Every finding on record at Farmville Health & Rehab Center

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to develop and/or implement a care plan for five of 44 residents in the survey sample, Residents #25, #40, #103, #91, and #11.The findings include:1. For Resident #25 (R25), the facility failed to develop a care plan for the use of side rails. On the following dates and times, R25 was observed lying in bed with bilateral side rails engaged: 3/9/26 at 1:50 p.m. and 4:24 p.m.; 3/10/26 at 8:31 a.m. and 3:52 p.m. (verified by CNA (certified nursing assistant) #1. A review of R25's care plan dated 12/19/25 revealed no information related to the use of side rails. On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that a care plan is geared to each individual resident's needs. She stated that the MDS (minimum data set) nurses are primarily responsible for developing care plans. She added that the clinical leaders meet a couple of times a day and communicate with the MDS staff about things like the use of bed rails. She stated that the use of side rails should be included on a resident's care plan. On 3/11/26 at 10:01 a.m., the MDS Coordinator was interviewed. She stated that a care plan is a working plan for the interdisciplinary team so everyone can look and see what is supposed to be going on with a resident. She stated the MDS nurses develop the care plans after the nurses develop the initial care plan immediately when a resident is admitted . She stated that floor nurses typically do not develop care plans. She stated she regularly reviews physician orders and speaks with the floor staff (at least twice a day) to determine if care plans need to be developed. She stated side rails should be a part of a resident's care plan because they are something that not all residents need or have. They are unique to some residents. On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns. A review of the facility policy, Comprehensive Care Planning, revealed, in part: The facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables.The services provided or arranged by the facility, as outlined by the comprehensive care plan, must.be provided by qualified persons in accordance with each resident's written plan of care. No additional information was provided prior to exit. 2. For Resident #40 (R40), the facility failed to develop a care plan for the use of side rails. On the following dates and times, R40 was observed lying in bed with bilateral side rails engaged: 3/9/26 at 1:53 p.m. and 4:26 p.m.; 3/10/26 at 3:53 p.m. (verified by CNA (certified nursing assistant) #1. A review of R40's care plan dated 6/24/24 revealed no information related to the use of side rails. On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that a care plan is geared to each individual resident's needs. She stated that the MDS (minimum data set) nurses are primarily responsible for developing care plans. She added that the clinical leaders meet a couple of times a day and communicate with the MDS staff about things like the use of bed rails. She stated that the use of side rails should be included on a resident's care plan. On 3/11/26 at 10:01 a.m., the MDS Coordinator was interviewed. She stated that a care plan is a working plan for the interdisciplinary team so everyone can look and see what is supposed to be going on with a resident. She stated the MDS nurses develop the care plans after the nurses develop the initial care plan immediately when a resident is admitted . She stated that floor nurses typically do not develop care plans. She stated she regularly reviews physician orders and speaks with the floor staff (at least twice a day) to determine if care plans need to be developed. She stated side rails should be a part of a resident's care plan because they are something that not all residents need or have. They are unique to some residents. On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns. No additional information was provided prior to exit. 3. For Resident #103 (R103), the facility failed to develop a care plan for the use of side rails On the following dates and times, R103 was observed lying in bed with bilateral side rails engaged: 3/9/26 at 1:20 p.m. and 4:22 p.m.; 3/10/26 at 8:25 a.m. and 3:51 p.m. (verified by CNA (certified nursing assistant) #1. A review of R103's care plan dated 8/14/24 revealed no information related to the use of side rails. On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that a care plan is geared to each individual resident's needs. She stated that the MDS (minimum data set) nurses are primarily responsible for developing care plans. She added that the clinical leaders meet a couple of times a day and communicate with the MDS staff about things like the use of bed rails. She stated that the use of side rails should be included on a resident's care plan. On 3/11/26 at 10:01 a.m., the MDS Coordinator was interviewed. She stated that a care plan is a working plan for the interdisciplinary team so everyone can look and see what is supposed to be going on with a resident. She stated the MDS nurses develop the care plans after the nurses develop the initial care plan immediately when a resident is admitted . She stated that floor nurses typically do not develop care plans. She stated she regularly reviews physician orders and speaks with the floor staff (at least twice a day) to determine if care plans need to be developed. She stated side rails should be a part of a resident's care plan because they are something that not all residents need or have. They are unique to some residents. On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns. No additional information was provided prior to exit. 4. For Resident #91 (R91), the facility staff failed to develop a care plan for the use of side rails. On the 3/10/26 at 8:30 a.m., R91 was observed sitting up in bed. The right hand side rail was engaged. A review of R91's care plan dated 4/25/25 revealed no information related to the use of side rails. On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that a care plan is geared to each individual resident's needs. She stated that the MDS (minimum data set) nurses are primarily responsible for developing care plans. She added that the clinical leaders meet a couple of times a day and communicate with the MDS staff about things like the use of bed rails. She stated that the use of side rails should be included on a resident's care plan. On 3/11/26 at 10:01 a.m., the MDS Coordinator was interviewed. She stated that a care plan is a working plan for the interdisciplinary team so everyone can look and see what is supposed to be going on with a resident. She stated the MDS nurses develop the care plans after the nurses develop the initial care plan immediately when a resident is admitted . She stated that floor nurses typically do not develop care plans. She stated she regularly reviews physician orders and speaks with the floor staff (at least twice a day) to determine if care plans need to be developed. She stated side rails should be a part of a resident's care plan because they are something that not all residents need or have. They are unique to some residents. On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns. No additional information was provided prior to exit. 5.The facility staff failed to implement the comprehensive care plan for splint application for Resident #11 (R11). R11 was admitted to the facility on [DATE]. R11 diagnoses included but were not limited to: CKD (chronic kidney disease), DM (diabetes mellitus), osteoarthritis and convulsions. R11's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/28/26, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: coded the resident as maximum assistant with bed mobility, transfers, dressing, personal hygiene and bathing; range of motion: upper limb-impaired one side. A review of R11's comprehensive care plan dated 9/27/24 revealed, PROBLEM: ADL (activities of daily living) FUNCTION / REHABILITATION POTENTIAL / PERSONAL HYGIENE: resident needs assistance from staff to maintain an appearance at satisfactory level and to complete ADLs. APPROACH: Right resting hand splint to improve Right hand function. A review of the physician orders dated 11/5/24 revealed, Patient was fitted with a right resting hand splint to reduce contracture and improve finger extension for use independent transfers. wearing instructions and precautions provided. Patient can remove splint but need staff to assist with applying it. A review of the MARs (medication administration records) for February and March 2026 revealed, splint on/off-coded off on following dates and shifts: day shift- 2/13, 3/11; evening shift- 2/1-2/13, 2/15-2/19, 2/21-2/28, 3/1, 3/3-3/10 and night shift- 2/1-2/17, 3/3-3/10/26. A review of the OT' (occupational therapy)'s progress note dated 9/2/25 and 11/26/25 revealed, Patient and Caregiver Training: instructed patient and primary caregivers in compensatory strategies in positioning maneuvers. Goal: Patient will be consistent with wearing RUE (right upper extremity) orthosis to prevent further contractures. R11 observed on 3/10/26 at 8:30 AM, 12:15 PM and 3/11/26 8:35 AM without splint on right hand. On 3/11/26 at 8:35 AM, R11 was observed without splint on right hand, when asked about right hand contracture, R11 stated, I am to wear a splint on the hand. The splint helps my hand stay open more. I do not know where the splint is. On 3/11/26 at 10:00 AM, an interview was conducted with the MDS coordinator, asked the purpose of the care plan, the MDS coordinator stated, it is for the interdisciplinary team, so everyone knows what is going on with the resident. The nurses do the baseline, then MDS does comprehensive care plan. If changes need to be made, MDS updates the care plan. If approaches on the care plan are not followed, the care plan was not implemented. On 3/11/26 at 2:00 PM, the administrator and director of nursing were made aware of the concerns. No further information was provided on exit.

Based on staff interview and clinical record review, the facility staff failed to accurately complete an annual minimum data set (MDS) assessment for 1 of 44 residents, Resident #105. The findings included:For Resident #105 (R105), the facility staff failed to code Section A1510 (Level II Preadmission Screening and Resident Review) of an annual MDS assessment to indicate the resident had a diagnosis of intellectual disability. R105's diagnoses included mild intellectual disabilities and bipolar disorder. Section C (cognitive patterns) of R105's annual MDS assessment with an assessment reference date (ARD) of 04/01/25 included a brief interview for mental status (BIMS) score of 13, indicating R105 was cognitively intact. Section A1510 was not coded to indicate R105 had been diagnosed with mild intellectual disability. R105's comprehensive care plan included the focus areas psychosocial well-being resident requires a level II PASRR (preadmission screening and resident review) related to intellectual disability and impaired cognitive function/impaired thought processes related to mild disability. R105's clinical record included a level II screening completed on 02/22/23. On 03/10/2026 at 2:35 p.m., during an interview with Registered Nurse (RN) #1 this staff reviewed R105's annual MDS and confirmed the diagnosis of intellectual disability had not been coded on Section A1510 of the annual MDS assessment and stated they would modify the assessment. On 03/10/2026 at approximately 5:00 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Director of Nursing, and Assistant Director of Nursing the above issue was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on observation, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide privacy during care for one of 44 residents in the survey sample, Resident #3.The findings include:For Resident #3 (R3), the facility staff failed to provide privacy during tracheostomy (1) care on 3/10/2026.On the most recent minimum data set (MDS), an admission assessment with an assessment reference date (ARD) of 2/4/2026, R3 was assessed as having a tracheostomy and receiving tracheostomy care at the facility.On 3/10/2026 at 10:52 AM, an observation was conducted of licensed practical nurse (LPN) #2 providing tracheostomy care to R3. LPN #3 was observed donning a mask, gown and gloves prior to performing tracheostomy care at the bedside of R3 which included changing the inner cannula of the tracheostomy tube, cleaning the outer stoma of the tracheostomy and suctioning the tracheostomy. During the procedure, R3's room door remained open, the privacy curtain open and pushed back to the wall and the blinds on the window remained open. Other residents, visitors and other staff were observed passing by the room in the hallway during the procedure. Additional staff entered the room to assist LPN #3 during the procedure including the unit manager and the director of nursing while the room door, privacy curtain and blinds remained open. On 3/10/2026 at 3:40 PM, an interview was conducted with LPN #2 who stated that privacy was provided during procedures by pulling the curtain in semi-private rooms and by closing the door in private rooms. She stated that she should have closed the door to R3's room during the tracheostomy care to provide privacy and had forgotten.The facility policy Resident Rights and Facility Responsibilities revised 10/7/2025 documented in part, It is the facility's policy to comply with all Resident Rights .On 3/10/2026 at approximately 5:00 PM, the administrator, the director of nursing, the regional director of clinical services, the regional director of operations and registered nurse #2, the assistant director of nursing, were made aware of the findings.No further information was provided prior to exit. Reference:(1) A tracheostomy is surgery to create a hole in your neck that goes into your windpipe. If you need it for just a short time, it will be closed later. Some people need the hole for the rest of their life. The hole is needed when your airway is blocked, or for some conditions that make it hard for you to breathe. You may need a tracheostomy if you are on a breathing machine (ventilator) for a long time; a breathing tube from your mouth is too uncomfortable for a long-term solution. The tracheostomy provides a way for your health care providers to gradually remove the ventilator if possible. After the hole is made, a plastic tube is placed in the hole to keep it open. A ribbon is tied around the neck to keep the tube in place . This information was obtained from the website: Tracheostomy care: MedlinePlus Medical Encyclopedia

Based on staff interview and clinical record review it was determined that the facility staff failed to electronically submit a completed MDS (minimum data set) resident assessment for one of 44 residents in the survey sample, Resident #19.The findings include:For Resident #19 (R19), the facility staff failed to electronically submit the discharge MDS (minimum data set) with the ARD (assessment reference date) of 1/18/26.Review of the clinical record revealed a list of Resident 19's MDS assessments. The list revealed that a discharge MDS was completed on 1/18/26. Section A of the assessment documented Resident R19 as death in facility. As of the date of the survey of 3/11/26, the assessment's status was documented as in progress and did not have an accepted date which would have indicated the assessment had been electronically submitted.On 3/11/26 at 10:06 am., RN (registered nurse) #3, MDS coordinator was interviewed. When asked what triggers her to complete a discharge MDS, she answered that she was notified in the morning meetings, by the social worker or in the electronic medical records. She stated a discharge MDS should be completed within 7 days. She stated it should say production accepted when it has been transmitted and accepted. She further stated they use the RAI manual as guidance to complete the MDS assessments. RN#3 was shown R19's MDS in electronic medical record and said that it was probably overlooked and needed to be sent.According to the RAI Manual, Version 3.0, dated October 2025, section 2.6 documented that a discharge assessment is to be electronically submitted no later than the MDS completion date plus 14 calendar days, making the required date of electronic submission for this assessment on or approximately 2/1/26.On 3/11/26 at approximately 2:02p.m., Administrator, Director of Nursing, Regional [NAME] President of Operation, and Regional Director of Clinical Services were notified of the findings.No further information was provided prior to exit.

Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide services to prevent a decrease in range of motion (ROM) for one of 44 current residents in the survey sample, Resident #11. The findings include:The facility failed to provide ROM services after identification of weakness and impaired mobility on admission for Resident #11 (R11). R11 was admitted to the facility on [DATE]. R11 diagnoses included but were not limited to: CKD (chronic kidney disease), DM (diabetes mellitus), osteoarthritis and convulsions. R11's most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/28/26, coded the resident as scoring 12 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was moderately cognitively impaired. MDS Section G- Functional Status: coded the resident as maximum assistant with bed mobility, transfers, dressing, personal hygiene and bathing; range of motion: upper limb-impaired one side.A review of R11's comprehensive care plan dated 9/27/24 revealed, PROBLEM: ADL (activities of daily living) FUNCTION / REHABILITATION POTENTIAL / PERSONAL HYGIENE: resident needs assistance from staff to maintain an appearance at satisfactory level and to complete ADLs. APPROACH: Right resting hand splint to improve Right hand function.A review of the physician orders dated 11/5/24 revealed, Patient was fitted with a right resting hand splint to reduce contracture and improve finger extension for use independent transfers. wearing instructions and precautions provided. Patient can remove splint but need staff to assist with applying it.A review of the MARs (medication administration records) for February and March 2026 revealed, splint on/off-coded off on following dates and shifts: day shift- 2/13, 3/11; evening shift- 2/1-2/13, 2/15-2/19, 2/21-2/28, 3/1, 3/3-3/10 and night shift- 2/1-2/17, 3/3-3/10/26.A review of the OT's progress note dated 9/2/25 and 11/26/25 revealed, Patient and Caregiver Training: instructed patient and primary caregivers in compensatory strategies in positioning maneuvers. Goal: Patient will be consistent with wearing RUE (right upper extremity) orthosis to prevent further contractures.R11 observed on 3/10/26 at 8:30 AM, 12:15 PM and 3/11/26 8:35 AM without splint on right hand.On 3/11/26 at 8:35 AM, R11 was observed without splint on right hand, when asked about right hand contracture, R11 stated, I am to wear a splint on the hand. The splint helps my hand stay open more. I do not know where the splint is.On 3/11/26 at 8:40 AM, LPN (licensed practical nurse) #5 stated, the splint was not on his right hand, it would be checked on after med pass.On 3/11/26 at 8:45 AM, LPN #6, the unit manager went to R11's room, looked in bedside cabinet top drawer and found the splint then put splint on resident with their help.On 3/11/26 at 8:55 AM, an interview was conducted with OSM (other staff member) #5, the occupational therapist (OT). The occupational therapist described R11's need for the splint, as he needs help putting it on, trying to get his fingers straightened out. Nursing has been informed multiple times about the need for assistance, but there are many staff across different shifts.On 3/11/26 at 2:00 PM, the administrator and director of nursing were made aware of the concerns.A review of the facility's Splint Issuance policy revealed, Splints shall be issued or fabricated with a provider's order and therapist must evaluate patient to determine need for splint, fit and issuance. Client will be instructed in wearing schedule, precautions and splint care. Patient splint schedule will be communicated to the multi-disciplinary team and documented in the care plan.No further information was provided on exit.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to implement bed rail requirements for three of 44 residents in the survey sample, Residents #25, #40, and #103.The findings include:1. For Resident #25 (R25), the facility failed to assess the resident for the need for side rails, failed to educate the resident on benefits and risks of using side rails, and failed to obtain informed consent prior to the implementation of side rails.On the following dates and times, R25 was observed lying in bed with bilateral side rails engaged: 3/9/26 at 1:50 p.m. and 4:24 p.m.; 3/10/26 at 8:31 a.m. and 3:52 p.m. (verified by CNA (certified nursing assistant) #1.A review of R25's clinical record revealed no evidence of a side rail assessment, resident education, or consent for side rails. A review of R25's care plan dated 12/19/25 revealed no information related to the use of side rails.On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that when a resident is admitted to the facility, the physical therapy staff assesses the resident for the need for side rails for bed mobility. If the therapy staff recommends the side rails, the nursing staff completes an Enabler Assessment. The Enabler Assessment assesses the resident's ability to use the side rails safely and provides the opportunity for education on the risks and benefits of use. She stated this assessment is required prior to the implementation of any side rails.On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns.A review of the facility policy, Bed Rail Policy, revealed, in part: 'Bed rails' are adjustable metal or rigid plastic bars that attach to the bed. This also includes grab and enabler bars.If a bed or side rail or bar is used, the facility will.Evaluate the potential risks associated with the use of bed rails, including the risk of entrapment, prior to bed rail installation.Evaluate the risk versus benefits of using a bed rail and review them with the resident or.the resident's representative.Obtain informed consent for the installation and use of bed rails prior to the installation.No additional information was provided prior to exit.2. For Resident #40 (R40), the facility failed to assess the resident for the need for side rails, failed to educate the resident on benefits and risks of using side rails, and failed to obtain informed consent prior to the implementation of side rails.On the following dates and times, R40 was observed lying in bed with bilateral side rails engaged: 3/9/26 at 1:53 p.m. and 4:26 p.m.; 3/10/26 at 3:53 p.m. (verified by CNA (certified nursing assistant) #1.A review of R40's clinical record revealed no evidence of a side rail assessment, resident education, or consent for side rails. A review of R40's care plan dated 6/24/24 revealed no information related to the use of side rails.On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that when a resident is admitted to the facility, the physical therapy staff assesses the resident for the need for side rails for bed mobility. If the therapy staff recommends the side rails, the nursing staff completes an Enabler Assessment. The Enabler Assessment assesses the resident's ability to use the side rails safely and provides the opportunity for education on the risks and benefits of use. She stated this assessment is required prior to the implementation of any side rails.On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns.No additional information was provided prior to exit.3. For Resident #103 (R103), the facility failed to assess the resident for the need for side rails, failed to educate the resident on benefits and risks of using side rails, and failed to obtain informed consent prior to the implementation of side rails.On the following dates and times, R103 was observed lying in bed with bilateral side rails engaged: 3/9/26 at 1:20 p.m. and 4:22 p.m.; 3/10/26 at 8:25 a.m. and 3:51 p.m. (verified by CNA (certified nursing assistant) #1.A review of R103's clinical record revealed no evidence of a side rail assessment, resident education, or consent for side rails. A review of R103's care plan dated 8/14/24 revealed no information related to the use of side rails.On 3/11/26 at 8:32 a.m., RN (registered nurse) #5 was interviewed. She stated that when a resident is admitted to the facility, the physical therapy staff assesses the resident for the need for side rails for bed mobility. If the therapy staff recommends the side rails, the nursing staff completes an Enabler Assessment. The Enabler Assessment assesses the resident's ability to use the side rails safely and provides the opportunity for education on the risks and benefits of use. She stated this assessment is required prior to the implementation of any side rails.On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns.No additional information was provided prior to exit.

