Every finding on record at Greenville Post Acute

Based on review of facility policy, record review, and interview, the facility failed to follow Resident (R)138's diet order which resulted in R138 choking and dying. This failure had the possibility to negatively impact the 34 residents on a mechanical soft diet residing in the facility. On 07/30/26 at 4:46 PM, the Administrator and Director of Nursing were provided with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 06/26/26. The IJ was related to 483.60 - Food and Nutrition Services. On 07/30/26, the facility provided an acceptable plan for removal of the IJ. The survey team verified all elements of the facility's removal plan and determined that the facility put forth due diligence in addressing the noncompliance. The SA is recommending this IJ at Past Noncompliance (PNC) as of 07/01/26. Findings include: Review of the facility's policy/guidance titled, Diet and Nutrition Care Manual Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet undated indicated, This diet is used for individuals with mild oral and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked or altered to make them easier to chew and swallow. Any foods that are very hard, sticky, chewy, or crunchy should be avoided.Food.Protein Foods.lean meat.Chopped or ground as tolerated.All the same guidelines apply with alterations being made to ease chewing/swallowing.Foods Allowed.Protein Foods Meats Must be very tender, small pieces, thin slices, chopped or ground and well moistened. Review of R138's Face Sheet located under the Profile tab of the electronic medical record (EMR) revealed R138 was admitted to the facility on [DATE], with diagnoses including but not limited to, chronic kidney disease, schizophrenia, post traumatic stress disorder (PTSD), anxiety disorder, restlessness and agitation, unspecified mood (affective) disorder, psychoactive substance abuse, and a cerebral aneurysm. Review of R138's EMR under the admission Minimum Data Set (MDS) tab with an Assessment Reference Date (ARD) of 06/10/26, indicated R138 needed set up for eating; supervision for bed mobility; substantial/maximum assistance for oral hygiene, toileting hygiene, showering, dressing, and personal hygiene. The MDS showed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R138 was moderately cognitively impaired. Review of R138's EMR under the Progress Notes tab indicated there was no documentation regarding the incident that occurred on 06/29/26 or that the resident died at the facility on 06/29/26. Review of R138's EMR under the Documents tab indicated a form titled, South Carolina Department of Public Health Burial-Removal-Transit Permit and Death Notification stated, R138 died on [DATE] at 4:15 PM at Greenville Post Acute. Review of R138's EMR under the Orders tab indicated Order Details a diet order, verbally ordered by the Medical Director on 06/05/26 stated, .Diet Texture: Mechanical Soft. Review of R138's diet slip, provided by the Dietary Manager (DM) on 07/30/26 indicated R138's Diet: Regular, Texture: Mechanical Soft. Review of the facility's investigation titled, Greenville Post-Acute Incident Review and Corrective Action Plan undated indicated, .Summary of Incident on June 26, 2026 [incorrect date], at approximately 3:35 PM, staff observed [R138] seated at the nurses station appearing to experience acute respiratory distress immediately after consuming a sandwich. Staff reported that the sandwich consisted of soft bread with very thinly sliced ham and cheese.Staff immediately intervened. Water was offered.Nursing staff attempted to visualize the airway.but could not identify a clear obstruction. Additional nursing staff responded and initiated abdominal thrusts.No immediate relief was achieved. The resident became unresponsive and collapsed. Staff transferred her to her room.called a Code Blue, initiated CPR [cardiopulmonary resuscitation], and activated 911. Facility staff continued life saving measures until EMS [emergency medical services] assumed care.the resident did not regain responsiveness and was pronounced deceased at approximately 4:15 PM. The coroner was notified and responded. The facility was initially advised the cause of death was cardiac arrest.the coroner subsequently added choking to the cause of death determination.Actions Taken.Staff were re-educated on strict adherence to physician diet orders and verification of diet texture before providing meals or snacks.Mechanical-soft snack identification signage was posted to assist staff in selecting appropriate snacks. The facility reviewed the availability of unit snacks and consistency with physician-ordered texture modifications. The facility reinforced communication among nursing, dietary, and Speech-Language Pathology regarding changes in diet texture, swallowing precautions, and feeding recommendations.Monitoring Plan Beginning July 1, 2026, the facility initiated weekly observation audits on every unit for two months to verify that snacks provided to residents are consistent with their ordered diets. During an interview on 07/29/26 at 12:55 PM, Licensed Practical Nurse (LPN)2 stated R138 was in a wheelchair by her medication cart. LPN2 said R138 began choking, but she was not red in the face. LPN2 stated she encouraged R138 to take a drink but she could not, so back blows were started. LPN2 stated the Unit Manager assisted and did the Heimlich maneuver and 911 was called. LPN2 stated R138 had not had any issues with swallowing in the past. LPN2 said they took R138 to her room and began CPR. LPN2 stated EMS came and took over. LPN2 said, Honestly we did the best we could. During an interview on 07/29/26 at 1:05 PM, Certified Nursing Assistant (CNA)1 stated R138 was at the nurses' station in her wheelchair and she gave R138 half of a sandwich. CNA1 explained she had walked down the hallway and when she came back to R138, she said, I am choking. CNA1 said to nurse, R138 was choking. CNA1 stated a nurse did the Heimlich to R138 and moved her to her room. CNA1 stated EMS was called and she witnessed their arrival. CNA1 stated R138 died at the facility. CNA1 said the incident occurred at the 100 nurses' station at about 3:45 PM. During an interview on 07/29/26 at 2:10 PM, CNA3 stated she was at the 100 nurses station (was working on 200 hall) and another CNA got a sandwich for R138 and she did fine eating the sandwich until the last bite. CNA3 said R138 said, I am choking, R138 was instructed to spit it out and she said, No, I want it. CNA3 said R138 was given something to drink and a little later she began choking. CNA3 said nursing did the Heimlich and she helped nursing get R138 to her room. CNA3 stated nursing began CPR and CNA3 left the room since there was nothing else she could do for R138 at that time. During an interview on 07/30/26 at 7:30 AM, the Director of Nursing (DON) and Administrator confirmed an investigation was completed and agreed to provide the investigation. Surveyor questioned the Administrator if the incident was reported to the State Agency and he stated he did not report it to the state because he did not feel he needed to since R138's family and the coroner were notified of the R138's death. During an interview on 07/30/26 at 7:46 AM, the Dietary Manager (DM) stated the type of sandwiches that were placed in the nourishment room/fridge were deli meat, cheese, egg salad, ham salad, pimento cheese, and tuna salad. The DM said currently a regular sandwich was cut in half and a mechanical soft sandwich was cut in a triangle shape in order to differentiate the type of sandwich for the staff. DM explained signs were posted in the nourishment rooms detailing the sandwich shape and type for all staff to refer to. DM stated also the regular and mechanical sandwiches were stored in separate bags. The DM explained the snack sandwiches were delivered by the kitchen staff to the nourishment room/fridge, then the CNAs looked up the resident's diet prior to providing a sandwich to a resident. The DM showed the surveyor a sample of mechanical soft ham that was used for mechanical soft ham sandwiches. During an interview on 07/30/26 at 9:17 AM, Registered Nurse (RN)1 stated on 06/29/26 she was walking down the hall near the 100 hall nurses' station and a nurse said she needed help. RN1 stated the events that occurred were as followed: she tried to sweep R138's mouth, the Heimlich maneuver was attempted but was not effective, she called for more assistance, took R138 to her room, R138 had a pulse at that time, called a code blue, tried the Heimlich maneuver again, called 911, a pulse was not felt so she began CPR and continued CPR until EMS arrived. RN1 stated staff had given R138 a sandwich. RN1 was not aware of a similar incident occurring at the facility previously. RN1 stated dietary education was provided to all CNAs and other staff following the incident. RN1 also stated education regarding what to do if a resident was choking was provided to nursing. RN1 said prior to this incident mechanical soft diet sandwiches were provided to floor by the kitchen staff. During a follow up interview on 07/30/26 at 10:00 AM, the DM confirmed this diet slip represented what diet R138 was on at the time of the incident on 06/29/26. During an interview on 07/30/26 at 10:30 AM, Speech and Language Pathology (SLP) stated she should be notified when a resident's diet has been downgraded. SLP explained during the week, the staff usually comes to her directly and verbally notifies her of the change and if it was during the weekend the staff would notify her by sending a text. SLP stated she had a good relationship with the Nurse Managers and they usually put in the order change and then came to her and verbally informed her of the change. SLP stated upon R138's admission she did review R138's EMR and there were no swallowing issues mentioned, but she did see R138 for cognitive issues, only. During an interview on 07/30/26 at 10:52 AM, the Registered Dietician (RD) confirmed there was a diet order for R138, dated 06/04/26, that indicated a regular diet, regular texture, thin liquids. RD stated there was an order on 06/05/26 that downgraded R138's diet to mechanical soft. RD stated she did not know why the order was changed. RD said nursing made the change in the order. RD stated she saw R138 on 06/04/26 and at that time there were not any issues with swallowing that she was aware of. During a follow-up interview with RN1 on 07/30/26 at 11:16 AM, stated no one had asked her to change the diet order for R138. RN1 explained that on 06/05/26 she was interacting with R138 and observed R138 was having difficulty chewing her food so she placed an order to change R138's diet order to mechanical soft. The change was not due to a swallowing issue it was due to dentation or lack thereof. During a follow-up interview with SLP on 07/30/26 at 11:25 AM, stated she did not recall the nurse manager notifying her in person of the change in R138's diet order. During a third interview with RN1 on 07/30/26 at 11:30 AM, stated she did notify the SLP verbally in person of the change in R138's diet order to mechanical soft. RN1 did not think she placed an order/consult in R138's EMR for SLP regarding the change. During a follow-up interview with CNA1 on 07/30/26 at 3:30 PM, stated R138 asked her for a sandwich and she gave her one. CNA1 confirmed she gave R138 a regular ham and cheese sandwich. CNA1 said LPN2 was sitting there when R138 asked for the sandwich and did not say anything about R138's diet. CNA1 confirmed that prior to the incident the kitchen had always provided mechanically altered sandwiches for snack sandwiches. CNA1 confirmed, following the incident, she had received education about checking a resident's diet order prior to providing a resident a sandwich. During a follow-up interview with LPN2 on 07/30/26 at 3:45 PM, stated she was at the medication cart and did not hear R138 ask for a sandwich. LPN2 confirmed she did not know what type of sandwich was provided to R138 on 06/29/26. LPN2 stated prior to the incident she was aware of the need to check a resident's diet order prior to providing a resident a sandwich. LPN2 stated, following the incident, she had received education about needing to check a resident's diet order. LPN2 confirmed that the kitchen staff had always provided mechanical soft snack sandwiches for the residents. On 07/30/26, the facility provided an acceptable plan for removal of the IJ, which included the following: Notifications and Immediate Post-Incident Actions Family/responsible party notified at approximately 3:40 PM. Attending provider notified at approximately 3:35 PM. Coroner notified and responded at approximately 4:l5 PM. Immediate internal review initiated, including staff interviews, dietary review, and documentation review on June 30, completed July 1. CNAs and nurses involved in the incident received education on the day of the incident starting June 30th, completed July l. Identification of Residents Potentially Affected The facility assessed which residents had experienced or could potentially experience a similar adverse outcome if the identified process concerns were present. Residents considered potentially affected included those with physician-ordered mechanically altered diets, including mechanical soft, pureed, or other texture modified diets, and residents with physician-ordered swallowing precautions or Speech-Language Pathology recommendations related to eating or swallowing. On June 3Oth interdisciplinary team reviewed current residents receiving texture-modified diets to verify: Physician diet orders accurately reflected each resident's prescribed diet. Dietary records and tray cards matched current physician orders. Snacks available on nursing units were consistent with ordered diet textures. Individualized swallowing precautions and feeding recommendations were reflected in the care plan and communicated to nursing, dietary, and ancillary staff. No additional resident was identified as having experienced an adverse outcome related to diet texture at the time of the review. Actions Taken The facility has taken the following steps to support resident safety: Facility leadership completed staff interviews and reviewed the circumstances of the July 1, 2026 event. On July l, 2026, the facility posted signage in nutrition closets and other designated areas to help staff distinguish between regular-texture sandwiches and sandwiches appropriate for residents on mechanically altered diets. Effective July I,2026, the facility implemented a standardized sandwich-identification system. Regular texture sandwiches are cut into rectangles, while sandwiches prepared for residents on mechanically altered diets are cut into triangles. On July l, 2026, facility posted dietary orders in all nutrition rooms for residents with altered texture diets. Staff were re-educated on strict adherence to physician diet orders and verification of diet texture before providing meals or snacks. Education completed July l, 2026. Staff were re-educated on resident rights and self-determination in the context of safe implementation of ordered diets. Education completed July l, 2026. Mechanical-soft snack identification signage was posted to assist staff in selecting appropriate snacks on July 1, 2026. The facility reviewed the availability of unit snacks and consistency with physician-ordered texture modifications on July 1, 2026. Monitoring Plan Beginning July 1, 2026, the facility initiated weekly observation audits on every unit for two months to verify that snacks provided to residents are consistent with their ordered diets. Audits to be complete September 1, 2026. During observation audits, staff are asked to explain how to verify a resident's diet order and determine whether a snack is appropriate for that resident. Beginning July 1,2026, initiated daily nursing-and-dietary checkoffs for residents with altered diets to verify that dietary tickets accurately reflect current orders. Audits to be complete September 1, 2026. Audit findings will be reviewed through QA oversight. Identified variances will be corrected promptly, with additional education or process revision completed as indicated. Conclusion Greenville Post-Acute completed an immediate review ofthe event and implemented education, identification controls, interdisciplinary verification, and ongoing monitoring intended to reduce the risk of a similar occurrence. The facility will continue to evaluate audit findings and modify interventions when indicated. Alleged Date of Compliance: July 1, 2026.

Based on review of facility policy, record review, and interview, the facility failed to thoroughly investigate an allegation of sexual abuse between Resident (R)143 and R6, for 2 of 6 residents reviewed for abuse out of 30 sampled residents. Findings include: Review of the facility's policy titled Abuse and Neglect - Clinical Protocol revised March 2018, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft:/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The individual conducting the investigation as a minimum: Reviews the documentation and evidence. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident. Observes the alleged victim, including his or her interactions with staff and other residents. Interviews the person(s) reporting the incident. Interviews any witnesses to the incident. Interviews the resident (as medically appropriate) or the residents' representative. Interviews the resident's attending physician as needed to determine the resident's condition. Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Interviews the resident's roommate, family members, and visitors. Interviews other residents to whom the accused employee provides care or services. Reviews all events Leading up to the alleged incident. Documents the investigation completely and thoroughly. 8. The following guidelines are used when conducting interviews: a. Each interview is conducted separately and in a private location. b. The purpose and confidentiality of the interview is explained thoroughly to each person involved in the interview process. c. Should a person disclose information that may be self-incriminating, that individual is informed of his or her rights to terminate the interview until such time as his/her rights are protected (e.g., representation by legal counsel). Witness statements are obtained in writing, signed, and dated. The witness may write his or her statement, or the investigator may obtain a statement. 1. Review of R143's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE], with diagnoses including but not limited to, cognitive communication deficit, major depressive disorder, adjustment disorder, and visual hallucinations. Review of R143's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/26 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. 2. Review of R6's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE], with diagnoses including but not limited to, cognitive communication deficient, major depressive disorder, anxiety disorder, and post-traumatic stress disorder. Review of R6's annual MDS with an ARD of 07/22/26 and located in the EMR under the MDS tab revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the facility Summary of Findings dated 04/30/26 revealed camera footage for 04/24/26 between 3:35 PM and 3:52 PM revealed R6 sitting in the library coloring when R143 entered in his wheelchair and positioned himself behind R6. R143 was observed rubbing on R6's back and neck and leaning closer to R6 and saying something but due to camera angles it was unclear R6's response or due to a lack of audio what R143 said to R6. R143 was later observed rubbing himself, exposing his genitalia and moving closer to R6. A short time later R143 leaves the library and R6 leaves shortly after. Further review revealed no staff that were working during the day, or evening shift on 04/24/26 were interviewed. During an interview on 07/28/26 at 2:30 PM, the Administrator stated they did not preserve a copy of the video of incident that occurred between R143 and R6 on 04/24/26. He further stated he did speak with staff, but he did not have any signed and dated statements by staff. He stated he called staff and asked them a list of prewritten questions and just marked yes or no on a sheet of paper.

Based on review of facility policy, record review, and interview, the facility failed to provide Resident (R)143 a proper discharge following a sudden discharge to another facility for 1 of 3 residents reviewed for discharge out of 30 sampled residents. Review of the facility policy titled, Transfer or Discharge Notices revised March 2025 revealed, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. Except as specified below, the resident and his or her representative are provided with a written notice of an impending transfer or discharge at least 30 days prior to the transfer or discharge. Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; The resident's health improves sufficiently to allow a more immediate transfer or discharge; An immediate transfer or discharge is required by the resident's urgent medical needs; or A resident has not resided in the facility for 30 days. The resident and representative are notified in writing the following information: The specific reason for the transfer or discharge, including the basis under 483.15; The effective date of the transfer or discharge; The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; An explanation of the resident's rights to appeal the transfer or discharge to the state, including: the name, address, email, and telephone number of the entity which receives such appeal hearing requests; information about how to obtain an appeal form; and how to get assistance in completing and submitting the appeal hearing request; The name, address, and telephone number of the Office of the State Long-term care ombudsman Review of R143's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE], with diagnoses including but not limited to, cognitive communication deficit, major depressive disorder, adjustment disorder, and visual hallucinations. Review of R143's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/26 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R143's Discharge Summary located in the EMR under the Assessments tab revealed there was no Discharge summary, dated [DATE], when the resident was discharged to another facility. Review of R143's Progress Note, dated 04/26/26 and located in the EMR under the Progress Notes tab revealed Resident was discharged from facility to another facility. All belongings and medication accompanied him. During an interview on 07/28/26 at 2:17 PM, Certified Nurse Aide (CNA)7 stated she was also the facility driver. She was the person who transported R143 to the new facility on 04/26/26 and she said R143 wasn't happy to be transferring to the other facility. During an interview on 07/30/26 at 6:27 PM, the Director of Nursing (DON) stated the Administrator told R143 verbally that he was being transferred to a different facility, but she was unsure if he was given anything in writing. She stated they did not complete a discharge summary or any documentation about the transfer since R143 was being transferred to a sister facility. During an interview on 07/28/26 at 2:30 PM, the Administrator stated he told R143 that he could not stay at the facility and they were going to find another placement for him. He was not given a 30 day notice or anything in writing about his discharge.

Based on review of facility policy, record review, and interview, the facility failed to provide Resident (R)143 and R104, and their resident representatives (RR) with the required written transfer notice following emergent hospital transfers and discharge to a different facility for 2 of 3 residents reviewed for hospitalization and discharge out of 30 sampled residents. Findings include: Review of the facility policy titled, Transfer or Discharge Notices revised March 2025 revealed, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. An immediate transfer or discharge is required by the resident's urgent medical needs; or A resident has not resided in the facility for 30 days. The resident and representative are notified in writing the following information: The specific reason for the transfer or discharge, including the basis under 483.15; The effective date of the transfer or discharge; The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; An explanation of the resident's rights to appeal the transfer or discharge to the state, including: the name, address, email, and telephone number of the entity which receives such appeal hearing requests; information about how to obtain an appeal form; and how to get assistance in completing and submitting the appeal hearing request; The name, address, and telephone number of the Office of the State Long-term care ombudsman; 1. Review of R143's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE], with diagnoses including but not limited to, cognitive communication deficit, major depressive disorder, adjustment disorder, and visual hallucinations. Review of R143's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/26 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of R143's Discharge Summary located in the electronic medical record (EMR) under the Assessments tab revealed there was no Discharge summary dated [DATE] when the resident was discharged to another facility. Review of R143's Progress Note dated 04/26/26 and located in the electronic medical record (EMR) under the Progress Notes tab revealed, Resident was discharged from facility to another facility. 2. Review of R104's Face Sheet located in the EMR under the Profile tab revealed the resident was admitted on [DATE], with diagnoses including but not limited to, vascular dementia, depression, and anxiety disorder. Review of R104's quarterly MDS with an ARD of 06/23/26 and located in the EMR under the MDS tab revealed a BIMS score of 6 out of 15, which indicated the resident was severely cognitively impaired. Review of R104's Notice of Proposed Transfer/discharge date d 02/06/26, located in the EMR under the Assessments tab revealed, R104 was transferred to the emergency room (ER) for a hip fracture. Further review revealed the form did not include a transfer notice that included the contact information related to the residents' appeal rights. During an interview on 07/30/26 at 6:27 PM, the Director of Nursing (DON) stated that the unit managers along with herself fill out the transfer notice. She stated this was the form that their legal department told them to use for transfer notices. She was unaware what specific appeal's information had to be listed on the form.

Based on review of facility policy, observation, record review, and interview, the facility failed to ensure that Residents (R)12's comprehensive Minimum Data Set (MDS) assessment was completed accurately for 1 of 4 residents in the sample of 30.Findings include: Review of the facility policy titled, Resident Assessments revised October 2023 revealed, A comprehensive assessment of each resident is completed at intervals designated by OBRA regulations and PPS requirements. Data from the Minimum Data Set (MD5) is submitted to the internet Quality Improvement Evolution System (iQlES) as required. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the residents' strengths and areas of decline. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 12. information in the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. Review of R12's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted on [DATE], with diagnoses including but not limited to, Bell's palsy and muscle weakness. Review of R12's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/23/26 and located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed under section P Restraints and Alarms was marked yes, less than daily, for Restraints used in chair/out of bed: other (P0100H). During an observation on 07/28/26 at 10:30 AM and on 07/29/26 at 2:40 PM, revealed R12 in bed. No restraint on bed could be observed. During an interview on 07/30/26 at 5:44 PM, the Minimum Data Set Coordinator (MDSC) stated she completed R12's MDS inaccurately. R12 did not have a restraint and that was a booboo [mistake]. She said there was no process for someone to review the MDS sections after they were completed to ensure they were completed accurately. During an interview on 07/30/26 at 6:27 PM, the Director of Nursing (DON) stated she expected MDS assessments to be completed accurately.

Based on review of facility policy, record review and interviews, the facility failed to notify Resident (R)1's physician of elevated blood pressures for 1 of 1 resident, reviewed for notification of changes.Findings Include:Review of the facility policy titled Change In a Resident's Condition or Status with a complete revision date of February 2021 states, Policy Statement: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care. billing/payments, resident rights, etc.). Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): . d. significant change in the resident's physical/emotional/mental condition; . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self - limiting); Review of R1's Face Sheet revealed that the facility admitted R1 on 12/19/25, with diagnoses including, but not limited to: Alzheimer's Disease, essential (primary) hypertension and hypothyroidism.Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/26/25, revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating R1 was unable to complete the interview. Further review of the Active Diagnoses Section noted R1 as having Hypertension.Review of R1's Physician Orders revealed an order for Benazepril 5 mg (milligram) tablets with instructions to give one tablet by mouth one time a day for hypertension. Hold for [systolic blood pressure] SBP less than 110.Review of R1's Blood Pressure Summary revealed the following:01/04/26 7:48 AM BP 172/10201/04/26 9:26 AM BP 172/10101/05/26 1:22 AM BP 171/119Review of R1's Nurses Notes did not revealed documentation that the physician was notified of R1's elevated blood pressures. Review of R1's Care Plan Report dated December 2025 revealed, Special Instructions: Resident is a PACE resident. Please contact PACE [Program for All-inclusive Care of the Elderly] for any medical needs [phone number].During an interview on 03/10/26 at 2:37 PM, the Unit Manager (UM) stated all of her medication orders would have come from PACE. The DON stated yes when asked if 171/119 was an elevated blood pressure. The DON then stated a call should have been placed to the on-call Medical Director (MD) with PACE. The nurse may have contacted the direct contact through PACE that works in our building.An attempted phone interview on 03/10/26 at 2:55 PM, with LPN2 was unsuccessful.During an interview on 03/10/26 at 3:21 PM, the patient liaison for the facility revealed, I do not recall receiving a call from the facility on the fourth or the fifth of January 2026 regarding R1 and an elevated blood pressure.During an interview on 03/10/26 at 6:25 PM, the weekend supervisor revealed, I was not made aware of R1's elevated blood pressure.During an interview on 03/10/26 at 6:28 PM, CNA1 revealed I notified Registered Nurse (RN)4 of the resident's elevated blood pressure right away. I am not sure what she did after that.During an interview on 03/10/26 at 6:34 PM, the DON revealed, her expectation is that the nurse on the floor should reach out to PACE. The nurse should also notify the family of the resident's change in condition. The nurse notifies PACE of the change in condition and then gets new orders. We should monitor the elevated blood pressure and follow the new physician orders from PACE.During an interview on 03/10/26 at 6:40 PM, RN4 revealed, I do not recall this patient, but I would have reached out to the onsite physician or the on call for PACE and gotten orders to address the blood pressure. I do not know what happened, the only place that we document is in the progress notes. If there is not a note there, it would not be documented anywhere else.

