Every finding on record at Grove of Skokie, The

Based on observation, interview, and record review the facility failed to provide needed care and services in accordance with resident's plan of care as ordered by physician, facility's protocol, and professional standard of practice. This deficiency affects two (R2 and R4) of three residents reviewed for Quality of care. Findings include:R2On 9/2/25 at 10:21AM, Observed R2 up in wheelchair. She is alert with cognitive and communication impairment due to intellectual disability. She needs assistance with ADLs (Activity of daily living) and transfers. Assessed skin condition of R2's bilateral under the breast with V8 LPN (Licensed Practical Nurse) and V9 CNA (Certified Nurse Assistant). Observed redness under both breasts. V9 CNA said that she applied this morning Vitamin D ointment. V8 LPN said that R2 has fungal rash, and she has an order of Nystatin powder twice daily, but she has not applied it yet. On 9/3/25 at 10:41AM, Reviewed R2's medical records with V4 Wound Care Nurse. V4 said that R2 's Braden scale upon admission on [DATE] indicated score of 19 at high risk for skin impairment. She developed fungal rash under the breast as reported by nursing staff due to complaint of family member. She said that she observed the skin impairment under R2's bilateral breast but did not do the assessment but initiated the treatment order on 8/25/25. She also said she did not update care plan. She said that their protocol requires written assessment of skin impairment to be documented in wound assessment or progress notes, notify the physician for appropriate treatment order and update the care plan. She said that she just updated the care plan yesterday 9/2/25 when surveyor asked for it. She is not aware that group home case manager came in for complaint on 8/20/25 based on grievance report completed by V2 DON. V4 said that she did not update R2's family member of the treatment obtained for the redness under the breast. V4 said that Vitamin D ointment is not an appropriate treatment for fungal rash under the breast. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Displaced fracture of olecranon process with intraarticular extension of right ulna, Cognitive communication deficit, Genetic related intellectual disability, Disorder of psychological development, Need for assistance with personal care, Difficulty walking, unsteadiness of feet. Physician order sheet indicated Nystatin external powder 100,000 unit/gm apply under both breasts topically every day and evening shift for fungal rash. Cleanse under the breast area with soap and water then apply powder under breast on affected areas ordered 8/25/25. No care plan formulated for under the breast fungal rash until 9/2/25. No documentation of under the breast fungal rash skin assessment and identification in R2's medical record. R2's admission Braden skin assessment indicated at high risk for skin impairment. R2's grievance form completed by V2 DON dated 8/20/25 indicated that R2's home care case manager presented concern about R2's redness under the breast. No documentation of assessment done. Treatment order not obtained until 8/25/25. R4On 9/2/25 at 11:02AM, Observed R4 lying in bed with low air loss mattress. He is alert and responsive to simple questions. He needs maximum to total care assistance with ADLs and transfers. V8 LPN said that R4 has sacral and right hip wound dressing. On 9/2/25 at 11:15Am, V2 DON (Director of Nursing) said that V4, Wound care nurse, is not yet in the building but will come later. She said that the floor nurse does the wound treatment in absence of wound care nurse. Informed V2 that surveyor will observe V8 LPN for R4's wound care. On 9/2/25 at 11:24AM, V8 LPN and V6 LPN reviewed R4's treatment orders and prepared for wound treatment. R4 has left AKA (Above the knee amputation). R4 repositioned to his right side. Observed no sacral wound dressing. R4 has moderate amount of soft brown bowel movement in his adult disposable brief. Observed redness with 100% epithelization tissue. V8 cleansed with NSS. Applied Nystatin powder 100,000 unit/gram to the sacral, applied gauze and covered with bordered gauze dressing. V8 also applied nystatin powder to perineal area. Then R4 repositioned to his left side. V8 removed the wound dressing saturated with moderate serosanguinous drainage. V8 cleansed with NSS. R4 has red wound tissue 50% granulation with 50% yellowish slough attached to the wound base. V8 applied calcium alginate and medical grade honey, gauze and covered with bordered gauze dressing. On 9/3/25 at 10:41AM, Reviewed R4's medical records with V4 Wound Care Nurse. V4 said that R4's re-admission Braden scale assessment dated [DATE] indicated high risk for skin impairment. He has DTI on sacrum and unstageable pressure ulcer on right hip. He has daily dressing and PRN to both sacral and right hip. She said that it's their protocol to follow physician