Based on staff interview, clinical record review, and facility document review, the facility staff failed to address a resident's weight loss for one of 44 residents in the survey sample, Resident #106.The findings include:For Resident #106 (R106), the facility staff failed to address the resident's significant weight loss occurring between 03/10/2025 and 09/08/2025.A review of R106's clinical record revealed the following weights: 3/10/25 - 209.9 pounds; 9/8/25 - 188.6 pounds. This represented a 10.15% loss.A further review of R106's clinical record revealed no evidence that the Registered Dietician (RD) had addressed this significant weight loss. This review revealed that after 9/8/25, the resident's weights stabilized.On 3/11/26 at 8:49 a.m., the RD was interviewed. She stated that she goes to the facility once a week on Monday and pulls a weight report for all residents at this time. She stated: I can only see what the report tells me. I would not have picked this [significant loss] up if I pulled the report on a day when it didn't show up. She presented a sample weight report to demonstrate her point. She explained that she only looked at the percentages and number of days between weights for weights taken 30 and 180 days prior running the report; she did not look at the weights themselves to identify other possible losses. She stated if she had known about R106's weight loss that showed on 9/8/25, she would have written a note. She added that for R106, the weight loss was desirable over time.On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns.No additional information was provided prior to exit.

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement safety interventions for one of 44 residents in the survey sample, Resident #103.The findings include:For Resident #103 (R103), the facility staff failed to implement a bolster on the resident's bed.On the following dates and times, R103 was observed lying in bed; a bolster was not observed at any time: 3/9/26 at 1:20 p.m. and 4:22 p.m.; 3/10/26 at 8:25 a.m. and 3:51 p.m. The lack of a bolster was verified on 3/10/26 at 3:51 p.m. by both CNA (certified nursing assistant) #1 and LPN (licensed practical nurse) #1.A review of R103's clinical record revealed the following order dated 9/13/24: Add bolsters to bed for resident safety.On 3/10/26 at 4:50 p.m., LPN #1 was interviewed. She stated R103 had not had a bolster on her bed since the beginning of 2026. She stated: She was switched to an air mattress. She added that the resident had not experienced a fall since July 2025. She explained: We didn't feel like she needed the bolster anymore.On 3/11/26 at 8:32 a.m., RN (registered nurse) #5, R103's unit manager, was interviewed. She stated that bolsters on a resident's bed are used as a fall prevention intervention. She stated the bolsters help define the perimeters of the bed, and in R103's case, were especially helpful because the resident is legally blind. She stated that an air mattress is used to help prevent or treat a resident's skin impairments, and that air mattresses do not take the place of bolsters. She stated: They are for two different things. She stated if there is a provider's order for a bolster, the order should be followed.On 3/11/26 at 2:00 p.m., the Administrator and Director of Nursing were informed of these concerns.A review of the facility policy, Fall Prevention and Management, revealed, in part: If [fall] risks are identified, preventive measures will be put in place.Individualized interventions will be implemented.No additional information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to ensure a level II PASARR (preadmission screening and resident review) was completed for 1 of 44 residents, Resident #7.The findings included:For Resident #7 (R7), the facility staff failed to ensure a level II PASARR was completed. A Level I PASARR's was completed on 02/12/26 and referred this resident for a level II. R7's diagnoses included schizoaffective disorder, anxiety disorder and major depressive disorder.Section C (cognitive patterns) of R7's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/24/26 included a brief interview for mental status (BIMS) score of 15, indicating R7 was cognitively intact. During the clinical record review, the surveyor was unable to locate a level I PASARR. On 03/10/26 at 2:25 p.m., the facility Social Worker (SW) provided the surveyor with a copy of a level I PASARR completed on 02/12/26. Under the heading of RECOMMENDATION the box that read Refer for Level II evaluation had been marked. The SW stated they had sent referrals to the company that completed the level II PASARR's on 02/12/26, 02/23/26, and 02/26/26 as they did not complete level II's at the facility. On 03/10/2026 at approximately 5:00 p.m., during an end of the day meeting with the Administrator, Regional Director of Clinical Services, Director of Nursing, and Assistant Director of Nursing the issue with the level II PASARR not being completed was reviewed. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that one of 43 residents in the survey sample was free from resident-to-resident abuse, Resident #29, which resulted in harm cited at past non-compliance. The findings include: Resident #103 intentionally pushed Resident #29, which resulted in a fall with a shoulder fracture for Resident #29. Resident #103 had documented behaviors and that the resident required increased supervision. There was no evidence that increased supervision was provided at the time of the occurrence. The facility abuse policy read: Abuse, Neglect and Exploitation documented, This facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone Definitions: Abuse - Includes actions such as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish Physical Abuse - includes hitting, slapping, pinching and kicking Verbal abuse - is defined as the use of oral, written or gestured language that willfully includes .threats of harm . A review of the facility synopsis of the event that occurred on 2/2/23 revealed the following: A witness statement documented that the hospice chaplain spoke with (Resident #103) and stated that the resident believes this is [their] home and all of these residents are trespassing. (Resident #103) was talking on [their] phone and (Resident #29) told (Resident #103) to get off the [profanity] floor. (Resident #103) felt disrespected and told (Resident #29) if [they are] going to talk to (Resident #103) like the floor [sic] (Resident #29) would end up on the floor. Another witness statement documented a statement made by Resident #29 (Resident #103) pushed me and I fell . A review of the Petition for Involuntary Admission for Treatment dated 2/2/23 documented, Resident exhibiting physical aggression. Pushed (Resident #29) down and broke [their] left shoulder .(Resident #103) felt disrespected and told (Resident #29) if (Resident #29) is going to talk to (Resident #1030 like the floor (Resident #29) would end up on the floor Resident #29 had diagnoses of but not limited to, brain cancer, psychosis, epilepsy, femur fracture, wedge compression fracture of thoracic vertebra and glaucoma. The most recent MDS was a quarterly assessment dated [DATE]. The resident was coded as being impaired with ability to make daily life decisions, scoring a 11 out of a possible 15 on the BIMS. The resident required supervision to limited assistance for all areas of activities of daily living except for bathing which was extensive assistance. A review of the clinical record for Resident #29 revealed the following: A nurse's note dated 2/2/23 documented, This note is a follow up to Fall secondary to resident assault .Evidence of pain noted Left shoulder/bilateral knees Pain is throbbing Pain is sharp Pain level is 8 out of 10. The pain is constant Pain is persistent daily. Guarding left shoulder to chest and bilateral knees . A nurse's note dated 2/2/23 documented, .Resident is Cooperative. Resident is Tearful. Range of motion deficits are Left Shoulder limited ROM any movement about chest she screams out in pain Evidence of pain noted Left Shoulder and Bilateral Knees Pain is throbbing Pain is sharp Pain level is 7 out of 10. The pain is intermittent Pain is persistent daily. Guarding Left Shoulder to chest. Non ambulation due to knee discomfort. A nurse practitioner note dated 2/2/23 documented, .Pt (patient) was seen, reports that another resident pushed [them] and [they] fell . [Resident] is c/o (complaining of) mainly of left shoulder pain, but states that [they] landed on [their] knees then shoulder. No contact to head with floor. [Resident] is crying and c/o pain. [Resident] is unable to AROM (active range of motion) left arm at shoulder. Gently moved left arm PROM (passive range of motion) approximate 10 degree abduction with pt screaming in pain. [Resident] c/o pain on palpation of shoulder at glenohumeral joint. Discussed with staff, and will send pt to ER for evaluation as there appears to be joint compromise . A nurse's note dated 2/2/23 documented, Resident returned to Facility via stretcher accompanied by 2 EMS (emergency medical services) providers. Resident has sling to left shoulder/arm .Er discharge instructions as follows: Diagnosis Fracture of proximal end of left humerus, fall, alleged assault and knee contusion . Resident #103 had documented behaviors. The facility staff documented evidence that the resident required increased supervision. There was no evidence that increased supervision was provided at the time of the resident-to-resident altercation. Resident #103 had the diagnoses of but not limited to cancer of the prostate and bone and dementia. The most recent MDS (Minimum Data Set) was a significant change MDS dated [DATE]. The resident was coded as being cognitively intact in ability to make daily life decisions, scoring a 14 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as requiring supervision only for eating, toileting and hygiene; and was coded as being completely independent for all other areas of activities of daily living. The resident was coded as having physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others. The resident was coded as behavior symptoms significantly interfered with the resident's ability to participate in activities and social interactions. The resident's behavior symptoms were coded as putting others at significant risk of physical injury. The resident's behavior was coded as being worse since the prior MDS assessment (Admission assessment dated [DATE] wherein the resident was coded as having delusions and wandering behaviors). A review of the clinical record for Resident #103 revealed the following notes: A social worker note dated 12/1/22 documented, .Charge Nurse also reported behaviors of vulgar language and comments to shoot their kneecaps off if [resident] wasn't allowed to go home . A nurse practitioner note dated 12/1/22 documented, .Staff report that [resident] often is wandering the facility and is sometimes not always easily redirected 1. Dementia with behaviors: Noted mild agitation and behaviors . A nurse's note dated 12/7/22 documented, .Resident becoming aggressive towards staff. Resident makes statements about hurting staff. A nurse practitioner note dated 12/27/22 documented, .Recently cane was removed from [resident] possession because of reports of striking out with cane .1. Dementia with behaviors: Noted mild agitation and behaviors, Continue sertraline (1), olanzapine (2), donepezil (3), memantine (4). Followed by psychology, continue with recommendations. Recent walking cane removal r/t (related to) aggressive behaviors per staff A nurse's note dated 1/7/23 documented, Resident was aggressive towards writer at the beginning of the shift. Resident pushed [their] walker towards writer to try and run writer over, [resident] then picked [their] walker up from the floor and again came towards this writer to try and hit again. [Resident] had displayed exit seeking behaviors, such as going to the door that lead to outside and has been trying to get out and find [their] truck. This writer redirected [resident] and informed [resident] [they] [do] not have truck outside. Hospice was called at 1040am and made aware, however, I am waiting on a call back from the nurse at this time. Activity staff is currently sitting one to one with resident because of exit seeking behavior. Will cont (continue) to monitor and document. RP (responsible party - resident family member) made aware. A nurse's note dated 1/7/23 documented, Hospice in to see resident at 1209 pm. Nurse spoke with resident. 2 (two) new orders in for resident. Since lunch [resident] has been pleasant. One to one aide has been with [resident] in close range . A nurse's note dated 1/15/23 documented, Aide overheard resident yelling from her room, yelling get out, aide noted resident from room (number) coming out of resident room, Aide redirected resident back into room and notified Writer, Writer went to talk to resident, resident says that resident came into the room and I told [Resident #103] no get out, resident continue to walk toward the bed and touch my foot then walked out of room . A physician's note dated 1/16/23 documented, .exhibits advanced confusion, with nonsensical speech and disorientation. Has been wandering aimlessly into other residents' rooms in past three weeks . A nurse practitioner note dated 1/18/23 documented, Staff concerned over pt (patient) continually wandering, slightly unsteady on [their] feet. [Resident] has been moved closer to nurses station . A social worker note dated 1/20/23 documented, Resident reviewed in IDT (interdisciplinary team) meeting due to behaviors. Resident is often verbally aggressive with staff and wandering into the rooms of other residents after being redirected and not wanting others to use [Resident #103] bathroom. Resident is often restless and has to be re-directed from trying to leave the facility. Resident has been moved to another room with a private bathroom. Resident will continue to be monitored and redirected as needed. A nurse's note dated 1/27/23 documented. Resident wandering in/out of multiple residents rooms. Res (resident) not redirectable. Resident went into room (number) with pants down. Residents in (room) scared, and stated they will call the cops if this keeps happening. A nurse's note dated 1/27/23 documented, .Unit Manager called Hospice (company) and spoke with Case manager (name) and asked for 1-1 sitter to help keep patient directed to prevent any further incidents which would avoid the police/ At this time hospice has no extra help or able to provide 1/1 and advised if redirecting does not work to send [resident] to ER [emergency room ] . A nurse's note dated 2/1/23 documented, Resident sitting in hallway, on wheeled walker, yelling HELP when approached about whats wrong resident stated [they] wanted a back scratcher. When resident realized I did not have one [they] became verbally aggressive, called this nurse A stupid ugly [profanity] Resident then grabbed walker like [they] was going to throw it at this nurse, resident then proceeded to use verbal slurs. Resident able to be directed back towards room after several minutes of coaxing. PRN medications administered to no avail. Spoke with Hospice. New orders implemented for agitation. A nurse's note dated 2/2/23 documented, Unit Manager was gotten out of Morning meeting from charge Nurse and reported that Resident had assaulted a female Resident and pushed her to the floor and the NP (nurse practitioner) was on the unit and is in with [other] resident and asking for [resident] to be sent out to the emergency room due to possible Fracture of left shoulder. A nurse's note dated 2/2/23 documented, Summary of Discharge: Resident discharged To: Resident ECO'd (emergency confinement order). discharged via: Ambulatory Accompanied by (local) Sheriff Department Social Service Summary: Resident was involved in an incident where [they] pushed a [another] resident and [other resident] fell and was injured. DON and SW went to the (county) Sheriff Dept to file an ECO and (county) Law Enforcement arrive at the facility around 7pm to pick resident up Resident's [family member]/emergency contact was contacted A nurse's note dated 2/3/23 documented, This writer called ER to follow up on resident. RN (Registered Nurse) (name) at (hospital) stated [Resident #103] is still in the ER and they are waiting on bed placement. They are seeking bed placement for Psychiatric care. A nurse's note dated 2/3/23 documented, Resident to resident incident 2/2/23 Resident initiated physical aggression on female peer. [Resident #103] was provided one to one care until an ECO could be obtained. [County] deputies transported resident to ER for evaluation of psychiatric services. Per report from (hospital) resident being sent to [psychiatric] Hospital for psychiatric stabilization. MD, Hospice, and family aware. A review of the comprehensive care plan for Resident #103 revealed one dated 11/30/22 for Resident is on antipsychotic therapy . This care plan was updated on 12/7/22 to include, verbally abusive and threatening towards staff. Another care plan, dated 1/10/23, documented, Resident shows behaviors by goes into other residents rooms and lying in their beds. This was updated on 1/23/23 to include Resident with episode of nudeness in the hallway. The above care plans did not include any interventions for the provision of supervision or the need of increased supervision related to wandering, behaviors, and aggression. Interviews: On 5/22/23 at 4:44 PM an interview was conducted with LPN #5 (Licensed Practical Nurse). She stated that If we didn't have [Resident #103] on 1:1 we didn't have the staff [to provide 1:1]. The only thing was to redirect him. Sometimes it was not effective. When asked about Resident #103's aggressive behaviors, she stated, It's a red flag he could be aggressive to other residents. And stated a 1:1 could have kept the resident from being able to hit someone else and could have separated him from others if he was becoming aggressive. On 5/23/23 at 10:58 AM an interview was conducted with RN #2 (Registered Nurse). She stated that the resident required increased supervision and that I would assign 1:1. She stated that it was her recommendation during a meeting to move Resident #103 and to provide 1:1. She stated that the facility called hospice for 1:1. She stated that it was not their [hospice] responsibility to but it was due to [facility] staffing. She stated that there should have been other interventions in place. On 5/23/23 at 12:30 PM an interview was conducted with the Director of Nursing (ASM-administrative staff member #1), who was not employed at the facility at the time of the incident; and ASM #3, the Regional Clinical Consultant. When asked about Resident #103's increase in behaviors of aggression and wandering in other residents rooms to the point that other residents threatened to call the cops if it did not stop, and that on 1/27/23 the facility even called hospice to provide a 1:1 sitter, why didn't the facility provide increased supervision or place the resident on 1:1 with facility staff, ASM #3 stated the staff would keep an eye on (Resident #103) more on days the resident wandered. When asked if the interventions were effective, ASM #1 stated they were not. The facility was unable to evidence that with the increase in aggression, behaviors and wandering that Resident #103 was provided with any increased supervision which resulted in a resident-to-resident abuse with injury. On 5/23/23 at 4:01 PM, in a follow up interview with ASM #3, when asked if Resident #29 was free from abuse, she stated, I would have to say that she wasn't. On 5/22/23 at 5:17 PM, ASM #1, ASM #2 (Regional [NAME] President of Operations), ASM #3, and ASM #5 (Divisional [NAME] President of Operations) were made aware of the concern for harm. A review of facility documentation evidenced the components of a plan of correction with a compliance date of 2/2/23 as described below: 1. Resident #103 was removed from the facility and more appropriate placement was arranged elsewhere. 2. The facility did a 100% audit of all residents for aggressive and wandering behaviors. 3. The facility did a 100% audit of all residents for evidence of abuse, that included skin checks. 4. The facility did a 100% education of all staff of the abuse policy Abuse, Neglect and Exploitation. 5. The facility completed weekly round audits of all residents to identify and address any concerns any residents had. This deficiency is cited at past non-compliance. References: (1) Sertraline is an antidepressant used to treat depression, obsessive-compulsive disorder, panic attacks, post traumatic stress disorder, and social anxiety disorder. Information obtained from https://medlineplus.gov/druginfo/meds/a697048.html (2) Olanzapine is an atypical antipsychotic used to treat schizophrenia Information obtained from https://medlineplus.gov/druginfo/meds/a601213.html (3) Donepezil is used to treat dementia. Information obtained from https://medlineplus.gov/druginfo/meds/a697032.html (4) Memantine is used to treat Alzheimer's disease. Information obtained from https://medlineplus.gov/druginfo/meds/a604006.html (4) Ativan is used to treat anxiety and insomnia caused by anxiety. Information obtained from https://medlineplus.gov/druginfo/meds/a682053.html