Based on review of facility policy, record review, and interviews, the facility failed to obtain and administer missing Lacosamide, a seizure medication, for Resident (R)2, resulting in the resident not receiving 11 doses of the medication from 1/7-1/13, for 1 of 1 resident reviewed.Findings Include: Review of the facility policy titled, Adverse Consequences and Medication Errors, with a revision date of June 2025 revealed, Policy Statement: The interdisciplinary team monitors medication usage to prevent and detect medication - related problems such as adverse drug reactions (ADRs) and side effects. Medication Errors: 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principals of the professional(s) providing services. 2. Examples of medication errors include: a. omission- a drug is ordered but not administered;Review of R2's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, Epilepsy, paranoid schizophrenia and dementia.Review of R2's Care Plan Report revealed that no care plan was developed relating to Epilepsy, seizure risk, or seizure medications. Review of R2's Medication Administration Record (MAR) dated 01/07/26 through 01/14/26 revealed that R2 did not receive the following medications as ordered: Lacosamide oral tablet 100mg, give 1.5 tablets by mouth two times a day for Seizures. R2 missed 11 doses of the medication.During an interview on 03/10/26 at 04:37 PM, Licensed Practical Nurse (LPN) 3 started, If I scratched out the progress note about the Lacosamide not being given, that means that I administered it. If I am waiting for a medication, I keep a running list and then I call the pharmacy for a status update.During an interview on 03/10/26 at 05:07 PM, the Staff Development Coordinator stated, we have a protocol when there is a missing medication. The nurses are to call the pharmacy and document that call. They are to notify the Medical Doctor (MD)for alternatives, and they can also check the Omnicell if the medication is not a narcotic.During an interview on 03/10/26 at 05:45 PM the Director of Nursing (DON) stated you are unable to speak with the Nurse Practitioner (NP) due to her being with her son that had surgery today.During a phone interview on 03/10/26 at 06:55 PM, R2's Primary Care Physician (PCP) revealed that she has no memory of being notified in any way regarding R2 missing any doses of Lacosamide 100mg. The PCP stated that typically the NP is notified first regarding any medication issues. If there is a medication that is missing or a prescription is needed, the NP should work with pharmacy to resolve it. If the NP is having an issue, I should be notified so that I can step in for an alternative solution if the medication is going to be delayed. Other options include ordering another medication or medication from the Pyxis. The missing medication should have been communicated immediately by phone, encrypted message, or verbal face to face not by a note left in a book.During an interview on 03/10/26 at 06:34 PM the DON revealed that when residents are admitted to the facility, the nurse on the floor should send all the residents' prescriptions to the pharmacy. If there is no prescription for a medication, the nurse should reach out to onsite/on call to get a new prescription. That is very simple. The on call can call the Omnicare Pharmacy and e fax a new prescription to the pharmacy and the pharmacy can send it out stat[immediately]. All the nurses have been educated on that. Typically, the nurses reach out to me or the unit managers to get a new prescription from NP, MD or whoever is on call. I was not aware that there was no prescription for the Lacosamide.

Based on observation, interview, and facility policy review, the facility failed to ensure that menus were followed in regard to serving sizes. This had the potential to affect 120 of 124 residents who consumed meals from the facility's kitchen and placed them at nutritional risk. The facility identified four resident who were nothing by mouth (NPO). Findings include: Review of policy titled Diet Accuracy with a revision date 2/23, revealed Tray cards are to be used on the tray line for service and checked prior to leaving the kitchen for accuracy. Proper portions are to be served according to menu extensions. During an observations on 04/24/25 at 11:30 AM of the serving line in the kitchen revealed the menu being served was, honey glazed turkey with poultry gravy, mashed potatoes, roasted brussels sprouts, cornbread square, margarine, and pumpkin cheesecake bar. Resident's meal tickets indicated they were to get anywhere from two ounces (oz) to six oz of turkey. While watching the serving line, some slices of turkey were large and some were small; there was no consistency to the size of the turkey slices and the turkey was not weighed to ensure the appropriate amount of turkey was served. Close to the end of the serving line, the turkey that residents were receiving was broken pieces of turkey that were being scooped out and placed on trays. During an interview on 04/24/25 at 12:50 PM with the Dietary Manager (DM), the DM revealed that the meat slicer was broken and the turkey had to be cut by hand, so some of the slices were different sizes. The DM revealed for the portion sizes, six oz was two slices of turkey, four oz was 1 1/2 slices of turkey, and three oz was one slice of turkey. When questioned about not knowing the amount of turkey the residents were getting, the DM did not reply. During an interview on 04/24/25 at 2:03 PM with the Registered Dietician (RD) revealed she did not know that the meat slicer was out of commission, and said there should be a way to measure portion sizes. Food is a big thing and is effective for the quality of life.

Based on observation, interview, and test tray sample, the facility failed to provide food that was palatable and at the proper temperature. This had the potential to affect 120 of 124 residents who consumed food from the kitchen and for them to be at nutritional risk. The facility identified four residents who were nothing by mouth. (NPO). Findings include: 1.Review of R89's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/25 and located under the MDS tab in the electronic medical record (EMR) revealed R89 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately impaired in cognition. During an interview on 04/22/25 at 11:15 AM with R89, R89 indicated that the food was served cold. 2. Review of R88's annual MDS with an ARD of 03/29/25 located under the MDS tab in the EMR, revealed that R88 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 04/22/25 at 11:35 AM with R88 indicated that the food was usually served cold, and the bread was always soaked in whatever vegetable that was on the plate. During a test tray sample on 04/24/25 at 1:16 PM, the Dietary Manager (DM) took the temperatures of the test tray. The mechanical turkey was at 94.5 degrees Fahrenheit (F). The DM and the surveyor tasted the mechanical chicken, the DM agreed that the chicken was cold. The DM indicated that the plate warmers were broken, and the pellet warmer was broken as well. During an interview on 04/24/25 at 3:03 PM with the Registered Dietitian (RD), revealed the RD was not aware that the plate warmers were not functioning. When putting food on a cold plate, the food is going to get cold. Food is a big thing, and it is effective for the quality of life.

Based on record review, interview, observation, and review of facility policy, the facility failed to allow immediate family or other relatives the right to visit at any time for one (Resident (R) 122), reviewed for visitation of 31 sample residents. This had the potential for the resident to experience a decreased quality of life. Findings include: Review of the facility's policy titled Visitation with a revision date of 08/22 revealed, Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. Policy Interpretation and Implementation: Residents are permitted to have visitors of their choosing at the time of their choosing. The facility provides 24-hour access to individuals visiting with the consent of the resident. Review of R122's Admission Record located under the Profile tab in the electronic medical record (EMR), indicated that R122 was admitted to the facility on [DATE]. Review of R122's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/25 and located under the MDS tab in the EMR revealed R122 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated she was cognitively intact. During an interview on 04/22/25 at 11:09 AM with R122, she stated that she did not like the fact that her parents have to leave at a certain time and she wanted them to be able to stay in the room and visit. She stated, My friends have been asked to leave, and my parents. During an on 04/22/25, at 11:09 AM with Family Member (FM)2 stated that the visitation hours are difficult because they want us to leave by 7:00 PM. FM2 stated, I work during the day, so when I get off and get here, I don't have much time. They have moved us to the common room, and we were able to stay until 9:00 PM once. My husband likes to eat breakfast with her and spend some time during the day, because she gets a little anxious when we are not here. So, we try to be here for her, but the visitation hours make it difficult. During an observation on 04/23/25 and 04/24/25, there were signs posted throughout the facility that revealed, Visitation Hours are currently 8:00 AM - 7:00 PM for patients in semi-private rooms. Residents have the option of visiting with their guest(s) in a public sitting area from 7:00 PM until 9:00 PM. All visitors must exit the building by 9:00 PM unless specific orders have been given/approved by MD [physician] or Hospice. Each unit is responsible for enforcing this policy!! During an interview on 04/23/25 at 6:33 PM with the Social Service Director (SSD), the SSD stated that visitation is from 8:00 AM - 7:00 PM, in a shared room, visitors can stay until 9:00 PM at night. If someone needs to set up a time outside those hours, they will need to speak with the Administrator. The signs that explain the visitation hours are posted throughout the facility. During an interview on 04/23/25 at 7:06 PM with FM3 revealed that they could stay in the room with R122 until 9:00 PM. FM3 stated, I would also come early in the morning so I could eat breakfast with her. R122 is experiencing anxiety about the visitation times because she is used to my wife and me being there with her. During an interview on 04/24/25 at 8:31 AM with the Director of Nursing (DON), the DON stated, R122 was very young, and the family is very protective. They are always in her room, from 5:30 AM till late at night. The dad is always in the room, and the roommate feels that she cannot get proper activities of daily living (ADLs) care with the dad in the room. We explained to the dad that he has to stay in the lobby until 8:00 AM so the roommate can get morning care. During an interview on 04/24/25 at 5:10 PM with the Administrator, the Administrator revealed We always want to make sure that it is a safe environment, and residents are protected. In referring to the signs that are posted in the facility about visitation, the Administrator did not reply.

Based on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of staff to resident verbal abuse for one (Resident (R) 89) reviewed for abuse was reported to the state agency (SA) within two hours of knowledge of the alleged verbal abuse. The failure to timely report allegations of abuse put the resident at risk for further abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating with a revision date 04/21, indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) . If resident abuse (staff to resident and/or resident to resident), neglect, exploitation, misappropriation of resident's property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator . All allegations of staff-to-resident abuse must be reported immediately, but no later than 2 hours. Review of R89's Admission Record located under the Profile tab in the electronic medical record (EMR), indicated that R89 was admitted to the facility on [DATE]. Review of R89's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/25 and located under the MDS tab in the EMR revealed R89 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately impaired in cognition. During an interview on 04/22/25 at 11:35 AM, R89 reported that Certified Nursing Assistant (CNA)4 called his mother an [expletive]. R89 said he informed his son, Family Member (FM)1 about these issues, who then discussed the situation with the Administrator. R89 was unable to remember when the alleged verbal abuse occurred. Review of R88's (R89's roommate) annual MDS with an ARD of 03/29/25, revealed that R88 had a BIMS score of 15 out of 15, which indicated the resident had intact cognition. During an interview on 04/22/25, at 11:35 AM, R88 reported an incident involving CNA4 and R89. According to R88, R89 used an offensive term to describe her (CNA4), and in response, CNA4 directed the same inappropriate language about R89's mother. During an interview on 04/23/25, at 10:14 AM, FM1 indicated that he had met two weeks ago with the Administrator to discuss several concerning incidents involving R89. FM1 stated, We discussed a staff member using abusive language to describe his grandmother, and his father being left unattended in the shower room for 40 minutes. Review of the facility provided Long-term Care (LTC) Reportable Event did not list any report for R89 identifying any incident of abuse and/or neglect being reported. During an interview on 04/23/25, at 2:28 PM, the Administrator confirmed that R89's son had previously discussed an incident where the resident was left unattended in the shower room for over 40 minutes. This concern was forwarded to the Director of Nursing (DON) for investigation. The Administrator recalled that the son's primary complaints focused on his father being placed in isolation and encountering a nurse with poor communication skills. Regarding the alleged verbal abuse from CNA4 to R89 about his mother, the Administrator stated he had no prior knowledge of this situation. During an interview on 04/23/25, at 3:17 PM, the DON acknowledged that R89's son had expressed concern about his father being left in the shower room for over 45 minutes. The DON stated she reviewed security camera footage but found no evidence of this occurrence, and when questioned, the CNAs denied the incident. When asked about the reported incident involving abusive language from CNA4 towards R89's mother, the DON claimed no prior knowledge until the Administrator inquired about it earlier today. During an interview on 04/24/25 at 5:10 PM with the Administrator, the Administrator confirmed he was made aware yesterday (04/23/25) of the allegation made by R89 regarding CNA4 using abusive language about R89's mother. The Administrator confirmed he did not report the allegation to the SA on 04/23/25 when he became aware, nor has he reported as of 04/24/25.

Based on interview, record review, and review of facility policy, the facility failed to ensure that an allegation of staff to resident verbal abuse for one (Resident (R)89) reviewed for abuse out of a total of 31 sampled, was thoroughly investigated. The failure to thoroughly investigate allegations of abuse had the potential for further abuse to the resident. Findings Include: Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program with a revision date 04/21, indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to . verbal abuse. Identifying barriers such as fear of retaliation or causing trouble for someone and implementing interventions to remove barriers and promote a culture of transparency and reporting, investigating, and reporting any allegations within the timeframes required by federal requirements, and protecting residents from any further harm during investigations. Review of R89's Admission Record located under the Profile tab in the electronic medical record (EMR), indicated that R89 was admitted to the facility on [DATE]. Review of R89's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/11/25 and located under the MDS tab in the EMR revealed R89 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was moderately impaired in cognition. During an interview on 04/22/25 at 11:35 AM, R89 reported that Certified Nursing Assistant (CNA) 4 called his mother an expletive. The resident expressed concerns to this surveyor about CNA4's abusive words and mentioned that while CNA4 had previously been reassigned to a different hall, she has since returned to working in his area. The resident informed his son, Family Member (FM)1 about these issues, who then discussed the situation with the Administrator. R89 was not able to remember when this allegation of verbal abuse occurred. Review of R88's annual MDS with an ARD of 03/29/25 located under the MDS tab in the EMR, revealed that R88 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. During an interview on 04/22/25, at 11:35 AM, R88 reported an incident involving CNA4 and R89. According to R88, R89 used an offensive term to describe CNA4 and in response, CNA4 directed the same inappropriate language toward R89's mother. During an interview on 04/23/25, at 10:14 AM, FM1 indicated that he had met two weeks ago with the Administrator to discuss several concerning incidents involving R89. We discussed a staff member using abusive language to describe his grandmother, and his father being left unattended in the shower room for 40 minutes. FM1stated that while the Administrator promised to investigate these incidents and provide follow-up information, no communication has been received in the two weeks since the meeting. During an interview on 04/23/25, at 2:28 PM, the Administrator confirmed that Resident 89's son had previously discussed an incident where the resident was allegedly left unattended in the shower room for over 40 minutes. This concern was forwarded to the Director of Nursing (DON) for investigation. The Administrator recalled that the son's primary complaints focused on his father being placed in isolation and encountering a nurse with poor communication skills. Upon inquiry about the facility's documentation procedures, the Administrator acknowledged that this family-reported concern was not documented as a formal grievance in the facility's recorded formal grievance log, and had no documentation of the investigation. Regarding the reported incident where CNA4 allegedly made inappropriate comments about Resident 89's mother, the Administrator stated he had no prior knowledge of this situation. During an interview on 04/24/25 at 8:05 AM with the Administrator, the Administrator indicated that the investigation was still ongoing. Messages were left for CNA4, but calls have not been returned. During an interview on 04/24/25 at 8:31 AM with the DON, the DON stated that she and a Unit Manager took R89 to a private place and talked on 04/23/25. R89 indicated that a couple of weeks ago, a black CNA with braids was nasty and had a bad attitude, called his momma an expletive, kicked the door, and bumped his chair. He said that he had seen her a couple of weeks ago, she had braids, but he did not know her name. The DON further indicated on 04/15/25 when FM1 came and talked with me and the Administrator, all he discussed was moving R89 around and being left in the shower for 40 minutes, however in reviewing the video this did not occur.

Based on record review, interview, and policy review, the facility failed to ensure a written transfer notice that contained all required information was provided to three of three residents and/or their representative (Resident (R) 87, R113, and R83) reviewed for facility initiated emergent hospital transfer out of 31 sample residents. This failure has the potential to affect the resident and their Resident Representative (RR) by not having the knowledge of where and why a resident was transferred and/or how to appeal the transfer, if desired. Findings include: Review of the facility's policy titled Transfer or Discharge, Emergency, dated December 2016, revealed .(4) should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: .(d) prepare a transfer form to send with the resident. 1. Review of the admission Record located under the Profile tab of the electronic medical record (EMR) revealed (R)87 admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease, major depressive disorder, muscle weakness, bipolar disorder, and fibromyalgia. Review of the significant change Minimum Data Set (MDS) located under the MDS tab of the EMR with and Assessment Reference Date (ARD) of 02/01/25 revealed R87 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating she was cognitively intact. Review of the Nurse's Note dated 01/26/25, located under the Progress Notes tab in the EMR revealed Resident returned to facility from weekend LOA [leave of absence]. Resident reports falling last night while at the Best Western with her male friend. Resident reports severe pain in L[eft] shoulder and ROM [range of motion] is restricted. Reports pain at 9/10. Body assessment completed. Bruising to chin, L[eft] breast, and R[ight] elbow. Dried blood under nose. [The] Resident reports she hit her mouth on the L[eft] side. Multiple teeth [were]chipped. [The] Resident reports missing some teeth before fall. Third eye NP notified of change in condition. New orders for pain control. L[eft] shoulder x-ray ordered. DON [Director of Nursing] notified. [The] Resident is [her] own RR, aware of new orders. Resident [is] lying in bed at this time with call light in reach. Review of the EMR did not reveal evidence that a written transfer/discharge notice was provided to R87 on 01/26/25. 2.Review of the admission Record located under the Profile tab in the EMR revealed R113 admitted on [DATE] with diagnoses of cystitis, unspecified without hematuria, muscle weakness, dependence on renal dialysis, acute on chronic diastolic heart failure, and essential hypertension. Review of the Medicare 5-day MDS located under the MDS tab in the EMR revealed R113 had a BIMS of 15 of 15 indicating he was cognitively intact. Review of the Nurse's Note dated 03/15/25, located under the Progress Notes tab in the EMR revealed [The] nurse was completing [the] pre-dialysis assessment. Pt [patient] presented with low bp [blood pressure] high hr [heart rate] [and] low-grade fever with c/o [complaints of] pain to RLE [right lower extremity]. On call [was] contacted. [The] nurse [was] concerned [the patient] pt would not be [able to] receive dialysis r/t [related to] fever and complications with low bp. ON call advised for pt to be sent to hospital for HLC. [The] nurse initiated EMS [emergency medical services] and [the] pt was transported via stretcher to [the hospital]. Review of the EMR did not reveal evidence that the resident received a transfer/discharge notice on 03/15/25. During an interview on 04/23/25 at 3:20 PM, Licensed Practical Nurse (LPN)2 stated she was not aware of a transfer/discharge form that should be given to the resident and their representative explaining why the resident was being sent to the hospital. During an interview on 04/23/25 at 3:22 PM, LPN3 stated a transfer discharge form should be sent with the residents but, she did not know if this facility provided them to the residents and their representatives upon discharge. During an interview on 04/23/25 at 3:33 PM, R87 stated the EMS personnel received all paperwork when she was transferred. She stated the staff verbally told her why she was being sent to the hospital on [DATE], and she did not receive a written transfer/discharge notice. During an interview on 04/23/25 at 4:15 PM, the Director of Nursing (DON) stated she was not aware the residents and their representative were supposed to receive a written copy of the transfer/discharge notice explaining why they were being sent out of the facility. She stated residents and families were verbally notified of why they were being transferred to the hospital. During an interview on 04/23/25 at 4:24 PM, R113 stated he did not receive a written transfer/discharge notice when he was sent to the hospital. 3. Review of the admission Record located under the Profile tab of the EMR revealed R83 was admitted on [DATE] with diagnoses of anoxic brain damage, respiratory failure, congestive heart failure, and tracheostomy. Review of the admission MDS with an ARD of 03/04/25 located under the MDS tab of the EMR revealed R83 had memory issues and severely impaired cognition. Review of the Nurse Progress Note dated 03/29/25, located in the EMR under the Progress Note tab in the EMR revealed R83 had shortness of breath, and the staff transferred the resident to the Emergency Department (ED). Although R83's Family Member was notified of her transfer to the hospital via telephone, there was no documentation that a written notice for R83's transfer to the hospital with the reason for her hospitalization was sent to the family. Review of the Nurse Progress Note dated 04/16/25, located in the EMR under the Progress Note tab of the EMR revealed R83 had a copious amount of respiratory secretions seeping out from pts HME (heat moisture exchanger). Nurse initiated care HME discarded, inner cannula changed and commenced suctioning. Nurse noticed consistency to be frothy and green with a foul order. Nurse then placed aerosol mask per respiratory order. Nurse started to prepare medications and bolus feed in that amount of time nurse noticed aerosol mask full of respiratory secretions. Nurse had to suction pt several times within the hour, she notified the medical staff, and R83 was transferred to the ED. Although R83's Family Member was notified of her transfer to the hospital via telephone, there was no documentation that a written notice for R83's transfer to the hospital with the reason for her hospitalization was sent to the family. During an interview with the Social Worker Director on 04/23/25 at 3:43 PM, she was asked for documentation to show that R83's family received written notification upon a R83's transfer/discharge to the hospital on [DATE] and 04/16/25 and the reason for the transfer/discharge. She stated the facility did not provide written notices to R83's family for the above discharges from the facility. The Social Worker Director said the staff notified family members by telephone about resident transfers to the hospital and did not send written notices to the family members/representatives regarding the date and reasons for their transfers/discharges to the hospital. During an interview on 04/25/25 at 10:20 AM, Unit Manager (UM)3 said at one time, the Ums sent written notification of the reason for a resident's discharge to a resident's family/representative. She said she had not sent written notices related to R83's hospital admissions and said the DON had assumed this task.

Based on record review, interview, review of maintenance documentation, and review of facility policy, the facility failed to ensure one siderail was securely attached to the bed for one Resident (R)33) of one resident reviewed for side rails, which resulted in a fall, which required hospitalization out of a sample of 31 residents. After the fall, R33 developed a hematoma and pain to the right leg. This had the potential for other residents to have side rail safety issues that had the potential for residents to fall or sustain injuries. Findings include: Review of the facility's policy titled, Bed Safety and Bed Rails Program, revised in August 2022, revealed: Maintenance staff routinely inspect all bed and related equipment to identify risks and problems including potential entrapment risks. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. Review of the Admission Record located under the Profile tab of the electronic medical record (EMR) revealed R33 was admitted on [DATE] with diagnoses of congestive heart failure, chronic kidney disease, acute and chronic respiratory failure, and morbid obesity. Review of the Bed Rail and Entrapment Risk Observation/assessment dated [DATE] and 12/24/24, located under the Evaluation tab of the EMR revealed R33 used a side rail on the left and right upper bed rail to enhanced mobility related to her balance and generalized weakness or frailty. The bed rail enhances R33's freedom of movement, moving from a lying to a sitting position, and turning and repositioning. Review of the quarterly Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 12/23/24 located under the MDS tab of the EMR revealed R33 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact, and was dependent and/or required maximal staff assist for positioning, transfer, and activities of daily living. Review of the Care Plan dated 01/09/25 located in the EMR under the Care Plan tab of the EMR revealed R33 was at risk for injury related to use of siderail/bedrail and required a 1/4 siderail on both sides of the bed as an enabler related to promoting bed mobility and positioning. Interventions included: Inspect residents' skin for potential complications or injury related to bedrail/siderail use. Review of R33's weight dated 03/10/25 located in the EMR under the Wts/VS tab of the EMR documented R33's weight was 465.8 pounds. During an interview on 04/22/25 at 11:18 AM, R33 stated the Certified Nursing (CNA) was providing care, she as she began to turn on her left side holding the left grab bar (side rail) with her right hand, the grab bar came apart from the bed frame, and she fell to the floor. She said she sustained a bruise on her right hip, which was painful. R33 said the grab bar was replaced shortly after she fell . Review of the Nurse's Note dated 03/13/25 under the Progress Note tab of the EMR documented the CNA called the nurse to room and the resident was observed lying on stomach between bed and air conditioner. The CNA stated when the resident rolled over on left side for CNA to perform perineal care, Resident grabbed bedrail and bedrail broke, and resident rolled out of bed. Review of the Witness Statement provided by the Director of Nurses (DON) dated 03/13/25, documented CNA went to help R33 with rolling to the side to remove her dress. As soon as she rolled to the side, CNA heard something break and the resident rolled out of bed onto the floor. R33's leg hit the air conditioner unit causing the bruise on her upper right leg. During an interview on 04/24/25 at 10:31 AM, CNA3 said on 03/13/25, she was removing R33's shirt to provide personal care. She said R33 held the left side rail with her right hand and when turning toward the left side of the bed, the side rail came off the bed, R33 rolled to the floor, and her right leg hit the air conditioner. CNA3 said prior to the incident, R33 had no issues with their side rails. Review of the Nurse Practitioner (NP) Progress Note dated 03/13/25 located under the Progress Note tab in the EMR documented R33's left side rail broke or became loose, and the resident rolled on the floor. R33 had no changes in her mental status and denied injury or pain. Review of the Nurse's Note dated 03/14/25 located under the Progress Note in the EMR documented R33 had slight bruising to the right thigh and no complaints of pain. Review of the NP Progress Note dated 03/14/25 located under the Progress Note tab in the EMR documented R33 had right leg pain and left foot pain. The Progress Note documented R33 had right anterior lateral thigh pain , decreased range of motion, and swelling. There was no decreased range of motion, swelling or pain on palpation to the left foot. The plan was to obtain X-rays of the right hip femur and knee to rule out any acute fractures or dislocations. Review of the evening shift Nurse's Note dated 03/14/25 documented, Resident could not receive an Xray to her right lower extremity due to her weight exceeding 400 pounds. Resident must be sent out for Xray. Review of the Nurse's Note, dated 03/15/25 documented R33 had right leg pain and was at the hospital for an Xray. During an interview on 04/24/25 at 2:21 PM, the NP said R33 had comorbidities and anemia. The NP said on 03/14/25, she assessed R33 and her bruising had increased and she had pain. She said R33 received anticoagulant medication and was at risk for bleeding. The NP said she was concerned about a fracture and/or a hematoma (a localized collection of blood outside of blood vessels, typically caused by an injury or trauma, can appear as a bruise or lump), and ordered x-rays at the facility. The NP said the swelling in R33's right thigh was soft and not hard. The NP said the staff notified her after 5:00 PM that due to her weight, the Xray could not be completed at the facility. She stated she told the staff to transfer R33 to the hospital for the Xray. The NP said the hospital completed Xrays and a Cat Scan, which confirmed hematoma, R33 returned to the facility on [DATE]. The NP said she was R33's fall was due to the pins not being placed back in the side rail. Review of the hospital Discharge Summary dated 03/18/25 revealed R33 sustained a fall from her bed at the facility. The Discharge Summary documented R33's right hip, right femur, and right knee x-rays revealed no fractures. The Discharge Summary documented R33 was transferred back to the facility on [DATE]. Review of the facility provided document titled Work History Report dated 02/07/24 documented the Assistant Maintenance Director inspected all residents' bed mattresses/beds, and bed rails and no issues were identified. Review of the User-Service Manual that included information about the side rail used on R33's bed, provided by the DON revealed Visually inspect the bed and accessories for broken welds or creaks and check for loose hardware on a monthly basis .lubricate pivot point, pins, and bolts as required. During an interview on 04/23/25 at 9:49 AM, the Maintenance Assistant said beds, mattresses, and bed rails are assessed for each resident every month. The Maintenance Assistant said on 02/07/25, she assessed R33's bed, mattress, and side rails. She stated there were two pins on each side rail that were secure and there was no safety issues observed. She stated the March 2025 bed/mattress/side rail audit for safety had not yet been completed. The Maintenance Assistant said on 03/13/25 after the incident, she assessed R33's bed, which was a bariatric bed and was to have a 1/4 side rail on each side of the upper bed. She stated the left side rail was on the floor, the two pins that held the siderail to the bed frame were not located, which had caused the side rail to become unattached from the bed. During further interview on 04/23/25 at 7:02 PM, the Maintenance Director said prior to 03/13/25, all residents' beds/mattresses/side rails were checked each month and there were never any issues. He said the Maintenance Director told him the pins that secured R33's bed to the bed frame were not in place at the time of her fall. The Maintenance Director said R33 was very heavy and he believed the force of her pushing or holding onto the left side rail and having no pins in that side rail to stabilize the side rail caused the saddle of the side rail (part of side rail that resident would hold) to bend, and the side rail became unattached to the bed, which caused her fall. He said 03/13/25, he corrected the side rail issue on R33's bed before R33 was transferred back to her bed. He confirmed that having no pins to secure the left side rail to the bed frame was a safety risk for R33. During an interview on 04/24/25 at 10:15 AM, with UM3 and on 04/24/25 at 12:49 PM with UM2, both stated that the UMs are responsible for doing weekly checks on resident's side rails, which includes assessing the correct side rail is on the bed and there are no safety issues. They said they shake and pull on the side rails to ensure they are not loose and are secure and sturdy. UM3 said on 03/12/25, she assessed R33's bed and side rails and the side rails were not loose and appeared safe and secure. UM2 and UM3 said they do not assess whether a side rails' pins are in place. During an interview on 04/23/25 at 10:05 AM, the DON, the Administrator, the Maintenance Director, and the Maintenance Assistant, the DON was asked about R33's fall. The DON said the Maintenance Director told her the bedrail became loose, R33 fell out of bed. The Maintenance Director said he told the DON the pins holding the side rail to the bed were not placed in the side rail, the side rail became loose, and R33 fell . The DON said she was not aware there were issues with missing pins on the side rail of R33's bed and the missing pins were the cause of R33's fall.

