficient practice. This will be completed by end of day on 12/03/13. The plan of correction was accepted; however, deficient practices still remained in the area of accident hazards. . Part II Based on observation, record review, policy review and staff interview, the facility failed to ensure the resident environment was free from known accident hazards over which the facility had control As a result of the immediate jeopardy on 12/02/13, twenty-one (21) residents were reviewed for the care area of accidents during Stage II of the Quality Indicator Survey. These residents had side rails so they were reviewed after it was identified bed side rails were loose and could be moved forward and backward, inward and outward with the slight touch of a hand. Each of the twenty-one (21) residents was reviewed for incident/accidents, assessments of side rails, care planning, and implementation of the facility's policy for bed safety. Resident identifiers: #37, #63, #81, #20, #52, #27, #91, #16, #45, #88, #25, #128, #58, #167, #163, #82, #79, #106, #13, #44, and #11. Facility census: 130. Findings include: a) Residents #37 At 4:28 p.m. on 12/02/13, Resident #37 was observed in his bed in Room 335 - B with both half side rails in the up position. Both side rails were loose and able to be moved inward and outward and forward and backwards. Moving the rails outward created a four inch gap between the rail and mattress. The resident stated the rails had been like this for a long time. At 7:48 p.m. on 12/02/13, Employee #178, the maintenance director, was interviewed in the resident's room. Employee #178 stated he was aware there were problems with the side rails being loose. He said the current process for monitoring and maintenance of the side rails was, "done by word of mouth." Employee #178 verified staff members verbally informed him when the rails were loose and he tightened them. He was unaware of how many times he had tightened the side rails because there was no formal record keeping process. When interview again on 2:20 p.m. on 12/09/13, Employee #178 said he estimated he would tighten about six (6) rails every other day, but this was just his estimate. He could not say how many times he had tightened Resident #37's side rails. b) Resident #63 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. On 12/02/13 at 7:48 p.m., Employee #178 demonstrated how he tightened the side rails by turning a knob attached to the side rail. This intervention was observed ineffective when demonstrated on Resident #63's bed. After Employee #178 turned the knob, the rails were still loose. Employee #178 stated the bed rails were not safe and he felt if pressure was applied to the rails they could easily break. He verified the rails were unable to be tightened to prevent injury. Observation revealed the turning of the knob did not prevent the rail from moving. Further observation with Employee #178 included a demonstration by the survey team which allowed the surveyor's hand and arm to easily fit between the side rails and the mattress. Employee #178 stated, " They (referring to the side rails) are not safe they are to keep him in bed if he puts pressure on them they will break." Employee #178 was again interviewed on at 2:20 p.m. on 12/09/13. He verified the resident no longer had the same side rails on his bed. Review of accident reports found this resident had fallen on 07/08/13 because the wheels on the bed were not locked. The resident fell again on 10/02/13 because the wheels on his bed were not locked and it was determined the wheels on the bed were unable to be locked. Employee #15, the registered nurse unit manager for this resident was interviewed on 12/12/13 at 10:00 a.m. She stated she had in-serviced staff after the first fall and had conducted another in-service after the 10/02/13 fall. This employee was asked if the facility had assessed/checked the wheels of the resident's bed to make sure they were not defective after the first fall. She stated she did not have any documentation to verify the wheels were checked. She said after the fall on 10/02/13 (the second fall), the facility removed the wheels from the resident's bed. At 2:43 p.m. on 12/12/13 the DON stated the facility only had information and documentation an in-service was conducted after each of the resident's falls. c) Resident #16 On 12/02/13 at 5:30 p.m. the resident's bed rails were observed loose and able to be rocked back and forth with the slight touch of a hand. Review of records revealed a side rail assessment was completed on 07/18/13. A determination was made to use two (2) 1/2 rails to enable the resident to reposition herself in bed. On 12/05/13, facility staff completed a new bed safety assessment and determined the bed rails did not appear to be indicated at this time. It was determined a low bed was appropriate. Stuffers were used to fill the space at the foot of the bed between the mattress and the footboard. The resident was observed in her bed on 12/16/13 at 3:38 p.m. The bed was not in a low position at