Every finding on record at Glendive Medical Center N H

Based on interview and record review, the facility failed to submit complete and accurate Payroll Based Journal information quarterly, for licensed nursing coverage 24 hours each day to the Centers for Medicare and Medicaid Services (CMS). The failure resulted in inaccurate staffing information being reported to the Centers for Medicare and Medicaid Services (CMS) and placed the facility at risk for inaccurate staffing data being used to evaluate the facility, which could impact all residents. Findings include:Review of the Centers for Medicare and Medicaid Services report titled, PBJ Staffing Data Report, for second quarter fiscal year 2026 (1/1/26 through 3/31/26), showed the facility . Failed to have Licensed Nursing Coverage 24 Hours/Day, on the following dates: 1/11/26, 1/25/26, 2/8/26, 2/15/26, 2/22/26, 3/8/26, and 3/28/26.Review of the facility's timecard system showed licensed nursing staff were on duty 24 hours each day on the following dates: 1/11/26, 1/25/26, 2/8/26, 2/15/26, 2/22/26, 3/8/26, and 3/28/26.During an interview on 8/11/26 at 3:00 p.m., staff member I stated the facility had licensed nursing coverage 24 hours every day. Staff member I stated the facility was able to identify a job code (LPN1) that was not identifiable by the file application. Staff member I stated when the facility's information was transferred electronically to the payroll-based journal, the system did not recognize the job code (LPN1) and did not report hours worked for employees listed with job code (LPN1).

Based on interview and record review, the facility failed to follow up on grievances identified during resident council meetings by investigating concerns, documenting actions, and communicating resolution to residents. The failure placed all residents at risk for having grievances remain unaddressed or unresolved, negatively affecting their psychosocial well-being. Findings include:During an interview and record review on 8/12/26 at 4:15 p.m., staff member G stated when resident concerns (grievances) were identified during resident council, she completed a Care and Concern form and submitted it to the appropriate department head for review and response. Staff member G stated she requested the form be returned to the activities department no later than one week before the next resident council meeting. Review of resident council minutes and attached Care and Concern forms showed the forms were not completed with documentation of follow-up, actions taken, or resolution. When asked about the incomplete forms, staff member G stated, That's because I don't get them back very often.Review of resident council meeting minutes, dated 5/25/26, showed three residents raised a concern regarding a CNA being on her phone, being snotty/short (in attitude) with the residents, and CNAs not taking trash from residents' rooms. An attached resident council recommendation form identified the grievance and requested it be returned to the activities department by 6/22/26. Review of the 6/29/26 resident council meeting minutes showed the same concern remaining under old business. No documentation was identified showing the grievance concern had been investigated, addressed, or resolved.Review of the 5/25/26 resident council meeting minutes showed residents reported desserts were being provided during the 1:00 p.m. snack rather than with dinner. The dietary manager stated desserts would be returned to the dinner meal. Review of the 6/29/26 meeting minutes showed the same concern remained under old business, with residents stating the change had not occurred, and desserts were still being provided at the 1:00 p.m. snack. No documentation was identified showing the concern had been investigated, addressed, or resolved.Review of the 7/27/26 resident council meeting minutes showed a concern regarding sausage links are burnt and would like moist eggs. The associated care and concern form was signed by the dietary manager, acknowledging receipt, but did not document actions taken, interventions, or resolution.Review of a facility document titled, Resident Council, undated, showed: PURPOSE:The purpose of the Resident Council1. To give residents greater participation in affairs within their own home.2. To make suggestions for improvements, to assist the administration and management in providing better services and programs.3. To promote friendship, charity, and understanding4. To provide and receive necessary information for the benefit of all residents. [sic]

Based on interview and record review, the facility failed to ensure that a resident and/or the resident's representative was made aware of the risks and benefits associated with the use of antipsychotic and psychotropic medication before the start of treatment for 1 (#35) of 5 residents sampled for unnecessary medication. Findings include:During an interview on 8/12/26 at 3:20 p.m., with staff members D and F, staff member D stated that medication consents for antipsychotic and psychotropic medications were obtained during the first care plan conference after a resident was admitted to the facility. Staff member D stated resident #35 was admitted to the facility on [DATE] and had not had his initial care plan conference. Staff member D stated a medication consent signed by a resident or resident's representative explaining the risks and benefits was not needed prior to a resident starting a medication. Staff member D stated if a medical provider ordered a new medication requiring consent from a resident or resident's representative on the weekend, the facility did not have a process for obtaining a signed medication consent. Review of resident #35's physician orders showed the following antipsychotic and psychotropic medications being given to the resident:- 8/5/26 to 8/11/26, aripiprazole 2 mg at bedtime related to depression, unspecified; and,- 8/6/26 to 8/12/26, citalopram hydrobromide 20 mg daily related to depression, unspecified.Review of a facility document titled, Psychotropic Medication Notification, showed resident #35's resident representative was informed on 8/12/26 of the medication's risks and benefits for aripiprazole and citalopram; six days after the medications were started and during the survey.

Based on interview and record review, the facility failed to report allegations of potential abuse or neglect to the State Survey Agency for 2 (#s 27 and 33) of 4 residents sampled for grievances. The failure resulted in allegations of potential abuse or neglect not being reported for timely regulatory review and follow-up. Findings include:1. Review of a grievance dated 6/18/26 showed a concern regarding resident #33 being left on the toilet unattended on the toilet for 30 minutes and crying while waiting for assistance, potentially neglect of care by a staff member. During an interview on 8/12/26 at 11:25 a.m., staff member E stated she was responsible for coordinating the grievance process as the facility's grievance official. Staff member E stated she would document grievances received, talk with the person who filed the grievance, investigate the concern, and meet with the interdisciplinary team to discuss the concern and possible resolutions. Staff member E stated the interdisciplinary team determined whether a concern was a reportable event. During an interview on 8/12/26 at 3:25 p.m., staff member B stated the concern involving resident #33 was not identified by the interdisciplinary team as potential abuse or neglect, based on her knowledge of the resident's toileting history. Staff member B stated she was familir with resident #33, and knows she takes a long time on the toilet and whimpers when she is seated on the toilet.2. Review of a grievance dated 6/22/26 showed a concern regarding the manner in which resident #27 was assisted by staff during toileting and a transfer. The grievance described resident #27 saying No while a staff member continued to physically assist the resident, including concerns regarding forceful handling during the transfer.During an interview on 8/12/26 at 3:25 p.m., staff member B stated the concern involving resident #27 was not identified by the interdisciplinary team as potential abuse or neglect. Staff member B stated the incident was considered a personnel or training issue and stated, That CNA is very well-liked by everyone.During an interview on 8/12/26 at 3:50 p.m., staff member E stated the interdisciplinary team review for grievances consisted of the administrator, the DON, and herself. Staff member E stated she did not know the grievances may have met the criteria for abuse or neglect but stated she defers to the entire team for decisions as she is new to her role.During the survey, the facility was notified the two grievances contained allegations of potential abuse or neglect, and if so, would require they be reported to the State Survey Agency. The facility subsequently submitted a report for each allegation to the State Survey Agency.Review of a facility document titled, Resident Abuse, dated 2/14/25, showed: . Neglect is failure of the facility, its employees or service providers to provide goods and services that are necessary to avoid physical harm, pain, mental anguish or emotional distress .'Alleged Violation' is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and if, verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse.Staff to resident Abuse of Any Type .When a nursing home accepts a resident for admission, the facility assumes the responsibility of ensuring the safety and well-being of the resident. It is the facility's responsibility to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to resident behavior .

Based on interview and record review, the facility failed to protect residents by failing to thoroughly investigate allegations of abuse for 2 (#s 2 and 22) of 6 residents sampled for Facility Reported Incidents. The facility's investigations did not adequately evaluate conflicting information, establish the circumstances surrounding the allegations, evaluate staff responses to resident behaviors, assess the residents' psychosocial responses following the events, or evaluate the need for staff education and corrective measures. The failure placed residents at risk due to abuse allegations not being thoroughly investigated or appropriate measures not being identified to protect residents. Findings include:1. Review of a Facility Reported Incident, submitted to the State Survey Agency on 1/31/26, showed the facility received an allegation involving resident #2, in which she was called a pain in the ass by staff member L when she requested assistance with her roommate's television. The facility initiated an investigation for the allegation.The investigation documentation did not include an interview with the initial allegation reporter to obtain additional information about the allegation. The investigation also did not reconcile conflicting accounts regarding staff member L's statement or the circumstances surrounding the incident. The facility concluded the allegation was unsubstantiated without documenting how the conflicting information was evaluated and resolved.The investigation included documentation that resident #2 continued to express concern regarding future contact with staff member L; however, no psychosocial assessment was completed after the incident to determine if the resident had psychosocial harm or fear. During an interview on 8/12/26 at 1:40 p.m., resident #2 stated she felt safe in the facility, but would not feel safe if [staff member L] was taking care of her.The facility's documentation of the investigation did not contain evidence of any staff education regarding appropriate communication and approaches when responding to resident concerns, agitation, or behavioral expressions, such as those voiced by resident #2. The investigation did not demonstrate evaluation of the need for additional education, counseling, or competency assessment following the allegation. It was unclear how the facility addressed monitoring for staff member L in the future related to the allegation and resident #2. During an interview on 8/12/26 at 7:02 p.m., staff member L stated the facility did not offer or provide any education following the incident between staff member L and resident #2. Staff member L stated, They just called to tell me I could return to work but would not be allowed to work on [Resident #2's name] hall any longer. The failure to educate staff member L continued the risk for other residents related to verbal abuse. 2. Review of a Facility Reported Incident, submitted to the State Survey Agency on 7/31/26, showed NF6 reported resident #22 became combative while receiving care on 7/31/26 at approximately 4:30 a.m. NF6 reported she held resident #22's hand while turning her and providing care. At approximately 6:20 a.m., NF6 noted two dense bruises, one on the back of resident #22's right hand and another on the right forearm, and NF6 reported the findings to the nurse. The facility initiated an investigation into the bruising. The investigation documentation showed:- There were conflicting accounts of the events surrounding the incident. The investigation did not establish how resident #22 sustained the bruises or resolve the conflicting accounts regarding the timing or details of the interaction between the CNA and the resident, or when the bruises developed.- The investigation relied, in part, on resident #22's history of dementia-related behaviors and combativeness when concluding the allegation could not be substantiated. The investigation did not show an evaluation of NF6's response to resident #22's resistance to care, adherence to resident #22's care plan, which included interventions for approaches to resident care when combative or refusing care. The investigation did not show whether NF6 used resident #22's care planned approaches for managing dementia-related behaviors. - The investigation did not contain evidence of education or assessment completed with NF6 regarding appropriate approaches to dementia-related behaviors, resistance to care, or implementation of resident-specific interventions. The facility removed NF6 from resident #22's care while the investigation was pending; however, the investigation did not demonstrate implementation or documentation of corrective education or competency assessment before the facility determined the allegation was unsubstantiated and allowed NF6 to return to work. During an interview on 8/12/26 at 7:50 p.m., NF6 stated the facility did not provide or offer additional education after the incident but called to inform her the investigation was unsubstantiated, and she was able to return to work. Despite the facility's approval for her to return to work, NF6 stated she no longer wanted to work at the facility and terminated her contract after the incident.During an interview on 8/12/26 at 4:05 p.m., staff member C stated no psychosocial follow-up was documented in the electronic health records for resident #2 or resident #22 for the events that occurred.A request for documentation on post-event staff education for both incidents was made on 8/12/26. No documentation was received by the end of the survey.A request for documentation on psychosocial follow-up for residents #2 and #22 was made on 8/12/26. No documentation was received by the end of the survey.Review of a facility policy titled, Resident Abuse, undated, showed:2. A written report of investigation will be submitted .This report may contain investigation information as applicable:- Details of the incident and injury- Signed statements from pertinent parties .- Information gathered from the investigation- Action taken by [facility name] - safeguarding the resident and preventing a reoccurrence.- The final action/conclusion made by the center . [sic]