Based on record review, interview, and facility policy review, the facility failed to ensure that facility's Binding Arbitration Agreement (BAA) was explained to residents in a manner that they understood for three out of three (Residents (R)68, R117, and R276) out of a total sample of 31 residents. The facility further failed to ensure the BAA informed residents and/or representative they had the right to rescind the agreement within 30 days. This failure placed the 122 residents at risk of signing an agreement they did not understand. Findings include: Review of the facility policy titled Binding Arbitration Agreements dated November 2023 revealed, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements . 1. Residents (or their representatives) have the right to make informed decisions about important aspects of their health, welfare, and safety . 5. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (i.e., litigation). 6. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manner that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning . a. A signature alone is not sufficient acknowledgement of understanding. Review of the facility's Arbitration Agreement revealed, 12.0 BINDING ON PARTIES AND OTHERS 12.1 The Parties intend that this Agreement shall benefit and bind the Facility and its owners, directors, administrators, employees, and agents and shall benefit and bind the Resident (as defined in 2.2) and the Resident's spouse, children, next of kin, heirs, administrator, executor, power of attorney, guardian, legal representative, responsible party, trustee, successors, assigns, and agents, all to the fullest extent allowable by law . 16.0 ACKNOWLEDGMENT OF UNDERSTANDING 16.1 BY SIGNING BELOW, THE RESIDENT CONFIRMS THAT: (1) The Resident has read this Agreement or had it read to him/her; (2) The Agreement has been explained to the Resident in a form and manner the Resident understands, including in a language the Resident understands, and the Resident has had an opportunity to ask questions of a Facility representative and receive answers to any questions about the terms and conditions of this Agreement. 1.Review of R68's Face Sheet located under the Profile tab of the Electronic Medical Record (EMR) revealed R68 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of cognitive communication deficit. Review of the Brief Interview for Mental Status (BIMS) dated 01/16/25 performed by the facility located under the Evaluations tab of the EMR revealed a BIMS score of nine out of 15, which indicated R68 had moderate cognitive impairment. The EMR indicated that R68 signed a BAA with no representative on 01/16/25. 2.Review of R117's Face Sheet located under the Profile tab of the EMR revealed R117 was admitted to the facility on [DATE]. Review of the BIMS dated 12/30/25 performed by the facility located under the Evaluations tab of the EMR revealed no score and indicated R117 had severe cognitive impairment. R117 signed a BAA with no representative on 12/30/24. 3.Review of R276's Face Sheet located under the Profile tab of the EMR revealed R276 was initially admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of cognitive communication deficit. Review of R276's admission Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/06/25 revealed R276 had a BIMS score of 10 out of 15, which indicated R276 had moderate cognitive impairment. R276 signed a BAA with no representative on 12/09/24. During an interview on 04/24/25 at 1:57 PM, the Director of Admissions (DA) stated Arbitration is if for any reason residents or their family want to take legal action against the facility, there is a choice to meet within the cooperation and not have to pay legal fees out of their own pocket. We can come to an agreement. When asked how she determined the residents signing the agreement by themselves had the capacity to understand the complex legal terms in the arbitration agreement, the DA stated she would first see what their BIMS was. If they did not have the capacity, she would reach out to the representative. The DA stated with a BIMS of 12 or lower, she would consider a resident incapable of understanding the facility's arbitration agreement. When asked if she explained to residents that they have a right to a neutral arbitrator, the DA stated either party can choose the arbitrator, and either party can demand arbitration. When asked if she explained to residents that they have the option to rescind the agreement after signing, the DA did not know the number of days the BAA provided for the residents to rescind the agreement. When asked if R68 was cognitively capable of understanding the BAA with a BIMS score of nine at admission, the DA stated R68 seemed to understand everything and signed it all after it was explained. DA further explained that when R68 was initially admitted , she signed the agreement on 01/16/25. The resident subsequently went to the hospital, and when she returned, she was no longer cognitively able to sign, so her responsible party which was her brother signed it. The DA stated, we have them sign the BAA more than once, that is what corporate wants. The DA further stated that R68 had a BIMS of nine at her initial admission and was only moderately impaired and understood everything. When asked how R68 could understand when the DA herself could not understand and explain the contents of the BAA, the DA had no response. During an interview on 04/24/25 at 5:00 PM with the Administrator, the Administrator stated the BAA was only for a duration of five years. When asked if this was reflected in the BAA that residents signed, the Administrator stated the time limitation was in the facility's Arbitration policy. When asked what his expectations were regarding the BAA process, the Administrator stated he would look into the arbitration agreement. During an interview 04/24/25 at 5:05 PM, R276 stated he did not recall signing a BAA, or anyone explaining what a BAA was, and did not know what this was. R276 stated he signed many documents at admission and did not remember what he signed. R68 was not available for interview. During an interview with R117 on 04/24/25 at 5:11 PM, the resident was neither able to verbalize nor demonstrate understanding of signing a BAA. The resident responded with unintelligible words.

Based on observation, record review, interview, and facility policy review, the facility failed to implement the Care Plan by not using the proper number of staff during a mechanical lift/transfer for 1 (Resident (R)19) of 40 residents reviewed for Care Plans. This had the potential to cause an injury to the resident. Findings include: Review of the facility policy titled, Lift Machine-Using a Mechanical, with a revised date of 2017, read in pertinent part, the mechanical lift must be utilized with two staff members. Review of R19's electronic medical record (EMR) under the Diagnosis tab revealed the resident was admitted to the facility on [DATE]. Review of R19's Nursing Comprehensive Assessment located in the EMR under the Assessment tab, dated 07/10/23, revealed the resident required total assistance of two persons for all aspects of Activities of Daily Living (ADLs). Review of R19's admission Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 07/10/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. The MDS also indicated R19 required two-person assistance with a lift device for all transfers. Review of R19's Care Plan located under the Care Plan tab in the EMR dated 07/10/23, revealed the resident had risk related to impaired mobility and required total assistance with two persons were needed for all aspects of Activities of Daily Living. During an observation and interview on 08/04/23 at 10:15 AM, revealed Certified Nursing Assistant (CNA)1 entered R19's room with a mechanical lift and closed the door. No other staff member was observed to go into the room. CNA1 confirmed she transferred R19 from her bed to the shower chair with the mechanical lift by herself. During an interview on 08/04/23 at 11:18 AM, the Director of Nursing (DON) confirmed that R19 required two-person assistance with all transfers. During an interview on 08/04/23 at 11:25 AM, CNA1 confirmed that R19's Care Plan instructed two staff to transfer the resident and she transferred the resident by herself.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure a potential hazard was secured and not accessible to vulnerable residents. Specifically, scissors were observed on 1 of 2 units and on top of 2 of 2 unattended medication carts. Findings include: Review of the facility policy titled, Hazardous Areas, Devices and Equipment states in the policy statement, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards, states, A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: a. Equipment and devices that are left unattended or are malfunctioning. c. Sharp objects that are accessible to vulnerable residents. An observation on 09/14/23 at 10:05 AM, revealed 2 of 2 medication carts outside a resident room in the hallway. A pair of silver colored, straight, sharp pointed scissors was noted on the top of an unattended medication cart. A resident was noted shuffling down the hall, holding onto the hand rail on the right hand side of the hall, coming towards the medication carts. The resident was also noted mumbling as she came closer to the medication carts with the scissors. A Certified Nursing Assistant walked out of a room and walked over toward the resident and walked with her back to her room. An interview on 09/14/23 at an unspecified time, Licensed Practical Nurse (LPN)3 confirmed the scissors and removed it from the top of the cart. LPN3 looked over at the second cart and removed a pair of scissors from the top of it which were also accessible to residents. LPN3 stated she did not know where they came from or why they were unsecured on the medication carts.

Based on observations, interviews, and review of the facility policy, the facility failed to ensure a potential hazard was secured and not accessible to vulnerable residents. Specifically, scissors were observed on 1 of 2 units and on top of 2 of 2 unattended medication carts. Findings include: Review of the facility policy titled, Hazardous Areas, Devices and Equipment states in the policy statement, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Identification of Hazards, states, A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: a. Equipment and devices that are left unattended or are malfunctioning. c. Sharp objects that are accessible to vulnerable residents. An observation on 09/14/23 at 10:05 AM, revealed 2 of 2 medication carts outside a resident room in the hallway. A pair of silver colored, straight, sharp pointed scissors was noted on the top of an unattended medication cart. A resident was noted shuffling down the hall, holding onto the hand rail on the right hand side of the hall, coming towards the medication carts. The resident was also noted mumbling as she came closer to the medication carts with the scissors. A Certified Nursing Assistant walked out of a room and walked over toward the resident and walked with her back to her room. An interview on 09/14/23 at an unspecified time, Licensed Practical Nurse (LPN)3 confirmed the scissors and removed it from the top of the cart. LPN3 looked over at the second cart and removed a pair of scissors from the top of it which were also accessible to residents. LPN3 stated she did not know where they came from or why they were unsecured on the medication carts.

Based on review of facility policy, record review, and interview, the facility failed to ensure the medical necessity of psychotropic medication administration for 1 out of 5 residents reviewed for Psychotropic Medication Administration. The facility failed to ensure informed consent for the administration of psychotropic medications and failed to track accurate behaviors for Resident (R)102, who was receiving multiple psychiatric medications. A total of 40 residents were reviewed in the sample. Findings include: Review of the facility's Behavioral Assessment, Intervention and Monitoring Policy dated 03/2019 read, in pertinent part, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care; and If the resident is being treated for altered behavior or mood, the IDT (Inter-disciplinary team) will seek and document any improvements or worsening of the individual's behavior, mood, and function. Review of R102's Admission Record, dated 08/04/23 and found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including psychotic disorder, homicidal ideations, hallucinations, unspecified, anxiety, and depression. Review of R102's significant change Minimum Data Set (MDS) located in the EMR with an Assessment Reference Date (ARD) of 06/20/23 indicated a Brief Interview for Mental Status (BIMS) score of 6 out of 15 indicating the resident was severely cognitively impaired. The assessment indicated the resident was receiving anti-psychotic, anti-anxiety, and anti-depressant medication on seven of seven days during the assessment period. The assessment indicated the resident was not exhibiting any behavioral symptoms during the assessment period. Review of R102's Psychotropic Medication Care Plan; dated 07/10/23 and found in the EMR under the Care Plan Tab, indicated the resident was receiving psychotropic medications related to her diagnoses of depression, homicidal ideation, and anxiety. Interventions included give medication as ordered, observe for side effects of medication, when gradual dose reduction or increase in psychotropic medication is attempted observe for changes and document/notify provider, and monitor for behaviors such as combativeness, wandering, suicidal/homicidal ideation, exit seeking, delusional thought processes, PTSD (Post-Traumatic Stress Disorder), and ruminations related to childhood abuse (per family). Review of R102's Medication Review Report; dated 08/04/23 and found in the EMR under the Orders Tab, indicated orders for Lexapro (an antidepressant medication)10 milligrams (MG) by mouth at bedtime for depression, Depakote Sprinkles Delayed Release Sprinkle (a mood stabilizing medication) 125 MG in the afternoon and 375 MG twice daily by mouth for manic behaviors, Zyprexa (an anti-psychotic medication) 2.5 MG by mouth at bedtime for Acute mania related to dementia with behaviors and psychosis, and lorazepam (an anti-anxiety medication) 0.5 MG by mouth one time a day and 0.5 MG as needed every 12 hours for anxiety and acute mania. Review of R102's Medication Administration Record (MAR) dated 07/01/23 through 08/04/23 indicated behaviors being tracked for the resident were agitation, being angry, being noisy, crying, combativeness, restlessness, and being withdrawn. The behavior tracking did not include the specific behaviors R102 was known to demonstrate related to her plan of care, including suicidal/homicidal ideation, exit seeking, delusional thought process, or ruminations related to her childhood abuse. Review of R102's Psychoactive Informed Consent document for the use of the resident's Depakote, dated 02/08/23 and reviewed 03/15/23, 04/06/23, and 05/02/23 and found in the resident's paper chart, was signed by a facility representative but never signed by the resident's Responsible Party (RP). There was no indication on the document that the consent was reviewed with the resident's RP, and he provided verbal consent for the medication. Comprehensive review of R102's EMR and paper record revealed nothing to indicate informed consent had been obtained for the administration of the resident's Ativan or Lexapro. During an interview with the Social Services Director (SSD) on 08/04/23 at 9:34 AM, she indicated consent was expected to be obtained for the use of all psychotropic medications. She further indicated behaviors specific to the resident were to be tracked, rather than generic behaviors, to ensure the appropriate administration of psychiatric medications. During an interview with the Administrator on 08/04/23 at 1:13 PM, she confirmed the behavior tracking for R102 was generic and not related to her specific behaviors were to be monitored for psychotropic medications and informed consent was to be obtained for each psychotropic medication a resident was receiving. She stated, We'll just have to fix it (the system).

Based on record review, observations, staff interviews, review of an on-line drug resource guide (Medline), and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Five errors were observed with a total of 35 opportunities for error, resulting in an 14.2% error rate. The errors involved one Resident (R)47 of eight residents observed for medication administration. Findings include: The facility's Administering Medications Policy revised 04/2019 read, in pertinent part, Medications are to be administered in a safe and timely manner, and as prescribed. Review of information related to the administration of Ferrous Sulfate (iron), Sodium Chloride, and Metoprolol Tartrate on Medline (an on-line drug resource guide), revealed, Swallow medication tablets whole. Do not crush. Review of R47's Order Summary Report, dated 08/04/23 and found in the EMR under the Orders tab, indicated orders for Ferrous Sulfate (Iron) give 325 milligrams (MGs) by mouth once daily for anemia (low iron), Metoprolol Tartrate 12.5 MG by mouth twice daily for high blood pressure, NACL (Sodim Chloride) 1 gram (GM) by mouth daily for supplemental sodium, Azathioprine 50 MG by mouth twice daily for abnormal immunological findings in blood, and Salonpas Patch 3.1-6-10% apply to lower mid back in morning and remove in evening for back pain. Observation of Licensed Practical Nurse (LPN)3 revealed the LPN was administering R47's medication on 08/04/23 at 7:32 AM. LPN3 was observed to crush the resident's sodium chloride, Metoprolol Tartrate, and Iron together with the rest of the resident's administered oral medications prior to administering them. The resident's Azathioprine was unable to be located in the medication cart or in the facility's medication storage room and so was not administered to R47. In addition, R47's Salonpas Patch was observed to be applied to the resident's lower mid back without being labeled with the date and LPN3's initials prior to administration. During an interview with LPN3 on 08/04/23 at 8:27 AM, she indicated she thought there was a Do Not Crush List somewhere in the facility but did not think she had one on her medication cart. She stated she was not aware the iron, sodium chloride, and metoprolol tartrate could not be crushed. She stated she knew liquid versions of the medication could be obtained but stated she had been crushing all of R47's medications. LPN3 indicated she was usually the staff member to remove R47's Salonpas patch at the end of the day and so that is why it was not labeled. She stated she would order the resident's Azathioprine from the pharmacy. During an interview with the Regional Nurse Consultant (RNC) on 08/04/23 at 2:17 PM, she indicated the facility had just obtained a new pharmacy earlier that week and R47's Azathioprine was likely in a plastic bag in the facility's medication room due to the change-over. She stated her expectation was medications was to be ordered ahead of time to allow enough time for medication to be delivered before running out. She stated R47's Salonpas patch should have been labeled with the nurse's initials and dated. The DON further confirmed the sodium chloride, iron and metoprolol tartrate were not to be crushed.

Based on interviews and record review, the facility failed to protect 1 of 5 residents (R2) from neglect. R2 had an successful elopement from the facility on 03/26/22 at approximately 3:10 PM. Certified Nursing Aide (CNA) 1 and Registered Nurse (RN) 1 failed to provide adequate care or supervision during their shift, so the resident was not noted as missing until approximately 9:15 PM that same day - 6 hours later. The facility called a Code Pink (missing resident alert) and the police found the resident on 03/27/22 at 2:30 AM approximately 1.5 miles from the facility. The neglect had the potential to result in serious bodily harm or death. R2 was admitted to the facility on [DATE] for respite care with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was located on the Transitional Care Unit. On 03/26/22, for the period of R2's absence, the weather was clear and without precipitation. R2 was observed wearing a sweater jacket and long pants. The temperature ranged from approximately 45 degrees Fahrenheit (F) to 64 degrees F. The sun set at approximately 7:46 PM. Review of elopement incident report on 03/29/22 at 10:45 AM revealed the facility staff reviewed camera footage showing R2 exiting the front door at approximately 3:10 PM on 03/26/22. The secure care device did not sound an alarm. The resident was located at approximately 2:00 AM by a search team. Review of facility investigation and summary of incident on 03/29/22 at 11:00 AM revealed the following timeline of events: On 03/26/22 at 2:15 PM, CNA 2 assisted R2 to the toilet. At 3:00 PM, CNA 1 observed the resident in her room while on rounds. At 4:30 PM, staff passed out evening meal trays and left one for R2 in her room. At 5:00 PM, RN 1 passed out medications to residents on her assignment, but R2 was not available. At 5:30 PM, staff collected meal trays. At an unspecified time, CNA 1 and RN1 recognized that R2 had not been present for meals or medication administration. At 9:15 PM, staff alerted the Assistant Director of Nursing (ADON) of the missing resident. At 9:30 PM, a Code Pink (missing resident alert) was called by the facility. At 2:30 AM on 03/27/22, the search party discovered the resident. The secure care alarm had been removed. Review of facility witness statements on 03/29/22 at 11:30 AM revealed CNA1 arrived at the facility on 03/26/22 at 3:00 PM. Contrary to facility timeline, she did not see the resident. RN 1 also arrived the facility at 3:00 PM the same day and only saw R2 one time during her shift. An interview with Director of Nursing (DON) on 03/29/22 at 11:50 AM revealed the facility was still unable to locate R2's secure alarm and could not identify how it had been removed. Interview also confirmed that facility cameras showed the resident leaving at 3:10 PM but the Code Pink was not called until 9:30 PM - a delay of approximately 6 hours. During that interim, the DON confirmed facility staff failed to check in on R2 as is standard practice, missing multiple opportunities to realize that R2 was not in the facility. Review of R2's medical record on 03/29/22 at 12:10 PM revealed the resident was assessed and care planned as high risk for wandering. A secure care alarm order was in place and review of Medication Administration Records (MARs) indicated it had been checked for function that previous shift. An interview with RN 1 on 03/29/22 at 12:25 PM revealed she entered the facility at approximately 3:00 PM on 3/26/22. She saw R2 once during her shift wearing a sweater jacket and long pants. During the 5:00 PM medication pass, R2 was not there to take her medications. RN 1 did not try to find R2 to offer her medications at the end of administration. When asked about facility policy / standard practice, RN 1 confirmed that nursing staff are expected to administer medications no later than 1 hour after the scheduled time. An interview with CNA 1 on 03/29/22 at 1:00 PM revealed she entered the facility at approximately 3:00 PM on 3/26/22. Contrary to the facility timeline, interview revealed that CNA 1 did not lay eyes on R2 at any point during her shift, for she assumed R2 to be wandering on another unit. When asked of facility policy / standard practice, CNA 1 confirmed nursing aides are expected to conduct rounds and visually check their assigned residents every 2 hours. Interview further revealed that CNA 1 passed R2's evening tray and collected it afterward. During supper, CNA 1 did not try to find R2 to ensure the resident had eaten her meal. An interview with RN 2 on 03/29/22 at 2:00 PM confirmed the secure care bracelet was in place the morning of 03/26/22. An interview with Administrator on 03/29/22 at 3:30 PM confirmed it was the police - notified during the Code Pink - who found R2 on the sidewalk of [NAME] Street. The facility is located on [NAME] Road which intersects with [NAME] Street. Her location was approximately 1.5 miles away. Review of Abuse and Neglect policy on 03/30/22 at approximately 11:15 PM revealed that Neglect is defined as the failure to provide goods and services necessary to avoid physical harm. Signs of physical neglect included inadequate provision of care, caregiver indifference to resident's personal care and needs, and leaving someone unattended who needs supervision. The actions taken by the facility to correct deficient practice relating to F600 include the following: 1. ADHOC QA meeting with medical director, Administrator, DON, and other members of the QA committee to discuss event and follow up measures conducted on 3/27/22 2. Physician was notified of elopement incident on 3/27/22 at 2:00am. 3. All resident with secure care bracelets were verified for placement and function by ADON by approximately 2:30am. 4. Initiated assessment on all resident for risk of abuse/neglect on 3/27/22 5. Body audits completed on all residents who determined as un-interviewable on 3/29/22 6. On 3/28/22 a daily audit was created to review all residents MARs, TARs, and Point of Care documentation qshift to ensure that residents were free of neglect. 7. On 3/28/22 a daily audit was created to review all residents meal consumptions for each meal to ensure that residents were free from neglect. 8. On 3/28/22 a weekly audit of 20 random residents will be initiated to review assessments for freedom of abuse/neglect. To be conducted weekly for 4 weeks, bi-weekly for an additional 4 weeks, and monthly until QA committee resolves concern. 9. Facility leadership interviewed all staff working on 3/26/22. 10. DON reviewed all entries on residents MAR for any missing secure care bracelet check off's. No concerns noted. 11. Frequency of secure care checks changed from q-shift to q4 hours. 12. Audit to ensure wander evaluations are completed and current on all residents for risk for wandering/elopement by Nurse Management. 13. Care plans reviewed and revised by Social Service Director on 3/27/22. 14. Any resident identified as an elopement risk will be observed every hour and documented. 15. Education on abuse/neglect initiated on 3/27/22 by Staff Development Coordinator. 16. Education on resident rights initiated on 3/27/22 by Staff Development Coordinator 17. Education on the sounding of alarms on 3/27/22 by Staff Development Coordinator. 18. No employee/agency will be allowed to work until they have received education and signed understanding of education. 19. A daily review by Nurse Management will be completed for any concerns so corrective action can be identified and/or implemented. 20. Elopement books on all units and at front desk updated by Social Service Director on 3/27/22. 21. Education provided by Staff Development Coordinator on elopement books and risk for exiting facility initiated on 3/27/22. 22. A root cause analysis was completed by the Administrator on 3/27/22.

