Every finding on record at Focused Care at Burnet Bay

Based on interview, observation and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #1) of 8 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received scheduled alprazolam on 7/15/26 and 7/16/26 and scheduled Hydrocodone-Acetaminophen/Norco on 7/7/26 at 12:00 p.m. This failure could place residents at risk of not receiving medications as ordered by the physician and increased pain or anxiety.Findings included:Record review of Resident #1's face sheet, dated 7/21/26, revealed the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 had diagnoses which included chronic pain syndrome (condition characterized by persistent pain that lasts beyond expected period of healing), unspecified low back pain, unspecified pain, and generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry).Record review of Resident #1's quarterly MDS assessment, dated 6/25/26, section C (Cognitive Patterns) revealed a BIMS score of 13 which indicated cognition was intact. Section I (Active Diagnoses) revealed anxiety disorder. Section J (Health Conditions) revealed Resident #1 received scheduled pain medication regimen in the last 5 days prior to the assessment.Record review of Resident #1's physicians order summary report, dated 7/21/26, revealed physician orders for alprazolam 1 mg oral tablet with instructions to give 1 mg by mouth every 24 hours as needed for anxiety and may have 1 mg repeat dose if initial schedule dose was ineffective only during nighttime if Resident #1 woke up during the night with start a date of 7/17/26, alprazolam 1 mg oral tablet with instructions to give 2 tablets at bedtime with start date of 5/27/26, and hydrocodone-acetaminophen 10/325 mg oral tablet with instructions to give 1 tablet by mouth every four hours for pain with start date of 5/20/26. Record review of Resident #1's care plan, dated 7/22/26, revealed a focus regarding psychosocial well-being related to anxiety.Record review of Resident #1's July 2026 MAR revealed alprazolam oral tablet 1 mg with instructions to give 2 mg by mouth at bedtime had chart code 5 documented on 7/15/26 at 8:00 p.m. and 7/16/26 at 8:00 p.m. by Resident Medication Provider B. Hydrocodone-acetaminophen oral tablet 10/325 mg with instructions to give 1 tablet my mouth every 4 hours for pain had chart code 9 documented on 7/7/26 at 12 p.m. by LPN A. Record review of the chart code key revealed 5 indicated Hold/See Progress Notes and chart code 9 indicated Other/See Progress Notes. Alprazolam 1mg oral tablet with instructions to give 1 mg by mouth every 24 hours as needed and may have 1 mg repeat dose if initial scheduled dose ineffective was administered on 7/1/26, 7/2/26, 7/5/26, 7/6/26, 7/7/26, 7/8/26, 7/9/26, 7/11/26, 7/12/26 and 7/13/26. Alprazolam 1 mg with instructions to give one time only for anxiety was documented as being administered on 7/17/26 at 8:54 p.m. by Resident Medication Provider B. Record review of Resident #1's progress notes 7/7/26 and 7/15/26-7/16/26 did not reveal any associated progress notes related to the alprazolam administration on 7/15/26 at 8:00 p.m. and 7/16/26 at 8:00 p.m. or hydrocodone-acetaminophen administration on 7/7/26 at 12:00 p.m.Record review of Resident #1's 24 hour nurse reports, dated 7/1/26 to 7/9/26, revealed the following: a note on the 7/1/26-7/2/26 24 hour report sheet that as needed alprazolam 1 mg was administered at 12 a.m.; 7/2/26-7/3/26 24 hour report revealed a note that hydrocodone-acetaminophen was to be refilled soon and the doctor was aware; 7/6/26-7/7/26 24 hour report sheet revealed a note that a Norco prescription was needed per the pharmacy with 0 left and the doctor was aware. and note was crossed out with a check next to the note and the word completed. 7/8-7/9/26 24 hour report sheet revealed note Norco received.Record review of MD A practitioner's progress note for date of service 7/7/26 written by MD A revealed past medical history of chronic midline low back pain unspecified sciatica (pain that travels down the lower back through the buttocks and each leg). Progress notes also revealed diagnosis, assessment and plan for chronic pain syndrome and to continue hydrocodone-acetaminophen 10/325 and acceptable control (the state in which a condition, process, or measurement is managed or regulated within a predefined, safe, and effective range). Record review of Resident #1's hydrocodone-acetaminophen 10/325 mg controlled drug administration record, dated 6/23/26 through 7/7/26, revealed last documentation of administration on 7/7/26 at 4:00 a.m. with end count of 0 tablets left.Record review of Resident #1's alprazolam 1 mg controlled drug administration record revealed date received at the facility 7/2/26 and last administration on 7/14/26 at 8:00 p.m. with end count of 0 tablet left. Record review of Resident #1's alprazolam 1 mg controlled drug administration record on the medication cart revealed the first date of administration was 7/17/26. Record review of Resident #1's hydrocodone-acetaminophen 10/325 mg controlled drug administration record revealed date received at the facility 7/7/26 and first administration on 7/8/26 at 1:22 a.m.Record review of Resident #1's practitioner's progress note, dated 7/17/26, written by Nurse Practitioner A, revealed Resident #1's medication list included alprazolam 1 mg tablet with instructions to take 2 tablets by mouth at bedtime and to take 1 tablet one time if Resident #1 awakens. Past medical history included general anxiety disorder and chronic midline low back pain unspecified sciatica (pain that travels down the lower back through the buttocks and each leg). Progress note revealed Resident #1 was seen for a follow up regarding his request regarding increased anxiety and depression for the past couple of days and the facility did not have the refill for alprazolam 2mg at bedtime and alprazolam 1 mg as needed. Progress note revealed Resident #1 stated he had not slept in two days because he relied on the alprazolam for sleep for the last ten years. Progress note revealed Resident#1 had gotten an alprazolam earlier that day as the pharmacy had refilled the prescription. During interview and observation on 7/21/26 at 9:59 a.m., Resident #1 said he had really bad PTSD that he took the antianxiety medication for. Resident #1 said he took two pills of the alprazolam before bedtime and he did not receive any alprazolam pills on Wednesday, 7/15/26, or Thursday, 7/16/26, and by the time he got the medication on Friday, 7/17/26, he had gone over 65 hours with no sleep. Resident #1 said staff said they were sending information to the doctor. Resident #1 said he had a panic attack for the first time in his life and cried for two days until he had no more tears. Resident #1 said the Administrator and someone else who he could not remember came Friday, 7/17/26, about 3:30-4:00 p.m. and told him something like the doctor had to send in a refill or there was a mix up with the pharmacy. Resident #1 said the CNAs kept telling him that the medication was coming on the next pharmacy delivery and the nurses would not come talk to him, but the night nurse was very concerned and said she did not know anything regarding the antianxiety medication. Resident #1 said he was seeing stuff crawling on the walls due to having withdrawals from the antianxiety medication, but he knew they were not there. Resident #1 said the week before they ran out of the alprazolam they ran out of his pain medication, hydrocodone-acetaminophen 10/325 but that was only for one day. Resident #1 said the doctor was at the facility last Tuesday, 7/14/26 and supposedly called into the pharmacy and said to deliver the antianxiety medication in a hurry. Resident #1 said the facility should have had an emergency supply of the medications.During interview on 7/22/26 at 10:11 a.m., LPN A said she would have to see the documentation in the chart regarding why the 7/7/26 12:00 p.m. dose of Resident #1's hydrocodone was not given. LPN A said there were no problems with Resident #1's medications being available. LPN A said when the medication card got to the last row the color would be bold in bright blue indicating to refill it. LPN A said then they call the doctor and they send the prescription into the pharmacy. LPN A said they always called the request into the doctor but depending on the doctor that was what may cause the delay in having the medication arrive from the pharmacy. LPN A said typically the nurses did a good job notifying the doctor to reorder medications. LPN A said they had an automated medication dispensing system and they were able to pull medications from there. LPN A said the pharmacy needed a prescription so that would be the only thing that would cause a delay to pull a medication from the automated medication dispensing system. LPN A said as long as the medication was in the automated medication dispensing system and they had a prescription they could pull the medication from the automated medication dispensing system. LPN A said she did not believe they could pull alprazolam from the automated medication dispensing system and she did not know why alprazolam was not in the automated medication dispensing system. LPN A said hydrocodone was in the automated medication dispensing system and knew the 5/235 mg tablets were in there because she had pulled them before but was not sure what other dosages were available.During interview on 7/22/26 at 11:18 a.m., Resident Medication Provider B said the alprazolam was not given to Resident #1 on 7/15/26 and 7/16/26. She said she told the nurse that they did not have the medication and they would have to tell the doctor. Resident Medication Provider B said she told the DON as well. Resident Medication Provider B said she informed the nurses that she called the pharmacy and they needed a new prescription. Resident Medication Provider B said it was her and the nurse's responsibility to call the doctor and pharmacy regarding unavailable medication. Resident Medication Provider B said only the nurses document a note in the chart and she would not have documented a note in the chart. Resident Medication Provider B said Resident #1's doctor, MD A, had come that day and she told him too regarding the alprazolam medication needing to be refilled and said, I tell everybody. Regarding obtaining medication out of an automated medication dispensing system at the facility, Resident Medication Provider B said the nurses had to call the pharmacist and see if the medication was in the emergency kit but said she did not think the facility had alprazolam in the emergency kit and she thought it included hydrocodone. Resident Medication Provider B said Resident #1 was upset regarding not having the alprazolam available and she told him she told the nurse. Resident Medication Provider B said she could not remember why the alprazolam was not available. During interview on 7/22/26 at 11:37 a.m., LPN A said on 7/7/26 the medication aide had notified her Resident #1 was going to run out of the hydrocodone and she notified the doctor immediately and the doctor said it was filled. LPN A said she called pharmacy they said they had not received a prescription. LPN A said she called the pharmacy back and the pharmacist still said they had not received the prescription. LPN A said sometimes the doctors did efax to send in prescriptions which took a while. LPN A said around 1 p.m. on 7/7/26 she called the pharmacy and they said the pharmacy had received the prescription and the medication was en route. LPRN A said Resident #1 should have missed one dose of the hydrocodone. LPN A said the hydrocodone was unable to be pulled from the automated medication dispensing system due to the delay in the doctor writing the prescription. LPN A said the hydrocodone was delivered around shift change which was 2 p.m. on 7/7/26. LPN A said typically they documented regarding refills but unfortunately that was the first time I was made aware of the situation regarding Resident #1 running out of the hydrocodone and every nurse had the ability to refill the medication. LPN A said she would write information regarding medication refills on the 24 hour report sheet that the nurses used to report to each other. LPN A said typically they were supposed to write in the progress notes regarding refilling medications and that would be best. During interview on 7/22/26 at 11:58 a.m. the ADON said the process for reordering medication was when there were 6-8 pills of a scheduled medication left, the medication aide let the nurse know the medication needed to be refiled and the nurse reached out to the provider or their team members to let them know the medication needs to be refilled. The ADON said there were only certain medications in the automated medication dispensing system but not all medications. The ADON said both alprazolam and hydrocodone would have to have a prescription written first before they were able to pull the medication from the automated medication dispensing system. The ADON said they would call the pharmacy and verify they had received the prescription and then they would be able to pull the medication from the automated medication dispensing system. The ADON said all staff should be aware that the doctor needs to be notified to reorder medications. The ADON said if the medication was not coming in then they called the pharmacy. The ADON said if pain medication was not available the resident could be in more pain and could lead to a hospitalization. The ADON said if alprazolam was being taken for anxiety and was not available then the residents' anxiety symptoms could be increased unless we could find something for their anxiety symptoms. During interview on 7/22/26 at 12:14 p.m., the DON said the process for reordering medication was the staff should let the physician or the representative before 2 p.m. The DON said typically the staff try to notify the physician regarding a refill when the medication was around 4-5 doses. The DON said regarding Resident #1 it looked like he used up his order for the alprazolam because he had a scheduled order and a breakthrough dose and the pharmacist did not want to reorder the medication. The DON said he talked to the doctor to get the order for the alprazolam straightened out and they were able to get the medication the following day. The DON said they talked about the alprazolam for two straight days and the pharmacy said if the facility was able to pay for the alprazolam out of pocket that was the only other way. The DON said Resident #1's family came in on 7/17/26 and were upset regarding Resident #1 not receiving his medication and the DON said he told the family the facility had to get an order and depending on what time the order was called in depended on when the medication was delivered. The DON said possibly the prescription did not get called in timely for the doctor. The DON said the doctor called the pharmacy because he said Resident #1 had three refills for the alprazolam and the pharmacy was saying he should not get another dose until the July 19th, he thought. The DON said they received the Xanax on the 7/17/26. The DON said he talked to Resident #1 on the 7/17/26 because he was under the impression everything was taken care of until the family came on 7/17/26. The DON said if a resident did not get their pain medication they could have increased pain, higher anxiety, decreased trust in the facility, and overall bad state. The DON said if a resident did not get anxiety medication, that in Resident #1's situation he could not sleep. The DON said other effects could include decreased mentation, being sleep deprived, delirious, or could affect the resident's overall care because they would not be feeling well, could raise the heart rate and put the resident at more risk due to comorbidities. The DON said Resident #1 did not report seeing things and only reported increased anxiety and not sleeping and being upset regarding the financial part of the issue. The DON said I told Resident #1 it was an issue with the pharmacy and the way the order was written. The DON said the pharmacy was only going off the scheduled dose and not the breakthrough doses. During interview on 7/22/26 at 1:14 p.m., LPN A said Resident #1 did not report any hallucinations to her during 7/15/26-7/16/26. LPN A said on 7/17/26 the off going medication aide told her Resident #1 needed the alprazolam refilled and, even though she was not the nurse during the time the medication was scheduled, she called the doctor and got an order for a one time dose of the medication. During interview on 7/22/26 at 1:24 p.m., MD A said Resident #1's alprazolam order was 1 mg to take two tablets at bedtime and to take another tablet when he woke at night. MD A said apparently an order was put in for alprazolam 1 mg once a day and when the facility sent the refill they sent the alprazolam 1 mg once a day so that meant when the pharmacy tried to run the alprazolam 2 mg the pharmacy denied it saying they had already run the alprazolam. MD A said he called the pharmacy to see what the issue was and they said they had already filled the 1 mg alprazolam so it took some time to get it corrected. MD A said the orders had to be written how the facility could implement them. MD A said the problem with getting the alprazolam refilled was due to poor communication between him, the facility, the pharmacy and the insurance. MD A said Resident #1 had went into full mode panic attack when he did not receive the alprazolam and he did not recall Resident #1 reporting any hallucinations. During interview on 7/22/26 at 1:45 p.m., regarding Resident #1 alprazolam administration from 7/15/26-7/16/26 LPN B said she knew the alprazolam was not there and she sent the request to pharmacy to see if they could get some and sent a notification to the doctor to get refills. LPN B said the pharmacy said it was too soon to get refills and she got in touch with the doctor and he said he would call the pharmacy, and she was assuming that was the during the time frame of 7/15/26-7/16/26. LPN B said she believed they received the medication the following day, 7/17/26, but could not say most definitely. LPN B said she typically did not document in the progress notes regarding refills and she just called the pharmacy that they need a refill. LPN B said the pharmacy would say ok they had refills left or they need a new prescription. LPN B denied Resident #1 reporting any hallucinations during the time he did not receive the alprazolam she did not think Resident #1 had any increased anxiety. During interview on 7/22/26 at 2:54 p.m., the Administrator said the problem with Resident #1's alprazolam prescription was that the insurance was not going to pay to refill the medication until 7/19/26.During interview on 7/22/26 at 2:54 p.m., the ADON said Resident #1 had two alprazolam orders with one scheduled and one if he was awake during the night. The ADON said when the alprazolam order got switched, they did not call in more medication and that same card was still being used instead of two cards, one for the scheduled order and one for the breakthrough order, so he ran out sooner. The ADON said the PRN order was only to be given at night if Resident #1 woke up. The ADON said they spoke to the physician to get the order fixed so Resident #1 could get the medication that he needs. During interview on 7/22/26 at 4:12 p.m., the Senior Pharmacy Technician said he showed a paid claim for alprazolam 1 mg for 60 tablets on 7/17/26. The Senior Pharmacy Technician said the prescription for the alprazolam was phoned in on 7/16/26 by MD A so it would have gone out on the next day. The Senior Pharmacy Technician said the 7/17/26 alprazolam prescription was originally rejected by insurance but got an approval or someone notified us to reprocess the prescription and it was approved.Record review of facility's policy Administration Procedures for All Medications with effective date 9/2018 revealed medications will be administered in a safe and effective manner and review the 5 rights at each of the following steps of medication administration.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 7 residents (Resident #2) reviewed for pharmacy services.The facility failed to ensure that medication was not left unattended at Resident #2's bedside on 7/21/26 at 9:43 a.m.This failure could place residents at risk for obtaining medications that were not ordered for them and potential adverse reactions or side effects.Findings included:Record review of Resident #2s's face sheet, dated 7/21/26, revealed the resident was a [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included end stage renal disease (final stage of chronic kidney disease characterized by a permanent loss of kidney function).Record review of Resident #2's quarterly MDS assessment, dated 4/24/26, section C (Cognitive Patterns) revealed a BIMS score of 15 that indicated cognition was intact. Record review of Resident #2's physicians order summary report, dated 7/21/26, revealed physician's order for Renvela oral tablet 800 mg (Sevelamer Carbonate) with instructions to give 2 tablets by mouth three times a day for end stage renal disease to take with meals/food with start date 3/27/26. Record review of Resident #2's physicians order summary report, dated 7/22/26, revealed physician's order that resident may take Renvela oral tablet 800 mg (Sevelamer Carbonate) at bedside with start date of 7/21/26. Record review of Resident #2's July 2026 MAR revealed Renvela oral tablet (Sevelamer Carbonate) with instructions to give 2 tablets by mouth three times a day was administered on 7/21/26 at 6 a.m. by Resident Medication Provider A.Record review of Resident #2's care plan, dated 7/21/26, did not reveal any focus related to self-administration of medications.Record review of Resident #2's care plan, dated 7/22/26, revealed focus that Resident #2 had a physician's order for self-administration of Renvela oral tablet 800 mg (Sevelamer Carbonate). During interview and observation on 7/21/26 at 9:43 a.m., two white oval pills were in a medication cup sitting on top of a water cup on the bedside table of Resident #2's room and no staff were in the room. Resident #2 said the pills were her Sevelamer (Renvela) which were a phosphate binder and she was supposed to take them before breakfast, but she had forgotten. Resident #2 took the two pills at 9:43 a.m. Resident #2 said facility staff usually watched her take her pills. Resident #2 said the only medication she did not take immediately was the Sevelamer (Renvela) because she was supposed to take it immediately before meals and she did not always get her pills immediately before meals. During interview on 7/21/26 at 9:51 a.m., the Resident Medication Provider A was informed that pills were found on Resident #2's bedside table that Resident #2 identified as Sevelamer. Resident Medication Provider A said she had not given Resident #2 any medications yet today. Resident Medication Provider A said Resident #2 was particular about those pills that were at bedside and normally takes them before breakfast, lunch and dinner and was not sure who gave Resident #2 the pills. Resident Medication Provider A said Resident #2 was very adamant about not telling her how to take her medications. Resident Medication Provider A said she normally watched Resident #2 take her medication and they had to give them to her. Resident Medication Provider A said she stayed with the residents while they took their medications other than the medications Resident #2 took with her to dialysis. Resident Medication Provider A said she had never experienced medications left at bedside because she stayed with the resident. Resident Medication Provider A said she would have said something to Resident #2 if she saw the pills at bedside. During interview on 7/21/26 at 3:12 p.m., the DON was informed that two Renvela (Sevelamer) tablets were found at Resident #2's bedside. The DON said there should not be medications left at bedside and staff should always observe the resident taking the medication. The DON said if medications were left at bedside another resident could come and take the medication, the medication could fall on the floor and become contaminated, could be a risk of poisoning or a risk of aspiration if the resident had swallowing issues and was not observed while taking the medication.During interview on 7/21/26 at 3:25 p.m., the ADON was informed that two Renvela (Sevelamer) tablets were found at Resident #2's bedside. The ADON said medications should not be left at the resident's bedside and staff were supposed to watch the resident take the medication. The ADON said if medications were left at the bedside the patient could possibly not take the medication or another resident could possibly take the medication. During a record review of an email received on 7/22/26 at 6:58 a.m. from the Administrator revealed Resident #2 had a BIMS score of 15 and was fully competent to self-administer medications. Also, that Resident #2 was capable of appropriately redirecting another resident if one were to enter the room and they had gotten an order from the doctor saying it was ok for Resident #2 to have medication at bedside.During interview on 7/22/26 at 10:47 a.m., Resident #2 said the Sevelamer (Renvela) tablets she got directly from the dialysis clinic and gave the medication aide as a matter of courtesy. Record review of facility's policy titled, Storage of Medications, dated 9/2018 revealed, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

Based on observation, records review and interview, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 5 (Resident #4, # 10, #12, #51 and Resident #64) of 18 residents reviewed for accuracy of assessment.Resident #4, #10, #12's and #51's MDS did not reflect their lack of natural, broken\lose teeth in their oral cavity.Resident #64 was not assessed for her fall on 12/04/25.These failures could place residents at risk of receiving inadequate care and services due to inaccurate assessments. Findings included:Record review of Resident #4's face sheet, dated 05/06/26, reflected [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Essential hypertension (primary diagnoses), dementia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance, overactive bladder, degenerative disease of envious system (a condition that damages, and destroys part of the nervous system over time) Record review of Resident #4's Significant change MDS dated [DATE] revealed her BIMs score was 7 out of 15 indicated sever cognitive impairment. Record review of section L on oral cavity revealed, Resident #4 was assessed as having all natural teeth in her oral cavity.Record review of Resident #4's care plan with a target date of 02/29/26 revealed resident #4 was care plan for Mechanical Soft texture, Regular consistency diet. initiated 07/27/2023- target date 02/19/26Dental care: I have oral/dental health problems r/t Poor nutrition, Poor oral hygiene. Target date 02/29/26:Interventions: Coordinate arrangements for dental care, transportation as needed/as ordered. Diet as Ordered. Consult with dietitian and change if chewing/swallowing problems are noted. Monitor/document/report PRN any signs and symptoms of oral/dental problems needing attention:Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Provide mouth care as per ADL personal hygiene.Observation on 05/05/26 at 10:00AM, revealed Resident # 4 was in bed sleeping attempt was made to communicate but did not respond verbally. Observation on 05/06/26 at 12:30PM, revealed she was in the dining room. Her meal was puree diet. Observation indicated she had no teeth on her upper oral cavity. An attempt was made to have an interview, but she did not answer. She attempted to speak but could not answer fully. During an interview with CNA E said Resident #4 did not have any teeth in her upper oral cavity. Review of Resident #10's face sheet, dated 05/06/26, reflected [AGE] year-old female who was admitted to the facility on [DATE] re-admitted on [DATE]. Her diagnoses included chronic congestive heart failure, chromic kidney failure, schizophrenia, dementia (a group of symptoms affecting memory, thinking and social abilities) mood disturbance and presence of cardiac pacemakers (device that sends electrical impulses to the heart muscle to keep a suitable heart rate and rhythm), altered mental status, and essential hypertension (high blood pressure), and cognitive communication deficit (lack of communication)Record review of Resident #10's admission MDS dated [DATE] revealed her BIMs score was 0 out of 15 indicated sever cognitive impairment. Record review of section L oral cavity indicated she had all her natural teeth in her oral cavity. She was coded as none of the above.Record review of Resident review of Resident #10's care plan with a target date of 06/18/26 indicated she was care-plan for impaired Dentition: Date Initiated: 05/05/2026Interventions: Assess cracked/loose teeth, bleeding gum, foul breath, white patches, or mouth, pain and report to MDDate Initiated: 05/05/2026 Maintain oral hygiene Date Initiated: 05/05/2026Diet: I am on a NAS, Pureed texture, Regular consistency Date Initiated: 01/25/20 Observation on 05/05/26 at 10:00am revealed Resident #10 was in bed alert. Attempt was made to have an interview but did not answer. She was none- communicative. Observation revealed she had few teeth on her lower oral cavity dark red in color.Observation on 05/06/26 at 12:30PM revealed her lunch was on her table. During an interview with CNA E on 05/06/26 at 1:40PM, she said Resident does not speak and was a total care resident. CNA E said resident #10 does not have any teeth on her upper oral cavity but had few in front (4). She said Resident #10 does not communicate and her teeth had been dark red color. Review of Resident #12's face sheet, dated 05/06/26, reflected [AGE] year-old female who admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included Alzheimer's disease, Lack of coordination, repeated falls, hypothyroidism, unspecified, malignant neoplasm (Brest cancer) of left female breast, diabetes mellitus (low blood sugar) neuropathy, anemia (low blood count), osteoarthritis, depressive disorders, hypertension heart disease, dementia, behavioral disturbance, lack of coordination, muscle weakness, cognitive communication deficit (lack of communication). unspecified dementia, and behavioral disturbance, Record review of Resident #12's annual MDS dated [DATE] revealed her BIMS score was 5 out of 15 indicated sever cognitive impairment. Record review of section L on dental, Resident #12 was assessed as having all natural teeth in her oral cavity.Record review of Resident #12's care plan revealed she was care-plan for -Impaired Dentition Date Initiated: 05/06/2026 goal: I will not have complications related to impaired dentition such as infection or pain through next review date Initiated: 05/06/2026Intervention: Assess for cracked/loose teeth, bleeding gum, foul breath, white patches, or mouth pain and report to Medical Director. Date Initiated: 05/06/2026 Maintain oral hygiene Date Initiated: 05/06/2026.Record review of Resident #12's clinical record revealed dental group note dated 04/07/26 that revealed X = Missing tooth FX = Fracture RR = Retained root NR = non-restorable. Inflamed. /Swollen, Bleeding Gums: ModerateObservation on 05/06/26 at 12:15PM, revealed Resident #12 was in the dining room. She had regular mechanical altered diet. She fed herself and tolerated her lunch at 90%. During an interview she said she was doing fine and did not speak much. Attempt was made to have an interview about her dentures, but she did not answer. Review of Resident #51's face sheet, dated 05/06/26, reflected [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Dementia, Anxiety, lack of coordination, Muscles weakness, abnormal gait, and hypertension, Record review of Resident #51's annual MDS assessment dated [DATE] revealed her BIMs score was 11out of 15 indicated moderate cognitive impairment. Record review of section L on dental, she was Resident #15 was assessed as having all natural teeth in her oral cavity. Record review of Resident review of Resident #51's care plan with a target date of 5/06/26 revealed resident #51 was care plan as Impaired Dentition Date Initiated: 05/06/2026Intervention: Assess for cracked/loose teeth, bleeding gum, foul breath, white patches, or mouth pain and report to MDDate Initiated: 05/06/2026. Target date 06/17/26 Maintain oral hygiene Date Initiated: 05/06/2026 Record review of Resident #51's clinical notes indicated resident #51 saw a dentist on 04/07/26: Notes indicated Resident #51 has no teeth in her upper oral cavity. Assessment revealed Pt is healing well following extractions and shows no signs of swelling, erythema or infection.; Denture Step 1 completed. PVS impressions taken for CD/.; Pt presents for annual exam w/ no complaints. No changes to dental charting noted.; Pt tolerated visit well. Observation on 05/05/26 at 9:45AM, Resident #51 was observed in bed. During an interview, she said she had no teeth in her upper oral cavity. She said she only ate soft food and had been waiting to see a dentist but had not. She said she fell, and all her upper teeth fell out of her mouth. During an interview with the facility social worker on 05/06/25 at t2:00PM, she said resident #51 did not fall but she had her upper dentures pulled. She said Resident #51 does not have teeth in her upper oral cavity. Review of Resident #64's face sheet, dated 05/07/26, reflected [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included Blindness, muscle weakness, difficulty in walking, unspecified lack of coordination, repeated falls, seizures or convulsions, anxiety, abnormalities of gait and mobility. Record review of Resident #64's Quarterly MDS dated [DATE] revealed Section on fall history (J-1700 and 1800) was coded as 0 indicating there was no fall since admission, and last assessmentRecord review of facility's provided incidents and accidents dated 05/05/25 revealed Resident #64 had an unwitnessed fall on 12/04/25 at 12:25PM.Record review of nurse's notes dated Nursing documentation: 12/4/2025 12:37 revealed: Called to residents' room by another resident, upon entry noted resident laying on fall matt next to bed. Resident stated she was trying to get back in bed by herself and lost her balance. Resident states she did not hit her head she landed on her bottom Observation on 05/05/26 at 10:40am revealed Resident # 64 was in her room.Observation and interview on 05/06/26 at 1:30Pm revealed Resident #64 was in her room. She was alert and oriented. Observation revealed she was blind. She said she had been blind since childhood and she has a daughter. She requested her stick that was on her nightstand. She said sometimes she bumps into things without knowing. She said she was doing well. During an interview with MDS coordinator and MDS supervisor on 05/07/26 at 11:40AM, MDS coordinator looked at all identified MDS assessments and acknowledged that the Identified MDS assessments. She said inaccurate assessment may delayed services for residents. The MDS supervisor's inaccurate assessment may also lead to care plans not being accurate. During an interview with the DON on 05/07/26 at 2:20PM, she said she expects all MDS assessment to accurately reflect resident conditions to provide accurate services.Record review of facility's provided policy titled MDS Completion Accuracy and Timeliness dated 11\20\23 revised 11\15\23 revealed POLICY The purpose of this policy is to ensure accuracy and timeliness of MDS completion.PROCEDURE 1. Each facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely.2. Each facility must also utilize most updated Texas TAC rules for MDS accuracy.

Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I for residents with mental illness were provided with an accurate PASRR Level I for 1 (Resident #10) and) of 4 Residents reviewed for PASRR screening.-Resident #10 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation for individualized care, or special services to meet their needs Findings included:Review of Resident #10's face sheet, dated 05/06/26, reflected [AGE] year-old female who was admitted to the facility on [DATE] re-admitted on [DATE]. Her diagnoses included chronic congestive heart failure, chromic kidney failure, schizophrenia, mood disturbance, presence of cardiac pacemaker, altered mental status, and Essential hypertension. High blood pressure)Record review of Resident #10's PASRR evaluation dated 11\19\23 revealed section C for diagnoses of Dementia as primary diagnoses was checked no. Section on IDD and MI was all checked no on all section of mental illness and IDD Record review of Resident #10's admission MDS dated [DATE] revealed his BIM score was 0 out of 15 indicated he was severely cognitive impaired on cognition. Section on level 11 PASRR screening was left blank.Record review of section I on psychiatric \mood disorder, she was checked yes for schizophrenia Record review of Resident #10's clinical records revealed no evidence of PASRR level 1 evaluation.During an interview with MDS coordinator and MDS supervisor on 05/07/26 at 11:40AM, MDS coordinator looked at all identified MDS assessments and acknowledged that Resident 10 Should have been refer to PASRR local authority for PASRR evaluation with diagnoses. She said PASRR evaluation was not done because Resident #10 was not on any antidepression medication. MDS supervisor said form 1092 should have been done to decide if Resident #10 needed services or not. He said not assessing residents correctly may prevent residents from receiving needed services.Record review of Facility provided policy dated 11/2023 revised 11/15/23 revealed POLICY The purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately.PROCEDURE 1. PASRRs are obtained from referring entity by the admissions department.2. PL1s are put in to Simple LTC by the facility CRC within 72hours of resident admitting to facility. The completed PL1 must also be uploaded into the resident's EMR.3. Communicate with LIDDA/LMHA to ensure all active positive PL1s have a completed PE and upload the PE into the resident's EMR.4. Review recommended Specialized Services on the PE once the PE is submitted.5. When discharging a resident to another NF, the facility is responsible for completing a PASRR for the NF.6. Follow Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 28% based on 7 errors out of 25 opportunities which involved 3 of 8 residents (Residents #20, #44 and #16) and 2 of 5 staff (MA A and RN M) reviewed for medication administration. 1. The facility failed to ensure MA A did not crush and administer Potassium CL micro 10 mEQ ER (an extended-release medication, that should not be crushed, used to prevent or to treat low blood levels of potassium) and failed to ensure MA A administered the full dose of Clearlax 3350 (used to treat occasional constipation) to Resident #20 on 3/5/25. 2. The facility failed to ensure MA A did not administer Ciprofloxacin 3% eye drops (antibiotic eye drop) and Dexamethasone 0.1 % eye drops (a steroid medicine used to treat eye inflammation) to Resident #44 on 3/5/25, without a Physicians order. 3. The facility failed to ensure MA A provided sufficient time for absorption between eye medications when she administered Bromfenac 0.09% along with other eye medications to Resident #44 on 3/5/25. 4. The facility failed to ensure MA A did not administer Refresh tears eye drops (lubricates and moisturizes the eyes) instead of Lacri-lube ointment (used to relieve dry, irritated eyes) to Resident #44 on 3/5/25 according to Physician orders. 5. The facility failed to ensure RN M set Resident #16's IV Vancomycin (an antibiotic used to treat or prevent bacterial infections that are resistant to other drugs) to the correct flow rate according to the pharmacy label on 3/6/25. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects and decline in health. Findings include: 1. Record review of Resident #20's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included dementia (a decline in cognitive functions such as memory, reasoning, and communication, significantly affecting daily life), chronic kidney disease (a condition characterized by a gradual loss of kidney function), and spondylosis (age-related condition where the joints and cartilage lined discs of the neck are affected). Record review of Resident #20's quarterly MDS assessment, dated 2/18/25, revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #20's Physician orders for March 2025 revealed orders for: Potassium chloride Crys ER 10 mEQ give 1 tablet by mouth one time a day for hypokalemia (low potassium) give with 8 oz of water. Do not crush and may dissolve in water, order date 10/8/24, Miralax oral powder 17 gm/scoop give 1 scoop by mouth one time a day for constipation, order date 7/11/24. May alter medications by crushing, opening capsules or administration in food or fluid (only open or crush medications if manufacture allows), order date 7/11/24. In an observation on 3/5/25 at 9:14 a.m. revealed MA A prepared Resident #20's medication for administration. She prepared 11 pills which included Potassium CL micro 10 mEQ ER. The pharmacy label on the Potassium read do not crush, may dissolve in water. MA A crushed the Potassium ER along with the other medications and administered it to Resident #20. MA A prepared Resident #20's Clearlax 3350. Observation of the inside of the Clearlax measuring top revealed there was the number 17 and an up arrow that pointed to the top of a white area. MA A poured Clearlax powder into the top but stopped below the 17-gram line. She mixed the powder with water and administered it to Resident #20. In an interview on 3/5/25 at 10:20 a.m., MA A said she crushed the potassium along with the other medications but should have put Potassium in the water and allowed it to dissolve. She said she crushed it instead of allowing it to dissolve in water because Resident #20 said sometimes the medication was too gritty. She said she administered approximately 15 - 16 grams of the Clearlax because the powder was underneath the 17-gram line. She said she was supposed to cover up the 17-gm line and she normally had a measuring cup. She said the resident did not receive the full dosage and there was a risk of him not having a bowel movement. She said she was trained to pay attention and limit distractions. In an interview on 3/6/25 at 2:57 p.m., the DON said the pharmacy label should be reviewed while preparing medications. She said the MA could not crush Potassium ER but was unsure why. She said Miralax (another name for Clearlax) was for constipation and staff should pour the powder to the dosage line. She said if the resident did not get the full amount, it could cause them not to have a bowel movement. 2. Record review of Resident #44's face sheet, dated 3/5/25, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), age-related cataract, right eye (a condition affecting the eye that causes clouding of the lens), optic atrophy, left eye (damage to your optic nerve), myopia, left eye (a condition in which one can see near objects but cannot see far objects clearly), and presence of intraocular lens (clear, artificial lenses that replace your eye's natural ones). Record review of Resident #44's quarterly MDS assessment, dated 2/26/25, revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. He was independent with eating, oral hygiene, toileting hygiene, and personal hygiene and required assistance from staff with showers and dressing. Record review of Resident #44's Physician orders for March 2025 revealed orders for: Dexamethasone ophthalmic solution 0.1% instill 1 drop in right eye drop one time a day for eye surgery for 1 week, order date 2/6/25, Refresh Lacri-Lube ointment (artificial tear ointment) instill 1 strip in both eyes three times a day for dry eyes, order date 6/20/23, There were no active orders for Ciprofloxacin 3% and Bromfenac 0.09%. Record review of Resident #44's Order Audit Report, dated 3/5/25, revealed Bromfenac 0.09% had an end date of 3/4/25. Record review of Resident #44's Order Audit Report, dated 3/6/25, revealed Ciprofloxacin 0.3% had an end date of 2/25/25. In an observation on 3/5/25 at 9:35 a.m., MA A prepared 4 eye medications for Resident #44 which included Refresh tears eye drops, Dexamethasone 0.1% eye drops, Bromfenac 0.09% eye drops, and Ciprofloxacin 3% eye drops. At 9:43 a.m., she administered two drops of Refresh tears to both of Resident #44's eyes, at 9:45 a.m. she administered one drop of Dexamethasone 0.1% to his right eye, at 9:46 a.m. she administered one drop of Bromfenac 0.09% to his right eye, and at 9:47 a.m. she administered one drop of Ciprofloxacin 3% to his right eye. The Bromfenac 0.09%, Ciprofloxacin 3%, and Dexamethasone 0.1% pharmacy label read wait at least 5 min between eye meds. In an interview on 3/5/25 at 10:05 a.m., MA A said she administered a total of 4 eye medications to Resident #44. She said she administered 2 drops of Refresh tears to each of Resident #44's eyes because he used to take two in both eyes. MA A said the MAR provided instructions. She reviewed the MAR and noted the order was for Lacri-lube ointment instead of the eye drops. She said she did not realize the order was for the ointment and thought he was prescribed 2 drops. She said she reviewed the MAR and thought the other eye medications were also on there, but said he completed them yesterday and it was a medication error. She said discontinued medications should be removed from the cart and put in the discontinued bin in the medication room to prevent errors. She said she gave the wrong medication and did not check for the correct patient, direction, time, and dose. She said it could affect his eyes. She said she should wait 2-3 minutes between eye medications to ensure the medication did not wash out or interfere with one another. She looked at the pharmacy label and said it instructed to wait 5 minutes between eye medications. In an interview on 3/6/25 at 2:57 p.m., the DON said the Medication aide should verify the correct resident, review the eMAR, and compare the eMAR to the medication. She said the MA should wait approximately 5 minutes between eye medications because of the absorption rate and drug interactions. She said discontinued medication should be removed from the cart and put in the discontinued pile. She said if the medication was not on the eMAR, there was no order. She said going past the duration time set forth by the MD could cause the resident to take too much antibiotic. 3. Record review of Resident #16's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included spontaneous bacterial peritonitis (an infection of the peritoneum, the thin membrane lining the inner abdominal wall), pancytopenia (all of the types of blood cells are low), and human immunodeficiency virus (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). Record review of Resident #16's Admission MDS assessment, dated 2/10/25, revealed a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. The MDS revealed he had central IV access and received IV antibiotics. Record review of Resident #16's Physician Orders for February 2025 revealed the following orders: Vancomycin intravenous 750 mg/150 ml use 750 mg intravenously every 12 hours for infection, order date 3/4/25. In an observation and interview on 3/6/25 at 9:20 a.m., RN M flushed Resident #16's PICC lumens and hung the Vancomycin. She selected Vancomycin 750 mg/150 mL premix in the machine, and it set the rate to 120 mL/hr. Observation of the vancomycin bag and pharmacy label revealed it was Vancomycin 750 mg/250 mL. The pharmacy label read, Activate and mix immediately prior to use vancomycin 750 mg in 250 mL 0.9% sodium chloride infuse intravenously at 166 mL/hr over 90 minutes: every 12 hours . This State Surveyor inquired about the rate and RN M said the machine had presets and she selected the closest premix and would ask the DON to have the machine calibrated. RN M reset the machine and updated the rate to 166 mL/hr to reflect the pharmacy label. She said she previously did not know she could adjust the rate on the machine. She said Vancomycin was a rough medication and the medication would run for a longer time now but was set to match the pharmacy label. In an interview on 3/6/25 at 2:57 p.m., the DON said the Consultant Pharmacist previously made rounds with the medication aide and nurse and conducted skills checks. She said she expected nursing staff to verify the right medication, patient, route, time, dose, and pain level. She said the pharmacy provided the IV rate. She said the rate was located on the packing and the machine and if the two did not match, staff should follow the rate on the packaging. She said the Vancomycin rate was important because of the therapeutic level. She said staff should ensure it did not infuse too fast or too slow. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she expected nursing staff to follow the guidelines per facility policy and to review the MARs prior to medication administration. She said staff should verify the right dosage and ensure the MAR matched. Record review of the facility's Administration Procedures for All Medications, revised 8/2020, read in part, .Medications will be administered in a safe and effective manner. The guidelines in this policy apply to all medications . Procedures . III. 5 Rights (at a minimum) at a minimum, review the 5 rights at each of the following steps of medication administration. 1. Prior to removing the medication package/container from the cart/drawer: a. check the MAR/TAR for the order . c. if unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information . 2. Prior to removing the medication from the container: a. Check the label against the order on the MAR. b. Note any supplemental labeling that applies

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 5 residents (Resident #39, #23, and CR #1) reviewed for abuse. 1. The facility failed to ensure Resident #39 was free from abuse when CR #1 hit her and made her cry on 3/7/24. 2. The facility failed to ensure Resident #23 was free from abuse when CR #1 screamed at her and made her cry on 1/16/24. These failures could place residents at risk for physical, mental, and psychosocial harm. The findings include: 1. Record review of Resident #39's face sheet, dated 3/14/24, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included dementia, need for assistance with personal care, anxiety, recurrent depressive disorders, hypertension (high blood pressure) and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs). Record review of Resident #39's incident report, dated 3/8/24, read in part, .nursing description: stated by another resident, that victim was on 200 hall and said assailant was passing and swung her arm and hit victim around chest and arm area No injuries observed at time of incident 2. Record review of CR #1's face sheet, dated 3/6/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and discharged to a psychiatric hospital on 3/8/24. Her diagnosis included cognitive communication deficit, bipolar disorder (a serious mental illness characterized by extreme mood swings), and atrial fibrillation (an irregular and often very rapid heart rhythm). Record review of CR #1's discharge-return anticipated MDS assessment, dated 3/8/24, revealed her cognitive skills for daily decision making was modified independence. The assessment indicated physical and verbal behavioral symptoms toward others were not exhibited. She was independent with eating and oral hygiene and required assistance from staff with toileting, dressing, and personal hygiene. Record review of CR #1's care plan, dated 2/1/24, revealed she had the potential to be physically and verbally aggressive towards staff and residents related to anger. Interventions were to administer medications as ordered, assess and anticipate resident's needs, provide physical and verbal cues to alleviate anxiety, monitor every shift and document observed behavior, monitor/document/report as needed any s/sx of resident posing danger to self and others, psychiatric/psychogeriatric consult as indicated, and intervene before agitation escalates. Record review of CR #1's nursing note, dated 1/10/24 at 4:42 p.m., written by LVN R, read in part, Resident aggressive and hollering at another resident, telling her to shut up. ADCO and DCO made several attempts to redirect resident, but resident continued to display aggressive behavior. The DCO removed resident away from the other resident but while in route resident punched DCO in the face on the right side Record review of CR #1's nursing note, dated 1/10/24 at 9:45 p.m., written by LVN J, revealed the resident was discharged from the facility. No signs of distress noted at time of departure. Record review of CR #1's nursing note, dated 1/15/24 at 9:50 a.m., written by LVN M, read in part, Resident arrived via wheelchair by ambulance for (local hospital) for long term care Record review of CR #1's nursing note, dated 1/15/24 at 11:07 p.m., written by LVN C, read in part, Resident could be heard screaming, when walked in room she was screaming at her roommate, roommate was not doing anthing [sic] other than laying in bed, she was standing over her screaming to turn off tv, her tv was not even on, it was her tv that was on, redirected resident to stop acting like that because she was scaring her she stated 'I don't give a dam, now get your black (expletive)(expletive) out of my room' . she continued to physically get out of bed and go over to roommate side and turn off her overhead light. [Resident #23] came out of room, I went back to room to turn light on and told her she cannot touch roommates things, she layed [sic] down and shut eyes, [Resident #23] went back to bed Record review of CR #1's nursing note, dated 1/16/24 at 12:45 a.m., written by LVN C, read in part, .while doing continuous checks on resident and her roommate she became aggitated [sic] that staff was in her room and started screaming more racial hate comments toward staff, then proceeded to chase CNA out of room running after her and hit her with cane, res finally went back to room and I went to room and removed [sic], RP called and message left, DON and Administrator notified Record review of CR #1's nursing note, dated 1/16/24 at 8:03 p.m., written by LVN R, read in part, Resident screaming and hollering at roommate telling her to shut her mouth. Resident then pulled TV cord out of the electric outlet. This narrator informed resident that room is for both of them and she cannot touch roommate's belongings. Resident called this narrator a witch and [expletive]. This narrator observed roommate crying and upset. Narrator attempted calmed [sic] roommate down while resident continues to scream and holler Record review of CR #1's nursing note, dated 1/17/24 at 11:59 a.m., written by the Social Worker, read in part, contacted (name and number) to inform of room change to (room number). Record review of CR #1's nursing note, dated 1/31/24 at 3:08 p.m., written by the previous Activities Director, read in part, .on 1/30/24 at 2:30 p.m. resident was in the dinning [sic] room with other residents and she was snatching items from the residents and one of the dietary staff came and tried to separate the two residents once I noticed the commotion, I quickly went and tried to defuse the situation, once (CR #1) became non-complanate [sic] I proceeded to get her nurse once she came into the dining room she tried to get (CR #1) out of the dining room and she started to resist. I started to explain to the nurse what had just transpired and (CR #1) started to exit out of the dinning room trying to go to her room, and once she passed the nurse & I she stated get out of my way then she proceeded to punch me in my stomach. I the activities director told the ADON, DON and the Admin as well as the nurse who also witnessed it. No incident report was done nor asked to be done Record review of CR #1's nursing note, dated 2/1/24, written by LVN J, read in part, Screaming heard on hall, upon reaching room, roommate reported to nurse that resident kicked her leg. Roommate transferred to another room. No further incidents by end of shift. Record review of CR #1's nursing note, dated 2/1/24, written by the Social Worker, read in part, Resident was observed rolling toward another resident's wheelchair hitting that resident's wheelchair in the dining hall and cursing at that resident. Resident was redirected by (staff); onset of repeated verbal aggression. Resident yelled out You lying (expletive)! Resident redirected again. Record review of CR #1's incident report, dated 3/8/24, read in part, .stated by another resident, Resident approached another resident hit her in the around chest area. Removed immediately from another resident and placed on 1:1 Record review of an, undated, witness statement for Staff Member H read in part, .the incident happened on 3/7/24 stated it happened coming out on [sic] the dining room when [CR #1] hit [Resident #39]. She [Staff Member H] reported it to staff on 3/8/24. Record review of CR #1's nursing note, dated 3/8/24, written by the Social Worker read in part, .Another resident notified DRSS that resident hit another resident. While attempting to redirect resident, resident stated 'that [expletive] hit me first' and 'that [expletive] had it coming!' Redirected again, and resident rolled her eyes, and stormed off in the dining room area. Other resident was observed crying Record review of CR #1's nursing note, dated 3/8/24, written by LVN J, read in part, Transportation set up with [EMS company] to transfer resident to [Behavioral hospital] in [city] Record review of CR #1's nursing note, dated 3/12/24 at 9:23 a.m., written by the DON, read in part, . Late entry for 3/8/24 Resident was accused by another hit another [sic] resident in the dining room. Resident placed on 1:1 immediately and (hospital) notified of needed behavioral management with the expectation of not be able [sic] to return as I am unable to meet needs and keep other residents safe. In an observation on 3/4/25 at 10:03 a.m. revealed Resident #39 was lying in bed. She did not respond completely to the state surveyor's questions. There was no distress noted. In an interview on 3/6/25 at 3:33 p.m., the DON said in the event of a resident-to-resident altercation staff were instructed to separate residents immediately, assess both residents and obtain statements from witnesses. Notification should be made to the MD, family, psych services and an incident report should be done. She said Resident #39's family visited her every other day and there was no more abuse to the resident. In an interview on 3/6/25 at 5:53 p.m., the Administrator said the facility sent CR #1 out to the behavioral hospital when it got bad. She said CR #1 mainly wanted to go home and was triggered by certain family members. She said she was on psych services, was quite alert, and had previously lived by herself. She said the facility kept the residents isolated from her and CR #1's behavior was not an everyday thing. She said CR #1 was not being abusive to residents but then said it was abusive to the resident but a lot of it was because of anger. She said she was pretty sure the facility care planned her behaviors. In an interview on 3/6/25 at 6:12 p.m., the DON said she could not recall all of the interventions she put in place with CR #1 but she had psych services on board, medication, and was sure she made referrals. She said CR #1 was not abusive to the residents but had incidents of containable aggression where she lashed out. She said examples of abuse were mental, physical, emotional and misappropriation. She said physical abuse included hitting and kicking someone. She said CR #1 kicked someone but could not say if she knew what she was doing because she had cognition issues. She said verbal abuse included calling someone out of their name and insulting them. She said abuse was subjective. She said she was positive she protected the residents from abuse because that was her main goal. In an interview on 3/6/25 at approximately 6:45 p.m. Resident #23 was sitting in the living area near the front entrance with no distress noted. She said she did not have any problems from her previous roommates. Record review of the facility's Abuse policy, last revised 1/1/23, read in part, .the purpose of this policy is to ensure that each resident has the right to be free from any type of abuse, neglect, intimidation, involuntary seclusion/confinement, and or misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed . Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals. This includes physical, verbal, sexual, physical /chemical restraint . In the event of resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility, as determined by the attending physician/or other physician, the resident will be discharged as soon as possible. During the time that the perpetrator has not been discharged , the facility will monitor this resident one-on-one to protect all other residents. The Director of Nursing will coordinate this and set up monitoring. If a threat does not exist then an assessment will be completed, and behavior will be care planned to meet resident's needs and protect others .

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #14) reviewed for respiratory care. The facility failed to ensure Resident #14's oxygen was not administered at 5 liters per minute on 3/4/25 and 3/6/25 instead of 2-4 liters per minute as ordered by the physician. This failure could place residents at risk of not receiving medications and treatments as ordered by the physician. The findings include: 1. Record review of Resident #14's admission record, dated 3/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnosis included cerebral infarction (stroke), dementia (a decline in cognitive functions such as memory, reasoning, and communication, significantly affecting daily life), congestive heart failure (a long-term condition in which your heart can't pump blood well enough to meet your body's needs), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), and atrial fibrillation (an irregular and often very rapid heart rhythm). Record review of Resident #14's quarterly MDS assessment, dated 2/4/25, revealed a BIMS score of 13 out of 15, which indicated her cognition was intact. She required assistance from staff with ADL care and was on oxygen therapy. Record review of Resident #14's, undated, care plan revealed she was on oxygen therapy related to respiratory illness; date initiated 8/23/21. Interventions were to give medications as ordered by the physician and oxygen settings: O2 2 liters/minute per nasal cannula, date initiated 8/23/21. Record review of Resident #14's Physician orders, dated 3/6/25, revealed an order for O2 at 2-4 L/min via nasal cannula PRN to maintain O2 sats > 90% as needed. Document each shift that oxygen was used, the resident's O2 sat, and notify MD for changes in condition, order date 9/13/24. Record review of Resident #14's Nursing note dated 1/22/25 written by RN P read in part, Upon entering in the room resident stated that I have breathing difficulty Resident head is already in up position and on O2 5L via NC. PRN breathing tx given. Vitals at this time . SPO2 - 97% on 5L O2 via NC. No RS destress [sic] noted. Resident is alert and oriented x 4. Notified to [sic] NP (name) is here in facility. Record review of Resident #14's Medication Administration Record for March 2025 revealed no documentation of O2 given or O2 saturations. Record review of Resident #14's, undated, O2 Sats Summary revealed the last recorded O2 saturation on the summary sheet was 96% on 12/28/24. In an observation on 3/4/25 at 10:17 a.m. revealed Resident #14 was lying in bed with her nasal cannula in place. The oxygen was on 5 L. In an observation on 3/6/25 at 11:08 a.m. revealed Resident #14 was lying in bed with her nasal cannula in place and oxygen running at 5 L. The resident said her oxygen was ok. In an interview on 3/6/25 at 11:12 a.m., LVN M said Resident #14's oxygen should be between 2-4 L. She said she had not checked the rate this morning yet. In an interview on 3/6/25 at 11:49 a.m., LVN M said Resident #14's oxygen was running at 5 L but was on 4 L when she checked it yesterday morning, 3/5/25. She said there was a risk of having to titrate her down off the oxygen. In an interview on 3/6/25 at 11:56 a.m., Resident #14 said she sometimes had to have the oxygen rate turned up because she wheezed a lot. She said she would notify the nurse that she could not breathe well and LVN M or another nurse (unknown) would come in and fix it. She said she sometimes had to have the oxygen turned up to 6 or 7 liters per minute. She said the oxygen was ok now. In an interview on 3/6/25 at 3:24 p.m., the DON said if the rate was not on the correct level staff would not be following MD orders. She said there was no risk to the patient for being on more oxygen. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she expected staff to follow MD orders and to document any changes. Record review of the facility's oxygen therapy policy, dated 4/2021, read in part, .it is the policy of this community to ensure all oxygen administration is conducted in a safe manner . Procedure: 1. Verify there is an order for oxygen administration to include: a. method of delivery b. flow rate, c. oxygen saturation parameters if indicated .3. Assess resident's respiratory status . 6. Start oxygen flow of rate as ordered. 7. Document resident's response to prn oxygen therapy: a. date and time of oxygen administration b. type of delivery c. oxygen rate d. assessment of resident's respiratory status to include oxygen saturation via pulse oximetry (a quick, noninvasive test that measures the oxygen saturation levels in the blood)

Based on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 03/06/2025) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by leaving out the winter fruit cup, egg roll, or water for all diet types on 03/06/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss. Findings include: Observation on 03/06/2025 at 11:52 AM, in the main dining area revealed trays were passed with a total of 18 residents in the dining room with 1 nurse. Upon observation, residents did not receive an egg roll, winter fruit cup, or water. Observation and record review on 03/06/2025 at 12:07 PM of the kitchen, revealed the food was already being put away and there was no food left on the steam tables. At that time, a test tray was requested, and the menu was reviewed. The menu displayed for 03/06/2025, reflected egg roll, mandarin chicken, steamed rice, seas broccoli florets, winter fruit cup, iced tea, and water. The test tray was received in the conference room for the state survey team at 12:23 PM. There were no egg rolls or bread, fruit cup, or water were observed, and there was observation of trays being sent to resident halls, who did not have the substitution of egg roll for bread, fruit cup, or water. Interview on 03/06/2025 at 12:36 PM with the Dietary Manager revealed the egg rolls were not served because there was a substitution for the day, which should have been bread. The Dietary Manager said everyone should have received bread, because there weren't enough egg rolls for all residents. The Dietary Manager also stated at time, the egg rolls were fried, which could make them hard for the residents to chew. The Dietary Manager stated each resident should get water with their meal and tickets were checked for each tray before it was given to a resident. The Dietary Manager stated orders for the following week were placed on Friday and delivered by Tuesday of the next week. If a substitution was made, there was a form completed by the Dietary Manager with why the meal option was being substituted and with what meal item. A record review of the meal substitution from March 1, 2025, to March 6, 2025, revealed there were 5 menu changes, due to not having the menu items that were displayed to residents. The Dietary Manager stated for the winter fruit cup, they did not have any fruit, and it was substituted with donut holes, regardless of special diets. Interview on 03/06/2025 at 4:11 PM, the Administrator stated her expectations of the food, was to be served as it was at a restaurant. The Administrator continued to say she expected the food to be palatable and at the proper temperature for the residents, but she knew sometimes that was not the case. The Administrator stated she checked tickets when she was assisting with serving the residents to ensure they were receiving everything on the ticket. It was to the Administrators understanding the reason why they had food complaints was regarding the menu not being resident focused, as they followed a corporate dietary menu for all residents. The Administrator stated she did the best she could with speaking to the Dietary Manager regarding the menu and how they could make changes to include all diets, while keeping the meal palatable. The Administrator stated they were going to try and add additional flavorful seasoning packets to each tray, as the seasoning did not contain salt. The Administrator stated for items that were to be substituted, but not placed on the resident's tray, she was not sure why that was happening. The Administrator stated the Dietary Manager was good at making sure all items were placed on each tray, according to the ticket of each resident. Record review of the facility's menu, dated 03/06/2025, reflected for Thursday (03/06/2025) the following: Lunch-Mandarin Chicken, Steamed Rice, Seas Broccoli Florets, Egg Roll, Winter Fruit Cup, Iced Tea, and Water.