orders in providing wound treatment. The floor nurses are knowledgeable to perform wound care as indicated in treatment record /Physician order. Informed above observation made during wound care with V8 LPN and V6 LPN. R4 is re-admitted on [DATE] with diagnosis listed in part but not limited to Acquired absence of left leg below the knee, Cognitive communication deficit, Dysphagia, Lack of coordination, Difficulty walking, Dermatitis, Type 2 Diabetes Mellitus, Parkinson's disease. Physician order sheet indicated: Right hip: Cleanse with normal saline, apply medical grade honey to wound bed, cover with calcium alginate and secure with bordered foam dressing daily and as needed. Sacrum: cleanse with normal saline, apply skin prep to site and cover with bordered foam dressing daily and as needed. Nystatin external powder 100,000 unit/gm apply to perineal area topically every day and evening shift for redness and itching. Comprehensive care plan indicated: R4 has an actual impairment to skin integrity related to contractures, Braden score and medical diagnosis. Left AKA- surgical wound, Sacrum- DTI (Deep tissue injury), Right hip- unstageable, and perineal fungal infection. He has an ADL self-care performance and impaired mobility. R4's wound /skin assessment report completed by V14 Wound care Nurse Practitioner dated 8/27/25 indicated: Sacrum Pressure ulcer, DTI, 2cm x 2cm x 0cm, 100% epithelial. Right hip Pressure ulcer, Unstageable, 2.8cm x 3cm x0.3cm, 40% slough, 60% granulation, peri wound-erythema, moderate amount of serosanguineous exudate. re-admission Braden scale assessment completed on 8/5/25 indicated at high risk for skin impairment. On 9/3/25 at 12:01PM, Informed V3 ADON of above observation made and concerns identified to R2 and R4. V3 said that V4 Wound nurse or floor nurse should document newly identified skin impairment to resident's wound assessment or progress notes, call physician for appropriate treatment order, update care plan and notify family member. The nurses should follow the physician orders when providing wound care. On 9/3/25 at 2:18PM, Informed V1 Administrator, V2 DON and V15 Nurse Consultant of concerns identified to R2 and R4. Facility's policy on Skin Care Regimen and Treatment Formulary reviewed 7/3/25 indicated: Policy Statement: it is the policy of the facility to ensure prompt identification, documentation and to obtain appropriate treatment for residents with skin breakdown. Procedures: 1. Charge nurse must document in the electronic health record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse or designee unless otherwise indicated by patient's attending physician.a) Pressure injuriesc) Other skin conditions5. Refer any skin breakdown to the skin care team and physician including wound physician/NP for further review and management as indicated.7. Notify the patient family/next of kin or POA for any new skin alteration that is identified during stay at the facility. 11. Treatment protocol: III. Stage 3 and Stage 4: Calcium alginate, Thera Honey, Deep tissue Injury (DTI): Foam dressinge) Rashes associated with allergy, dermatitis:*Incontinent rash with yeast infection: Antifungal: Triamcinolone/NystatinFacility's policy on Wound Care Guidelines reviewed 1/24/24 indicated: Procedures: 9. Documentation: c. The care plan shall be evaluated and revised based on resident's response to treatment, treatment, goals, and outcomes.d. The resident's skin alteration/breakdown shall be documented in the resident's clinical records in accordance with the facility's policy and in compliance with current regulatory standards. 12. Wound assessment for non-pressure skin alterations: non-pressure skin alterations documentation shall include but are not limited to perineal dermatitis, excoriation, skin tears, cuts, abrasions, surgical wounds, burns, rashes and abrasions and wound related pain. Facility's policy on Physician orders revised 7/3/5 indicated: Policy statement: It is the policy of this facility to ensure that all resident/patient medications, treatment, and plan of care must be accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. 9. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director. Facility's policy on Care plan revised 6/30/25 indicated: Policy statement: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Procedures: 5. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on interview and record review, the facility failed to conduct a PASARR (pre-admission screening and resident review) for residents in the facility for a mental disorder or related condition prior to being admitted and failed to ensure residents identified with a mental disorder or related condition were evaluated and provided care in the most appropriate setting for 4 (R2, R4, R7, and R25) of 6 residents reviewed for PASARR screening. Findings include: R2 is [AGE] years of age. R2's medical diagnoses include but are not limited to Dementia diagnosed 6/14/24, Schizoaffective disorder upon admission, Major Depressive Disorder upon admission, and Anxiety upon admission. R2's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 11 out of 15. A score of 8-12 indicates R2 has moderate cognitive impairment. On 05/07/25 at 1:14 PM, V10 Admissions Director was inquired of R2's PASARR screening. V10 said, I just started a year ago. I know the PASARR screening was started in 2022 or 2023. I didn't know R2 was supposed to be screened. V10 did not provide a PASARR screening for R2. V10 provided R2's OBRA (Federal Omnibus Budget Reconciliation Act) pre-admission screening from June 1996. On 05/07/25 at 01:21 PM, review of R2's census indicates he was admitted to the facility on [DATE]. Upon review of R2's medical record, there was no documentation of a PASARR (preadmission screening resident review) upon admission. R2's current physician orders document the following medications- Ativan Oral Tablet 1 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth two times a day. (Antianxiety medication) and Risperidone Oral Tablet 4 MG Give 1 tablet by mouth two times a day for schizophrenia, bipolar. (Antipsychotic medication). R4 is [AGE] years of age. R4 was admitted to the facility on [DATE]. R4's medical diagnoses include but are not limited to Dementia and Schizophrenia diagnosed on admission. Review of R4's electronic medical records does not document a PASARR screening upon admission. R4's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 3 out of 15. A score of 0-7 indicates R4 has severe cognitive impairment. On 05/07/25 at 11:56 AM, V10 provided R4's preadmission screening and resident review submitted on 5/7/25 at 10:51 AM. V10 Admissions Director was inquired of the newly submitted information. V10 said, R4 never had one so I ran it today. V10 submitted a level 1 screening to the state appointed agency on 5/7/25 when inquired of R4's screening. R4's current physician orders document the following - Behavior Monitoring for Schizophrenia: Monitor for the following: Delusion, Hallucinations, Disorganized speech, Grossly disorganized or catatonic behavior and Negative Symptoms (e.g. reduced emotional expression). There are no current medications related to her diagnoses. R7 is [AGE] years of age. R7 was admitted to the facility on [DATE]. R7's medical diagnoses include but are not limited to Epilepsy, Major Depressive Disorder, and Schizophrenia diagnosed on admission. Dementia was diagnosed on [DATE]. Review of R7's electronic medical records does not document a PASARR screening upon admission. R7's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 13 out of 15. A score of 13-15 indicates R7 is cognitively intact. On 05/07/25 at 11:00 AM, V10 provided R7's preadmission screening and resident review submitted on 5/7/25 at 10:42 AM. V10 Admissions Director was inquired of the newly submitted information. V10 said, R7 never had one so I ran it today too. V10 submitted a level 1 screening to the state appointed agency on 5/7/25 when inquired of R7's PASARR screening upon admission. R7's current physician orders document the following medications- Haloperidol Tablet 2 MG Give 1 tablet by mouth two times a day for Anxiety Disorder (Antipsychotic medication), Zoloft Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression (Antidepressant medication), and Ativan Oral Tablet 1 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth three times a day for Anxiety. R25 is [AGE] years of age. R25's medical diagnoses include but are not limited to Dementia diagnosed 10/1/22, Schizoaffective Disorder, Major Depressive Disorder, and Visual Hallucinations diagnosed upon admission. R25's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 3 out of 15. A score of 0-7 indicates R25 has severe cognitive impairment. On 05/06/25 at 01:43 PM, V1 Administrator was inquired of R25's PASARR screening. V1 said, R25 did not have a PASARR assessment done. On 05/07/25 at 11:19 AM, review of R25's electronic medical record, no assessment was found. V10 Admissions Director initiated R25's PASARR screening upon surveyor request on 05/06/2025. R25 was admitted to the facility on [DATE]. Upon review of R2's medical record, there was no documentation of a PASARR (preadmission screening resident review) upon admission. Upon review of R25's electronic medical record, there was no documentation of a PASARR (preadmission screening resident review) upon admission. R25's current physician orders document the following medications- Olanzapine Oral Tablet 5 MG Give 1 tablet by mouth at bedtime. (Antipsychotic medication) and Mirtazapine Oral Tablet 30 MG Give 1 tablet by mouth at bedtime for depression, anxiety. (Antidepressant medication). The facility did not provide a policy regarding PASARR screening. Resident #25 PASARR 05/06/25 01:43 PM V1 said, R25 did not have a PASARR assessment done. 05/07/25 11:19 AM No assessment, initiated upon surveyor request on 05/06/2025.