Based on interview and record review, the facility failed to protect 1 of 5 residents (R2) from accidents and hazards. R2 had an successful elopement from the facility on 3/26/22 at approximately 3:10 PM. Certified Nursing Aide (CNA) 1 and Registered Nurse (RN) 1 failed to provide adequate care or supervision during their shift, the resident was not noted as missing until approximately 9:30 PM that same day - 6 hours later. The facility called a Code Pink (missing resident alert) and the police found the resident on 03/27/22 at 2:30 AM approximately 1.5 miles from the facility. The elopement had the potential to result in serious bodily harm or death. R2 was admitted to the facility on [DATE] for respite care with diagnoses including, but not limited to, unspecified dementia with behavioral disturbance and type 2 diabetes mellitus. The resident was located on the Transitional Care Unit. On 03/26/22, for the period of R2's absence, the weather was clear and without precipitation. R2 was observed wearing a sweater jacket and long pants. The temperature ranged from approximately 45 degrees Fahrenheit (F) to 64 degrees F. The sun set at approximately 7:46 PM. Review of elopement incident report on 03/29/22 at 10:45 AM revealed the facility staff reviewed camera footage showing R2 exiting the front door at approximately 3:10 PM on 03/26/22. The secure care device did not sound an alarm. The resident was located at approximately 2:00 AM by a search team. Review of facility investigation and summary of incident on 03/29/22 at 11:00 AM revealed the following timeline of events: On 03/26/22 at 2:15 PM, CNA 2 assisted R2 to the toilet. At 3:00 PM, CNA 1 observed the resident in her room while on rounds. At 4:30 PM, staff passed out evening meal trays and left one for R2 in her room. At 5:00 PM, RN 1 passed out medications to residents on her assignment, but R2 was not available. At 5:30 PM, staff collected meal trays. At an unspecified time, CNA 1 and RN 1 recognized that R2 had not been present for meals or medication administration. At 9:15 PM, staff alerted the Assistant Director of Nursing (ADON) of the missing resident. At 9:30 PM, a Code Pink (missing resident alert) was called by the facility. At 2:30 AM on 03/27/22, the search party discovered the resident. The secure care alarm had been removed. Review of facility witness statements on 03/29/22 at 11:30 AM revealed CNA1 arrived at the facility on 03/26/22 at 3:00 PM. Contrary to facility timeline, she did not see the resident. RN 1 also arrived the facility at 3:00 PM the same day and only saw R2 one time during her shift. An interview with Director of Nursing (DON) on 03/29/22 at 11:50 AM revealed the facility was still unable to locate R2's secure alarm and could not identify how it had been removed. Interview also confirmed that facility cameras showed the resident leaving at 3:10 PM but the Code Pink was not called until 9:30 PM - a delay of approximately 6 hours. During that interim, the DON confirmed facility staff failed to check in on R2 as is standard practice, missing multiple opportunities to realize that R2 was not in the facility. Review of R2's medical record on 03/29/22 at 12:10 PM revealed the resident was assessed and care planned as high risk for wandering. A secure care alarm order was in place and review of Medication Administration Records (MARs) indicated it had been checked for function that previous shift. An interview with RN 1 on 03/29/22 at 12:25 PM revealed she entered the facility at approximately 3:00 PM on 3/26/22. She saw R2 once during her shift wearing a sweater jacket and long pants. During the 5:00 PM medication pass, R2 was not there to take her medications. RN 1 did not try to find R2 to offer her medications at the end of administration. When asked about facility policy / standard practice, RN 1 confirmed that nursing staff are expected to administer medications no later than 1 hour after the scheduled time. An interview with CNA 1 on 03/29/22 at 1:00 PM revealed she entered the facility at approximately 3:00 PM on 3/26/22. Contrary to the facility timeline, interview revealed that CNA 1 did not lay eyes on R2 at any point during her shift, for she assumed R2 to be wandering on another unit. When asked of facility policy / standard practice, CNA 1 confirmed nursing aides are expected to conduct rounds and visually check their assigned residents every 2 hours. Interview further revealed that CNA 1 passed R2's evening tray and collected it afterward. During supper, CNA 1 did not try to find R2 to ensure the resident had eaten her meal. An interview with RN 2 on 03/29/22 at 2:00 PM confirmed the secure care bracelet was in place the morning of 03/26/22. An interview with Administrator on 03/29/22 at 3:30 PM confirmed it was the police - notified during the Code Pink - who found R2 on the sidewalk of [NAME] Street. The facility is located on [NAME] Road which intersects with [NAME] Street. Her location was approximately 1.5 miles away. Review of Emergency Procedure policy on 03/29/22 at approximately 6:00 PM revealed that residents at risk for wandering and / or elopement will be monitored, and staff will take necessary precautions to ensure their safety. The actions taken by the facility relating to correct deficient practice relating to F689 include the following: 1. Facility updated wander risk/elopement policy on 3/27/22. 2. ADHOC QA meeting with medical director, Administrator, DON, and other members of the QA committee to discuss event and follow up measures conducted on 3/27/22. 3. Facility leadership interviewed all staff working on 3/26/22. 4. DON reviewed all entries on residents MAR for any missing secure care bracelet check off's. No concerns noted. 5. DON audited last 30 days of all residents with secure care bracelets to ensure daily verification of proper placement and functionality was performed by scheduled nurse. 6. Frequency of secure care checks changed from q-shift to q4 hours. 7. Audit to ensure wander evaluations are completed and current on all residents for risk for wandering/elopement by Nurse Management. 8. Care plans reviewed and revised by Social Service Director on 3/27/22. 9. Any resident identified as an elopement risk will be observed every hour and documented. 10. Education on elopement initiated on 3/27/22 by Staff Development Coordinator. 11. Education on abuse/neglect initiated on 3/27/22 by Staff Development Coordinator. 12. Education on resident rights initiated on 3/27/22 by Staff Development Coordinator 13. Education on the sounding of alarms on 3/27/22 by Staff Development Coordinator. 14. Education on the proper placement of secure care bracelet on 3/27/22 by Staff Development Coordinator. 15. No employee/agency will be allowed to work until they have received education and signed understanding of education. 16. A daily review by Nurse Management will be completed for any concerns so corrective action can be identified and/or implemented 17. Elopement books on all units and at front desk updated by Social Service Director on 3/27/22. 18. Education provided by Staff Development Coordinator on elopement books and risk for exiting facility initiated on 3/27/22 19. Elopement drill conducted at facility on 3/28/22 by Staff Development Coordinator. 20. Front doors will be programmed to secure front lobby doors 24 hours a day effective 3/27/22. 21. Facility will monitor exit doors for proper function daily by Maintenance, including weekends by MOD/Nurse Management, to ensure exit doors are secured and residents identified as wanderers are secure 22. Secure Care was contacted on 3/27/22 to evaluate proper operations of the secure care system at the facility. 23. Secure Care on-site evaluation of doors monitors on 3/28/22 for proper functioning 24. A root cause analysis was completed by the Administrator on 3/27/22.

Based on observation, interviews, record review, and review of the facility's abuse and inventory control of controlled substances policies, the facility failed to prevent misappropriation of controlled medications for two (Residents #1 and #2) of three sampled residents who were reviewed for misappropriation of property. This deficient practice had the potential to cause unrelieved pain for Resident #1 and untreated attention deficit [CONDITION(S)] disorder (ADHD) for Resident #2. This had the potential to affect 50 residents identified on the facility's form titled, CMS (Centers of Medicare and Medicaid Services) 672 Resident Census and Conditions Of Residents, dated 05/21/2020, as being on a pain management program. The Assistant Director of Nursing identified one resident as receiving medication for ADHD. The facility Administrator was informed on 05/21/2020 at approximately 4:42 PM that Immediate Jeopardy existed on 04/26/2020. The facility provided an Immediate Jeopardy Removal Plan that was accepted on 05/22/2020 at approximately 3:00 PM and the Immediate Jeopardy at F602 was removed with an effective completion date of 05/22/2020 and lowered to the scope and severity of D. The findings included: 1. The facility's policy titled, Abuse Prevention Program, dated 12/2016, revealed . Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . the administration will . Protect our residents from abuse by anyone . Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Implement measures to address factors that may lead to abusive situation . Identify and assess all possible incidents of abuse . Investigate and report any allegations of abuse within timeframes as required . Protect residents during abuse investigations . Establish and implement a QAPI [quality assurance and performance improvement] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse . The facility's policy titled, Inventory Control of Controlled Substances, revised 01/01/2013, indicated, . Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on the 'Controlled Substance Count Verification/Shift Count Sheet' . Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and remove medications that are completed or discontinued from the inventory . 2. Review of Resident #1's undated Face Sheet, located under the Profile tab of the electronic medication record (EMR), indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Minimum Data Set (MDS), with an Assessment Reference Date (ARD of 01/14/20, specified the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact for daily decision making, was on a scheduled pain medication regimen, did not receive as needed pain medications, had pain occasionally, which did not affect his/her sleeping or eating. It was documented the resident rated a 4 out of 10, with 10 indicating the worst pain possible. Review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Care Plan, dated 01/20/2020 and located under the Care Plan tab of the EMR, indicated the resident had a problem related to back pain, due to compression fractures to the lumbar region and immobility. The goal included the resident would not have any symptoms of unrelieved pain through the next review date. Interventions included to give routine pain medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an untitled pharmacy delivery receipt, dated 04/01/2020 and provided by the Assistant Director of Nursing (ADON), indicated 120 [MEDICATION(S)] 7.5/325 mg tablets were delivered to the facility for Resident #1. Review of a facility document titled, Shift Change Controlled Substance Inventory Log, dated 04/2020 and for the 500 Hall, indicated on 04/02/2020, four cards of [MEDICATION(S)] 7.5/325 mg, each with 30 tablets for a total of 120 tablets, and four Controlled Medication Utilization Record forms were added to the 500 Hall medication cart for Resident #1 by Licensed Practical Nurse (LPN) #8. Review of a facility document titled, Controlled Medication Utilization Record; with a received date of 04/01/20 and labeled 1 of 4, indicated from 04/02/20 at 9:38 AM through 04/10/2020 at 1:40 PM, the resident received 30 tablets of [MEDICATION(S)] 7.5/325 mg. Review of a facility document titled, Controlled Medication Utilization Record, with received date of 04/01/2020 and labeled 2 of 4, indicated from 04/10/2020 at 8:00 PM through 04/15/2020 at 8:00 PM, the resident received 20 tablets of [MEDICATION(S)] 7.5/325 mg. Review of a facility document titled, Shift Change Controlled Substance Inventory Log, for the 500 Hall and dated 04/2020, indicated on 04/16/2020, two cards of [MEDICATION(S)] 7.5/325 mg and two Controlled Medication Utilization Record forms for Resident #1 were removed from 500 Hall medication cart by LPN #2. Review of a facility document, titled, Shift Change Controlled Substance Inventory Log, for the 400 Hall and dated 04/2020, indicated on 04/16/2020, two cards of [MEDICATION(S)] 7.5/325 mg and two Controlled Medication Utilization Record forms for Resident #1 were added to the 400 Hall medication cart by Registered Nurse (RN) #1. Review of a facility document titled, Controlled Medication Utilization Record, with a received date of 04/01/2020 and labeled 2 of 4, indicated from 04/16/2020 at 2:00 AM through 04/18/20 at 10:28 AM, the resident received 10 tablets of [MEDICATION(S)] 7.5/325 mg. Review of a facility document titled, Controlled Medication Utilization Record, with a received date of 04/01/2020 and labeled 4 of 4, indicated from 04/18/20 at 3:43 PM through 04/25/2020 at 9:00 PM, the resident received 30 doses of [MEDICATION(S)] 7.5/325 mg. This was a total of 90 [MEDICATION(S)] 7.5/325 mg tablets the resident received since 04/02/2020 (date added to medication cart). There was no Controlled Medication Utilization Record: labeled 3 of 4 noted. Per review of the facility's forms titled, Controlled Medication Utilization Records, and labeled 1 of 4, 2 of 4, and 4 of 4, there should have been 30 [MEDICATION(S)] tablets left from the 04/01/2020 pharmacy delivery. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A 5 was documented in the box where a check mark would be if the medication had been administered. Review of the Medication Administration Note, dated 04/26/2020 at 3:01 AM and located under the Progress Notes tab of the EMR, indicated, . Med [medication] on hold v/o [verbal order] [Name withheld] NP [nurse practitioner] pharm [pharmacy] states too soon to fill medication . Review of a facility form titled, Witness Statement, dated 05/05/2020 and signed by LPN #3, indicated, . When I [LPN #3] worked on 500 [Hall] on 4/11/2020 cart count was correct . Review of a facility form titled, Witness Statement, dated 05/06/2020 and signed by LPN #4, indicated, . On 04/11/2020, when [LPN #3]and I [LPN #4] counted the cart, the count was correct . A DHEC [(South Carolina) Department of Health and Environmental Control] Accident/Incident Reporting Form Bureau Of Health Facilities Licensing, dated 05/13/2020 with a facsimile time of 4:40 PM, indicated, . Type of Report : 5 Day Report . possible misappropriation of property . Narcotic count was noted incorrect and medication for resident missing as well as narcotic count sheet. Investigation immediately initiated . Resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When pharmacy was notified they could not refill the prescription based on amount sent previously that resident should have 1 [one] card remaining. Investigation and review of the inventory and count sheets did show that a card of 30 tablets as well as the count sheet for that card were not accounted for. Resident had a room change and all meds were moved to a different med cart due to +COVID-19 test and it is believed the card was misplaced or accidentally thrown away during the change of carts. All med [medication] rooms and med carts as well as discontinued narcotic supply and return drug bins were searched but the card was not located. QA [quality assurance] was initiated for controlled substance handling and education initiated for all nurses regarding controlled substances. Upon conclusion of the investigation including staff interviews, review of all count sheets, delivery slips etc [etcetera] the medication is missing. Pharmacy was notified. Call to [name withheld] as well with SC [South Carolina] Bureau of Drug Control and investigation is ongoing at this time . Interventions in place prior to Reportable Incident: Procedure for controlled substances and maintaining records. Drug screen and background check complete with all newly hired nurses . Immediate corrective action/assessment . Investigation was initiated immediately. All med carts were looked thru [sic] thoroughly as well as med rooms, d/c'd [discontinued] narcotic supply, return medication bin etc. Due to COVID-19 and numerous room changes and moving of meds to different cards [carts] the meds with room changes are not checked and moved by administrative nurses. QA initiated and education for all nurses regarding controlled substances . Interventions by facility to prevent future injury/Alleged Abuse: QA for controlled substances. Education initiated for all licensed nurses to review controlled substance procedures. Continued background checks as well as drug screens for all newly hired nurses. Notification to SC Bureau of Drug Control . Review of an undated, untitled, and handwritten sheet containing the names of 15 nurses (RN #2 and 3 and LPN #2, 3, 4, 8, 10, 11, 12, 13, and 11 - 17), located in the investigative file for Resident #1, indicated seven names. Next to seven of the names (RN #2 and 3 and LPN #3, 4 12, 13, and 14) the word Ok was written. On 05/21/2020 at 9:00 AM, the Administrator provided an Employee List Report, dated 05/21/2020. The Employee List Report indicated there were 34 licensed nursing staff actively employed by the facility, including LPNs and RNs. On 05/21/2020 at 12:49 PM, the Assistant Director of Nursing (ADON) stated he/she and the Director of Nursing (DON) were responsible for conducting the investigation of Resident #1's missing medication. The ADON stated on 04/02/2020, the facility received four medication cards, each containing thirty (30) 7.5/325 mg [MEDICATION(S)] tablets, for Resident #1. He/she stated this totaled 120 tablets. He/she stated the resident was administered 50 tablets of [MEDICATION(S)] from 04/02/2020 through 04/15/2020. The ADON further stated on 04/16/2020, the resident's medications were moved from the 500 Hall medication cart to the 400 Hall medication cart. According to the ADON, from 04/16/2020 through 04/25/2020, the resident was administered 40 more tablets, for a total of 90 tablets administered. He/she said there should have been 30 tablets of [MEDICATION(S)] left. The ADON revealed that on 04/26/2020 at 3:01 AM, it was noted the resident did not have any [MEDICATION(S)] left. He/she stated LPN #1 called the pharmacy to get a refill but was told the pharmacy could not send any more medication because the resident should have another card (30 tablets) of medication. The ADON stated when the resident's medications were moved, only two cards of [MEDICATION(S)] and two Controlled Medication Utilization Record Forms were moved. He/she stated that out of the delivery made on 04/02/2020, one full card of [MEDICATION(S)] and one Controlled Medication Utilization Record Forms had been used. The ADON said there should have been three cards of [MEDICATION(S)] and three Controlled Medication Utilization Record Forms moved. He/she stated he/she did not know where the other card of medication or Controlled Medication Utilization Record Form, labeled 3 of 4, was. The ADON revealed the nurses were supposed to count the number of controlled medication utilization record forms and the number of individual narcotic medication cards at the beginning and end of each shift. He/she said the nurses were to document those numbers on the shift change count sheets. According to the ADON, when cards were added to or removed from the cart, it was supposed to be logged on the Shift Change Controlled Substance Inventory Log. He/she stated those numbers were supposed to be compared with the previous shifts' numbers as an accountability method. He/she stated it didn't flag as a problem because the numbers were off on the shift change count sheets. The ADON said, They just didn't track from day to day. The ADON revealed the undated, untitled, and handwritten list of names in the investigative file, for Resident #1, were the names of the nurses (RN #2 and 3 and LPN #2 - 4, and LPN #8 - 17) who had access to the resident's medications. He/she stated he/she had interviewed the nurses who had ok written by their names (RN #2 and 3 and LPN #3, 4 12, 13, and 14). He/she said each of the nurses who were interviewed denied knowledge of any discrepancies with the resident's medications. He/she also stated, he/she had not written down what he/she had asked the nurses or what their responses had been. The ADON said he/she asked those nurses, who had been interviewed, to write witness statements, but he/she had gotten distracted and had not followed through to ensure they did. The ADON stated if there was not an ok by the nurses' name, it meant he/she had not interviewed them. He/she stated LPN #2 and RN #1 (whose name was not on the list) were the nurses who had moved the resident's medications, but he/she had not conducted interviews with either of them. The ADON further stated he/she and the DON had been notified of the missing [MEDICATION(S)] medication card on 04/29/2020. He/she stated they began searching in all the medication carts, the medication storage rooms, the discontinued medication storage, the trash can, and everywhere they could think of to search. He/she stated the medication card was not found. The ADON revealed an audit had been completed of all narcotics to ensure the residents had their medications. Continuing with the interview, the ADON stated as part of the investigation, he/she audited the shift change count sheets on all the medication carts in the facility. He/she stated he/she found multiple misses (meaning instances where the number of medication cards and number of Controlled Medication Utilization Records documented on the Shift Change Controlled Substance Inventory Log did not match the actual inventory of medication cards and/or Controlled Medication Utilization Records.) that occurred when residents were moved back and forth throughout the facility as the facility responded to their COVID-19 outbreak. He/she stated he/she identified staff was having difficulty in filling out the shift change count sheets, so the form was revised. According to the ADON, staff was being re-educated on the form, and the instructions were very specific. He/she stated a group in-service was not completed to deliver the education, but the staff educator was giving individual training on the revised form. The ADON stated he/she did not know if all the nurses had been educated yet. On 05/21/2020 at 1:51 PM, the Staff Educator stated he/she had provided education on the revised shift change controlled substance inventory log through individual training sessions and he/she had placed the copies of the education into a book at each nurses' station. He/she stated he/she educated the staff as they reported for their shifts, on whatever day that might be. The Staff Educator said all nursing staff had not been educated at this time. At 1:55 PM, the Staff Educator provided a facility document titled, Inservice Training, and dated 05/18/2020. The document indicated a training titled, Narcotic Count Sheet, occurred on 05/18/2020. The signatures of 18 nursing staff (LPNs #2, 3, 4, 7, 13, and 18 - 30) were noted on the form. On 05/21/2020 at 1:57 PM, Resident #1 was observed lying in his/her bed. He/she confirmed that he/she did not get his/her pain medications for a few days at the end of 04/2020. He/she stated he/she asked staff why he/she was not receiving his/her pain medications, but they would not tell him/her anything. On 05/22/2020 at 3:07 PM, the Administrator stated the facility's policy on misappropriation of property was to protect residents from misappropriation of property. 3. Review of Resident #2's undated Admission Record, located under the Profile tab of the EMR indicated the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A hand-written statement; dated 05/03/20, located in an investigative file for Resident #2, and written by LPN #5; indicated, . Upon arrival to start of my shift at 7pm [7:00 PM] nurse [LPN #6] was sitting at desk. [He/She] then gave me report. We then starting [sic] the narcotic count, [he/she] told me there were 15 cards because [he/she] took one card out. I then counted the narcotic cards then counted the narcotic sheets, which matched the amt [amount] [he/she] said it was. I admit I should have realized the numbers on sign on narc [narcotic] sheet was [sic] not right, but I forgot to sign on. Then that following morning around 6 am [6:00 AM] I was cleaning nurses station disinfecting area. Nurse [LPN #6] had a pile of papers on desk that [he/she] said [he/she] had to sort through when [he/she] came back next day for shift. I was moving his/her papers when I realized there was a narc card in his/her pile of papers. I didn't know what to think of it. I put card in narc book and was waiting on nurse to arrive to ask about missing card, at this point I know I should have reported it asap [as soon as possible] but I was not thinking. I didn't know if the med was d/c [discontinued] or what. Then around 720 am [7:20 AM] nurse [LPN #6] still hadn't showed up for shift. I then called unit manager [LPN #3] [he/she] told me to count with unit nurse [LPN #7]. I looked at narc sign on sheet and stated we should [have] 16 cards. [LPN #7] counted then said there were 15 cards, then I recounted cards and there were 15 cards. Then I counted narc sheets which were 16, then started matching sheets with the cards that's when I realized a resident was missing a card for addrol [sic, [MEDICATION(S)]] . A hand-written statement; dated 05/05/2020, signed by LPN #6, and located in an investigative file for Resident #2; indicated, . On Saturday upon my arrival at 6:45 AM . We did a brief oncoming report; there after we did our normal routine narcotic count in exchange for the keys to the medication cart where the narcotic box is securely locked. We both signed off on the narcotic count sheets and number of narcotic cards in the box . Medication cards were not documented during this shift change . After that routine narcotic count was initiated and completed, everything available in the narcotic box and printed sheets for each narcotic matched. Cards in the narcotic box were not counted. Therefore I only put my signature on the going off log . A DHEC Initial 2/24-Hour Report, dated 05/07/2020, indicated, . Possible misappropriation of resident property . [AGE] year [male] female admitted to the facility on [DATE] for LTC [long term care] to meet his/her healthcare needs . [He/she] has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse [LPN #5] brought it to the attention of administration that his/her card of 30 mg tablets were [sic] missing but the narcotic count sheet was present at the nurses station. Investigation was initiated immediately . On 05/22/2020 at 1:27 PM, the DON stated on 05/02/2020, when LPNs #5 and #6 completed their narcotic count for the beginning of the 7:00 PM shift, neither nurse followed the facility's policy for controlled substance inventory control. [He/she] stated LPN #6 reported they did not complete a count of medication cards and individual count sheets, and LPN #5 reported they did count but not per policy and procedure. This deficiency was cited based on complaint #SC 024. The Immediate Jeopardy Removal Plan included the following: Summary of Incident: . On April 26th, 2020 resident #l was scheduled to receive routine [MEDICATION(S)] (7 XXX milligrams (mg) every six hours (q6) per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . From 4/2/2020 thru 4/26/2020 resident #1 received the dosages for 3 cards, and at that time the 4th card was not found in the medication cart. The facility attempted to refill the medication, but the pharmacy stated it was too soon to refill. At 2:00 am on 4/26/2020 the nurse attempted to give the medication, but the card was not located. At 3:01am on 4/26/2020 an electronic medication progress note (e-Mar) note was created that medication on hold, verbal order (v/o) [Name withheld], Nurse Practitioner (NP). Pharmacy states too soon to fill medication. The resident did not receive his/her routine [MEDICATION(S)] from 4/26 until 6:00 pm on 4/29/2020. On 4/29/2020 the DON and ADON were notified of the missing medication and began attempting to locate the missing medication by looking through all medications in the cart. On 4/29/2020, Medical Director discontinued (d/c'd) [MEDICATION(S)] and ordered oxycodone 7.5 mg q6. During the investigation the [Director of Nursing] DON, ADON, and RDCS (Regional Director of Clinical Services) began looking for the medication in the cart, as well as looked for the medication in the previous cart that held the resident's medications. They also searched through all medication carts in the facility, as well as the return medications, d/c'd medications locked in DON office, the return medication bins, and searched through all the medication room. They looked through all the completed narcotic sheets. The ADON audited the narcotic log located on the cart that held the resident's meds and started counting all medications. ADON also pulled all the delivery slips over the past two months to perform a complete audit. ADON counted all the carts and the medication logs in the building. After counting all the logs and all the carts three times and could not locate the card the facility contacted [name withheld] Registered Pharmacy Consultant on 5/5/2020 and received guidance after hours. On 5/6/2020 the facility contacted [name withheld] of the Bureau of Drug Control and informed him [her] of the situation and guidance. [He/she] informed the facility that they would need to inform DHEC of the incident and the facility submitted a self-report incident to DHEC of misappropriation of a missing medication and began the investigation process. During the misappropriation investigation process, the facility spoke with l4 different nurses to investigate the process. At the time the missing card was made known, Greenville Post-Acute was dealing with a COVID outbreak and had 46 confirmed positive resident cases of COVID- 19. During the time the 4 cards were delivered on 4/2/2020 to the time the missing card was identified, resident #l was moved from his original room to another room in a different hall, in order to accommodate the COVID quarantined unit. The facility moved the resident's medications (among many other resident medications) to another cart to accommodate the nursing staff assigned to pass medications. During the investigation process the facility did l4 interviews of nurses. The facility failed to document the staff interviews, or witness statements of those l4 nurses during the investigation processes . Immediate Changes to Facility Systems: . 1. Physician notification of the missed narcotics on the resident (notification on e[DATE]/26/2020, Med change 4/29/2020). 2. Pain assessment on all residents in the facility will be completed by the unit coordinators by 05/22/2020. 3. Audit all med carts comparing to Medication Administration Records (MARs) to validate that all prescribed meds are available will be completed by unit coordinators on 5/22/2020. 4. Develop new narcotic system that includes the following: a. Delivery receipts are turned into the DON/ADON daily. The following morning DON/ADON or designee verifies new cards were received, located in correct cart, and added to inventory sheet correctly. b. When narc card is emptied, nurse places card in a bin at the nurse's station. Cards are to be collected daily by DON or ADON. DON/ADON verifies on the inventory sheet daily that medication card was removed from cart. c. This will be completed by 05/22/2020 by the ADON 5. Ad hoc QA with Medical Director, Administrator, DON, ADON, Pharmacy, and other Administrative nurses discussing the IJ and creating a QA plan, this meeting was held on 05/22/2020. 6. Corrective measures/discipline with nurses involved. a. Written warnings given to 4 ([name withheld] LPN (License No. ), [name withheld] LPN (License No. ), [name withheld] RN (License No. 5), [name withheld] (License No. 8), [name withheld] LPN (License No. ) floor nurses for documenting medication held w/o notifying physician, this will be completed by a unit coordinator ([name withheld]) by 05/22/2020. b. Verbal warning to ADON ([name withheld] (License NoXXX 7) for not documenting interviews during the investigation process, this will be completed by the Regional Director of Operations ([name withheld]) by 05/22/2020 . . l8. Completed interviews with the remaining 7 nurses not interviewed on 05/06/2020. These interviews were conducted on 05/21/2020 by the ADON. a. Received signed attestations from the 7 Nurses originally interviewed on 05/06/2020 and no discrepancies were noted in the residents' narcotic supply. This was completed on 05/22/2020 by the ADON and the Administrator in Training. b. one Nurse of the original 15 listed has since been terminated. 19. Interview resident #1 regarding his receiving pain medication and general well being conducted by Administrator on 05/21/2020. a. Resident noted no concerns and voiced no concern over missed medications. 20. SSD performed a DISDAT (discomfort and distress assessment) with resident #l 5/21/2020. a. No concerns noted. 21. Facility will notified pharmacy and business office to ensure that Resident #1 (on 05/21/2020 at approximately 6:30 PM) and pharmacy know that the facility will cover the cost of the missing medication for Resident #1 and not charge the resident nor his [her] insurance carrier, email was sent 05/22/2020 at 11:46 AM and confirmation was received from the pharmacy medication billing office at 12:26 PM . Education Plan . 7. In-service on Abuse and misappropriation of goods and services for all staff, this will be completed by the facility educator; 149 out of 185 staff have received in-service as of 05/22/2020. Any staff member unable to be in-serviced for reasons such as vacation or medical leave of absence, will be in-serviced prior to their next shift, and will not be allowed to work until the in-services are completed. 8. Education on notifying physician when medication is unavailable, this will be completed by the facility educator by 05/22/2020. 9. Education on following physicians' orders and following care plans on administering medications, this will be completed by the facility educator; 28 out of 32 have-been educated as of 05/22/2020. Any staff member unable to be in-serviced for reasons such as vacation or medical leave of absence, will be in-serviced prior to their next shift, and will not be allowed to work until the in-services are completed. 10. Education on new narcotic system and turning in delivery slips to DON/ADON, this will be completed by the facility educator by 05/22/2020 . . 16. In-service on incident report investigation tool for Administrator, DON, ADON conducted by Regional Director of Operations, and Regional Director of Clinical Services, this meeting was held on 05/21/2020 . Monitor Removal Plan Outcomes: . 11. 2x week audit of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date: 05/22/2020. 12. Daily audit on missed documentation on MAR, to include anything documented as held/see nurse note, these audits will be completed by unit coordinators indefinitely. Start date: 05/22/2020. 13. Daily audit to ensure held or missed meds have a notification to MD, these audits will be completed by unit coordinators indefinitely. 14. Q shift pain assessment on Resident #1 for 7 days to be completed by the floor nurse. 15. Weekly lost items meeting to be held by Administrator and Social Services Director (SSD), lst meeting held on 5/21/2020, this will continue indefinitely. . l7. Incident report investigation tool to be included during all facility investigations. Start date: 05/22/2020 . Completion Date: . Completion Date 05/22/20 . On 05/22/20 from 2:00 PM to 4:30 PM, the survey team validated the facility's implementation of the above Removal Plan through observations, staff and resident interviews, and facility record reviews.