Based on observation, interview and record review the facility failed ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 (medication room refrigerator) of 1 medication refrigerators reviewed for pharmacy storage. The facility failed to maintain the medication refrigerator in the medication room between 36-46 degrees Fahrenheit per facility policy. This failure could place residents at risk of not receiving the desired therapeutic effect from their medications. The findings include: Record review of the Med Room Refrigerator Log, dated March (no year), revealed on 3/1 the morning and evening temperature was 20 degrees Fahrenheit. From 3/2 - 3/4 the morning and evening temperature was 31 degrees Fahrenheit. From 3/5 - 3/6 the morning and evening temperature was 30 degrees Fahrenheit. The bottom of the log read, Maintain refrigerator temperature within the following range: 36 - 46 F. Temperatures were documented by MA A from 3/2 - 3/6. In an observation on 3/6/25 at 1:35 p.m. of the white refrigerator in the medication room revealed the thermometer read 30 degrees F. There were multiple medications in there which included: Influenza Vaccine Flucelvax, box read to store between 36 - 46 degrees F; Lantus Solostar insulin pens; 4 boxes of Trulicity injection, box indicated to refrigerate at 36 - 46 degrees F; and Humira, box read to store in refrigerator at 36 - 46 degrees F. No medication appeared frozen. In an interview on 3/6/25 at 2:25 p.m. MA A said any temperature reading less than 30 degrees F indicated the refrigerator was not working per the DON. She said if the thermometer read 21 degrees F it was out. She said she checked the refrigerator in the morning at 6 a.m. and again at 2 p.m. She said the temperature was between 30- and 31-degree F and it may need a new thermometer. She said the DON was aware the thermometer read 30 degrees F and if the medications froze it would be no good. In an interview on 3/6/25 at 3:19 p.m., the DON said the medication refrigerator temperature should be between 38 - 41 degrees F. She said 30 degrees F was below freezing and nothing in the refrigeration was frozen. She said staff should notify her of the temperature readings to either get a new refrigerator and/or thermometer. She said staff informed her about the readings approximately one week ago and she replaced an old thermometer, but staff did not report readings to her again. She said certain temperatures could destroy the medication making them non-effective. She said medications should be stored properly. In an interview on 3/6/25 at 4:12 p.m., the Administrator said staff should check the medication refrigerator daily to ensure medication were stored at the proper temperature. Record review of the facility's Storage of Medications policy, revised 8/2024, read in part, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . II. Temperature 1. All medications are maintained within the temperature ranges noticed in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC) . c. refrigerated: 36F to 46F with a thermometer to allow temperature monitoring .2. Medications and biologicals are stored at their appropriate temperatures and humidity according to the USP guidelines for temperature ranges .4. Medications requiring refrigeration are kept in a refrigerator at temperatures between 36F and 46F with a thermometer to allow temperature monitoring

Based on interview and record review the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #35) reviewed for PASRR (Preadmission Screening and Resident Review Services). The facility failed to ensure Resident #35 had a new level 1 PASRR screening completed with a new diagnosis of major depressive disorder and delusional disorders which were added on 4/2/24. This failure could place residents at risk of not receiving the needed PASRR services to meet their individual needs and could result in a decreased quality of life. The findings were: Record review of Resident #35's admission record, dated 3/5/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included metabolic encephalopathy, principal diagnosis (brain dysfunction caused by an underlying condition that affects your metabolism), delusional disorder - onset 4/2/24, major depressive disorder severe with psychotic features - onset 4/2/24, alcoholic cirrhosis of liver with ascites (a type of liver disease where scarring has led to permanent damage to the liver), hepatic (liver) failure, and dementia. Record review of Resident #35's PASRR Level 1 Screening, dated 10/25/21, indicated there was no evidence or indicator that the resident had mental illness, intellectual disability, or developmental disability. There were no other PASRR screenings provided. Record review of Resident #35's annual MDS Assessment, dated 12/13/24, revealed a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. The Preadmission Screening and Resident Review was marked No to the question: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. His primary medical condition was other neurological conditions, he had non-Alzheimer's dementia, depressions, and psychotic disorder. In an interview on 3/5/25 at 3:40 p.m., the CRC nurse said major depressive disorder could be a diagnosis that would trigger a positive screening. She said a Form 1012 needed to be completed for Resident #35 and she would document his diagnosis and notify the doctor. She said she inputted the major depressive diagnosis for Resident #35 (in April) but did not realize it triggered the need for another PASRR level 1 screening. She said there was nothing in the system to alert them a resident needed a form 1012 completed. She said the form 1012 was completed if a resident developed a diagnosis from (psych company) that they did not have on admission. She said there was no risk to the resident for not completing a new PASRR level 1. She said the purpose of the screening was to identify positive residents to see if they could receive certain services. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she informed the CRC nurse to check any resident who could possibly require a 1012 back in December 2024. She said the CRC nurse should review the diagnoses on admission and during the care plan review. She said there was nothing to alert the staff on a repeat PASRR screening, but she educated them on reviewing diagnoses. Record review of the facility's PASRR policy, revised 11/15/23, read in part, .the purpose of this policy is to ensure PASRRs are being obtained and completed timely and accurately . 2. PL1s are put into Simple LTC by the facility CRC within 72 hours of resident admitting to facility .6. Follow Texas PASRR policy for all mandatory meetings and care coordination including any changes that may require a change in resident's PASRR status.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 residents (Resident #16) reviewed for infection control. The facility failed to ensure RN M wore appropriate PPE when administering IV medication to Resident #16 on 3/5/25, who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes). This failure could place residents at risk of infectious diseases due to improper infection control practices. Findings include: Record review of Resident #16's face sheet, dated 3/6/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #16 had diagnoses which included spontaneous bacterial peritonitis (an infection of the peritoneum, the thin membrane lining the inner abdominal wall), pancytopenia (all of the types of blood cells are low), and human immunodeficiency virus (a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases). Record review of Resident #16's Admission MDS assessment, dated 2/10/25, revealed a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #16 had central IV access and received IV antibiotics. Record review of Resident #16's Physician Orders for March 2025 revealed the following orders: Normal Saline Flush use 10 ml intravenously every shift for infection PICC line - flush with 10 ml normal saline prior to medication administration, order date 2/8/25, Vancomycin intravenous 750 mg/150 ml use 750 mg intravenously every 12 hours for infection, order date 3/4/25. In an observation on 3/6/25 at 9:20 a.m. revealed RN M prepared Resident #16's IV medication for administration. She entered his room, washed her hands, put on gloves but did not put on a gown. There was an orange enhanced barrier precautions sign posted behind his bed that read, STOP . providers and staff must also wear gloves and gown for the following high-contact resident care activities . device care or use: central line There were two individually wrapped gowns on top of the resident's dresser, there were no gowns in a plastic bin near the doorway. RN M flushed his PICC lumen (a smaller tube that splits from a PICC line outside the body) with normal saline and hung his IV Vancomycin. In an interview on 3/6/25 at 9:45 a.m., RN M said Resident #16 was on enhanced barrier precautions and she should gown up. She said she did not gown up because the PPE cart in the resident's room was empty. She said enhanced barrier precautions was used for infection control and there could be a risk of transferring germs from resident to staff and/or staff to resident. She said Resident #16 was on IV Vancomycin for a peritoneal infection. In an interview on 3/6/25 at 2:32 p.m. the DON, who was also the Infection Preventionist, said she educated staff that enhanced barrier precautions were to provide extra protection for the residents and staff. She said staff should wear nonsterile gowns and gloves when providing direct care or if staff would be around the resident more than 5 minutes. She said enhanced barrier precautions were used for residents who had any opening that was not natural such as a central and PICC line, g-tube, foley catheter, and wound. She said the nurse should wear gown and gloves if giving an IV medication. She said the box at the door was an indicator to staff that a resident was on EBP. She said there was a greater risk for transmission of infection if proper PPE was not worn. In an interview on 3/6/25 at 4:12 p.m., the Administrator said she expected staff to follow guidelines and protocol regarding enhanced barrier precautions. She said there were signs up for enhanced barrier precautions and staff should don a gown, gloves, and mask when entering the resident's room. She said they went over EBP for months and staff should know exactly what to do. She said the DCO and ADCO were responsible to ensure EBP protocol was in place. Record review of the facility's Enhanced Barrier Precautions policy, dated 4/1/24, read in part, .Enhanced Barrier Precautions are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes. EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO, or who have open wound or indwelling medical device . Procedure .2. Determine if any of the following indwelling medical devices are in use: . central lines . EBP will be implemented if any of the above wounds or invasive medical devices are present. 3. Place signage on resident's closet door, maintain PPE in residents' room and assure all team members aware of resident status and need for EBP during high contact care. 4. High contact resident care activities . device care or use: central line

Based on interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to assess and provide treatment for CR #1's vagus nerve stimulator. On [DATE], facility staff used a magnet device when CR #1 was in respiratory distress and he passed away at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not receiving appropriate care and treatment services resulting in serious harm and/or risk of death. The findings included: Record review of CR #1's Admission Record, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included sepsis (infection of the blood stream), UTI (an infection that affects a part of the urinary tract), Marfan syndrome (genetic disorder that affects the connective tissue), and epilepsy (seizures). Record review of CR #1's orders revealed there was no order for a magnet device. Record review of CR #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Section I-Active Diagnoses, Neurological, revealed I5400. Seizure Disorder or Epilepsy was checked. Record review of CR #1's undated care plan revealed it was opened but not initiated. Record review of CR #1's Baseline Care Plan, dated [DATE], read in part .D. Nursing Summary, Input from Care Givers: a. Concerns/needs .Full code status .magnet in chest (diastatin); neurostimulant . Record review of CR #1's hospital admission paperwork read in part .seizures - magnetic device noted . In an interview on [DATE] at 9:01 a.m., Nurse A said the CNA (could not remember her name) got her around noon. She said the CNA told her she was trying to get CR #1 fed, but he was making a gurgling sound. She said she assessed him, that he only responded to painful stimuli, was still making the gurgling sound, and had a pulse. She said she could not get an O2 sat or BP reading. She said she put the non-rebreather on him and within 2 to 3 minutes he had no pulse, was not making the gurgling sound, and said she started CPR at approximately 12:04 p.m. She said she saw him the morning of [DATE]. She said he was a little drowsy, would open his eyes, and was heavily sedated, but around 10ish in the morning he started to become more aroused. She said he was heavily sedated because the ER gave him Ativan for a seizure he had at the ER the day before, [DATE]. In an interview on [DATE] at 11:21 a.m., CNA B said she was assigned to CR #1 on [DATE]. She said she first saw him at approximately 6:05 a.m. and he was asleep. She said she woke him up for breakfast around 7:10 a.m. and he was very sleepy. She said he was eating slowly and was not in distress. She said he did not finish his breakfast and later on, about an hour or two, he asked for water. She said when she went back to give the water to him it sounded like he had a lot of mucus when he was breathing. She said she could hear it in his lungs, and his breathing did not sound normal. She said she got Nurse A and Nurse A said it looked like he was seizing. She said Nurse A said the resident's family member gave the facility a device to pass along his chest to stop his seizures. She said Nurse A passed the device across his chest, but he did not respond. She said Nurse A started screaming out CR #1's name and tapping his chest, but he still did not respond. She said Nurse A directed her to get Nurse C and to tell her to call 911 and go to his room. She said Nurse A started CPR and was not doing it for long because EMS showed up and took over. She said EMS worked on him for 20 minutes and pronounced him deceased at 12:21 p.m. In a follow-up interview on [DATE] at 12:05 p.m., Nurse A said CR #1's family member gave them a device (she said did not know what it was) and said that when he had a seizure to pass it over his heart area. She said the resident had a magnet over his heart area that was a round raised area. She said she was not sure if he was having a seizure but said she passed the device over his chest because he may have been having a possible seizure. She said the resident had a seizure the previous day, [DATE], at the hospital after he was sent out and thought it could have been a seizure. She said it did not look like he was having a seizure, but she did not know what his seizure activity looked like because he was so new to the facility. She said she was not sure if the doctor was aware of the device. She said there was no change in his condition when it was passed over chest and that he still had a gurgle. She said she was not sure what the name of the device was. In an interview on [DATE] at 12:18 p.m., the family member said CR #1 had a nerve stimulator and a magnet that got passed across his chest for seizure activity. In an interview on [DATE] at 12:51 p.m., the Doctor said he was not aware CR #1 had a device over his heart area or a magnet device. He said there should always be an order for anything used on a patient. In an interview on [DATE] at 2:23 p.m., Nurse C said she could feel what was like a wire that ran down from behind CR #1's ear and down his neck and could see it because he was thin. She said the device the was a vagus nerve stimulant magnet. She said there was not an order in the order summary and there should be an order for everything used or given. She said her understanding was that the resident's family member brought it from home. She said she was not sure if there was enough time to get an order due to his condition, because he was fragile. She said she was not sure if the family member provided an order or if they were supposed to get it. In an interview on [DATE] at 2:40 p.m., the DON said CR #1's family member brought the magnet device to the facility and that it did not come with him from the hospital. She said the charge nurse would have been the one to notify the doctor about the device. She said CR #1 went to the hospital 1 time within a 24-hour period, and it was for respiratory distress and not a seizure. She said both instances were for respiratory distress and not a seizure. She said they did not have him long enough to know what his seizure activity looked like. She said the resident's family member brought the device to the facility on [DATE] when he was at the ER. She said she did not know if there was an order for the device. She said she did not think it was a device since it was a magnet. She said on [DATE], Nurse A called her down to the resident's room and said he had shallow breathing and was in respiratory distress again. She said she assessed the resident and CPR was initiated with absence of breathing. She said Nurse A and B performed CPR. She said ,d+[DATE] rounds of CPR was given before EMS arrived and took over. She said she could not recall if Nurse A said the device was used. In a follow-up telephone interview on [DATE] at 5:03 p.m., Nurse A said she had not personally requested doctor's orders for the magnet device. She said she thinks CR #1's family member brought the device on [DATE] when he was still at the hospital. She said all she knew was that the resident was in respiratory distress, and she started CPR after no pulse was detected. She said if there was an order it would be in the system. In a follow-up telephone interview on [DATE] at 12:01 p.m., the Doctor said a vagus nerve stimulator activated the vagus nerve to parasympathetic (part of the automatic nervous system that counterbalances the action of the sympathetic nerves. It consists of nerves arising from the brain and the lower end of the spinal cord and supplying the internal organs, blood vessels, and glands) activity. He said it helped relax the body, lower heart rate, and made one more relaxed. He said it could help with depression and seizures. He said when he saw CR #1, he performed a full physical, but was not sure he saw the vagus nerve stimulant at the time. He said it would be hard to say if using the magnet would accelerate anything as CR #1 was having acute respiratory failure. Record review of the facility's policy titled Admission Criteria, dated ,d+[DATE], read in part . 5. Prior to or at the time of admission, the resident's Attending Physician must provide the community with information needed for the immediate are of the resident, including orders covering at least .c. Routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on [DATE] at 10:48 a.m. The IJ template was presented to the facility and the POR was requested at this time. The following Plan of Removal submitted by the facility was accepted on [DATE] at 9:01 a.m. and included: Name of Facility: [] Date: [DATE] Immediate action: Plan of Removal Status of resident is deceased . * The Regional Director of Clinical Operations initiated Inservice on [DATE] with Licensed nurses on Obtaining Physician orders for Adaptive devices prior to utilizing device for resident care. All Licensed Nurses will receive in-service prior to starting their next shift. Completion Date [DATE] * The Regional Director of Clinical Operations initiated Inservice on [DATE] with Licensed Nurses on how to properly assess residents for Change in Condition to include signs and symptoms of Seizure activity and signs and symptoms of Respiratory Distress. All Licensed Nurses will receive Inservice prior to starting their next shift. Completion Date [DATE] * The Director of Clinical Operations and/or designee will complete an audit of all residents who have adaptive devices to ensure there is a Physician Order for Device and Staff have received adequate training on device. The audit was conducted and completed on [DATE]. No issues identified and No residents found with adaptive devices. * The Director of Clinical Operations and/or Designee will review all Admission Orders during the daily clinical meeting to ensure any Adaptive Devices are on a proper Physician order and Licensed Staff has prior training for using the device for resident care and any devices received after admissions. Not a new policy. * ALL newly hired licensed nursing staff will be trained in adaptative devices during orientation prior to taking care of residents. DCO and/ or designee will review hospital records on new residents prior to admissions. Once admission is confirmed, in-service and training will be conducted, and care plan will be completed ,d+[DATE] hours after admission. DCO and/or designee will train after hours and weekend staff on adaptive devices. Nursing Staff will use the 24-hr report to identify residents with adaptive devices. * The Medical Director notified of alleged facility noncompliance with Admission Physicians Orders for Immediate Care and Competent Nursing Staff on [DATE]. * In-service was done for Executive Director of Operations and Director of Clinical Operations (Via phone [DATE] and will sign when she returns on [DATE]) by Regional Director of Operations Inservice covered *Admission is to be reviewed in morning clinical meeting, any adaptive devices must have physicians order and licensed nurses must have training on devices prior to utilizing device for resident care. Monitoring of the POR included: Interviews on [DATE], between 10:09 a.m. and 3:46 p.m., with staff from all shifts, revealed the following licensed nurses were able to verbalize an understanding on obtaining physician orders for adaptive devices prior to utilizing the device for resident care and how to properly assess residents for change in condition to include signs and symptoms of seizure activity and signs and symptoms of respiratory distress: MDS Coordinator, DON, Nurse A, B, C, D, E and F. Interviews on [DATE] at 11:34 a.m. with the Administrator and at 1:46 p.m. with the DON, revealed they were able to verbalize an understanding of reviewing admission orders for adaptive devices and proper physician orders and that all licensed nursing staff receives training prior to the use of the device or any device for resident care. Record review of in-service sign in sheet, dated [DATE], for Assessing: Knowing the difference between a seizure and respiratory distress a change in condition, revealed 12 signatures. Record review of in-service sign in sheet, dated [DATE], for MD Orders for Resident Care, revealed 12 signatures. Record review of audit findings revealed one was completed on [DATE] by the MDS Coordinator and no residents were found to have external adaptive devices. The Administrator was informed the Immediate Jeopardy was removed on [DATE], at 4:03 p.m. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

Based on interviews and records reviewed, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (CR #1) of 5 residents reviewed for nursing services. -The facility failed to train nursing staff on how to use CR #1's magnet device. The magnet device was used on [DATE] when CR #1 was in respiratory distress and passed away at the facility. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of being cared for by insufficiently trained staff during a medical emergency resulting in serious injury and risk of death. The findings included: Record review of CR #1's Admission Record, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included sepsis (infection of the blood stream), UTI (an infection that affects a part of the urinary tract), Marfan syndrome (genetic disorder that affects the connective tissue), and epilepsy (seizures). Record review of CR #1's orders revealed there was no order for magnet device. Record review of CR #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Section I-Active Diagnoses, Neurological, revealed I5400. Seizure Disorder or Epilepsy was checked. Record review of CR #1's undated care plan revealed it was opened but not initiated. Record review of CR #1's Baseline Care Plan, dated [DATE], read in part .D. Nursing Summary, Input from Care Givers: a. Concerns/needs .Full code status .magnet in chest (diastatin); neurostimulant . Record review of CR #1's hospital admission paperwork read in part .seizures - magnetic device noted . In an interview on [DATE] at 9:01 a.m., Nurse A said the CNA (could not remember her name) got her around noon. She said the CNA told her she was trying to get CR #1 fed, but he was making a gurgling sound. She said she assessed him, that he only responded to painful stimuli, was still making the gurgling sound, and had a pulse. She said she could not get an O2 sat or BP reading. She said she put the non-rebreather on him and within 2 to 3 minutes he had no pulse, was not making the gurgling sound, and said she started CPR at approximately 12:04 p.m. She said she saw him the morning of [DATE]. She said he was a little drowsy, would open his eyes, and was heavily sedated, but around 10ish in the morning he started to become more aroused. She said he was heavily sedated because the ER gave him Ativan for a seizure he had at the ER the day before, [DATE]. In an interview on [DATE] at 11:21 a.m., CNA B said she was assigned to CR #1 on [DATE]. She said she first saw him at approximately 6:05 a.m. and he was asleep. She said she woke him up for breakfast around 7:10 a.m. and he was very sleepy. She said he was eating slowly and was not in distress. She said he did not finish his breakfast and later on, about an hour or two, he asked for water. She said when she went back to give the water to him it sounded like he had a lot of mucus when he was breathing. She said she could hear it in his lungs, and his breathing did not sound normal. She said she got Nurse A. She said Nurse A said it looked like he was seizing. She said Nurse A said the resident's family member gave the facility a device to pass along his chest to stop his seizures. She said Nurse A passed the device across his chest, but he did not respond. She said Nurse A started screaming out CR #1's name and tapping his chest, but he still did not respond. She said Nurse A directed her to get Nurse C and to tell her to call 911 and go to his room. She said Nurse A started CPR and was not doing it for long because EMS showed up and took over. She said EMS worked on him for 20 minutes and pronounced him deceased at 12:21 p.m. In a follow-up interview on [DATE] at 12:05 p.m., Nurse A said CR #1's family member gave them a device (she said did not know what it was) and said that when he had a seizure to pass it over his heart area. She said the resident had a magnet over his heart area that was a round raised area. She said she was not sure if he was having a seizure but said she passed the device over his chest because he may have been having a possible seizure. She said the resident had a seizure the previous day at the hospital after he was sent out and thought it could have been a seizure. She said it did not look like he was having a seizure but did not know what his seizure activity looked like because he was so new to the facility. She said she was not sure if the doctor was aware of the device. She said there was no change in his condition when it was passed over chest and that he still had a gurgle. She said she was not sure what the name of the device was. In an interview on [DATE] at 12:18 p.m., the family member said CR #1 had a nerve stimulator and a magnet that got passed across his chest for seizure activity. In an interview on [DATE] at 12:51 p.m., the Doctor said he was not aware CR #1 had a device over his heart area or a magnet device. In an interview on [DATE] at 2:23 p.m., Nurse C said the device the was a vagus nerve stimulant magnet. In an interview on [DATE] at 2:40 p.m., the DON said CR #1's family member brought the magnet device to the facility and that it did not come with him from the hospital. She said the charge nurse would have been the one to notify the doctor about the device. She said CR #1 went to the hospital 1 time within a 24-hour period, and it was for respiratory distress and not a seizure. She said both instances were for respiratory distress and not a seizure. She said they did not have him long enough to know what his seizure activity looked like. She said the resident's family member brought the device to the facility on [DATE] when he was at the ER. She said she did not know if there was an order for the device. She said she did not think it was a device since it was a magnet. She said on [DATE], Nurse A called her down to the resident's room and said he had shallow breathing and was in respiratory distress again. She said she assessed the resident and CPR was initiated with absence of breathing. She said Nurse A and B performed CPR. She said ,d+[DATE] rounds of CPR was given before EMS arrived and took over. She said she could not recall if Nurse A said the device was used. In a follow-up interview on [DATE] at 11:07, Nurse A said after she assessed CR #1 and once CNA B returned to the room, she left the room to get the magnet device prior to the crash cart. She said she was aware that he had a magnet in his chest. She said his family member came to the facility on [DATE] when he was still in the ER and left the magnet device. She said no one told her what signs/symptoms to look for and only that it was for seizure activity and that was what the family member said. She said she did not recall if the family member said how many times to swipe the magnet device over the magnet in CR #1's chest. She said she did not know if the magnet in his chest he had was new or how long he had it. She said she was not that familiar with the resident. In an interview on [DATE] at 12:52 p.m., Nurse B said she was aware CR #1 had the magnet over his chest area because the family member brought a magnet device in a Ziplock bag. She said the family member gave it to the DON and was telling the DON that they were supposed to pass the magnetic device when he was having a seizure. She said she did not see if the magnet was used by the Nurse A, but Nurse A told her she passed it over his chest and that it did not change anything. She said Nurse A did not mention how many times it was passed over. In an interview on [DATE] at 1:15 p.m., Nurse C said when she initially assessed him on the morning of [DATE], she thought CR #1 had a shunt but when she started touching his neck it felt like there were wires and felt a clamp further down and then wires and something where the wires went to (left side, not far below the clavicle). She said he was combative when she did his skin assessment, so she did not antagonize him. She said he was admitted the night of [DATE]. She said she does not recall anyone ever mentioning that he had a magnet implanted. She said she did not know how long he had the implant. She said she did not know if he was seeing a doctor for the implant. She said she did not recall seeing who was following him for magnet. She said CR #1 was not at the facility long enough for her to be educated on his implant. She said she did not know if his care plan had any interventions or mentioned the magnet in chest. In a follow-up interview on [DATE] at 10:15 a.m., Nurse C said she did not receive training on how to use the magnet device. She said the first time she saw it was on [DATE]. In a follow-up interview on [DATE] at 10:24 a.m., Nurse B said she did not receive training on how to use the magnet device. In an interview on [DATE] at 11:24 a.m., the Administrator said the facility did not have a policy on competent nursing staff. In a follow-up interview on [DATE] at 11:35 a.m., LVN A said she did not receive training on the magnet device or on how to use from the facility. This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on [DATE] at 10:48 a.m. The IJ template was presented to the facility and the POR was requested at this time. The following Plan of Removal submitted by the facility was accepted on [DATE] at 9:01 a.m. and included: Name of Facility: [] Date: [DATE] Immediate action: Plan of Removal F726: Competent Nursing Staff: The Facility Failed to train nursing staff on how to use CR # 1's magnet device. CR # 1 had a medical emergency on [DATE] and passed away at the facility. Status of the resident is deceased . * The Regional Director of Clinical Operations initiated Inservice on [DATE] with Licensed nurses on Obtaining Physician orders for Adaptive devices prior to utilizing devices for resident care. All Licensed Nurses will receive in-service prior to starting their next shift. Completion Date [DATE] * The Regional Director of Clinical Operations initiated Inservice on [DATE] with Licensed Nurses on how to properly assess residents for Change in Condition to include signs and symptoms of Seizure activity and signs and symptoms of Respiratory Distress. All Licensed Nurses will receive Inservice prior to starting their next shift. [DATE] * The Director of Clinical Operations or Designee will review all Admission Orders during the daily clinical meeting to ensure that any needed Adaptive Devices are on the orders and Licensed Nursing Staff has training prior to using the device for resident care. DON and/or designee with in-services weekend and after hour shifts on adaptive devices. * The Director of Clinical Operations will do skills a check off on adaptive devices for licensed nursing staff. * In-service was done for Executive Director of Operations and Director of Clinical Operations (Via phone [DATE] and will sign when she returns on [DATE]) by Regional Director of Operations. Inservice covered Admission is to be reviewed in morning clinical meeting, any adaptive devices must have physicians order and licensed nurses must have training on devices prior to utilizing device for resident care. * Medical Director notified of alleged facility noncompliance with Admission Physicians Orders for Immediate Care and Competent Nursing Staff on [DATE]. Monitoring of the POR included: Interviews on [DATE], between 10:09 a.m. and 3:46 p.m., with staff from all shifts, revealed the following licensed nurses were able to verbalize an understanding on obtaining physician orders for adaptive devices prior to utilizing the device for resident care and how to properly assess residents for change in condition to include signs and symptoms of seizure activity and signs and symptoms of respiratory distress: MDS Coordinator, DON, Nurse A, B, C, D, E and F. Interviews on [DATE] at 11:34 a.m. with the Administrator and at 1:46 p.m. with the DON, revealed they were able to verbalize an understanding of reviewing admission orders for adaptive devices and proper physician orders and that all licensed nursing staff receives training prior to the use of the device or any device for resident care. Record review of in-service sign in sheet, dated [DATE], for Assessing: Knowing the difference between a seizure and respiratory distress a change in condition, revealed 12 signatures. Record review of in-service sign in sheet, dated [DATE], for MD Orders for Resident Care, revealed 12 signatures. The Administrator was informed the Immediate Jeopardy was removed on [DATE], at 4:03 p.m. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