Based on interview and record review, the facility failed to assess pressure ulcer for 1 (R105) of 4 residents reviewed for pressure ulcers in a sample of 50. Findings include: R105 is an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: congested heart failure, atrial fibrillation, and osteomyelitis of the vertebral, sacral, and sacrococcygeal region. On the (MDS) Minimal Data Set assessment of 4/4/2025, section C, the BIMS (Brief Interviewed Mental Status) score was 11/15 and indicates moderate cognitive impairment. On MDS of 4/4/2025, GG section R105 requires partial/moderate assistance - Helper does less than half the effort. The helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort. Behavior Section E dated 1/24/205 and 2/10/2025 showed no refusal care behavior. On 5/5/2025 at 10:36 AM, R105 was observed in his room, upset because staff members just told him that he had to go to the hospital to treat his buttocks wound and did not want to talk about his care and just said, I don't feel good. Record review of wound treatment of the sacrum for April 2025 and May 2025, R105 only refused treatment on one day, dated 4/5/2025. Record review of 5/5/2025 hospital records read: R105 feels 'lousy and stated he is in pain and the sacrum wound is painful, moving around makes the pain worse. V19 (Hospital Physician) assessment described the sacrum wound as unstageable but I can see muscle, it is foul smelling with purulent discharge. On 05/05/25 at 2:32 PM, V7(Registered Nurse) said, R105 was transferred to the hospital because of losing weight and refusing care, wound worsening, and pain. I did not do the dressing today, but the DON (V2) and V14 (Certified Nursing Assistant) changed the dressing, and V18 (NP) called and gave the order to send the resident to the Emergency Department. When questioned, V7 (RN), what R105's weight-loss was and how the wound appeared, the nurse indicated she didn't know how much the resident lost and could not describe the wound because she had not seen it. The surveyor asked if R105 was her resident. V7 said it was, but she had received directives from the DON and followed V18's NP orders. The surveyor asked how much the resident ate today, but V7 was not able to provide the information either. On 5/6/2025 at 8:57 AM, requested skin assessment of R105's coccyx area to V6 (Wound Care Nurse) for the month of January 2025, and no skin assessment was provided upon request. V6 said, R105 did not have a current coccyx wound, and the 1/15/2025 wound assessment is a new stage 4 facility-acquired coccyx wound. V6 said that CNAs (Certified Nursing Assistants) assess the residents twice a week during showers and incontinence care and will notify the nurses and me if there is a skin impairment noted during care. I am not sure how long R105's wound was present before I was notified. 05/6/2025 at 11:30 AM, V2 (Director of Nursing) said, nurses are not expected to complete skin assessment, and the facility no longer enters skin assessment as an order. Certified nursing assistants will notify nurses or the wound care nurse if there is any skin impairment. The surveyor requested facility provide shower sheets from January to the current, and skin assessment, but only one skin evaluation dated 4/8/2025 was provided. Coccyx wound assessment dated [DATE] described the initial assessment as a Coccyx stage 4, and V2 was not able to discuss why treatment and assessment were not done sooner. The surveyor asked V2 if the resident came in with an existing pressure ulcer. V2 stated, No, it is facility-acquired. On 5/6/2025 at 12:40 PM, V12 (Licensed Practical Nurse) said that V14 (Certified Nursing Assistant Supervisor) called her to assist with R1's wound around 9:00 AM on 5/5/2025. V12 said, I am assigned to R105 sometimes, but the floor nurse was not available, so I went in the room to help. The wound looked big, and with a lot of drainage that looked like pus, and with an odor. On 5/6/2025 at 4:57 PM, V13(Family Member) said, I received a phone call on Monday from the facility that (R105) was going to the hospital because of the wound worsening, pain, and failure to thrive. I know that (R105) did not want to turn and move because of the pain. I spoke with the physician from the hospital today and indicated that the buttocks wound will never heal. That is what my uncle will have to live with. On 5/7/2025 at 1:45 PM, V18 (Nursing Practitioner) said her company recently started to provide services to the facility starting April 2025 and had to debride the wound a couple of times for non-viable tissue necrotic (dead) tissue. On 04/30/2025, V18 provided a description of the sacrum wound to have exposed tissue and be able to see Bone, Muscle,/Fascia after the debridement. V18 said, I used lidocaine numbing medication