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to provide adequate supervision for one of 43 residents in the survey sample, Resident #100, which resulted in a fall with fracture. This was cited as harm at past non-compliance. The findings include: For Resident #100 (R100), the facility staff failed to implement the plan of care, while providing ADL (activities of daily living) assistance, which resulted in the resident falling from the bed and suffering a fractured femur (1) resulting in harm. R100 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (2) and hemiplegia (3). On the residents MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/16/2022, the resident scored 12 out of 15 on the BIMS (brief interview for mental status) indicating the resident was moderately impaired for making daily decisions. Section G documented R100 being totally dependent on two persons for toileting and transfers and requiring extensive assistance of two persons for bed mobility. The assessment further documented R100 being always incontinent of bowel and bladder and not having any falls since the previous assessment. The progress notes for R100 documented in part: 6/13/2022 17:00 (5:00 p.m.) Overview: Occurrence Details: Resident stated that she rolled off the bed while being changed, she couldn't stop herself from rolling. Immediate Intervention: head to toe assessment, pain assessment, Vs (vital signs) taken, assisted off floor, Md (medical doctor) and RP (responsible party) made aware .Range of motion deficits are previous left sided weakness. Neurological checks are within normal limits. Evidence of pain noted left hip. Pain is acute. Pain level is 7 out of 10. The pain is constant .Residents family/responsible party was notified of occurrence. [Name of family member] resident has left sided weakness and was unable to prevent self from rolling while on the left side, staff educated on assisting with adl care. - 6/13/2022 17:15 (5:15 p.m.) Situation: The Change In Condition/s reported on this CIC (change in condition) Evaluation are/were: Falls .Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: mobile x-ray stat (now), if not able to come on today send to ER (emergency room ) for x-ray . - 6/13/2022 22:02 (10:02 p.m.) Note Text: writer called to get update from [Name of hospital]ER on resident and was informed that resident has a left femur fracture and was being shipped to [Name of hospital] ER. The comprehensive care plan for R100 documented in part, Resident is at risk for falls r/t (related to) left sided weakness, neuropathy. Actual: Date Initiated: 01/25/2020. Revision on: 09/10/2021. Under Interventions it documented in part, 6/13/22 fall with left femur fracture. Sent to ER and admitted . Staff educated on assisting with ADL care using 2 staff for all ADL care. Date Initiated: 06/14/2022. The care plan further documented, Resident has self-care deficit r/t left sided hemiparesis, left hand contracture, left heel arterial ulcer. Date Initiated: 01/25/2020. Revision on: 05/17/2021. Under Interventions it documented in part, Bed Mobility: The resident requires (1-2) staff participation for turning and repositioning in bed. Revision Date: 2/23/2022 .Toileting: The resident requires (1-2) staff participation with toileting. Revision Date: 2/23/2022. The fall risk assessment for R100 dated 5/12/2022 documented the resident being a high risk for falls. On 5/22/2023 at 8:00 a.m., ASM #1 provided a fall risk evaluation dated 6/13/2022 for R100 which documented a witnessed fall. On 5/22.2023 at approximately 12:30 p.m., a request was made to ASM #1 for additional information regarding the witnessed fall on 6/13/2022 for R100, including any education provided to the aide as documented in the progress notes, witness statements or any investigation completed. A request was made to speak with the LPN (licensed practical nurse) on duty 6/13/2022 who assessed R100 after the fall and the aide who provided care to R100 at the time of the fall from bed. On 5/22/2023 at approximately 1:45 p.m., ASM #1 provided a post fall huddle form for R100 dated 6/13/2022 which documented in part, .Ask Resident .What were you trying to do, go to? What happened? Slid/rolled out of bed .What were they doing? Receiving ADL care .The 5 whys and root cause: Why? CVA. Why? left sided weakness. Why? Improper rolling procedure. Why? Decreased ROM (range of motion). Why? General weakness . On 5/22/2023 at 3:39 p.m., ASM #1, the mobile director of nursing stated that the aide who provided care for R100 on 6/13/2022 no longer worked at the facility, the LPN who assessed R100 after the fall and the unit manager no longer worked at the facility. ASM #1 stated that they had looked for the education for the aide documented in the progress notes and were unable to find anything. ASM #1 reviewed the MDS for R100 with the ARD of 5/16/2022 and stated that the resident was a total assistance of two persons and the staff member should have had a second person in the room with them and it looked like they did not. On 5/22/2023 at 12:16 p.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that they had worked at the facility for six to seven months and was not working when R100 had the fall with injury. CNA #5 stated that they worked with the resident after they returned to the facility after surgery. CNA #5 stated that they reviewed the Kardex (written plan of care) for residents to determine the assistance required for residents and either had another CNA or the nurse assist them when two staff were required for toileting assistance. On 5/22/2023 at 5:18 p.m., ASM #1, the mobile director of nursing, ASM #2, the regional vice president of operations, ASM #3, the regional clinical consultant and ASM #5, the divisional vice president of operations were made aware of the concern for harm. On 5/23/2023 at 8:00 a.m., ASM #2 provided a plan of correction for R100 dated 6/14/2022. ASM #2 stated that the date of compliance for the plan of correction was 9/15/2022. Review of the plan of correction documented a root cause analysis completed for the event, education provided to staff, including the aide involved in the event on proper protocol for bed mobility with competency, evaluation of other potential affected residents in the facility, weekly observations conducted of staff providing care for 12 weeks and mattress audits completed. Verification of the facility plan of correction was completed by observations, staff interviews and review of the completed mattress audits, completed staff bed mobility competency check offs. No concerns were identified. No further information was provided prior to exit. Past non-compliance. Reference: (1) femur fracture You had a fracture (break) in the femur in your leg. It is also called the thigh bone. You may have needed surgery to repair the bone. You may have had surgery called an open reduction internal fixation. In this surgery, your surgeon will make a cut to open your fracture. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000166.htm. (2) cerebrovascular disease, infarction or accident A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm . (3) hemiplegia Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to implement the care plan for four of 43 residents in the survey sample, Residents #57, #85, #31, and #10. The findings include: 1a. For Resident #57 (R57) the facility staff failed to follow the care plan for diabetes. R57 was admitted to the facility with a diagnosis of diabetes mellitus (1). A review of R57's physician orders revealed the following order dated 9/8/22: Trulicity (2) Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1.5 mg subcutaneously week every Fri related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42). A review of R57's MAR (medication administration record) for September 2022 revealed R57 received two doses of Trulicity on 9/9/22. A review of R57's progress notes revealed the following: 9/9/22 8:26 p.m. Writer was phoned about resident receiving an extra dose of Trulicity. Writer spoke with both daughters about this. Writer informed them resident will be assessed and monitored. Writer in to assess resident. Skin warm and dry. In bed with HOB elevated on phone talking with her daughter .Blood sugar taken -197. Writer phoned on-call and spoke with Dr. March to inform of listings. New orders obtained to increase blood sugars to ac (with meals) and hs (at bedtime) x 7 days. Glucagon was added to med orders. At present, resident alert and verbal. She is responding in usual fashion. A review of R57's care plan dated 11/26/21 revealed, in part: Resident is at risk for hypo/hyperglycemia episodes R/T: diabetes .administer medications as ordered. On 5/22/23 at 3:34 p.m., RN (registered nurse) #2, the MDS (minimum data set) coordinator, was interviewed. She stated the care plan is what we go by to care for our residents. She stated that the entire facility staff is responsible for making sure the care plan is implemented for every resident. On 5/23/23 at 2:25 p.m., ASM (administrative staff member) #2, the regional vice president of operations, ASM #3, the regional clinical consultant, and ASM #1, the mobile director of nursing, were informed of these concerns. A review of the facility policy, Interim/Baseline Care Planning Policy, revealed no information related to implementing the comprehensive care plan. No further information was provided prior to exit. NOTES (1) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. (2) Dulaglutide (Trulicity) injection is used with a diet and exercise program to control blood sugar levels in adults with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood). This information is taken from the website https://medlineplus.gov/druginfo/meds/a614047.html 1.b. For R57, the facility staff failed to follow the care plan for allergies. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 4/17/23, R57 was coded as being cognitively intact for making daily decisions, having scored 13 out of 15 on the BIMS (brief interview for mental status). On 5/22/23 at 1:02 p.m., R57 was observed sitting up in bed. The lunch tray was open on the overbed table next to the resident. The lunch plate contained pulled pork and pork and beans. R57 stated she cannot eat either the pork or the pork and beans because of the Alpha-Gal (1) allergy. The resident stated she cannot have beef or pork products, but the facility serves them to her all the time. R57 shared the meal ticket that accompanied the lunch tray. A review of the meal ticket revealed: Allergies: Beef, Pork. A review of R57's physician orders revealed the following order dated 4/13/22: Regular diet, Regular texture, Thin consistency, for diet NO BEEF, PORK or Dairy Products. A review of R57's diagnoses revealed: 7/21/22 Allergy Avoid all o Mammalian Meats. A review of R57's care plan dated 9/22/22 revealed, in part: Avoid all mammalian meats. On 5/22/23 at 1:17 p.m., OSM (other staff member) #6, the dietary manager, was interviewed. She stated the facility's EMR (electronic medical record) software generates the meal ticket for each resident, and includes food allergies. She stated the cook who serves the plate is responsible for making sure the resident is not allergic to any of the food on the tray. She stated residents with an Alpha Gal allergy should not receive any pork or beef. She stated she had not been at the facility long enough to know if any current residents have this allergy. When informed of R57's Alpha Gall allergy, she stated the resident should not have received pork and beans and pulled pork on the lunch tray. On 5/22/23 at 3:34 p.m., RN (registered nurse) #2, the MDS (minimum data set) coordinator, was interviewed. She stated the care plan is what we go by to care for our residents. She stated that the entire facility staff is responsible for making sure the care plan is implemented for every resident. On 5/23/23 at 2:25 p.m., ASM (administrative staff member) #2, the regional vice president of operations, ASM #3, the regional clinical consultant, and ASM #1, the mobile director of nursing, were informed of these concerns. No further information was provided prior to exit. NOTES (1) Alpha-gal syndrome is a type of food allergy. It makes people allergic to red meat and other products made from mammals. This information is taken from the website https://www.mayoclinic.org/diseases-conditions/alpha-gal-syndrome/symptoms-causes/syc-20428608#:~:text=Alpha%2Dgal%20syndrome%20is%20a,alpha%2Dgal%20into%20the%20body. 42183 2. For Resident #85, the facility staff failed to implement the comprehensive care plan for ADL (activities of daily living) care. Resident #85 was admitted to the facility on [DATE] with diagnoses that included but not limited to: traumatic spinal cord injury, neurogenic bladder, quadriplegia and hypertension. Resident #85's most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an assessment reference date of 5/9/23, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as total dependence with bed mobility, transfers, dressing, eating, hygiene and bathing. Walking did not occur. Locomotion is supervised in motorized wheelchair. A review of MDS Section H- Bowel and Bladder: coded the resident as external catheter for bladder and frequently incontinent for bowel. A review of the comprehensive care plan dated 11/1/22 documented in part, At risk for constipation/dehydration related to decreased mobility, weakness and history of constipation and quadriplegia. Resident has skin breakdown related to: decreased mobility, weakness, Quadriplegia and history of dermatitis. INTERVENTIONS: Monitor for signs/symptoms of allergic reaction .Incontinence products per routine and as needed. Provide incontinence care as needed. A review of Resident #85's ADL (activities of daily living) record for March 2023 revealed missing bladder elimination documentation for 1 of 31-day shifts (3/14), 7 of 31 evening shifts (3/1, 3/9, 3/10, 3/12, 3/14, 3/15, 3/25) and 3 of 31-night shifts (3/16, 3/26, 3/31). A review of April's ADL record revealed missing bladder elimination documentation for 1 of 30 day shifts (4/1), 4 of 30 evening shifts (4/1, 4/2, 4/17, 4/20) and 2 of 30 night shifts (4/14, 4/15). A review of [NAME] ADL record revealed missing bladder elimination for 2 of 22 day shifts (5/13, 5/22), 5 of 22 evening shifts (5/4, 5/12, 5/18, 5/21, 5/22) and 2 of 22 night shifts (5/16, 5/22). A review of Resident #85's ADL (activities of daily living) record for March 2023 revealed missing bowel elimination documentation for 2 of 31 day shifts (3/11, 3/14), 7 of 31 evening shifts (3/1, 3/9, 3/10, 3/12, 3/14, 3/15, 3/25) and 3 of 31-night shifts (3/16, 3/26, 3/31). A review of April's ADL record reveals missing bowel elimination documentation for 1 of 30 day shifts (4/1), 4 of 30 evening shifts (4/1, 4/2, 4/17, 4/20) and 2 of 30 night shifts (4/14, 4/15). A review of [NAME] ADL record reveals missing bowel elimination for 2 of 22 day shifts (5/13, 5/22), 5 of 22 evening shifts (5/4, 5/12, 5/18, 5/21, 5/22) and 2 of 22 night shifts (5/16, 5/22). An interview was conducted on 5/21/23 at 2:45 PM with Resident #85. When asked if incontinent care is being provided, Resident #85 stated, It does not always happen. I sometimes stay wet or have a bowel movement and I am not cleaned up. An interview was conducted on 5/22/23 at 7:00 AM with CNA (certified nursing assistant) #2. When asked if there is no evidence of incontinence care being provided but the care plan includes the intervention of provide incontinence care, was the care plan being followed, CNA #2 stated, no, it would be not followed. An interview was conducted on 5/22/23 at 11:00 AM with LPN (licensed practical nurse) #3. When asked the purpose of the care plan, LPN #3 stated, it is to provide a detailed plan for each resident's care. When asked if the care plan interventions included incontinence care being provided but there was no evidence of incontinence care being provided, was the care plan followed, LPN #3 stated, no, it is not being followed. An interview was conducted on 5/22/23 at 3:30 PM with RN (registered nurse) #2. When asked the purpose of the care plan, RN #2 stated, the purpose of care plan is to provide plan of care for our residents. When asked if the incontinence care plan is being followed when there is no evidence of incontinence care being provided, RN #2 stated, no, the care plan is not being followed. On 5/23/23 at approximately 2:00 PM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional vice president of operations, were made aware of the findings. No further information was provided prior to exit. 29125 3. For Resident #31, the facility staff failed to implement the comprehensive care plan for pain management. On the most recent MDS (Minimum Data Set), an annual assessment dated [DATE], Resident #31 was coded as being cognitively intact in ability to make daily life decisions. On 5/21/23 at 2:52 PM, an interview was conducted with Resident #31, who stated that the facility runs out of their pain meds and they don't get it. A review of the comprehensive care plan revealed one dated 10/16/20 for chronic pain that included the intervention Administer analgesia/medications per orders and note effectiveness dated 10/16/20. A review of the physician's orders revealed one dated 10/31/22 for Hydrocodone-Acetaminophen (1) 5-325 mg (milligrams) tablet, 1 tablet every 4 hours when awake, for moderate pain of gastric polyp. A review of the MARs (medication administration record) for March 2023, April 2023 and May 2023, and the progress notes revealed the following: 1. On 3/26/23 at 2:00 PM, (Resident #31) did not get this scheduled medication. A nurse's note associated with this documented, .Pharmacy called will come on next run MD aware. 