Based on observation, interview, and record review, the facility failed to implement appropriate measures to prevent skin breakdown, to provide consistent care and monitoring of the pressure ulcers, and failed to ensure pressure ulcers were identified, classified, and the severity determined and documented accurately, for 1 (#6) of 15 sampled residents, resulting in the development of multiple pressure ulcers. Findings include: Review of resident #6's nurse's note dated 6/27/25 at 11:48 a.m., showed the resident complained because her knee popped. An x-ray was ordered of resident #6's right knee. The results of the x-ray were negative. Review of resident #6's nurse's note dated 6/28/25 at 3:06 a.m., showed the resident was found on the floor. Review of resident #6's nurse's note dated 6/28/25 at 4:04 p.m., showed resident #6 was diagnosed with a non-displaced tibial plateau fracture. The resident was to wear a knee immobilizer and be non-weight bearing for two to three months. Review of resident #6's nurse's note dated 6/29/25 at 4:59 a.m., showed the resident's immobilization brace was put on and the resident was tolerating the brace well. The resident was reminded to let staff know if she had any discomfort from the brace. Review of resident #6's nurse's note dated 6/29/25 through 7/18/25, failed to document resident #6's skin had been assessed under the immobilizer brace. Review of a nurse's note dated 7/19/25 at 11:12 a.m., showed the brace on resident #6's right leg had rubbed an open area on the outer Achilles area on the ankle, and this caused some purple bruising, related to pressure. The wound was draining serous fluid. The note showed an area on the resident's lower back leg above the ankle had an abrasion with a scab, and a small abrasion to the inner right ankle. The brace was left off for comfort. Review of resident #6's nurse's note dated 7/20/25 at 6:16 p.m., showed the right lower extremity brace had been placed on the resident during the night shift. The nurse's note showed . Metal bar was once again pushing into an edematous area on resident's outer ankle. Review of resident #6's Significant Change Nutrition Assessment, dated 7/24/25, completed by the dietitian, showed resident #6's skin was intact. The dietitian did not include the pressure ulcers resident #6 had on her right ankle area and did not take into consideration the increased caloric, protein, or fluid needs associated with pressure ulcers. Review of resident #6's nurse's note dated 7/28/25 at 4:05 p.m., showed the first measurement of the lateral malleolus wound bed had tan slough and measured two centimeters. The facility failed to follow the facility procedure directing the staff to identify the type of wound. No other wounds were identified or measured according to this note. Review of a hospital progress note dated 7/30/25 by a physician showed resident #6 had an open wound of her right ankle caused by the immobilization splint. Review of resident #6's, nurse's note dated 8/1/25 at 4:05 p.m., showed the staff alerted the nurse that the resident had a blister on her right medial heel. The blister measured four centimeters by three centimeters and was fluid-filled. The note showed the staff first noted the blister on 7/30/25, but no treatment was started at that time. The nurse's note showed the nurses could not find the cause of the blister. The immobilizer brace had been discontinued on 7/28/25. Bunny boots were applied 8/1/25 after the development of the pressure wounds. Review of resident #6's nurse's note dated 8/1/25 at 4:12 p.m., showed resident #6 had an open area on her right lateral heel. The wound was cleansed and measured 1.7 centimeters by 1.4 centimeters and had a tan slough area of 0.6 centimeters by 0.6 centimeters. The facility failed to identify the type of wound and failed to stage the pressure ulcer on resident #6's right heel. No other wound was mentioned or measured. Review of resident #6's Skin Observation Tool - (Licensed Nurse) dated 8/2/25 was completed. The assessment showed the skin was pink, moist and intact. The assessment failed to identify the blister area on resident #6's heel and the wound on the lateral malleolus. Review of resident #6's NAR (nutrition at risk) meeting note, dated 8/7/25 at 4:43 p.m., showed resident #6 had a significant weight loss. The identified reason for weight loss was addressed. The only skin issues identified in the weight meeting was the blister on resident #6's right ankle. The heel pressure wound was not taken into consideration. The facility failed to identify the resident's need for increased nutrition related to wound healing.Review of resident #6's physical therapy note, dated 9/9/25 at 3:08 p.m., showed, . Wounds were first evaluated by (physical therapist name) on 8/7/25 please see this note for details. It is approximately 2 weeks later the patient still has this blister with discoloration of the blister therefore upon nursing notification. The physical therapist failed to stage resident #6's pressure ulcer. The physical therapist decided to debride the wound to abate any unknown problems contained underneath the blister. 4) Measurements: Lateral wound = 1.0 cm 0.7 cm wide X unknown depth.Posterior superior wound = 2.7cm X 2cm X unknown depth.Posterior wound = 0.1cm by 0.8cm by unknown depth. [sic] Review of resident #6's nurse's note dated 8/7/25 at 4:58 p.m., showed, . PT returned later and popped the blister and debrided the open area. New dressing orders - for area that had the blister. Orders are to cleanse with wound wash, cover with Xeroform and gauze daily. After blister was popped a light red area that is 5 cm x 3m with a depth of less than 1 mm was noted. Open area on lateral ankle wound bed is red after being debrided by PT. The area measures 1.7 cm x 1.2 cm x 1.5 mm. The skin around the open area is slightly red. It measures 4 cm x 4cm. The areas capillary refill is less than 1 second. [sic]. The facility failed to identify and document the stage of the pressure ulcer on resident #6's lateral ankle wound. Review of resident #6's nurse's note dated 8/8/25 at 5:33 p.m., showed resident #6 had a small circular reddish/purple area on the end of her great toe. The size of the wound was the size of a pencil eraser. The area was blanchable. Review of resident #6's nurse's note dated 8/9/25, showed the wound to the tip of resident #6's right great toe was .25 cm round and dark blue/black in color. The area was non-blanchable. The note showed a foot cradle would be added to the bed.Review of resident #6's care plan, dated 8/12/25, showed a foot cradle had been added to the resident's care plan. This showed a delay in treatment of three days for resident #6. Review of resident #6's nutrition at risk meeting note dated 8/14/25 at 4:58 p.m., showed the facility identified two wounds and implemented a fortified diet for resident #6. Review of resident #6's current care plan showed, the Bunny Boots were to be put in place on 8/1/25. The care plan did not include treatment for the heel pressure ulcer. The foot cradle was not added to the care plan until 8/12/25, after resident #6 developed a wound on her right great toe. The care plan failed to identify that Physical Therapy would assist in the treatment and care of the pressure ulcers. The care plan failed to identify the leg immobilizer was being used and when the immobilizer was discontinued.During an observation and interview on 9/11/25 at 9:46 a.m., staff member F notified the surveyor and resident #6 she was going to do the dressing change on the sores the resident got from her leg immobilizer. During the observation, staff member F provided pressure ulcer treatment to two open areas on resident #6's right lower leg. One area was just above the round portion of the heel, and the other area was to the right and below the malleolus. A small red/brown wound was observed on the tip of resident #6's right great toe. No treatment was provided to that wound. Review of the facility's policy titled, Subject: Skin Integrity (impaired) Documentation, undated showed:Policy: All patients and residents having a wound present will have the wound identified according to type.Purpose: To provide guidelines for required documentation regarding all new and existing skin integrity issues .To provide a standardized assessment tool wound healing chart to monitor healing over time. Procedure: Identify the type of wound: The nurse initially observing a new skin integrity issue will identify the type of skin integrity issue present. Initiate a treatment plan. All nursing departments will use the following policies on specific wound types to choose and initiate treatment. Documentation: The nurse who assesses and existing skin integrity issue will document the following in the nursing notes or on the skin problem treatment sheet. a. onsetb. description of skin integrity issuec. Locationd. Size measured in metric system (head to toe) Width (right to left)e. Depth of the tissue involvementf. Presence of undermining or tunneling.

Based on observation, interview, and record review, the facility failed to ensure the dietary manager completed a certification program approved by a national certifying body or had higher education in a related field. This had the potential to affect residents and their nutritional status or meal safety for those who consumed food prepared and served by the facility. Findings include:During the initial tour of the kitchen, on 9/8/25 at 11:56 a.m., no documentation of advanced training for the dietary manager was posted.During an interview on 9/9/25 at 3:45 p.m., staff members A, G, and K were present. Staff member G said he did not have the CDM certificate.During an interview on 9/10/25 at 8:50 a.m., staff member E and Q were present. Staff member Q said he coordinates nourishment for the facility. He assesses the residents and recommends diets and textures for the residents. Staff member Q said he does not complete any kitchen sanitation tours and does not go into the kitchen to monitor the dietary requirements. Staff member E said staff member K is the kitchen manager's supervisor. Staff member E said she and the administrator agreed the facility needs to have a certified dietary manager.

Based on observation and interview, the facility failed to ensure clean and sanitary conditions were maintained throughout the kitchen and the dietary storage areas; fand failed to ensure kitchen staff labeled and dated food in the coolers. This deficient practice increased the risk for the development of foodborne illnesses and deficient practices related to sanitary conditions for all residents who received food from the kitchen. Findings include:During the initial tour of the kitchen, on 9/8/25 at 11:56 a.m., the following observations were made:-The coffee machine nozzles were soiled.-The juice machine nozzles and the plates behind the nozzles were heavily soiled with a sticky substance.-Three fans were observed in the kitchen, and all fans were coated with fuzzy brown material. One fan blew air directly on a food prep area, the industrial fan blew air directly into the kitchen, and the third fan blew air into the clean dish area. -Staff member L had her personal food and drink stored in the resident reach in refrigerator.-Chicken and ham soup base paste was open and not dated.-An open and partially used tub of vanilla yogurt was not dated.-A gallon jug of buttermilk, with an expiration date of 8/15/25, was in the cooler. The buttermilk whey was floating on top of the curds.-An opened and partially used carton of liquid eggs was not dated.-Two cans of apples and two cans of mandarin oranges were significantly dented along the bottom seam of the cans.-A case of bottled water was sitting directly on the floor.-The area under the small and the large mixers were splattered with white and tan food debris.-The shelf under the mixer was soiled and sticky from an opened bottle of honey.-Large rolling bins of panko, flour, and sugar were not labeled or dated, and the bin lids were soiled.-A bag of spaghetti and a bag of linguini were opened and not dated when opened.-Two, three-tiered carts were soiled with food particles and stains from dried liquid. -Corn was observed on the floor of the freezer.-Food not labeled or dated in the walk-in refrigerator included bacon, cream cheese, chili sauce, black olives, melon, pineapple, fruited Jello, cake, and mixed lettuce. The food was identified by staff member M.-A bucket of pickles was stored on the floor.-Pizza sauce was dated 9/2/25.-28 small tubs of food and 14 glasses of liquid were unlabeled and undated.-Spices were opened and not dated for red peppers, parsley, taco, pepper, chili powder, bay leaves, and rosemary.-The small reach in freezer contained opened bags of pepperoni, mozzarella sticks, and chicken strips. The bags were not labeled, dated or closed.-The food prep area was soiled with a greasy substance. -The area under the large-sized spices, near the poles holding the spice shelf, was dirty, greasy, and felt sticky to touch. -There was an unlabeled and uncovered cup filled with a white granular substance. This cup was sitting on the top of the oven in the cooking area. Staff member M was unable to identify the contents of the cup. -Chicken was being held in a small container and was placed in a tub with melted ice. The temperature of the chicken breast was 73 degrees. Staff member M said the chicken should be chilled to and held at 40 degrees.-The small freezer was missing the documented temperatures for September 4th, 6th, and 7th, 2025. One red sanitation bucket was observed in the kitchen. The chemical tested at over 500 parts per million. Staff member M said the chemical should be 200-400 parts per million. Staff member M said there should be three buckets out and being used. The areas near the grill, soup tureen, and pizza oven were heavily soiled with a brown/black greasy substance which could be scraped with a thumbnail. The front panel from the grill to the floor was missing. The floor from the grill to the Vulcan steamer was covered with a black oily substance. Under the soup tureen, cloth fabric was observed lying on the floor over the gas lines. The cloth, which had some white areas showing, was covered in a black layer of debris. The tile grout under the steam table was black, and the orange tiles were soiled with a greasy black substance. The bin to catch water near the soup tureen was half full of a substance which had a caked dry appearance. During an interview on 9/8/25 at 11:56 a.m., Staff member M said the food was only good for five days when it is left over in the cooler. Staff member M said the pizza sauce was outdated in the cooler. Staff member M stated, We don't use dented cans. Staff member M removed the dented cans and threw them in the garbage. Staff member M said there was a flood, and the towels probably got thrown under the soup tureen area then. Staff member M was unable to identify when the flood occurred. During an observation on 9/9/25 at 10:00 a.m., staff member N was serving food to the residents in the main dining area. Staff member N failed to have a beard net covering his beard.During an observation on 9/9/25 at 10:08 a.m., staff members G, P, and O were all in the food service area. The three staff members all had beards, and none of the staff wore beard nets. During an interview on 9/9/25 at 3:45 p.m., staff members A, G, and K were present. Staff member G said the floors are cleaned every night, and environmental services come in monthly to do a deep clean. Staff member G said there are schedules for cleaning the entire kitchen. Staff member K said he thinks the kitchen was not getting cleaned per the schedule.Refer to F801 related to the lack of oversight by a Certified Dietary Manager of the kitchen and dietary services.