during the wound procedure and believes that R105 has other pain medication ordered, but could not provide which pain medication to the surveyor. When questioned on how long a wound would take to get to a stage 4, V18 said that it is not an easy question to answer because R105 had some comorbidities to take in consideration. On record review of the May TAR (Treatment Administration Record), V7 entered NN on the electronic treatment record for 5/5/2025, which means see nurses' notes, but no wound nurses' notes were recorded or provided to the surveyor when requested. On the electronic medication record, pain medication was ordered until 5/2/2025. Physician orders read: Acetaminophen Tablet 325 MG. Give 2 tablets by mouth every shift for pain (give 1 hour before treatment). There were no pain medications provided as needed for pain for the month of April 2025. R105's wound of the Coccyx initial assessment dated [DATE], and there are no weights completed since 4/9/2025 to determine percentage weight loss. When a pressure ulcer list was requested by the survey team on 5/5/25, R105 was not included on the pressure ulcer list until requested again by the survey team to provide a more precise list. Surveyors asked V6 about the discrepancy, but only indicated that it was because the resident was being discharged the same day as the start of the annual survey. On 5/06/2025 at 4:11 AM, V1(Administrator) provided the policy title, Skin Care Regimen and Treatment Formulary, reviewed dated 1/24/2024. Which reads in part (but not limited to), Policy Statement It is the policy of this facility to ensure prompt identification, documentation, and to obtain appropriate treatment for residents with skin breakdown. Procedures 1. Charge nurses must document in the Electronic Health Record any skin breakdown upon assessment and identification. Furthermore, treatment must be obtained from the patient's physician. 2. Routine daily wound care treatment/ dressing change is administered by the wound care nurse or designee daily unless otherwise indicated by the patient's attending physician. Pressure Injuries: III. Stage 3 and Stage 4: Clean Wound Bed: Calcium Alginate, Thera Honey, Hydrocolloid, Xeroform Gauze

Based on observation, interview and record review the facility failed to ensure soiled linens were handled in a manner to prevent cross contamination, and failed to ensure incontinence care was completed in a manner to prevent contamination for 1 of 3 residents (R1) reviewed for infection control in the sample of 3. The findings include: R1's admission sheet shows he was admitted to the facility on [DATE] with multiple diagnoses. His 7/24/24 facility assessment and care screening documents him to be cognitively intact. The same document shows R1 has a colostomy and to always be incontinent of urine. The functional assessment shows R1 requires substantial to maximal assistance to roll side to side, sit up, and to transfer between surfaces. On 10/12/24 at 9:30 AM, R1 was observed lying in bed wearing a hospital gown, and an incontinence brief. V4 CNA (Certified Nursing Assistant) entered the room and removed the top sheet. V4 removed R1's incontinence brief, and V5 CNA assisted her with positioning. R1's scrotum and groin area were bright red after the removal of the soiled brief. V4 and V5 rolled R1 over to his right side. The pad and sheet under him were visibly soiled from the buttocks area and up his back. After the brief was removed, V4, using a disposable wipe, did not open the wipe, and blotted parts of R1's buttocks. She did not wash his buttocks or his backside. V4 then wiped the buttocks with ointment. V4 and V5 rolled R1 over to his left side to remove the soiled linens. Once the linens were removed from under R1, V5 threw them on the floor. Without cleaning up the groin and scrotum from urine, V4 placed ointment across the area and placed the clean incontinence brief. On 10/12/24 at 1:00 PM, V2 DON (Director of Nursing) said R1 should be changed every 2 hours. When he is changed, the CNA should be using soap and water and cleaning wherever the skin has been soiled. The areas should include the groin and scrotum. V2 said if the urine is not cleaned off it could cause skin breakdown. The disposable wipes should have soap on them, and opened up to use. V2 said the soiled linens are to be placed in a bag and should not be thrown on the floor, that is an infection control issue. The facility's 7/31/24 policy for Incontinent and Perineal Care documents it is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident to prevent infection and skin irritation, and to observe the resident's skin condition. Procedures: 6. Wash the perineal area and gently dry after the procedure. 7. Discard disposable items into designated container/plastic bag.