Based on interviews and records reviewed, the facility failed to ensure at the time each resident was admitted , they had physician orders for immediate care for 1 (CR #1) of 5 residents reviewed for admission orders. -The facility failed to have physician orders for the use of a magnet device used when CR #1 was in respiratory distress on [DATE] and passed away at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not receiving appropriate care and treatment services resulting in serious harm and/or risk of death. The findings included: Record review of CR #1's Admission Record, dated [DATE], revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included sepsis (infection of the blood stream), UTI (an infection that affects a part of the urinary tract), Marfan syndrome (genetic disorder that affects the connective tissue), and epilepsy (seizures). Record review of CR #1's orders revealed there was no order for a magnet device. Record review of CR #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Section I-Active Diagnoses, Neurological, revealed I5400. Seizure Disorder or Epilepsy was checked. Record review of CR #1's undated care plan revealed it was opened but not initiated. Record review of CR #1's Baseline Care Plan, dated [DATE], read in part .D. Nursing Summary, Input from Care Givers: a. Concerns/needs .Full code status .magnet in chest (diastatin); neurostimulant . Record review of CR #1's hospital admission paperwork read in part .seizures - magnetic device noted . In an interview on [DATE] at 9:01 a.m., Nurse A said the CNA (could not remember her name) got her around noon. She said the CNA told her she was trying to get CR #1 fed, but he was making a gurgling sound. She said she assessed him, that he only responded to painful stimuli, was still making the gurgling sound, and had a pulse. She said she could not get an O2 sat or BP reading. She said she put the non-rebreather on him and within 2 to 3 minutes he had no pulse, was not making the gurgling sound, and said she started CPR at approximately 12:04 p.m. She said she saw him the morning of [DATE]. She said he was a little drowsy, would open his eyes, and was heavily sedated, but around 10ish in the morning he started to become more aroused. She said he was heavily sedated because the ER gave him Ativan for a seizure he had at the ER the day before, [DATE]. In an interview on [DATE] at 11:21 a.m., CNA B said she was assigned to CR #1 on [DATE]. She said she first saw him at approximately 6:05 a.m. and he was asleep. She said she woke him up for breakfast around 7:10 a.m. and he was very sleepy. She said he was eating slowly and was not in distress. She said he did not finish his breakfast and later on, about an hour or two, he asked for water. She said when she went back to give the water to him it sounded like he had a lot of mucus when he was breathing. She said she could hear it in his lungs, and his breathing did not sound normal. She said she got Nurse A and Nurse A said it looked like he was seizing. She said Nurse A said the resident's family member gave the facility a device to pass along his chest to stop his seizures. She said Nurse A passed the device across his chest, but he did not respond. She said Nurse A started screaming out CR #1's name and tapping his chest, but he still did not respond. She said Nurse A directed her to get Nurse C and to tell her to call 911 and go to his room. She said Nurse A started CPR and was not doing it for long because EMS showed up and took over. She said EMS worked on him for 20 minutes and pronounced him deceased at 12:21 p.m. In a follow-up interview on [DATE] at 12:05 p.m., Nurse A said CR #1's family member gave them a device (she said did not know what it was) and said that when he had a seizure to pass it over his heart area. She said the resident had a magnet over his heart area that was a round raised area. She said she was not sure if he was having a seizure but said she passed the device over his chest because he may have been having a possible seizure. She said the resident had a seizure the previous day, [DATE], at the hospital after he was sent out and thought it could have been a seizure. She said it did not look like he was having a seizure, but she did not know what his seizure activity looked like because he was so new to the facility. She said she was not sure if the doctor was aware of the device. She said there was no change in his condition when it was passed over chest and that he still had a gurgle. She said she was not sure what the name of the device was. In an interview on [DATE] at 12:18 p.m., the family member said CR #1 had a nerve stimulator and a magnet that got passed across his chest for seizure activity. In an interview on [DATE] at 12:51 p.m., the Doctor said he was not aware CR #1 had a device over his heart area or a magnet device. He said there should always be an order for anything used on a patient. In an interview on [DATE] at 2:23 p.m., Nurse C said she could feel what was like a wire that ran down from behind CR #1's ear and down his neck and could see it because he was thin. She said the device the was a vagus nerve stimulant magnet. She said there was not an order in the order summary and there should be an order for everything used or given. She said her understanding was that the resident's family member brought it from home. She said she was not sure if there was enough time to get an order due to his condition, because he was fragile. She said she was not sure if the family member provided an order or if they were supposed to get it. In an interview on [DATE] at 2:40 p.m., the DON said CR #1's family member brought the magnet device to the facility and that it did not come with him from the hospital. She said the charge nurse would have been the one to notify the doctor about the device. She said CR #1 went to the hospital 1 time within a 24-hour period, and it was for respiratory distress and not a seizure. She said both instances were for respiratory distress and not a seizure. She said they did not have him long enough to know what his seizure activity looked like. She said the resident's family member brought the device to the facility on [DATE] when he was at the ER. She said she did not know if there was an order for the device. She said she did not think it was a device since it was a magnet. She said on [DATE], Nurse A called her down to the resident's room and said he had shallow breathing and was in respiratory distress again. She said she assessed the resident and CPR was initiated with absence of breathing. She said Nurse A and B performed CPR. She said ,d+[DATE] rounds of CPR was given before EMS arrived and took over. She said she could not recall if Nurse A said the device was used. In a follow-up telephone interview on [DATE] at 5:03 p.m., Nurse A said she had not personally requested doctor's orders for the magnet device. She said she thinks CR #1's family member brought the device on [DATE] when he was still at the hospital. She said all she knew was that the resident was in respiratory distress, and she started CPR after no pulse was detected. She said if there was an order it would be in the system. In a follow-up telephone interview on [DATE] at 12:01 p.m., the Doctor said a vagus nerve stimulator activated the vagus nerve to parasympathetic (part of the automatic nervous system that counterbalances the action of the sympathetic nerves. It consists of nerves arising from the brain and the lower end of the spinal cord and supplying the internal organs, blood vessels, and glands) activity. He said it helped relax the body, lower heart rate, and made one more relaxed. He said it could help with depression and seizures. He said when he saw CR #1, he performed a full physical, but was not sure he saw the vagus nerve stimulant at the time. He said it would be hard to say if using the magnet would accelerate anything as CR #1 was having acute respiratory failure. Record review of the facility's policy titled Admission Criteria, dated ,d+[DATE], read in part . 5. Prior to or at the time of admission, the resident's Attending Physician must provide the community with information needed for the immediate are of the resident, including orders covering at least .c. Routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed Interdisciplinary Care Plan . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on [DATE] at 10:48 a.m. The IJ template was presented to the facility and the POR was requested at this time. The following Plan of Removal submitted by the facility was accepted on [DATE] at 9:01 a.m. and included: Name of Facility: [] Date: [DATE] Immediate action: Plan of Removal F635: Admission Physician Orders for Immediate Care: The facility failed to obtain orders upon CR# 1's admission for the use of his magnet device. CR # 1's had a medical emergency on [DATE] and passed away at the facility. Status of resident is deceased . * The Regional Director of Clinical Operations initiated Inservice on [DATE] with Licensed nurses on Obtaining Physician orders for Adaptive devices prior to utilizing device for resident care. All Licensed Nurses will receive in-service prior to starting their next shift. Completion Date [DATE] * The Regional Director of Clinical Operations initiated Inservice on [DATE] with Licensed Nurses on how to properly assess residents for Change in Condition to include signs and symptoms of Seizure activity and signs and symptoms of Respiratory Distress. All Licensed Nurses will receive Inservice prior to starting their next shift. Completion Date [DATE] * The Director of Clinical Operations and/or designee will complete an audit of all residents who have adaptive devices to ensure there is a Physician Order for Device and Staff have received adequate training on device. The audit was conducted and completed on [DATE]. No issues identified and No residents found with adaptive devices. * The Director of Clinical Operations and/or Designee will review all Admission Orders during the daily clinical meeting to ensure any Adaptive Devices are on a proper Physician order and Licensed Staff has prior training for using the device for resident care and any devices received after admissions. Not a new policy. * ALL newly hired licensed nursing staff will be trained in adaptative devices during orientation prior to taking care of residents. DCO and/ or designee will review hospital records on new residents prior to admissions. Once admission is confirmed, in-service and training will be conducted, and care plan will be completed ,d+[DATE] hours after admission. DCO and/or designee will train after hours and weekend staff on adaptive devices. Nursing Staff will use the 24-hr report to identify residents with adaptive devices. * The Medical Director notified of alleged facility noncompliance with Admission Physicians Orders for Immediate Care and Competent Nursing Staff on [DATE]. * In-service was done for Executive Director of Operations and Director of Clinical Operations (Via phone [DATE] and will sign when she returns on [DATE]) by Regional Director of Operations Inservice covered *Admission is to be reviewed in morning clinical meeting, any adaptive devices must have physicians order and licensed nurses must have training on devices prior to utilizing device for resident care. Monitoring of the POR included: Interviews on [DATE], between 10:09 a.m. and 3:46 p.m., with staff from all shifts, revealed the following licensed nurses were able to verbalize an understanding on obtaining physician orders for adaptive devices prior to utilizing the device for resident care and how to properly assess residents for change in condition to include signs and symptoms of seizure activity and signs and symptoms of respiratory distress: MDS Coordinator, DON, Nurse A, B, C, D, E and F. Interviews on [DATE] at 11:34 a.m. with the Administrator and at 1:46 p.m. with the DON, revealed they were able to verbalize an understanding of reviewing admission orders for adaptive devices and proper physician orders and that all licensed nursing staff receives training prior to the use of the device or any device for resident care. Record review of in-service sign in sheet, dated [DATE], for Assessing: Knowing the difference between a seizure and respiratory distress a change in condition, revealed 12 signatures. Record review of in-service sign in sheet, dated [DATE], for MD Orders for Resident Care, revealed 12 signatures. Record review of audit findings revealed one was completed on [DATE] by the MDS Coordinator and no residents were found to have external adaptive devices. The Administrator was informed the Immediate Jeopardy was removed on [DATE], at 4:03 p.m. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

Based on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters (Fiscal year 2023 for the third quarter April 01, 2023 to June 30, 2023) reviewed for administration. -The facility failed to submit accurate registered nurse hours for the following dates: 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. This failure could place residents at risk for personal needs not being identified and met. Findings include: Record review of PBJ reporting for Quarter 3 (April 01, 2023 to June 30, 2023) indicated no RN hours for 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023. Record Review of timecard editor for 04/01/2023, 04/02/2023, 04/08/2023, 05/13/2023, 05/14/2023, 05/20/2023, and 06/25/2023 revealed an RN was onsite for at least 8 consecutive hours on those days. The facility did not report those RN hours to PBJ for quarter 3 reporting cycle. During an interview on 12/11/2023 at 2:15 pm, the staffing coordinator stated that she was responsible for scheduling the nurses and aides. She stated there was an RN present on those days and provided timecard for RN D revealing RN D had worked on those days for 8 consecutive hours. During an interview on 12/11/2023 at 3:00 pm, the administrator stated she had started in September 2023 and the PBJ report and hours were completed at the corporate level. She stated she was not sure why there were no RN hours reported for those days. During an interview on 12/12/2023 at 9:44 am, the VP of program management stated the staffing hours were pulled from the clock in and out system. She stated there had been an issue with the system and was not aware and those RN hours could have gotten missed during that time. She stated the facility was to monitor hours onsite and she only submitted the hours that were in the system. She stated there was no system to check that the staffing hours were accurate and submitted what information was on the time spreadsheet. During an interview on 12/12/2023 at 2:22 pm, the administrator stated she was not aware that accurate RN hours were not being submitted to the PBJ. She stated she reviewed the RN hours for the missing days and there was an RN present. She stated that the RN working was a shared employee, and a report had to be sent to corporate payroll for shared hour employees. She stated those hours must have gotten missed. She stated she did not see any risk to inaccurate reporting of RN hours but would review the hours more closely before submitting to the corporate payroll. Record review of policy manual for Electronic Staffing Data Submission Payroll-Based Journal dated June 2022 indicated, .accuracy: staffing information is required to be accurate and complete submission of a facility's staffing records. Hours: facility must submit the number of hours each staff member is paid to deliver services for each day worked .

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 7 of 15 employees (LVN G, LVN H, CNA J, CNA K, CNA L, FSS, and Rehab Director) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to LVN G, LVN H, CNA J, CNA K, CNA L, FSS, and Rehab Director. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings: Record review of LVN G's personnel file revealed LVN G was hired on 9/19/2023 and had not completed on hire QAPI training. Record review of LVN H's personnel file revealed LVN H was hired on 08/02/2022 and had not completed annual training on QAPI. Record review of CNA J's personnel filed revealed CNA J was hired on 8/29/2023 and had not completed on hire QAPI training. Record review of CNA K's personnel file revealed CNA K was hired on 8/08/2017 and had not completed annual training on QAPI. Record review of CNA L's personnel file revealed CNA L was hired on 9/12/2023 and had not completed on hire QAPI training. Record review of FSS's personnel file revealed the FSS was hired on 11/28/2023 and had not completed on hire QAPI training. Record review of the rehab director's personnel file revealed the rehab director was hired on 10/26/2020 and not completed annual training on QAPI. During an interview on 12/13/2023 at 2:15 pm, the DON stated she had been employed as the DON since April 2023. She stated she and the ADON were responsible for overseeing the on hire and annual trainings and was not aware of the required QAPI training for all employees. She stated there was no monitoring system to ensure trainings were completed and each employee was aware of their required trainings in the online system. She stated if staff are not properly trained it could affect resident care. During an interview on 12/13/2023 at 2:49 pm, the administrator stated she was ultimately responsible for oversight all trainings. She stated trainings were assigned in the online training system and each employee was responsible for completing the required trainings. She stated she was not aware that all employees required QAPI training but would see that the training was assigned to every employee. She stated staff that were not trained could affect resident care and expected all staff to complete required regulated trainings annually and on hire. She stated the facility did not have a policy on staff development or training education.

Based on interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #40) reviewed for MDS assessment accuracy. -The facility did not accurately document Resident #40's hospice services on the quarterly MDS dated [DATE]. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: Record review of Resident #40's face sheet dated 12/12/2023 indicated Resident #40 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of dementia. Record review of Resident #40's consolidated orders indicated an order dated 05/25/2021 for hospice services. Record review of Resident #40's quarterly MDS dated [DATE] did not indicate resident was receiving hospice services. Record review of Resident #40's comprehensive care plan indicated Resident #40 had a terminal prognosis and was receiving hospice services. Interview on 12/12/23 at 8:33 am, with the MDS Coordinator, she said she had been completing MDS for one year. She stated she had received training on MDS data collection and submission of resident assessments. She said Resident #40 had been receiving hospice services for some time and she was not sure how hospice care was missed on her quarterly MDS in September 2023. She said she reviewed each residents progress notes, orders and completed interviews before completing the MDS. She said by not accurately reflecting resident care on the MDS it could affect the resident plan of care and care provided. Interview on 12/13/2023 at 10:05 am, with the DON who said the MDS Coordinator was responsible for accurately reporting resident assessments and she signed the MDS after completion. She said the MDS, and care plans were reviewed and was not sure how Resident #40's hospice care was missed. She said by not accurately assessing a resident it could cause incomplete care and she expected all resident assessments were accurate and complete. Interview on 12/13/2023 at 10:07 am, with the Administrator who said the MDS Coordinator and DON were responsible for accurately assessing and reporting resident conditions through the MDS. She said the corporate MDS nurse also reviewed the MDS, and she was not sure how Resident #40's hospice care was missed. She stated by not accurately assessing residents for the MDS it could cause missed information for the resident and expected that all MDS were accurate. Record review of facility policy titled Resident assessment dated ,d+[DATE] indicated, .each facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely . .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 2 of 6 resident's (Resident #16 and 18) personal refrigerators reviewed for food safety -The facility failed to ensure the refrigerator for Resident #16 did not contain a cup of peach cobbler with mold present. -The facility failed to ensure the refrigerator for Resident #18 did not contain jello, vanilla pudding and salad dressing that were expired. These failures could place residents at risk for food borne illnesses. Findings include: Record review of a facility policy titled Food from Outside Sources with a revised date of ,d+[DATE] read in part, . Residents may have outside sources of food brought in. The community will ensure that proper steps are taken so that the food remains safe. 2. Community personnel will be responsible for the managing of appropriate temperatures and food stored in resident refrigerator . Resident #16 Record review of an Admission Record dated [DATE] for Resident #16 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic congestive heart failure (the heart's inability to pump effectively), chronic kidney disease stage 3 (mild to moderate kidney damage), obesity and diabetes mellitus (too much sugar in the blood). Record review of a Quarterly MDS assessment dated [DATE] for Resident #16 indicated she had mild impairment in thinking with a BIMS score of 12. She required set up assistance with eating. During an observation and interview on [DATE] at 10:15 AM, Resident #16's personal refrigerator had a cup of peach cobbler with clear, plastic wrap that had mold on top of the crust. Resident #6 said she ate foods that were in her refrigerator and staff checked it daily. Interview on [DATE] at 3:09 PM, with RA, she said she had been employed at the facility for 2 years and started in the position of RA about 2 months ago. She said she was responsible for checking the personal refrigerators for expired foods. She said she checked the refrigerators daily except for the weekends when she did not work. She said sometimes she would forget to check them if she was busy. During an observation and interview on [DATE] at 3:12 PM, RA was in the room of Resident #6. RA observed the refrigerator and said it looked like the cobbler had mold on top of it and placed it in the trash. She said she did not check her refrigerator that morning and residents could get sick if they ate foods that had mold or was eaten past the expiration dates. Resident #18 Record review of an Admission Record dated [DATE] for Resident #18 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of bipolar (a mental illness that causes shifts in mood), major depressive disorder (persistent feeling of sadness or loss of interest), atherosclerotic heart disease (buildup of fats and cholesterol that clogs the arteries) and GERD (acid reflux). Record review of an Annual MDS assessment dated [DATE] for Resident #18 indicated she did not have any impairment in thinking with a BIMS score of 15. She was independent in eating. During an observation and interview on [DATE] at 10:42 AM, Resident #18 was present and said she ate foods out of her personal refrigerator. Her personal refrigerator had multiple four packs of jello that expired [DATE], [DATE], and [DATE]. It also had three packs of vanilla pudding that expired [DATE], [DATE], and [DATE]. It had a bottle of salad dressing dated [DATE]. She said staff checked the refrigerators daily. During an observation and interview on [DATE] at 3:18 PM, RA observed the refrigerator of Resident #18 and multiple items that included jello and pudding were removed and placed in the trash. She said the items were expired. She said residents could get sick if they ate foods that were eaten past the expiration dates. Interview on [DATE] at 9:40 AM, with the Administrator, she said she had been employed at the facility since [DATE]. She said the department heads and families were supposed to check the personal refrigerators and no one person was assigned to check them. She said going forward the department heads would be responsible for checking the personal refrigerators daily along with the RA. She said residents could get sick if they ate items out of their refrigerators that were past the expiration dates or if mold was present.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 2 of 16 (room [ROOM NUMBER] and room [ROOM NUMBER]) rooms reviewed for pest control. -The facility failed to ensure room [ROOM NUMBER] and room [ROOM NUMBER] did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. Findings include: During an observation on 12/11/23 at 9:57 am, one live roach was observed crawling around the toilet in room [ROOM NUMBER]. During an observation on 12/11/23 at 10:16 am, one live roach was observed crawling under the bed in room [ROOM NUMBER]. During an interview on 12/11/23 at 10:37 am, HSK E stated she had been in housekeeping for [AGE] years. She stated there had been roaches in the rooms and building on and off and she would kill them, clean the area and report to the administrator and maintenance director. She stated pest control was in the facility about 1-2 weeks ago and sprayed but the families bring in items that have roaches. During an interview on 12/11/23 at 10:40 am, CNA F stated she had worked as needed at the facility for two years. She stated she had not seen any roaches in any rooms, but this was the first time she had worked 200 hall in 4 months. She stated if she were to see any pest like roaches she would report to the administrator and maintenance director. During an attempted interview on 12/11/23 10:45 am, Maintenance director was on leave and unavailable for interview. During an interview on 12/11/23 at 11:47 am, the administrator stated she was aware of the roaches on 200 hall and pest control had been treating the rooms. She stated pest control comes monthly and did an emergent visit a few weeks ago for roaches in room [ROOM NUMBER]. She stated families bring in items and the facility frequently monitored and notified pest control of any issues. She stated the facility had not put in place a food storage system for resident rooms. She stated she thought the roaches were gone on 200 hall and would contact pest control again. During an interview on 12/12/23 at 11:09 am, the pest control service manager stated they had been servicing the facility monthly and as needed for active pest. He stated the facility had an oncoming issue with roaches, but they had been treating them and controlling the situation. He stated German roaches were brought in by visitors and were difficult to eradicate. He stated they were now inspecting all rooms monthly for signs of pest and treating rooms as needed. He stated the technician treated the rooms on 200 hall on 11/28/2023 and again 12/12/2023. He stated the pest control plan was appropriate and the facility did not require a change at this time. During an interview on 12/13/2023 at 10:10 am, the administrator stated pest control came again 12/12/2023 and sprayed rooms [ROOM NUMBERS]. She stated the residents in those rooms had been relocated until after the rooms were treated. She stated by not having an effective pest control program it could lead to infection from pest. She stated she would implement a new program for food storage in the rooms and expected for the facility to be pest free. Record review of monthly pest control service report from 05/01/2023 to 11/01/2023 revealed the facility had roaches and required regular treatment. The roaches were reported in the kitchen and on 200 hall during those times. On 11/28/2023 an emergent visit was made for live roaches in room [ROOM NUMBER]. Record Review of policy titled Pest Control dated May 2008 indicated, .this facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and to establish an accurate reconciliation of controlled drugs in sufficient detail for 1 of 5 residents (Resident #1) and 1 of 5 medication carts (nurse cart for hall 100) reviewed for pharmacy services, in that: The facility failed to verify the amount of lorazepam for Resident #1 in the refrigerated lock box. The facility failed to discard an insulin pen for Resident #39 that had an open date of 11/5/2023. These failures could place residents at risk for misappropriation, drug diversion and the unsafe administrator of medications and not receiving the intended therapeutic benefit of medications. Findings include: 1.Record review of an Admission Record dated 12/12/2023 for Resident # 1 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of epilepsy (seizure disorder), idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions), atherosclerotic heart disease (a buildup of fats and cholesterol that clog the arteries), and Alzheimer's disease (a progressive disease that involves parts of the brain that control thought, memory and language). Record review of a care plan dated 4/25/2022 for Resident #1 indicated he was at risk for injury secondary to seizure disorder with interventions of lorazepam injection prn monitor/document side effects and effectiveness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #1 indicated he had moderate impairment in thinking with a BIMS score of 10. No injections of any type were received during the 7 day look back period. Record review of a physician order summary report dated 12/12/2023 for Resident #1 indicated an order for lorazepam solution 2 mg/ml inject 1 mg intramuscularly every 4 hours as needed for seizures dated 9/21/2023. Record review of a narcotic record for Resident #1, undated, indicated amount received from the pharmacy of five vials for Lorazepam 2 mg/ml. Narcotic record sheet did not have any signatures of staff administering medications to Resident #1. During an observation and interview on 12/11/2023 at 3:03 PM, LVN A was assigned the nurse medication cart for hall 100. A narcotic count was conducted with LVN A and during the count, LVN A indicated that Resident #1 had five vials of lorazepam in the lock box in the refrigerator in the medication room. The narcotic sheet indicated that Resident #1 had five vials, and none had been given. LVN A obtained the lorazepam for Resident #1 from the refrigerator in the medication room and the plastic bag had five vials of lorazepam present. Three vials had the tops still on them, two had tops inside of the plastic bag at the bottom. One vial appeared to be a full and the other was partially full. LVN A said she would notify the DON and the DON came into the medication room and said she would contact the Pharmacy Consultant. LVN A said she was not aware that the vials were not accurate and did not notice the tops were not on the two vials. Interview on 12/11/2023 at 3:08 PM, with the DON who said she had the Pharmacy Consultant on the phone who said that the lorazepam vial top could have come off and the contents spilled inside of the bag. The DON said she could not explain how or why the nurse staff did not recognize the vial was not full or that the tops were off of the vials. Interview on 12/12/2023 at 8:14 AM, with LVN B she said she had been employed at the facility for 4 months and worked days on the 6am-2pm shift. She said before the nurses accept the cart, they count the narcotics with the off going nurse and verify the counts were correct. She said it depended on if the narcotic count was correct, if it was not then they were to contact the DON. She said there was a lock box in the refrigerator in the medication room and they had to go in and count the medications that were there as well. She said she was assigned to work with Resident #1 yesterday morning 12/11/2023. She said she counted with the nurse on 10pm-6am and physically counted the medications. She said they just picked up the bag and saw that there were five vials inside and placed them back. She said that it could be detrimental if they did not verify the counts were accurate or a medication diversion could occur. Interview on 12/12/2023 at 8:21 AM, the DON said she had been employed at the facility since April 2023. She said the nurse that was coming on shift and the nurse that was going off, should be counting, and verifying at the beginning of the shift, if any discrepancies, they should contact her immediately. She said she would then notify the pharmacy, physician and trace down the drug diversion or if an education moment I would be needed if only a signature was missing. She said the pharmacist visited the facility monthly and performed audits of the carts and the medication room. She said residents could be at risk of missing medications, staff could be taking meds, and residents could be missing out on medications. She said she started an in-service yesterday 12/11/2023 on verifying counts and accuracy in vials. Interview on 12/12/2023 at 11:15 AM, LVN C said she had been employed at the facility for 5 years on the 6am-2pm shift. She said with the oncoming nurse they verify the narcotic counts and check the amounts of both and would go into the medication room to verify if the medication had to be refrigerated. She said if any counts were off, they would notify the DON immediately and the DON would back track and trace if someone forgot to sign out for the medication or not. She said the nurse must verify the correct amount that was in the vials. She said staff could be reprimanded if counts were off and not reconciled. She said they had an in-service on yesterday 12/11/2023 to count and verify narcotics. 2. Record review of an Admission Record dated 12/12/2023 for Resident #39 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of vascular dementia (a problem caused by brain damage from impaired blood flow to the brain), bipolar disorder (a mental illness that causes shifts in mood), type 2 diabetes (the body either doesn't produce enough insulin or it resists insulin) and myasthenia gravis (causes muscles under your voluntary control to feel weak and get tired quickly). Record review of a physician order summary report dated 12/12/2023 for Resident #39 indicated he did not have an order for an insulin Basaglar Kwik pen. Record review of a Quarterly MDS dated [DATE] for Resident #39 indicated he did not have any impairment in thinking with a BIMS score of 15. No injections were given during the last 7 days of the look back period. Record review of a care plan dated 4/1/2021 for Resident #39 had diabetes and was at risk for complications with interventions to educate regarding medications and importance of compliance. During an observation on 12/11/2023 at 2:33 PM of the nurse cart for hall 200, LVN A was present. Resident #39 had an insulin Basaglar Kwik pen with an open date of 11/5/2023. LVN A said the pen should have been discarded within 28 days of the open date. She said Resident #39 had been refusing to take the insulin and did not know why it had not been discarded. She said the medication carts should be checked daily for medications that needed to be discarded or that were expired. Interview on 12/12/2023 at 8:21 AM, with the DON said she had been employed at the facility since April 2023. She said the nurse that was coming on shift and the nurse that was going off were responsible for counting and verifying the cart at the beginning of the shift, if any discrepancies, the DON should be contacted immediately. She said insulin should be discarded within 28 days of the open date. She said she started an in-service with nursing staff on yesterday 12/11/2023 that included insulin dates and expirations. She said Resident #39 had been refusing to take his insulin and did not know why the insulin was still on the medication cart. Interview on 12/12/2023 at 11:33 AM, with the Pharmacy Consultant said she visited the facility monthly and conducted cart audits, medication room checks, medication pass and drug destruction. She said her last visit at the facility was on 12/4/2023 and did not have any concerns at that time. She said insulin should be discarded within 28 days from the open date and if a resident was refusing, then the physician should be notified to discontinue the medication. She said going forward the DON or ADON would do weekly checks on medications for accuracy and medication carts. She said residents could be at risk for their blood sugar not being controlled, giving a false reading of blood sugars, or the potency of the medication could not be good anymore. Interview on 12/12/2023 at 11:33 AM, with the Pharmacy Consultant said she visited the facility monthly and conducted cart audits, medication room checks, medication pass and drug destruction. She said she was contacted by the DON on yesterday 12/11/2023 about some lorazepam vials that were not signed off on the narcotic sheet for Resident #1 and (2) of the five vial tops were off. She said when she visited the facilities, she did not go into the lock boxes in the refrigerators, and it was generally no need to check off and verify if there had not been any doses given. She said every shift the nurses should be checking for accuracy, verifying the count, and checking for any missing volume of liquid medications. She said Resident #1's lorazepam was used for an emergency seizure disorder. She said her last visit at the facility was on 12/4/2023 and she did not have any concerns at that time. She said going forward the DON or ADON would do weekly checks on medications for accuracy and medication carts. She said insulin should be discarded within 28 days from the open date and if a resident was refusing, then the physician should be notified to discontinue the reading of blood sugars, or the potence of the medication could not be good anymore. Interview on 12/13/2023 at 9:40 AM, with the Administrator said she had been employed at the facility since September 18, 2023. She said the medication aides, ADON's, Nurses and Pharmacy Consultant were responsible for checking the medication carts and fridges. She said she was made aware of the discrepancy with the lorazepam vials. She said going forward the nurses would be checking the refrigerator lock box daily and would sign a sheet daily to ensure the lock box had been checked. She said the medication carts would be checked every shift. She said residents could be at risk for reactions to receiving expired medications. Record review of an in-service training report dated 12/11/2023 conducted by the DON indicated a training on verifying count and correct amount in vial along with insulin dates and discontinue expiration was conducted. Record review of a facility policy titled Storage of Medications with a revision date of 8/2020 read in part, . Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of the supplier. 5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. a. The nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacture recommends another date or regulations/guidelines require different dating. b. If a vial or container is found without stated date opened, the date opened will automatically default to the date dispensed and the expiration date will be calculated accordingly, unless otherwise indicated in a facility specific policy. 8. All expired medication will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining .

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 (CR #1) of 5 residents reviewed for baseline care plans. -The facility failed to care plan and implement interventions to address CR #1's history of hallucinations, need for supervision, and behavioral interventions which resulted in CR #1 attempting suicide on 09/16/2023. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. The findings included: Record review of CR #1's Admission Record, dated 09/19/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE] to the hospital. Resident's diagnoses included cardiac arrest (cessation of normal circulation of blood due to failure of the heart to pump effectively), cognitive communication deficit (difficulties with thinking and how someone uses language), muscle weakness, abnormalities of gait and mobility (walking), lack of coordination, need for assistance with personal care, [NAME] lymphoma (type of cancer that affects the lymphatic system), and type 2 diabetes mellitus (high blood sugar) with hypoglycemia (low blood sugar) without coma. Record review of CR #1's hospital admission paperwork, dated 08/11/2023, revealed CR #1's medical problems included visual hallucinations. Further review revealed discharged medications, dated 09/12/2023, included Mirtazapine 30 mg daily and Quetiapine 50 mg, take 1 tablet by mouth once daily in the morning for 90 days. Record review of CR #1's Admission MDS assessment, dated 09/15/2023, revealed Section C, Cognitive Patterns, C0500, BIMS Summary Score was in progress. Further review revealed Section E, Behavior, E0100, Potential Indicators of Psychosis, A. Hallucinations, was checked. Resident required one-person physical assist with bed mobility, dressing, and toileting. Resident required two-person physical assist with transferring. Record review of CR #1's orders, dated 09/19/2023, reflected in part .behavior monitoring for: depression medication: Remeron, Order Date 09/12/2023 . Mirtazapine Tablet 30 mg, Give 1 tablet by mouth one time a day for depression, Order Date 09/12/2023 . Quetiapine Fumarate 25 mg Tablet, Give 1 tablet by mouth two times a day for antipsychotic, Order Date 09/13/2023 .and Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg (Quetiapine Fumarate), Give 1 tablet by mouth one time a day for antipsychotic . Record review of CR #1's Baseline Care Plan, dated 09/13/2023, revealed it did not reflect CR #1's history of hallucinations, history of depression, need for behavior monitoring for depression medication, and/or behavioral interventions to prevent suicidal attempts. Further review revealed Section 4., Social Services, Section C., was incomplete. Section C. included mental health needs, behavioral concerns, intervention suggestions to de-escalate situations, and depression screening. Record review of CR #1's Care Plan, dated 09/14/2023, revealed it did not reflect CR #1's needs for use of an antidepressant medication, behavior monitoring r/t antidepressant medication for depression, use of an antipsychotic medication, history of hallucinations, and/or history of depression. Record review of CR #1's Care Conference Summary notes, dated 09/14/2023, read in part .resident had history of anti-depressants .history of hallucinations .level of confusion is higher . Record review of CR #1's Progress Notes, effective date 09/16/2023, read in part Called to [CR #1's] room by charge nurse .[CR #1] lying in bed .blood covered over body and left arm .skin and fatty tissue hanging from left arm .Found in [CR #1's] right hand holing glass from picture frame in which [CR #1] stated he cut his wrist .Left forearm noted large laceration with tissue and skin cut out to left forearm and wrist area. Tendon and bone exposed to forearm approximately 12 x 9 x 0.7 cm . [CR #1] stated that the staff was trying to kill him, and he was trying to kill himself first before the staff did. [CR #1] was experiencing visual hallucinations but able to respond to questions appropriately . [CR #1] .kept stating they trying to kill me during the time with patient until EMS arrived . [CR #1] transported to [hospital]. In an interview on 09/19/2023 at 11:58 a.m., the Director of Clinical Operations/Director of Nursing (DCO/DON) said she had been working at the facility approximately since April 2023. She said CR #1 was at the facility for approximately 3-4 days. She said different team members from different departments (nursing, social services, activities, and dietary) were responsible for completing their section of the baseline care plan. She said each team member signed off on their section and once signed, the RN signed. She said CR #1 did not have any mental health diagnoses at the time of his admission and his PASRR did not indicate a mental illness. She said the resident was admitted from the hospital with orders for an antidepressant (Mirtazapine) and antipsychotic (Seroquel). She said baseline care plans were to be completed within 48-hours of admission. She said the facility also had 48-72 hours to complete medication diagnosis and list of disease processes. She said in-house behavior monitoring orders for depression medication were put into place for residents who were on an antidepressant. She said she was not aware CR #1 had a history of hallucinations until after his suicidal attempt and investigation. She said she learned about the hallucinations from the Director of Resident Support Services/Social Worker (DRSS/SW). She said CR #1 did not display any alarming behaviors prior to the incident. In an interview on 09/19/2023 at 2:27 p.m., the DRSS/SW said she had been working at the facility approximately since April 2022. She said it took her time to complete the baseline care plan because it took her a period to obtain the full scope of the resident's needs. She said she met with CR #1's family member on 09/11/2023. She said she asked the family member twice if CR #1 had any suicidal ideations and the family member told her no. She said the family member told her the resident had a history of hallucinations. She said she asked about CR #1's hallucinations, but the family member did not give her any details. She said she attempted to meet with the resident on the day he was admitted , but he was in therapy. She said CR #1 showed no signs of hallucinations and/or homicidal or suicidal ideations. She said the resident's Care Conference was held on 09/14/2023 with the IDT and two of CR #1's family members. In a follow-up interview on 09/20/2023 at 1:33 p.m., DRSS/SW she said she was not sure when her part of the baseline care plan should be completed. She said she received training on baseline care plans but did not recall by whom. She said the purpose of a baseline care plan was for it to include purposeful information about the resident, and it helped create a plan of care. She said she did not complete the Social Services section of the baseline care plan. She said the depression screening was not completed. She said the baseline care plan was opened but she was unable to complete her section because she had other facility duties (talking to families, talking to residents, giving updates to the families to address any questions, resolving concerns with other residents and families, NOMNCS, meetings, and discharges) that limited her from being able to complete her portion. She said to her knowledge, the history of the resident's hallucinations was relayed to the DCO/DON and nursing staff. She said the MDS Nurse communicated the information to the nursing staff. In a follow-up interview on 09/20/2023 at 12:29 p.m., the DRSS/SW said she had never known her not completing her section of the baseline care plan could affect a resident while she had been in her role as a DRSS/SW. She said she was not sure how it would affect the resident if it were not completed timely and/or if it was completed inaccurately. Record review of the facility's policy titled Comprehensive Care Plan, effective and revised 01/20/2021, read in part . Policy Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission . The Administrator was notified on 09/20/2023 at 5:15 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at this time. The facility's Plan of Removal was accepted on 09/21/2023 at 4:41 p.m. and included: PLAN OF REMOVAL Name of facility: [] Date: Sept. 20th, 2023 Immediate action: F655 -Director of Clinical Operations initiated in service on Baseline care plans per facility policy on 9/20/23 with the Interdisciplinary team. In-service covered completion of baseline care plan within 48 of admission, ensuring all disciplines complete their sections, and ensure interventions are in place for any behaviors, mental health, or psychosocial issues are identified. Inservice to be complete by 9/21/23. -The Director of Clinical Operations completed an audit on baseline care plans. Random selection of baseline care plans was checked for accuracy and completion. Random selection was based off residents admitted within the last 30 days because comprehensive care plans are due by 21st day of admission. Audit of baseline care plans completed on 9/20/23 identified baseline care plan meetings occur within the 48 hours timeframe according to policy and procedure or a comprehensive care plan was in place for residents residing in community longer than 14 days. -Inservice RNs on ensuring that baseline care plan was complete prior to signing and locking; DCO initiated by 9/20/23 and completed by 9/21/23. -Director of Clinical Operations in serviced all Interdisciplinary Team on completion of Baseline Care plans within 48 hours of admission on 9/20/2023. -All new Admissions will be reviewed during morning standup meeting to ensure the baseline care plan are completed within 48 hours of admission and signed by all members of the inter disciplinary team. -Medical Director notified of alleged facility noncompliance with completion of baseline care plans on 9/20/23. -Resident #1 was discharged to the hospital on 9/16/2023 and has not returned to the facility and no updates since discharge. Discharge MDS indicates return is anticipated. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 09/22/2023 through 09/23/2023. Monitoring of the POR included: In an interview on 09/22/2023 at 2:50 p.m., the Administrator said she received baseline care plan in-service training. She said she made sure the baseline care plan was completed within 48-hours of admission and that all sections were completed so they could be closed in a timely manner. She said the IDT were to bring their computers to the morning meeting the day after a resident admits. She said if a resident admits to the facility late Friday through Sunday, the baseline care plan was completed no later than Monday morning at 11 a.m. In a follow-up interview on 09/22/2023 at 3:21 p.m., the Administrator said she and the DCO/DON completed the baseline care plan audit for last 30 days of admission. She said once the audit was completed, she got with the MDS Nurse to make sure those residents that had incomplete baseline care plans had a completed comprehensive care plan in the system. In an interview on 09/22/2023 at 2:26 p.m., the DCO/DON said the in-service training she provided covered the importance of completing the baseline care plan, timeline for completion, and the inclusion of accurate information. She said IDT were to bring their computers to the daily morning meetings to facilitate the signatures being completed before the morning meeting ended. She said the baseline care plan had to be completed along with signatures within 24-hours. She said every discipline must complete their section of the baseline care plan. She said interventions needed to meet the needs of the residents and had to be followed through. She said it was determined that residents who were at the facility for longer than 14 days had their comprehensive care plans completed. She said RNs were trained to open the baseline care plans upon admission and to leave it open until all information and signatures were entered, but no later than 48-hours. She said the medical director was notified of the alleged noncompliance. In an interview on 09/22/2023 at 3:33 p.m., the Assistant Director of Clinical Operations/Assistant Director of Nursing (ADCO/ADON) said she received in-service training. She said the training covered baseline care plans. She said they talked about completing the baseline care plans within 48-hours of a resident's admission. She said if the resident was residing in the facility for more than 14-days, they needed to have a comprehensive care plan completed. She said all disciplines must be completed and interventions such as mental health, psychosocial, and any behaviors had to be documented on the baseline care plan and the comprehensive care plan. In an interview on 09/23/2023 at 5:44 a.m., Nurse C said he had been working at the facility for [AGE] years. He said he worked the 10:00 p.m. to 6:00 a.m. Shift. He said he received in-service training. He said they discussed baseline care plans, and the time frame to complete them. He said they had to be completed within 48-hours. He said the baseline care plan was started by the nurse who started the resident's admission and other parts were completed by the other designated departments. In an interview on 09/23/2023 at 12:48 p.m., the DRSS/SW said she received in-service training. She said the plan put into place was for them to bring their laptops to the morning meetings so they could review the baseline care plans to ensure they were able to review and complete the plan. She said if a resident were to admit late Friday through Sunday, the goal was to have the baseline care plans completed by Monday morning by 11:00 a.m. She said the timeframe to have the baseline care plan completed was 48-hours within admission. In a follow-up interview on 09/23/2023 at 1:12 p.m., Nurse A said she worked the 2:00 p.m. to 10 p.m. shift. She said she received in-service training over baseline care plans. She said baseline care plans had to be initiated and completed within 48-hours of admission. She said nursing staff was responsible for completing some of the sections. Record review of the facility's audit findings for comprehensive care plans for admissions in the past 30 days revealed there were 11 new admits, all who had comprehensive care plans completed. Record review of the facility's in-service training records related to baseline care plans and behavior monitoring, dated 09/20/2023 and 09/21/2023, confirmed a total of 61 staff members were trained over behavior monitoring and/or baseline care plans. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and records reviewed, the facility failed to ensure resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR #1) of 5 residents reviewed for accident hazards and supervision. -The facility failed to provide adequate supervision for CR #1 to prevent harm from suicidal ideations and self-injurious behaviors that resulted in him cutting his arm and wrist with broken glass and being hospitalized . -The facility failed to care plan and put interventions in place for CR#1 when he admitted to the facility with history of hallucinations, need for behavioral monitoring for depression, and behavioral interventions to prevent suicidal attempts resulting in CR#1 cutting his arm and wrist. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was removed on 09/23/2023 at 1:19 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure place residents at risk of not having their needs met, serious physical harm, injury, and/or death. The findings included: Record review of CR #1's Admission Record, dated 09/19/2023, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and discharged on [DATE] to the hospital. Resident's diagnoses included cardiac arrest (cessation of normal circulation of blood due to failure of the heart to pump effectively), cognitive communication deficit (difficulties with thinking and how someone uses language), muscle weakness, abnormalities of gait and mobility (walking), lack of coordination, need for assistance with personal care, [NAME] lymphoma (type of cancer that affects the lymphatic system), and type 2 diabetes mellitus (high blood sugar) with hypoglycemia (low blood sugar) without coma. Record review of CR #1's hospital admission paperwork, dated 08/11/2023, revealed CR #1's medical problems included visual hallucinations. Further review revealed discharged medications, dated 09/12/2023, included Mirtazapine 30 mg daily and Quetiapine 50 mg, take 1 tablet by mouth once daily in the morning for 90 days Record review of CR #1's Admission MDS assessment, dated 09/15/2023, revealed Section C, Cognitive Patterns, C0500, BIMS Summary Score was in progress. Further review revealed Section E, Behavior, E0100, Potential Indicators of Psychosis, A. Hallucinations, was checked. Resident required one-person physical assist with bed mobility, dressing, and toileting. Resident required two-person physical assist with transferring. Record review of CR #1's orders, dated 09/19/2023, reflected in part .behavior monitoring for: depression medication: Remeron, Order Date 09/12/2023 . Mirtazapine Tablet 30 mg, Give 1 tablet by mouth one time a day for depression, Order Date 09/12/2023 . Quetiapine Fumarate 25 mg Tablet, Give 1 tablet by mouth two times a day for antipsychotic, Order Date 09/13/2023 .and Seroquel XR Oral Tablet Extended Release 24 Hour 50 mg (Quetiapine Fumarate), Give 1 tablet by mouth one time a day for antipsychotic . Record review of CR #1's Baseline Care Plan, dated 09/13/2023, revealed it did not reflect CR #1's history of hallucinations, history of depression, need for behavior monitoring for depression medication, and/or behavioral interventions to prevent suicidal attempts. Further review revealed Section 4., Social Services, Section C., was incomplete. Section C. included mental health needs, behavioral concerns, intervention suggestions to de-escalate situations, and depression screening. Record review of CR #1's Care Plan, dated 09/14/2023, revealed it did not reflect CR #1's needs for use of an antidepressant medication, behavior monitoring r/t antidepressant medication for depression, use of an antipsychotic medication, history of hallucinations, and/or history of depression. Record review of CR #1's Care Conference Summary notes, dated 09/14/2023, read in part .resident had history of anti-depressants .history of hallucinations .level of confusion is higher . Record review of CR #1's Progress Notes, effective date 09/16/2023, read in part Called to [CR #1's] room by charge nurse .[CR #1] lying in bed .blood covered over body and left arm .skin and fatty tissue hanging from left arm .Found in [CR #1's] right hand holing glass from picture frame in which [CR #1] stated he cut his wrist .Left forearm noted large laceration with tissue and skin cut out to left forearm and wrist area. Tendon and bone exposed to forearm approximately 12 x 9 x 0.7 cm . [CR #1] stated that the staff was trying to kill him, and he was trying to kill himself first before the staff did. [CR #1] was experiencing visual hallucinations but able to respond to questions appropriately . [CR #1] .kept stating they trying to kill me during the time with patient until EMS arrived . [CR #1] transported to [hospital]. In a telephone interview on 09/19/2023 at 3:05 p.m., CNA A said she had been working at the facility for approximately 1 year and 5 months. She said she worked the 6:00 a.m. to 6:00 p.m. shift the day of resident CR #1's incidents on 09/16/2023. She said the resident was kind of mobile. She said he could stand-up but needed one-person assistance. She said he was responsive to incontinence care. She said that was the first time she had worked with the resident. She said prior to the resident's 2nd incident, the resident was lying in bed and appeared to be sleeping. She said the resident did not appear to be depressed and did not display any suicidal ideations. She said she was passing out lunch trays when he cut himself. She said she observed the wound care nurse applying pressure to his arm. She said CR #1 kept saying y'all are not going to kill me. She said she did not know who he was referring to. In a telephone interview on 09/19/2023 at 3:17 p.m., CNA B said she had been working at the facility for approximately 1 year. She said she worked the 6:00 a.m. to 6:00 p.m. shift the day of CR #1's incidents on 09/16/2023. She said she had not worked with the resident prior to 09/16/2023. She said she was working in hall 300 when she heard a boom, like books falling. She said when she went inside CR #1's room, she found him on the floor, leaning up against the wall, in a sitting position, on the side of the bed that was located beside the window. She said she called out to Nurse A, and they helped the resident off the floor and moved him to bed A. She said when they were helping him up from the floor and back onto the other bed, he said they were trying to kill him. She said Nurse A assessed the resident, put his bed in the lowest position, covered him up, and everyone left the room. She said incident #1, when CR #1 was found on his bedroom floor, happened approximately 15 to 20 minutes before CR #1 cut himself. In a telephone interview on 09/19/2023 at 3:47 p.m., Nurse B said she had been working at the facility for approximately 11 months. She said she worked the 6:00 a.m. to 6:00 p.m. shift the day of CR #1's incident. She said she worked hall 300. She said it was the first time she worked with the resident. She said she saw CR #1 approximately 2 or more times during her rounds. She said when she first saw the resident, he was asleep in his bed and during another round he was lying in bed with his eyes open. She said throughout the day, the resident was calm and did not express that he wanted to hurt himself. She said he did not show signs of hallucinations or suicidal ideations. She said she was the one who found the resident when he cut his arm and wrist. She said the resident was lying in bed and was cutting himself with glass from a broken picture frame. She said CR #1 said staff were trying to kill him with medications, but he was going to kill himself first. In a telephone interview on 09/19/2023 at 4:41 p.m., Nurse A said she was headed toward the lounge when CNAs B and A were passing by CR #1's room and called her. She said she was assigned to a different hall that day but was the closest nurse at that time. She said when she got to the resident's room, he was sitting on the floor by his bed, on the side that was near the window. She said she assessed the resident and asked him what happened. She said the resident told her that he sat too close to the edge of the bed and slid down to the floor. She said CNAs B, A, and herself helped the resident to bed B and then moved him to bed A because bed B still had some movement to it when it was in the locked position. She said the resident told her one time that someone was trying to kill him. She said she sat on the bed with him, told him no one was trying to kill him, and talked with him for a little while. She said the CNAs left the room to pass meal trays and she left to go report the incident. She said when she was on her way to report the incident to Nurse B, she got called away to hall 400. She said by the time she finished in hall 400, CR #1 had already cut himself. She said she did not complete an incident report for the unwitnessed fall or report the resident's hallucinations to the DCO/DON and/or ADCO/ADON because she got busy doing something else. She said per the facility's policy, she should have completed an incident report. In a follow-up telephone interview on 09/19/2023 at 5:30 p.m., CNA A said CR #1 had an unwitnessed fall prior to cutting himself. She said CNA B found him in his room approximately 20 minutes before he cut himself. She said CNA B came down the hallway and told her and Nurse A that she heard a bang in another resident's room. She said CNA B told them she found CR #1 on the floor, in a sitting position, closest to the window that was near the left of the air conditioner. She said Nurse A, CNA B, and she picked CR #1 up, laid him on his bed and Nurse A assessed him and took his vitals. CNA A said CR #1 was moved to A bed because something was wrong with his bed (B bed). She said when CR #1 was on the floor he said once that y'all trying to kill me. CNA A said she did not mention what CR #1 said to anyone. She said after the incident, the resident was put back into bed, and she left and passed out lunch trays. In a follow-up interview on 09/19/2023 at 4:59 p.m., the DCO/DON said CR #1 had a fall and Nurse A forgot to complete an incident report. In a follow-up interview on 09/20/2023 at 2:33 p.m., the DCO/DON, said she was not aware of CR #1's history of hallucinations until the incident occurred. In a follow-up telephone interview on 09/20/2023 at 2:59 p.m., CNA B she said she did not remember if she asked CR #1 any follow-up questions. She said the resident was not upset, crying, or in distress after his fall. She said he only made the comment once. She said she was never told that the resident had a history of hallucinations. She said the resident was not hers. In a follow-up telephone interview on 09/20/2023 at 3:04 p.m., CNA A said she did not ask CR #1 any follow-up questions. She said the resident showed no emotion and was his regular self. She said he was quiet and only made the one comment. She said she was never told about his history of hallucinations. She said he showed no signs of suicidal ideations. She said CR #1 was not her regular resident. In a follow-up interview on 09/20/2023 at 3:50 p.m., the MDS Nurse said the CNAs knew what behaviors to monitor because it was in the residents' Point of Care located under Monitor-Behavior Symptoms in their computer system. She said the Charge Nurses told the CNAs about any behavior problems with residents. She said CNAs also gave reports to the oncoming shift CNAs. In a follow-up interview on 09/20/2023 at 4:15 p.m., Nurse A said she asked CR #1 who was trying to kill him, and he said staff. She said when she asked him what staff, he did not answer. She said the resident did not show any signs of distress. She said the resident was not crying or upset. She said she was never told he had a history of hallucinations. She said he did not show any signs of homicidal or suicidal ideations. She said incident reports should be documented in the computer system under risk management. She said she was not exactly sure what the policy said but incidents should be documented within an hour. Record review of the facility's policy titled Incident and Accident effective 03/01/2017, read in part . Policy Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations. Procedure 1. Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred . 2. Incident reports are located in the electronic health record and are completed electronically. 3. Licensed nurse will complete a fall investigation report after every fall . 4. Licensed nurse will .and update resident's care plan after each fall. 5. Director of Clinical Operations will request a medication review by the pharmacist if new meds have been started . 6. Social Services will assess resident for any psycho-social changes related to the Incident or Accident . The Administrator was notified on 09/20/2023 at 5:15 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was presented to the facility at that time. The facility's Plan of Removal was accepted on 09/21/2023 at 4:41 p.m. and included: PLAN OF REMOVAL Name of facility: [] Date: Sept. 20th, 2023 Immediate action: F689- -The Director of Nurses completed Inservice initiated Inservice on 9/20/23 with nursing staff. The in service covered assessing residents for behaviors, completion of behavior monitoring sheet on residents with psychotropic medications requiring monitoring and assuring interventions are identified. In-service reads behavior monitoring, hallucinations, aggressive behavior, verbal aggression notify DCO, Charge Nurse, and/or Administrator. Assessment and properly assessing residents, act on assessment and notify management immediately, initiate 1:1 with the notification of delusion and hallucination. Staff are to follow the interactive care path for symptoms of acute mental status change. Director of Clinical Service's in service will be completed by 9/21/23. Revisions to care plan for Resident # 1 cannot be made due to resident being transferred to the hospital after incident occurred. -The Director of Clinical Operations completed an audit of all residents' antipsychotic, Psychotropic medications to ensure behavior monitoring sheets and interventions are in place. The audit was conducted and completed on 9/20/23. -The Director of Clinical Operations and Designee Assessed all residents currently on antipsychotic, psychotropic medication with no notable signs of abnormal behavior on 9/20/2023. -Nurse A was in serviced on 9/20/2023 by Regional Director of Operations on timely completing I/A [incident/accident] documentation and to ensure monitoring and interventions are put in place and residents are place on monitoring and/or 1:1 if resident displaying signs of behavioral or psychosis with suicidal ideation until psychologist or psychiatrist can assess for safety. Employee must follow interact care path for symptoms of acute mental status change. -Medical Director notified of alleged facility noncompliance with completion of behavior monitoring with interventions on 9/20/23. -Staff to include Social Worker was in-serviced on 9/20/2023 by Regional Director of Resident Support on obtaining order and initiating psychological services for any resident displaying signs or having history of psychosis to include hallucinations. Following the acceptance of the facility's Plan of Removal (POR), the facility was monitored from 09/22/2023 through 09/23/2023. Monitoring of the POR included: In an interview on 09/22/2023 at 1:35 p.m., the DCO/DON, said she initiated and completed in-service training with staff from department heads all the way to dietary. She said the in-service for behavior monitoring, baseline care plans, assessing the residents for behaviors, and the directions on how to follow the care path symptoms of acute mental status change (tool used by RN's and LVN's that outlined what to do if a changed in a residents' mental status was identified) was reviewed and discussed. She said the in-service covered hallucinations, delusions, suicidal ideations, including if a resident reported that someone wanted to kill them or if the resident wanted to kill themselves, and verbal and physical aggression. She said staff were told to report any of those behaviors to the Charge Nurses, DCO/DON, and the Administrator. She said she told nursing staff to assess the resident immediately for any of the above-mentioned behaviors. She said Nurses were to follow the Care Path Symptoms of Acute Mental Status Change assessment tool. She said it gave a clinical path to initiate for a resident, ex. 1:1 supervision if suicidal ideations were voiced by the resident during the assessment and gave directions to notify the resident's MD, DCO/DON, and the Administrator. In the same interview, the DCO/DON said if a resident voiced suicidal ideations, hallucinations, delusions, verbal and/or physical aggressive behaviors to a CNA, the CNA was to implement behavior monitoring which included 1:1 supervision, were not to leave the resident alone, were to simultaneously notify the charge nurse over the assignment of the resident, DCO/DON, and the Administrator. She said the CNAs were to take the resident with them and/or use their cell phone to call the nurse and/or the Administrator for help. She said an audit was completed on 09/20/2023 of all residents' clinical records who were on an antipsychotic and/or psychotropic medication. She said the audit yielded that 100% of the residents that had a behavior monitoring in place listed behavior monitoring and the outcome of the monitoring in place. She said the behaviors listed to monitor for antidepressants included looking for behaviors such as crying, sadness, and tearfulness. She said they looked for antidepressants, antipsychotics, hypnotics, and antianxiety medications which warranted monitoring for listed exhibited behaviors. She said monitoring for the listed exhibited behaviors would be recorded on their online system under the LMAR behavior monitoring sheet. She said there were questions that were prompted for the charge nurses, LVNs and/or RNs, to monitor residents for behaviors that included antidepressants, antipsychotics, and hypnotics. She said there was an action to relieve the behavior that was being exhibited and an outcome to note if the action was effective. She said the ADCO/ADON completed the behavior monitoring audit on 09/20/2023. She said an audit for psychotropic medications was also completed by the ADCO/ADON and herself. She said the ADCO/ADON, and she also completed verbal assessments on all residents at the facility, including those that were taking antipsychotics and psychotropic medications. She said the ADCO/ADON, and she made rounds throughout the facility and asked those residents how they were doing. She said they asked the residents how they felt and whether they felt safe. In an interview on 09/22/2023 at 2:50 p.m., the Administrator said she received in-service training over the behavior monitoring process, mental status pathway (care path for mental health) and initiating psychiatric consults when a resident said anything that was out of the norm. In the same interview, she said she received training over the behavior monitoring process for resident's identified with behavior concerns. She said residents who displayed behavior concerns were not to be left alone. She said if the resident was bedridden, the staff member was to stay with them and was to use their cell phone to call the nurse on duty, the DCO/DON, ADCO/ADON, and/or herself. She said If the resident was wheelchair bound and/or ambulatory, staff were to assist the resident to the nurse/nurse's station so the nurse could complete an assessment. She said in case the CNAs heard the resident make any comments or display any behaviors such as saying they wanted to kill themselves, cause harm to others, or displayed any aggressive behaviors, including verbal and physical aggression, and/or any type of hallucinations, she said the assessment process included the nurse taking vitals, notifying the residents' physician, the medical director, and starting a psychiatric services consultation. She said the in-service training also covered the care path assessment tool. She said when these types of behaviors were displayed, the tool gave nurses a guide on how to respond as far as documentation, who to notify, and covered the different steps to take. She said the assessment tool was an additional resource for the nurses to use. She said their Medical Director was notified of the alleged non-compliance on 09/20/2023 by telephone and text message. She said the Regional Director of Resident Support and the RVP were emailed. She said the email included what the in-service needed to cover with the Director of Resident Support Services. She said the in-service covered if a resident displayed psychiatric issues, when family members reported any psychiatric issues, and when to refer residents to psychiatric services. She said some examples and reasons to refer to psychiatric services were also included. In an interview on 09/22/2023 at 3:33 p.m., the ADCO/ADON said she received in-service training. She said assessments on all residents were conducted verbally. She said the DOC/DON and she went to each residents' rooms and talked to them. She said they made sure their needs were being met, asked them if they felt safe, and asked them if they were experiencing hallucinations. She said they had an interactive care path tool that they followed/used. She said if the residents showed signs/symptoms of any acute mental health status changes they were to notify the DCO/DON. She said the interactive care path provided guidance and gave them a path on what to do based on what behaviors the resident was displaying. In a follow-up interview on 9/22/2023 at 3:48 p.m., the ADCO/ADON said the DCO/DON and she took the team lead and assisted with the audit on psychotropic medications. She said she found that the residents who were on those medications had their behavior monitoring orders in place. She said she helped complete in person rounds on the residents. She said she received training on how to complete the behavior monitoring sheet (LMAR) in their computer system. She said the behavior monitoring sheets were completed upon a resident's admission. She said during admission, residents were assessed, and medications were reviewed for antidepressants. She said residents that took psychotropic medications were flagged and the order(s) would be entered into the facility's computer system. She said the nurses completed the behavior monitoring sheets. She said 1:1 would be initiated, the DCO/DON would be notified and/or the Administrator if behavior concerns arose. In an interview on 09/22/2023 at 4:02 p.m., Nurse D said she worked the 3:00 p.m. to 10:00 p.m. shift. She said she received in-service training that talked about behavior monitoring and residents that had different ideations such as if someone wanted to kill them and/or if the resident planned and/or talked about wanting to harm themselves. She said she would inform the DCO/DON, Administrator, and doctor. She said she would put behavior monitoring in place. She said she would have someone sit with the resident or have them sit by the nurse's station where everyone could see them. She said there was guidance that could be used if there was a change in condition. She said the assessment tool included checking the resident's vitals to see if anything was abnormal and reporting to the doctor. She said she would consider the resident's baseline and would look for anything that deviated from their baseline. She said she would also look at their medication orders to see if it was a contributing factor to their behavior change. In an interview on 09/22/2023 at 4:21 p.m., CNA C said she had been working at the facility approximately since 2021. She said she worked the 6:00 a.m. to 6:00 p.m. shift. She said she received in-service training over behavior monitoring. She said if she noticed any behavior concerns, she had to document them in the computer system and would tell the Nurse, DCO/DON, and/or the Administrator. She said if the resident was suicidal, she would stay with the resident, provide 1:1 monitoring, and would call the Nurse, DCO/DON, and/or Administrator. She said anytime a resident had signs of hallucinations they must take the above steps because it was a serious matter. She said behavior problems should be documented on the resident's POC (Point of Care). She said the nurses assessed the residents if there was a change in the residents' mental status. In an interview on 09/23/2023 at 12:48 p.m., the DRSS/SW said she received in-service training. She said they discussed the different reasons to refer residents to psychiatric services, such as trauma, if their sleep pattern changed, if they had agitation, were anxious, or experienced isolation. She said residents who were prescribed psychotropic medications was also a reason to refer for services. She said they talked about steps moving forward such as what to do to minimize the likelihood of this happening again. She said she also received training over the care path assessment tool. She said if a resident had any mental health status changes and/or symptoms, the tool outlined what steps to take. She said it was an interact care path that was ultimately a map to be followed if a resident were to have any new mental status changes. She said it would guide staff step by step if a behavior was being displayed and what next steps were to be taken. In an interview on 09/23/2023 at 5:44 a.m., Nurse C said he had been working at the facility for [AGE] years. He said he worked the 10:00 p.m. to 6:00 a.m. Shift. He said he received the behavior monitoring training and received the Care Path assessment sheet that covered what to do and how to assess the resident for behavior abnormalities. He said the tool covered who to notify, such as the facility's DCO/DON, MD, Administrator, and ultimately the resident's family. He said they discussed aggressive behaviors such as if a resident wanted to kill themselves, falls, depression, and altered mental status such as hallucinations and suicidal ideations. He said anytime residents took antipsychotic medications, they put behavior monitors in the computer system and every day they checked off whether any behaviors were present such as yelling, hollering, crying, and/or aggression. He said residents with suicidal ideations had to be monitored, could not be left alone, and must be placed on 1:1 supervision. In an interview on 09/23/2023 at 5:55 a.m., CNA D said she had been working at the facility for approximately 1 month. She said she worked the 6:00 p.m. to 6:00 a.m. shift. She said she received in-service training regarding behavior monitoring. She said if a resident was acting suicidal or threatening, she would let the Nurse, DCO/DON, and Administrator know. She said residents were not to be left alone. She said if the resident was unable to leave the room, she would stay with them and use her telephone to call for help. She said they must also document the behavior in their online computer system. In an interview on 09/23/2023 at 6:38 a.m., CNA E said she worked the 6:00 a.m. to 6:00 p.m. shift. She said she received training over behavior monitoring. She said residents who displayed any type of behavior concerns needed to be reported to the Nurse, DCO/DON, and the Administrator immediately. She said the training covered behaviors such as hallucinations, yelling, kicking, screaming, and suicidal ideations. She said once those behaviors occurred, they should not be brushed aside. She said they were to provide 1:1 monitoring, stay with the resident, never leave them alone, and call for help. She said the types of behaviors listed above must also be recorded in their online computer system under behavior symptoms. She said the system also asked if the displayed behaviors were new or ongoing. She said if she was not sure about something and/or a procedure, she would report to the nurse. In an interview on 09/23/2023 at 6:52 a.m., CMA A said she had been working at the facility for approximately 1 year. She said she worked the 6:00 a.m. to 2:00 p.m. shift. She said she received training over behavior monitoring. She said if a resident had behavior concerns or expressed that they were going to kill themselves or someone, the CNAs needed to report it to the charge nurse, DCO/DON, and/or Administrator. She said if the resident showed signs of suicidal ideations, the resident was to not be left alone. She said the resident was to be taken to the nurse's station. She said if the resident was bedridden and unable to be taken to the nurse's station, she would stay in the room with the resident to provide 1:1 monitoring and would call for help using her cellular phone. She said the in-service training also covered when residents showed signs of hallucinations. She said she was a medication aide and would notify the charge nurse, DCO/DON, and administration. She said the CNAs would need to document the occurrence in the computer system, but in her case, she would notify administration who would be responsible for documenting. In a follow-up interview on 09/23/2023 at 1:12 p.m., Nurse A said she worked the 2:00 p.m. to 10:00 p.m. shift on the weekends. She said she received in-service training over behavior monitoring and assessing the residents for change in mental status, and documenting changes in their behavior in their computer system. She said the behavior monitoring training covered behaviors such as aggression, physical, verbal and what to do when a resident showed signs of suicidal ideations. She said residents who indicated they wanted to hurt themselves or others were never to be left alone. She said the DCO/DON, Administrator and resident's physician were all to be notified immediately if residents displayed those behaviors. She said psychiatric services should also be notified. She said they went over the Care Path tool to use for guidance when such behaviors were being displayed and a handout was provided. She said the tool provided steps to take when a mental status change was detected in a resident. She said it included taking vital signs and notifying all required personnel and their family immediately. She said the in-service training went over assessing residents' mental status. She said residents who took antipsychotic medications are monitored for behaviors and was documented in their online computer system to track any changes to their baseline status. Record review of the facility's behavior monitoring audit findings were reviewed. The findings revealed the audits for behavior monitoring, comprehensive care plans, and medication class were completed and were entered in the facility's computer system. Record review of the Care Path assessment sheet/tool was completed. The assessment/tool was a flow chart that separated the ordered steps to take when a resident displayed new symptoms of an acute mental status change. Ordered steps included: noting an acute status change in the resident, taking vitals, evaluating symptoms and signs, and evaluating results; considering contacting the physician for further evaluation and management, ordering and evaluating test results, managing the resident's behavior in the facility, and/or monitoring the resident's response. Record review of the facility's in-service training records related to the Care Path assessment/tool, dated 09/20/2023, confirmed 61 facility staff members received training over behavior monitoring, and the Care Path assessment/tool. An Immediate Jeopardy (IJ) was identified on 09/20/2023 at 5:15 p.m. While the IJ was [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 2 residents (Resident #1 and Resident #2) were reviewed for quality of care in that; -The facility failed to ensure Resident #1 who required a two-person extensive assist transfer was properly transferred to prevent fracture of her right tibia and fibula. -Resident #1 required total assistance with transfers and was unable to assist. CNA A used a gait belt and transferred the resident from bed to Geri-chair without the assistance of a 2nd CN[NAME] Nursing staff stated the resident is a total two-person assist and cannot assist with transfers. -Resident #2 required two-person extensive assistance with transfers and was transferred by CNA F and CNA G and then later by CNA C and CNA D improperly using a gait belt as a sling. -The facility failed to ensure all nursing staff were properly trained to transfer dependent residents using a gait belt. -The facility failed to ensure nursing staff who completed transfer training could properly transfer residents using a gait belt. -The facility failed to ensure CNAs knew where to look for resident transfer status prior to transferring residents. -These failures resulted in an immediate jeopardy on 9/13/19. While the IJ was removed on 9/14/19 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 2 residents, 1 resident experiencing a fractured tibia and fibula, placing both residents at risk of further injury and decline in health. Findings include: Resident #1 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, the BIMS was not completed because, resident was rarely/never understood. The Staff assessment for Mental Status revealed, the resident had long-term and short-term memory problems and her cognitive skills for daily decision making was severely impaired. Further record review revealed, the resident required two or more-person physical assist to total dependence for transfers and ADL care. Record Review of Resident #1's Care plan dated 7/25/16 with revision on 2/26/18 read in part, Focus I have an ADL Self Care Performance Deficit r/t Limited Mobility and advanced dementia. Goal, left blank, Interventions: TRANSFER: I require 2 staff for extensive to total assist participation with transfers into my Geri-chair. Record review of Resident #1's nursing progress notes dated 8/30/19 read in part, CNA asked nurse to come and see resident right leg which was swollen and had a bruise on the upper tibia area. Resident could not move her right leg as it is contracted. Pedal pulses were present, skin warm to touch with 1 + pedal [MEDICAL CONDITION]. Assistant DON and Administrator was notified. -(3:55 p.m.)- Resident's (family member) was called and no response to phone call. Nurse left message for family.(3:46 p.m.)-(NP) was called and was informed of resident right leg. Order given for X-ray and if results are positive for fractures to go ahead and send resident to the hospital for further evaluation and treatment.(3:29 p.m.)-(radiology) was called for Stat X-ray. (8:00 p.m.)- X-ray here to do a portable X-ray and results was sent at (10:30 p.m.) .(10:30 p.m.)- (family member) returned called and was notified of incident and was told she will be sent out to (local hospital). Further record review of Resident #1's nursing progress notes dated 8/31/19 read in part, X-Ray results Acute tibia and fibula Fractures. Resident was sent to the ER for evaluation and treatment left at 11:30 p.m. 8/30/19 Via (EMS) and 2 EMTs bp 136/78 pulse 102 resp. 20 temp 99 o2 sat 97% RA (family member) was notified. Record review of Hospital radiology report dated 8/31/19 read in part, EXAM: XR TIBIA FIBULA 2 VW RIGHT CLINICAL HISTORY: obvious deformity tib fib fx COMPARISON: None. IMPRESSION: 1. Evidence for a mildly comminuted, spiral [MEDICAL CONDITION] tibia with one half of shaft width volar displacement of the main distal fracture fragment, best see on the lateral view. Mildly comminuted, spiral [MEDICAL CONDITION]-mid fibular diaphysis also noted. Expected overlying soft tissue swelling . Record review of the facility Witness Interview of CNA A dated 9/03/19 read in part, I transferred the resident with my gait belt from bed to Geri chair. I transferred the resident by myself. Interview on 9/10/19 at 11:37 AM with PT, she stated Resident #1 required an extensive two-person assist transfer. She stated the resident had been non-ambulatory for quite a while and was not on therapy services at the time she acquired the fracture. She stated when Resident #1 was on therapy, they used the extensive two-person pivot transfer. When asked if a gait belt was used, she stated PT always used a gait belt. When asked if the nursing staff used a gait belt during the residents' transfer, she stated they should, but she was not sure, the nursing staff would have to be asked. When asked if she knew how the resident could have sustained the injury, she stated she was not sure what happened, but in her opinion, residents with [MEDICAL CONDITION] could easily have a fracture, further stating the resident's x-rays looked like little spider webs. Interview on 9/10/19 at 1:06 PM with LVN A, she stated she did not witness Resident #1's injury but was told when a CNA went to lay her down, the CNA noticed her right leg or knee was swollen. When asked what the resident's transfer status was, she stated the resident required a two-person transfer or mechanical lift. When asked if the resident could stand on her own, she said no, she could not stand. When asked if the resident always required a two-person assist or mechanical transfer, she stated yes. Interview on 9/10/19 at 1:20 PM with CNA A, when asked if she could explain the incident that occurred with Resident #1, she stated she got the resident up from her bed and transferred her to the Geri-chair using a gait belt. She stated she didn't notice the resident moaning or groaning or any disfigurement to her right leg. She stated she got the resident up and out of bed around 4:30 - 5:00 am. When asked if she was aware the resident was a two-person transfer, she stated she did not know this, further stating she has always transferred the resident by herself using the gait belt. When asked if the residents feet were able to touch the ground to assist with the transfer, she stated No, the resident was on her tippy toes, her feet did not touch the ground. She was unable to state who transferred the resident back into her bed after lunch. She stated she did not know where to look for the type of transfer and didn't know if it was documented in the EHR. She stated usually it would be on the wall on paper near the kiosk, but she had not seen it. She stated she had been transferring the resident by herself for four years. Further interview on 9/10/19 with CNA A, when asked who and when she was trained on transfers, she stated she was trained by therapy a couple of days ago regarding using a gait belt, mechanical lift and two-person transfer, and her last training on transfers before that was when she started at the facility five years ago. She stated she had never witnessed another CNA transfer the resident because she worked night-shift and she was the only one on that hall. Surveyor asked how she knew what type of transfer a new resident required, she stated therapy would tell the staff if they are on PT services. When asked when a resident was not on PT services, how would she know the type of transfer a resident required, she stated she would not know until staff got the resident up. She said she did not know if Resident #1 currently required a mechanical lift or two-person transfer. Interview on 9/10/19 at 2:16 PM with CNA B, she said Resident #1 required a two-person gait belt assist. She stated the resident was not able to help with the transfer and needed total assistance. When asked if a mechanical lift was ever used, she stated no. She said using a mechanical lift would probably be a safer way to transfer because of her [MEDICAL CONDITION] and conditions. She further stated some of the newer staff do not like to use the mechanical lift. She reported her last transfer training was last Thursday after the incident with Resident #1 and prior to that she said, Maybe 3-4 months ago. Interview on 9/10/19 at 2:20 PM with CNA C, when asked if she could explain the incident that occurred with Resident #1, she reported she worked with the resident that day. She said when she went into her room the resident was facing the window, and she left the room and came back around 1:15 PM and the resident was facing the door, stating she did not touch the resident. She said when she went to get wipes because her brief was wet, CNA [NAME] was in the room doing her hair and took her pants off and noticed something was wrong with her leg. She stated there was nothing wrong with her leg the night before. She said she had not transferred the resident she only turned her and changed her. When asked what type of transfer the resident required, she stated the resident needed a two-person transfer. When asked if she received transfer training, she stated she had been working at the facility for about two weeks and received training but could not state the type of training she received, further stating she completed a bunch of tests but was not physically trained on transfers. She said she has been a CNA for [AGE] years and it's all up here. Interview on 9/10/19 at 2:57 PM with CNA E, when asked to explain the incident that occurred with Resident #1, she stated when she went to do care, stating the resident needed to be changed, and she noticed her right leg wasn't right. She said she immediately got her charge nurse LVN B and the nurse assessed the resident. She said Resident #1 required a two-person assist with gait belt, stating she has been a two person assist since she had been working at the facility, which has been for a little over three years. When asked if the resident was able to move herself or turn herself in bed, she stated no. When asked if the resident was able to place her feet on the ground or assist with the transfer she stated no. She could not recall when she received transfer training other than after the incident occurred. When asked how she knew what type of transfer a resident required, she stated sometimes it was on the hospital document if they were a new admit, otherwise she would get a charge nurse and ask. When asked about using a mechanical lift for Resident #1, she stated I really believe a Hoyer lift would be a safe way to transfer her. Interview on 9/11/19 at 12:40 PM with LVN B, she stated she did not know exactly what happened to Resident #1 stating at 3:00 p.m. CNA [NAME] asked her to come look at the resident because something was wrong with her leg. She said the resident was lying on her back with her right leg flexed and she noticed a bruise on her right shin and it looked like something had happened. She said when she touched her leg she could see the bone moving, stating she assessed her pulse and she saw swelling and an indentation in her leg so she knew something was wrong. She was unable to say who transferred the resident back to the bed after lunch stating she came in at 2pm and the resident was already in bed. When asked what type of transfer the resident was, she stated she required a two-person mechanical lift transfer. She stated she had no training on transfers while at this nursing home. When asked if the resident had any falls, she stated she has been working at the facility for two years and the resident had not had any falls since she has been working there. When asked how she thinks the resident sustained [REDACTED]. She further stated she really doesn't know how or when the injury occurred. Interview with the ADON on 9/10/19 at 3:18 PM, she stated she did not witness the incident involving Resident #1, stating she was told that the aide went into the room and found a bruise on her leg and the aide asked the charge nurse to assess the resident. She stated she did not know the type of transfer the resident required at that time but stated she did now. When asked how she thought the resident injury occurred, she stated the resident had [MEDICAL CONDITION] and she was very brittle and just lying there, being moved or if someone touched her, could cause a fracture. She stated Resident #1 required a two-person gait belt transfer. When asked if Resident #1 could participate in the transfer, she stated no, she could never participate in the transfer. When asked if the resident was able to place her feet on the floor during the gait transfer, she stated passively, but not actively, someone would have to put her feet on the floor. Observation on 9/11/19 at 7:33 AM revealed Resident #1 was asleep, lying on her back. The resident's right leg was contracted, she was wearing a soft cast which started below the knee and extended onto the right foot with her toes exposed, a soft splint was over the cast. The resident's left leg was contracted. The resident was not interviewed due to her cognitive impairment. Record review of Resident #1's physician orders dated (MONTH) 2019, reviewed on 9/11/19, revealed there were no orders for non-weight bearing status. Interview on 9/11/19 at 7:35 AM with the DON, when asked what type of transfer Resident #1 required, she said she thought the resident was non-weight bearing, but she would have to look this up because she was not sure. She said they were just turning and repositioning her. When the surveyor informed the DON multiple nursing staff have stated the resident was a two-person transfer to the Geri-chair and there were no orders for non-weight bearing status, she stated she would have to follow-up. Record review of hospital Discharge Instructions/Physician Orders dated 09/07/19 revealed, None checked for Resident #1's weight bearing status. Record review of facility Physician orders dated (MONTH) 2019 revealed, an order dated 9/13/19 for Resident #1's weight bearing status and read in part, non wt bearing status, remain in bed til (sic) fracture heals, log roll, turn and reposition as needed every shift. Interview on 9/10/19 at 2:24 PM with CNA D, she stated she had been working at the facility for about 1 ½- 2 weeks. She stated she never transferred Resident #1. She stated she received transfer training on mechanical lift, gait belt to chair and chair to bed by therapy about 1-2 weeks ago after the incident involving Resident #1. Interview on 9/11/19 at 8:49 AM with CNA F, she stated she determined resident's transfer status needs by looking at the care plan in the P[NAME]. She stated she was trained by another CNA on two-person, Hoyer and gait belt transfers, stating they were short staffed, so it was hard to get staff trained when she started. She said her last transfer training was during orientation, she could not provide a date. Interview on 9/11/19 at 9:22 AM with the DON, when asked what the policy was on resident transfers, she stated she could not answer this because she just started working two days ago. She said generally it depends what the residents are coming in for. She said if PT was ordered they would assess the resident. She said she only knows based on what she used to do. Resident #2 Record review of Resident #2's Face sheet revealed she is a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, the BIMS was not assessed because resident was rarely/never understood. Further record review of the Staff Assessment for Mental Status revealed the resident had long-term and short-term memory problems and her cognitive skills were severely impaired. Further record review of Resident #2's MDS assessment revealed, the resident required total dependence for transfers using one-person physical assist. Record review of the Provider Investigation Report dated 09/08/19 read in part, 5. Transfer status audit completed, 6. all employees in-service on all transfer by therapy with return demonstration 8. Care Plans updated. Further record review of the Provider Investigation Report revealed, the facility P[NAME] was not updated on all resident transfer status resulting in nursing staff not knowing resident transfer status prior to transferring residents. CNAs C, D, F, and G who were trained on transfers were observed transferring Resident #2 incorrectly and there was no documentation of transfer training for CNA C and D. Nursing staff did not know where to look to determine resident transfer status. Record review of Resident #2's Care plan revised on 9/11/19, read in part, F[NAME]US I have ADL Self-Care Performance Deficit r/t Dementia .Interventions .TRANSFER: I require 2 staff extensive assist with transfers. The Care plan was revised after surveyor intervention. Observation on 9/11/19 at 10:22 AM with Resident #2 with CNA F and CNA G revealed, during the transfer, the resident's feet did not touch the floor nor was she able to place her feet on the floor. CNA G lifted the resident from the Geri-chair and placed her in the bed using the gait belt, CNA F held the residents legs until she was positioned in the bed. The Geri-chair was not locked and moved throughout the transfer. The resident was not wearing slip resistant socks or shoes during the transfer. Interview on 9/11/19 at 10:30 AM with CNA G, when asked if the resident's feet should be on the floor during the transfer, she stated yes. When asked if the resident should be lifted during a two-person gait belt transfer, she stated yes. When asked if she was trained to lift residents during a gait belt transfer, she stated yes, therapy trained her to lift the resident. When asked if the wheels should be locked on the Geri-chair prior to moving the resident, she stated yes, further stating the wheels move when the chair is locked. She then stated the chair tilted because it was on a mat. When asked how she determines the residents transfer status, she stated the nurse will tell her how the resident is transferred. She stated her last transfer training was last Thursday. She stated she was trained on mechanical lift and gait belt transfers. When asked what the transfer status was for Resident #2, the CNA could not state the type of transfer. Interview on 9/11/19 at 10:32 AM with CNA F, when asked if a resident's feet should touch the floor during a two-person gait belt transfer, she stated The residents' feet should always touch the floor at all the times, further stating that's how she was trained. She stated the resident is not supposed to be lifted during a two-person gait belt transfer. She said the Geri-chair should be locked during the transfers, further stating the chair moves even when it is locked. She stated she should tell the nurse or maintenance so a new chair could be used because the resident could be injured if the chair moves during the transfer. Interview on 9/11/19 at 11:18 AM with the Physical Therapy Director, when asked what types of transfers were nursing staff trained on, she stated in-services included mechanical lift and 1-2 person transfers using a mannequin. She stated once they completed a return demonstration on the mechanical lift, they demonstrated a 1-person, then 2-person transfer with gait belt stating a gait belt should always be used. When asked if the residents feet should touch the ground during a gait belt transfer and if nursing staff were trained to lift a resident during a transfer with a gait belt, she stated it depends on the resident, stating some residents can assist and it depends if their feet can touch the ground. She said the Geri-chair should always be locked before transferring. She said there was not a separate competency check off for the gait belt transfer, and it was included in the mechanical lift competency check off. Interview on 9/11/19 at 12:24 PM with PT, when asked if a resident should be lifted during a gait-belt transfer, she stated in her opinion, the residents' feet should at least be able to make contact on the floor, further stating if the resident was lifted then a mechanical lift should be used. She stated sometimes the residents who are light, the CNAs will lift them, but in her opinion, the residents' feet should be touching the ground to assist with the transfer. Observation on 9/11/19 at 4:11 PM with Resident #2 with CNA C and D revealed, the resident was not able to assist with the transfer, she had contractures to her hands bilaterally with stiff lower extremities. CNA D lifted the resident by the gait belt and her feet slid across the floor during the transfer. CNA C was positioned behind the resident during the transfer and then moved behind the Geri-chair once the resident was positioned on the chair by CNA D. Interview on 09/11/19 at 4:25 PM with the DON, when asked if a resident should ever be lifted during a two-person gait belt transfer, she stated no, further stating sometimes the CNAs don't know their strength and may pick the resident up because the resident is light and doesn't weigh much. When asked if a Hoyer lift would be a safer way to transfer Resident # 2 since she is unable to place her feet on the floor or assist with the gait belt transfer, the DON stated no because the resident's skin may tear if the Hoyer lift was used. Record review of American Nurse today Gait belts 101: A tool for patient and nurse safety dated (MONTH) 2019 read in part, .After the gait belt is properly secured, ensure that the patient's feet are placed flat on the floor (no tiptoes or dangling feet) .A gait belt is used to steady a patient-it is not a lifting device. You can help the patient by raising or lowering the bed Resource Gait belts are one option for steadying patients and should never be substituted for lifting devices. Interview with the Administrator on 09/13/19 at 8:43 AM, when asked what the facility process or system was regarding transfer training for nursing staff, she stated Therapy spear headed the transfer training for nursing staff. She said new hires have generalized skills check off which includes transfers and by the time they finish training each department should have checked off their skills. She said this is all new, stating there was no process previously, but the facility now has skills check offs for the new employees, stating she was not sure if it was previously being done. She said she was not sure of the frequency of the skills check offs for transfers, stating they do not have a system or process set up and there is no policy. She further stated this is all new. When asked what the process is for PRN staff regarding transfer training, she stated just recently the ADON contacted the PRN staff and sent out texts to let them know training is going on. She further stated the break rooms have signs stating training is going on. When asked how is nursing staff audited to ensure training is continued or if further training is needed prior to transferring a resident, she stated they used an employee roster to audit and moving forward they will use the roster. She was unable to provide individual skills check off lists for gait belt, 1 or 2 person transfers, or in-services which showed nursing staff were trained on where to look to determine resident transfer status. Further interview with the Administrator on 9/13/19 at 8:43 AM, when asked what the system was for identifying and assessing all resident transfer type, she stated when residents are admitted they will look at the hospital they came from, or if they came from another facility they will go by the transfer they had at that facility or hospital. She said the nurse would determine if the resident is a 1-person or 2-person transfer and if there is a question, then Therapy would be asked about the transfer type. When asked how this system is audited to ensure all residents are assessed properly, she stated there is no process or system to ensure the assessments are being completed properly, further stating the nurses can ask PT if there is a question. Interview with the DON on 9/13/19 at 9:02 AM, she stated there currently is no policy or process in place regarding transfer training or resident assessments to determine the type of transfer the residents need. She stated she wants therapy to assist with the process when it's implemented and wants nursing staff to be checked off and trained by the (MONTH) 30th further stating this is about two weeks. She said, I need to be real here, so in 2-3 weeks I would like all nursing staff to be trained on transfers. Record review of the facility's undated Transfer status audit revealed Resident #1 and Resident #2 were not re-assessed to determine appropriate transfer type. Resident #1's status indicated she should be transferred by two persons with a gait belt even though she had a fractured tibia. Resident #2's status indicated she should be transferred by two persons with a gait belt even though she could not bear weight and was being carried with the weight belt. Record review of the facility's transfer training revealed, there was not a competency check off list for gait belt, one-person, or two-person transfers. Record review of the facility Hoyer Lift Transfer skills check off dated 06/14 revealed, a total of 12 nursing staff were checked off on Hoyer lift transfer which included 7 CNAs, 4 LVNs, and 1 medical records staff. Based on the employee roster, there was a total of 29 staff who did not receive training; 16 CNAs', 10 LVN's and 3 RN's. Further record review of 5 Hoyer Lift Transfer skill check off revealed, the 5 check offs which included 3 CNAs and 2 LVNs did not have the staff signature on the bottom of the form showing the training was completed. Record review of the facility's employee roster documenting staff who completed transfer training revealed, a total of 16 nursing staff checked off on transfers and a total of 29 nursing staff left to be checked off. The facility Administrator and the DON were notified on 9/13/19 at 9:23 a.m. that an IJ had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 9/13/19 at 12:44 p.m After several revisions, the final Plan of Removal was accepted on 9/14/19 at 9:11 a.m The plan of removal included the following: -In-service all Certified Nursing assistance on proper transfer by therapy/DON/ADON initiated 9/9/2019. In-service expected to be completed by 9/14/2019, any staff who are not available will be required to complete the training prior to working with residents. -In-service all CNAs on using the Kardex to validate type of transfer to use on the resident by therapy/DON/ADON initiated 9/9/2019. In-service expected to be complete by 9/14/2019, any staff who are not available will be required to complete training prior to working with residents. -DON/ADON will be provided in-service on transfers, and to update the Kardex/care plan when there is a change in condition by Therapy/Regional Nurse initiated 9/13/2019. -Resident #1 is being transferred by Hoyer, and care plan updated 9/13/2019. -Resident #2 is being transferred by Hoyer, and care plan updated 9/13/2019. -Transfer competency to be completed on Hoyer, gait belt, and two-person transfer with nursing staff before the start of assignment. Any staff not included with the training will not work until competency is completed. Transfer training/competency will be completed with all new nursing staff during orientation process. -ADL Care Plans updated in Point Click Care starting 9/3/2019 and completed 9/13/2019. -Policy and procedure on Safe Lifting and Movement of residents initiated 9/13/2019 will be provided to Dept. Head, Nursing Staff, and Rehab Staff by Regional Nurse. -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. -All residents who require a two-person transfer were re-assessed to determine if Hoyer was appropriate and Kardex updated on 9/13/2019. -DON/ADON will monitor 5 transfers a week to ensure compliance x four weeks and results will be discussed in QAPI meeting starting 9/13/2019. -Confirmation of adequate number of slings and gait belts to provide care to all residents on 9/13/2019. Validation/Monitoring tool -Gait Belt transfer competency check list -Hoyer lift transfer competency check list -New resident will be reviewed in morning clinical meeting to identify the transfer technique/change -Use of Kardex on P[NAME] with the CNAs on individual resident. -Employee Monitoring checklist for compliance The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Observations on 09/14/19 revealed, CNAs properly transferring residents using two-person gait belt and Hoyer lift transfers. Observation on 09/14/19 revealed, there was an of appropriate number of gait belts and Hoyer lifts available for resident transfers. Multiple interviews with nursing staff on 09/14/19 revealed, they were able to state where to locate resident transfer status. Record review of Resident #1 and Resident #2's Care plan revealed transfer status was updated to a Hoyer lift. Record review of all resident Care Plans revealed, ADL transfer status was updated for all residents at the facility and carried over to the Kardex for CNAs to review. Record review of the facility in-services conducted on 9/14/19 revealed CNAs were trained on proper transfer techniques by therapy staff and the DON. The Administrator provided a list of staff who were not available and will be required to complete the training prior to working with residents. Record review of in-services initiated on 9/13/19 revealed the DON and ADON received training on transfers, and how to update the Kardex/care plan when there is a change of condition. This training was provide by the Therapy staff and the Regional Nurse. Record review of the facility Policy and procedure on Safe Lifting and Movement revealed and inservice was provided to provided to the Dept. Head, Nursing Staff, and Rehab Staff by Regional Nurse. Record review of the Kardex revealed, all residents who require a two-person transfer were re-assessed to determine if Hoyer was appropriate and Kardex was updated on 9/13/2019. The facility had a total of 18 Hoyer lift transfers after audit was completed. Record review of facility's validation and monitoring tools revealed, individual skills check list for Hoyer, gait belt and two-person transfers and employee monitoring to determine staff compliance for transfers and knowledge of identifying and locating resident transfer status, morning clinical meetings tool to address new resident assessments and transfer status. The Administrator was notified that the IJ was lowered o