this time. At 3:40 p.m. on 12/16/13, Employee #40, a registered nurse, confirmed the resident's bed should have been placed in the low position. She stated, "I will lower the bed and talk to the girls." d) Resident #106 Observation of the resident's side rails on 12/02/13 at 5:30 p.m. found the rails were loose and could be easily moved inward and outward. The facility completed a bed safety assessment on 12/02/13. They determined the resident continued to need side rails to aide in turning and repositioning. The resident's bed was replaced on the evening of 12/02/13. Employee #178, the maintenance director, confirmed the "crank bed" had been replaced with an electric bed at 2:18 p.m. on 12/09/12. e) Resident #20 Observation of the resident's side rails on 12/02/13 at 5:30 p.m. found the rails were loose and could be easily moved inward and outward, forward and backward. The facility completed a bed safety assessment on 12/02/13. They determined the resident continued to need side rails to aide in turning and repositioning. On 12/07/13 a new order was obtained from the resident's physician to discontinue the Medastat II mattress currently being used by the resident and replace it with a Wound Surface 300 air mattress. Employee #14, a registered nurse, was asked, on 12/16/13, why the resident's mattress had been replaced. She stated the resident's rails were just loose, the new mattress did not have anything to do with safety issues. Employee #14 was asked if she had ever had to tighten the resident's bed rails. She stated, "Sometimes we try to tighten the rails but if we can't we just call maintenance." f) Resident #79 Observation of the resident's side rails on 12/02/13 at 5:30 p.m. found the rails were loose and could be easily moved inward and outward, forward and backward. A new side rail assessment was completed on the evening of 12/02/13. The facility staff determined the resident needed both 1/2 side rails to aide in turning and repositioning. Employee #178, the maintenance director, confirmed on 12/09/13 at 2:18 p.m., the bed had been replaced with an electric bed instead of the "crank bed," which was being used prior to 12/02/13. g) Resident #25 At 5:30 p.m. on 12/02/13, the bed for Resident #25 was identified with a 1/2 side rail up. It was loose and could be shaken easily, creating an area that could result in entrapment. The other side of the bed was against the wall with no rail used. The facility was made aware of this situation at 8:00 p.m. on 12/02/13. The resident's bed rail was changed before 11:15 p.m. on 12/02/13 to correct this accident hazard and prevent possible entrapment. On 12/03/13 this resident was observed in a different bed with a smaller rail (1/4 rail) at the top of the bed. It was observed secure and did not move when pressure was placed against it. The medical record was reviewed on 12/03/13. It revealed Resident #25 had frequent falls. He utilized his rails for mobility and often got up unassisted. He had multiple fall prevention measures initiated; however, the loose rails that were on his bed had not been identified as potentially hazardous to this resident. The director of nursing (Employee #86) provided a new bed safety assessment for this resident dated 12/02/13. She verified this resident now had a different rail that fit tightly against the bed mattress. During an interview with Employee #77 (Registered Nurse) on 12/05/13 at 2:30 p.m., she verified the old side rails that were on these beds came loose at times and you had to tighten them up. She stated Resident #25 used his rails to move around a lot and they had to keep a close eye on him because he was at risk for falls. She said his rails were tightened when they became loose. When asked about reporting this issue, she said she had never reported it because they would just fix it if it was loose. Employee #178, the maintenance director was interviewed on 12/09/13 at 2:20 p.m. He verified he got new beds to replace all of those "other ones." He stated the new ones were electric. Employee #178 said he frequently had to tighten the bed rails for all of the residents who had the old rails they replaced. He verified he did not have a formal record to show how often he tightened them, but estimated about 6 rails every other day had to be tightened. h) Resident #82 At 5:30 p.m. on 12/02/13, Resident #82 was identified with 1/2 side rails present on both sides of her bed. These rails were observed loose and could be easily shaken, creating a hazard for this resident. The facility was made aware of this situation at 8:00 p.m. on 12/02/13. The resident's bed rails were changed before 11:15 p.m. on 12/02/13, to correct this hazardous environment and prevent falls or possible entrapment. The resident had a bed safety assessment completed on 11/21/13. This assessment stated her bed rails were safe and there was no gap. The assessment indicated the rails were stable and would not fall down when shaken. During an interview with Resident #82 on 12/09/13, she stated she used her rails to help her