Based on interview and record review, the facility failed to report allegations of resident abuse to the State Survey Agency within 24 hours of the incident for 2 (#s 13 and 34) of 15 sampled residents. Findings include:Review of the facility reported incident dated 9/11/24 at 8:40 a.m., showed a resident representative reported to social services resident #13's roommate (resident #34) had been making resident #13 feel uncomfortable by rubbing resident #13's thigh and groin area. The allegation of resident-to-resident abuse was not reported to the State Survey Agency until 9/11/24.During an interview on 9/11/25 at 8:10 a.m., staff member D stated she received a call from resident #13's representative on 9/11/24 requesting a potential room change for resident #13. Staff member D stated the residents representative stated resident #13 had felt uncomfortable with her roommate (resident #34) due to unwanted touching of resident #13's leg. Staff member D stated it was then reported to the State Survey Agency on 9/11/24. Staff member D stated during the facility's investigation it was found resident #13 reported the unwanted touching by resident #34 to a nurse on 9/8/24. Staff member D stated she did not know why the facility reported incident was not reported to the State Survey Agency within 24 hours from the event which occurred on 9/8/24.During an interview on 9/11/25 at 10:35 a.m., staff member B and E were present. Staff member B stated the incident involving residents #13 and 34 on 9/8/24 was not reported to the State Survey Agency within 24 hours because the nurse failed to report the incident to administration. Staff member B stated social services spoke to resident #13's representative on 9/11/24 at which time she was first made aware of the incident which occurred on 9/8/24. Staff member B stated the facility then reported the incident to the State Survey Agency on 9/11/24.Review of resident #13's nursing progress note dated 9/8/24 at 5:00 p.m., showed resident #13 stated to the nurse her roommate (resident #34) rubbed her leg and asked the nurse to talk to her (resident #34). Resident #13 then came down the hallway an hour later and reported to the nurse in a low tone of voice her roommate (resident #34) had touched her leg again.Review of the facility's policy titled, Resident Abuse, last revision dated 2/14/25, showed: . SUBJECT: RESIDENT ABUSElt will be the responsibility of any department head receiving the complaint of alleged abuse, corporate punishment, involuntary seclusion, neglect, mistreatment, misappropriation or resident property, or exploitation to inform the administrator or designee immediately.REPORTING1. Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source, misappropriation of resident property or reasonable suspicion of a crime against a resident or an individual receiving care from the facility will be immediately reported. Collective reporting may occur, which means, that a staff member will report it to SS, DON, ADON or Administrator and those individuals will notify the state, however, it is the covered individuals responsibility to follow up and assure the suspect or known abuse/crime was reported timely. [sic]

Based on interview and record review, the facility failed to complete a Significant Change minimum data assessment within fourteen days after the facility identified a major decline in 1 (#6) of 15 sampled residents. The decline had the potential to impact the resident's physical and health status. Findings include:Review of resident #6's nursing note, dated 6/28/25 at 4:04 p.m., showed resident #6 was diagnosed with a non-displaced tibial plateau fracture. The resident was to wear a knee immobilizer and was non-weight bearing for two to three months. Review of resident #6's MDS, with an assessment reference date of 5/8/25, showed the resident needed partial to moderate assistance with performing oral care, getting herself on and off the toilet, showering, removing her footwear, personal hygiene, toilet transfer, transfer from bed to chair, and moving from a sitting to a standing position. Comparing the minimum data assessment with an assessment reference date of 7/17/25, showed the resident had declined and needed substantial to maximum assistance. During an interview on 9/11/25 at 9:30 a.m., staff member C said she had been completing the minimum data assessments for about one year. Staff member C said she had been trying to educate herself with online training. Staff member C said she had not completed all the training yet. Staff member C said she now knows that you have two weeks to set the assessment reference date for a resident who had a significant change in condition. Staff member C said the Significant Change minimum data set assessment reference date was not set on time, and the minimum data assessment was late.

Based on observation, interview, and record review, the facility failed to update the comprehensive care plan for a resident who developed avoidable pressure ulcers for 1 (#6) of 15 sampled residents. Findings include:During an interview on 9/11/25 at 9:30 a.m., staff member C said she updated the care plans when needed and reviewed care plans quarterly. Staff member C said she was not sure how she failed to identify the wounds on resident #6's ankle which were caused by the immobilizer. Review of resident #6's nurse's note, dated 7/19/25 at 11:12 a.m., showed the brace on resident #6's right leg had rubbed an open area on the outer Achilles area on the ankle with some purple bruising related to pressure. Review of resident #6's care plan, dated 8/1/25, showed an open area to resident #6's right ankle below the ankle was identified. The care was not updated timely as the Bunny Boots were added to the care plan on 8/1/25, a delay of 13 days following the development of pressure ulcers on resident #6's ankle area. The care plan did not include the pressure ulcer to resident #6's right heel. The care plan did not show resident #6's had a right heel pressure ulcer or a wound to the right great toe. The care plan was updated on 8/14/25 when the nutrition at risk team determined a fortified diet would be an appropriate intervention for wound healing. The foot cradle was not added to the care plan until 8/12/25 after resident #6 developed a wound on her right great toe. The care plan failed to identify Physical Therapy would assist in treatment and care of the pressure ulcers. The care plan failed to identify the leg immobilizer was being used and when the immobilizer was discontinued. During an observation and interview on 9/11/25 at 9:46 a.m., staff member F informed the surveyor and resident #6 she was going to do the dressing change on the sores she got from her leg immobilizer. During the observation staff member F provided pressure ulcer treatment to two open areas on resident #6's right lower leg. One area was just above the round portion of the heel, and the other area was to the right and below the ankle bone. A small red/brown wound was observed on the tip of resident #6's right great toe.

Based on interview and record review, the facility staff failed to have the necessary knowledge and skill set related to the proper monitoring and documentation of quality control checks for a blood glucose testing machine, and it was found a system was not in place for the checks. This deficient practice had the potential to affect all residents who require blood glucose monitoring, as inaccurate readings could lead to improper assessment, delayed interventions, or incorrect treatment decisions.During an interview on 9/10/25 at 9:40 a.m., staff member F stated a blood glucose control solution test was completed daily, but not on her shift. Staff member F stated she did not know where to find documentation showing a controlled test was completed on the glucose monitoring system.During an interview on 9/10/25 at 9:45 a.m., staff member B stated the blood glucose monitoring system was new and she was not sure if the controlled test was completed weekly or monthly. Staff member B stated she would need to review the current policy. Staff member B could not find documentation showing when control testing was completed for the glucose monitoring system.During an interview on 9/11/25 at 10:35 a.m., staff member B confirmed the facility did not have a system in place to ensure quality control checks were being completed and documented as required by the facility policy and manufacturer guidelines. Staff member B stated the facility had implemented a blood glucose quality control testing log as of 9/11/25.A request was made to the facility for blood glucose quality control documentation. No documentation was received by the end of the survey.Review of the facility's policy titled, [NAME] Real-Time blood glucose monitoring system Policy, undated, showed: Policy: It is the policy of (facility name) to ensure accurate blood glucose readings are documented within the Electronic Medical Record (EMR).Purpose: To guide licensed staff on the use of the [NAME] Real-Time blood glucose monitoring system. Performing a Control Solution TestDo a control solution test when:You first receive the meterAt least once a week to routinely check the meter and test stripsYou begin using a new vial of test stripsYou suspect the meter or test strips are not working properly,Patients' blood glucose test results are not consistent with how they feel, or if you think the results are not accurate,Practicing the testing process or have dropped or think you may have damaged the meter. [sic]

Based on interview and record review, the facility failed to ensure social services were provided to assist 2 (#s 19 and 26) of 15 sampled residents with emotional and psychosocial support following allegations of abuse. The deficient practice had the potential to cause emotional distress for the residents. 1. Review of a facility reported event, submitted to the State Survey Agency, on 10/4/24, showed resident #19 was spoken to harshly by a staff member. Review of resident #19's medical record progress notes, dated 10/4/24 through 10/25/25, failed to show any allegations of abuse, and there was no follow-up to the alleged incident of a staff member talking harshly to resident #19. There were not social service notes to determine if the resident had any negative outcomes from the event or if the resident was comfortable with care provided by the staff member. 2. Review of resident #19's nurse's note, dated 10/6/24 at 4:40 a.m., showed the resident was picking frequently at the skin on her face and chest, causing open areas. The behavior was difficult to direct. There were no social service notes to show what was done for resident #19's psychosocial health and to help identify the cause of the behavior or if it was in relation to the recent allegation of staff to resident abuse. 3. Review of the facility reported incident, submitted to the State Survey Agency, on 12/18/24, showed resident #26 was handled roughly during a transfer. No progress notes were found or provided showing social services followed up with the resident after the allegation where she was treated roughly. During an interview on 9/10/25 at 9:10 a.m., staff member E said there should be a note documenting the residents had been followed by social services after an allegation of abuse. Staff member E said she would expect a social services note to identify how the residents were doing. Staff member E said she had heard the staff discussing how the residents were doing but would guarantee there probably isn't a note. During an interview on 9/10/25 at 9:15 a.m., staff member D said she followed up with resident #26 after her rough treatment. Staff member D said she should have completed a psychosocial assessment after an allegation of abuse. Staff member D said a note should be documented in the medical record showing how the resident was doing following the event.

Based on interview and record review, the facility failed to submit complete and accurate Payroll Based Journal information quarterly, for licensed nursing coverage 24 hours each day to the Centers for Medicare and Medicaid Services. Findings include: Record review of the Centers for Medicare and Medicaid Services report titled, PBJ Staffing Data Report, dated Fiscal Year Quarter 2, 2024 (January 1 - March 31), showed: . Metric . Failed to have Licensed Nursing Coverage 24 Hours/Day, Triggered . Record review of the facility timecards for the following dates: 1/1/24, 2/20/24, 2/27/24, 3/5/24, 3/19/24, and 3/26/24, showed licensed nursing staff in the facility 24 hours each day. During an interview on 7/31/24 at 1:44 p.m., staff member H stated the facility had licensed nursing coverage 24 hours each day. Staff member H stated the facility was able to identify a job code (LPN2) was missing from the file application. Staff member H stated when the facility's information was transferred electronically to the payroll-based journal the system did not recognize the job code (LPN2) and did not report hours worked for employees listed with job code (LPN2).

Based on observation, interview, and record review, the facility failed to update resident care plans when changes to the resident's care occurred for 4 (#s 13, 14, 24, and 137) of 19 sampled residents. Findings include: 1. During an observation and interview on 7/31/24 at 8:36 a.m., resident #137 was seen with an ostomy appliance on his stomach, and a white adhesive bandage located just below the resident's ostomy. Resident #137 also had a urinary drainage bag hanging from the bed frame. Resident #137 stated he had a small wound below his ostomy which was covered with a dressing because it drained on occasion. Staff member P pointed out the ladybug sticker on the resident's name plate which indicated the resident was on enhanced barrier precautions because of his ostomy, urinary catheter, and abdominal wound dressing. Staff member P stated she had to wear a gown if she changed the resident's wound dressing. Review of resident #137's care plan, dated 7/16/24, showed the resident had rectal cancer resulting in the placement of a colostomy and urinary retention necessitating a urinary catheter. The care plan failed to show the need for enhanced barrier precautions and what interventions were in place because of the resident's diagnoses. 2. During an observation on 7/31/24 at 8:04 a.m., resident #24 was dressed in street clothes and sitting in a chair near the nurse's station. Resident #24 had a urinary drainage (leg bag) protruding below the hem of her left pant leg. Review of resident #24's care plan, initiated on 7/5/23 and last revised on 6/25/24, showed the resident had a urinary catheter in place because of urinary retention. The care plan failed to show the resident was on enhanced barrier precautions because of the catheter. 3. During an observation on 7/29/24 at 2:37 p.m., resident #14 was lying in bed with her eyes closed. The resident's tube feeding was infusing at 65 ml/hr on a feeding tube pump. There was a ladybug sticker on the resident's name plate, indicating the use of enhanced barrier precautions. Review of resident #14's care plan, initiated on 7/21/23 and revised on 7/9/24, showed the resident had a feeding tube for nutritional support. The care plan failed to show staff were to use enhanced barrier precautions when working with the resident's feeding tube. During an interview on 8/1/24 at 8:30 a.m., staff member C stated enhanced barrier precautions were implemented when residents had tubes, drains, and wounds. Staff member C stated a ladybug sticker was placed on the resident's name plate which meant the resident had drains or tubes which necessitated additional infection prevention strategies. Staff member C stated she maintained a list of residents who were to have enhanced barrier precautions. Staff member C could not explain why the enhanced barrier precautions were not identified on resident #s 14, 24, and 137's care plans. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated 4/5/24, showed, 1. Enhanced Barrier Precautions (EBP) are indicated for residents with any of the following: . b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. The policy also showed, EBP is employed when performing the following high-contact resident care activities: . g. Device care or use: central line, urinary catheter, feeding tube . 4. During an observation on 7/30/24 at 8:50 a.m., resident #13 was seated in a recliner near the nurse's station. Resident #13's bed was made and a foot cradle was present. Resident#13 did not interact with staff and sat in the chair with her eyes closed. During an interview on 7/31/24 at 9:04 a.m., staff member O stated resident #13 was assisted by one staff member for dressing and personal cares. Staff member O stated the resident had a foot cradle on her bed, so her blankets did not put excess pressure on the tops of her toes. Staff member O stated the staff also used lotion on the resident's skin to prevent excessive dryness. Review of resident #13's physician orders, dated 3/1/24, showed the addition of a foot cradle for the prevention of breakdown on the tops of the resident's toes. Review of resident #13's care plan, initiated on 7/7/23 and revised on 3/26/24, showed the resident was at risk for impaired skin integrity with the goal of intact skin. The interventions on the care plan failed to show the use of a foot cradle. During an interview on 8/1/24 at 11:20 a.m., staff members B and E stated currently care plans were only updated quarterly at the time of each resident's MDS completion and quarterly care conference. Staff member E stated she was working on a process which would allow for more real-time revisions to the resident care plans.