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 2 of 6 residents (Resident #1 and Resident #2) reviewed for neglect in that; -The facility failed to ensure nursing staff who completed transfer training could properly transfer Resident #1 and Resident #2, and other residents who were dependent on staff using two-person extensive assist with a gait belt. Resident #1 fractured her right tibia and fibula after being transferred by CNA using a gait belt. -The facility failed to ensure all nursing staff knew where to look for resident transfer status. -The facility failed to ensure there was a system in place to ensure all nursing staff received transfer training prior to transferring residents and all residents were properly assessed to determine transfer status. -These failures resulted in an immediate jeopardy on 9/13/19. While the IJ was removed on 9/14/19 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. -These failures affected 2 residents, placing them at risk of neglect. Findings include: Resident #1 Record review of Resident #1's face sheet revealed she was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's Quarterly MDS dated [DATE] revealed, the BIMS was not completed because, resident was rarely/never understood. The Staff assessment for Mental Status revealed, the resident had long-term and short-term memory problems and her cognitive skills for daily decision making was severely impaired. Further record review revealed, the resident required two or more-person physical assist to total dependence for transfers and ADL care. Record Review of Resident #1's Care plan dated 7/25/16 with revision on 2/26/18 read in part, Focus I have an ADL Self Care Performance Deficit r/t Limited Mobility and advanced dementia. Goal, left blank, Interventions: TRANSFER: I require 2 staff for extensive to total assist participation with transfers into my Geri-chair. Record review of Resident #1's nursing progress notes dated 8/30/19 read in part, CNA asked nurse to come and see resident right leg which was swollen and had a bruise on the upper tibia area. Resident could not move her right leg as it is contracted. Pedal pulse was present in both legs, skin warm to touch with 1 + pedal [MEDICAL CONDITION]. Assistant DON and Administrator was notified. -(3:55 p.m.)- Resident's (family member) was called and no response to phone call. Nurse left message for family.(3:46 p.m.)-(NP) was called and was informed of resident right leg. Order given for X-ray and if results are positive for fractures to go ahead and send resident to the hospital for further evaluation and treatment.(3:29 p.m.)-(radiology) was called for Stat X-ray. (8:00 p.m.)- X-ray here to do a portable X-ray and results was sent at (10:30 p.m.) .(10:30 p.m.)- (family member) returned called and was notified of incident and was told she will be sent out to (local hospital). Further record review of Resident #1's nursing progress notes dated 8/31/19 read in part, X-Ray results Acute tibia and fibula Fractures. Resident was sent to the ER for evaluation and treatment left at 11:30 p.m. 8/30/19 Via (EMS) and 2 EMTs bp 136/78 pulse 102 resp. 20 temp 99 o2 sat 97% RA (family member) was notified. Record review of Hospital radiology report dated 8/31/19 read in part, EXAM: XR TIBIA FIBULA 2 VW RIGHT CLINICAL HISTORY: obvious deformity tib fib fx COMPARISON: None. IMPRESSION: 1. Evidence for a mildly comminuted, spiral [MEDICAL CONDITION] tibia with one half of shaft width volar displacement of the main distal fracture fragment, best see on the lateral view. Mildly comminuted, spiral [MEDICAL CONDITION]-mid fibular diaphysis also noted. Expected overlying soft tissue swelling . Record review of the facility Witness Interview of CNA A dated 9/03/19 read in part, I transferred the resident with my gait belt from bed to Geri chair. I transferred the resident by myself. Interview on 9/10/19 at 11:37 AM with PT, she stated Resident #1 required an extensive two-person assist transfer. She stated the resident had been non-ambulatory for quite a while and was not on therapy services at the time she acquired the fracture. She stated when Resident #1 was on therapy, they used the extensive two-person pivot transfer. When asked if a gait belt was used, she stated PT always used a gait belt. When asked if the nursing staff used a gait belt during the residents' transfer, she stated they should, but she was not sure, the nursing staff would have to be asked. When asked if she knew how the resident could have sustained the injury, she stated she was not sure what happened, but in her opinion, residents with [MEDICAL CONDITION] could easily have a fracture, further stating the resident's x-rays looked like little spider webs. Interview on 9/10/19 at 1:06 PM with LVN A, she stated she did not witness Resident #1's injury but was told when a CNA went to lay her down, the CNA noticed her right leg or knee was swollen. When asked what the resident's transfer status was, she stated the resident required a two-person transfer or mechanical lift. When asked if the resident could stand on her own, she said no, she could not stand. When asked if the resident always required a two-person assist or mechanical transfer, she stated yes. Interview on 9/10/19 at 1:20 PM with CNA A, when asked if she could explain the incident that occurred with Resident #1, she stated she got the resident up from her bed and transferred her to the Geri-chair using a gait belt. She stated she didn't notice the resident moaning or groaning or any disfigurement to her right leg. She stated she got the resident up and out of bed around 4:30 - 5:00 am. When asked if she was aware the resident was a two-person transfer, she stated she did not know this, further stating she has always transferred the resident by herself using the gait belt. When asked if the residents feet were able to touch the ground to assist with the transfer, she stated No, the resident was on her tippy toes, her feet did not touch the ground. She was unable to state who transferred the resident back into her bed after lunch. She stated she did not know where to look for the type of transfer and didn't know if it was documented in the EHR. She stated usually it would be on the wall on paper near the kiosk, but she had not seen it. She stated she had been transferring the resident by herself for four years. Further interview on 9/10/19 with CNA A, when asked who and when she was trained on transfers, she stated she was trained by therapy a couple of days ago regarding using a gait belt, mechanical lift and two-person transfer, and her last training on transfers before that was when she started at the facility five years ago. She stated she had never witnessed another CNA transfer the resident because she worked night-shift and she was the only one on that hall. Surveyor asked how she knew what type of transfer a new resident required, she stated therapy would tell the staff if they are on PT services. When asked when a resident was not on PT services, how would she know the type of transfer a resident required, she stated she would not know until staff got the resident up. She said she did not know if Resident #1 currently required a mechanical lift or two-person transfer. Interview on 9/10/19 at 2:57 PM with CNA E, when asked to explain the incident that occurred with Resident #1, she stated when she went to do care, stating the resident needed to be changed, and she noticed her right leg wasn't right. She said she immediately got her charge nurse LVN B and the nurse assessed the resident. She said Resident #1 required a two-person assist with gait belt, stating she has been a two person assist since she had been working at the facility, which has been for a little over three years. When asked if the resident was able to move herself or turn herself in bed, she stated no. When asked if the resident was able to place her feet on the ground or assist with the transfer she stated no. She could not recall when she received transfer training other than after the incident occurred. When asked how she knew what type of transfer a resident required, she stated sometimes it was on the hospital document if they were a new admit, otherwise she would get a charge nurse and ask. When asked about using a mechanical lift for Resident #1, she stated I really believe a Hoyer lift would be a safe way to transfer her. Interview on 9/11/19 at 12:40 PM with LVN B, she stated she did not know exactly what happened to Resident #1 stating at 3:00 p.m. CNA [NAME] asked her to come look at the resident because something was wrong with her leg. She said the resident was lying on her back with her right leg flexed and she noticed a bruise on her right shin and it looked like something had happened. She said when she touched her leg she could see the bone moving, stating she assessed her pulses and she saw swelling and an indentation in her leg so she knew something was wrong. She was unable to say who transferred the resident back to the bed after lunch stating she came in at 2 p.m. and the resident was already in bed. When asked what type of transfer the resident was, she stated she required a two-person mechanical lift transfer. She stated she had no training on transfers while at this nursing home. When asked if the resident had any falls, she stated she has been working at the facility for two years and the resident had not had any falls since she has been working there. When asked how she thinks the resident sustained [REDACTED]. She further stated she really doesn't know how or when the injury occurred. Interview on 9/10/19 at 2:16 PM with CNA B, she said Resident #1 required a two-person gait belt assist. She stated the resident was not able to help with the transfer and needed total assistance. When asked if a mechanical lift was ever used, she stated no. She said using a mechanical lift would probably be a safer way to transfer because of her [MEDICAL CONDITION] and conditions. She further stated some of the newer staff do not like to use the mechanical lift. She reported her last transfer training was last Thursday after the incident with Resident #1 and prior to that she said, Maybe 3-4 months ago. Interview on 9/10/19 at 2:20 PM with CNA C, when asked if she could explain the incident that occurred with Resident #1, she reported she worked with the resident that day. She said when she went into her room the resident was facing the window, and she left the room and came back around 1:15 PM and the resident was facing the door, stating she did not touch the resident. She said when she went to get wipes because her brief was wet, CNA [NAME] was in the room doing her hair and took her pants off and noticed something was wrong with her leg. She stated there was nothing wrong with her leg the night before. She said she had not transferred the resident she only turned her and changed her. When asked what type of transfer the resident required, she stated the resident needed a two-person transfer. When asked if she received transfer training, she stated she had been working at the facility for about two weeks and received training but could not state the type of training she received, further stating she completed a bunch of tests but was not physically trained on transfers. She said she has been a CNA for [AGE] years and it's all up here. Interview with the ADON on 9/10/19 at 3:18 PM, she stated she did not witness the incident involving Resident #1, stating she was told that the aide went into the room and found a bruise on her leg and the aide asked the charge nurse to assess the resident. She stated she did not know the type of transfer the resident required at that time but stated she did now. When asked how she thought the resident injury occurred, she stated the resident had [MEDICAL CONDITION] and she was very brittle and just lying there, being moved or if someone touched her, could cause a fracture. She stated Resident #1 required a two-person gait belt transfer. When asked if Resident #1 could participate in the transfer, she stated no, she could never participate in the transfer. When asked if the resident was able to place her feet on the floor during the gait transfer, she stated passively, but not actively, someone would have to put her feet on the floor. Observation on 9/11/19 at 7:33 AM revealed Resident #1 was asleep, lying on her back. The resident's right leg was contracted, she was wearing a soft cast which started below the knee and extended onto the right foot with her toes exposed, a soft splint was over the cast. The resident's left leg was contracted. The resident was not interviewed due to her cognitive impairment. Record review of Resident #1's physician orders [REDACTED]. Interview on 9/11/19 at 7:35 AM with the DON, when asked what type of transfer Resident #1 required, she said she thought the resident was non-weight bearing, but she would have to look this up because she was not sure. She said they were just turning and repositioning her. When the surveyor informed the DON multiple nursing staff have stated the resident was a two-person transfer to the Geri-chair and there were no orders for non-weight bearing status, she stated she would have to follow-up. Record review of hospital Discharge Instructions/Physician order [REDACTED].#1's weight bearing status. Record review of facility Physician orders [REDACTED].#1's weight bearing status and read in part, non wt bearing status, remain in bed til (sic) fracture heals, log roll, turn and reposition as needed every shift. Interview on 9/10/19 at 2:24 PM with CNA D, she stated she had been working at the facility for about 1 ½- 2 weeks. She stated she never transferred Resident #1. She stated she received transfer training on mechanical lift, gait belt to chair and chair to bed by therapy about 1-2 weeks ago after the incident involving Resident #1. Interview on 9/11/19 at 8:49 AM with CNA F, she stated she determined resident's transfer status needs by looking at the care plan in the P[NAME]. She stated she was trained by another CNA on two-person, Hoyer and gait belt transfers, stating they were short staffed, so it was hard to get staff trained when she started. She said her last transfer training was during orientation, she could not provide a date. Interview on 9/11/19 at 9:22 AM with the DON, when asked what the policy was on resident transfers, she stated she could not answer this because she just started working two days ago. She said generally it depends what the residents are coming in for. She said if PT was ordered they would assess the resident. She said she only knows based on what she used to do. Resident #2 Record review of Resident #2's Face sheet revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's Quarterly MDS dated [DATE] revealed, the BIMS was not assessed because resident was rarely/never understood. The Staff Assessment for Mental Status revealed the resident had long-term and short-term memory problems and her cognitive skills were severely impaired. She resident was totally dependant on one person for transfers. Record review of Resident #2's Care plan revised on 9/11/19, read in part, F[NAME]US I have ADL Self-Care Performance Deficit r/t Dementia .Interventions .TRANSFER: I require 2 staff extensive assist with transfers. The Care plan was revised after surveyor intervention. Record review of the Provider Investigation Report dated 09/08/19 read in part, 5. Transfer status audit completed, 6. all employees in-service on all transfer by therapy with return demonstration 8. Care Plans updated. Further record review of the Provider Investigation Report revealed, the facility P[NAME] was not updated on all resident transfer status resulting in nursing staff not knowing resident transfer status prior to transferring residents. CNAs C, D, F, and G who were trained on transfers were observed transferring Resident #2 incorrectly and there was no documentation of transfer training for CNA C and D. Nursing staff did not know where to look to determine resident transfer status. Observation on 9/11/19 at 10:22 AM with Resident #2 with CNA F and CNA G revealed, during the transfer, the resident's feet did not touch the floor nor was she able to place her feet on the floor. CNA G lifted the resident from the Geri-chair and placed her in the bed using the gait belt, CNA F held the residents legs until she was positioned in the bed. The Geri-chair was not locked and moved throughout the transfer. The resident was not wearing slip resistant socks or shoes during the transfer. Interview on 9/11/19 at 10:30 AM with CNA G, when asked if the resident's feet should be on the floor during the transfer, she stated yes. When asked if the resident should be lifted during a two-person gait belt transfer, she stated yes. When asked if she was trained to lift residents during a gait belt transfer, she stated yes, therapy trained her to lift the resident. When asked if the wheels should be locked on the Geri-chair prior to moving the resident, she stated yes, further stating the wheels move when the chair is locked. She then stated the chair tilted because it was on a mat. When asked how she determines the residents transfer status, she stated the nurse will tell her how the resident is transferred. She stated her last transfer training was last Thursday. She stated she was trained on mechanical lift and gait belt transfers. When asked what the transfer status was for Resident #2, the CNA could not state the type of transfer. Interview on 9/11/19 at 10:32 AM with CNA F, when asked if a resident's feet should touch the floor during a two-person gait belt transfer, she stated The residents' feet should always touch the floor at all the times, further stating that's how she was trained. She stated the resident is not supposed to be lifted during a two-person gait belt transfer. She said the Geri-chair should be locked during the transfers, further stating the chair moves even when it is locked. She stated she should tell the nurse or maintenance so a new chair could be used because the resident could be injured if the chair moves during the transfer. Interview on 9/11/19 at 11:18 AM with the Physical Therapy Director, when asked what types of transfers were nursing staff trained on, she stated in-services included mechanical lift and 1-2 person transfers using a mannequin. She stated once they completed a return demonstration on the mechanical lift, they demonstrated a 1-person, then 2-person transfer with gait belt stating a gait belt should always be used. When asked if the residents feet should touch the ground during a gait belt transfer and if nursing staff were trained to lift a resident during a transfer with a gait belt, she stated it depends on the resident, stating some residents can assist and it depends if their feet can touch the ground. She said the Geri-chair should always be locked before transferring. She said there was not a separate competency check off for the gait belt transfer, and it was included in the mechanical lift competency check off. Interview on 9/11/19 at 12:24 PM with PT, when asked if a resident should be lifted during a gait-belt transfer, she stated in her opinion, the residents' feet should at least be able to make contact on the floor, further stating if the resident was lifted then a mechanical lift should be used. She stated sometimes the residents who are light, the CNAs will lift them, but in her opinion, the residents' feet should be touching the ground to assist with the transfer. Observation on 9/11/19 at 4:11 PM with Resident #2 with CNA C and D revealed, the resident was not able to assist with the transfer, she had contractures to her hands bilaterally with stiff lower extremities. CNA D lifted the resident by the gait belt and her feet slid across the floor during the transfer. CNA C was positioned behind the resident during the transfer and then moved behind the Geri-chair once the resident was positioned on the chair by CNA D. Interview on 09/11/19 at 4:25 PM with the DON, when asked if a resident should ever be lifted during a two-person gait belt transfer, she stated no, further stating sometimes the CNAs don't know their strength and may pick the resident up because the resident is light and doesn't weigh much. When asked if a Hoyer lift would be a safer way to transfer Resident # 2 since she is unable to place her feet on the floor or assist with the gait belt transfer, the DON stated no because the resident's skin may tear if the Hoyer lift was used. Record review of American Nurse today Gait belts 101: A tool for patient and nurse safety dated (MONTH) 2019 read in part, .After the gait belt is properly secured, ensure that the patient's feet are placed flat on the floor (no tiptoes or dangling feet) .A gait belt is used to steady a patient-it is not a lifting device. You can help the patient by raising or lowering the bed Resource Gait belts are one option for steadying patients and should never be substituted for lifting devices. Interview with the Administrator on 09/13/19 at 8:43 AM, when asked what the facility process or system was regarding transfer training for nursing staff, she stated Therapy spear headed the transfer training for nursing staff. She said new hires have generalized skills check off which includes transfers and by the time they finish training each department should have checked off their skills. She said this is all new, stating there was no process previously, but the facility now has skills check offs for the new employees, stating she was not sure if it was previously being done. She said she was not sure of the frequency of the skills check offs for transfers, stating they do not have a system or process set up and there is no policy. She further stated this is all new. When asked what the process is for PRN staff regarding transfer training, she stated just recently the ADON contacted the PRN staff and sent out texts to let them know training is going on. She further stated the break rooms have signs stating training is going on. When asked how is nursing staff audited to ensure training is continued or if further training is needed prior to transferring a resident, she stated they used an employee roster to audit and moving forward they will use the roster. She was unable to provide individual skills check off lists for gait belt, 1 or 2 person transfers, or in-services which showed nursing staff were trained on where to look to determine resident transfer status. Further interview with the Administrator on 9/13/19 at 8:43 AM, when asked what the system was for identifying and assessing all resident transfer type, she stated when residents are admitted they will look at the hospital they came from, or if they came from another facility they will go by the transfer they had at that facility or hospital. She said the nurse would determine if the resident is a 1-person or 2-person transfer and if there is a question, then Therapy would be asked about the transfer type. When asked how this system is audited to ensure all residents are assessed properly, she stated there is no process or system to ensure the assessments are being completed properly, further stating the nurses can ask PT if there is a question. Interview with the DON on 9/13/19 at 9:02 AM, she stated there currently is no policy or process in place regarding transfer training or resident assessments to determine the type of transfer the residents need. She stated she wants therapy to assist with the process when it's implemented and wants nursing staff to be checked off and trained by the (MONTH) 30th further stating this is about two weeks. She said, I need to be real here, so in 2-3 weeks I would like all nursing staff to be trained on transfers. Record review of the facility's undated Transfer status audit revealed Resident #1 and Resident #2 were not re-assessed to determine appropriate transfer type. Resident #1's status indicated she should be transferred by two persons with a gait belt even though she had a fractured tibia. Resident #2's status indicated she should be transferred by two persons with a gait belt even though she could not bear weight and was being carried with the weight belt. Record review of the facility's transfer training revealed, there was not a competency check off list for gait belt, one-person, or two-person transfers. Record review of the facility Hoyer Lift Transfer skills check off dated 06/14 revealed, a total of 12 nursing staff were checked off on Hoyer lift transfer which included 7 CNAs, 4 LVN's, and 1 medical records staff. Based on the employee list, there was a total of 29 staff who did not receive training; 16 CNAs, 10 LVN's and 3 RN's. Further record review of 5 Hoyer Lift Transfer skill check off revealed, the 5 check offs which included 3 CNAs and 2 LVNs did not have the staff signature on the bottom of the form showing the training was completed. Record review of the facility's employee roster documenting staff who completed transfer training revealed, a total of 16 nursing staff checked off on transfers and a total of 29 nursing staff left to be checked off. Interview on 09/14/19 at 11:41 AM with the DON, when asked where the system failed to cause the IJ, she stated she feels there were breaks in the system because staff weren't educated, and they needed to be educated on how to do a transfer and where to look to determine the resident's transfer status. She stated she could not state if Resident #1's injury was a result of neglect because she wasn't working at the facility when it occurred. Interview on 09/14/19 at 12:24 PM with the ADON, when asked where the system failed to cause the IJ she stated she would say it was because some of the data entry in the care plan did not carry over, so the aides could see the information. She further stated she thinks if the information was carried over onto the Kardex, We wouldn't possibly be sitting here. She further stated again, the information was not entered into the system from the beginning, so ADL's were not transferred into the Kardex for the CNAs to see. When asked to define neglect, the ADON stated neglect was The act of not taking care of a person when care is warranted. She further stated, not changing a soiled diaper, not assisting the resident off of the floor. Interview on 09/14/19 at 12:56 PM with the Administrator, when asked where the system failure occurred to cause the IJ, she stated she thinks the transfer status was in the care plan, but it was not carried over to the Kardex, further stating she was not sure if there was a person responsible to do this. She stated the facility did have a system, but it was removed, stating this is hearsay, I just don't know. She stated there should be a system for training and assessments of residents to determine if a resident is a two-person or can be a Hoyer transfer. She said now, Therapy went back and looked at the two residents affected, Resident #1 and Resident #2 to see if those two should be a Hoyer lift and now they are. She stated the facility now has 18 residents who required mechanical lift transfers. Record review of the facility's Policy on Recognizing Signs and Symptoms of Abuse/Neglect revised 01/2011 read in part, Our facility will not condone any form of resident abuse or neglect .2. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness .b. Signs of Actual Physical Neglect .(6) Inadequate provision of care . The facility Administrator and the DON were notified on 9/13/19 at 9:23 a.m. that an IJ had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 9/13/19 at 12:44 p.m After several revisions, the final Plan of Removal was accepted on 9/14/19 at 9:11 a.m The plan of removal included the following: -In-service all Certified Nursing assistance on proper transfer by therapy/DON/ADON initiated 9/9/2019. In-service expected to be completed by 9/14/2019, any staff who are not available will be required to complete the training prior to working with residents. -In-service all CNAs on using the Kardex to validate type of transfer to use on the resident by therapy/DON/ADON initiated 9/9/2019. In-service expected to be complete by 9/14/2019, any staff who are not available will be required to complete training prior to working with residents. -DON/ADON will be provided in-service on transfers, and to update the Kardex/care plan when there is a change in condition by Therapy/Regional Nurse initiated 9/13/2019. -Resident #1 is being transferred by Hoyer, and care plan updated 9/13/2019. -Resident #2 is being transferred by Hoyer, and care plan updated 9/13/2019. -Transfer competency to be completed on Hoyer, gait belt, and two-person transfer with nursing staff before the start of assignment. Any staff not included with the training will not work until competency is completed. Transfer training/competency will be completed with all new nursing staff during orientation process. -ADL Care Plans updated in Point Click Care starting 9/3/2019 and completed 9/13/2019. -Policy and procedure on Safe Lifting and Movement of residents initiated 9/13/2019 will be provided to Dept. Head, Nursing Staff, and Rehab Staff by Regional Nurse. -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. -All residents who require a two-person transfer were re-assessed to determine if Hoyer was appropriate and Kardex updated on 9/13/2019. -DON/ADON will monitor 5 transfers a week to ensure compliance x four weeks and results will be discussed in QAPI meeting starting 9/13/2019. -Confirmation of adequate number of slings and gait belts to provide care to all residents on 9/13/2019. Validation/Monitoring tool -Gait Belt transfer competency check list -Hoyer lift transfer competency check list -New resident will be reviewed in morning clinical meeting to identify the transfer technique/change -Use of Kardex on P[NAME] with the CNAs on individual resident. -Employee Monitoring checklist for compliance The surveyors confirmed the Plan to lower the Immediately Jeopardy had been implemented sufficiently by: Observations on 09/14/19 revealed, CNAs properly transferring residents using two-person gait belt and Hoyer lift transfers. Observation on 09/14/19 revealed, there was an of appropriate number of gait belts and Hoyer lifts available for resident transfers. Interviews with multiple nursing staff on 09/14/19 revealed, they were able to state where to locate resident transfer status. Record review of Resident #1 and Resident #2's Care plan revealed transfer status was updated to a