move around because her bed was so little. She verified the new rails were much more sturdy. i) Resident #11 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when the were shaken, creating a potential for injury. The facility was made aware of this situation at 8:00 p.m. on 12/02/13. The unsafe rails were corrected by 11:15 p.m. Review of the medical record revealed the resident was to have 1/2 side rails up on his bed to assist him with turning and positioning. The medical record identified the resident was cognitively impaired,with a [DIAGNOSES REDACTED]. An order was written on 12/02/13 to discontinue his side rails due to non usage. Employee #15 ( Registered Nurse) was interviewed, on 12/17/13 at 10:00 a.m., regarding the resident's side rail use. She stated on 12/03/13 the facility completed a new assessment. She said the resident was asked if he used the side rails anymore, and he said he did not. The resident said it would be okay if they took them off. Employee #15 said it was determined the resident no longer needed these rails on his bed, so they were removed. j) Resident #128 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when the were shaken, creating a potential for injury. The facility was made aware of this situation at 8:00 p.m. 12/02/13. The resident's side rails were changed before 11:15 p.m. on 12/02/13, to correct this hazardous potential for falls or entrapment. During an interview with Employee #77, on 12/16/13 at 2:30 p.m., she confirmed this resident's loose rails were no longer on her bed. Employee #77 verified the resident had a mattress with built in bolsters. She stated the manufacturer's recommendations indicated bolsters were sufficient, so side rails were not needed. Employee #77 verified this resident was also in a low bed and moved very little. k) Resident #27 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. The facility was made aware of this situation on 12/02/13 at 8:00 p.m. The loose side rails were corrected by 11:15 p.m. l) Resident #52 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. The facility was made aware of this situation on 12/02/13 at 8:00 p.m. The loose side rails were corrected by 11:15 p.m. m) Resident #44 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. The facility was made aware of this situation on 12/02/13 at 8:00 p.m. The loose side rails were corrected by 11:15 p.m. n) Resident #81 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. The facility was made aware of this situation on 12/02/13 at 8:00 p.m. The loose side rails were corrected by 11:15 p.m. o) Resident #45 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. The facility was made aware of this situation on 12/02/13 at 8:00 p.m. The loose side rails were corrected by 11:15 p.m. p) Resident #88 At 5:30 p.m. on 12/02/13, this resident's bed was observed with side rails that were loose when they were shaken, creating a potential for injury. The facility was made aware of this situation on 12/02/13 at 8:00 p.m. The loose side rails were corrected by 11:15 p.m. q) Resident #13 Observations were conducted at 5:30 p.m. on 12/02/13. Resident #13's bed was observed with side rails which were loose, creating a potential for entrapment. With a slight touch of the hand, the rails were able to be tilted inward, outward, forward, and backwards. Resident #13's medical record was reviewed at 12:33 p.m. on 12/05/13. The resident had physician's orders for bed side rails since 01/01/13. The [DIAGNOSES REDACTED]. The resident's medical record contained multiple bed safety assessments which addressed the resident's need for side rails. Bed safety assessments dated 07/19/13, 11/13/13, and 11/15/13 all addressed the need for bilateral 1/2 side rails for seizure precautions. The bed safety assessment dated [DATE] indicated the resident used his bed side rails for turning and repositioning. The medical record contained no indication the resident was actually able to use the side rails for turning and repositioning. His Minimum data set (MDS), with an assessment reference date (ARD) of 11/21/13, revealed the resident was dependent for bed mobility, which indicated the resident was not able to use the side rails for turning and repositioning. A new bed safety assessment, dated 12/02/13, indicated the resident did not need bed side rails. This assessment noted, "Bed rails not needed. Resident does not turn and reposition self in bed." There was another bed safety assessment, dated 12/03/13. This assessment indicated side rails were not needed, but a low bed was needed. The facility noted,"Resident is dependent with bed mobility therefore does not require side rails." The final bed safety assessment, dated 12/06/13, indicated bed rails were not needed at this time. The assessment identified the resident had a low bed with mats on the floor next to the bed. Employee #86, the director of nursing services (DNS), was interviewed at 10:11 a.m. on 12/11/13. She stated the resident's side rails were discontinued on 12/02/13 because it was determined he no