On the days of the survey, based on record reviews, interviews, and review of the facility policy entitled "Detection and Prevention of Resident Abuse and Neglect," the facility failed to ensure that one of three residents (Resident #142) reviewed for abuse was free from mental/emotional abuse. Residents #142 and #209 (her/his roommate) stated staff had been demeaning to them, resulting in emotional harm. The facility failed to establish an environment wherein residents felt free to voice concerns/grievances without fear of reprisal. The findings included: Review of the 9-26-12 Admission and 10-15-12 thirty day Minimum Data Set (MDS) Assessments on 10-30-12 at 6 PM revealed that Resident #142 was able to understand questions posed and responses were able to be understood. Her/His Brief Interview for Mental Status (BIMS) score was 15, meaning s/he was cognitively intact. There were no documented behaviors. S/he required extensive assistance of one person for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Her/His balance was unsteady. From the Admission to the 30 day MDS, the resident changed from being frequently incontinent to being always continent. Upon admission, Resident #142 was short of breath with exertion. At the 30 day MDS, s/he was noted as short of breath at rest and on oxygen therapy. [DIAGNOSES REDACTED]. During the resident interview on 10/30/2012 at approximately 10:35 AM, Resident #142 was asked if s/he had ever been treated roughly by the staff. In response, s/he stated that staff had told her/him that s/he could not have her/his inhaler (medication) because they could not find it. They always told her/him to "wait a minute," "hold on". The resident became visibly anxious when s/he stated if s/he did not get the inhaler, s/he would have "to go on that machine." When asked if staff had yelled or been rude to her/him, the resident responded "Yes." Resident # 142 also stated that when s/he put the call light on to request assistance to the bathroom, staff would not respond a timely manner. When they did come they would say, "Why didn't you go to the bathroom? You can get off that bed." The resident stated s/he had "cried" because of treatment. Initially, Resident #142 did not specify when this had occurred, but stated that the surveyor could question the roommate, "They do her the same way. I just wish they wouldn't yell at me." When asked if the staff treated her/him with dignity, s/he responded, "No. You have to ask several times" before you get medication (inhaler). "It takes awhile to come get me out of the bathroom and then they don't speak respectfully. They make me cry. I've gotten so I don't say anything any more." On 10-31-12 at 11 AM, it was noted that the surveyor could not hear the audible portion of the call light when just steps down the hall from the nursing station. This was discussed with and confirmed by the 100 Hall Unit Manager. At 8:30 AM 10-31-12, Resident #142 stopped the surveyor and stated that the person who s/he had spoken about the previous day during the interview "was on duty last night". This statement was further clarified to mean the 11-7 shift. The resident described the person who had been rude to her/him, treated her/him disrespectfully as "heavy set", and "black". The surveyor asked if the person was a nurse or Certified Nursing Assistant (CNA). The resident responded, "A CNA." Immediately following the interview, the surveyor obtained assignments for 10-30-12 and 10-31-12 from the 100 Hall Unit Manager. The Unit Manager stated that only one CNA had been on duty on the hall on the 11 PM-7 AM shift the night before. S/he described the CNA as had the resident, additionally stating that the CNA was "light-skinned." The Unit Manager stated that this CNA was the "relief" and only worked 2-3 days per week. During an interview on 10-31-12 at 2 PM, Resident #142 again stated that the person who had yelled at her/him and had not been respectful was "the CNA on last night". S/he stated s/he did not know her/his name. S/he noted that this CNA was the one who did not answer the bathroom call light and when s/he did come, was rude and disrespectful. "S/he acted mad all the time when s/he was working. I'm scared to call when s/he's working. I wonder if s/he'll jump on me or not. S/he always acts mad." The resident denied hearing the CNA curse. S/he stated, "I'm telling truth. (The CNA) works 2-3 times a week. When I had siderails on the bed, I had to put on the (call) light (for assistance). I went in my clothes because I was scared all the time. Yesterday, I couldn't make it to bathroom because I had diarrhea." The resident stated that this was the same CNA who had asked her/him why s/he didn't go to the bathroom and said s/he "could get off that bed". When asked how that made her/him feel, s/he stated, "Scared she's gonna jump on me." When asked if s/he had reported her/his concerns about this staff member, the resident responded, "No." S/he further stated, "When the call light is on, they don't come. Then they say I wait too late to call. I just know they're going to get mad at me." When asked if the resident had been informed upon admission of the right to voice grievances, s/he stated, "Not that I know of. My sister may have. I was sick when I first came in." When asked if s/he knew who to report her/his concerns to, the resident stated, "The nurse's desk." S/he reiterated that s/he did not report even though it had "happened 3 times. I didn't know what to do. I thought people would get mad at me. I don't know why I thought that." The resident also stated that s/he "could not get juice at times when s/he asked for it." This was also attributed to the same CNA and had occurred on two separate occasions. When asked about the problem that had occurred with the inhaler, the resident stated that "the same CNA said I asked for it too much. The CNA stated, "You really don't need that. I used it one time, only one puff, and s/he took it back." Observation during evening medication pass revealed that the nurse on duty from 7 AM-7 PM was short, Caucasian. On 10-31-12 at 3:55 PM, review of the facility policy entitled "Detection and Prevention of Resident Abuse and Neglect" revealed the following bullet under "EDUCATION PRACTICES:...Residents and families will receive information and education regarding the issues of abuse and neglect by: a) A review, with the resident and family during the admissions process, of Resident's Rights and the facility's policies and procedures on detection and Prevention of Abuse and Neglect..." Further review of the policy revealed the following: "2. HIRING PRACTICES: the facility will conduct a thorough pre-employment screening of prospective employees which includes the following: A thorough investigation of the histories of the individual being considered for hire included inquiry to the State Nurse aide registry, criminal background checks per State and federal regulation, and reasonable attempts to check references..." During an interview on 10-31-12 at 2:45 PM, the Admissions Coordinator stated that Resident Rights and grievances were covered with family during the admissions process prior to the resident actually arriving at the facility. S/he stated that they "don't go over it word for word, but they sign they get a copy." New admissions' family members were also given an admission booklet which had a section that covered resident's rights, including the right to voice grievances without fear of reprisal. However, there was no evidence that this information was reviewed with the resident, though s/he was noted as cognitively intact, and, according to the physician, able to make health care decisions. The Admissions Coordinator explained an "iGreet" policy in which each department head introduced themselves and their role to each new resident. A copy of this signed form was obtained from Social Services on 11-1-12, but did not specify that resident rights or grievances were discussed with Resident #142. The Admissions Coordinator stated that s/he checked with the Administrator who stated there was no written policy/procedure on the "iGreet" program. During an interview on 10-31-12 at 3:10 PM, Social Services stated that s/he went over resident rights and the grievance policy after admission as part of "iGreet" program. Review of Social Service Notes on 11-1-12 at 9:04 AM revealed no evidence of discussion of resident rights or the grievance policy with the resident. This was verified on 11-1-12 at 10:40 AM by Social Services. At approximately 5 PM on 10-31-12 Resident #209 (#142's roommate) stopped the surveyor and stated that the same CNA was "very short" with her/him. "S/he didn't start out this way-think s/he just doesn't like her job". During an interview on 11-1-12 at approximately 10 AM, Resident #209 stated s/he had witnessed the CNA's behavior toward Resident #142. "S/he acted like s/he didn't want to do what you wanted her to do-acted like s/he didn't want to do the job. S/he talks grouchy. S/he talks that way to me, too. I hope I'm wrong but I think I heard a curse word. It made my roommate upset to crying-and me too. I can't remember exactly what was said, but it made me feel bad. S/he has something against me." The CNA "turns call light off and says s/he will be back. I went on myself. S/he went to stay with the smokers and didn't come back for 3 hours. S/he worked last night again. S/he says s/he has the whole hall and you'll just have to wait." The resident stated s/he did not report the incidents. Resident #209 further stated that s/he had another CNA "about I month ago-haven't seen since-talked to me so hateful because I wet myself. I couldn't get anyone to come. S/he told me I should never wet my pants." Resident #142 re-entered the room on 10-31 shortly after 5 PM and added to the conversation. S/he stated that when the CNA on nights was on 2-3 times a week, the CNA stated, "You need to quit doing that" when the resident would have a bowel movement or be incontinent. Record review on 11-1-12 revealed no evidence of discussion of the Care Plan with Resident #142. During an interview on 11-1-12 at 9 AM, the Admissions Director stated that the MDS Coordinator was responsible for notifying/involving the resident in Care Plan meetings. During an interview with the MDS Coordinator and staff, there was no evidence that the resident had been notified of the plan of care meeting. The MDS Coordinator stated that the resident's family had been notified and that it was up to the family to notify the resident and ask them to attend with them if they wanted. During an interview on 11-1-12 at 10:05 AM, the Medical Director was questioned regarding Resident #142's reliability of information. After discussion of the allegations as above noted, the physician stated, "If she came to me with this, I would believer her." During an interview on 11-1-12 at 10 AM, the Director of Nursing (abuse coordinator) stated s/he had been advised of the incidents involving Resident #142 by the Medical Director and that the CNA had been suspended. The DON was advised of Resident #209's concerns as well. In response to questions posed related to abuse policies, s/he related the policies on pre-hire screening and stated that the reference checks and verification of licenses/certification were the responsibility of the Personnel Director. During an interview on 10-31-12 at 5 PM, the Director of Personnel stated s/he went over resident rights with all new personnel and placed a signed copy in their file. Review of the personnel files with her/him at that time revealed that the facility had failed to verify the certification of one of three newly hired CNAs reviewed. Reference checks were requested on the five personnel files reviewed for compliance with abuse prohibition policies. On 11-1-12 at 11:07 AM, the Director of Personnel stated no reference checks could be located on any of the five personnel files reviewed (one of which was the alleged perpetrator). Cross Refer CFR 483.13(c)(1)-(4) F225 Related to facility failure to verify I of 3 newly hired nursing assistant's certification prior to hire. Cross Refer CFR 483.13(c) F226 Related to facility failure to follow established policies/procedures regarding screening of new hires. Cross Refer CFR 483.20(d)(3) F280 Related to facility failure to afford residents the right to participate in her/his own plan of care/treatment.