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 6 residents (Resident #3) reviewed for pain management. The facility failed to provide Resident #3 with ordered pain medication to treat the resident's pain for at least 5 days. This failure affected one resident, placing her at risk for further decline in her mental or physical functioning. Findings include: Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old female with admission date of [DATE] and re-admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #3's Quarterly MDS dated [DATE] revealed a SAMS revealed resident's cognition of severely impaired. Record review of Resident #3's care plan initiated on 9/10/19 revealed Resident #3 had potential for pain and was at risk for injury from decrease in ADL's. The goal was to have the pain/discomfort relieved within 1 hour after intervention. The interventions included administer pain medication as ordered. Discuss with physician that for maximum pain relief pain medication are best given around the clock, with PRNs for breakthrough pain. Record review of Resident #3's final report from the hospital dated 9/2/19 revealed resident had a cervical fracture, nasal bone fracture and right [MEDICAL CONDITION] from a fall in the skilled nursing facility. Record review of Resident #3's Physician order [REDACTED]. Tylenol Table 325 MG - 2 tablets by mouth every 6 hours as needed for mild pain. This was started on 4/17/19 and was active. Tylenol with [MEDICATION NAME] #3 - 1 tablet by mouth 2 times a day. This was started on 9/5/19 and was active. Tylenol with [MEDICATION NAME] #3 - 1 tablet by mouth every 8 hours as needed for moderate-severe pain for 10 days. This was started on 9/5/19 and was active. Record review of Resident #3's Medication Administration Record [REDACTED] Evening monitoring on 9/3/19 revealed a level pain of 1 - resident was repositioned, and no medications were given. Day monitoring on 9/4/19 revealed a level pain of 4 - no medications were given. Day monitoring on 9/8/19 revealed level of pain of 4 and PRN Tylenol tablet 325 MG was given, and resident was cold. Tylenol with [MEDICATION NAME] #3 at 9:00 AM was blank. Evening monitoring on 9/8/19 revealed level of pain of 2 and resident was repositioned. Tylenol with [MEDICATION NAME] #3 at 5:00 PM was blank. Observation on 9/10/19 at 9:40 AM of Resident #3 found resident in bed working with SLP. Resident was unable to speak or answer questions. She was moaning and grimacing. She had yellow bruising across and down the right side of her face. Bruising was down both arms. She had a brace on her neck. Resident was very thin and looked very frail. Interview on 9/10/19 at 9:40 AM with SLP. She said Resident #3 had always been thin and frail. She had been in pain. She said she played music to help her calm down. Interview on 9/10/19 at 9:47 with CNAs B. She said Resident #3 was struggling with pain. She said the pain had to do with the fall. She said she did not have these problems before the fall. Interview on 9/10/19 at 3:20 PM with ADON. She said her diet had changed when she came back from the hospital to pureed and nectar thick liquids. She was now a 2 person assist for ADL's, but she had not been out of bed since she returned. She said they turn her and reposition. Interview on 9/10/19 at 1:10 PM with LVN [NAME] She said Resident #3 was currently on Tylenol #3 scheduled and PRN. When she came back from the hospital, she just had Tylenol. She said the NP ordered the Tylenol #3 when she came in. She said she was having lots of pain and should be on something stronger. She said they were talking to the family about hospice. Interview on 9/11/19 at 10:02 AM with CNAs B. She said Resident was in pain the past day and ½. When she first came back from the hospital she slept a lot. She said the nurses took care of her when she would be screaming, and they knew about her pain. Interview on 9/11/19 at 12:50 PM with LVN B. She said Resident #3 would answer no to pain, but she would be grimacing. She was very confused, and she was sleeping a lot in the first few days. She said her pain was bad when they had to touch her. Interview on 9/11/19 at 3:35 PM with RN [NAME] She said she had multiple fractures when she came back from the hospital. She said she recorded a 1 for her pain level on the 9/3/19 but she did not know why she did not give her any medication. Interview on 9/11/19 at 4:00 PM with DON. She said she does not know why the nurses would not give Resident #3 medication at a level 4 on 9/4/19. Interview on 9/11/19 at 5:10 PM with LVN [NAME] She said she did not give Resident #3 any pain medication until 9/5/19 when the NP ordered the Tylenol with [MEDICATION NAME]. She said resident was sleeping a lot the first few days from the hospital. She did not remember documenting a level 4 of pain on 9/4/19. I am not sure why I did not give her any medications. I would document and record if I give medications. Interview on 9/12/19 at 10:40 PM with NP. She said she ordered pain medication when I cam in and saw Resident #3 on 9/5/19. She said she was not contacted about her having pain. The on-call person could have been contacted. Record review of undated facility policy titled Pain Management Policy read in part, .Residents are routinely evaluated for level of pain (0-10) each shift and is designated by initials on the nurse MAR. If resident is expressing pain, the pain is to be addressed

Based on observation, interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 of 6 residents (Resident #1) in that: -The facility failed to carry out MD verbal orders for Urinalysis (UA) for Resident #1's change of condition on 4/27/18. The resident complained of pain 11 days later and another UA was ordered. -The facility failed to consult the physician about Resident #1's UA results that was collected on 5/8/18. Antibiotics were not ordered until 5/16/18. -The facility failed to start antibiotics for Resident #1 in a for [DIAGNOSES REDACTED]. This failure affected one resident and had the potential to affect 19 other residents on the 400 hall by placing them at risk for neglect, increased pain, delay in treatment, and/or a decline in health status. Findings include: Intake # 6 Record review of Resident #1's clinical record revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His admission [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed he could make himself understood and was able to understand others. He had a BIMS score of 13 which indicated no cognitive impairment. He required extensive assistance for bed mobility, transfers, toilet use and bathing, limited assistance with personal hygiene, and supervision with locomotion on the unit and eating. Resident #1 had limited range of motion to one side of the lower extremity and a limb prosthesis. He did not have a history of a urinary tract infection in the last 30 days. He had frequent urine incontinence. Record review of Resident #1's care plan initiated 5/17/18 revealed the following in part: *Focus. The resident is on antibiotic [MEDICATION NAME] related to Urinary Tract Infection [MEDICAL CONDITION]. *Goal. The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included, Administer Antibiotic medication as ordered by the physician. Monitor/document/report PRN adverse reactions to Antibiotic therapy . Interview on 6/6/18 at 11:30am with Resident #1's family member revealed Resident #1 had increased confusion on 4/24/18 and family raised concerns of a UTI to the facility. The family member stated that Resident # 1 had a history of [REDACTED]. On 4/27/18 the facility called Resident #1's responsible party to inform him that Resident #1 was exhibiting symptoms consistent with a UTI and asked if they could do a UA and the family consented. On 5/8/18 the family asked for the results of the UA and the facility had not done one because they said he did not have symptoms. The facility finally ordered a UA after the family got upset. Record review of Resident #1's nurses' notes revealed the following in part: *4/26/18 at 4:59pm by ADON H. Spoke over the phone with power of attorney. Verbal consent given for (family member) to inquire about Resident #1's condition and ok to receive update regarding care. The (family member) voiced concern regarding resident's urine observed to be dark color and wound dressing was off when she came that morning and was draining. Regarding observation of dark urine. Assured (family member) that we will offer fluids i.e. water, because resident tends to drink soda most of the time. Also, for nurse to observe for signs and symptoms of UTI for 72 hours; to report to MD for symptoms of infection. *4/27/18 at 10:09am by LVN F. Resident showing signs of increased confusion. He stated he does not know why he is here and refused his breakfast and accucheck this morning. NP A in the building making rounds and noted resident's AMS and gave writer verbal order for UA with culture and sensitivity. Will continue to monitor. *4/27/18 at 10:57am by LVN F. Writer notified resident's RP and informed him of resident's change in mental status, and that an order was obtained to have a UA culture and sensitivity done. RP stated ok and thanks for calling. *4/29/18 at 9:40pm by LVN F. Resident noted with increased confusion, asking writer when he was leaving, why was he here, and that he was getting ready to leave and go home. Record review of SBAR Communication Form dated 4/27/18 by LVN F revealed the following in part: *Situation: -This started on 4/27/18 *Background: -Mental Status Evaluation (compared to baseline)- Increased confusion or disorientation -Behavioral Evaluation- Personality change -GU/Urine Evaluation- Other, dark yellow urine with loud odor *Appearance (Summarize your observations and evaluation): -Resident showing signs and symptoms of increased confusion. He's uncertain why he is here and wants to go home. Resident refused breakfast and accucheck, resident's room has a strong urine odor. *Review and Notify: -Primary Care Clinician Notified: NP A .Date: 4/27/18 .Time: 10:15am -Recommendations of Primary Clinicians: UA culture and sensitivity ordered -Testing- Urinalysis and or culture Record review of Resident #1's physician orders [REDACTED]. Interview on 6/6/18 at 12:51pm LVN F revealed Resident #1 had a change of condition on 4/27/18 and after notifying NP A, she received orders from NP A for a UA. LVN F stated that she could not enter orders in the system because she did not have access. She stated that she notified another nurse, whom she could not recall who it was, to enter the orders. LVN F revealed that she did not collect the urine on her shift or after that. She said the 10p-6a shift usually collected labs because the lab comes in the morning to collect. Interview on 6/6/18 at 1:41pm NP A revealed she was in the building on 4/27/18, but she could not recall if she gave verbal orders to LVN F for a UA for Resident #1. NP A revealed that if a change of condition for Resident #1 was reported to her she would have ordered UA on Resident #1 at that time. NP A revealed she would not have said to monitor 72 hours. Record review of Resident #1's nurses' notes revealed the following in part: *5/8/18 at 7:47pm by LVN N. Resident sitting on wheelchair alert and able to voice needs. Noted foul urine smell in resident room, resident is incontinent when assessed resident stated he sometimes feels a stinging sensation when he pees. Call placed to Improved Patient Care (IPC) physician group, spoke with (nurse) received new orders to increase fluid intake of 250ml per shift for 24 hours, vital signs every shift for 3 days, collect UA with culture and sensitivity and CBC, BMP. Record review of Resident #1's physician orders [REDACTED].>Record review of Resident #1's lab results with a collection date of 5/8/18 revealed the following in part: Urinalysis: Final Approved 5/10/18 at 10:17am *Clarity- cloudy (Reference range: clear) *Protein- 2+ (Reference range: negative) *Blood- 1+ (Reference range: negative) *WBC- 50-99 (Reference range: negative) *RBC- 6-10 (Reference range: negative) *Bacteria- many (Reference range: none seen) Urine culture and sensitivity: Final, Updated Result Approved 5/12/18 at 438am. *[MEDICATION NAME] species isolated. Colony Count >100,000. -[MEDICATION NAME]---susceptible Record review of nurses' notes and clinical record revealed no documentation of physician notification of urinalysis results collected 5/8/18. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Treatment Administration Record for the month of (MONTH) (YEAR) revealed [MEDICATION NAME] 500mg capsules was given to Resident #1 starting 5/17/18 at 5:00pm. Record review of Resident #1's nurses' notes revealed the following: *5/18/18 t 5:38am by LVN L. Antibiotics in progress day 2 of 7 for UTI, no untoward effects. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Medication Administration Record [REDACTED]. Observation on 6/6/18 at 12:07pm Resident #1 was sitting up in his wheelchair. Resident had right leg amputation. Resident #1 denied pain, no sign of distress. Interview on 6/6/18 at 1:23pm ADON T revealed that no order was found in the clinical record for a urinalysis on 4/27/18 and she is not sure what happened. ADON T revealed there was no documentation or evidence that the physician was notified of lab results from 5/8/18. Interview on 6/6/18 at 1:41pm NP A revealed that she was not notified by phone of Resident #1's urinalysis results from 5/8/18. NP A stated she saw the results on 5/16/18 when she came to the facility and reviewed Resident #1's lab results. Interview on 6/6/18 at 3:24pm the DON revealed that when a resident had a change of condition, the physician should be notified, and orders should be carried out. The DON stated that abnormal labs should be reported to the physician or NP right away. Record review of the facility's Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property, undated, revealed the following in part: *No resident will be deprived by any individual of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being, including abuse facilitated or enabled by the use of technology. Record review of the facility's Acute Condition Changes-Clinical Protocol policy, dated 2001, revealed the following in part: *During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. *Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician. *Nurses are encouraged to use the SBAR Communication Form and progress note *Nursing staff will contact the Physician based on the urgency of the situation. *The Attending Physician or a practitioner providing coverage, will respond in a timely manner to notifications of problems or changes in condition and status *The Physician will help identify and authorize appropriate treatments. *The nurse will repeat any verbal orders to the physician to ensure accurate transcription. According to facility census dated 6/6/18 revealed 20 residents resided on the 400 hall.