Based on observation, interview, and record review the facility failed to follow the Kitchen Policy by not labeling and dating a package of pita bread and a bulk bag of Indian (Baking) Flour. This failure has the capacity to affect 131 residents with an oral diet. The facility also failed to follow Sanitizer Manufacturer Instructions and Procedures for 3 Compartment Sinks by not immersing blender items for one minute. This failure has the capacity to affect 13 residents on a puree diet. Findings include: On 6-4-24 at 8:00 AM, surveyor observed walk-in refrigerator and noted pita bread wrapped in foil. The pita had no label with open/made date and expiration date. On 6-4-24 at 8:08 AM, surveyor observed dry food storage and noted an (opened) bag of Indian flour with no label with open date or expiration date. On 6-4-24 at 8:08 AM, V11 (Dietary Manager) said all food should be dated with open date and expiration date. V11 said the open date determines how long the food can be used. V11 said he will remove the pita bread and the Indian flour. Kitchen Policy dated 7-23-23 documents: e. Refrigerated food should be covered, dated, and labeled, and shelved to allow air circulation. i. Dry Storage: iv. large bulk items rice, flour, etc, are labeled. On 6-4-24 at 9:40 AM, surveyor observed V13 (Cook) sanitize blender items for less than 30 seconds in the 3 compartment sink. Manufacturer's Instructions documents: 3. Sanitize equipment and utensils by immersion in a use-solution of 1-2 ounces of this product per 4 gallons of water (or equivalent dilution) for at least 60 seconds at a temperature of 75 degrees. Procedures For 3 Compartment Sinks documents: Immerse utensils in Sanitizer Sink for a full minute. On 6-6-24 at 11:45 AM, V13 (Cook) said items are sanitized for 2 minutes to ensure all the bacteria is removed. On 6-4-24 at 9:45 AM, V11 (Dietary Manager) said staff should sanitize items for 30 seconds. Facility Roster dated 6-4-24 documents: 13 residents on puree diet. Facility Roster dated 6-4-24 documents: 131 residents on oral diet.