On the days of the Complaint Inspection and Partial Extended Survey, based on observation, record review and interview, the facility failed to ensure ten of ten residents' physicians were notified of unrelieved pain or the effectiveness of pain intervention. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 5 PM "Resident C/O (complains of) pain to L (left) knee, observed knee c (with) swelling notes and res c/o pain." At 5:50 PM, the RP (responsible party) was contacted regarding the x-ray of the left knee. At 10 PM, "Resident taken to hospital 2 (secondary) fractured femur per MD order. C/O pain and discomfort, noted (increased) swelling. Family and MD notified." On [DATE] at 12 PM, "Returned to facility. N/O (new order) noted (no) surgery planned, too risky... Res medicated c 15 of [MEDICATION NAME] c good results, soft brace applied." Review of the physician's orders [REDACTED].#1 was ordered ,[DATE] mg of [MEDICATION NAME] every 4 hours as needed for pain. The resident received the pain medication 25 times between [DATE] and [DATE]. Review of the back of the MAR revealed the nurses were administering 5, 10 and 15 mg of [MEDICATION NAME], however, no pain assessments were documented to determine the resident's intensity, location, characteristics, or duration of the pain. In addition, there was not consistent documentation of the medication's effectiveness. The staff was reassessing the resident ,[DATE] hours after administration in some cases, however, 10 times had no time of the reassessment recorded. The reassessments that were conducted after administration, the staff was documenting + or "eff" indicating a positive result, however, there was no a pain assessment conducted at that time. Also, four administrations had no follow up assessment documented. One time, the resident had "mod effect" (moderate effectiveness) of the 10 mg [MEDICATION NAME] administered. No additional interventions were implemented at that time, nor was the physician notified for further instructions. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 11:14 AM, "called to room by CNA, resident observed on floor lying on her left side over the legs of hoyer lift. Resident noted to be alert and responsive. Large hematoma noted to back of head. No open areas were noted. Resident was assisted back to bed x 3 staff members. Neuro checks WNL (within normal limits)..." 11:30 AM, (Provider) called and informed...911 activated." 11:40 AM, "Resident transferred via stretcher by EMS..." 12:45 PM, "Received call from ER MD wanting information on residents condition and fall. Reported to (MD) that CNA informed nurse that resident slipped out of Hoyer lift and fell on floor." 5 PM, "...no additional orders were received." Further review of the Nurses Notes revealed no pain assessment had been conducted related to the injury upon return from the hospital. In addition the nurses were documenting inconsistent partial pain assessments by documenting "no c/o pain", "no s/s distress." At [DATE] the resident was noted to have labored breathing at 11:30 AM. An as needed dose of [MEDICATION NAME] ,[DATE] every 6 hours for pain was added to the already scheduled twice daily dose. At 11:45 AM, the resident received a dose of the as needed [MEDICATION NAME], however no pain assessment was documented. Further review of the Nurse's Notes from [DATE] through [DATE] revealed no documentation of pain or pain assessments. On [DATE] at 5:30 PM, "...D/C [MEDICATION NAME] PRN and (change) [MEDICATION NAME] order to ([MEDICATION NAME]) ,[DATE] [MEDICATION NAME] 7.5 ml every 4 hours while awake..." On ,[DATE] and [DATE] the nurses documented no distress, however there was no indication that the resident's pain was assessed. From ,[DATE] through ,[DATE] there was no pain assessment documented. On ,[DATE] at 3:30 PM "Resident s (without) c/o pain..." From ,[DATE] through ,[DATE] there was no indication of a pain assessment documented. On [DATE] at 2 PM, "no s/sx of pain or discomfort" was documented. On [DATE] at 3:30 PM, "no s/sx pain or discomfort" was documented again. No other pain assessment was documented. Review of the physician's orders [REDACTED]. No documentation on the back of the MAR was located related to a pain assessment or effectiveness. On [DATE] the resident received 2 doses of as needed [MEDICATION NAME] ,[DATE] at 12:15 PM and 9 PM. There was no documentation related to the 9 PM dose on the back of the MAR. Related to the 12:15 PM dose, the staff documented "[MEDICATION NAME] ,[DATE] per PEG for discomfort." There was no other pain assessment documented and no documentation of effectiveness was located. (No corresponding nurses notes either.) The resident was also noted to receive a scheduled dose of [MEDICATION NAME] ,[DATE] twice daily. Review of the [DATE] Physician order [REDACTED]. On [DATE] the resident received an as needed dose at 1 AM due to "grunting noise and s/sx of discomfort." No other pain assessment was documented and no follow up assessment was recorded. There were no corresponding nurses notes located. On [DATE] at 9 PM, the resident received [MEDICATION NAME] ,[DATE] for "grimacing." There was no documentation of a pain assessment and no follow up was recorded. Again, no corresponding nurses notes were located. Review of the February 2012 physician's orders [REDACTED]. The medication was held 48 times between [DATE] and [DATE]. Review of the back of the MAR revealed only 15 entries related to why the [MEDICATION NAME] was held. No pain assessments were documented to assure the resident was not in pain due to the held doses. Review of the [DATE] Physician order [REDACTED]. The medication was held 51 times between [DATE] and [DATE]. Review of the back of the MAR revealed only 5 entries related to reason why the medication was held all were due to resident was sleeping. No pain assessments were documented related to ensure the resident was not in pain due to the held medications. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Observation/Interview of Resident #3 on [DATE] at 9:20 AM revealed the resident sitting in a wheelchair in her room. The resident reported pain to her right leg and stated that the nurse had already been in her room that morning to give her medications, however the resident reported that the nurse did not ask about her pain at that time. During an interview with the assigned nurse, she stated that she had administered the scheduled Tylenol and stated that the resident did not report pain to her at that time. The nurse promptly assessed the resident and informed the surveyor that the resident reported an ,[DATE] pain in her right leg. She stated that she administered an as needed dose of [MEDICATION NAME]. Review of the Nurse's Notes revealed on [DATE] at 10:45 AM, "called to room by CNA. Res observed on floor beside bed in front of w/c (wheelchair). CNA reported that while attempting to transfer, s/c rolled back causing her to have to lower resident to floor. Res c/o bil knee pain and left lower leg pain. Denies hitting head. Res assessed by this nurse c moderate swelling noted to both knees s discoloration noted. (Physician) notified c order for x rays of areas. DON and family also notified of orders. Mobilex notified of x-rays bil knees and L tib/fib." At 11:58 PM, "In bed resting c both eyes closed. No c/o pain or discomfort and (no acute distress) noted." On [DATE] at 8 AM, "X-ray report called to (physician) of rt knee distal shaft fx. Order to send to ER for eval..." At 11 AM, "Res was transferred to the ER..." At 5:50 PM, "Res returned to the facility and to keep splint in place..." At 7 PM, the resident had "no complaints of pain or discomfort." On [DATE] on the night shift (7P-7A) "[MEDICATION NAME] given at 9 PM for pain and effective." On [DATE] at 9 PM, "Resident c/o leg pain. [MEDICATION NAME] ,[DATE] given for pain. Effective, will cont to monitor." There were no other pain assessments documented. Review of the X-Ray report taken on [DATE] revealed "Acute mildly displaced fracture of distal shaft of femur." The report was not read by the Radiologist until [DATE] at 8:06 AM. There was no indication that the facility contacted the physician for further orders related to the delay in x-ray results. The resident's pain was not assessed or managed. The resident received her scheduled Tylenol, however, this intervention was in place prior to the acute fracture. Review of the physician's orders [REDACTED]. The first dose was given on ,[DATE] at 9 PM (2 days after the fracture occurred). Review of the back of the MAR, revealed 7 entries made related to the administration of the narcotic. Three of the seven entries documented [MEDICATION NAME] ,[DATE] for "pain." No other assessment was documented. The remaining four entries documented "leg pain." However, there was no indication which leg or where any other pain assessment was made. Four times had an "eff" documented approximately one hour after administration, no other assessment was completed. Two times had a + documented without any other indication of assessment. One time had no follow up recorded. No corresponding nurse's notes with pain assessments were located. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from [DATE] through [DATE] (last recorded note) revealed sporadic documentation of "no complaint of pain." No pain assessments were documented in the nurse's notes. During observation and interview of the resident on ,[DATE] at 2:10 PM, the resident stated that she was "always in pain" and "always has to ask for pain pill." She stated that the nurses do not ask her about her pain. She stated that she would tell the nurses where the pain was but the nurses would not ask any other questions related to her pain. Review of the Physician order [REDACTED]. She also received two as needed doses of Tylenol 1 G. Review of the back of the MAR revealed 22 entries related to administration of the as needed medications. The staff documented "c/o pain", "c/o leg pain" and "c/o back pain". No other assessment was documented related to the pain. The nurses documented "eff" approximately one hour after administration of the medications, however, there was not a pain assessment conducted related to the effectiveness of the medication. No corresponding nurse's notes were located related to the pain. Review of the February 2012 MAR and physician's orders [REDACTED]. She also received 2 doses of as needed Tylenol 1 G. Review of the back of the MAR revealed the nurses were documenting "pain", "general pain", "back pain", "arm pain" and "leg pain." On three occasions the nurses documented an ,[DATE] pain scale, however, no other assessment was completed. The nurses were also documenting "+" or "eff." The time of the reassessment was not consistently documented and there was no follow up assessment documented. No corresponding nurses notes were located related to the frequent pain. There was no indication that the physician was notified of the frequent pain. Review of the [DATE] physician's orders [REDACTED]. Review of the back of the MAR revealed 28 entries related to the administration of the medication. The nurses were documenting "general pain", "pain everywhere", "back pain", "pain" and "leg pain." Seven times the nurses documented 10+ for the pain scale. Two other pain scales were recorded. However, no other pain assessment was documented. The nurses were documenting "+" and "eff" for the follow up approximately ,[DATE] hours after the administration of the medications. Twice, no follow up was completed. Twice the resident had no relief from the pain. There was no indication the physician was contacted related to the unrelieved pain or the frequent reports of pain. No nurses notes were located for [DATE]. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the back of the MAR revealed the resident received the narcotic for "c/o pain." Twice a pain scale of ,[DATE] was recorded. Three times the follow up was documented as "effect", however, no other assessment was recorded. One time no follow up was recorded. Review of the Nurse's Notes revealed on [DATE] at 11 PM, "complaint of back pain, [MEDICATION NAME] ,[DATE] given for pain and effective." No other assessment was completed related to the reported pain. Further review revealed "no co pain", "no s/sx pain" and "voices no complaints" were documented. There were no corresponding nurse's notes related to the administration of the as needed medication. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from [DATE] through [DATE] (last entry noted) revealed no documentation of a pain assessment. Review of the Physician order [REDACTED]. No as needed medications were prescribed. Observation of the resident on [DATE] at 1:30 PM revealed the resident sitting in her wheelchair in her room. A splint to the left arm was noted. The resident stated that she has aches and pains and takes Tylenol daily for pain relief. She stated that the nurses were in and out of her room checking on her frequently during the day and she has not required anything other than Tylenol for pain relief. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident was noted to have refractured his hip on [DATE] while at the facility. Review of the Nurse's Notes revealed the following entries: [DATE] at 10:25 AM "Left Hip X-ray...C/O pain left leg/hip. PRN pain med given... ,[DATE] (no time recorded) "c/o pain to L hip at 5 AM, Narco ,[DATE] given and effective." ,[DATE] (no time recorded), "Resident c/o pain to lt leg c brace, Narco ,[DATE] given for pain and effective." ,[DATE] at 2:30 PM, "Request pain med for pain. [MEDICATION NAME] PRN given c some relief..." 5 AM, "Res complaint pain to lt leg with brace, Narco ,[DATE] given and effective." ,[DATE] at 5 AM, "Resident complaint pain to lt leg, Narco 500 mg given, effective..." ,[DATE] at 3:10 PM, "Res c/o leg/hip pain today, requested pain med. PRN pain med administered + results." ,[DATE] at 3:30 PM, "requests pain med r/t leg pain. Administered + results." ,[DATE] at 7 PM, "complains of pain at this time." (There was no indication from the nurses notes any intervention was done) ,[DATE] at 1:15 PM, "C/O and pain...sent to ER." ,[DATE] at 12 AM, "resident c/o pain 6 on scale of [MEDICATION NAME] ,[DATE] given." 1 AM, "Resident states 2 on a scale of 10..." 12:20 PM, "c/o pain x1 today. PRN pain med administered c + results." ,[DATE] at 2:20 PM, "c/o hurting to back of L thigh. Pain med administered c + results..." No other nurses notes in February indicated any pain or pain assessment. Review of the physician's orders [REDACTED]. The resident received 41 times in February 2012. Review of the back of the MAR revealed 28 entries recorded. The nursing staff documented Narco given/requested for "pain", "hip/leg pain", "discomfort", "res request", "kidneys are killing me"and "pain pill". No pain assessments were documented related to the administration of the narcotic. Nurses documented "eff" for the follow up intervention. However, the times were not consistently recorded. Three times, no follow up was documented in addition to the 13 times no documentation was done. There were no corresponding nurse's notes with a pain assessment related to the 41 doses received of the narcotic. During an interview with the resident on [DATE] at 12:45 PM, the resident stated that the pain was "rough" when the fracture first occurred. He stated that as long as he doesn't move the pain is "ok." He stated that it "hurt pretty bad" when therapy does some stuff. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed on [DATE] at 6 PM, the resident fell out of the wheelchair and complained of pain to the left leg. The resident was sent to the ER where an acute fracture was identified. (The resident re-fractured the same leg, however the prosthesis was intact, therefore no surgical intervention). On [DATE] at 1:30 AM, "resident was in pain when returned, PRN [MEDICATION NAME] given c little effect..." On ,[DATE] from 7A-7P, "PRN pain med for pain control." ,[DATE] at 8:30 PM, "medicated c [MEDICATION NAME] ,[DATE] for pain management L hip and leg." ,[DATE] at 1:35 AM, "c/o pain in L femur, PRN pain med given c + effect." No other pain assessment was documented. Staff were noted to document "offers no complaints of pain." Review of the physician's orders [REDACTED]. Six entries were recorded on the back of the MAR that noted the medication was given for "hip" and "leg pain". On ,[DATE] at 8 PM "(increased) pulse, sweaty, no c/o pain of some pain ,[DATE] gave to calm pain (negative) effect." Only one other entry documented "(+) effect." No pain assessment or follow up was documented related to the pain. No nurse's notes corresponded to the administration of the medications. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. The resident fell in the bathroom resulting in a right shoulder dislocation on [DATE]. Review of the Physician order [REDACTED]. On ,[DATE] an order was written for [MEDICATION NAME] 50 mg ,[DATE] tabs as needed for Right shoulder. The [MEDICATION NAME] order was filled by pharmacy, however was not transcribed onto the MAR. Review of the MAR from [DATE] revealed the resident had not received any pain medication at the facility related to the dislocated shoulder. During an interview on [DATE] at 11:45 AM, the resident stated that her shoulder "hurt very badly" when the injury first happened. She also stated that her should continued to hurt after she received therapy. The resident exposed her right elbow, a purple and yellow bruised area was noted to extend up her arm towards her shoulder and midway down her forearm. The resident touched her shoulder and winced and stated that it was still "sore." Review of the Nurse's Notes from [DATE] through [DATE] revealed no pain was recorded. The nursing staff documented "offers no complaints of pain" and "no pain complaints." During an interview on [DATE], the Interim Director of Nurses (IDON) confirmed Resident #9's [MEDICATION NAME] was not transcribed onto the MAR. She also confirmed that Resident #9 did not receive any pain medication for the shoulder dislocation while in the facility. The IDON confirmed the resident's nurses notes that indicated the nursing staff were not consistently documenting a pain assessment. She confirmed the nurses were documenting that the nursing staff were documenting "offers no complaints" or "voices no complaints," indicating that the staff were relying on the resident to report the pain instead of proactively assessing and treating the pain. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 9 PM, "c/o pain to lower abdominal and upper extremities, [MEDICATION NAME] given for pain..." ,[DATE] at 10:15 AM, "[MEDICATION NAME] given for pain all over..." 8 PM, "c/o generalized body pain, [MEDICATION NAME] PRN effective..." ,[DATE] at 9:15 AM, "moaning out in pain/discomfort..." 10 AM, "(Provider) notified of increased in pain...sent to ER." ,[DATE], "c/o pain, [MEDICATION NAME] given for pain..." [DATE] "generalized pain." ,[DATE] "res c/o of pain to buttock and legs, [MEDICATION NAME] PRN given for pain and effective..." ,[DATE] "[MEDICATION NAME] given for pain control." 12:30 PM "When returned (from whirlpool therapy) resident refused packing to backside. Resident yelled out not to touch her..." 8 PM, "C/O pain [MEDICATION NAME] PRN given..." ,[DATE] "[MEDICATION NAME] administered for c/o pain to buttocks..." 7 PM, "C/o pain to hip, [MEDICATION NAME] given..." ,[DATE] at 3 PM, "Res refused rectal tx c/o pain... [MEDICATION NAME] ,[DATE] given from stat box c tx 1 hour later per (Physician)..." One hour later..."In to do treatment to ischiorectal after medication administered one hour earlier- Resident refused tx stating she was dying in pain and ain't nobody messing in my ass. Resident stated maybe next time...Will notify (Physician) via communication MD book." ,[DATE] "req(uired) pain med before treatment and req more p (after) tx..." ,[DATE], "Resident c/o pain to buttock, [MEDICATION NAME] given..." ,[DATE], "res request [MEDICATION NAME] frequently for pain..." "PRN [MEDICATION NAME] given for pain and effective..." ,[DATE] "Res cries out in pain often..." 9 PM, "Resident c/o pain to back and lower legs, [MEDICATION NAME] PRN given and effective..." ,[DATE], "Res c pain/tenderness to [DEVICE] site and surrounding area, noted to Dr. book. PRN [MEDICATION NAME] administered and helped some c [MEDICATION NAME] scheduled." ,[DATE], "Observed yelling out this [MEDICATION NAME] ordered..." ,[DATE], "Res c/o pain/discomfort often..." ,[DATE] "Res cont to c/o pain at all times, requesting pain pills throughout NOC (night)." The resident was noted to refuse care and treatments frequently. ,[DATE] "c/o extreme pain...send res to ER..." ,[DATE] "yelling on and off at times this shift..." At 9:30 PM, "cont to yell at staff while performing care c/o pain ,[DATE], PRN [MEDICATION NAME] given, mod (moderate) effect." ,[DATE], "Yelled out constantly this shift c c/o generalized pain. PRN [MEDICATION NAME] 10 mg x 2 this shift c minimal effect." ,[DATE] at 5 PM, "Notified supervisor that pt was looking bad and her resp were 44. Supervisor assessed and spoke c NP to transport to ER. Code status full. Crash cart at bedside. 911 called by supervisor...explained AM refusal of meds. Noon meds via tube. 5 PM change observed, VS erratic c 911 transport." The resident expired en route to the hospital per resident's family member. Review of the MAR from [DATE] revealed the resident received scheduled [MEDICATION NAME] four times daily. The resident was also noted to receive 33 doses of [MEDICATION NAME] 7XXX,[DATE] every ,[DATE] hours as needed for pain. Review of the back of the MAR revealed 30 entries related to the administration of [MEDICATION NAME]. The nursing staff documented the medication was administered for "c/o pain", "hurting all over", "back pain", "buttocks pain" and "crying in pain." No pain assessment was done to indicate intensity or other characteristics. The staff documented "eff" but was inconsistent with documenting the time the follow up took place. However, there was not a complete follow up assessment completed. Review of the MAR from [DATE] revealed the resident received the scheduled [MEDICATION NAME] until ,[DATE] when the order was discontinued. [MEDICATION NAME] ,[DATE] every 6 hours was scheduled beginning ,[DATE] at 9 AM. As needed [MEDICATION NAME] 7XXX,[DATE] every 6 hours as needed for pain was given 10 times, [MEDICATION NAME] ,[DATE] as needed was given 22 times. [MEDICATION NAME] 50 mg as needed was given three times. Review of the back of the MAR revealed 30 entries related to pain medication administration. Of the 30 entries, 9 times had no follow up assessment completed. Twice the nursing staff documented only some relief, no other interventions were recorded and no physician notification was located related to the unrelieved pain. The other entries recorded "helpful", "eff", "relief", however, there was not a follow up assessment completed to determine the efficacy of the intervention. Review of the February 2012 MAR revealed the resident received the scheduled [MEDICATION NAME] four times daily until [DATE] when the order was discontinued. A new order for [MEDICATION NAME] 5 or 10 mg every 4 hours as needed for pain was ordered. The resident received 34 times from ,[DATE] through [DATE]. Review of the back of the MAR revealed 31 entries related to pain medication administration. The nurses were administering 2 [MEDICATION NAME] (10 mg) for "c/o pain", "gen pain", "foot pain" and "yelling out in pain." There were 10 documented pain scales, however no other pain assessment was documented. The nursing staff were documenting "eff" ,[DATE] hours after administration of the medication, however, no other follow up assessment was documented. Review of the [DATE] MAR revealed the resident was no longer receiving any scheduled opiate. She received 29 doses of as needed [MEDICATION NAME] ,[DATE] mg from ,[DATE] through [DATE]. Reviwe of the back of the MAR revealed 28 entries related to pain medication administration. The [MEDICATION NAME] was given for "yelling out in pain", "moaning" and "pain". Six times a pain scale was documented. No other pain assessment was documented related to intensity, duration and other characteristics. Five times had no follow up assessment completed. Twice, minimal effect was documented. No other intervention was attempted and no physician notification was noted. Otherwise, the nursing staff documented "eff" or "helpful", however, a follow up pain assessment had not been documented. During an interview on [DATE] at 2 PM, the IDON and the Nurse Consultant stated that if the residents pain was increasing in intensity or unrelieved by the nursing interventions then the physician should be notified and would expect the nurses to document the change. The Nurse Consultant and IDON confirmed Resident #10's unrelieved and untreated pain and confirmed that the physician was not notified of those incidents. Both confirmed the resident's multiple refusals of dressing changes, whirlpool therapy, ostomy care, Foley Catheter care and meals. Both the IDON and Nurse Consultant confirmed that the pain assessments that were documented were not sufficient. The Nurse Consultant stated that the nurses should be documenting one hour after medication administration to determine the effectiveness of the pain medication. She stated that she did not necessarily expect the staff to perform another pain assessment but expected them to document "effective." She confirmed that "effective" did not evaluate the resident's pain and did not indicate whether the resident reached an acceptable level of pain or if further intervention could be required. During a telephone interview on [DATE] 2:20 PM, the Interim Medical Director stated that he expected the nursing staff to perform a pain assessment at least every shift. He also stated that the assessment should include pain scale, frequency, duration, type, location, new pain, chronic pain, etc. The IMD stated that any new onset of pain should be documented and reported to the physician and chronic pain should be assessed and the quality of the pain should be documented to determine the characteristics of the pain. The IMD stated that he preferred to keep residents on an as needed basis for pain control instead of scheduling pain medications even if the resident is taking the as needed doses most of the time. He stated that he would "rather have patient ask for medicine then have nursing dispense." However, he did state that he expected the nurses to document the reason why the as needed medication was given and document the pain assessment to include a pain scale, frequency, duration, quality, etc. Cross Refer to F 309 as it relates to the facility failure to ensure each resident's pain was assessed and treated appropriately.

On the days of the Complaint Inspection and Partial Extended Survey, based on observation, record review, interview and review of Nursing Practice and Skill; Pain Assessment in the Older Adult, ten of ten residents failed to have accurate and complete pain assessments. The nursing staff failed to perform pain assessments and document the findings prior to and after the administration of as needed pain medication. Resident #10 had unrelieved and untreated pain, the nursing staff failed to provide interventions related to the unrelieved pain. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status. Further review of Section J Health Condition revealed the resident was coded as receiving as needed pain medications, pain was present and the resident experienced pain frequently. The pain was noted to limit the resident daily activities. Review of the Care Plan dated [DATE] revealed a problem area related to pain due to recent left femur fracture, back pain, [MEDICAL CONDITION] and spinal stenosis. The resident goal was "pain will be relieved with in one hr (hour) after receiving pain meds thru next review date. The approaches included "notify MD as indicated, assess location, frequency, duration and intensity of pain. Document assessment. Report increased pain trend to physician. Attempt non-pharmacological pain relief measures such as re positioning, back rubs. Document effectiveness. Administer pain medication as requested. Document effectiveness. Review resident pain management plan routinely and provide diversional activities, if applicable." Review of the Nurses Notes revealed on [DATE] at 5 PM "Resident C/O (complains of) pain to L (left) knee, observed knee c (with) swelling notes and res c/o pain." At 5:50 PM, the RP (responsible party) was contacted regarding the x-ray of the left knee. At 10 PM, "Resident taken to hospital 2 (secondary) fractured femur per MD order. C/O pain and discomfort, noted (increased) swelling. Family and MD notified." On [DATE] at 12 PM, "Returned to facility. N/O (nurses order) noted (no) surgery planned, too risky...Res medicated c 15 of [MEDICATION NAME] c good results, soft brace applied." (Further investigation revealed Resident #1's fracture occurred at approximately 10:45 AM on [DATE] due to an inappropriate transfer. However, the incident was not reported until the next day. The CNA reported to the nurse at 3 PM that the resident complained of knee pain. Again there was no pain assessment documented at that time.) Review of the physician's orders [REDACTED]. No pain assessment was conducted. Resident #1 then received 0.5 mg [MEDICATION NAME] at 5 PM after the x-ray of her left leg was obtained. No other pain assessment or interventions were noted on [DATE]. Review of the physician's orders [REDACTED]. The resident received 25 times between [DATE] and [DATE]. Review of the back of the MAR revealed the nurses were administering 5, 10 and 15 mg of [MEDICATION NAME], however, no pain assessments were documented to determine the resident's intensity, location, characteristics, or duration of the pain. In addition, there was not consistent documentation of the medication's effectiveness. The staff were reassessing the resident ,[DATE] hours after administration in some cases, however, 10 times had no time of the reassessment recorded. The re-assessments that were conducted after administration, staff were documenting + or "eff" indicating a positive result, however, there was not a pain assessment conducted at that time. Also, four administrations had no follow up assessment documented. One time, the resident had "mod effect" (moderate effectiveness) of the 10 mg [MEDICATION NAME] administered. No additional interventions were implemented at that time, nor was the physician notified for further instructions. Resident #1 was noted to be receiving Hospice services beginning on [DATE]. Resident #1 expired on [DATE]. Resident #1's pain medications were held on ,[DATE] twice and on [DATE] due to lethargy. The resident received her last dose of [MEDICATION NAME] on [DATE] at 12 PM, 24 hours prior to her death. Review of the Pain assessment dated [DATE] revealed the resident had no pain at present, scored a ,[DATE] on the Painad scale, had no nonverbal indicators of pain and was prescribed as needed Tylenol for pain. The Conclusion of the assessment was "no pain, intervention is not necessary. Re-assess quarterly or with onset of pain." Review of the Pain Assessment conducted on [DATE] revealed the resident verbalized pain of the left femur. No documentation was located related to the characteristics of the pain, however it was noted that the pain increased with movement. The resident reported pain of ,[DATE] at present, ,[DATE] one hour after medication and a ,[DATE] 3 hours after medication. The resident reported ,[DATE] was the worst the pain she experienced. Resident #1 received a ,[DATE] on the Painad scale indicating that she had occasional shortness of breath and hyperventilation, occasional moan or groan, low level speech with a negative disapproving quality, facial grimacing, tense distressed, pacing, fidgeting and was unable to console, distract or reassure. The section on Activities of Daily Living was not completed. Nonverbal indicators of pain were grimacing, clenched jaw, frowning, turned down mouth, moaning, crying, pallor, rubbing body parts, increased vital signs, clenched fists, wringing of hands and depressed mood. The pain was noted to be relieved by medication. No acceptable pain level was recorded. No scheduled medications were prescribed for the recent fracture. The resident was prescribed [MEDICATION NAME] ,[DATE] mg every 4 hours as needed for pain (no parameters were ordered to determine how much should be given at any one time), and Tylenol 325 mg-650 mg every 6 hours as needed for pain. The Conclusion was: "No pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident had short term and long term memory problems and was severely impaired with daily decision making abilities. The resident was noted to be dependent on staff for all needs and was tube fed. The resident was noted to be non-verbal and did not respond to questions on [DATE] during observations. Review of Section J Health Conditions revealed the resident was on scheduled pain medication and the resident pain interview should not be conducted related to the resident was rarely understood/stands. The staff assessment for pain was left "BLANK." However, none of these signs observed was "checked." Review of the Care Plan dated updated on [DATE] revealed the resident was at risk for pain related to [MEDICAL CONDITIONS], Stenosis and Contractures. Unable to voice needs. The goal was for the resident to be "free from pain/discomfort within one hour of nursing measures/administration of medications x 3 months." Approaches included: "assess residents level of pain and document, administer medications as ordered, observe for effectiveness of medication/nursing measures, assess need for routine pain management instead of prn, notify MD if current regime ineffective and assure position changes, adequate room temp etc." Review of the Nurses Notes revealed on [DATE] at 11:14 AM, "called to room by CNA, resident observed on floor lying on her left side over the legs of hoyer lift. Resident noted to be alert and responsive. Large hematoma noted to back of head. No open areas were noted. Resident was assisted back to bed x 3 staff members. Neuro checks WNL (within normal limits)..." At 11:30 AM, (Provider) called and informed...911 activated." At 11:40 AM, "Resident transferred via stretcher by EMS..." At 12:45 PM, "Received call from ER MD wanting information on residents condition and fall. Reported to (MD) that CNA informed nurse that resident slipped out of Hoyer lift and fell on floor." At 5 PM, "...no additional orders were received." Further review of the Nurses Notes revealed no pain assessment had been conducted related to the injury upon return from the hospital. In addition the nurses were documenting inconsistent partial pain assessments by documenting "no c/o pain", "no s/s distress." On [DATE] the resident was noted to have labored breathing at 11:30 AM. An as needed dose of [MEDICATION NAME] ,[DATE] every 6 hours for pain was added to the already scheduled twice daily dose. At 11:45 AM, the resident received a dose of the as needed [MEDICATION NAME], however no pain assessment was documented. Further review of the Nurses Notes from [DATE] through [DATE] revealed no documentation of pain or pain assessments. On [DATE] at 5:30 PM, "...D/C [MEDICATION NAME] PRN and (change) [MEDICATION NAME] order to ([MEDICATION NAME]) ,[DATE] [MEDICATION NAME] 7.5 ml every 4 hours while awake..." On ,[DATE] and [DATE] the nurses documented no distress, however there was no indication that the resident's pain was assessed. From ,[DATE] through ,[DATE] there was no pain assessment documented. On ,[DATE] at 3:30 PM "Resident s (without) c/o pain..." From ,[DATE] through ,[DATE] there was no indication of a pain assessment documented. On [DATE] at 2 PM, "no s/sx of pain or discomfort" was documented. On [DATE] at 3:30 PM, "no s/sx pain or discomfort" was documented again. No other pain assessment was documented. Review of the physician's orders [REDACTED]. No documentation on the back of the MAR was located related to a pain assessment or effectiveness. On [DATE] the resident received 2 doses of as needed [MEDICATION NAME] ,[DATE] at 12:15 PM and 9 PM. There was no documentation related to the 9 PM dose on the back of the MAR. Related to the 12:15 PM dose, the staff documented "[MEDICATION NAME] ,[DATE] per PEG for discomfort." There was no other pain assessment documented and no documentation of effectiveness was located. (No corresponding nurses notes either.) The resident was also noted to receive a scheduled dose of [MEDICATION NAME] ,[DATE] twice daily. Review of the [DATE] Physician order [REDACTED]. On [DATE] the resident received an as needed dose at 1 AM due to "grunting noise and s/sx of discomfort." No other pain assessment was documented and no follow up assessment was recorded. There were no corresponding nurses notes located. On [DATE] at 9 PM, the resident received [MEDICATION NAME] ,[DATE] for "grimacing." There was no documentation of a pain assessment and no follow up was recorded. Again, no corresponding nurses notes were located. Review of the February 2012 physician's orders [REDACTED]. The medication was held 48 times between [DATE] and [DATE]. Review of the back of the MAR revealed only 15 entries related to why the [MEDICATION NAME] was held. No pain assessments were documented to assure the resident was not in pain due to the held doses. Review of the [DATE] Physician order [REDACTED]. The medication was held 51 times between [DATE] and [DATE]. Review of the back of the MAR revealed only 5 entries related to reason why the medication was held all were due to resident was sleeping. No pain assessments were documented related to assure the resident was not in pain due to the held medications. Review of the Pain Evaluation dated [DATE] revealed the resident had pain due to [MEDICAL CONDITION] and "disbility." The resident was unable to express pain but yelled out at times. The resident was unable to express where pain was located but bilateral lower legs were contracted. The resident scored a ,[DATE] on the Painad scale indicating she yelled out, had a sad, frightened or frowning face and was distracted or reassured by touch or voice. No effect on function was documented. The resident had grimacing and yelling out checked as nonverbal indicators of pain. The resident was on a scheduled medication regimen and had as needed medication ordered that was documented as effective. An expected level of pain was not completed. The Conclusion was "No pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The next evaluation completed was dated [DATE]. No general information was listed other than chronic pain BLE contractures. No pain scale was documented, no Painad scale was recorded, no effect on function was documented, no nonverbal indicators of pain were listed and no conclusion was recorded. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident received a ,[DATE] on the BIMS indicating mild impairment. Review of Section J Health Conditions revealed the resident was on both as needed and scheduled pain medications. The resident reported the presence of pain frequently. The verbal descriptor scale was "moderate." Review of the Care Plan dated [DATE] revealed a problem area of Pain was identified related to a recent fracture. The goal was pain "will be relieved within 1 hour after receiving pain meds." Approaches included "meds as ordered, encourage to reposition frequently, provide diversional activity, diet as ordered, labs as ordered, notify MD of unrelieved pain." Observation/Interview of Resident #3 on [DATE] at 9:20 AM revealed the resident sitting up in a wheelchair in her room. The resident reported pain to her right leg and stated that the nurse had already been in her room that morning to give her medications, however the resident reported that the nurse did not ask about her pain at that time. During an interview with the assigned nurse, she stated that she had administered the scheduled Tylenol and stated that the resident did not report pain to her at that time. The nurse promptly assessed the resident and informed the surveyor that the resident reported an ,[DATE] pain in her right leg. She stated that she administered an as needed dose of [MEDICATION NAME]. Review of the Nurses Notes revealed on [DATE] at 10:45 AM, "called to room by CNA. Res observed on floor beside bed in front of w/c (wheelchair). CNA reported that while attempting to transfer, s/c rolled back causing her to have to lower resident to floor. Res c/o bil knee pain and left lower leg pain. Denies hitting head. Res assessed by this nurse c moderate swelling noted to both knees s discoloration noted. (Physician) notified c order for x rays of areas. DON and family also notified of orders. Mobilex notified of x-rays bil knees and L tib/fib." At 11:58 PM, "In bed resting c both eyes closed. No c/o pain or discomfort and (no acute distress) noted." On [DATE] at 8 AM, "X-ray report called to (physician) of rt knee distal shaft fx. Order to send to ER for eval..." At 11 AM, "Res was transferred to the ER..." At 5:50 PM, "Res returned to the facility and to keep splint in place..." At 7 PM, the resident had "no complaints of pain or discomfort." On [DATE] on the night shift (7P-7A) "[MEDICATION NAME] given at 9 PM for pain and effective." On [DATE] at 9 PM, "Resident c/o leg pain. [MEDICATION NAME] ,[DATE] given for pain. Effective, will cont to monitor." There were no other pain assessments documented. Review of the X-Ray report taken on [DATE] revealed "Acute mildly displaced fracture of distal shaft of femur." The report was not read by the Radiologist until [DATE] at 8:06 AM. There was no indication that the facility contacted the physician for further orders related to the delay in x-ray results. The resident's pain was not assessed or managed. The resident had received her scheduled Tylenol, however, this intervention was in place prior to the acute fracture. Review of the Pain Evaluation dated [DATE] revealed the resident had pain related to "Distal shaft rt femur fracture." The resident reported the pain as throbbing and at present reported a ,[DATE] pain rating to the right leg. The resident's pain was not assessed, one hour or three hours after medication, nor was the worst and best rating recorded. The resident scored a ,[DATE] on the Painad scale indicating occasional shortness of breath, occasional moan or groan, sad, frightened face, tense, distressed and fidgeting. The effect on function was not assessed. Nonverbal indicators were grimacing and rubbing body parts. The acceptable level of pain was not assessed and the resident was noted to receive scheduled Tylenol and as needed [MEDICATION NAME]. The Conclusion was "no pain, intervention not necessary. Re-assess quarterly or with onset of pain. Another pain assessment was completed on [DATE] that documented no pain on assessment. The pain was not assessed related to medication administration, effect on function, non verbal pain indicators. The residents expected level of pain was not assessed and the conclusion was, "no pain, intervention not necessary." Review of the physician's orders [REDACTED]. The first dose was given on ,[DATE] at 9 PM (2 days after the fracture occurred). Review of the back of the MAR, only 7 entries were made related to the administration of the narcotic. Three of the seven entries documented [MEDICATION NAME] ,[DATE] for "pain." No other assessment was documented. The remaining four entries documented "leg pain." However, there was no indication which leg or where or any other pain assessment. Four times had an "eff" documented approximately one hour after administration, no other assessment was completed. Two times had a + documented without any other indication of assessment. One time had no follow up recorded. No corresponding nurses notes with pain assessments were located. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed the resident scored a ,[DATE] on the BIMS indicating no cognitive impairment. Review of Section J revealed the resident reported pain frequently and scored the pain as an ,[DATE]. She was noted to receive as needed medications only. Review of the Care Plan updated on [DATE] revealed a problem area of Pain was identified with a goal of pain relief within one hour of intervention. Approaches included "Administer meds as ordered, schedule labs/diagnostic works as ordered, report results to MD and follow up as needed, notify MD as needed, provide diversional activities, assess location, frequency, duration and intensity of pain. Document assessment, report increased pain trend to MD. Attempt non-pharmacological relief measures such as repositioning, back rubs, document effectiveness, review resident pain management plan routinely." Review of the Nurses Notes from [DATE] through [DATE] (last recorded note) revealed sporadic documentation of "no complaint of pain." No pain assessments were documented in the nurses notes. During observation and interview of the resident on ,[DATE] at 2:10 PM, the resident stated that she was "always in pain" and "always has to ask for pain pill." She stated that the nurses do not ask her about her pain. She stated that she would tell the nurses where the pain was but the nurses would not ask any other questions related to her pain. Review of the Physician order [REDACTED]. She also received two as needed doses of Tylenol 1 G. Review of the back of the MAR revealed 22 entries related to administration of the as needed medications. The staff documented "c/o pain", "c/o leg pain" and "c/o back pain". No other assessment was documented related to the pain. The nurses documented "eff" approximately one hour after administration of the medications, however, there was not a pain assessment conducted related to the effectiveness of the medication. No corresponding nurses notes were located related to the pain. Review of the February 2012 MAR and physician's orders [REDACTED]. She also received 2 doses of as needed Tylenol 1 G. Review of the back of the MAR revealed the nurses were documenting "pain", "general pain", "back pain", "arm pain" and "leg pain." On three occasions the nurses documented an ,[DATE] pain scale, however, no other assessment was completed. The nurses were also documenting "+" or "eff." The time of the reassessment was not consistently documented and there was no follow up assessment documented. No corresponding nurses notes were located related to the frequent pain. There was no indication that the physician was notified of the frequent pain. Review of the [DATE] physician's orders [REDACTED]. Review of the back of the MAR revealed 28 entries related to the administration of the medication. The nurses were documenting "general pain", "pain everywhere", "back pain", "pain" and "leg pain." Seven times the nurses documented 10+ for the pain scale. Two other pain scales were recorded. However, no other pain assessment was documented. The nurses were documenting "+" and "eff" for the follow up approximately ,[DATE] hours after the administration of the medications. Twice, no follow up was completed. Twice the resident had no relief from the pain. There was no indication the physician was contacted related to the unrelieved pain or the frequent reports of pain. No nurses notes were located for [DATE]. Review of the Pain Evaluation dated [DATE] revealed the resident had a history of [REDACTED]. No description of the pain was documented. No resident reported frequent pain in her lower back and occasional pain in her mid back. No pain was recorded at present. However, the pain was not assessed after medications or the worst and the best. The resident scored a ,[DATE] on the Painad scale indicating occasional labored breathing, occasional moan or groan, sad, frightened face, tense, distressed body language and was unable to be consoled or redirected. The resident had the following non verbal indicators listed: grimacing, clenched jaw, frowning, turned down mouth, moaning, crying, cursing, threatening gestures, rubbing body parts, increased vital signs, perspiration, clenched fists, wringing of hands, striking out at others and depressed mood." An acceptable level of pain was not assessed. The resident was noted to receive as needed [MEDICATION NAME] ,[DATE] every 6 hours for pain. The conclusion was "no pain, intervention not necessary." Review of the Pain Evaluation dated [DATE] revealed the resident reported no pain at present, pain of a ,[DATE] one hour after medication in the lower back and ,[DATE] in the mid back region. A rating of ,[DATE] three hours after administration in the lower back and a ,[DATE] in the mid back. The resident reported a ,[DATE] was the worst pain she experienced and the best was no pain. The resident again scored a ,[DATE] on the Painad scale. No effect on function was assessed. The following non verbal pain indicators were documented: clenched jaw, frowning, tightly shut lips, turned down mouth, moaning, crying, screaming, cursing, rubbing body parts, increased vital signs, perspiration, clenched fists and depressed mood." The resident's acceptable level of pain was assessed as a ,[DATE]. The resident was prescribed [MEDICATION NAME] for back pain scheduled twice daily and received as needed Tylenol and [MEDICATION NAME]. The Conclusions were "no pain, intervention is not necessary." (The [MEDICATION NAME] was originally ordered in 2009 and was not a new medication.) The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Admission MDS revealed the resident scored a ,[DATE] on the BIMS assessment indicating moderate impairment. Review of Section J revealed the resident reported occasional pain of a ,[DATE]. Review of the Care Plan dated [DATE] revealed a problem area of alteration in comfort related to pelvic fracture. The goal was to have the pain relieved within one hour of nursing measures/administration of medication. Approaches included: "Assess level of pain and document, administer medications as ordered, observe for effectiveness of medication/nursing measures, assure position changes, adequate room temp, etc, assess the need for routine pain management instead of PRN and notify MD if current regime is ineffective." Review of the physician's orders [REDACTED]. Review of the back of the MAR revealed the resident received the narcotic for "c/o pain." Twice a pain scale of ,[DATE] was recorded. Three times the follow up was documented as "effect", however, no other assessment was recorded. One time no follow up was recorded. Review of the Nurses Notes revealed on ,[DATE] at 11 PM, "complaint of back pain, [MEDICATION NAME] ,[DATE] given for pain and effective." No other assessment was completed related to the reported pain. Further review revealed "no co pain", "no s/sx pain" and "voices no complaints" were documented. There were no corresponding nurses notes related to the administration of the as needed medication. Review of the Pain Evaluation dated [DATE] revealed the resident had a pelvic fracture that occurred on [DATE] and reported the pain as throbbing. The pain was not assessed at present, after medication administration or the worst and best the pain got. The resident scored a ,[DATE] on the Painad scale indicating occasional labored breathing, occasional moan or groan, sad or frightened facial expression and was reassured by voice or touch. The pain was noted to effect the resident's participation in activities. The non verbal indicators of pain were wrinkled brow, moaning and altered gait/posture. The resident reported a ,[DATE] as an acceptable level of pain and was noted to receive an as needed narcotic. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed the resident scored a ,[DATE] on the BIMS indicating no cognitive impairment. Review of Section J revealed no pain was recorded as present. Review of the Care Plan dated [DATE] revealed a problem area of alteration in comfort was identified with a goal of free from pain/discomfort within one hour of nursing measures/administration of medications. Approaches included assess level of pain and document, administer medication as ordered, observe for effectiveness, assess the need for routine pain management, notify MD if current regime is ineffective..." Review of the Nurses Notes from [DATE] through [DATE] (last entry noted) revealed no documentation of a pain assessment. Review of the Physician order [REDACTED]. No as needed medications were prescribed. Review of the Pain Evaluation dated [DATE] revealed the resident had [MEDICAL CONDITION] and did not verbalize pain. No pain was present at the time of assessment. The pain was not assessed at present, one or three hours after administration or the worst or best the pain got. The resident scored a ,[DATE] on the Painad scale. The resident was not assessed for the effect on function or non verbal indicators. An acceptable level of pain was not assessed. The Conclusions were "no pain, intervention is not necessary. Another Pain Evaluation dated [DATE] revealed the resident had [MEDICAL CONDITION] and had experienced pain within the last 5 days. However, the pain characteristics were not assessed. The Pain Location/Type/Frequency/Intensity and Duration Section was not completed. The resident was not assessed for Pain Effect on Function or Non Verbal Pain Indicators. The resident was noted to received scheduled Tylenol. No acceptable pain level was assessed, nor was the effectiveness of the medication. No Conclusions were documented. Observation of the resident on [DATE] at 1:30 PM revealed the resident sitting up in her wheelchair in her room. A splint to the left arm was noted. The resident stated that she has aches and pains and takes Tylenol daily for pain relief. She stated that the nurses were in and out of her room checking on her frequently during the day and has not required anything other than Tylenol for pain relief. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident was noted to have refractured his hip on [DATE] while at the facility. Review of the Significant Change MDS dated [DATE] revealed the resident scored a ,[DATE] on the BIMS assessment indicating moderate cognitive impairment. Review of Section J revealed the resident reported pain occasionally and rated the pain as a ,[DATE]. The resident was noted to be on both scheduled and as needed pain medications. Review of the Care Plan dated [DATE] revealed a problem area of alteration in comfort due to [MEDICAL CONDITION] with a goal of pain relief within one hour of nursing intervention. Approaches included "assess resident's level of pain and document, administer medication as ordered, observe for effectiveness, assess the need for routine pain management, notify MD if current regime is ineffective..." Review of the Nurses Notes revealed the following entries: [DATE] at 10:25 AM "Left Hip X-ray...C/O pain left leg/hip. PRN pain med given..XXX,[DATE] (no time recorded) "c/o pain to L hip at 5 AM, Narco ,[DATE] given and effective." ,[DATE] (no time recorded), "Resident c/o pain to lt leg c brace, Narco ,[DATE] given for pain and effective." ,[DATE] at 2:30 PM, "Request pain med for pain. [MEDICATION NAME] PRN given c some relief..." ,[DATE] at 5 AM, "Res complaint pain to lt leg with brace, Narco ,[DATE] given and effective." ,[DATE] at 5 AM, "Resident complaint pain to lt leg, Narco 500 mg given, effective..." On ,[DATE] at 3:10 PM, "Res c/o leg/hip pain today, requested pain med. PRN pain med administered + results." ,[DATE] at 3:30 PM, "requests pain med r/t leg pain. Administered + results." ,[DATE] at 7 PM, "complains of pain at this time." (There was no indication from the nurses notes any intervention was done) ,[DATE] at 1:15 PM, "C/O and pain...sent to ER." ,[DATE] at 12 AM, "resident c/o pain 6 on scale of [MEDICATION NAME] ,[DATE] given." At 1 AM, "Resident states 2 on a scale of 10..." ,[DATE] at 12:20 PM, "c/o pain x1 today. PRN pain med administered c + results." ,[DATE] at 2:20 PM, "c/o hurting to back of L thigh. Pain med administered c + results..." No other nurses notes in February indicated any pain or pain assessment. Review of the physician's orders [REDACTED]. The resident received 41 times in February 2012. Review of the back of the MAR revealed 28 entries recorded. The nursing staff documented Narco given/requested for "pain", "hip/leg pain", "discomfort", "res request", "kidneys are killing me"and "pain pill". No pain assessments were documented related to the administration of the narcotic. Nurses documented "eff" for the follow up intervention. However, times were not consistently recorded. Three times, no follow up was