Based on interview and record review, the facility failed to ensure a registered pharmacist performed medication regimen reviews at least monthly for 1 (#33); and failed to ensure the physician addressed the pharmacy recommendations and irregularities timely for 2 (#s 4 and 24) of 19 sampled residents. The facility also failed to maintain a policy and procedure for monthly medication regimen reviews which identified documentation required and the time frames for the steps taken by the pharmacist when an irregularity was identified. The deficient practice had the potential to affect all residents receiving medication at the facility. Findings include: 1. Review of resident #4's MRR, dated 4/18/24, showed staff member Q recommended a GDR for mirtazapine, paroxetine, and risperidone. The physician did not address the recommendation until 5/31/24, resulting in a six week delay (4/18/24 to 5/31/24). Review of resident #4's mood and behavior team note, dated 6/19/24, failed to show documentation a physician or pharmacist was present for the GDR discussion. Review of resident #4's MRR, dated 7/4/24, showed staff member Q requested a GDR review. There was a handwritten note (not dated or signed) which showed, GDR discussed 6/19/24. The provider did not address the recommendation until 7/30/24, resulting in a six week delay (6/19/24 to 7/30/24). During an interview on 7/31/24 at 2:15 p.m., staff member Q stated he was new to the MRR process and was responsible for MRRs starting in April of 2024. Staff member Q stated he requested the mood and behavior team discuss the GDRs for resident #4 during the April (2024) meeting. Staff member Q stated he was not sure what documentation was required for the MRRs and GDRs which were requested. There was no documentation of recommendations or irregularities identified by staff member Q and addressed by the attending provider which showed the medication name and dose for the recommended GDRs. The mood and behavior team note for 6/19/24 did not contain documentation a physician or pharmacist was present. 2. Review of resident #24's MRR, dated 3/18/24, showed staff member Q recommended continuing Protonix at the same dose due to the resident's high risk of gastrointestinal bleeding, recommended Duonebs and Tessalon Perls be discontinued due to non-use, and recommended changing from risperidone to Seroquel due to the increased risk of EPS associated with risperidone use. The recommendations were not addressed until 5/31/24, resulting in a 10 week delay (3/18/24 to 5/31/24). Review of resident #24's MRR, dated 4/19/24, showed two medication orders did not have a corresponding diagnosis in the resident's EHR. The recommendations were not addressed until 5/31/24, resulting in a six week delay (4/19/24 to 5/31/24). Review of resident #24's mood and behavior note, dated 6/5/24, failed to show the pharmacist or the attending provider were present for the GDR discussion. Review of resident #24's MRR, dated 7/4/24, showed a request for a GDR review. There was a handwritten note (not dated or signed) which showed, Done - GDR discussed 6/5/24. The attending provider addressed the recommendation on 7/30/24, resulting in an eight week delay (6/5/24 to 7/30/24). During an interview on 7/31/24 at 2:15 p.m., staff member Q stated he was new to the MRR process. Staff member Q stated he was familiar with the regulations associated with nursing home residents but was unsure what the process was supposed to look like. Staff member Q was not aware the pharmacist was responsible for the identification of irregularities in the resident's medication regimen. There was no documentation by the pharmacist and addressed by the attending provider which identified the medication name and dose for the medications recommended to have a GDR. The mood and behavior team note for 6/5/24 included the necessary medication information but did not contain documentation of the presence of the pharmacist or the provider. 3. Review of resident #33's MRR, dated 7/30/24, showed, ADDENDUM TO JUNE 2024 REPORTS: No concerns or recommendations at this time. The form was signed by the attending provider on 7/30/24. Review of resident #33's EHR, accessed on 7/31/24, failed to show an MRR was completed within 30 days of the resident's admission on 6/4/24. During an interview on 7/31/24 at 2:15 p.m., staff member Q stated he was not sure if an MRR was done for resident #33 during the first 30 days after the resident was admitted to the facility (6/4/24). Staff member Q stated he was not able to find documentation of an MRR done after the resident's admission on 6/4/24. Review of the facility policy titled, Drug Regimen Review, not dated, failed to show the steps to be taken by the pharmacist during the medication review and the time frames associated with each of the steps. The policy failed to show the process for resolving situations involving a disagreement between the pharmacist's recommendation and the attending provider's orders for resident care. The policy also failed to identify what should be done if the anticipated length of stay was less than 30 days.

Based on observation, interview, and record review, the facility failed to implement a comprehensive, resident-centered care plan which identified the resident's history of recurrent urinary tract infections and the interventions related to prevention of urinary tract infections for 1 (#9) of 19 sampled residents. Findings include: During an interview on 7/29/24 at 1:40 p.m., resident #9 was sitting up in her recliner. Resident #9 stated she has a history of urinary tract infections and has been on antibiotics for them. Resident #9 stated she experienced frequency in the past when she was diagnosed with a urinary tract infection. During an interview on 7/31/24 at 8:54 a.m., staff member N stated resident #9 needed assistance with toileting and appropriate perineal care after urinating and was encouraged to increase fluid intake. During an interview on 7/31/24 at 9:20 a.m., staff member F stated resident #9 had received antibiotics for treatment of urinary tract infections. The resident was also started on probiotics and cranberry pills in May of 2024 for prevention of urinary tract infections. Review of resident #9's MAR, dated May of 2024, showed the resident received Cipro 500 mg twice daily from 5/7/24 to 5/14/24 for the treatment of a urinary tract infection. Review of resident #9's EHR, accessed on 7/31/24, showed the following nursing progress notes: - 5/3/24, resident complained of slimy urine, increased fluid intake, - 5/7/24, resident complained of urinary frequency and foul-smelling urine, urinalysis collected and sent to the lab, started on Cipro, - 6/21/24, resident complained of urinary frequency, - 6/23/24, resident complained of suprapubic discomfort and was started on Keflex, and - 6/26/24, urine culture results received, antibiotic changed to Bactrim DS until 7/3/24. Review of resident #9's MAR, dated June of 2024, showed the resident received Keflex 500 mg four times a day from 6/23/24 to 6/26/24 and Bactrim DS twice daily from 6/27/24 to 7/3/24. Both the Keflex and Bactrim DS were administered for a urinary tract infection. Review of resident #9's care plan, dated 7/25/24, failed to show a focus area related to recurrent urinary tract infections or goals and interventions for the prevention of urinary tract infections. During an interview on 8/1/24 at 11:20 a.m., staff members B and E stated care plans were updated on a quarterly basis, but they were working on a process for more real time updating of care plans. Staff member B stated resident #9 was admitted on [DATE] and was due (in late July of 2024) for her first quarterly care conference.

Based on observation, interview, and record review, the facility failed to ensure orders for as needed psychotropic medications did not exceed 14 days unless the rationale was documented by the provider for 1 (#33) of 19 sampled residents. Findings include: During an observation and interview on 7/29/24 at 1:56 p.m., resident #33 was walking in the hallway using a front-wheeled walker. When asked what brought her to the facility, resident #33 stated her memory was not very good and she was not sure. No pacing or exit-seeking behavior was seen. Review of resident #33's medication orders, dated 7/7/24, showed an order for lorazepam 0.5 mg every four hours as needed for anxiety. The order was still in place and active as of 7/30/24. During an interview on 7/31/24 at 8:28 a.m., staff member F stated resident #33 became restless, began pacing or looking for her purse when she was anxious. Staff member F stated the resident responded well to redirection and distraction techniques. During an interview on 7/31/24 at 2:15 p.m., staff member Q stated he became responsible for medication regimen reviews some time in April of 2024. Staff member Q stated he got some training from the previous consultant pharmacist, but was new to the nursing home regulations. Staff member Q stated he did not have documentation of resident #33's medication regimen review after the resident was admitted on [DATE]. Staff member Q was not aware resident #33 had an as needed order for lorazepam which had been in place for more than 14 days. Review of resident #33's medication regimen review, dated 7/30/24 (after the start of the survey), showed there were no concerns or recommendations as of 7/30/24. The pharmacy review failed to identify the presence of an as needed psychotropic medication which had been in place for more than 14 days. Review of resident #33's EHR, accessed on 7/31/24, failed to show any medical provider documentation of the rationale for continuing the as needed lorazepam. Review of the facility's policy titled, Psychotropic Drug Use, not dated, showed as needed psychotropic medications were limited to 14 days. The policy showed the attending prescriber was able to extend the use of as needed psychotropic medications beyond 14 days if there was documentation, by the prescriber, explaining the rationale for continued use.

Based on observation and record review, two licensed nursing staff members failed to follow the manufacturer's recommendations for an Unsulin Aspart FlexPen, when administering medications, for 1 (#22) of 1 sampled resident. This failure had the potential to affect all residents in the facility receiving insulin by a FlexPen. Findings include: During an observation on 8/15/23 at 9:33 a.m., staff member D administered four units of Insulin Aspart FlexPen into resident #22's right arm. Staff member D did not prime the Flexpen before administering the insulin. During an observation on 8/16/23 at 9:06 a.m., staff member E administered four units of Insulin Aspart Flexpen into resident #22's left arm. Staff member E did not prime the FlexPen before administering the insulin. Review of a facility document titled, Subcutaneous Injection Policy showed the following: Procedure: 1. Check physician's order. 2. Check patient allergies. 3. To prepare appropriate dose of medication: clean rubber stopper with alcohol. Attach pen safety needle to insulin pen. Turn dial to 2 units and prime needle with insulin. Turn dial to ordered units . Review of manufacturer instructions for FlexPen insulin showed, .before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units (see diagram E). F. Hold your NovoLog(R) FlexPen(R) with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge (see diagram F). G. Keep the needle pointing upwards, press the push-button all the way in (see diagram G). The dose selector returns to 0. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times . Failure to properly prime an insulin pen may result in improper insulin dosing or injecting air into the subcutaneous tissue.

Based on observation, interview, and record review the facility failed to monitor staff for signs and symptoms of COVID-19, ensure staff who had returned to work were free of COVID-19 symptoms and wearing proper PPE, failed to communicate outbreak status to other departments, and failed to have a contingency plan in place for unvaccinated staff. This deficient practice had the potential to affect all residents in the facility. Findings include: 1. During an observation and interview, on 6/21/22 at 7:22 a.m., Staff member B stated the facility was in outbreak status until 6/30/22. Staff member B stated all staff members were not required to wear N-95 masks. Staff member B stated staff members were testing COVID-19 positive and the residents were negative for COVID-19. All staff were noted to be wearing regular masks and eye protection upon entry to the facility. During an observation on 6/21/22 at 7:58 a.m., all staff members were observed to be wearing N-95 masks and eye protection. 2. During an observation and interview on 6/22/22 at 7:23 a.m., staff member O was wearing goggles and a surgical mask. Staff member O stated today was her first day of trying work out from being off from COVID-19. She stated she tested positive for COVID-19 on June 13th. She stated she can not wear a N-95 mask because it made her, almost pass out, but tried to wear one for the first hour and a half of work. Staff member O stated she needed to sit down for a second and sat at the nurses station, staff member O began wiping her forehead with a napkin. Staff member O stated she was doing better than she had been with symptoms, but was still having hot flashes and got light headed. During an observation on 6/22/22 at 7:35 a.m., staff member O was in room [ROOM NUMBER] providing direct care to residents while wearing a surgical mask. During an observation and interview on 6/22/22 at 7:42 a.m., staff member O was not listed as being tested before her shift. Staff member C stated staff member O was not tested because she just came back from having COVID-19 and was with in her 90 days. During an interview on 6/22/22 at 7:45 a.m., staff member A stated on day six after the onset of symptoms staff members are tested again for COVID-19. Staff member A stated they try to follow the CDC guidance for personal protective equipment. Staff member A stated when an employee comes back to work, they should be wearing a N-95 mask. Staff member A stated they were working off a staffing contingency plan especially in extended care due to staffing shortages. She said if staff cannot wear an N-95 mask they give them the highest grade surgical mask. Staff member A was unable to recall when staff member O had been tested last. Staff member A stated they were unaware of staff member O still having symptoms, and she was to be sent home. During an interview 6/22/22 at 7:54 a.m., staff member C stated staff member O was tested on day six and was going to check her records, but the facility goes by the ten day quarantine period for staff members. During an interview on 6/22/22 at 7:57 a.m., staff member C stated that day was the end of her work restrictions. Staff member C stated staff member O has a medical condition and that was why she was wearing a surgical mask. She said during an outbreak staff were to wear N95 masks unless they have a medical reason to not do so due to their policy and procedure. Staff member C stated if a staff member had symptoms of COVID-19 the staff member should be evaluated and sent home. During an interview on 6/22/22 at 8:36 a.m., staff member A stated staff members who are unvaccinated should be wearing an N-95 mask and have to test at least weekly, at a minimum, for COVID-19. She stated staff members that continue to have symptoms should not return to work until their 10 days are completed. She said if an employee cannot wear an N-95 mask, then the staff member would wear the next highest level surgical mask, and physically distance from other staff. Staff member A stated staff members are screened upon arrival to work. Review of the [Facility Name] Daily Employee Symptom Screen, dated 6/22/22, showed staff member O had circled yes to having new shortness of breath and a new cough or stuffy/runny nose. Review of Staff Vaccination status, showed, staff member O had an exemption and was unvaccinated. A request for staff member O's COVID test results for day six, and physician paper work for her medical condition that exempted her from wearing an N-95 mask, was made on 6/22/22. No documentation was supplied by the facility. 3. During an observation and interview on 6/22/22 at 7:51 a.m., staff member N was preparing food items and beverages for the residents' continental breakfast. Staff member N was wearing goggles and a blue surgical mask. Staff member N said she got the surgical mask from the main kitchen. Staff member N said no one had told her she should be wearing an N-95 mask. Staff member N said she thought since she had received the COVID-19 vaccine she was okay to wear a surgical mask. During an observation and interview on 6/22/22 at 8:38 a.m., staff member K said he was not aware the extended care area was in outbreak status. Staff member K was wearing a blue surgical mask. Staff member K said the surgical masks were from the kitchen, and they were what the dietary staff wore. Staff member K said he would have to ask the director of nursing for N-95 masks for the dietary staff to wear when they were working on the extended care unit. 4. During an infection control interview on 6/22/22 at 1:24 p.m. with staff members A and C , C stated, if there is an outbreak in the facility, whether it be a positive staff member or a positive resident, I will gather the staff members and then do an education with the staff on shift. Staff member C stated there would not be a sign in sheet to show who was educated. Staff member A stated, The staff members that have a religious exemption, or a medical exemption would wear an N-95. If they are someone who can be reassigned, then we can look into that. However, it's hard to reassign a CNA so they would just be asked to wear an N-95 for source control. The staff who are not vaccinated do not get tested any more frequently than the other staff members. Staff member A stated, there was a screening sheet at the front door and at the back door, staff can use either one. Staff member A stated, When they come in the back door, they will go into the nurse's station to test and not go any further in the building. They test every shift during out-break. Right now we are testing twice a week and we test based on the county transmission rate. Staff member A stated staff member B is responsible for reviewing the screening sheet. The screening sheets are reviewed in the mornings and, maybe late afternoon. They would review signs and symptoms, that person would then find the staff member and notify infection control. Staff member A stated if a staff member had signs and symptoms of COVID-19, the facility expects that the staff member would have called in before their shift and then notified infection control, and not come into the building. Staff member A stated, Pretty much anyone that goes on the floor would need to be screened. Staff member A stated she was not sure if dietary staff are screened before they enter the long-term care, or how the dietary staff are notified of an out-break in the long-term care. Review of facility policy titled Employee Immunization Policy with a Effective Date of 4/2022, showed, .For those staff members, that an exemption has been granted; the following additional precautions will be institutied: a. Binax test i. Weekly, at a minimum ii. Twice weekly is County Transmission level is substantial or high . b. Source control N-95 will be always worn, in hallways, meetings of 2 or more people, in any patient facing encounters, etc.: c. Staff, that have been granted an exemption, will physically distance (at least 6 feet) from other employees during meetings, breaks, etc . CDC Guidance showed: Follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for [CONDITION(S)]-CoV-2 infection. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed: 1) a positive [CONDITION(S)] test for [CONDITION(S)]-CoV-2, 2) symptoms of COVID-19, or 3) close contact with someone with [CONDITION(S)]-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel (HCP). Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility. HCP should report any of the 3 above criteria to occupational health or another point of contact designated by the facility, even if they are up to date with all recommended COVID-19 vaccine doses. Recommendations for evaluation and work restriction of these HCP are in the Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html