Based on observation, interview, and record review the facility failed to follow the Statement of Resident Rights when a resident was left exposed showing his bare chest and legs visible from the hallway. This failure affected one resident (R86) reviewed for privacy in a total sample of 26. Findings include: On 06/04/24 at 05:56 AM, R86 was observed with his bare chest and legs exposed in his wheelchair from the hallway while V12 (Certified Nurse Aide) was observed changing the linen on R86's bed. On 06/04/24 at 05:59 AM, R86 said he prefers his door closed when changing and does not want to be exposed to the public. On 06/05/24 at 01:07 PM, V2 (Director of Nursing) stated staff should use the privacy curtain or close the door for privacy. On 06/04/24 at 06:00 AM, V12 (Certified Nursing Assistant) said staff should close the door or use the privacy curtain when changing a resident to ensure privacy. On 06/04/24 at 06:22 AM, R60 said R86 was exposed and visible from across the hallway. On 06/06/24 at 02:32 PM, V14 (Social Service Director) said she was told by V1 (Administrator) R86 has a preference to be in his brief and does not want to use the privacy curtain or his door closed. V14 said she added the behavior care plan today. V14 said she was unaware of R86 having these behaviors/preferences and did not see any of these behaviors charted in R86's medical record. Statement of Resident Rights documents: Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on interviews and record reviews the facility failed to keep a resident free from being physically abused by another resident. This failure applied to two (R3 and R4) of three residents reviewed for abuse. Findings include: R3 is a [AGE] year-old female with a diagnoses history of Bipolar Disorder, Schizophrenia, Schizoaffective Disorder, Paranoid Personality Disorder, Unspecified Psychosis not due to a Substance or Known Physiological Condition who was admitted to the facility 01/31/23. R3's admission's hospital report dated 01/20/23 documents R3 was sent to the hospital with a petition form nursing facility due to increasing agitation, paranoid, aggressive and bizarre behavior. R3 was petitioned from a healthcare facility related to delusional, paranoid, and physically aggressive behaviors towards co peers. R3's current care plan for abuse revised 05/11/23 documents she has a history of medical and mental health comorbidities, denies being a victim or perpetrator of abuse, has trouble with personal boundaries, may have some risk of engaging in untoward or conflictual behavior and evoking responses from others due to decline in cognitive functioning; she was involved in an altercation with a peer, the situation was instigated by a peer and involved inappropriate language; R3's current care plan for behavior initiated 03/29/23 documents she has trouble regulating personal behavior, demonstrates behavioral distress (such as physical aggression) with interventions including monitor and assess for mood/behaviors and provide redirection; R3's current care plan for history of aggressive/inappropriate behavior initiated 02/05/23 documents she has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, verbal or physical aggression with interventions including intervene when any inappropriate behavior is observed. R3's progress note dated 5/11/2023 05:18 PM documents writer was made aware by staff that resident was physically aggressive towards another resident. Resident remains on 1:1 monitoring. R3's abuse investigation report dated 05/17/23 documents on 05/11/23 at approximately 5 PM V10 (Licensed Practical Nurse) reported to V2 (Director of Nursing) that R3 became aggressive with R4 when they were attempting to pass each other in the hallway. R4 was interviewed and reported while ambulating in the hallway by wheelchair she was suddenly attacked by R3 who when passing by suddenly got up and tried to grab R4's arm. R4's arm was observed with three small scratch [NAME] with no bleeding. V10 was interviewed and reported he observed R3 get up from her wheelchair and walk towards R4 in the hall and R3 reported while passing R4 in the hallway R4 was rude to her which R4 denied; V10 reported R3 immediately got up from her wheelchair and aggressively went towards R4 and tried to grab her arm. A total of five staff members were interviewed and reported they have never witnessed R3 physically abuse R4. The report did not include any information that any other staff witnessed the incident or were present during the incident. R4's progress note dated 05/11/2023 5:59 PM documents resident was sent out after she got in physical fight with another resident and was admitted to the hospital for right upper arm contusion. R4's progress note dated 05/13/2023 documents the resident readmitted from the hospital with diagnosis of shoulder pain post altercation. R4's hospital report dated 05/13/23 documents her chief complaint as right shoulder pain after altercation; she presented to the hospital with right shoulder pain after being hit by another resident and reported feeling a bone on her shoulder that isn't usually there. She was admitted by the emergency room after concern for safety at nursing home. R4 reported taking Tylenol and tramadol with relief for chronic arthritis. For shoulder pain after altercation with chronic osteoarthritis, increased tramadol to QID (four times daily) as needed. R4's current physician orders document an active