On the days of the Complaint Survey based on observation, interview, record review and review of the facility's policy on Pain Management and Assessment, Substandard Quality of Care was identified and the facility was notified on [DATE] at 2:45 PM. Ten of ten residents (Residents #1-#10) reviewed for accurate and completion of periodic Pain Evaluations failed to have pain assessments completed and documented prior to the administration of pain medications and failed to have pain assessments completed after the administration of the medications. Resident #10 had unrelieved and untreated pain on several occasions without physician notification of further interventions. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status (BIMS). Further review of Section J Health Condition revealed the resident was coded as receiving "as needed" pain medications, pain was present and the resident experienced pain frequently. The pain was noted to limit the resident's daily activities. Review of the Care Plan with problem onset date [DATE] revealed a problem area related to pain due to recent left femur fracture, back pain, [MEDICAL CONDITION] and spinal stenosis. The resident goal was "pain will be relieved with in one hr (hour) after receiving pain meds thru next review date. The approaches included "notify MD as indicated, assess location, frequency, duration and intensity of pain. Document assessment. Report increased pain trend to physician. Attempt non-pharmacological pain relief measures such as re positioning, back rubs. Document effectiveness. Administer pain medication as requested. Document effectiveness. Review resident pain management plan routinely and provide diversional activities, if applicable." Review of the Nurses Notes revealed on [DATE] at 5 PM "Resident C/O (complains of) pain to L (left) knee, observed knee c (with) swelling notes and res c/o pain." At 5:50 PM, the RP (responsible party) was contacted regarding the x-ray of the left knee. At 10 PM, "Resident taken to hospital 2 (secondary) fractured femur per MD order. C/O pain and discomfort, noted (increased) swelling. Family and MD notified." On [DATE] at 12 PM, "Returned to facility. N/O (nurses order) noted (no) surgery planned, too risky...Res medicated c 15 of [MEDICATION NAME] c good results, soft brace applied." (Further investigation revealed Resident #1's fracture occurred at approximately 10:45 AM on [DATE] due to an inappropriate transfer. However, the incident was not reported until the next day. The CNA reported to the nurse at 3 PM that the resident complained of knee pain. Again there was no pain assessment documented at that time.) Review of the physician's orders [REDACTED]. No pain assessment was conducted. Resident #1 then received 0.5 mg [MEDICATION NAME] at 5 PM after the x-ray of her left leg was obtained. No other pain assessment or interventions were noted on [DATE]. Review of the physician's orders [REDACTED]. The resident received 25 times between [DATE] and [DATE]. Review of the back of the MAR revealed the nurses were administering 5, 10 and 15 mg of [MEDICATION NAME], however, no pain assessments were documented to determine the resident's intensity, location, characteristics, or duration of the pain. In addition, there was not consistent documentation of the medication's effectiveness. The staff were reassessing the resident ,[DATE] hours after administration in some cases, however, 10 times had no time of the reassessment recorded. The re-assessments that were conducted after administration, staff were documenting + or "eff" indicating a positive result, however, there was not a pain assessment conducted at that time. Also, four administrations had no follow up assessment documented. One time, the resident had "mod effect" (moderate effectiveness) of the 10 mg [MEDICATION NAME] administered. No additional interventions were implemented at that time, nor was the physician notified for further instructions. Resident #1 was noted to be receiving Hospice services beginning on [DATE]. Resident #1 expired on [DATE]. Resident #1's pain medications were held on ,[DATE] twice and on [DATE] due to lethargy. The resident received her last dose of [MEDICATION NAME] on [DATE] at 12 PM, 24 hours prior to her death. Review of the Pain assessment dated [DATE] revealed the resident had no pain at present, scored a ,[DATE] on the Painad scale, had no nonverbal indicators of pain and was prescribed as needed Tylenol for pain. The Conclusion of the assessment was "no pain, intervention is not necessary. Re-assess quarterly or with onset of pain." Review of the Pain Assessment conducted on [DATE] revealed the resident verbalized pain of the left femur. No documentation was located related to the characteristics of the pain, however it was noted that the pain increased with movement. The resident reported pain of ,[DATE] at present, ,[DATE] one hour after medication and a ,[DATE] 3 hours after medication. The resident reported ,[DATE] was the worst the pain she experienced. Resident #1 received a ,[DATE] on the Painad scale indicating that she had occasional shortness of breath and hyperventilation, occasional moan or groan, low level speech with a negative disapproving quality, facial grimacing, tense distressed, pacing, fidgeting and was unable to console, distract or reassure. The section on Activities of Daily Living was not completed. Nonverbal indicators of pain were grimacing, clenched jaw, frowning, turned down mouth, moaning, crying, pallor, rubbing body parts, increased vital signs, clenched fists, wringing of hands and depressed mood. The pain was noted to be relieved by medication. No acceptable pain level was recorded. No scheduled medications were prescribed for the recent fracture. The resident was prescribed [MEDICATION NAME] ,[DATE] mg every 4 hours as needed for pain (no parameters were ordered to determine how much should be given at any one time), and Tylenol 325 mg-650 mg every 6 hours as needed for pain. The Conclusion was: "No pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident had short term and long term memory problems and was severely impaired with daily decision making abilities. The resident was noted to be dependent on staff for all needs and was tube fed. The resident was noted to be non-verbal and did not respond to questions on [DATE] during observations. Review of Section J Health Conditions revealed the resident was on scheduled pain medication and the resident pain interview should not be conducted related to the resident was rarely understood/stands. The staff assessment for pain was left "BLANK." However, none of these signs observed was "checked." Review of the Care Plan dated updated on [DATE] revealed the resident was at risk for pain related to [MEDICAL CONDITIONS], Stenosis and Contractures. Unable to voice needs. The goal was for the resident to be "free from pain/discomfort within one hour of nursing measures/administration of medications x 3 months." Approaches included: "assess residents level of pain and document, administer medications as ordered, observe for effectiveness of medication/nursing measures, assess need for routine pain management instead of prn, notify MD if current regime ineffective and assure position changes, adequate room temp etc." Review of the Nurses Notes revealed on [DATE] at 11:14 AM, "called to room by CNA, resident observed on floor lying on her left side over the legs of hoyer lift. Resident noted to be alert and responsive. Large hematoma noted to back of head. No open areas were noted. Resident was assisted back to bed x 3 staff members. Neuro checks WNL (within normal limits)..." At 11:30 AM, (Provider) called and informed...911 activated." At 11:40 AM, "Resident transferred via stretcher by EMS..." At 12:45 PM, "Received call from ER MD wanting information on residents condition and fall. Reported to (MD) that CNA informed nurse that resident slipped out of Hoyer lift and fell on floor." At 5 PM, "...no additional orders were received." Further review of the Nurses Notes revealed no pain assessment had been conducted related to the injury upon return from the hospital. In addition the nurses were documenting inconsistent partial pain assessments by documenting "no c/o pain", "no s/s distress." On [DATE] the resident was noted to have labored breathing at 11:30 AM. An as needed dose of [MEDICATION NAME] ,[DATE] every 6 hours for pain was added to the already scheduled twice daily dose. At 11:45 AM, the resident received a dose of the as needed [MEDICATION NAME], however no pain assessment was documented. Further review of the Nurses Notes from [DATE] through [DATE] revealed no documentation of pain or pain assessments. On [DATE] at 5:30 PM, "...D/C [MEDICATION NAME] PRN and (change) [MEDICATION NAME] order to ([MEDICATION NAME]) ,[DATE] [MEDICATION NAME] 7.5 ml every 4 hours while awake..." On ,[DATE] and [DATE] the nurses documented no distress, however there was no indication that the resident's pain was assessed. From ,[DATE] through ,[DATE] there was no pain assessment documented. On ,[DATE] at 3:30 PM "Resident s (without) c/o pain..." From ,[DATE] through ,[DATE] there was no indication of a pain assessment documented. On [DATE] at 2 PM, "no s/sx of pain or discomfort" was documented. On [DATE] at 3:30 PM, "no s/sx pain or discomfort" was documented again. No other pain assessment was documented. Review of the physician's orders [REDACTED]. No documentation on the back of the MAR was located related to a pain assessment or effectiveness. On [DATE] the resident received 2 doses of as needed [MEDICATION NAME] ,[DATE] at 12:15 PM and 9 PM. There was no documentation related to the 9 PM dose on the back of the MAR. Related to the 12:15 PM dose, the staff documented "[MEDICATION NAME] ,[DATE] per PEG for discomfort." There was no other pain assessment documented and no documentation of effectiveness was located. (No corresponding nurses notes either.) The resident was also noted to receive a scheduled dose of [MEDICATION NAME] ,[DATE] twice daily. Review of the [DATE] Physician order [REDACTED]. On [DATE] the resident received an as needed dose at 1 AM due to "grunting noise and s/sx of discomfort." No other pain assessment was documented and no follow up assessment was recorded. There were no corresponding nurses notes located. On [DATE] at 9 PM, the resident received [MEDICATION NAME] ,[DATE] for "grimacing." There was no documentation of a pain assessment and no follow up was recorded. Again, no corresponding nurses notes were located. Review of the February 2012 physician's orders [REDACTED]. The medication was held 48 times between [DATE] and [DATE]. Review of the back of the MAR revealed only 15 entries related to why the [MEDICATION NAME] was held. No pain assessments were documented to assure the resident was not in pain due to the held doses. Review of the [DATE] Physician order [REDACTED]. The medication was held 51 times between [DATE] and [DATE]. Review of the back of the MAR revealed only 5 entries related to reason why the medication was held all were due to resident was sleeping. No pain assessments were documented related to assure the resident was not in pain due to the held medications. Review of the Pain Evaluation dated [DATE] revealed the resident had pain due to [MEDICAL CONDITION] and "disbility." The resident was unable to express pain but yelled out at times. The resident was unable to express where pain was located but bilateral lower legs were contracted. The resident scored a ,[DATE] on the Painad scale indicating she yelled out, had a sad, frightened or frowning face and was distracted or reassured by touch or voice. No effect on function was documented. The resident had grimacing and yelling out checked as nonverbal indicators of pain. The resident was on a scheduled medication regimen and had as needed medication ordered that was documented as effective. An expected level of pain was not completed. The Conclusion was "No pain, intervention is not necessary. Re-assess quarterly or with onset of pain." The next evaluation completed was dated [DATE]. No general information was listed other than chronic pain BLE contractures. No pain scale was documented, no Painad scale was recorded, no effect on function was documented, no nonverbal indicators of pain were listed and no conclusion was recorded. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident received a ,[DATE] on the BIMS indicating mild impairment. Review of Section J Health Conditions revealed the resident was on both as needed and scheduled pain medications. The resident reported the presence of pain frequently. The verbal descriptor scale was "moderate." Review of the Care Plan dated [DATE] revealed a problem area of Pain was identified related to a recent fracture. The goal was pain "will be relieved within 1 hour after receiving pain meds." Approaches included "meds as ordered, encourage to reposition frequently, provide diversional activity, diet as ordered, labs as ordered, notify MD of unrelieved pain." Observation/Interview of Resident #3 on [DATE] at 9:20 AM revealed the resident sitting up in a wheelchair in her room. The resident reported pain to her right leg and stated that the nurse had already been in her room that morning to give her medications, however the resident reported that the nurse did not ask about her pain at that time. During an interview with the assigned nurse, she stated that she had administered the scheduled Tylenol and stated that the resident did not report pain to her at that time. The nurse promptly assessed the resident and informed the surveyor that the resident reported an ,[DATE] pain in her right leg. She stated that she administered an as needed dose of [MEDICATION NAME]. Review of the Nurses Notes revealed on [DATE] at 10:45 AM, "called to room by CNA. Res observed on floor beside bed in front of w/c (wheelchair). CNA reported that while attempting to transfer, s/c rolled back causing her to have to lower resident to floor. Res c/o bil knee pain and left lower leg pain. Denies hitting head. Res assessed by this nurse c moderate swelling noted to both knees s discoloration noted. (Physician) notified c order for x rays of areas. DON and family also notified of orders. Mobilex notified of x-rays bil knees and L tib/fib." At 11:58 PM, "In bed resting c both eyes closed. No c/o pain or discomfort and (no acute distress) noted." On [DATE] at 8 AM, "X-ray report called to (physician) of rt knee distal shaft fx. Order to send to ER for eval..." At 11 AM, "Res was transferred to the ER..." At 5:50 PM, "Res returned to the facility and to keep splint in place..." At 7 PM, the resident had "no complaints of pain or discomfort." On [DATE] on the night shift (7P-7A) "[MEDICATION NAME] given at 9 PM for pain and effective." On [DATE] at 9 PM, "Resident c/o leg pain. [MEDICATION NAME] ,[DATE] given for pain. Effective, will cont to monitor." There were no other pain assessments documented. Review of the X-Ray report taken on [DATE] revealed "Acute mildly displaced fracture of distal shaft of femur." The report was not read by the Radiologist until [DATE] at 8:06 AM. There was no indication that the facility contacted the physician for further orders related to the delay in x-ray results. The resident's pain was not assessed or managed. The resident had received her scheduled Tylenol, however, this intervention was in place prior to the acute fracture. Review of the Pain Evaluation dated [DATE] revealed the resident had pain related to "Distal shaft rt femur fracture." The resident reported the pain as throbbing and at present reported a ,[DATE] pain rating to the right leg. The resident's pain was not assessed, one hour or three hours after medication, nor was the worst and best rating recorded. The resident scored a ,[DATE] on the Painad scale indicating occasional shortness of breath, occasional moan or groan, sad, frightened face, tense, distressed and fidgeting. The effect on function was not assessed. Nonverbal indicators were grimacing and rubbing body parts. The acceptable level of pain was not assessed and the resident was noted to receive scheduled Tylenol and as needed [MEDICATION NAME]. The Conclusion was "no pain, intervention not necessary. Re-assess quarterly or with onset of pain. Another pain assessment was completed on [DATE] that documented no pain on assessment. The pain was not assessed related to medication administration, effect on function, non verbal pain indicators. The residents expected level of pain was not assessed and the conclusion was, "no pain, intervention not necessary." Review of the physician's orders [REDACTED]. The first dose was given on ,[DATE] at 9 PM (2 days after the fracture occurred). Review of the back of the MAR, only 7 entries were made related to the administration of the narcotic. Three of the seven entries documented [MEDICATION NAME] ,[DATE] for "pain." No other assessment was documented. The remaining four entries documented "leg pain." However, there was no indication which leg or where or any other pain assessment. Four times had an "eff" documented approximately one hour after administration, no other assessment was completed. Two times had a + documented without any other indication of assessment. One time had no follow up recorded. No corresponding nurses notes with pain assessments were located. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed the resident scored a ,[DATE] on the BIMS indicating no cognitive impairment. Review of Section J revealed the resident reported pain frequently and scored the pain as an ,[DATE]. She was noted to receive as needed medications only. Review of the Care Plan updated on [DATE] revealed a problem area of Pain was identified with a goal of pain relief within one hour of intervention. Approaches included "Administer meds as ordered, schedule labs/diagnostic works as ordered, report results to MD and follow up as needed, notify MD as needed, provide diversional activities, assess location, frequency, duration and intensity of pain. Document assessment, report increased pain trend to MD. Attempt non-pharmacological relief measures such as repositioning, back rubs, document effectiveness, review resident pain management plan routinely." Review of the Nurses Notes from [DATE] through [DATE] (last recorded note) revealed sporadic documentation of "no complaint of pain." No pain assessments were documented in the nurses notes. During observation and interview of the resident on ,[DATE] at 2:10 PM, the resident stated that she was "always in pain" and "always has to ask for pain pill." She stated that the nurses do not ask her about her pain. She stated that she would tell the nurses where the pain was but the nurses would not ask any other questions related to her pain. Review of the Physician order [REDACTED]. She also received two as needed doses of Tylenol 1 G. Review of the back of the MAR revealed 22 entries related to administration of the as needed medications. The staff documented "c/o pain", "c/o leg pain" and "c/o back pain". No other assessment was documented related to the pain. The nurses documented "eff" approximately one hour after administration of the medications, however, there was not a pain assessment conducted related to the effectiveness of the medication. No corresponding nurses notes were located related to the pain. Review of the February 2012 MAR and physician's orders [REDACTED]. She also received 2 doses of as needed Tylenol 1 G. Review of the back of the MAR revealed the nurses were documenting "pain", "general pain", "back pain", "arm pain" and "leg pain." On three occasions the nurses documented an ,[DATE] pain scale, however, no other assessment was completed. The nurses were also documenting "+" or "eff." The time of the reassessment was not consistently documented and there was no follow up assessment documented. No corresponding nurses notes were located related to the frequent pain. There was no indication that the physician was notified of the frequent pain. Review of the [DATE] physician's orders [REDACTED]. Review of the back of the MAR revealed 28 entries related to the administration of the medication. The nurses were documenting "general pain", "pain everywhere", "back pain", "pain" and "leg pain." Seven times the nurses documented 10+ for the pain scale. Two other pain scales were recorded. However, no other pain assessment was documented. The nurses were documenting "+" and "eff" for the follow up approximately ,[DATE] hours after the administration of the medications. Twice, no follow up was completed. Twice the resident had no relief from the pain. There was no indication the physician was contacted related to the unrelieved pain or the frequent reports of pain. No nurses notes were located for [DATE]. Review of the Pain Evaluation dated [DATE] revealed the resident had a history of [REDACTED]. No description of the pain was documented. No resident reported frequent pain in her lower back and occasional pain in her mid back. No pain was recorded at present. However, the pain was not assessed after medications or the worst and the best. The resident scored a ,[DATE] on the Painad scale indicating occasional labored breathing, occasional moan or groan, sad, frightened face, tense, distressed body language and was unable to be consoled or redirected. The resident had the following non verbal indicators listed: grimacing, clenched jaw, frowning, turned down mouth, moaning, crying, cursing, threatening gestures, rubbing body parts, increased vital signs, perspiration, clenched fists, wringing of hands, striking out at others and depressed mood." An acceptable level of pain was not assessed. The resident was noted to receive as needed [MEDICATION NAME] ,[DATE] every 6 hours for pain. The conclusion was "no pain, intervention not necessary." Review of the Pain Evaluation dated [DATE] revealed the resident reported no pain at present, pain of a ,[DATE] one hour after medication in the lower back and ,[DATE] in the mid back region. A rating of ,[DATE] three hours after administration in the lower back and a ,[DATE] in the mid back. The resident reported a ,[DATE] was the worst pain she experienced and the best was no pain. The resident again scored a ,[DATE] on the Painad scale. No effect on function was assessed. The following non verbal pain indicators were documented: clenched jaw, frowning, tightly shut lips, turned down mouth, moaning, crying, screaming, cursing, rubbing body parts, increased vital signs, perspiration, clenched fists and depressed mood." The resident's acceptable level of pain was assessed as a ,[DATE]. The resident was prescribed [MEDICATION NAME] for back pain scheduled twice daily and received as needed Tylenol and [MEDICATION NAME]. The Conclusions were "no pain, intervention is not necessary." (The [MEDICATION NAME] was originally ordered in 2009 and was not a new medication.) The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the Admission MDS revealed the resident scored a ,[DATE] on the BIMS assessment indicating moderate impairment. Review of Section J revealed the resident reported occasional pain of a ,[DATE]. Review of the Care Plan dated [DATE] revealed a problem area of alteration in comfort related to pelvic fracture. The goal was to have the pain relieved within one hour of nursing measures/administration of medication. Approaches included: "Assess level of pain and document, administer medications as ordered, observe for effectiveness of medication/nursing measures, assure position changes, adequate room temp, etc, assess the need for routine pain management instead of PRN and notify MD if current regime is ineffective." Review of the physician's orders [REDACTED]. Review of the back of the MAR revealed the resident received the narcotic for "c/o pain." Twice a pain scale of ,[DATE] was recorded. Three times the follow up was documented as "effect", however, no other assessment was recorded. One time no follow up was recorded. Review of the Nurses Notes revealed on ,[DATE] at 11 PM, "complaint of back pain, [MEDICATION NAME] ,[DATE] given for pain and effective." No other assessment was completed related to the reported pain. Further review revealed "no co pain", "no s/sx pain" and "voices no complaints" were documented. There were no corresponding nurses notes related to the administration of the as needed medication. Review of the Pain Evaluation dated [DATE] revealed the resident had a pelvic fracture that occurred on [DATE] and reported the pain as throbbing. The pain was not assessed at present, after medication administration or the worst and best the pain got. The resident scored a ,[DATE] on the Painad scale indicating occasional labored breathing, occasional moan or groan, sad or frightened facial expression and was reassured by voice or touch. The pain was noted to effect the resident's participation in activities. The non verbal indicators of pain were wrinkled brow, moaning and altered gait/posture. The resident reported a ,[DATE] as an acceptable level of pain and was noted to receive an as needed narcotic. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed the resident scored a ,[DATE] on the BIMS indicating no cognitive impairment. Review of Section J revealed no pain was recorded as present. Review of the Care Plan dated [DATE] revealed a problem area of alteration in comfort was identified with a goal of free from pain/discomfort within one hour of nursing measures/administration of medications. Approaches included assess level of pain and document, administer medication as ordered, observe for effectiveness, assess the need for routine pain management, notify MD if current regime is ineffective..." Review of the Nurses Notes from [DATE] through [DATE] (last entry noted) revealed no documentation of a pain assessment. Review of the Physician order [REDACTED]. No as needed medications were prescribed. Review of the Pain Evaluation dated [DATE] revealed the resident had [MEDICAL CONDITION] and did not verbalize pain. No pain was present at the time of assessment. The pain was not assessed at present, one or three hours after administration or the worst or best the pain got. The resident scored a ,[DATE] on the Painad scale. The resident was not assessed for the effect on function or non verbal indicators. An acceptable level of pain was not assessed. The Conclusions were "no pain, intervention is not necessary. Another Pain Evaluation dated [DATE] revealed the resident had [MEDICAL CONDITION] and had experienced pain within the last 5 days. However, the pain characteristics were not assessed. The Pain Location/Type/Frequency/Intensity and Duration Section was not completed. The resident was not assessed for Pain Effect on Function or Non Verbal Pain Indicators. The resident was noted to received scheduled Tylenol. No acceptable pain level was assessed, nor was the effectiveness of the medication. No Conclusions were documented. Observation of the resident on [DATE] at 1:30 PM revealed the resident sitting up in her wheelchair in her room. A splint to the left arm was noted. The resident stated that she has aches and pains and takes Tylenol daily for pain relief. She stated that the nurses were in and out of her room checking on her frequently during the day and has not required anything other than Tylenol for pain relief. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. The resident was noted to have refractured his hip on [DATE] while at the facility. Review of the Significant Change MDS dated [DATE] revealed the resident scored a ,[DATE] on the BIMS assessment indicating moderate cognitive impairment. Review of Section J revealed the resident reported pain occasionally and rated the pain as a ,[DATE]. The resident was noted to be on both scheduled and as needed pain medications. Review of the Care Plan dated [DATE] revealed a problem area of alteration in comfort due to [MEDICAL CONDITION] with a goal of pain relief within one hour of nursing intervention. Approaches included "assess resident's level of pain and document, administer medication as ordered, observe for effectiveness, assess the need for routine pain management, notify MD if current regime is ineffective..." Review of the Nurses Notes revealed the following entries: [DATE] at 10:25 AM "Left Hip X-ray...C/O pain left leg/hip. PRN pain med given..XXX,[DATE] (no time recorded) "c/o pain to L hip at 5 AM, Narco ,[DATE] given and effective." ,[DATE] (no time recorded), "Resident c/o pain to lt leg c brace, Narco ,[DATE] given for pain and effective." ,[DATE] at 2:30 PM, "Request pain med for pain. [MEDICATION NAME] PRN given c some relief..." ,[DATE] at 5 AM, "Res complaint pain to lt leg with brace, Narco ,[DATE] given and effective." ,[DATE] at 5 AM, "Resident complaint pain to lt leg, Narco 500 mg given, effective..." On ,[DATE] at 3:10 PM, "Res c/o leg/hip pain today, requested pain med. PRN pain med administered + results." ,[DATE] at 3:30 PM, "requests pain med r/t leg pain. Administered + results." ,[DATE] at 7 PM, "complains of pain at this time." (There was no indication from the nurses notes any intervention was done) ,[DATE] at 1:15 PM, "C/O and pain...sent to ER." ,[DATE] at 12 AM, "resident c/o pain 6 on scale of [MEDICATION NAME] ,[DATE] given." At 1 AM, "Resident states 2 on a scale of 10..." ,[DATE] at 12:20 PM, "c/o pain x1 today. PRN pain med administered c + results." ,[DATE] at 2:20 PM, "c/o hurting to back of L thigh. Pain med administered c + results..." No other nurses notes in February indicated any pain or pain assessment. Review of the physician's orders [REDACTED]. The resident received 41 times in February 2012. Review of the back of the MAR revealed 28 entries recorded. The nursing staff documented Narco given/requested for "pain", "hip/leg pain", "discomfort", "res request", "kidneys are killing me"and "pain pill". No pain assessments were documented related to the