2. On 4/5/23 at 6:00 PM, (Resident #31) did not get this scheduled medication. A nurse's note associated with this documented, Pharmacy made aware. coming on night run, resident aware, no further complaints at this time of or discomfort or pain , No other issues at this time, resident has no problem waiting until next pill run to receive medication. resident own RP. MD made aware. 3. On 5/6/23 at 6:00 AM, 10:00 AM, 2:00 PM and 10:00 PM, (Resident #31) did not get this scheduled medication. 3.a. A nurse's note for the 5/6/23 6:00 AM dose documented, .Pharmacy to send due to calling pharmacy. 3.b. A nurse's note for the 5/6/23 10:00 AM dose documented, .Script sent to Rx (pharmacy), waiting for rx to deliver. Resident made aware will continue to monitor. 3.c. A nurse's note for the 5/6/23 2:00 PM dose documented, .waiting on script from rx, resident made aware will continue to monitor. 3.d. A nurse's note for the 5/6/23 10:00 PM dose documented, Pharmacy made aware, being delivered tonight, Resident aware, no complaints, MD aware, no new orders, Resident own RP. A review of the facility Omnicell (automated medication dispensing machine) medication supply list was provided. This list included the ordered medication at the ordered dose, therefore, it was available to be administered. On 5/23/23 at 10:58 AM an interview was conducted with RN #2 (Registered Nurse). She stated staff should check the Omnicell to see if it is in there. When stated that the medication was on the Omnicell list but still was not administered, then was the care plan to administer medication as ordered being followed, she stated that it was not. On 5/23/23 at 1:54 PM, ASM #1 (Administrative Staff Member) the Director of Nursing, ASM #2 the Regional [NAME] President of Operations and ASM #3 the Divisional [NAME] President of Operations, were made aware of the findings. A care plan policy regarding implementation was requested however only a baseline care plan policy was provided by the facility staff. No further information was provided. References: (1) Hydrocodone-Acetaminophen is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a601006.html 4. For Resident #10, the facility staff failed to implement the comprehensive care plan to administer medication as ordered. On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #10 was coded as being moderately impaired in ability to make daily life decisions. A review of the comprehensive care plan revealed one dated 3/12/20 for depression and anxiety behaviors. This care plan included the intervention Medications as ordered by physician dated 3/12/20. A review of the clinical record revealed two orders dated 1/5/23. One was for Trazodone (1) 25 mg (milligrams) every morning and one was for Trazodone 75 mg every evening at bedtime. On 5/22/23 at 8:11 AM, LPN #4 (Licensed Practical Nurse) was observed preparing and administering medications to Resident #10. LPN #4 pulled the medication card for Trazodone, 75 mg, removed a pill from the package and placed it in the medication cup and administered it to Resident #10. Resident #10 was administered the bedtime dose at the time the morning dose was due. On 5/23/23 at 10:58 AM an interview was conducted with RN #2 (Registered Nurse). She stated that the care plan was not followed if the medication was not given as ordered. On 5/23/23 at 1:54 PM, ASM #1 (Administrative Staff Member) the Director of Nursing, ASM #2 the Regional [NAME] President of Operations and ASM #3 the Divisional [NAME] President of Operations, were made aware of the findings. A care plan policy regarding implementation was requested however only a baseline care plan policy was provided by the facility staff. No further information was provided. References: (1) Trazodone is used to treat depression. Information obtained from https://medlineplus.gov/druginfo/meds/a681038.html

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 43 residents in the survey sample, Resident #63. The findings include: For Resident #63 (R63), the facility staff failed to monitor the resident for side effects (bleeding) from the anticoagulant (blocks the activity of certain clotting substances in the blood) medication Eliquis (1). A review of R63's clinical record revealed a physician's order dated 4/7/23 for Eliquis 5 mg (milligrams) twice a day (for a history of pulmonary embolism). A review of R63's March 2023 and April 2023 MARs (medications administration records) revealed the resident was administered Eliquis twice a day from 4/7/23 (the date of admission) until 5/20/23 (except for the days the resident was on a leave of absence from the facility). Further review of R63's clinical record (including the MARs and nurses' notes for April 2023 and May 2023) failed to reveal the resident was monitored for side effects (bleeding) from the Eliquis. R63's comprehensive care plan dated 5/3/23 documented, Resident is at risk for bleeding/bruising/abnormal labs R/T (related to) receiving blood-thinning medications. Monitor for medication side effects of bruising & internal bleeding . On 5/23/23 at 10:45 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated residents receiving anticoagulant medication should be monitored for bleeding. LPN #4 stated there is no documentation that staff monitors residents receiving anticoagulant medications for bleeding other than nursing notes. LPN #4 stated she has never seen a documentation sheet to show consistent monitoring. On 5/23/23 at 2:37 p.m., ASM (administrative staff member) #1, the director of nursing, and ASM #2, the regional vice president of operations were made aware of the above concern. The facility policy titled, Anticoagulation Policy documented, Residents will be monitored for possible complications associated with anticoagulation . Reference: (1) ELIQUIS is indicated to reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF) .Bleeding Risk: ELIQUIS increases the risk of bleeding and can cause serious, potentially fatal, bleeding. This information was obtained from the website: https://www.eliquis.com/eliquis/hcp/wellcareform?cid=sem_2167331&ovl=isi&gclid=64c052d127001aa9ec1836cd1510884c&gclsrc=3p.ds&

Based on observation, staff interview and facility document review, the facility staff failed to promote resident choice of eating venue, for one of three meals, the dinner meal. The findings include: The facility staff failed to offer residents the choice to eat dinner in the dining room. The facility dinner time was documented as 5:00 p.m. On 5/21/23 at 5:15 p.m., observation of the dining room was conducted. No residents were observed in the dining room. On 5/22/23, breakfast and lunch were observed to be served in the dining room. The staff carried plates of food on trays from the kitchen into the dining room. On 5/22/23 at 11:35 a.m., an interview was conducted with OSM (other staff member) #6, the dietary manager. OSM #6 stated she was employed at the facility since 5/9/23 and dinner has not been served in the dining room since she began employment. OSM #6 stated a new steam table was ordered before she began employment, and she was waiting on the steam table to arrive. OSM #6 stated breakfast and lunch were being served in the dining room, but she did not have an explanation why dinner was not being served in the dining room. On 5/22/23 at 1:07 p.m., an interview was conducted with ASM (administrative staff member) #2, the regional vice president of operations. ASM #2 stated he was not aware dinner was not being served in the dining room and something could be done to provide dinner in the dining room. The administrator was not available for interview during the survey. On 5/23/23 at 2:37 p.m., ASM #1, the director of nursing, and ASM #2 were made aware of the above concern. The facility policy titled, Dining Experience at Mealtimes Policy documented, Staff will encourage residents to eat in the dining areas and encourage and assist them to consume food and beverages.

Based on staff interview and facility document review, it was determined the facility staff failed to arrange timely outside medical appointments as ordered for one of 43 residents in the survey sample, Resident #85. The findings include: The facility failed to evidence outside neurology and dry needling medical appointments were made timely as ordered for Resident #85. Resident #85 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: traumatic spinal cord injury, neurogenic bladder, quadriplegia and hypertension. Resident #85's most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an assessment reference date of 5/9/23, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the physician orders revealed the following: -Refer to Neurology related to spasticity on 10/7/22 and 10/12/22. -2/16/23 order: Physical Therapy outpatient referral for muscle rebuilder, dry needling for neck. -3/2/23 orders: Needs referral to outside Physical Therapy for dry needling per pain clinic. Refer to neurology for reported headaches, blacking out spells, and questionable seizures with history of brain trauma. -3/24/23 orders: Refer to Spasticity clinic for evaluation. Refer to Neurology for resident reported headache, blacking out episodes, questionable seizures with history of traumatic brain injury (TBI) and spasticity. Re: original NP order dates of 3/2/2023 and 3/24/2023. A review of Resident #85's medical record notes revealed: -3/1/23 at 2:34 PM appointment note revealed, Unit Manager (UM) called outpatient therapy to schedule dry needling for Resident and was asked to fax a consult over for review, upon review they would contact writer back as to if appointment would be given. -3/2/23 at 4:01 PM NP (nurse practitioner) note revealed, Spasticity: Chronic, continues with frequent spasms, continue tizanidine. No change to baclofen at this time related to possible absence seizures. PRN (as needed)-methocarbamol available. Awaiting appointment at spasticity clinic for management. -3/15/23 at 2:00 PM, appointment note revealed, Writer received call from therapy to notify writer that the Therapist would not be able to accept Resident for dry needling due to review of his medical diagnosis. Resident was notified and is requesting writer to try other cities. Writer will call and submit as he requested. -3/27/23 at 9:45 AM, appointment note revealed, Transportation did not pick resident up for appointment. Called and rescheduled pain clinic appointment to Tue, May 2, 2023 @9:00 AM. Pain clinic provided information as per UM request for listing of a provided that could assess/manage resident's complaint of dry needling at Physical Therapy. Resident is own RP (responsible party) and aware of transport failure and rescheduled date. -3/27/23 at 4:34 PM, social services note revealed, Residents transportation did not show for 8:15 AM appointment. Transportation coordinator called and dispatch stated the ride was canceled and not rescheduled. Facility staff called pain clinic who stated they would accept resident at 2:15PM on this day. Resident was transported by facility to the 2:15 PM appointment without issue. -5/4/23 at 6:53 AM, ADON (assistant director of nursing) note revealed, Facility NP requests referral to Neurology for resident reported headaches, blacking-out episodes, questionable seizures with TBI, and spasticity. Referral ordered and this writer spoke with neurology group, on 5/3/2023 @ 12:30 PM to obtain information to fax referral for appointment. Awaiting neurology group to schedule appointment. This writer also spoke with Physical Therapy at the Lynchburg office, to obtain appointment for resident to receive dry needling procedure to treat spasticity condition. This writer was informed of need for referral from Neurologist to schedule appointment and that Physical Therapy was able to accommodate resident, that this therapy group treats several patients with quadriplegia and to fax referral when resident is seen by Neurologist. Will continue to follow up on appointment status for resident. -5/4/23 at 8:39 AM, revealed Writer rounding on unit this AM. Writer knocked on resident door and entered with consent. Writer spoke with resident concerning Neurology and outside PT center referrals and that resident would be advised of appointments as they are scheduled. Resident expressed appreciation to writer for updates. -5/4/23 at 12:37 PM, ADON note revealed, This writer advised resident of Neurology appointment on 8/28/2023 @ 1:00 PM. An interview was conducted on 5/21/23 at 2:45 PM with Resident #85. When asked if he had been to his outside medical appointments, Resident #85 stated, Only the pain clinic. I have been waiting for months for appointment to neurologist and for dry needling. There is an appointment now at the end of August. An interview was conducted on 5/23/23 at approximately 9:00 AM with ASM (administrative staff member) #4, the nurse practitioner. When asked about the outside appointments for Resident #85, ASM #4 stated, Yes, they were ordered months ago. We did not know that we had to have a neurology consult prior to the dry needling appointment. Then when we tried to get a neurology appointment, there was none in this town. When asked if the Resident would have been sent to another town for the appointment, ASM #4 stated, Yes, we could send them to Lynchburg, Charlottesville or Richmond. An interview was conducted on 5/23/23 at 9:20 AM with OSM (other staff member) #12, the transportation coordinator. When asked if she was managing the appointments for Resident #85, OSM #12 stated she only makes the transportation arrangements; the unit manager makes the appointments. When asked if Resident #85's unit manager was here, OSM #12 stated, No, she no longer works here. An interview was conducted on 5/23/23 at 9:45 AM with RN (registered nurse) #1. When asked about the appointments for Resident #85 that had been ordered in October 2022, RN #1 stated, I am following up on this. I started a few months ago and am not sure why we never got it resolved. We now have an appointment for the end of August. When asked about the delay in getting appointments, RN #1 stated, We have changed staff and the appointments did not get made. We did not know we needed neurology appointment first, then had problems getting a neurology appointment. On 5/23/23 at approximately 2:00 PM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional vice president of operations, were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of practice for four of 43 residents in the survey sample, Residents #57, #10, #349, and #38. The findings include: 1. For Resident #57 (R57) the facility staff failed to correctly transcribe a physician's order for Trulicity (1), resulting in the resident receiving a double dose of the medication on 9/9/22. R57 was admitted to the facility with a diagnosis of diabetes mellitus (2). A review of R57's physician orders revealed the following order dated 9/8/22: Trulicity Solution Pen-injector 1.5 MG/0.5ML (Dulaglutide). Inject 1.5 mg subcutaneously week every Fri related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY (E11.42). A review of R57's MAR (medication administration record) for September 2022 revealed R57 received two doses of Trulicity on 9/9/22. A review of R57's progress notes revealed the following: 9/9/22 8:26 p.m. Writer was phoned about resident receiving an extra dose of Trulicity. Writer spoke with both daughters about this. Writer informed them resident will be assessed and monitored. Writer in to assess resident .Blood sugar taken -197 .New orders obtained to increase blood sugars to ac (with meals) and hs (at bedtime) x 7 days. Glucagon was added to med orders . A review of R57's care plan dated 11/26/21 revealed, in part: Resident is at risk for hypo/hyperglycemia episodes R/T: diabetes .administer medications as ordered. A review of a facility correction plan dated 9/9/22 revealed, in part: On 9/9/22, ADON (assistant director of nursing) (Registered Nurse #2) and Admin (administrator) were made aware that resident [resident's initials] received two of her weekly doses of Trulicity, due to an order entry error. The order was changed on 9/8/22 to start on Friday 9/9/22 to increase dosage for Q week *every week) dose. Nurse entered order as two times Q Friday (every Friday). On 5/23/23 at 10:55 a.m., RN #2 was interviewed regarding the incorrect transcription of R57's Trulicity order. She stated the physician was adjusting the Trulicity in an effort taper it. She stated when the unit manager, who was a new employee, entered the order into the EMR (electronic medical record), the dose had already been administered on 9/9/22. The unit manager incorrectly entered the order so that it would show up to be administered again on 9/9/22. She stated: [Name of software] picked it up to be given again, instead of a week later. The nurse who administered the second dose of Trulicity on 9/9/22 was unavailable for interview during the survey. On 5/23/23 at 2:25 p.m., ASM (administrative staff member) #2, the regional vice president of operations, ASM #3, the regional clinical consultant, and ASM #1, the mobile director of nursing, were informed of these concerns. No further information was provided prior to exit. References: (1) Dulaglutide (Trulicity) injection is used with a diet and exercise program to control blood sugar levels in adults with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood). This information is taken from the website https://medlineplus.gov/druginfo/meds/a614047.html. (2) Diabetes (mellitus) is a disease in which your blood glucose, or blood sugar, levels are too high. This information is taken from the website https://medlineplus.gov/diabetes.html. 29125 2. For Resident #10, the facility staff failed to follow the rights of medication administration, which resulted in the resident getting the wrong dose of the medication, Trazodone (1). On the most recent MDS (Minimum Data Set), a quarterly assessment dated [DATE], Resident #10 was coded as being moderately impaired in ability to make daily life decisions. A review of the clinical record revealed two orders dated 1/5/23. One was for Trazodone 25 mg (milligrams) every morning and one was for Trazodone 75 mg every evening at bedtime. On 5/22/23 at 8:11 AM, LPN #4 (Licensed Practical Nurse) was observed preparing and administering