Based on observation, interview, and record review, the facility failed to implement a swallow evaluation to determine a safe diet texture, and failed to provide safe upright positioning, for 1 (#28) of 2 sampled residents, causing the resident to cough and possibly choke on food and fluids; and failed to adequately investigate and provide timely treatment for two falls, resulting in a wrist and shoulder fracture, for 1 (#28) of 5 sampled residents. Findings include: 1. During an observation on 10/26/21 at 10:05 a.m., staff member O was attempting to assist resident #28 with the brunch meal. The resident was lying in her bed. Staff member O gave resident #28 three spoonfuls of oatmeal, which she coughed on after each bite. Staff member O then provided water to the resident in a sippy cup by pouring it in her mouth. The resident did not exhibit a visible swallow and coughed on the water. The resident's brunch meal included diced honeydew, which she could not chew or swallow. Staff member O stated she would let the nurse know about resident #28's coughing concerns while eating. Review of resident #28's Nursing Progress Note, dated 10/22/21, showed, Resident is not eating or drinking at this point, she has taken 2 Boosts and some pudding with her PO meds so far this shift with much difficulty. It took 30 minutes for each boost. She yells out and will not swallow when asked to swallow. Review of resident #28's Nursing Progress Note, dated 10/24/21, showed Nursing noted today that resident having difficulty swallowing regular fluids - took 60 ml of thickened apple juice. Review of resident #28's Nursing Progress Notes showed no further follow-up on her difficulty swallowing. Review of the Physician diet order change, dated 10/17/21, showed the resident's diet change was temporary until evaluated by [staff member S, SLP] Review of resident #28's physician orders, dated 10/26/21, showed a diet texture change to 'pureed with mildly thickened water.' No swallow evaluation was ordered to determine the extent of the resident's swallowing deficit or causal factors. During an observation and interview on 10/26/21 at 4:35 p.m., resident #28 received soft bite sized foods and thin liquids for the dinner meal. Staff member R stated the nurse told him the meal should have been pureed, so he would not be feeding her the meal provided. He stated the nurse said to give her pudding or yogurt in place of the meal. During an interview on 10/26/21 at 4:40 p.m., staff member H stated she had heard resident #28's diet had been changed earlier in the day, but she had not seen the order. During an interview on 10/27/21 at 7:43 a.m., staff member P stated resident #28 had lost her dentures while she had COVID-19, and the diet was changed to soft and bite sized foods on 10/17/21. She stated she was not sure about the status of the resident's swallow, but nursing would usually order a swallow evaluation with a diet change if needed. During an interview on 10/27/21 at 8:08 a.m., staff member S stated she had not heard of any change in status for resident #28. She stated You could encourage nursing to order a swallow evaluation. During an interview on 10/27/21 at 9:05 a.m., staff member J stated he had been notified of the need for a texture change for resident #28. He did not know why it had not been changed for the dinner meal, and stated that would be the dietary manager's job. He said he had thought nursing had ordered the swallow evaluation. He stated he had not observed resident #28 eat a meal. During an observation on 10/28/21 at 10:30 a.m., staff member Q was attempting to assist resident #28 with the pureed brunch. Resident #28 was not upright in the bed, and her feet were touching the bottom of the bed, and her neck was bent down on her chest. Staff member P was requested to evaluate the resident's positioning for the meal, and she stated it was not safe. Staff member Q and R proceeded to reposition the resident in the bed with several pillows for her head and back. Staff member B stated the staff would put resident #28 in her Broda chair for dinner for safer positioning. Resident #28 appeared to tolerate the pureed brunch well after being repositioned. Review of resident #28's ADL care plan, with a review date of 10/20/21 did not include how staff were to safely position the resident in bed while eating. Review of resident #28's October MARs, showed the resident received IV and IM [MEDICATION(S)], an antipsychotic, from 10/22 - 10/26/21, for agitation, and [MEDICATION(S)] every night. Reference for [MEDICATION(S)] and Zyprexia: This medicine may cause serious allergic reactions . Tell your doctor right away if you have a cracks in the skin, loss of heat from the body, rash, itching, hoarseness, red, swollen skin, scaly skin, trouble breathing, trouble swallowing, or any swelling of your hands, face, or mouth after receiving this medicine . SIDE EFFECTS More common; [MEDICATION(S)]® . trouble with breathing, speaking, or swallowing . Mayoclinic.org https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-intramuscular-route/side-effects/drg- 783 Zyprexia Side Effects More common .difficulty with swallowing, drooling . Mayoclinic.org https://www.mayoclinic.org/drugs-supplements/[MEDICATION(S)]-intramuscular-route/side-effects/drg- 193 2. Review of resident #28's FAST committee notes, for a fall on 9/14/21, showed the root cause for the fall was poor safety awareness, and the resident's intellectual disabilities. She also takes several medications which cause dizziness, lightheadedness, and hypertension. Review of resident #28's FAST committee notes, for a fall on 9/28/21, showed the root cause for the fall was poor safety awareness and increased anxiety related to Covid-19 isolation. Review of resident #28's Nursing Progress Note, for a fall on 10/9/21, showed Resident was seen in hallway without a mask at 6:30 p.m. Resident was told to return to room but instead walked opposite direction down hallway and fell in another resident's doorway. Resident had some swelling on the right side of nose. Pressure was applied to nose to stop the bleeding and was effective. The note did not include a full assessment for injuries or range of motion for resident #28. During an interview on 10/28/21 at 8:00 a.m., staff member A stated the fall notes for resident #28 should include a full assessment for injuries. She stated the resident had been flailing her body, so no concerns were noted for her unidentified fractures. Staff member A stated it had been a difficult situation to discern what was pain and what were behaviors for resident #28. Review of resident #28's Nursing Progress Note, dated 10/12/21, showed the index phalange was edematous with a bluish discoloration. [Resident #28] was screaming aloud without any clear origin or cause. An x-ray of the hand, wrist, and hips was ordered for the resident. The aides reported to the nurse that resident #28 had a bruise to the left shoulder. The resident returned from radiology with a diagnosis of a left humerus fracture, and was started on [MEDICATION(S)] QID, 5/325 mg., for pain. Review of resident #28's Nursing Progress Note, dated 10/17/21, showed She continues to grimace if her right hand is manipulated at all. Review of resident #28's Nursing Progress Note, dated 10/18/21, showed the hospitalist was contacted regarding a concern with resident's right hand x-ray report. The hospitalist reported he would review the x-ray report again and let nursing staff know. Review of resident #28's Nursing Progress notes did not include follow-up on the wrist x-ray report. Nine days had passed since the fall, but the facility had not yet received notification of, or confirmed, the type/severity of hand injury, which ended up being a non-displaced ulnar styloid fracture . Review of a 'late entry' FAST note, dated 10/19/21, for review of resident #28's fall on 10/9/21, showed the resident's vitals were WNL. Neurological assessments were started immediately. Resident states she was not in any pain, and no grimacing noted. Pain rating 0/10. Resident #28's fall had occurred ten days before the late entry was written. Review of resident #28's Physician Progress Note, dated 10/20/21, showed She does not appear oriented, cannot answer questions. Her shoulder immobilizer is in place. Her left shoulder shows some moderate bruising. Palpation of the area does not really increase her pain. Right wrist also shows mild pain with range of motion. Review of a FAST Fall committee note, dated 10/21/21, showed a review of resident #28's fall on 10/9/21, and that she fell face first into the room. The right wrist x-ray showed a non-displaced ulnar styloid fracture and the left shoulder fracture. A wrist splint was ordered. She was diagnosed with Covid-19 on 9/23/21. A PRN [MEDICATION(S)] order was placed on 9/23/21 for possible behaviors while resident #28 was in isolation, and was discontinued on 10/6/21. On 10/7/21 [MEDICATION(S)] was ordered for an increase in behaviors. On 10/10/21 the day after the fall, [resident] was noted to be staring at the ceiling and unsteady when sitting up on her bed. She was non-verbal. The [MEDICATION(S)] was discontinued on 10/11/21, as [resident] was lethargic, not swallowing meds and did have the fall on 10/9. She had increased pain and continued to be increasingly restless and an urgent care plan meeting was scheduled. The root cause of the fall was determined by the FAST committee to be 'impaired balance and weakness with recent Covid-19.' Review of residents #28's October 2021 TAR showed the shoulder immobilizer was initiated on 10/17/21, eight days after the fall, and the wrist splint was initiated on 10/20/21, 11 days after the fall. Review of resident #28's Physician orders showed pain medication was ordered on 10/12/21, four days after the fall with fractures.