On the days of the Complaint Inspection and Partiel Extended Survey, based on observations, record review, interview and review of the facility policy on Transfers, Substandard Quality of Care was identified and the facility was informed on [DATE] at 2 :45 PM related to the failure of the facility to provide adequate supervision to prevent accidents. Resident #1, #2, #3 were transferred inappropriately by facility Certified Nursing Assistants (CNA) resulting in significant injury. The facility failed to provide sufficient training to the CNAs and failed to ensure each CNA was aware of the current transfer method. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status (BIMS). The resident was coded as requiring extensive, two person assist with transfers. Review of the Kardex revealed Resident #1 was to be transferred with the assist of two people. Review of the Nurse's Notes revealed on [DATE] at 5 PM "Resident C/O (complains of) pain to L (left) knee, observed knee c (with) swelling notes and res c/o pain." At 5:50 PM, the RP (responsible party) was contacted regarding the x-ray of the left knee. At 10 PM, "Resident taken to hospital 2 (secondary) fractured femur per MD order. C/O pain and discomfort, noted (increased) swelling. Family and MD notified." On [DATE] at 12 PM, "Returned to facility. N/O (new order) noted (no) surgery planned, too risky....Res medicated c 15 of Oxycodone c good results, soft brace applied." ( Review of the facility investigation revealed Resident #1's fracture occurred at approximately 10:45 AM on [DATE] due to an inappropriate transfer. However, the incident was not reported until the next day. The CNA reported to the nurse at 3 PM that the resident complained of knee pain. Again there was no pain assessment documented at that time. Review of the Physician's Orders and Medication Administration Record (MAR) for [DATE] revealed Resident #1 received Tylenol 650 mg on [DATE] at 3 PM for complaints of pain to bilateral legs. No pain assessment was conducted. Resident #1 received 0.5 mg Ativan at 5 PM after an x-ray of her left leg was obtained. No other pain assessment or interventions were noted on [DATE]. Review of the 5 Day Report dated [DATE] revealed CNA #1 "transferred (Resident #1) by herself when she was listed as a two person assist resulting in injury to the resident. Employee required to comply with company policy. We feel that failing to follow policy resulting in injury to a resident is neglectful, CNA terminated." Review of the facility obtained statement from CNA #1 revealed: "I (CNA #1) was putting (Resident #1) in the chair, she was saying her leg was hurting. I (CNA #1) transferred her by myself with (CNA #2) holding the chair for me." During a telephone interview on [DATE] at 11:15 AM, CNA #1 stated that she was transferring the resident from the bed to her chair. CNA #1 stated that she used her feet and legs to "block" Resident #1's legs from sliding. CNA #1 stated that the resident did not ever fall. CNA #1 stated that CNA #2 was in the room and was holding the wheelchair to keep it from rolling, however was not actually assisting with the transfer of the resident. CNA #1 stated that she working with Resident #1 frequently and "no one ever used a two person assist" to transfer the resident because the resident was able to assist with her own transfers. CNA #1 stated that she received training on transfers during orientation ([DATE]) and could not remember any other time she received training. She stated she was aware that the transfer method was listed on the resident's door, however if there was a change, the CNAs were responsible for contacting the nurses to see if there had been a change. Review of the facility obtained statement from CNA #2 revealed "I (CNA #2) walked in (Resident #1's) room and I seen (CNA #1) ready to transfer (Resident #1) from the bed to the chair, the chair was moving so I ask (CNA #1) do she need help, she said yes hold the chair so I held the chair while (CNA #1) transferred her to the chair." During an interview on [DATE] at 12:30 PM, CNA #2 stated that she was walking by the room and saw CNA #1 transferring Resident #1 to the chair. She stated that the chair was rolling even though the brakes were activated. CNA #2 stated that she went into the room and steadied the chair for the remainder of the transfer but did not actually assist with the transfer. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident had short term and long term memory problems and was severely impaired with daily decision making abilities. The resident was noted to be dependent on staff for all needs and was tube fed. The resident was noted to be non-verbal and did not respond to questions on [DATE] during observations. Review of the Kardex revealed Resident #2 was to be transferred with a Hoyer Lift and two staff members. Review of the Nurse's Notes revealed on [DATE] at 11:14 AM, "called to room by CNA, resident observed on floor lying on her left side over the legs of hoyer lift. Resident noted to be alert and responsive. Large hematoma noted to back of head. No open areas were noted. Resident was assisted back to bed x 3 staff members. Neuro checks WNL (within normal limits)..." At 11:30 AM, (Provider) called and informed... 911 activated." At 11:40 AM, "Resident transferred via stretcher by EMS..." At 12:45 PM, "Received call from ER MD wanting information on residents condition and fall. Reported to (MD) that CNA informed nurse that resident slipped out of Hoyer lift and fell on floor." At 5 PM, "...no additional orders were received." Review of the 5 Day Report dated [DATE] revealed CNA #3 "was transferring resident via hoyer lift from bed to chair for shower. As she moved her from over the bed, Resident slipped out of lift pad and landed on floor beside bed-hitting the back of her head... Hematoma to back of head. Approx 4 inches in circumference. Purple and red in color. Very swollen. No bleeding... Resident suffered injury r/t neglect of CNA to follow company policy of 2 person assist c Hoyer at all x's." Review of the facility obtained statement from CNA #3 revealed: "I (CNA #3) was getting (Resident #2) up for a shower. I was beginning to move her from over the bed, and as I was pulling the lift from over the bed she slipped out of the lift pad. I am aware of the policy and I should not have attempted to do this by myself without help..." CNA #3 was unavailable for interview during the survey. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum (MDS) data set [DATE] revealed the resident received a ,[DATE] on the BIMS indicating mild impairment. Review of the Kardex revealed Resident #3 was to be transferred with a stand up lift and two person assist. The resident's transfer method was changed from a one person assist to a stand up lift at the end of [DATE]. Review of the Nurse's Notes revealed on [DATE] at 10:45 AM, "called to room by CNA. Res observed on floor beside bed in front of w/c (wheelchair). CNA reported that while attempting to transfer, s/c rolled back causing her to have to lower resident to floor. Res c/o bil knee pain and left lower leg pain. Denies hitting head. Res assessed by this nurse c moderate swelling noted to both knees s discoloration noted. (Physician) notified c order for x rays of areas. DON and family also notified of orders. Mobilex notified of x-rays bil knees and L tib/fib." At 11:58 PM, "In bed resting c both eyes closed. No c/o pain or discomfort and (no acute distress) noted." On [DATE] at 8 AM, "X-ray report called to (physician) of rt knee distal shaft fx. Order to send to ER for eval..." At 11 AM, "Res was transferred to the ER..." At 5:50 PM, "Res returned to the facility and to keep splint in place..." Review of the X-Ray report taken on [DATE] revealed "Acute mildly displaced fracture of distal shaft of femur." The report was not read by the Radiologist until [DATE] at 8:06 AM. There was no indication that the facility contacted the physician for further orders related to the delay in x-ray results. Review of the 5 Day Report dated [DATE] revealed CNA #4 "report to nurse that while transferring resident to w/c, w/c rolled back causing CNA to lower resident to floor. Res c/o bil knee and left leg pain. X-ray obtained and revealed right femur fracture of the distal shaft. Resident is to be transferred w a stand lift. CNA used 1 person assist during transfer." Review of the facility obtained statement from CNA #4 revealed: "Be over on 500 for a period of time and I was used to transferring her 1 person. I wasn't aware they changed the transfer method the chair was locked but still rolled so I eased (Resident #3) to the ground and got help." During a telephone interview on [DATE] at 12 PM, CNA #4 stated that she was very familiar with Resident #3 and known the resident to be a one person assist with transfers. She stated that she was aware the transfer method was on the resident's door, however, because she was familiar with the resident she did not look at the door. She stated that no one had informed her that the resident's method of transfer had changed. She stated that whenever there was a change with the residents the CNAs were responsible for asking the nurses. During an interview on [DATE] at 11 AM, the Nurse Consultant stated that the Director of Nurses and the Therapy Department were responsible for in-servicing the staff related to transfers. In services were requested related to the above three staff members. The Nurse Consultant confirmed the last training CNA #1, CNA #2 and CNA #3 received on transferring residents was in [DATE]. During an interview on [DATE] at 2 PM, the Interim Director of Nurses and the Nurse Consultant stated that the transfer method was on each resident's door and was on the Kardex for the CNAs to review. Both confirmed that the CNAs should be informed of when there was a change in transfer. The Nurse Consultant stated that improper transfers was identified as a problem area over a year ago. She stated that "transfer audits" were completed randomly. The Nurse Consultant stated that there "were not as many people out there as before" supervising the CNAs. The Nurse Consultant confirmed that what was in place related to improper transfers was not effective due to three CNAs transferring three residents inappropriately resulting in significant injury. Review of the Transfer Policy revealed "Therapy will screen all new residents to determine safe transfer method. Use two person assist until therapy has completed its screen. Resident transfer method will be placed on the resident name plate using a coding system. Two staff members will be present when a lift is used. If resident transfer status is unclear, obtain clarification of status from DON, Unit Manager or Rehab Director before attempting transfer. Failure to follow transfer status posed for each resident will result in disciplinary action up to and including termination."

On the days of the Complaint Inspection and Partial Extended Survey, based on observations, record review, interview and review of the facility policy and procedure on Pain Management, the facility failed to implement its resources effectively to ensure each resident's pain was assessed and managed as appropriate. Ten of ten residents did not have routine or reliable pain assessments completed per policy. Ten of ten residents' pain was not assessed prior to administration of pain medication and a follow up assessment was not documented. The Residents' pain was left unrelieved and untreated by the facility staff. The failure of the facility to provide the necessary supervision to prevent accidents for Residents #1, #2, and #3. The findings included: During an interview on 3/27/12 at 2 PM, the IDON and the Nurse Consultant stated that pain assessments should be completed at least every shift. Periodic Pain Evaluations were done upon Admission, with a change in pain medication or a change in condition. Both stated that the nurses should be asking the residents if they are experiencing pain during the medication pass. The Nurse Consultant stated that the nurses should be assessing pain prior to therapy and medicating as indicated. She also stated that the nurses should be assessing pain prior to the administration of the medication and expected that the nursing staff document the location, quality and intensity of the pain on the back of the MAR indicated [REDACTED]. The IDON was asked how other disciplines and other nurses would know if the pain regime was effective, she stated that the Pain Evaluations that were completed periodically would document what the baseline level of pain was as well as what an acceptable level of pain was for the individual. The IDON was asked how the Interdisciplinary Team could determine that information if the periodic Pain Evaluations were incomplete or inaccurate. The IDON and Nurse Consultant confirmed the incomplete and inaccurate pain assessments. The Nurse Consultant stated that if the residents pain was increasing in intensity or unrelieved by the nursing interventions then the physician should be notified and would expect the nurses to document the change. The Nurse Consultant and IDON confirmed Resident #10's unrelieved and untreated pain and confirmed that the physician was not notified of those incidents. Both confirmed the resident's multiple refusals of dressing changes, whirlpool therapy, ostomy care, Foley Catheter care and meals. Both the IDON and Nurse Consultant confirmed that the pain assessments that were documented were not sufficient. The Nurse Consultant stated that the nurses should be documenting one hour after medication administration to determine the effectiveness of the pain medication. She stated that she did not necessarily expect the staff to perform another pain assessment but expected them to document "effective." She confirmed that "effective" did not evaluate the resident's pain and did not indicate whether the resident reached an acceptable level of pain or if further intervention could be required. During a follow up interview, the Nurse Consultant confirmed the policy as the facility's only current policy on Pain Management and Assessment. The Nurse Consultant verified that the policy did not address a complete pain assessment per acceptable standards of nursing practice. She also verified that the policy did not address pain assessments upon administration of a pain medication or address the necessary follow up assessment after the administration of the pain medication. The Nurse Consultant confirmed that the Pain Management policy was insufficient to address the pain needs of the residents. The Administrator was notified of the concerns with Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 related to pain assessment and pain management. Cross Refer to F 309 as it relates to the failure of the facility to ensure each resident's pain was assessed, treated and the necessary documentation was in place. Cross Refer to F 323 as it relates to the failure of the facility to provide the necessary supervision to prevent accidents.

On the days of the Complaint Inspection and Partial Extended Survey, based on observations, record review, interview, review of the facility inservice's, review of the facility's policies and procedures, the facility failurd to identify pain assessment/management as a concern and failed to implement an effective action plan related to an identified concern of improper transfers. The findings included: During an interview on 3/27/12 at 2 PM, the Interim Director of Nurses and the Nurse Consultant stated that improper transfers was identified as a problem area over a year ago. She stated that "transfer audits" were completed randomly. The Nurse Consultant stated that there "were not as many people out there as before" supervising the CNAs. The Nurse Consultant confirmed that CNAs #1, #2 and #3 were last trained on transfers in April 2010. The Nurse Consultant confirmed that what was in place related to improper transfers was not effective due to three CNAs transferring three residents inappropriately resulting in significant injury. Review of the Action Plan related to Appropriate Transfers was identified in January 2010. Actions put in place were "100% audit of all residents for safest method of transfer...PCR's updated on each resident...door labeling system...Safety training...Plan on how to communicate transfer needs prior to discharging from therapy...Random observations (3 per unit/day)..." The Target date was 3/12/10 and 3/18/10. The Evaluation of the Action Plan on 6/2010 was "Transfers audit randomly." Review of the Transfer Audits revealed 1-5 staff members were observed transferring residents using a variety of methods. CNA #1 was observed on 12/20/11 transferring a resident with the correct method. CNA #3 and #4 were not observed. During a follow up interview, the Interim Director of Nurses and the Nurse Consultant confirmed that Pain Assessments and Pain Management were not identified as areas of concern by the Quality Assurance Committee. The Administrator was notified of the concerns with Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 related to pain assessment and pain management. The Administrator stated that the facility was changing Provider groups and the change over was already in progress. Cross Refer to F 309 as it relates to the failure of the facility to ensure each resident's pain was assessed, treated and the necessary documentation was in place. Cross Refer to F 323 as it relates to the failure of the facility to provide the necessary supervision to prevent accidents.