medications to Resident #10. LPN #4 pulled the medication card for Trazodone, 75 mg, removed a pill from the package, placed it in the medication cup, and administered it to Resident #10. Resident #10 was administered the bedtime dose at the time the morning dose was due. On 5/22/23 at 8:44 AM, an interview was conducted with LPN #4. When asked what were the five rights of medication administration, she stated, the right patient, right medication, right dose, right time, and right route. When asked how does she ensure she is following these rights when she is preparing medications, she stated that she checks the medication cards against computer (electronic medication administration record), and checks again when popping the medication out of the package. When asked about the dose of Trazodone that was administered, she pulled the card from the medication cart for the 75 mg dose. When it was noted that this was the incorrect dose for the time that it was administered, she rechecked the cart, and did not locate the 25 mg dose in the drawer with the resident's other medications. On further checking, she found a card of the 25 mg dose in the overstock drawer. When asked if the five rights were followed for this medication, she stated that she did not follow all the checks. A review of the comprehensive care plan revealed one dated 3/12/20 for depression and anxiety behaviors. This care plan included the intervention Medications as ordered by physician dated 3/12/20. The facility policy General Dose Preparation and Medication Administration was reviewed. This policy documented, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule . On 5/23/23 at 1:54 PM, ASM #1 (Administrative Staff Member) the Director of Nursing, ASM #2 the Regional [NAME] President of Operations and ASM #3 the Divisional [NAME] President of Operations, were made aware of the findings. No further information was provided. References: (1) Trazodone is used to treat depression. Information obtained from https://medlineplus.gov/druginfo/meds/a681038.html 42106 3. For Resident #349 (R349), the facility failed to administer medications in a timely manner. R349 was admitted to the facility with diagnoses that included but were not limited to striatonigral degeneration (1) and fibromyalgia (2). The MDS (minimum data set) assessment was not due at the time of the survey. On the admission nursing assessment dated [DATE], R349 was assessed as being alert and oriented to person, place, time and situation. On 5/21/2023 at 2:54 p.m., an interview was conducted with R349 in their room. R349 stated that they were new to the facility and had problems getting their medications on time. R349 stated that they took medications for their neurological disorder which had to be given on time to control their symptoms. R349 stated that they felt that the nurses did not understand their diagnoses or the medications enough because they felt that they gave the medications whenever they wanted. The physician orders for R349 documented in part, - Gabapentin Oral Capsule 300 MG (milligram) (Gabapentin) Give 1 capsule by mouth three times a day for pain. Order Date: 05/13/2023. - Carbidopa-Levodopa ER (extended release) Oral Tablet Extended Release 50-200 MG (Carbidopa-Levodopa) Give 1 tablet by mouth every 12 hours related to Fibromyalgia (M79.7). Order Date: 05/13/2023. - Clonazepam Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth every 12 hours for multi-system degeneration of the autonomic nervous system. Order Date: 05/13/2023. - Carbidopa-Levodopa Oral Tablet 10-100 MG (Carbidopa-Levodopa) Give 0.5 tablet by mouth every 2 hours for for Parkinson's like symptoms while awake, may break tab in half per resident request. Order Date: 05/18/2023. Review of the medication administration audit report for R349 dated 5/1/2023-5/23/2023 documented the medications listed above. The report documented the Gabapentin scheduled at 8:00 a.m. administered late on 5/16/2023 at 9:36 a.m., and on 5/17/2023 at 10:03 a.m The Gabapentin 300mg scheduled at 4:00 p.m. was administered late on 5/15/2023 at 7:52 p.m. The Carbidopa-Levodopa 50-200mg scheduled at 8:00 a.m. was administered late on 5/16/2023 at 9:36 a.m., and on 5/17/2023 at 10:02 a.m. The Carbidopa-Levodopa 50-200mg scheduled at 8:00 p.m. was administered late on 5/17/2023 at 10:07 p.m. The Clonazepam 0.5mg scheduled at 8:00 a.m. was administered late on 5/16/2023 at 9:36 a.m. and on 5/17/2023 at 10:02 a.m. The Clonazepam 0.5mg scheduled at 8:00 p.m. was administered late on 5/17/2023 at 10:07 p.m. The Carbidopa-Levodopa 10-100mg 0.5 tablet scheduled at 6:00 p.m. was administered late on 5/21/2023 at 9:03 p.m. Review of the clinical record failed to evidence documentation regarding the late administration of the medications documented above. On 5/23/2023 at 10:07 a.m., an interview was conducted with LPN (licensed practical nurse) #7. LPN #7 stated that medications were scheduled to be administered at specific times and they were to be administered within an hour before or an hour after the time. LPN #7 stated that if they were unable to administer the medication within the hour before or hour after timeframe they were supposed to contact the physician to get a one time order to administer the medication late and let the resident know. LPN #7 stated that this should be documented in the nurses notes. LPN #7 stated that the medications were administered on a schedule for the best effects on the disease process, to give the medication enough time to work and not cause a delay in treatment. LPN #7 reviewed the medication administration audit report for R349 and stated that the medications were administered outside of the hour before and hour after window and there should be documentation of the physician notification in the record. The facility policy, General Dose Preparation and Medication Administration revised 1/1/2022 documented in part, .Facility Staff should: Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule .Administer medications within timeframes specified by Facility policy or manufacturer's information . On 5/23/2023 at 1:54 p.m., ASM (administrative staff member) #1, mobile director of nursing, ASM #2, regional vice president of operations and ASM #5, divisional vice president of operations were made aware of the concern. No further information was provided prior to exit. Reference: (1) Striatonigral degeneration is a neurological disorder caused by a disruption in the connection between two areas of the brain that work together to enable balance and movement-the striatum and the substantia nigra. Striatonigral degeneration is a type of multiple system atrophy (MSA). Symptoms of the disorder resemble some of those seen in Parkinson's disease, including: Rigidity; Instability; Impaired speech; Slow movements. There is no cure for striatonigral degeneration, and treatments for the disorder have variable success. Treatments used for Parkinson's disease are recommended. This information was obtained from the website: https://www.ninds.nih.gov/health-information/disorders/striatonigral-degeneration (2) Fibromyalgia is chronic condition that causes pain all over the body, fatigue, and other symptoms. People with fibromyalgia may be more sensitive to pain than people who don't have it. This is called abnormal pain perception processing. This information was obtained from the website: https://medlineplus.gov/fibromyalgia.html 27660 4. For Resident #38 (R38), the facility staff failed to clarify the physician order for the use of hand splints. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/9/2023, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. An interview was conducted on 5/21/2023 at 3:04 p.m. with R38. They stated they were getting range of motion exercises and wears their hand splints at bedtime. A review of the physician orders dated 3/2/2022, documented in part, Bilateral hand splints at all times except hygiene. The comprehensive care plan dated, 12/6/2022, documented in part, Focus: Able to participate in a Splint Restorative program. The Interventions documented in part, Splint/brace to be worn day and off qhs (every bedtime). An interview was conducted on 5/22/2023 at 3:35 p.m. with RN (registered nurse) #2, the MDS coordinator. RN #2 was asked to review the physician orders and the care plan above. RN #2 was informed of the interview with R38. When asked if the above order should be clarified, RN #2 stated, yes. ASM (administrative staff member) #1, the mobile director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional director of operations, were made aware of the above concern on 5/23/2023 at 1:56 p.m. No further information was provided prior to exit.

Based on staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for three of 43 residents in the survey sample, Residents #41, #63 and #103. The findings include: 1.a. For Resident #41 (R41), the facility staff failed to review and revise the resident's comprehensive care plans for pressure ulcer/injuries that were acquired on 2/1/23. A review of R41's clinical record revealed weekly wound assessments that documented the resident acquired the following pressure injuries: -a pressure injury on the left thigh that was acquired on 2/1/23. -a pressure injury on the left foot that was acquired on 2/1/23. -a pressure injury on the right ischium that was acquired on 2/1/23. A review of R41's comprehensive care plan dated 9/23/22 failed to reveal the care plan was reviewed and revised for the above acquired pressure injuries. On 5/22/23 at 3:21 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is that it's the plan of care and what the staff goes by to care for the residents. RN #2 stated the care plan should be reviewed and revised when a resident develops a new pressure injury. On 5/23/23 at 2:37 p.m., ASM (administrative staff member) #1, the director of nursing, and ASM #2, the regional vice president of operations were made aware of the above concern. The facility policy titled, Interim/Baseline Care Planning Policy failed to document information regarding reviewing and revising the comprehensive care plan. 1.b. For Resident #41 (R41), the facility staff failed to review and revise the resident's comprehensive care plan for psychotropic medication use. A review of R41's clinical record reveal a physician's order dated 9/21/22 for zolpidem (a hypnotic medication) 5 mg at bedtime and a physician's order dated 5/9/23 for trazadone (an antidepressant medication) 150mg (milligrams) at bedtime. A review of R41's comprehensive care plan dated 9/23/22 failed to reveal the care plan was reviewed and revised for psychotropic medication use. On 5/22/23 at 3:21 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is that it's the plan of care and what the staff goes by to care for the residents. RN #2 stated the care plan should be reviewed and revised for psychotropic medication use. On 5/23/23 at 2:37 p.m., ASM (administrative staff member) #1, the director of nursing, and ASM #2, the regional vice president of operations were made aware of the above concern. 2. For Resident #63 (R63), the facility staff failed to review and revise the resident's comprehensive care plans for pressure ulcer/injuries that were acquired on 5/10/23. A review of R63's clinical record revealed weekly wound assessments that documented the resident acquired the following pressure injuries: -a pressure injury on the left heel that was acquired on 5/10/23. -a pressure injury on the left leg that was acquired on 5/10/23. A review of R63's comprehensive care plan dated 4/8/23 failed to reveal the care plan was reviewed and revised for the above acquired pressure injuries. On 5/22/23 at 3:21 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated the purpose of the care plan is that it's the plan of care and what the staff goes by to care for the residents. RN #2 stated the care plan should be reviewed and revised when a resident develops a new pressure injury. On 5/23/23 at 2:37 p.m., ASM (administrative staff member) #1, the director of nursing, and ASM #2, the regional vice president of operations were made aware of the above concern. 29125 3. For Resident #103, the facility staff failed to review and revise the comprehensive care plan to address the resident's need for increased supervision based on documented behaviors. Resident #103 had the diagnoses of but not limited to cancer of the prostate and bone and dementia. The most recent MDS (Minimum Data Set) was a significant change MDS dated [DATE]. The resident was coded as being cognitively intact in ability to make daily life decisions, scoring a 14 out of a possible 15 on the BIMS (Brief Interview for Mental Status). The resident was coded as having physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others. The resident was coded as behavior symptoms significantly interfered with the resident's ability to participate in activities and social interactions. The resident's behavior symptoms were coded as putting others at significant risk of physical injury. The resident's behavior was coded as being worse since the prior MDS assessment (admission assessment dated [DATE] wherein the resident was coded as having delusions and wandering behaviors). A review of the clinical record for Resident #103 revealed the following notes: A social worker note dated 12/1/22 documented, .Charge Nurse also reported behaviors of vulgar language and comments to shoot their kneecaps off if [resident] wasn't allowed to go home . A nurse practitioner note dated 12/1/22 documented, .Staff report that [resident] often is wandering the facility and is sometimes not always easily redirected 1. Dementia with behaviors: Noted mild agitation and behaviors . A nurse's note dated 12/7/22 documented, .Resident becoming aggressive towards staff. Resident makes statements about hurting staff. A nurse practitioner note dated 12/27/22 documented, .Recently cane was removed from [resident] possession because of reports of striking out with cane .1. Dementia with behaviors: Noted mild agitation and behaviors .Followed by psychology, continue with recommendations. Recent walking cane removal r/t (related to) aggressive behaviors per staff A nurse's note dated 1/7/23 documented, Resident was aggressive towards writer at the beginning of the shift. Resident pushed [their] walker towards writer to try and run writer over, [resident] then picked [their] walker up from the floor and again came towards this writer to try and hit again. [Resident] had displayed exit seeking behaviors, such as going to the door that lead to outside and has been trying to get out and find [their] truck. This writer redirected [resident] and informed [resident] [they do] not have truck outside. Hospice was called at 1040am and made aware, however, I am waiting on a call back from the nurse at this time. Activity staff is currently sitting one to one with resident because of exit seeking behavior. Will cont (continue) to monitor and document. RP (responsible party - resident family member) made aware. A nurse's note dated 1/7/23 documented, Resident displayed aggressive behavior towards writer this morning. Resident attempted to hit writer with [their] walker twice. [Resident] was redirected and complied. [Resident] also has been displaying exit seeking behaviors at all facility doors. [Resident] is currently sitting one to one with activity staff until CNA (certified nursing assistant) arrives. Hospice called, and made aware, writer is waiting for the On call nurse to call back at this time. Resident is (their) own RP, however I called [family member] and [they] did not answer, so I then called [another family member],who visited [resident] yesterday, and made [family member] aware of residents behaviors thus far. Will cont to monitor for changes and/or behaviors. A nurse's note dated 1/13/23 documented, 1/12/23 3/11 tour. About 17:16 Resident received in back hall of North unit sitting on floor. Charge nurse and other staff with [resident]. Writer was informed by the charge nurse that the resident sat [them] self on the floor. Resident was assisted up and placed in a wheelchair. About 30 min (minutes) later the resident was observed getting out of wheelchair and placing [them] self on the floor. DON (Director of Nursing) and Unit manager notified, came to the unit where they spoke with the resident. Resident was given PRN (as-needed) Ativan 0.25mg (milligrams) for anxiety. DON to speak with Hospice to have [resident] care planned for this behavior. Resident displayed no further behavior after being redirected back to [their] room where [they] had the dinner meal and rested the remainder of the tour. A nurse's note dated 1/15/23 documented, Aide overheard resident yelling from her room, yelling get out, aide noted resident from room (number) coming out of resident room, Aide redirected resident back into room and notified Writer, Writer when to talk to resident, resident says that resident came into the room and I told [Resident #103] no get out, resident continue to walk toward the bed and touch my foot then walked out of room, Writer told resident she would talk to resident from room (missing room number) . A physician's note dated 1/16/23 documented, .exhibits advanced confusion, with nonsensical speech and disorientation. Has been wandering aimlessly into other residents' rooms in past three weeks . A nurse practitioner note dated 1/18/23 documented, Staff concerned over pt (patient) continually wandering, slightly unsteady on [their] feet. [Resident] has been moved closer to nurses station . A social worker note dated 1/20/23 documented, Resident reviewed in IDT (interdisciplinary team) meeting due to behaviors. Resident is often verbally aggressive with staff and wandering into the rooms of other residents after being redirected and not wanting others to use {Resident #103] bathroom. Resident is often restless and has to be re-directed from trying to leave the facility. Resident has been moved to another room with a private bathroom. Resident will continue to be monitored and redirected as needed. A nurse's note dated 1/27/23 documented. Resident wandering in/out of multiple residents rooms. Res (resident) not redirectable. Resident went into room (number) with pants down. Residents in (room) scared, and stated they will call the cops if this keeps happening. A nurse's note dated 1/27/23 documented, Resident wandering in other Residents rooms majority of shift redirected but with no success. Resident was in a [resident of opposite gender] room with no pants on and [Resident #103] genital exposed, (Opposite gender) Residents voicing concerns of not feeling safe and will call the police next time. Unit Manager called Hospice (company) and spoke with Case manager (name) and asked for 1-1 sitter to help keep patient directed to prevent any further incidents which would avoid the police/ At this time hospice has no extra help or able to provide 1/1 and advised if redirecting does not work to send [resident] to ER (emergency room ) . A nurse's note dated 2/2/23 documented, Unit Manager was gotten out of Morning meeting from charge Nurse and reported that Resident had assaulted a [opposite gender] Resident and pushed her [other resident] to the floor and the NP (nurse practitioner) was on the unit and is in with [other] resident and asking for [resident] to be sent out to the emergency room due to possible Fracture of left shoulder. A nurse's note dated 2/2/23 documented, Summary of Discharge: Resident discharged To: Resident ECO'd (emergency confinement order). discharged via: Ambulatory Accompanied by (local) Sheriff Department Social Service Summary: Resident was involved in an incident where [they] pushed a [another] resident and [other resident] fell and was injured. DON and SW went to the (county) Sheriff Dept to file an ECO and (county) Law Enforcement arrive at the facility around 7pm to pick resident up Resident's [family member]/emergency contact was contacted A review of the comprehensive care plan for Resident #103 revealed one dated 11/30/22 for Resident is on antipsychotic therapy . This care plan was updated on 12/7/22 to include, verbally abusive and threatening towards staff. Another care plan, dated 1/10/23, documented, Resident shows behaviors by goes into other residents rooms and lying in their beds. This was updated on 1/23/23 to include Resident with episode of nudeness in the hallway. The above care plans did not include any interventions for the provision of supervision or the need of increased supervision related to wandering, behaviors, and aggression. On 5/23/23 at 10:58 AM an interview was conducted with RN #2 (Registered Nurse). She stated that the resident required increased supervision and that I would assign 1:1. She stated that it was her recommendation during a meeting to move Resident #103 and to provide 1:1. She stated that the facility called hospice for 1:1. She stated that it was not their (hospice) responsibility to but it was due to (facility) staffing. She stated that there should have been other interventions in place. She stated the care plan should have been revised for the need of increased supervision. On 5/23/23 at 1:54 PM, ASM #1 (Administrative Staff Member) the Director of Nursing, ASM #2 the Regional [NAME] President of Operations and ASM #3 the Divisional [NAME] President of Operations, were made aware of the findings. No further information was provided.