Based on observation, interview, and record review, the facility failed to indentify and implement interventions for a resident with severe weight loss for 1 (#31) of 3 sampled residents. The deficient practice resulted in a 21% weight loss over six months. Findings include: During an observation on 10/25/21 at 4:32 p.m., resident #31 was sitting in the dining room eating her dinner. The surveyor overheard resident #31 tell a staff member she was, very full. A review of resident #31's weights since admission on 4/4/21, showed a 21.01 percent weight loss in six months. Resident #31's weight on 4/6/21 was 119 pounds and 94 pounds on 10/26/21. Review of the State Operations Manual, Appendix PP, F692 Nutrition/Hydration, shows the suggested parameters for evaluating the significance of an unplanned and undesireable weight loss. To determine the amount of loss, the following calculation would be used: The percent of body weight loss = (usual weight - actual weight) / (usual weight) x 100; and, for a severe weight loss, the loss must meet the following criteria: - In one month, a weight loss which is greater than 5% - In three months, a weight loss which is greater than 7.5% - In six months, a weight loss which is greater than 10% During an interview on 10/27/21 at 9:12 a.m., staff member J stated he did not personally notify the resident's provider regarding resident #31's severe weight loss. He stated he assumed someone in nursing had notified the provider. Staff member J stated resident #31 wanted to lose weight, and her son was aware of it. Staff member J stated, We all see it (continued weight loss) as a problem. Staff member J stated additional supplementation had been suggested, and the CNA's were encouraging resident #31 to eat more. Staff member J stated he was part of the facility NAR committee and was responsible for updating the nutrition care plans when needed. During an interview on 10/27/21 at 9:43 a.m., staff member B stated resident #31 was being reviewed by the NAR committee. Staff member B stated the dietitian was responsible for updating nutrition care plans. Staff member B was aware of the resident's weight loss and refusal of supplements. Staff member B stated she guessed the resident may be getting a fortified diet. Review of resident #31's current care plan, last edited on 7/15/21, showed she was on a consistent carbohydrate, regular diet, with thin liquids. The care plan did not show supplements or a fortified diet was in place for interventions related to the weight loss concerns. During an interview on 10/27/21 at 4:28 p.m., NF1 stated the communication from the facility, regarding resident #31's weight loss, had been poor. NF1 stated he was made aware of the resident's weight loss in April of 2021. NF1 stated he had not been made aware of the ongoing weight loss. NF1 stated he requested resident #31's weights from staff member H. NF1 requested the facility try Boost (supplement) three weeks ago. NF1 stated resident #31 had always had concerns about her weight. NF1 stated he [NAME] made suggestions about resident #31's food likes and dislikes, but did not feel like his specific food suggestions, such as turkey and mashed potatoes, cake, and pie, were implemented. NF1 stated resident #31 was able to maintain her weight between 120 and 125 pounds, despite being active and a picky eater. During an interview on 10/28/21 at 7:22 a.m., staff member M stated he was aware of resident #31's diet, that she was receiving vanilla Boost, and she was a picky eater. Staff member M stated he had not spoken to NF1 or any staff members about resident #31's weight loss. During an interview on 10/28/21 at 7:26 a.m., staff members K and L stated they were not aware of any specific nutritional interventions on resident #31's care plan. Staff member K stated resident #31 was on a regular diet, usually refused snacks, liked unsweetened almond milk and coffee, was a picky eater, and, Eats like a bird. Staff member L stated resident #31 was a picky eater. During an interview on 10/28/21 at 7:30 a.m., staff member I stated she had taken care of resident #31, but knew nothing about her weight loss. During an interview on 10/28/21 at 7:34 a.m., staff member G stated he had taken care of resident #31 six times in the previous three weeks. When asked about resident #31's weight loss, care plan, and interventions, staff member G stated he did not really know anything about her weight, and, I don't really deal with it. Review of resident #31's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A voicemail message was left for the physician on 10/28/21 at 8:09 a.m., to discuss his involvement in resident #31's weight loss concern. No call back was received. Review of resident #31's nutrition note by nursing, dated 5/6/21, showed an identified weight loss of 5.88 percent and, no supplements are being offered at this time. Review of resident #31's nutrition note by nursing, dated 7/5/21, showed a continued downward trend in weight at 10.08 percent since admission on 4/4/21. The note showed resident #31 would continue to be reviewed monthly by the NAR committee, and the dietitian would continue to monitor the resident's intake, weight, and preferences. Review of resident #31's Nutrition Assessment, dated 7/15/21, showed the following: Weight has decreased 11.9% over 3 months which is severe. Discussed weight loss with resident and she states she is eating what she wants to eat and feels as though she's getting enough. Res [sic] states weight loss is desirable, discussed goal of maintaining weight and possible supplementation but resident requests no changes to diet or supplementation. Will continue to monitor weight, intake, and update preferences PRN. The note showed interventions to continue current diet, weekly weights, labs as needed, and update food preferences as needed. The note failed to show the number of calories consumed, or the number of calories required to maintain resident #31's weight. A review of resident #31's Significant Change MDS, with an ARD of 7/7/21, showed a BIMS of 7 which correlates with severe cognitive impairment. Resident #31 may have lacked the cognitive ability to understand the consequences of her nutritional choices. A review of resident #31's nutrition note by nursing, dated 10/4/21, showed a total weight loss of 15.96 percent since admission six months ago. The note showed resident #31 was not receiving any supplements, and was to continue to be reviewed by the NAR committee monthly. The note failed to show any new interventions or care plan revisions although resident #31 continued to lose weight. A review of resident #31's Nutrition Assessment, dated 10/14/21, showed continued weight loss and no changes to the resident's care plan. The note showed the, significant weight loss r/t (related to) possible increased activity and decreased energy intake . The note failed to show any calorie intake calculations, or caloric needs. A review of resident #31's Nutrition Note, dated 10/22/21, showed the family had requested Boost to be given at meals. A review of resident #31's nutrition care plan, last edited date 7/15/21, showed interventions of the provision of a regular concentrated carbohydrate diet with thin liquids and to encourage adequate intake at meals and snacks. No changes in resident #31's plan of care or nutritional interventions were found since 7/15/21, although the resident continued to have a weight loss.