Based on observation, interviews and record review, the facility failed to ensure that 1 of 6 residents (Resident #1) was free from neglect in that: -The facility failed to carry out MD verbal orders for Urinalysis (UA) for Resident #1's change of condition on 4/27/18. The resident complained of pain 11 days later and another UA was ordered. -The facility failed to consult the physician about Resident #1's UA results that was collected on 5/8/18. Antibiotics were not ordered until 5/16/18. -The facility failed to start antibiotics for Resident #1 in a for [DIAGNOSES REDACTED]. This failure affected one resident and had the potential to affect 19 other residents on the 400 hall by placing them at risk for neglect, increased pain, delay in treatment, and/or a decline in health status. Findings include: Intake # 6 Record review of Resident #1's clinical record revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His admission [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed he could make himself understood and was able to understand others. He had a BIMS score of 13 which indicated no cognitive impairment. He required extensive assistance for bed mobility, transfers, toilet use and bathing, limited assistance with personal hygiene, and supervision with locomotion on the unit and eating. Resident #1 had limited range of motion to one side of the lower extremity and a limb prosthesis. He did not have a history of a urinary tract infection in the last 30 days. He had frequent urine incontinence. Record review of Resident #1's care plan initiated 5/17/18 revealed the following in part: *Focus. The resident is on antibiotic [MEDICATION NAME] related to Urinary Tract Infection [MEDICAL CONDITION]. *Goal. The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions included, Administer Antibiotic medication as ordered by the physician. Monitor/document/report PRN adverse reactions to Antibiotic therapy . Interview on 6/6/18 at 11:30am with Resident #1's family member revealed Resident #1 had increased confusion on 4/24/18 and family raised concerns of a UTI to the facility. The family member stated that Resident # 1 had a history of [REDACTED]. On 4/27/18 the facility called Resident #1's responsible party to inform him that Resident #1 was exhibiting symptoms consistent with a UTI and asked if they could do a UA and the family consented. On 5/8/18 the family asked for the results of the UA and the facility had not done one because they said he did not have symptoms. The facility finally ordered a UA after the family got upset. Record review of Resident #1's nurses' notes revealed the following in part: *4/26/18 at 4:59pm by ADON H. Spoke over the phone with power of attorney. Verbal consent given for (family member) to inquire about Resident #1's condition and ok to receive update regarding care. The (family member) voiced concern regarding resident's urine observed to be dark color and wound dressing was off when she came that morning and was draining. Regarding observation of dark urine. Assured (family member) that we will offer fluids i.e. water, because resident tends to drink soda most of the time. Also, for nurse to observe for signs and symptoms of UTI for 72 hours; to report to MD for symptoms of infection. *4/27/18 at 10:09am by LVN F. Resident showing signs of increased confusion. He stated he does not know why he is here and refused his breakfast and accucheck this morning. NP A in the building making rounds and noted resident's AMS and gave writer verbal order for UA with culture and sensitivity. Will continue to monitor. *4/27/18 at 10:57am by LVN F. Writer notified resident's RP and informed him of resident's change in mental status, and that an order was obtained to have a UA culture and sensitivity done. RP stated ok and thanks for calling. *4/29/18 at 9:40pm by LVN F. Resident noted with increased confusion, asking writer when he was leaving, why was he here, and that he was getting ready to leave and go home. Record review of SBAR Communication Form dated 4/27/18 by LVN F revealed the following in part: *Situation: -This started on 4/27/18 *Background: -Mental Status Evaluation (compared to baseline)- Increased confusion or disorientation -Behavioral Evaluation- Personality change -GU/Urine Evaluation- Other, dark yellow urine with loud odor *Appearance (Summarize your observations and evaluation): -Resident showing signs and symptoms of increased confusion. He's uncertain why he is here and wants to go home. Resident refused breakfast and accucheck, resident's room has a strong urine odor. *Review and Notify: -Primary Care Clinician Notified: NP A .Date: 4/27/18 .Time: 10:15am -Recommendations of Primary Clinicians: UA culture and sensitivity ordered -Testing- Urinalysis and or culture Record review of Resident #1's physician orders [REDACTED]. Interview on 6/6/18 at 12:51pm LVN F revealed Resident #1 had a change of condition on 4/27/18 and after notifying NP A, she received orders from NP A for a UA. LVN F stated that she could not enter orders in the system because she did not have access. She stated that she notified another nurse, whom she could not recall who it was, to enter the orders. LVN F revealed that she did not collect the urine on her shift or after that. She said the 10p-6a shift usually collected labs because the lab comes in the morning to collect. Interview on 6/6/18 at 1:41pm NP A revealed she was in the building on 4/27/18, but she could not recall if she gave verbal orders to LVN F for a UA for Resident #1. NP A revealed that if a change of condition for Resident #1 was reported to her she would have ordered UA on Resident #1 at that time. NP A revealed she would not have said to monitor 72 hours. Record review of Resident #1's nurses' notes revealed the following in part: *5/8/18 at 7:47pm by LVN N. Resident sitting on wheelchair alert and able to voice needs. Noted foul urine smell in resident room, resident is incontinent when assessed resident stated he sometimes feels a stinging sensation when he pees. Call placed to Improved Patient Care (IPC) physician group, spoke with (nurse) received new orders to increase fluid intake of 250ml per shift for 24 hours, vital signs every shift for 3 days, collect UA with culture and sensitivity and CBC, BMP. Record review of Resident #1's physician orders [REDACTED].>Record review of Resident #1's lab results with a collection date of 5/8/18 revealed the following in part: Urinalysis: Final Approved 5/10/18 at 10:17am *Clarity- cloudy (Reference range: clear) *Protein- 2+ (Reference range: negative) *Blood- 1+ (Reference range: negative) *WBC- 50-99 (Reference range: negative) *RBC- 6-10 (Reference range: negative) *Bacteria- many (Reference range: none seen) Urine culture and sensitivity: Final, Updated Result Approved 5/12/18 at 438am. *[MEDICATION NAME] species isolated. Colony Count >100,000. -[MEDICATION NAME]---susceptible Record review of nurses' notes and clinical record revealed no documentation of physician notification of urinalysis results collected 5/8/18. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Treatment Administration Record for the month of (MONTH) (YEAR) revealed [MEDICATION NAME] 500mg capsules was given to Resident #1 starting 5/17/18 at 5:00pm. Record review of Resident #1's nurses' notes revealed the following: *5/18/18 t 5:38am by LVN L. Antibiotics in progress day 2 of 7 for UTI, no untoward effects. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Medication Administration Record [REDACTED]. Observation on 6/6/18 at 12:07pm Resident #1 was sitting up in his wheelchair. Resident had right leg amputation. Resident #1 denied pain, no sign of distress. Interview on 6/6/18 at 1:23pm ADON T revealed that no order was found in the clinical record for a urinalysis on 4/27/18 and she is not sure what happened. ADON T revealed there was no documentation or evidence that the physician was notified of lab results from 5/8/18. Interview on 6/6/18 at 1:41pm NP A revealed that she was not notified by phone of Resident #1's urinalysis results from 5/8/18. NP A stated she saw the results on 5/16/18 when she came to the facility and reviewed Resident #1's lab results. Interview on 6/6/18 at 3:24pm the DON revealed that when a resident had a change of condition, the physician should be notified, and orders should be carried out. The DON stated that abnormal labs should be reported to the physician or NP right away. Record review of the facility's Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property, undated, revealed the following in part: *No resident will be deprived by any individual of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being, including abuse facilitated or enabled by the use of technology. Record review of the facility's Acute Condition Changes-Clinical Protocol policy, dated 2001, revealed the following in part: *During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. *Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician. *Nurses are encouraged to use the SBAR Communication Form and progress note *Nursing staff will contact the Physician based on the urgency of the situation. *The Attending Physician or a practitioner providing coverage, will respond in a timely manner to notifications of problems or changes in condition and status *The Physician will help identify and authorize appropriate treatments. *The nurse will repeat any verbal orders to the physician to ensure accurate transcription. According to facility census dated 6/6/18 revealed 20 residents resided on the 400 hall.

Based on observation, interview and record review the facility failed to provide services in accordance with the written plan of care and physician's orders for one of 10 residents (Resident #1) reviewed for plans of care. -Resident #1 had to remain in bed due to his pain because he was not administered his scheduled pain medication per the physician ' s order for 15 days during the month of November 2016. This failure affected one resident and placed 47 additional residents who were on a pain management program at risk for decreased psychosocial well-being, pain and decline in health status. # 2 Findings include: Resident #1 Record review of Resident #1 ' s face sheet revealed a [AGE] year old male with an admission date of [DATE] to the facility. [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. The MDS further revealed Resident #1, required extensive assistance with two persons physical assist for bed mobility, transfer, dressing and toilet use. The section for pain was left blank. Record review of Resident #1 ' s Care Plans revealed the following care plans dated 08/09/2016 with a revision date of 11/14/16 and 12/06/16: -Pain management therapy related to procedure of [MEDICATION NAME] (used for removal of earwax) ear drops related to excessive cerumen (earwax). Interventions: Review for pain medication efficacy, assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. -Pain related to disease process. Interventions: Monitor/record/report to Nurse any signs or symptoms of non-verbal pain and verbal complaints of pain, or request for pain medications. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Provide me with reassurance that pain is time limited. Encourage me to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application muscle stimulation, ultra sound. Evaluate effectiveness of pain interventions. Review compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Record review of Resident #1 ' s Physician Medication Review Report for the month of November 2016 revealed a physician ' s order for Tylenol #3 Tablet 300-30MG (milligram) give 1 tablet by mouth three times a day for pain. Record review of Resident #1 ' s physician ' s order dated 10/19/2016 read: Tylenol #3 by mouth three times daily. Record review of Resident #1 ' s Medication Administration Record [REDACTED] -11/12/2016 at 9:00 am, 1:00 pm and 5:00pm -11/13/2016 at 9:00 am, 1:00 pm and 5:00pm -11/14/2016 at 9:00 am, 1:00 pm and 5:00pm -11/15/2016 at 9:00 am, 1:00 pm and 5:00pm -11/16/2016 at 9:00 am, 1:00 pm and 5:00pm -11/17/2016 at 9:00 am, 1:00 pm and 5:00pm -11/18/2016 at 9:00 am and 1:00 pm -11/19/2016 at 9:00 am, 1:00 pm and 5:00pm -11/20/2016 at 9:00 am, 1:00 pm and 5:00pm -11/21/2016 at 9:00 am, 1:00 pm and 5:00pm -11/22/2016 at 9:00 am, 1:00 pm and 5:00pm -11/23/2016 at 9:00 am, 1:00 pm and 5:00pm -11/24/2016 at 9:00 am, 1:00 pm and 5:00pm -11/25/2016 at 9:00 am, 1:00 pm and 5:00pm -11/26/2016 at 9:00 am, 1:00 pm and 5:00pm -11/27/2016 at 9:00 am, 1:00 pm and 5:00pm -11/28/2016 at 9:00 am, 1:00 pm and 5:00pm The number 5 or 15 was typed into the space for the scheduled dosages for Tylenol #3 on all days listed above. The number 5 in the chart codes on the MAR indicated [REDACTED]. The number 15 stood for Awaiting Prior Authorization . Record review of nurse ' s notes for the following days revealed: -11/12/2016 at 12:07 pm: waiting on pharmacy. -11/13/2016 at 9:18 am: waiting on pharmacy. -11/13/2016 at 12:25 pm: waiting on pharmacy. -11/14/2016 at 11:12 am: pending pharmacy -11/15/2016 at 9:08 am: waiting on pharmacy. -11/15/2016 at 9:37 am: waiting on pharmacy. -11/15/2016 at 12:21 pm: waiting on pharmacy. -11/16/2016 at 8:41 am: waiting on pharmacy. -11/16/2016 at 12:14 pm: waiting on pharmacy. -11/17/2016 at 8:27 am: waiting on pharmacy. -11/17/2016 at 12:36 pm: On order with pharmacy. -11/21/2016 at 8:13 am: waiting on pharmacy. -11/21/2016 at 12:33 pm: waiting on pharmacy. -11/22/2016 at 8:59 am: waiting on pharmacy. -11/23/2017 at 8:39 am: waiting on pharmacy. -11/23/2016 at 12:06 pm: waiting on pharmacy. -11/25/2016 at 8:55 am: waiting on pharmacy. -11/25/2016 at 12:33 pm: waiting on pharmacy. -11/26/2016 at 12:10 pm: waiting on pharmacy. -11/27/2016 at 12:22 pm: waiting on pharmacy. -11/28/2016 at 12:42 pm: waiting on pharmacy. Record review of progress notes revealed no pain assessments completed or physician notification for Resident #1 regarding not being medicated for pain per physician orders for the following dates: -11/15/2016 at 9:37 am -11/12/2016 at 12:07 pm -11/13/2016 at 9:18 am -11/13/2016 at 12:25 pm -11/14/2016 at 11:12 am -11/15/2016 at 9:08 am -11/15/2016 at 12:21 pm -11/16/2016 at 8:41 am -11/16/2016 at 12:14 pm -11/17/2016 at 8:27 am -11/17/2016 at 12:36 pm -11/21/2016 at 8:13 am -11/21/2016 at 12:33 pm -11/22/2016 at 8:59 am -11/23/2017 at 8:39 am -11/23/2016 at 12:06 pm -11/25/2016 at 8:55 am -11/25/2016 at 12:33 pm -11/26/2016 at 12:10 pm -11/27/2016 at 12:22 pm -11/28/2016 at 12:42 pm In an interview with the Director of Nurses (DON) on 01/19/2017 at 12:25 pm she said Charge Nurse A should have medicated Resident #1 with Tylenol #3 per the physicians order for scheduled pain medication and the resident should not have gone un-medicated. The DON said she was not aware that Resident #1 had not been medicated for several days in the month of November 2016. The DON said the medication (Tylenol #3) was available in the Cubex system (a medication inventory system). She said she did not know why the Nurses did get the Tylenol #3 for Resident #1 out of the Cubex system.The DON said she became aware that Resident #1 was missing medications at the end of November 2016 when Charge Nurse A and the ADON reported it to her. In an interview on 01/04/2017 at 1:04 pm Resident #1 said his physician did not come to see him on 01/03/2017 as promised and he did not receive his pain medication for two days. Resident #1 could not recall what days he did not get his medications. Resident #1 denied pain at the time of interview. In an interview with Charge Nurse A on 1/04/2017 at 1:06 pm she said she was not aware Resident #1 had not received his medication for several days in November 2016. Charge Nurse A said the Medication Aides (MA) had never informed her of not having Tylenol #3 available. Charge Nurse A said she became aware of the situation on Thursday 12/01/2016 during the morning shift when there was not any Tylenol #3 to medicate Resident #1 per the physician ' s orders. Charge Nurse A said the Assistant Director of Nursing (ADON) was notified that there was no available Tylenol #3 for Resident #1. The ADON and Charge Nurse A audited all medication carts looking for Resident #1 ' s Tylenol #3, but it was not found. Charge Nurse A called the pharmacy regarding Resident #1 ' s Tylenol #3 prescription and it had been ordered on [DATE]. Charge Nurse A said she was told by pharmacy that Tylenol #3 (90 tablets) was delivered to facility 11/29/2016 for Resident #1 and it was too early for a refill. Charge Nurse A said the medication was never found. When Charge Nurse A was asked what she did for Resident #1 ' s pain since Tylenol #3 was not available, she said she assessed him for pain and he did not complain of pain so he was not medicated. Charge Nurse A said she assessed residents for pain daily, usually first thing in the morning. Charge Nurse A said Resident #1 was verbal and could communicate if he was in pain but was sometimes confused. When Charge Nurse A was asked what options were available when a Resident ' s scheduled medications were not available she said they had a Cubex system they could call the pharmacy and get a code to remove medications from the Cubex for residents when they had run out of medications. Charge Nurse A said she did not use the Cubex system to medicate Resident #1 for pain per the physician ' s orders. Charge Nurse A said Honestly, I can ' t say why she did not use the Cubex to pull medications to medicate Resident #1. Charge Nurse A said Resident #1 did not receive schedule pain medications for 12/01/2016 and 12/02/2016 during her shift. In an observation and interview with Resident #1 on 01/19/2017 at 11:30 am revealed Resident #1 sitting in his wheelchair in his room. Resident #1 was well groomed. He said he was not medicated all the time when he was in pain. Resident #1 said sometimes he was not medicated when he had pain and he just stayed in bed all day due to the pain. Resident #1 complained of having pain rating 3 out of 10 with 10 being the highest pain level during the interview. Record review of Policy for Drug Orders provided by facility and not dated revealed the following: All drugs must be prescribed by the resident ' s physician of consulting physician, dentist, podiatrist, or other individual allowed by law to prescribe. If drugs orders are verbal, they must be taken by a licensed nurse, pharmacist, physician assistant, or a physician, and immediately recorded and signed by the person receiving the order. All drug orders will be counter-signed by the prescriber and returned to the chart in a timely manner. Verbal drug orders for Schedule II drugs are permitted in an emergency. Medications will be ordered and reordered on a timely basis so as to ensure residents do not miss doses. Record review of Policy for Drug Administration provided by facility not dated revealed the following: The facility has established drug administration procedures to ensure: 1) drugs being administered are checked against the physician orders; 2) the resident is identified prior to administering the drug; 3) each resident has an individual medication record where doses of drugs administered can be recorded by the person; and 5) drugs prescribed for one resident are not administered to any other resident. All drug errors and adverse drug reactions will be reported to the resident ' s physician in a timely manner, as warranted by an assessment of the resident ' s condition, and recorded in the resident ' s record. An incident report will be completed. If the incident appears to be serious, it will be investigated by the director of nursing and the administrator. In addition, special reporting to DADS, the resident ' s responsible party, and the attending physician will be done immediately. Drug administration in error can occur in several instances whereas there is an adverse drug reaction, the wrong dose is given, medication administered after it has been discontinued, the drug is not administered as ordered, the drug is administered at the wrong time, administration is by wrong route, the drug is administered to the wrong resident, the wrong drug is administered, and the drug is administered without a physician ' s order. The facility reported 48 residents were on a pain management program.

Based on observation, interview and record review the facility failed to provide necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one of 10 residents (Resident #1) reviewed for quality of care including pain. -Resident #1 had to remain in bed due to his pain because he was not administered his scheduled pain medication per the physician's order [REDACTED]. This failure affected one resident and placed 47 additional residents who were on a pain management program at risk for decreased psychosocial well-being, pain and decline in health status. # 2 Findings include: Resident #1 Record review of Resident #1 ' s face sheet revealed a [AGE] year old male with an admission date of [DATE] to the facility. [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. The MDS further revealed Resident #1, required extensive assistance with two persons physical assist for bed mobility, transfer, dressing and toilet use. The section for pain was left blank. Record review of Resident #1 ' s Care Plans revealed the following care plans dated 08/09/2016 with a revision date of 11/14/16 and 12/06/16: -Pain management therapy related to procedure of [MEDICATION NAME] (used for removal of earwax) ear drops related to excessive cerumen (earwax). Interventions: Review for pain medication efficacy, assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. -Pain related to disease process. Interventions: Monitor/record/report to Nurse any signs or symptoms of non-verbal pain and verbal complaints of pain, or request for pain medications. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Provide me with reassurance that pain is time limited. Encourage me to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application muscle stimulation, ultra sound. Evaluate effectiveness of pain interventions. Review compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Record review of Resident #1 ' s Physician Medication Review Report for the month of November 2016 revealed a physician's order [REDACTED]. Record review of Resident #1 ' s physician's order [REDACTED].#3 by mouth three times daily. Record review of Resident #1 ' s Medication Administration Record [REDACTED] -11/12/2016 at 9:00 am, 1:00 pm and 5:00pm -11/13/2016 at 9:00 am, 1:00 pm and 5:00pm -11/14/2016 at 9:00 am, 1:00 pm and 5:00pm -11/15/2016 at 9:00 am, 1:00 pm and 5:00pm -11/16/2016 at 9:00 am, 1:00 pm and 5:00pm -11/17/2016 at 9:00 am, 1:00 pm and 5:00pm -11/18/2016 at 9:00 am and 1:00 pm -11/19/2016 at 9:00 am, 1:00 pm and 5:00pm -11/20/2016 at 9:00 am, 1:00 pm and 5:00pm -11/21/2016 at 9:00 am, 1:00 pm and 5:00pm -11/22/2016 at 9:00 am, 1:00 pm and 5:00pm -11/23/2016 at 9:00 am, 1:00 pm and 5:00pm -11/24/2016 at 9:00 am, 1:00 pm and 5:00pm -11/25/2016 at 9:00 am, 1:00 pm and 5:00pm -11/26/2016 at 9:00 am, 1:00 pm and 5:00pm -11/27/2016 at 9:00 am, 1:00 pm and 5:00pm -11/28/2016 at 9:00 am, 1:00 pm and 5:00pm The number 5 or 15 was typed into the space for the scheduled dosages for Tylenol #3 on all days listed above. The number 5 in the chart codes on the MAR indicated [REDACTED]. The number 15 stood for Awaiting Prior Authorization . Record review of nurse ' s notes for the following days revealed: -11/12/2016 at 12:07 pm: waiting on pharmacy. -11/13/2016 at 9:18 am: waiting on pharmacy. -11/13/2016 at 12:25 pm: waiting on pharmacy. -11/14/2016 at 11:12 am: pending pharmacy -11/15/2016 at 9:08 am: waiting on pharmacy. -11/15/2016 at 9:37 am: waiting on pharmacy. -11/15/2016 at 12:21 pm: waiting on pharmacy. -11/16/2016 at 8:41 am: waiting on pharmacy. -11/16/2016 at 12:14 pm: waiting on pharmacy. -11/17/2016 at 8:27 am: waiting on pharmacy. -11/17/2016 at 12:36 pm: On order with pharmacy. -11/21/2016 at 8:13 am: waiting on pharmacy. -11/21/2016 at 12:33 pm: waiting on pharmacy. -11/22/2016 at 8:59 am: waiting on pharmacy. -11/23/2017 at 8:39 am: waiting on pharmacy. -11/23/2016 at 12:06 pm: waiting on pharmacy. -11/25/2016 at 8:55 am: waiting on pharmacy. -11/25/2016 at 12:33 pm: waiting on pharmacy. -11/26/2016 at 12:10 pm: waiting on pharmacy. -11/27/2016 at 12:22 pm: waiting on pharmacy. -11/28/2016 at 12:42 pm: waiting on pharmacy. Record review of progress notes revealed no pain assessments completed or physician notification for Resident #1 regarding not being medicated for pain per physician orders [REDACTED]. -11/15/2016 at 9:37 am -11/12/2016 at 12:07 pm -11/13/2016 at 9:18 am -11/13/2016 at 12:25 pm -11/14/2016 at 11:12 am -11/15/2016 at 9:08 am -11/15/2016 at 12:21 pm -11/16/2016 at 8:41 am -11/16/2016 at 12:14 pm -11/17/2016 at 8:27 am -11/17/2016 at 12:36 pm -11/21/2016 at 8:13 am -11/21/2016 at 12:33 pm -11/22/2016 at 8:59 am -11/23/2017 at 8:39 am -11/23/2016 at 12:06 pm -11/25/2016 at 8:55 am -11/25/2016 at 12:33 pm -11/26/2016 at 12:10 pm -11/27/2016 at 12:22 pm -11/28/2016 at 12:42 pm In an interview with the Director of Nurses (DON) on 01/19/2017 at 12:25 pm she said Charge Nurse A should have medicated Resident #1 with Tylenol #3 per the physicians order for scheduled pain medication and the resident should not have gone un-medicated. The DON said she was not aware that Resident #1 had not been medicated for several days in the month of November 2016. The DON said the medication (Tylenol #3) was available in the Cubex system (a medication inventory system). She said she did not know why the Nurses did get the Tylenol #3 for Resident #1 out of the Cubex system.The DON said she became aware that Resident #1 was missing medications at the end of November 2016 when Charge Nurse A and the ADON reported it to her. In an interview on 01/04/2017 at 1:04 pm Resident #1 said his physician did not come to see him on 01/03/2017 as promised and he did not receive his pain medication for two days. Resident #1 could not recall what days he did not get his medications. Resident #1 denied pain at the time of interview. In an interview with Charge Nurse A on 1/04/2017 at 1:06 pm she said she was not aware Resident #1 had not received his medication for several days in November 2016. Charge Nurse A said the Medication Aides (MA) had never informed her of not having Tylenol #3 available. Charge Nurse A said she became aware of the situation on Thursday 12/01/2016 during the morning shift when there was not any Tylenol #3 to medicate Resident #1 per the physician's order [REDACTED].#3 for Resident #1. The ADON and Charge Nurse A audited all medication carts looking for Resident #1 ' s Tylenol #3, but it was not found. Charge Nurse A called the pharmacy regarding Resident #1 ' s Tylenol #3 prescription and it had been ordered on [DATE]. Charge Nurse A said she was told by pharmacy that Tylenol #3 (90 tablets) was delivered to facility 11/29/2016 for Resident #1 and it was too early for a refill. Charge Nurse A said the medication was never found. When Charge Nurse A was asked what she did for Resident #1 ' s pain since Tylenol #3 was not available, she said she assessed him for pain and he did not complain of pain so he was not medicated. Charge Nurse A said she assessed residents for pain daily, usually first thing in the morning. Charge Nurse A said Resident #1 was verbal and could communicate if he was in pain but was sometimes confused. When Charge Nurse A was asked what options were available when a Resident ' s scheduled medications were not available she said they had a Cubex system they could call the pharmacy and get a code to remove medications from the Cubex for residents when they had run out of medications. Charge Nurse A said she did not use the Cubex system to medicate Resident #1 for pain per the physician's order [REDACTED].#1. Charge Nurse A said Resident #1 did not receive schedule pain medications for 12/01/2016 and 12/02/2016 during her shift. In an observation and interview with Resident #1 on 01/19/2017 at 11:30 am revealed Resident #1 sitting in his wheelchair in his room. Resident #1 was well groomed. He said he was not medicated all the time when he was in pain. Resident #1 said sometimes he was not medicated when he had pain and he just stayed in bed all day due to the pain. Resident #1 complained of having pain rating 3 out of 10 with 10 being the highest pain level during the interview. Record review of Policy for Drug Orders provided by facility and not dated revealed the following: All drugs must be prescribed by the resident ' s physician of consulting physician, dentist, podiatrist, or other individual allowed by law to prescribe. If drugs orders are verbal, they must be taken by a licensed nurse, pharmacist, physician assistant, or a physician, and immediately recorded and signed by the person receiving the order. All drug orders will be counter-signed by the prescriber and returned to the chart in a timely manner. Verbal drug orders for Schedule II drugs are permitted in an emergency. Medications will be ordered and reordered on a timely basis so as to ensure residents do not miss doses. Record review of Policy for Drug Administration provided by facility not dated revealed the following: The facility has established drug administration procedures to ensure: 1) drugs being administered are checked against the physician orders; 2) the resident is identified prior to administering the drug; 3) each resident has an individual medication record where doses of drugs administered can be recorded by the person; and 5) drugs prescribed for one resident are not administered to any other resident. All drug errors and adverse drug reactions will be reported to the resident ' s physician in a timely manner, as warranted by an assessment of the resident ' s condition, and recorded in the resident ' s record. An incident report will be completed. If the incident appears to be serious, it will be investigated by the director of nursing and the administrator. In addition, special reporting to DADS, the resident ' s responsible party, and the attending physician will be done immediately. Drug administration in error can occur in several instances whereas there is an adverse drug reaction, the wrong dose is given, medication administered after it has been discontinued, the drug is not administered as ordered, the drug is administered at the wrong time, administration is by wrong route, the drug is administered to the wrong resident, the wrong drug is administered, and the drug is administered without a physician's order [REDACTED].>The facility reported 48 residents were on a pain management program.