longer needed the side rails. She stated a low bed with landing strips was not an option before, because the resident was in a manual bed which would not go to a low position. She stated they got the resident a new bed which was now able to go to a low position and this is why the bed side rails were able to be discontinued. The DNS stated the resident's new bed was in storage. She said the facility went to the storage unit and got the bed after the immediate jeopardy was called on 12/02/13. She was unable to state why this bed had not all ready been brought out of storage for this resident's use. r) Resident #167 Observations were conducted at 5:30 p.m. on 12/02/13. Resident #167's bed was observed with bed side rails which were loose, crating a potential for entrapment. With a slight touch of the hand, the rails were able to be tilted inward, outward, forward, and backwards. s) Resident #163 Observations were conducted at 5:30 p.m. on 12/02/13. Resident #163's bed was observed with bed side rails which were loose, creating a potential for entrapment. With a slight touch of the hand, the rails were able to be tilted inward, outward, forward, and backwards. The resident's medical record was reviewed at 10:36 a.m. on 12/17/13. There was a physician's order, dated 12/06/13, for bilateral 1/2 side rails to aide in positioning and turning. No physician's order's were found for side rails prior to 12/06/13, although the resident was observed with side rails on 12/02/13. The residents record contained bed safety assessments dated 10/24/13, 12/02/13, 12/03/13, and 12/06/13. Each bed safety assessment indicated the resident used bilateral 1/2 side rails for turning and repositioning. The resident's care plan was reviewed. The care plan contained an intervention of "assist of two (2) with bed mobility, encourage resident to use his two (2) half side rails to assist with turning and positioning. "This intervention contained an initiated date of 10/30/13 with a revision date of 12/09/13. Based on the information in the care plan and the bed safety assessment dated [DATE], the resident had bilateral 1/2 side rails since his admission to the facility on [DATE]. . Employee #15, a Registered Nurse (RN), Unit Manager was interviewed at 2:00 p.m. on 12/17/13. She confirmed the resident had bilateral 1/2 side rails since his admission to the facility on [DATE]. She stated there was not a physician order for [REDACTED]. The ADNS was interviewed at 2:20 p.m., on 12/17/13. She confirmed it was facility practice to have a physician order for [REDACTED]. t) Resident #58 Observations were conducted at 5:30 p.m. on 12/02/13. Resident #58's bed was observed with bed side rails which were loose, creating a potential for entrapment. With a slight touch of the hand, the rails were able to be tilted inward, outward, forward, and backwards. Resident #58's medical record was reviewed at 2:58 p.m. on 12/09/13. There was a physician's order dated 12/02/13 which indicated the resident's side rails were to be discontinued because their use was not indicated. On 12/04/13, a physician's order was placed in the residents medical record for 1/2 bilateral side rails to aid in turning, repositioning, and transferring. A bed safety assessment, completed on 12/02/13, indicated the resident no longer needed side rails. Another bed safety assessment, completed on 12/04/13, indicated the resident requested side rails be placed back on his bed. The assessment indicated the resident used the the bilateral side rails to aid in bed mobility and transferring. u) Resident #91 Observations were conducted at 5:30 p.m. on 12/02/13. Resident #58's bed was observed with bed side rails which were loose, creating a potential for entrapment. With a slight touch of the hand, the rails were able to be tilted inward, outward, forward, and backwards. On 12/10/13 at 2:11 p.m. Resident #91's medical record was reviewed. There was a physician's order, dated 09/27/12 ,which read: "Admission Clarifications: Seizure Precautions Padding to side rails (1/2 SR X 2) d/t seizure disorder." Part III Based on observation and staff interview, the facility failed to ensure the environment was free of accident hazards, over which the facility had control. Medications were accessible to residents. In addition, the face plate on an electrical outlet was broken in Room #119, exposing the wiring behind the outlet. This was found during two (2) random observations during Stage 2 of the Quality Indicator Survey. Facility census: 130. Findings include: a) A random observation, at 1:00 p.m. on 12/03/13, revealed two (2) medications sitting unattended on a desk at the north hall nurses' station. These included 58 tablets of Guaifenesin 600 milligrams (mg) and 20 tablets of Montelukast 10 mg. Employee #95, Licensed Practical Nurse (LPN) was interviewed at 1:46 p.m. on 12/03/13. He confirmed the medications should not be sitting on the desk at the nurses' station. He reported they should have been put in the locked medication room so residents would not have acce