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to implement a pain management program for one of 43 residents in the survey sample, Resident #31. The findings include: On the most recent MDS (Minimum Data Set), an annual assessment dated [DATE], Resident #31 was coded as being cognitively intact in ability to make daily life decisions. On 5/21/23 at 2:52 PM, in an interview with Resident #31, they stated that the facility runs out of their pain meds (medications) and they don't get it. A review of the physician's orders revealed one dated 10/31/22 for Hydrocodone-Acetaminophen (1) 5-325 mg (milligrams) tablet, 1 tablet every 4 hours when awake, for moderate pain of gastric polyp. A review of the MARs (Medication Administration Record)s for March 2023, April 2023 and May 2023, and the progress notes revealed the following: 1. On 3/26/23 at 2:00 PM, Resident #31 did not get the scheduled medication. A nurse's note associated with this documented, .Pharmacy called will come on next run MD aware. 2. On 4/5/23 at 6:00 PM, Resident #31 did not get the scheduled medication. A nurse's note associated with this documented, Pharmacy made aware. coming on night run, resident aware, no further complaints at this time of or discomfort or pain , No other issues at this time, resident has no problem waiting until next pill run to receive medication. resident own RP. MD made aware. 3. On 5/6/23 at 6:00 AM, 10:00 AM, 2:00 PM and 10:00 PM, Resident #31 did not get the scheduled medication. 3a. A nurse's note for the 5/6/23 6:00 AM dose documented, .Pharmacy to send due to calling pharmacy. 3b. A nurse's note for the 5/6/23 10:00 AM dose documented, .Script sent to Rx (pharmacy), waiting for rx to deliver. Resident made aware will continue to monitor. Another nurse's note dated 5/6/23 at 12:16 PM documented, Pharmacy called meds out on next run MD (medical doctor) aware Tylenol (2) order given. Resident aware of same an own RP (responsible party). 3c. A nurse's note for the 5/6/23 2:00 PM dose documented, .waiting on script from rx, resident made aware will continue to monitor. Another nurse's note dated 5/6/23 at 4:43 PM documented, Resident asked writer when pain medication will be here, says day shift nurse made her aware pain medication will arrive on evening shift run, Writer made resident aware pharmacy has not arrived yet, Pharmacy called, medication is on the way with medication run for evening shift. Resident made aware, Resident understood with no complaints at this, polite and cooperative with news, PRN (as-needed) offered, No other concerns, Call bell within reach. MD made aware, no new orders at this time. 3d. A nurse's note for the 10:00 PM dose documented, Pharmacy made aware, being delivered tonight, Resident aware, no complaints , MD aware, no new orders, Resident own RP. A review of the comprehensive care plan revealed one dated 10/16/20 for chronic pain that included the intervention Administer analgesia/medications per orders and note effectiveness dated 10/16/20. A review of the Omnicell (automated medication dispensing system) supply list was provided. This list included the above medication at the ordered dose. Therefore, it was available to be administered. On 5/23/23 at 10:58 AM an interview was conducted with RN #2 (Registered Nurse). She stated that the medication is supposed to be reordered when it gets down to a certain number. She stated that she would reorder around 3 days before it runs out. She stated that the nurse practitioner is in the building if scripts are needed. She stated that the pharmacy delivers every morning and every night and that new orders or reorders usually come on the next run or within 24 hours. She stated that a medication should never should run out. She stated staff should check the Omnicell to see if it is in there. When stated that the medication was on the Omnicell list but still was not administered, then was the care plan to administer medication as ordered being followed, she stated that it was not. The facility policy, Medication Shortages / Unavailable Medications documented, .1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the time of medication administration, Facility staff should immediately take action to notify the Pharmacy 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose On 5/23/23 at 1:54 PM, ASM #1 (Administrative Staff Member) the Director of Nursing, ASM #2 the Regional [NAME] President of Operations and ASM #3 the Divisional [NAME] President of Operations, were made aware of the findings. No further information was provided. References: 1. Hydrocodone-Acetaminophen is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a601006.html 2. Tylenol is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html

Based on resident interview, staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide ADL care for dependent residents, for three of 43 residents in the survey sample, Residents #38, #101 and #85. The findings include: 1. For Resident #38, the facility staff failed to provide bathing/baths/showers. On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 4/9/2023, in Section G - Functional Status, the resident was coded as being totally dependent upon two or more staff members for bathing. The ADL (activities of daily living) documentation for March 2022, revealed the resident did not receive any form of bathing on 3/2/2022, 3/5/2022 and 3/27/2022. The blocks on the form where documentation would be were blank. The ADL (activities of daily living) documentation for April 2022, revealed the resident did not receive any form of bathing on 4/5/2022, 4/6/2022, 4/7/2022, 4/10/2022, 4/23/2022, 4/24/2022, 4/26/2022 and 4/29/2022. The blocks on the form were blank. The ADL (activities of daily living) documentation for May 2022 revealed the resident did not receive any form of bathing on 5/1/2022 through 5/8/2022, 5/13/2022, 5/19/2022 through 5/23/2022, and 5/28/2022. The blocks on the form were blank. The comprehensive care plan dated, 4/24/2019, documented in part, Focus: The resident has an ADL Self Care Performance Deficit r/t (related to) quadriplegia. The Interventions documented in part, BATH/SHOWER: The resident is totally dependent on (2) staff for a bath. An interview was conducted with CNA (certified nursing assistant) #3 on 5/22/2023 at 2:43 p.m. When asked what the blanks on the ADL documentation meant, CNA #3 stated it meant the CNA didn't chart it. CNA #3 was asked if it's not documented can you tell if it was done, CNA #3 stated, no, it's supposed to be documented in shower sheets and POC (point of care - computer program). The facility policy, Resident Bath/Showering/Scheduling Policy, documented in part, POLICY: Residents will be bathed or showered according to their preferences in order to maintain healthy hygiene and skin condition. Staff who have demonstrated competence may bathe the resident via shower, tub bath, whirlpool bath, or bed bath. Bed linens will be changed on baths days and as needed, but minimally once weekly .(E) When the bath or shower is complete, the nursing assistant will document the activity on the shower sheet or in Point of Care section of the electronic record. ASM (administrative staff member) #1, the mobile director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional director of operations, were made aware of the above concern on 5/23/2023 at 1:56 p.m. No further information was provided prior to exit. 2. For Resident #101, the facility staff failed to provide bathing/baths/showers. On the most recent MDS, a significant change assessment, with an assessment reference date of 5/2/2022, the resident was coded in Section G - Functional Status, the resident was coded as being totally dependent upon one staff members for bathing. The ADL (activities of daily living) documentation for March 2022, revealed the resident did not receive any form of bathing on 3/1/2022, 3/6/2022, 3/7/2022, 3/12/2022 through 3/14/2022, 3/20/2022, 3/26/2022 through 3/28/2022 and 3/31/2022. The blocks on the form were blank or documented na. The ADL (activities of daily living) documentation for April 2022, revealed the resident did not receive any form of bathing on 4/1/2022, 4/2/2022, 4/3/2022, 4/7/2022, 4/9/2022, 4/10/2022, 4/14/2022, 4/17/2022 through 4/19/2022, 4/21/2022 through 4/23/2022, 4/26/2022, and 4/28/2022. The blocks on the form were blank or documented na. The ADL (activities of daily living) documentation for May 2022, revealed the resident did not receive any form of bathing on 5/2/2022, 5/3/2022, 5/10/2022, 5/18/2022 and 5/20/2022. The blocks on the form were blank or documented na. The comprehensive care plan documented in part Focus: The resident has an ADL Self Care Performance Deficit r/t limited mobility, limited ROM (range of motion) .resident does not like showers she prefers bed baths. The Interventions documented in part, BATHING/SHOWERING: the resident requires (1) staff participation with bathing. An interview was conducted with CNA (certified nursing assistant) #3 on 5/22/2023 at 2:43 p.m. CNA #3 was asked what na meant on the ADL documentation, CNA #3 stated, not applicable. When asked what the blanks on the ADL documentation meant, CNA #3 stated it meant the CNA didn't chart it. CNA #3 was asked if it's not documented can you tell if it was done, CNA #3 stated, no, it's supposed to be documented in shower sheets and POC (point of care - computer program). ASM (administrative staff member) #1, the mobile director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional director of operations, were made aware of the above concern on 5/23/2023 at 1:56 p.m. No further information was provided prior to exit. 42183 3. The facility staff failed to provide ADL (activities of daily living) care, specifically incontinent care for a dependent resident, Resident #85. Observations were made during the survey period of 5/21/23-5/23/23 on day, evening and night shift. Incontinence care was observed being provided. Resident #85 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: traumatic spinal cord injury, neurogenic bladder, and quadriplegia. An interview was conducted on 5/21/23 at 2:45 PM with Resident #85. When asked if incontinent care was being provided, Resident #85 stated, It does not always happen. I sometimes stay wet or have a bowel movement and I am not cleaned up. Resident #85's most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an assessment reference date of 5/9/23, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. MDS Section G- Functional Status: coded the resident as total dependence with bed mobility, transfers, dressing, eating, hygiene and bathing. Walking did not occur. Locomotion is supervised in motorized wheelchair. A review of MDS Section H- Bowel and Bladder: coded the resident as external catheter for bladder and frequently incontinent for bowel. A review of Resident #85's ADL (activities of daily living) record for March 2023 revealed missing bladder elimination documentation for 1 of 31 day shifts (3/14), 7 of 31 evening shifts (3/1, 3/9, 3/10, 3/12, 3/14, 3/15, 3/25) and 3 of 31 night shifts (3/16, 3/26, 3/31). A review of April 2023 ADL record revealed missing bladder elimination documentation for 1 of 30 day shifts (4/1), 4 of 30 evening shifts (4/1, 4/2, 4/17, 4/20) and 2 of 30 night shifts (4/14, 4/15). A review of May 2023 ADL record reveals missing bladder elimination for 2 of 22 day shifts (5/13, 5/22), 5 of 22 evening shifts (5/4, 5/12, 5/18, 5/21, 5/22) and 2 of 22 night shifts (5/16, 5/22). A review of Resident #85's ADL (activities of daily living) record for March reveal missing bowel elimination documentation for 2 of 31 day shifts (3/11, 3/14), 7 of 31 evening shifts (3/1, 3/9, 3/10, 3/12, 3/14, 3/15, 3/25) and 3 of 31-night shifts (3/16, 3/26, 3/31). A review of Aprils ADL record reveals missing bowel elimination documentation for 1 of 30 day shifts (4/1), 4 of 30 evening shifts (4/1, 4/2, 4/17, 4/20) and 2 of 30 night shifts (4/14, 4/15). A review of [NAME] ADL record reveals missing bowel elimination for 2 of 22-day shifts (5/13, 5/22), 5 of 22 evening shifts (5/4, 5/12, 5/18, 5/21, 5/22) and 2 of 22 night-shifts (5/16, 5/22). An interview was conducted on 5/22/23 at 7:00 AM with CNA (certified nursing assistant) #2. When asked the process for incontinence care, CNA #2 stated, we round at least every two hours and answer call bells also. When asked what blank spaces in documentation mean. CNA #2 stated, that would mean that it was not done. An interview was conducted on 5/22/23 at 1:00 PM with CNA #11. When asked how incontinence care is provided for residents, CNA #11 stated, we round every two hours. We know the residents and some of them need cleaned up before two hours, so we attend to them also. When asked where it is documented, CNA #11 stated, on the ADL record. When shown the ADL record and asked how there is evidence that incontinence care is provided when there are blanks in the documentation, CNA #11 stated, there is no evidence. If it is not documented, it is not done. An interview was conducted on 5/22/23 at 3:30 PM with CNA #12. When asked the process for incontinence care, CNA #12 stated, we round every two hours and provide the care. If residents need it more often, they ring their call bell and we clean them up. When asked where incontinence care is documented, CNA #12 stated, it is documented on the ADL record. When asked what it indicates if there are blanks in the ADL documentation, CNA #12 stated, if means that it was not done. On 5/23/23 at approximately 2:00 PM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional vice president of operations, were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to promote a resident's right to respect and dignity, for one of 43 residents in the survey sample, Resident #85. The findings include: The facility staff failed to ensure Resident #85 was treated with respect and dignity during interactions with the nurse practitioner (NP). Resident #85 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: traumatic spinal cord injury, neurogenic bladder, and quadriplegia. Resident #85's most recent MDS (minimum data set) assessment, a quarterly Medicare assessment, with an assessment reference date of 5/9/23, coded the resident as scoring 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the facility grievance log revealed the following: 1/4/23: wants to speak to NP about medications, NP rushes past him and states she does not have time. 1/5/23 UM (unit manager) witnessed resident trying to stop NP and she told him Not today and she would see him the next day. Resident replied that she always tells him that. (UM spoke with resident about his concerns, resident reached out to state ombudsman). A review of the NP (nurse practitioner) note dated 3/24/23 at 2:16 PM, revealed, He continues to complain of spasticity, discussed that he was seen by MD (physician) on Monday and that this provider cannot see him on same days as MD. An interview was conducted on 5/21/23 at 2:45 PM with Resident #85. When asked about physician and NP coverage, Resident #85 stated, It has gotten so much better in the last 4 weeks. The physician sees me twice a week. He communicates well with me. The nurse practitioner does not see me regularly. I complained to the unit manager and the previous administrator about the NP brushing me off. When asked how it made them feel, Resident #85 stated, I feel dismissed and not respected when I just want to ask her for clarification and ask some questions, sometimes it was about appointments. An interview was conducted on 5/23/23 at approximately 9:00 AM with ASM (administrative staff member) #4, the nurse practitioner. When asked about the interactions with Resident #85, ASM #4 stated, He wants to stop me and ask me questions when he has already seen the physician. I have told him that I cannot see him that day, that he will have to wait till the next day. Why did he not ask the physicians those questions? When asked what questions he would ask, ASM #4 stated, Sometimes about medications or appointments. When asked what actions she takes when Resident #85 asks her questions and she does not see him, ASM #4 stated, Well I see him the next day. Only one of us can see him per day. When asked if it was due to billing, ASM #4 did not respond. When asked what actions are taken to communicate and collaborate with the physician if she does not see the physician, ASM #4 stated, she talked with the physician about concerns voiced, but when asked if she documents that in a progress note, ASM #4 stated, no, not usually. On 5/23/23 at approximately 2:00 PM, ASM (administrative staff member) #1, the director of nursing, ASM #2, the regional vice president of operations and ASM #5, the divisional vice president of operations, were made aware of the findings. No further information was provided prior to exit.