Based on observation, record review and interview, the facility failed to: identify the individual risk factors relating to residents who had falls or were at risk for falls; failed to evaluate the environmental or individual hazards for residents who had falls; failed to implement individualized interventions to prevent future falls; and failed to monitor interventions developed to determine effectiveness for 8 (#s 1, 2, 5, 8, 9, 10, 12, and 14); and, failed to identify and evaluate risk factors and environmental hazards for residents who were at risk for elopement or who had eloped; failed to implement interventions to reduce the hazards or risks relating to elopement; and failed to monitor the effectiveness of the interventions implemented, update the resident's plan of care for residents who eloped, or have a policy and procedure for elopements for 1 (# 1) out of 17 sampled and supplemental residents. The facility also failed to ensure hazardous chemicals were stored appropriately. IMMEDIATE JEOPARDY The facility failed to respond to repeated falls and injuries for 8 identified residents. The facility failed to develop plans of care based on the residents' fall history. The facility failed to implement preventative measures for injuries. The facility failed to notify the physician and/or responsible parties in a timely manner for injuries or trends with repeated injuries for resident falls. The facility failed to respond to repeated elopements for one resident. The facility failed to accurately assess and develop a plan of care based on the resident's elopement history. The facility failed to provide and document the provision of education to the facility staff for the risks and potential harm as related to the resident's elopement history. On 03/12/15 at 10:20 a.m., the facility administrator was notified by the surveyors that an immediate jeopardy situation existed for 8 of 17 sampled residents. PLAN TO ABATE THE IMMEDIATE JEOPARDY The facility submitted an acceptable plan to abate the immediate jeopardy on 03/13/15 at 12:17 p.m. A summary of the facility's abatement plan to remove the immediate jeopardy was as follows: 1) Update fall risk assessments for the 8 identified residents. 2) Update elopement risk assessments for the 8 identified residents. 3) Update the care plan for falls and elopements for the 8 identified residents. 4) Write a fall prevention and management policy. 5) Write an elopement policy. 6) Develop an outline and task list for the FAST team. 7) Develop a post fall assessment tool. 8) All falls and elopements will be reviewed routinely during the monthly QA meeting. 9) Assess all residents to identify who is at risk for falls and elopements. 10) All staff will be educated on the updated care plans for the 9 identified residents. 11) All staff will be educated on the fall prevention and management policy before they start their shift. 12) All staff will be educated on the elopement policy before they start their shift. 13) New staff will be educated on the fall prevention and management policy and the elopement policy during orientation. 14) Any staff on leave or not available for training will receive fall prevention and management policy and elopement policy training prior to their first shift upon returning to work. 1. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Falls Review of the resident's Significant Change MDS, with an ARD of 1/19/15, showed the resident was coded as a two, moderately impaired, for daily decision making. The MDS showed the resident had short and long term memory deficits, and constant inattention and disorganized thinking. For ambulation, the resident was coded as an extensive assistance of one person. Review of the resident's Fall Risk Assessments showed on 12/11/13 the resident was coded as a 7 (normal risk). The most recent Fall Risk Assessment, dated 1/12/15, showed the resident was scored as a 58 (very high risk). The medical record lacked evidence for Fall Risk Assessments completed between 12/11/13 and 1/12/15. Review of the resident's nursing progress notes showed the resident fell nine times between 4/20/14 and 3/2/15. The falls occurred on: 4/20/14, 8/6/14, 12/4/14, 12/12/14, 1/4/15, 1/14/15, 2/14/15, 2/21/15 and 3/2/15. The resident received the following injuries during the falls: -8/6/14 Complaints of pain, swollen left ankle and swollen left wrist. The resident was sent to the ER and was treated with ice and elevation to the swollen areas. -1/4/15 The resident had a skin tear to his left elbow and complaints of pain in the left hip. The resident was sent to the ER for an evaluation and was diagnosed with [REDACTED]. A left hip endoprosthetic replacement surgery was completed on 1/5/15. -1/14/15 Left elbow edema and pain. The resident was sent out for an x-ray which was negative for a fracture. -2/14/15 The resident had complaints of pain in the right hip, an abrasion to the right elbow and abrasion to his right knee. The resident was sent to the ER for an evaluation. No further injuries were identified. -3/2/15 The resident voiced pain in his left wrist, shoulder and forearm, and had swelling to the right elbow. Ice was applied to the elbow and x-rays were ordered. Review of the resident's March 2015 physician's orders [REDACTED]. The order did not specify the type of alarms to be used. Review of the resident's physician progress notes [REDACTED]. Review of the resident's Transfer Guideline Assessment Sheet within the care plan, dated 3/4/14, showed that the resident had a bed alarm and was a contact guard assistance of one person. The fall care plan showed three risk factors were identified for the care plan problem, which included Parkinson's, BPH, and a left hip fracture. The fall care plan did not include interventions, or identify falls, which may have been affected by the resident's risk of elopements, how the resident's constant pacing, restlessness, and/or agitation may increase fall risk, how pain may limit his mobility and/or safety, and increase fall risk, or the risk he posed to himself when attempting to be independent but cognitively unable to make safe decisions related to his mobility. During an observation and interview on 3/10/15 at 7:55 a.m., staff member W, CNA, assisted the resident with ADL care. The CNA stated fall interventions utilized for the resident included bilateral assistance bars, a low bed, a fall pad, and an alarm. The resident dressed with CNA assistance. Hip protectors were not placed on the resident, which was one of the fall interventions identified on the care plan. During an observation and interview on 3/10/15 at 1:30 p.m., the resident was observed sitting in a recliner by the nursing station. The resident did not have an alarm attached to his clothing or the recliner. At 1:40 p.m., an observation was made of staff member W, CNA, placing the alarm on the resident's wheelchair. The CNA stated she had to go and retrieve the alarm from the resident's room. During an interview on 3/11/15 at 8:40 a.m., staff member N, CNA care coordinator, stated the nurse would document the fall details and the interventions that were put into place to prevent future falls. The nurse would also attempt to identify the cause of a fall. Staff member N was a member of the FAST interdisciplinary fall review committee. The committee met each week to review falls from the prior week. The committee would review the care plan, pocket care plan, identify concerns, and update the care plans as needed. The IDT would also review the fall investigation for concerns. During an interview on 3/11/15 at 9:20 a.m., staff member B, DON, stated she was a member of the FAST committee. The nursing progress note, dated 12/12/14, was shown to staff member B. She stated she was unsure why the nursing progress note lacked information relating to the fall investigation. Wander Risk and Elopement Review of the Significant Change assessment dated [DATE], the Significant Change assessment dated [DATE], and the Quarterly assessment dated [DATE], showed the resident was coded as a zero (0) for wandering presence and frequency. Review of the nursing progress notes for resident #1 showed the resident had eloped on seven occasions. The main doors for the extended care facility were located approximately 100 feet inside the main building entrance, which also housed the local hospital and a clinic. Elopement details included: -6/17/14 The resident followed a visitor out the main doors of the extended care, and was found in the hallway of the main building. -6/21/14 The wanderguard alarm system sounded at 12:25 p.m. Staff checked the exit doors and did not observe any residents outside. Nursing progress notes showed a, "room to room check of all residents not in the dining room" was completed. At 12:40 p.m., the facility was contacted by the resident's son, who said the resident was found at a local gas station on his knees. The resident had to cross a four lane road prior to reaching the gas station. The resident was transported to the ER. The facility had not identified the resident was missing prior to this call, although the nursing note included the room to room check. The resident did not sustain injuries from his fall at the gas station. -8/6/14 The resident was found after a fall in the courtyard, and had a swollen wrist and swollen left ankle, which also had a scratch. -9/30/14 The resident eloped from the extended care, went up the stairs and was found sitting on a couch. -9/30/14 The facility was contacted stating the resident was at the local clinic housed in the main building. Staff went to the clinic and returned with the resident. -12/1/14 The resident eloped two times on this day. He was found at the elevator doors of the main building, which were down the hall from the front entrance to the extended care. On the second elopement, he had exited the extended care and was found exiting the main doors to the building. -12/12/14 The resident exited the extended care, got on the elevator to the main building, and was found on the lower level of the building. The wanderguard bracelet was replaced when he returned. -Nursing note documentation did not always include information relating to whether or not the wanderguard alarm sounded or if the resident's bracelet was checked upon the resident's return when he eloped. On 12/29/14 at 8:04 p.m., the resident was found locked in an administrative office by the extended care main exit. During an interview on 3/11/15 at 8:45 a.m., staff member W, CNA, stated it was after normal hours, so the key for the office had to be located prior to the resident being let out of the office. Review of the resident's care plan showed under the mood and pacing problems, that wandering door to door, looking to go home, and attempting to get out the exit doors were identified as concerns. The plans lacked evidence for the use of the wanderguard bracelet and the resident's high risk of elopement due to his behavior, or interventions for staff if the resident eloped. Review of the facility's Pocket Care Plan for CNAs, dated 3/4/15, showed the resident was marked as having a wanderguard. No further concerns or interventions were listed on the plan for the use of the wanderguard. Review of the facility's Report of Elopement showed the resident had eloped on only two occasions, which were documented as 6/21/14 and 9/30/14. In an interview on 3/11/15 at 8:30 a.m., staff member U, maintenance director, stated every time resident #1 eloped, they first checked the door with a pendant, if it worked, then they checked the door using resident #1's pendant. It worked each time they checked. In an interview on 3/12/15 at 4:00 p.m., staff member U stated he had only been asked to check the doors two or three times in regards to resident #1 eloping. During an observation on 3/11/15 at 8:17 a.m., the wanderguard alarm sounded. Staff member M, CNA, checked the alert panel at the nursing station, ran down the 500 hall to the exit door, looked out the door window, opened the door a couple of inches and immediately pulled it closed again, disarmed the alarm, and returned to the nursing station. The CNA did not check the hallway outside of the exit doors, which went to the clinic and main building exit. During an interview at 8:25 a.m., the CNA stated she just looked out the window of the door because she thought someone attempted to pull the door from the hallway on the other side, which may have sounded the alarm. During an interview on 3/11/15 at 2:20 p.m., staff member Q, CNA, stated if a wanderguard alarm sounded she would go to the door to see if anyone went out. After that, she stated she did not know what steps to carry out and would need to check. She stated during orientation she received instructions, and was tested on elopements, but she wasn't finished with her orientation book. She stated she was newer to the facility. She stated she did not know the difference between the two elopement alarm sounds, or what she would do for them. During an interview on 3/11/15 at 8:40 a.m., staff member N, CNA care coordinator, stated when the elopement alarm sounded, staff were required to check the door alarm panel by the nursing station. Staff would then check outside the exit of the door that alarmed. Staff member N stated she was working on the night of 6/21/14 (when the resident was found at the gas station). She stated the alarm sounded and the staff thought someone from outside of the 500 exit pulled on the door from the other side, which made the alarm sound. The staff checked the exit and did not observe anyone who may have eloped. The facility then received a telephone call from the local authorities alerting them to the resident's elopement. Staff member N stated the facility was not aware the resident was missing, and room to room checks were not completed as per nursing note documentation. During an interview on 3/12/15 at 10:00 a.m., the resident's son stated he had contacted the facility on 6/21/14 to report his father's elopement. The son was aware of the elopement because he had been in contact with the local authorities previously. He stated the facility had no idea his father had been missing when he contacted them. 2. Resident #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's Fall Risk Assessment, completed on 5/29/14, showed the resident's fall score was a 20 (Moderate risk). The medical record lacked evidence of Fall Risk Assessments completed after this date. Review of the resident's nursing progress notes showed the resident had a fall on 12/24/14. The nurse documented, "Resident found lying supine with head and shoulders flexed forward against sl (sic) raised foot of recliner in room with feet on top of the bedside table bottom, facing bed. The resident said his slippers slid on the floor, which was 'dampened by pop or water from a spill.' The resident complained of hip pain after the fall. The nursing progress note lacked evidence for the family and physician notification after the fall, interventions in place at the time of the fall, interventions implemented after the fall to prevent future falls or how the slippers would be addressed for safety. Review of the physician progress notes [REDACTED]. Review of the FAST committee progress notes showed the IDT met and reviewed the fall for resident #10 on 1/7/15. The progress note showed, "FAST committee met to review care plans, Res. ind. in facility with FWW (front wheel walker) with distant supervision. No changes." The progress note lacked evidence for any further investigative information, future fall prevention efforts or steps taken to address the slippery slippers the resident was wearing. Review of the resident's care plan, reviewed by the FAST committee on 1/7/15, failed to show how the slippers were addressed or further fall prevention efforts put into place. During an interview on 3/12/15 at 12:30 p.m., staff member C, RN/MDS coordinator, stated fall risk assessments were completed on admission, readmission, significant changes or if a resident was a fall risk. She stated if the resident fell regularly, the facility may not do a fall assessment with each fall, but if someone fell on occasion an assessment should be completed. During an interview on 3/11/15 at 10:30 a.m., staff member D, Risk Manager, stated each fall is documented by the nurse, then the FAST committee reviews the fall information. The FAST IDT would review trends for falls, why a resident fell , and if anything was missed by the nurse. The fall information was then input into the Risk Master system by the compliance department. Staff member D stated information relating to fall trends, to include the number of falls, or concerns, were presented each month to the executive Quality Assurance Committee by the director of nursing of the extended care facility. Attendees of the executive QA meeting included the administrator of the extended care, the CEO of the local hospital, the director of nursing for all clinical services, the director of nursing for the extended care facility and the risk/compliance manager. 3. Resident # 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Fall Risk Assessment showed the last assessment was completed on 2/10/14, which resulted in a score of 33 (high risk). Review of the resident's Significant Change MDS, with an ARD of 12/11/14, showed the resident was coded as a three (severely impaired) for cognition. The resident exhibited mild depression, rejected care one to three days of the week and intruded on others with behavior. Review of the resident's nursing progress notes showed the resident had 14 falls between 7/21/14 and 2/19/15. Injuries received during the falls included: -11/28/14 and 12/2/14 The resident's knees were pink/red -12/21/14 Abrasion and swelling to right cheek with a skin tear -1/3/15 A bump on the head with a headache -2/15/15 A bump to the head -2/19/15 Bruising to the cheek and open area to her hand between the fingers Review of the nursing progress notes also showed the following trends: -Investigations completed immediately following the falls often lacked evidence for the determination for the direct cause of the fall. -Physician/responsible party notification for the fall and injuries were not evident in the record. -Neurological checks were incomplete after the resident fell and hit her head. -The care plan was not updated to reflect the seriousness of the resident's fall risk, repeated falls, or show how the facility evaluated the interventions for success or failure to determine if they were effective. -Documentation lacked evidence for interventions implemented at the time of a fall to prevent future falls. -The interdisciplinary FAST fall team reviewed 7 of the 14 falls. The review documentation lacked supporting information for investigative details, potential causes for the falls, interventions developed through the FAST review process, or how the care plan would be updated. During an interview on 3/11/15 at 9:20 a.m., staff member B, director of nursing, stated the nurse would notify the physician and responsible party after a resident had a fall. Review of the resident's physician orders [REDACTED]. The resident also had an order for [REDACTED]. Review of the admission orders [REDACTED]¹ Review of the resident's medication order sheet showed the Risperdal dose was adjusted or changed 12 times between 7/23/14 and 2/20/15. The time span between dosage changes ranged from three days to 36 days.¹ During an observation and interview on 3/9/15 at 7:50 p.m., the resident was observed ambulating with CNA assistance and her knees buckled and she almost fell . The CNAs stopped the fall. A nurse, staff member K, LPN, approached the resident from behind and held the resident up with the gait belt as his knee supported the resident's buttocks. The wheelchair was retrieved and the resident was assisted back into the chair. Staff member K stated sometimes this happened when the resident was tired or would also exhibit the falling behavior on purpose. He stated the resident was being observed closely due to her behaviors and poor safety. During an interview on 3/12/15 at 11:50 a.m., a family member of the resident stated he felt the facility could do more to prevent the resident's falls. He said he talked with the staff often, and did not always agree with the care provided relating to medications and fall prevention efforts. The spouse stated the resident was worse since starting the Risperdal and it was not helping at the dose being given, but when the dose was higher the resident was sedated. Since starting the Risperdal, he said, she has more behaviors, is worse at night, and is not sleeping. During an interview on 3/13/15 at 8:30 a.m., staff member X, pharmacist, stated he preferred to not have a resident utilize atypical antipsychotic medications (the resident was ordered Risperdal) as the drugs caused more negative effects in the elderly. The pharmacist stated he did not recall addressing this topic in his monthly regimen review, nor was he asked to review the resident's medications to determine if they could have contributed to the resident's falls. The resident's [DIAGNOSES REDACTED]. At 10:15 a.m., staff member X stated the [DIAGNOSES REDACTED]. During an interview and observation on 3/13/15 at approximately 10:00 a.m., a consulting psychiatrist stated Risperdal should be used for a resident who had a [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. The psychiatrist stated he would notify the physician assistant, whom he supervised, that was treating the resident. 4. Resident #5 was admitted on [DATE] and readmitted on [DATE]; current [DIAGNOSES REDACTED]. Review of resident #5's fall risk assessment dated [DATE] showed a score of 64 (very high). The fall risk assessment also showed a standing balance score of 2 (support required). Review of resident #5's fall risk assessment dated [DATE] showed a score of 48 (high risk). This assessment did not include an additional score of 21 for "Doesn't recognize hazards," which was on the initial fall risk assessment. Review of resident #5's MDS with an ARD of 1/20/2015 reflected a BIMS (MDS section C0500) score of 99 (unable to interview due to resident being rarely or never understood). It also reflected daily decision making as severely impaired (MDS section C1000). Review of the resident #5's nurses notes reflected the resident fell three times in October, 2014, three times in November, 2014, one time in December, 2014, four times in January, 2015, one time in February, 2015, and one time in March, 2015, for a total of 13 falls in five months resulting in five falls with injury. Resident #5 had injuries from falls on: - 10/17/2014 resulting in a fracture of her left hip - 1/18/2015 resulting in a scrape to her left elbow and redness to her right elbow - 1/23/2015 resulting in a red area on her left buttock - 2/28/2015 resulting in raised area on the back of her head - 3/2/2015 resulting in a fracture of her left humeral head. Review of the Fall and Prevention Management Policy and Procedure reflected: PREVENTING RESIDENT FALLS Every resident will be assessed for basic fall risk factors: 1. On admission to the facility 2. Following any change of status 3. Following a fall 4. On a regular interval with each quarterly and annual assessment The facility failed to complete fall assessments after falls from 10/23/14 until 3/12/2015. Review of resident #5's undated Self Care Deficit with ADL's (activities of daily living) care plan showed, "Resident transfers and ambulates with distant supervision or limited assist." The undated Fall care plan showed "Independent in facility." The Fall and Self Care Deficit care plan dated 11/12/2014 showed "CGA c 1 c FWW (contact guard assist with one staff with front wheeled walker) for ambulation; Silent bed alarm; Alarm on when in W/C (wheelchair), recliner, dining room chair." The Fall care plan dated 1/21/2015 showed "Distant supervision c (with) ambulation or may require extensive assist R/T (related to) severe cognitive impairment." The Fall care plan, dated 3/4/2015 showed, "May use a W/C for locomotion R/T her physical ability @ the time." The Self Care Deficit care plan and the Fall care plan both dated 3/4/2015 showed, "uses wheelchair for locomotion." Review of the CNA pocket care plan dated 2/23/2015, showed "Distant Supervision" under the heading of Locomotion for resident #5. Review of the CNA pocket care plan dated 3/4/2015 showed, "Ambulate CGAc2 (contact guard assist with two staff) w/c if needed," under the heading of Locomotion. Review of resident #5's physician orders [REDACTED]. It further showed an order to "discontinue therapy as resident is independent with supervision," and on 1/26/15, "resident to be independent with ambulation with SBA (stand by assist) without carrying any objects to prevent falls." During an interview on 3/10/2015 at 12:50 p.m., staff member M, CNA, stated she had just found resident #5 unattended in the activity room without a personal alarm in place. The staff were not alerted that she was unattended while ambulating. Review of staff member M's CNA pocket care plan reflected it was outdated. It reflected resident #5 was independent with distant supervision. Staff member M stated the outdated CNA pocket care plans were supposed to be removed from the drawer when the new care plans were printed, which was done on 3/4/2015. During an interview on 3/11/2015 at 9:15 a.m., staff member B, DON, stated she thought the outdated CNA pocket care plans had been removed from the drawer. During an interview on 3/11/2015 at 9:00 a.m., staff member Q, CNA, stated her CNA pocket care plan was not current and did not contain accurate information for taking care of resident #5. During an interview on 3/11/2015 at 8:15 a.m., staff member C, MDS coordinator, stated when there has been a fall, she has an alert on her computer screen so she knows there has been a fall. The IDT meets every morning and discusses all falls prior to the FAST (Fall and Safe Transfer Committee) meeting. The FAST committee meets every Wednesday and makes changes to the delivery of care to prevent future occurrences. She stated she, the charge nurse, and the DON could update the care plan. She stated these changes are passed on in the shift report meeting and she is ultimately responsible for making the care plan match the care actually provided. She stated the CNA coordinators update the CNA pocket care plan based on the information they receive from the IDT (interdisciplinary team) meeting, care plan meetings, and shift reports. They are updated on the day the IDT makes changes to the resident's care plan. During an interview on 3/11/2015 at 8:25 a.m., staff member F, RN, stated after a resident has had a fall, and the proper assessments of injuries were completed, the charge nurse would enter the pertinent information under the Reportable Incident (RI) tab in the computer and place the same information in the acute care charting book for five days. She stated the 24 hour report was developed from the acute care book. The information was then used by the IDT to update the care plan. The charge nurse should have made any immediate changes necessary for patient safety. The charge nurse was responsible for notifying the POA and the provider. The rehab aide, who attended the shift report meeting, would notify the floor staff of any changes in the resident's plan of care. The CNAs would have also received report of resident care changes from the off going shift. During an interview on 3/11/2015 at 8:20 a.m., staff member K, LPN, stated after the immediate assessment of a resident who has fallen is completed, he is responsible for entering the information into the RI since he works at night. He stated he notifies the POA and the provider if it is not too late. He stated the MDS coordinator and the ADON update the care plan. He stated he gives a verbal report to the oncoming shift if there have been any changes in cares. 5. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on 3/11/15 at 3:05 p.m., resident #12 was seated next to the nursing station in an easy chair, her walker was in front of her, her tab alarm was attached to her shirt and the chair, her wander guard was on her left ankle, and she had a large deep purple and black left eye. Review of resident #12's annual MDS with the ARD of 12/16/14 reflected severe cognition impairment (C500). Review of the most current Fall Risk assessment dated [DATE], reflected a score of 57, indicating a very high fall risk. Review of the electronic Charting Entries for resident #12 from 9/4/14 - 3/11/15 reflected five falls, two with minor injuries and one with a more serious injury: - On 10/23/14 the resident fell near the nurse's station while ambulating with her walker. No injuries were reported or noted. - On 11/8/14 the resident was found on the hall floor after ambulating with her walker. The resident reported pain in her right rib area. - On 12/4/14 the resident fell after attempting to ambulate without her walker. The resident reported posterior head and left rib pain. She sustained a one centimeter skin tear on her left elbow and a bump and a small laceration on her posterior head. - On 12/17/14 the resident was found on the floor of her bathroom. She sustained an abrasion on her right buttocks and a reddened area on her right knee. - On 3/6/15 the resident was found on the floor of her bathroom. The resident reported pain in her right hand, shoulder and hip. She had bleeding in her right hand that was later steri-stripped. She sustained a small laceration above her right eye brow and a five inch by three inch bruise. She was sent to the Emergency Department for assessment, minor treatment, and then discharged back to the facility. The notes reflected resident #12 did not sustain any fractures and should be seen by her primary provider in one to two days. The discharge instructions included ice compresses to her injury for 15-20 minutes three to four times daily. Review of the facility's Policy and Procedure for Fall Prevention and Management reflected: "C. If the resident is in any distress or if his/her head was hit during the fall: 1. Monitor vita (sic) signs and perform neuro-checks every 15 minutes for one hour. 2. Then every 30 minutes for one hour and then every hour for two hours or if transferred to ED, monitor vital signs and neuro checks every 2 hours X 4 then every 4 hours X 2 then every 24 hours or as MD orders." Review of resident #12's Charting Entries and Vitals Audit reflected vital sign entries 3/6/15 at 16:39 and 20:45, and on 3/7/15 at 10:44. No evidence was provided that neurological assessments were completed for the 3/6/15 fall. During interviews on 3/11/15 at 2:50 p.m., staff member R, LPN, and at 2:55 p.m., staff member S, LPN, did not state neurological assessments were a part of their five day post-fall assess