Based on staff interview, facility document review, and clinical record review the facility staff failed to ensure that two of 24 residents in the survey sample were transferred and or provided care in a safe manner to prevent injury, Resident # 4 and # 5. 1. Resident # 4 was transferred using a one person assist when the Care Guide directed a two person assist; Resident # 4 sustained a fall with a fracture injury during the improper transfer. 2. While bathing Resident #5 without assistance, the CNA (certified nurse's assistant) turned Resident #5 and the resident rolled out of the bed. Resident #5 did not sustain an injury as a result of this fall. The findings include: 1. Resident # 4 was transferred using a one person assist, when the Care Guide directed a two person assist; Resident # 4 sustained a fall with a fracture injury during the improper transfer. Resident # 4 was admitted to the facility on [DATE] and readmitted most recently on 1/9/15 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 11/14/14, coded the Resident as being moderately impaired cognitively (decisions poor; cues/supervision required). Resident # 4 was coded as being totally dependent of two+ persons physical assist for transfers. Review of the MDS that was completed in August, the month before Resident # 4's fall, revealed the following: A quarterly assessment with an ARD of 8/23/14, coded the Resident as being moderately impaired cognitively. Resident # 4 was coded as being totally dependent of two+ persons physical assist for transfers. Review of Resident # 4's clinical record documented in the nurses' note, dated 9/28/14 at 9:00 p.m., "Writer transferred resident X 1 assist (with assist of one) from w/c (wheel chair) to bed resident lowered to floor onto knees. Called CNA (certified nurse's assistant) to assist from floor to bed. Resident noted ? (right) lower leg redness. No c/o (complaint of) pain voiced at this time. V.S. (vital signs) (temperature) 97.4, (pulse) 84, (respirations) 20, (blood pressure) 136/80." Review of the pain assessment and the nurse's notes for 9/28/14 for the 3 to 11 shift and 9/29/14 for the 11 to 7 shift revealed that Resident # 4 did not complain of pain. Review of a nurse's note dated 9/29/14 at 10:20 a.m. documented the following: CNA advised this writer that Resident was c/o ? leg pain & that leg looked abnormal. Residents (sic) leg was assessed and it was observed to be swollen, bruised, hard and warm to touch with c/o pain. NP (nurse practitioner) notified & N.O. (new order) given 9/29/14, "Xray to (symbol for lower) ? extremity." Review of the medication administration record for September 2014, revealed that Resident # 4 was medicated for pain with Lortab* (narcotic prescription pain reliever) 5/325 at 10:40 a.m. Documentation did not reveal any further complaint of pain noted prior to the Resident being sent to the emergency room . Review of the report of the xray that was obtained in the facility revealed an "Oblique fracture of the distal tibial shaft with slight lateral displacement of the distal fragment. Mild swelling." Further review of the clinical record revealed a telephone order dated 9/29/14, "Send to ER (emergency room ) DX: (diagnosis) Oblique fracture of the distal tibial shaft." Review of the emergency room record revealed the following: "Chief Complaint: right leg deformity noted today by staff; xray reveals displaced fx (fracture) of distal fibia (sic) shaft; patient also makes mention of right upper leg/hip pain also." "Nursing Notes" document: "Patient complains of musculoskeletal pain." There is the right lower legs(s) is/are tender markedly swollen and ecchymotic. Unable to test ROM (range of motion) because of pain elicited. No deformity is present. No dislocation is found." Examinations ordered while in the emergency room and their results: CT (computed tomography): Pelvis: Findings: CT of pelvis shows osteopenia or osteoporosis. Impression: no acute fracture seen. Xray: single view of pelvis impression: no definite fracture seen Xray: two-view right hip impression: no definite fracture seen Xray: 4 view right knee impression: no acute fracture seen Xray: two-view right lower leg impression: There appears to be new deformity of the area of previous healed fracture of the distal right tibia with loss of definition of the cortex anteriorly raising question of nondisplaced fracture. Discharge instructions: Diagnosis: [REDACTED]. Review of the emergency room notes revealed that Resident # 4 did complain of pain but was not medicated while in the emergency room . Review of the facility investigation revealed a written statement by the nurse that transferred Resident # 4. This nurse was no longer employed by the facility so an interview was not possible. This nurse also wrote the nurse's note, documented above, dated 9/28/14 at 9:00 p.m. This statement was sent via email to the facility and the date stamp was, "Wednesday, October 01, 2014 3:01 PM (sic)" "On October (sic-should be September) 28, 2014 I was pulled to work an extra shift due to a 3-11 shift nurse calling out. I had to go to the opposite side of the building than I usually work on to start my second shift. At approx 9pm that night the resident in (room number identified) was still up. This resident has been known to refuse care before. It is extremely rare for this resident to ask someone to put her to bed, however she came up to me and asked if I would help her get ready for bed. Her CNA was busy helping other residents to bed. I wheeled resident into room, and asked her to stand up. She then stood up out of her wheel chair. While supporting her, I then pivoted her to the bed. Right before going to sit her down on the bed her legs gave way. I was still holding her off the ground, and she was still holding on to me. I then lowered her down to the floor on to her knees. I then looked out the door and saw a CNA near the nursing station. I asked her into the room. With the Resident's assistance and 2 person Assist the resident was sat down onto the side of the bed and assessed. Resident was then gotten ready for bed and went to sleep." This was signed by LPN (licensed practical nurse) # 17. Written statement by the CNA (certified nurse's assistant) # 7, that assisted LPN # 17, "On [DATE]th, 2014 I was in the hallway and the nurse (name of LPN # 17) called me and requested my assistance in (Resident # 4's room) to transfer resident (initials to identify resident) from the floor to the bed." This written statement (signed on 10-1-14) was reviewed and confirmed by the CNA (# 7) that wrote it. Facility final report dated 10/3/14 concerning this incident was reviewed and appears in part below: "Upon investigation (name of Resident # 4) asked (name of LPN # 17) to assist her to bed. (LPN # 17) went in, asked the resident to stand from the wheelchair and she assisted her to pivot towards the bed and (Resident # 4) said her leg was giving out. (LPN # 17) lowered her to the floor on to her knees, (LPN # 17) looked out the door and asked for assistance from a CNA to assist her with getting (Resident # 4) off the floor. No injuries were noted nor did (Resident # 4) complain of pain at that time. On 9/29/14 staff noticed a reddened area on her leg; MD was contacted and ordered an x-ray. The finding was a fracture of the tibia/ankle. (Resident # 4) was sent out to the ER for evaluation and returned with a soft cast and a follow-up appointment with orthopedics." "Interviews of staff and residents related to (LPN # 17) and her interactions with residents were done and no staff or residents ever noted a concern. (Resident # 4) is a two person assist and (LPN # 17) did not follow her care giver guide thus causing harm. (LPN # 17) was terminated and reported to the VA Board of Nursing. Staff education was performed to instruct staff to follow the care giver guides and plan of care." This report was signed by ASM (administrative staff member) # 2, the director of nurses. During an interview on 1/21/15 at 2:20 p.m. with ASM # 1, the administrator, ASM # 2, the director of nurses, ASM # 3, the assistant director of nurses, and ASM # 4, the regional director of clinical services, Resident # 4's fall was discussed. This was the first time that the Administrative staff members were apprised of the possibility of harm. This interview was done in the presence of one other survey team member. An interview on 1/21/15 at 4:10 p.m. with CNA # 5 revealed that if staff were new and did not know the transfer status of a resident staff could go to the charge nurse to find out if they were a lift or just assisted. During an interview on 1/21/15 at 4:15 p.m. with CNA # 6, CNA # 6 stated that to find out transfer status and just to find out how to care for a resident one looks in the daily care guide that is kept in the ADL (activities of daily living) book. CNA # 6 further stated that sometimes they have meetings and if there is a change they tell you then. CNA # 6 remembered working with Resident # 4 over the summer and that at that time the resident was a two person assist for transfers but was switched to the hoyer lift after she broke her ankle. When asked if Resident # 4 would ever have tried to transfer herself, CNA # 6 stated that Resident # 4 would never try to get out of her wheelchair either before or after she broke her ankle. An interview on 1/21/15 at 4:20 p.m. with LPN # 3 revealed that if staff needed to know how to transfer a resident staff could look on the care card or the care plan. An interview on 1/21/15 at 4:30 p.m. with LPN # 9 revealed that if staff did not know the transfer status of a resident staff would look at the care guide on the front of the chart and the care guide. Staff could also call the rehab (rehabilitation) department, but one always does what is the safest for the resident. During an interview on 1/21/15 at 4:35 p.m. with LPN # 8, the unit manager on Resident # 4's unit, LPN #8 stated now she (Resident # 4) is a hoyer lift transfer, "I don't really remember but I believe she was a two-person transfer." An interview on 1/21/15 at 4:50 p.m. with LPN # 1 revealed that staff would look on the admission assessment or the therapy notes. LPN # 1 remembered working with Resident # 4 over the summer and stated Resident # 4 was a two-person stand and pivot transfer, one person could not have transferred her by themselves. During an interview on 1/21/15 at 5:00 p.m. with LPN # 11, the LPN stated that he would ask another staff member to find out whether they were two person transfer or a hoyer lift. LPN # 11 further stated that he is new and did not work with Resident # 4 over the summer. An interview on 1/21/15 at 5:15 p.m. with CNA # 7 revealed that she has worked with Resident # 4 before and after her fall. CNA # 7 stated there should have been two staff to transfer the resident. Sometimes they would use the lift if the resident was tired; she (Resident # 4) has no strength in her legs so if she was tired they used a lift. It was on the care card (two person transfer) in the ADL tracking. The nurse did not ask CNA # 7 for help or ask what the resident's transfer status was prior to the Resident's fall. When asked whether the resident ever tried to transfer herself, CNA # 7 stated that she would never try to transfer herself, if she was in the wheelchair she would stay there, if she was in the bed she would stay there. During the end of day interview on 1/21/15 at 6:05 p.m. with ASM # 1, ASM # 2, ASM # 3, and ASM # 4, Resident # 4 was again reviewed and a request was made for the facility transfer policy, fall policy, care guide for September 2014, therapy screens and assessments for 2014. Review of the Resident's fall risk completed on 4/5/14 indicated that the resident was a medium risk for falls. Review of the facility policy "Safe Lifting and Movement of Residents" documented under "Policy" the following: "In order to protect the safety and well-being of staff and residents and to promote quality care this facility uses appropriate techniques and devices to lift and move residents." "Guidelines 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible ..." During an interview on 1/22/15 at 8:40 a.m. with ASM # 2 the following was requested: therapy notes prior to October 2014, admission assessments prior to October 2014, Care Giver Guide that was mentioned in the facility investigation, September 2014 medication administration record, September 2014 treatment administration record, any fall assessments, and LPN # 17's employee record. During an interview on 1/22/15 at approximately 10:00 a.m. with ASM # 3 another request was made for the "care giver guide" mentioned in the facility investigation. On 1/22/15 at 10:30 a.m. ASM # 3 provided a copy of the "CNA CARE CARD" and stated that this was the care guide that was in effect at the time of Resident # 4's fall. Review of this "CNA CARE CARD" (that was in effect at the time of the fall) documented that Resident # 4 was under "Transferring: HH (human help) # 2, also "Does not walk" was checked. Under "Physical Problems" "Limited Joint Movements" was checked. Review of Resident # 4's care plan did not reveal any instruction on how the Resident should be transferred. Review of Resident # 4's current "CNA CARE CARD" identified as the current care card documented that Resident # 4 was a Hoyer Lift for all transfers. The care plan was also noted to be updated on 9/30/14 after Resident # 4's fall to include "Hoyer Lift for all transfers." On 1/22/15 at 10:35 a.m. ASM # 3, provided the only therapy screen that could be found: a Speech Therapy Plan of Care dated 6/4/13. ASM # 3 stated, "This is all they have." During an interview on 1/22/15 at 11:45 a.m. with ASM # 1, ASM # 2, ASM # 3, and ASM # 4 the issue concerning Resident # 4's fall was again discussed. This interview was done in the presence of one other survey team member. A request was made for the staff education mentioned in the facility investigation, any policies, and therapy notes. Also, a request was made for anything else that facility staff would like to present. When the education that was referred to in the facility investigation was reviewed it was found that there was only documentation that eighteen licensed staff members received education. During an interview on 1/22/15 at 3:00 p.m. with ASM # 2 stated, "We don't have anything else in regards to education and we also don't have anything else to present." Prior to exit no further information was presented. In "Fundamentals of Nursing" 7th edition, 2009; Patricia A. Potter and Anne Griffin Perry; Mosby, Inc; Page 5. "Client safety is a priority in health care. You need to protect clients from physical and emotional injury by continually assessing for and eliminating safety hazards. Clients fall due to many factors, such as improper transfer techniques, client age, side effects of medications, impaired mobility, or confusion. Learn your agency's fall prevention program for reducing client falls. Programs that use a multidimensional approach in designing fall prevention strategies have the greatest reduction in fall rates." *Lortab? (as a combination product containing Acetaminophen, Hydrocodone) www.nlm.nih.gov/medlineplus/druginfo/meds/a 6.html - 2. While bathing Resident #5 without assistance, the CNA (certified nursing assistant) turned Resident #5 and the resident rolled out of the bed. Resident #5 did not sustain an injury as a result of this fall. Resident #5 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with [DIAGNOSES REDACTED]. On the most recent MDS (minimum data set), a significant change assessment with assessment reference date 12/1/14, Resident #5 was coded as being severely cognitively impaired for making daily decisions, having scored three out of 15 on the Brief Interview for Mental Status. She was coded as requiring the extensive assistance of two staff members for bed mobility, dressing, toileting and personal hygiene. Resident #5 was coded as being dependent on the assistance of two staff members for transfers, eating and bathing. A review of Resident #5's clinical record revealed an admission nursing assessment dated [DATE] by LPN (licensed practical nurse) #3. Under the section labeled "Mode of Locomotion," Resident #5 was checked for two-person assistance for bed mobility. On the Resident Risk Assessment Profile, completed 4/7/14 by LPN #3, Resident #5 was coded as being dependent on staff for bed mobility. On 1/22/15 at 9:15 a.m., LPN #3 was interviewed about the above-referenced documents. She stated that the facility no longer uses the Resident Risk Assessment Profile, but that, at the time, for Resident #5 it reflected that the resident was totally dependent on staff for moving around. She stated that her assessment of Resident #5 on admission was that Resident #5 was not helping at all with turning and repositioning in the bed because of her bilateral leg amputations. She stated that Resident #5 needed two staff members for turning and repositioning "for her own safety." When asked how those needs are communicated to staff members, LPN #3 stated that the nurses speak to the physician, the CNAs and other nurses through the caregiver card and through verbal reports. When asked if she recalled speaking specifically to any other staff members about Resident #5's safety needs, LPN #3 stated she did not remember one way or the other. A review of Resident #5's clinical record failed to reveal a caregiver card for April and May of 2014. A review of the Activities of Daily Living Reports for April and May 2014 for Resident #5 revealed that she consistently received the assistance of at least two staff members for bed mobility. On Resident #5's admission MDS dated [DATE]; she was coded as being completely dependent on two facility staff members for bed mobility. A review of the nurses' notes for Resident #5 revealed the following note, written 5/4/14 at 12:40 p.m. by a nurse who was unavailable for interview at the time of the survey: "Resident rolled to floor from bed. Resident was being changed and rolled to put brief under her, she rolled off bed. Resident replied to CNA when asked if she was hurt by shaking her head no. Writer in to take VS (vital signs) and assess resident. No injuries noted and no c/o (complaints of) pain. Intervention - two person assist for bed mobility and incontinent care. Family, Dr. (physician) and DON (director of nursing) notified." A review of the Incident Report for the above date revealed, in part, the following incident witness statement: "While changing, resident rolled off bed. Asked resident if she was hurt, resident shook her head saying no." The statement was signed by CNA (certified nursing assistant) #1. On 1/22/15 at 8:30 a.m., CNA #1 was interviewed regarding what she remembered about Resident #5's above-referenced fall. CNA #1 stated that she was giving the resident a bath. When the CNA turned the resident, "she slid out of the bed." CNA #1 stated that she had bathed Resident #5 without assistance several times previously, and had never had any issues. She stated, "I was new to the facility. I can't remember if anybody actually told me how I was supposed to help her move around in the bed." A review of the comprehensive care plan for Resident #5, dated 4/3/14 and not updated prior to the above referenced fall, revealed, in part, the following: Refer me to PT for evaluation. Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician. I use a wheelchair for long distance mobility. I use a mechanical lift; please use two staff members when operating this." The update on 5/4/14 stated: "Staff education 5/4/14." On 1/22/15 at 9:45 a.m., ASM (administrative staff member) #1, the administrator, and ASM # 3, the assistant director of nursing, were informed of these concerns. A copy of the facility policy on fall prevention was requested. A review of the facility policy entitled "Falls Potential and Risk Reduction Protocol" revealed, in part, the following: "Complete the Resident Risk Assessment Profile on admission and quarterly. . . The care plan should be updated after a fall to address the most recent cause of the fall." Nothing further was provided prior to exit. According to Mosby's Textbook for Long-Term Care Assistants, fourth edition, 2003. Page 144, "Safety is a basic need. Nursing center residents are at great risk for falls and other accidents....You need to know the factors that increase a person's risk of accidents and injury. You also need to follow the person's care plan."

Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure adequate supervision, accurate fall risk assessments, implementation and revision of interventions to prevent an accident resulting in a fracture injury for one of 23 residents in the survey sample, Resident #2. Resident #2 sustained a fall on 5/27/12. The facility staff failed to implement interventions to ensure Resident # 2 was frequently monitored, provided a therapy screen and wearing appropriate footwear as indicated on her care plan. Resident # 2 fell again 2 days later on 5/30/12, and sustained a lumbar (spinal) fracture. Resident # 2 continued to sustain multiple falls and the facility staff failed to accurately assess Resident #2's fall risk and failed to implement new interventions after each fall to prevent further falls. The findings included: Resident #2 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's most recent MDS (minimum data set) prior to her 5/30/12 fall, a quarterly assessment, with an ARD (assessment reference date) of 4/17/12, coded Resident # 2's BIMS (brief interview for mental status) score as a 7 of a possible 15, indicating her cognitive status was severely impaired. The resident was coded as usually being understood and as usually understanding what is spoken to her. Resident #2 was coded as being independent with setup help only for transfers, walking, dressing and toileting. The resident was coded as "Not steady, but able to stabilize without staff assistance" with "Balance: moving from seated to standing position, walking (with assistive device if used), turning around while walking, moving on and off toilet and surface to surface transfer". The resident was coded as using a walker. Resident #2 was coded as not having any falls since the prior assessment. On 11/6/12 at 2:30p.m., Resident # 2 was observed in her room in bed, with a bed alarm in place. On 11/7/12 7:20a.m., Resident # 2 was observed in bed with her eyes closed. No bed alarm was observed in place. Review of Resident #2's clinical record revealed a nurse's note dated 5/27/12- 7:24p.m. that documented "Resident resting at this time without discomfort. Res. (Resident) noted on the floor sitting upright on buttocks yelling out 'Help'. When asked Res. 'What happened' Res. stated 'I was trying to get a cup off the floor and my wheels came from up under me'. Notified MD (medical doctor). Tylenol administered c/o (complaint of) back pain. Eff (effective) - no injury noted- v/s (vital signs)". Neither vital signs nor a signature were documented. Review of a nurse's note dated 5/28/12- 3:30p.m. documented "Resident alert & verbal. c/o lower back pain s/p (status [REDACTED]. No visual deformity noted. No bruises/abrasions noted. Up to BR (bathroom) with 1 assist with rolling walker for safety. 1 assist with ADLs (activities of daily living). Resident requesting x-ray. Referred to notify MD". Review of a nurse's note dated 5/28/12 (no time documented) documented "...Resident c/o some pain in back when transferring. ROM intact. Resident requests assist with transfers d/t (due to) fall". Review of a nurse's note dated 5/29/12- 4:00p.m., documented "...Resident alert & verbal. c/o pain to lower back this AM. PRN (as needed) Tylenol given with relief. 1 assist with transfers/ambulating to BR s/p fall. (Name of physician) gave order x-ray LS (lumbar sacral) spine secondary to c/o pain s/p fall". Further review of Resident #2's clinical record revealed a physician's telephone order dated 5/29/12 that documented "T/O (telephone order) (name of physician) x-ray LS spine. Pain after fall". A lumbar spine x-ray report dated 5/29/12 documented "Results: No fracture or bony destructive lesion is seen of the lumbar spine ... Conclusion: Mild osteoarthritis of the lumbar spine". A nurse's note dated 5/30/12- 9:39p.m. documented "Resident will be sent to ER (emergency room ) for a fall that happened at 8:50p.m. Resident stated she tried to stand up to go to bed and fell . She did not have shoes on ...Resident states she feels weakness. (Name of Physician) gave the order to send the resident to the hospital for evaluation". A CT (computed tomography) scan conducted on 5/31/12 at the hospital documented "Impression: Acute or subacute L (lumbar)1 vertebral body compression fracture with 20% vertebral body height loss". Resident #2's comprehensive care plan updated on 4/10/12 documented under the heading "Problem Onset: Risk for injury from falls r/t (related to) psychotropic medication, hx (history) of falls, impaired vision and impaired mobility". Under the "Approaches" column, the care plan documented "Thoroughly orient resident to her surroundings and keep call light within reach at all times when in room ...; PT (physical therapy)/OT (occupational therapy) to screen, evaluate and treat as indicated; PT and OT as ordered; assist resident with appropriate footwear ..." On 11/8/12 at approximately 9:30a.m., nurse's notes from May through present and Resident #2's care plan were reviewed with RN (registered nurse) #1, the MDS coordinator. Handwritten interventions written on the care plan failed to include a date for when the interventions where initiated. RN #1 reported interventions for the 5/27/12 fall were the handwritten interventions that included: "*Monitor frequently/ educate on call bell use. *Therapy referral". On 11/9/12 at approximately 8:30a.m., the 5/30/12 nurse's note that documented the resident "did not have shoes on" and the "Assist resident with appropriate footwear" care plan approach was shown to RN #1. RN #1 stated "Sometimes they stop wearing shoes and will put on footie socks". Review of an investigation report dated 5/30/12- 9:29p.m., documented "Did resident have on appropriate footwear?" An 'x' was placed inside a box beside the word "No". On 11/9/12 at approximately 8:30a.m., RN # 1 was shown the 5/30/12 nurse's note regarding Resident #2's fall and asked to verify the nurse who wrote the note. She stated, "That was (name of LPN #2)". When asked if LPN #2 was available, RN #1 stated, "She is off today". An investigation report dated 5/27/12 documented "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Resident was assessed for injury, helped to her bed. Therapy referral. Will reeducate on proper positioning". Review of therapy documentation failed to reveal a therapy referral was conducted. Review of the clinical record failed to reveal any education regarding proper positioning. An investigation report dated 5/30/12 documented "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Sent to ER for evaluation." According to RN #1, the care plan interventions for this fall were: " educate Res. on using her call bell to call for help" and "keep in/or around nsg. (nursing) Station at res. (resident) preference." Review of all nurses' notes from February through October revealed the following documentation regarding staff monitoring of Resident #2: 8/5/12 "...allowed resident to sit at nursing station in wheelchair for observation and safety. Staff reported that resident will get up to ambulate without ringing bell for assistance ..." 9/14/12 "...Up to w/c (wheelchair) @ lunch to nsg. station for monitoring ..." 9/14/12 " ...Ate dinner at nurse's station ... " 9/19/12 "...up to w/c to nsg. station for monitoring ..." On 11/8/12 at approximately 9:30a.m., RN #1 was asked if Resident # 2 was capable of understanding call bell education since her BIMS was a 7. RN #1 stated even though her BIMS was a 7, elderly people could be educated with repetition. Review of the clinical record revealed the following documented entries in the nurse's notes regarding call bell education to Resident # 2: - A nurse's note: 5/31/12 "...Encouraged to use call bell for assistance. Re-orientation provided. Resident able to do return demonstration and express understanding to call for assistance for transferring. Will continue to monitor." - 7/28/12 "...call bell is in reach of resident ..." -7/29/12 " ...call bell is in reach of res ... " - 8/5/12 " ...allowed resident to sit at nursing station in wheelchair for observation and safety. Staff reported that resident will get up to ambulate without ringing bell for assistance ..." - 9/15/12 "CNA stated to writer that alarm (chair) was sounding went into room and res was up walking to BR, res stated she needed help and res yelled I am going to fall. Went into room helped res down to floor and then back into chair. No injuries. RN supervisor aware. Res. Was placed in w/c and then helped in BR. When ask res why she didn't use CB for help to BR she stated 'I didn't know I needed help' Explained to res that she need to use CB for help to BR she said 'o.k.' Res then brought up to alcove for lunch". (No Investigation Report was provided by the facility for this incident.) On 11/7/12 at 10:50a.m., an interview was conducted with LPN #1 who did not work with Resident #2 in May but presently works with Resident #2. When asked if she thought Resident #2 understands education regarding ringing the call bell, LPN #1 stated, "I don't think she understands". On 11/8/12 at 2:45p.m., CNA #2 was asked if she thought Resident #2 was capable of ringing her call bell for assistance in May 2012. CNA #2 stated " Yes " . The clinical record failed to reveal any documentation regarding physical and occupational therapy or a physical therapy screen after the 5/27/12 fall as care planned. On 11/8/12 at 10:55a.m., an interview was conducted with OSM (other staff member) #6, the director of therapy. OSM #6 was asked to present all therapy documentation for Resident #2 for the past year. On 11/8/12 at 3:15p.m., OSM #6 presented four therapy notes dated 1/18/12, 4/10/12, 7/13/12 and 10/3/12. When asked if there was any therapy documentation regarding Resident #2 for the months of May or June, OSM #6 stated "That's all I could see but I will go back and check". Review of the documentation provided by OSM #6 did not reveal any documented evaluation of Resident #2's fall risk with interventions and or recommendations. The forms documented: 1/18/12 (daily therapy schedule) documented "screen" and nothing else. 4/10/12 (daily therapy schedule) documented, "Pt. refuse to do anything 3 more trials. No change, continue routine nurse. No skilled therapy at this time." 7/13/12 (rehabilitation screen) documented "No change with CLOF (client's level of function) per notes in chart". 10/3/12 (rehabilitation screen) documented "Patient refused therapy services at this time". On 11/9/12 at 8:45a.m., OSM #6 stated Resident #2 was not on therapy caseload in May or June and no referrals had been received. According to Mosby's Textbook for Long-Term Care Assistants, fourth edition, 2003. Page 144, "Safety is a basic need. Nursing center residents are at great risk for falls and other accidents....You need to know the factors that increase a person's risk of accidents and injury. You also need to follow the person's care plan." On 11/9/12 at 11:10a.m., the Administrator and Director of Nursing were made aware of the concern for Resident #2's fall with fracture. On 11/9/12 at approximately 1:30p.m., the Regional Vice President stated that maybe resident #2 had taken her footwear off. However review of the clinical record including the date of the incident with fracture as well as the comprehensive care plan did not evidence any documentation of Resident # 2 removing footwear. Resident # 2 continued to sustain multiple falls and the facility staff failed to accurately assess Resident #2's fall risk and failed to implement new interventions after each fall to prevent further falls. Review of Resident #2's clinical record and review of facility documents revealed in addition to the falls documented above on 5/27 and 5/30/12, Resident #2 sustained multiple falls on the following dates: ? 7/26/12- Per a facility investigation report, Resident #2's walker slipped from under her and she fell . Resident #2 was taught to not get up without assistance and educated to use the call bell for assistance. No nurse's note dated 7/26/12 was observed regarding this fall. ? 7/27/12- Per a nurse's note documented at 6:56a.m., Resident #2 was noted on the floor in front of the sink. The resident reported she hit her head. Neurological checks were initiated and the physician was notified. ? 7/27/12- Per a nurse's note documented at 12:12p.m., Resident #2 was signed out by her granddaughter and fell at the end of the hall while exiting the facility. Resident #2 fell again while out of the facility. ? 9/12/12-Per a nurse's note, Resident #2 lost her balance in the bathroom. The note did not state whether Resident #2 made contact with the floor. This was in the presence of a CNA (certified nursing assistant). The resident was assisted with toileting and assisted back to bed. No Investigation Report was provided by the facility for this incident. ? 9/13/12-Per a nurse's note, Resident #2 was noted on the floor and stated, "I was trying to use the bathroom". The physician was notified. The resident was assisted to bed and a bed alarm was attached. ? 9/15/12- Per a nurse's note, Resident #2's chair alarm was sounding. A CNA went into the resident's room and Resident #2 was walking to the bathroom. Resident #2 yelled "I am going to fall" The CNA assisted the resident to the floor then into a wheelchair, then assisted Resident #2 to the bathroom. No Investigation Report was provided by the facility for this incident. ? 9/18/12-Per a nurse's note, Resident #2's bed alarm was sounding and Resident #2 was observed on the floor in the bathroom. The resident was assessed for injuries (none noted) and assisted to a wheelchair. The physician was notified. ? 10/1/12-Per a facility investigation report, Resident #2 went to the bathroom without her walker and fell . The resident was assessed and assisted to bed with a bed alarm attached. No nurse's note dated 10/1/12 was observed regarding this fall. Review of Resident #2's fall risk assessments revealed the following: - Fall risk assessment dated [DATE] documented Resident #2's fall risk as being medium. - Fall risk assessment dated [DATE] documented Resident #2's fall risk as being medium. - Fall risk assessment dated [DATE] documented Resident #2's fall risk as being low. On 11/9/12 at 8:30a.m., an interview was conducted with RN #1. When asked how Resident #2's fall risk was determined, RN #1 stated the fall risk assessment was generated through a computer program and based on the resident's MDS. RN #1 stated she completes the MDS, goes into the computer program, clicks on the word "pre-populate" and the fall risk assessment is generated. Resident #2's most recent MDS, a significant change assessment, with an ARD of 8/28/12 documented under Section J1800 that Resident #2 had not had a fall since the prior assessment. Resident #2's prior assessment was a quarterly MDS with an ARD of 7/8/12. Facility documents and nurse's notes documented Resident #2 sustained three falls in the facility (one which occurred while she was signed out by her granddaughter) and one fall outside the facility between 7/8/12 and 8/28/12. The facility document titled "Falls Potential and Reduction Risk Protocol" documented the following: "...If the resident has fallen in the past month, the resident will be considered at high risk regardless of their risk score. Note: The assessor must use their judgment in cases of scores which constitute 'low risk' and look further for prime indicators. If in the judgment of the assessor the resident is at high risk regardless of their score, the protocol is to be followed ..." Review of facility investigation reports provided by the facility for the above falls documented the following: 7/26/12- "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Teaching resident not to get up without assistance; educated res. to use call bell for assistance." 7/27/12- "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Resident assisted to chair. W/C (wheelchair) obtained from PT (physical therapy) and educated on the importance of not trying to walk too far without rest." 9/13/12- "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Res. assessed and helped back to bed with bed alarm attached." 9/18/12- "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Resident assisted out of floor to w/c ...Resident assessed for injury. At nurses station at this time for close observation." 10/1/12- "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent future recurrences of this incident? Taught resident the importance of using call bell to request assistance & instructed resident on how to use call bell. Referral to therapy for evaluation." Resident #2's care plan, updated 4/10/12, documented "Problem Onset: Risk for Injury from falls r/t psychotropic medications, hx (history) of falls, Impaired Vision and Impaired Mobility". Under the "Approaches" column, the care plan documented: "Keep schedule as close to the same daily as possible. Provide rest periods according to resident's needs. Monitor environment for hazards and correct identified hazards. Thoroughly orient resident to her surroundings and keep call light within reach at all times when in room. Answer call light promptly. PT/OT to screen, evaluate, and treat as indicated. Ensure appropriate lighting in room and in bedroom. Assist resident with appropriate footwear. Discuss side effects of medications with resident and monitor for side effects. Encourage resident to wear her glasses. Resident walks with a walker. Staff to ensure that walker is in good repair. PT and OT as ordered". Under this, the following was handwritten on the care plan. "*Monitor frequently/educate on call bell use *Therapy referral *Educate Res on using her call bell to call for help. *Keep in/or around nsg (nursing) station at Resident's preference. *Consider Room change RE (regarding) to fall, move closer to nsg. station. *Monitor Frequently." The handwritten approaches written on the care plans did not include a date for when the approaches were initiated. Resident #2's care plan, updated on 8/29/12, documented "Problem Onset: Risk for Injury from falls r/t psychotropic medication, hx of falls with fracture, Impaired Vision and Impaired Mobility". Under this, "decreased safety awareness" was handwritten. Under the "Approaches" column, were all the same approaches documented on the 4/10/12 care plan. A handwritten approach with no date for when the approach was initiated documented, "*personal alarm while up in w/c to alert staff of movements. Staff to check q (every) shift and personal alarm". On 11/7/12 at 9:30a.m., and 11/8/12 at approximately 9:30a.m., nurse's notes from May through present and Resident #2's care plan was reviewed with RN #1. RN #1 reported the following: RN # 1 stated interventions for the 5/27/12 fall included, "*Monitor frequently/ educate on call bell use. *Therapy referral". Review of therapy documentation and interviews with the director of therapy failed to reveal a therapy referral was conducted after the 5/27/12 fall. RN # 1 reported interventions for the 5/30/12 fall included, "*Educate Res. On using her call bell to call for help. *Keep in or around nsg. (nursing) station at Resident's preference". No new interventions were identified on the care plan for the 7/26/12 fall. RN # 1 reported, interventions for the 7/27/12 fall included: "*Consider room change re (regarding) to fall, move closer to nsg. Station". (According to facility documentation, Resident #2 was moved on 10/3/12 for isolation reasons). No new interventions were handwritten under the "Approaches" column for when Resident #2 lost her balance in the bathroom on 9/12/12. On 11/7/12, at approximately 9:30 a.m., RN #1 stated "We added decreased safety awareness and staff may have been in serviced". On 11/8/12, at approximately 9:30 a.m., RN #1 stated "It wouldn't be any intervention other than what we already have in place". RN #1 reported interventions for the 9/13/12 fall were "same thing; decreased safety awareness; same interventions". No new interventions were identified on the care plan for the 9/18/12 fall. On 11/7/12 at 9:30a.m., RN #1 stated, "Decreased safety awareness still counts and since it (the fall) happened in the bathroom, that would be under self care deficit- assist to toilet. On 11/8/12 at approximately 9:30a.m., RN #1 stated "We also provide frequent monitoring". When asked how the monitoring is provided, RN #1 stated, "We monitor and perform incontinence care every two hours". RN # 1 reported, interventions for the 10/1/12 fall included: "*personal alarm while up in w/c to alert staff of movements. Staff to check Q (every) shift and personal alarm". Review and comparison of Resident #2's MDS assessments relative to a scheduled incontinence care/ toileting revealed the following: Quarterly MDS ARD 4/17/12: Always continent of bowel and bladder. No toileting program. This assessment was completed prior to Resident #2's fall with fracture on 5/30/12. Quarterly MDS ARD 7/8/12: Always continent of bowel and bladder. No toileting program. Significant change MDS ARD 8/28/12: Frequently incontinent of bowel and bladder." H0200A Urinary toileting program: has been attempted- 0. No" "H0500 Bowel toileting program being used- 0. No." Resident #2's self care deficit care plan, dated 8/29/12, did not reveal any documented fall approaches or interventions, other than, "Keep personal items within reach of resident at all times, Assist resident in BR (bathroom) as needed; assist to BR or to use bedpan at regular intervals and as requested. Keep call light within resident's reach at all times." On 11/8/12 at approximately 9:30a.m., an interview was conducted with RN #1 regarding the facility process for falls. RN #1 stated, "We identify the risk, implement an intervention and if the intervention is not working, we try other interventions. After every fall, we document the intervention on the care plan unless it's already in place". When asked if facility staff implement and document new interventions after each fall, RN #1 stated, "We use some interventions twice. If it is the same intervention that is already on the care plan then we don't document it. We don't want them to fall but it's her right to have the least restrictive measures ...I think the measures we put in place were least restrictive for her and to keep her safe ". The facility policy titled "Falls Potential and Risk Reduction Protocol" documented "Policy: It is the policy of this facility to assess residents for the potential for falls and identify factors that might contribute to falls. The facility will address those factors identified in order to reduce the risk for falls. Procedure: 1. Complete the Resident Risk Assessment Profile on admission and quarterly. 2. The care plan will address special needs and/or risk factors identified on the Resident Risk Assessment Profile. This may include any of the following: a. Review of the resident's ambulatory status, and the potential benefits of physical therapy and/or restorative nursing for retraining or training in safety techniques. b. Review of the circumstances surrounding past falls, if any. If the resident requires increased attention at peak times of the day, or if the resident has other unmet needs, these will be addressed on the care plan. c. Review of medication regimen; d. Vision assessment, if appropriate; and e. Restraint reduction assessment if appropriate. 3. If the resident has fallen in the past month, the resident will be considered at high risk regardless of their risk score. Note: The assessor must use their judgment in cases of scores which constitute 'low risk' and look further for prime indicators. If in the judgment of the assessor the resident is at high risk regardless of their score, the protocol is to be followed. 4. The care plan should be updated after a fall to address the most recent cause of the fall". According to Fundamentals of Nursing Lippincott Williams and Wilkins 2007 pages 65-77 documented, "A written care plan serves as a communication tool among health care team members that helps ensure continuity of care...The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care...expected to review, revise and update the care plan regularly, when there are changes in condition, treatments, and with new orders..." On 11/9/12 at 11:10a.m., the Administrator and Director of Nursing were again informed of the concern regarding Resident #2's fall with fracture. In addition they were informed of the concern Resident #2's fall risk was not accurately assessed; and of the concern new interventions were not implemented after each of Resident #2's falls. No further information was provided regarding the above concerns by completion of the survey process.