Based on observation, interview and record review, the facility failed to: have an effective system for review and implementation of appropriate pharmacy pain management recommendations, accurately assess a resident with pain; failed to evaluate pain interventions and the effectiveness of the individualized interventions; failed to implement alternate approaches to address pain; and failed to utilize the resident's history and behavioral patterns to anticipate changes related to pain, which potentially impaired the resident's mobility and increased the resident's risk for falls and elopements for two (#s 1 and 3) out of 12 sampled residents. Findings include: 1. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS, with an ARD of 1/19/15, showed the resident utilized scheduled and PRN pain medications, but did not have any non-medication related interventions coded as being in place. The pain presence, frequency and the effect on the resident's function were not completed on the MDS. The resident exhibited pain indicators by his expression and vocalization. The resident was coded as having severely impaired cognition and short and long term memory deficits. Review of the Physician order [REDACTED]. -IBU ([MEDICATION NAME]) 400 mg by mouth twice a day for pain -[MEDICATION NAME] 5/325 mg 1 tablet by mouth every four hours as needed for pain -Tylenol 325 mg (2 tabs) by mouth every four hours as needed for pain -[MEDICATION NAME] 5 mg by mouth every four hours as needed for pain -[MEDICATION NAME] 0.125 mg by mouth three times a day for Parkinson agitans -[MEDICATION NAME] 3 mg by mouth every evening as needed for [MEDICAL CONDITION] -[MEDICATION NAME] 6 mg 1 caplet by mouth twice a day for dementia without behavioral disturbances Review of the resident's Medication Administration Records showed administration of pain medication in: March 1-10 : [MEDICATION NAME], 6 times prn; [MEDICATION NAME] 2 times prn; Tylenol 3 times prn (pain). February 1-28: [MEDICATION NAME] 29 times prn; [MEDICATION NAME] 14 times prn (pain); [MEDICATION NAME] 10 times ([MEDICAL CONDITION]). January 1-31: in 20 days, he received: [MEDICATION NAME] 24 times; [MEDICATION NAME] 15 times prn pain; Tylenol 10 times prn and [MEDICATION NAME] 5 times. Review of the PRN Explanation forms for January-March 2015 showed the prn pain medications were given to promote comfort, complaints of back pain, grimacing, hip pain, leg pain, shaking, diaphoretic, restless, agitation, anxiousness, wandering, exit seeking and elbow pain. The nursing notes showed the resident had eloped on seven occasions. Prior to the resident's readmission on 1/12/15, the MARs showed the prn pain medications were rarely used or not used at all for the entire month. After his readmission, the prn pain medication usage increased, and the resident's behaviors were documented less frequently. Review of the resident's medication listing for 12/11/13 to 2/10/15 showed no changes were made to the resident's pain regimen. Review of the resident's care plan showed pain was related to the problems of chronic pain and a fractured left hip, which was evidenced by his verbal complaints, facial grimacing, disturbed sleep patterns and moaning. The plan lacked non-pharmacological interventions staff could attempt to alleviate pain, how staff should anticipate the resident's pain, identify causal factors of the pain, report the pain, or how pain increased the resident's behavior, his fall risk, increased wandering, and elopement risk. Review of the nursing progress notes showed: The resident had nine falls, one resulting in a [MEDICAL CONDITION]. Entries in the nursing notes showed when the resident was exhibiting behavior, anxiousness or increased pain, he constantly wandered; was described as pacing to the point of exhaustion, continuous exit seeking and repeatedly sounding the exit door alarms, was frantic, diaphoretic, sweating, perspiring and short of breath. The nursing progress notes showed an increase in behavior began around 3/26/14 when the resident believed a child was on the facility roof and could possibly be hurt. After this, behavioral documentation becomes more frequent. The resident was treated for [REDACTED]. Documentation included several entries where the nurse determined the behaviors were exhibited due to pain, and gave the resident a dose of [MEDICATION NAME] or [MEDICATION NAME] pain medication, which altered the resident's behavior. Results showed the resident was more comfortable. When this occurred, nursing notes showed he slept better, ate better, was calmer, more cooperative with care and had a decrease in his wandering, pacing, exit seeking and diaphoretic episodes. Review of the resident's psychoactive medication review progress note, dated 10/19/14, showed the resident had paranoid behavior, was difficult to redirect and experienced pain, which he could not always voice and which escalated his behaviors. When documentation lacked evidence that the nurse assessed or anticipated the resident's pain when agitated, the behaviors would continue. Documentation showed that if pain medication was provided at a lower dose only, such as with the prn Tylenol, the pain was uneasily altered and behaviors would continue. If the nurse provided the resident with a narcotic such as the [MEDICATION NAME] or [MEDICATION NAME], the resident was documented as being more comfortable and behaviors would decline or not be exhibited at all. During the last year, the nursing progress notes do not show any negative effects related to the use of the [MEDICATION NAME]/[MEDICATION NAME] medication when used. Review of the physician progress notes [REDACTED]. Review of the resident's monthly pharmacy reviews for March 2014-February 2015 lacked evidence for any concerns relating to pain. During an observation and interview on 3/10/15 at 4:30 p.m., the resident was observed sitting in a recliner adjacent to the nursing station. The resident would scoot his buttocks up to the edge of the chair, look around and reach for his walker, attempt to stand up, then sit back in the chair. The resident was readjusting his buttocks in the recliner side to side constantly and would lift his left side up while pushing his left arm off the chair seat to relieve pressure to his side. This behavior occurred repeatedly until 5:10 p.m. Staff did not approach or ask the resident if he needed anything, but were in and out of the area assisting other residents. At 4:50 p.m., the resident was asked if he was uncomfortable or in pain, but the response was about a truck as he pointed out the window of the building. During an interview on 3/12/15 at 11:00 a.m., staff member F, RN, and staff member J, RN, stated they always looked at pain, hunger or question a UTI, if a resident had an increase in agitation. If the resident was unable to provide an accurate description of the pain, a prn over the counter medication, such as Tylenol, could be utilized as an intervention to alter the pain/behavior. Staff member F stated when resident #1's pain increased, the resident would exhibit an increase in restlessness, would pace more up and down the halls, frown more, and have an increase in tremors/shaking. During an interview on 3/12/15 at 10:00 a.m., a family member of the resident stated he had asked the facility about the resident's behaviors and the staff were "short on answers." He had talked with the facility about the resident's anxiety, falls and elopements. He felt the resident's pain was managed well, but could be managed better at times. During an interview on 3/13/15 at 8:30 a.m., staff member X, pharmacist, stated he had met many times with the facility regarding the resident. He stated the resident had [MEDICAL CONDITION] and medications were adjusted often in an attempt to alter tremors, but these adjustments were unsuccessful. Staff member X stated the monthly reviews were not always completed at the facility, but done offsite. Because of this, the MARs were not always checked for usage, patterns or concerns. Staff member X stated prior to the resident's fall in January, he had not reviewed the resident's medications for how they may have effected his fall risk, contributed to elopements, or behavioral concerns in relation to pain management. During an interview on 3/13/15 at 9:30 a.m., staff member X stated he had reviewed the MARs for the resident and determined a change would be recommended, and perhaps a [MEDICATION NAME], or a scheduled dose of narcotic medication would manage the resident's pain better. He was going to consult with the physician. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour on 3/9/15 at 6:35 p.m., staff member K, LPN, stated resident #3 had pain issues. Review of the admission MDS, with an ARD of 8/14/14, and quarterly MDS, with an ARD of 1/27/15, reflected severe pain levels 9-10 out of a 10 (J300). Review of resident #3's physician's orders [REDACTED]. - [MEDICATION NAME] Patch 25 mcg/hr placed [MEDICATION NAME] and changed every 72 hours, - [MEDICATION NAME] 650 mg by mouth taken every four-six hours as needed for pain, - [MEDICATION NAME] 325/10 mg by mouth every four hours as needed for pain, and - [MEDICATION NAME] 5 mg by mouth every four hours as needed for pain. Review of resident #3's Medication Sheet for 3/2015 reflected frequent narcotic [MEDICATION NAME] use: - [MEDICATION NAME] used once, - [MEDICATION NAME] used zero to five times daily, and - [MEDICATION NAME] was used zero to three times daily. Review of resident #3's Charting entries from 1/3/15 - 2/2/15 reflected: - 1/3/15 at 9:03 a.m., "Resident states she hurts all over," - 1/8/15 at 15:16 p.m., "Cried t/o entire procedure," - 1/9/15 at 15:25 p.m., "Res c/o of pain off and on t/o procedure," - 1/12/15 at 17:50 p.m., "Less hollering out than usual," - 1/15/15 at 2:01 a.m., "Resident complains of an increase in pain in her legs as she did last night. She is given a pain med and then not 2 hours later she is having severe leg pain," - 1/18/15 at 19:02, "the pain is constant all over and about an 8 (out of 10)," - 1/24/15 at 2:51 a.m., "states pain level is a 9 (out of 10)," - 1/26/15 at 15:17 p.m., "generalized pain 7 on pain scale 1-10," - 1/28/15 at 16:34 p.m., "Resident is having more pain with wounds on her legs especially the right shin," - 1/29/15 at 13:57a.m., "Refused cares due to pain issues on 1/27/15," - 1/29/15 at 17:27 p.m., "c/o 8 on pain scale 1-10," - 1/29/15 at 13:57 p.m., "refused cares due to pain issues, " and - 2/2/15 at 10:31 a.m., "c/o 8 on pain scale 1-10." Review of the resident's Pharmacy Review reflected: - The pharmacy reviewed date was 1/1/15, - The pharmacist recommended increasing the [MEDICATION NAME] to 50mcg/hr, - The DON signature was dated 2/1/15, and - The physician lacked a documentation signature. During an interview on 3/13/15 at 8:50 a.m., staff member X, pharmacist, reviewed his 1/1/15 Pharmacy Review recommendation to increase resident #3's [MEDICATION NAME]. The document reflected a lack of a physician signature and staff member X stated he was uncertain if the physician had seen his recommendations. During an interview on 3/13/15 at 10:15 a.m., staff member B, DON, reviewed the 1/1/15 Pharmacy Review recommendation to increase resident #3's [MEDICATION NAME], stated her signature on the Pharmacy Review indicated she was in agreement with the pharmacist's recommendation. Staff member B stated she did not know why the physician had not signed the 1/1/15 Pharmacy Review document or why resident #3's pain meds were not adjusted per the pharmacist's recommendation.