order effective 05/13/23 for 50mg of Tramadol tablet by mouth every 12 hours as needed for pain. On 05/31/22 from 11:47 AM - 12:10 PM V13 (Social Services Worker) reported R3's mood fluctuates from being joyous and happy to delusional. V13 stated R3 can lash out at a resident for no reason if they are talking to themselves and she believes they are talking to her. V5 (Social Services Director) stated she did observe in R3's admission paperwork that while in the hospital she was noted with exhibiting auditory hallucinations, aggravated aggression, and paranoia. V5 stated prior to being in the hospital before admission to the facility R3 had been noted to be at of halfway house. V5 stated per R3's admission paperwork while she was at the halfway house, she exhibited delusional, paranoid, and physically aggressive behaviors to her co peers. V5 stated typically when residents exhibit these behaviors they are monitored. V5 stated R3's triggers involve her delusions. On 05/31/23 from 12:30 PM - 12:45 PM R4 stated during the incident with R3 as she was heading to her room R3 suddenly lunged at her. R4 stated she raised her arm to protect herself and R3 grabbed down on her arm. R4 stated her right shoulder still hurts and they tell her it's ok but she feels its probably dislocated. R4 reported her pain in her right shoulder at a level 10. R4 stated she needs to use her hands and arms daily and it is difficult because of her shoulder pain. R4 stated although she has arthritis her pain seems worse after the incident where she was attacked by R3. R4 stated she is terrified of being at the facility because of the attack by R3 and is only remaining at the facility for the sake of her R7 (Family Member) On 05/31/23 from 12:51 PM - 1:00 PM V10 (Licensed Practical Nurse) stated he was R3's nurse on 05/11/23. V10 stated before the incident R3 was talking with him while he was working behind the nurses station. V10 stated R3 left the nurses station and began walking down the hallway towards the beverage cart. V10 stated he assumed R3 was going to get some tea from the cart. V10 stated he suddenly heard R3 yell from the hallway and upon responding to the yelling he then found R3 standing with her feet caught under R4's wheelchair and holding R4's arm. V10 stated R4 reported to him that R3 attacked her and R3 reported to him that while she was getting tea R4 called her profane names. V10 stated he did not see the interaction between R3 and R4 before or during the incident. V10 stated he only recalled a male dietary staff present during the incident and he did not witness any part of the situation because his back was turned towards the residents. On 05/31/23 from 2:00 PM - 2:33 PM V1 (Administrator) would not specify the level of supervision needed for R3 due to her delusional behavior and history of physical aggression with others as reported by social services. V1 stated the residents are monitored at all times by all staff and includes frequent rounding and staff assigned for frequent rounding, however it is not possible to observe them at every moment. V1 stated an incident can occur if a staff member looks away for even a second. V1 stated it is possible to adequately monitor residents while performing other duties by alternately observing the residents whereabouts and activity between performing work duties such as reviewing health records or passing medication. V1 stated the facility cannot provide one to one supervision for residents on a consistent basis. V1 stated she had not received any information that there were any dietary staff present during R3's incident of being physically aggressive with R4 on 05/11/23. V1 stated all the staff who were interviewed regarding the incident reported that they did not witness the incident. V1 stated due to R3 being delusional it's possible that her report of being verbally attacked by R4 did not occur. V1 agreed if there was a verbal altercation between R3 and R4 prior to the physical altercation as reported by V10 (Licensed Practical Nurse) that any staff present should have been alerted to the situation and intervened to prevent escalation. The facility's abuse policy reviewed 06/01/23 states: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. Abuse is willful infliction of mistreatment or injury. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Physical abuse includes but not limited to infliction of injury that occurs other than by accidental means and requires medical attention. Examples include grabbing and roughly handling. Prevention includes identify, correct and intervene in situations in which abuse is more likely to occur; deployment of sufficient staff to deal with behaviors in the units; monitoring of residents with needs and behaviors that might lead to conflicts.

Based on observation, interview, and record review, the facility failed to prevent or identify the formation of a pressure injury; failed to follow physician's orders to provide adequate pressure ulcer treatment to prevent the worsening of a pressure injury, and failed to follow their skin care treatment facility policy for 1 of 4 (R49) residents reviewed for pressure injury in a sample size of 30. As a result, R49 acquired a right heel pressure ulcer which progress to an open stage 4 pressure injury Findings include: R49's face sheet showed she is a [AGE] year-old female resident with a past medical history not limited to rhabdomyolysis, acute kidney failure, hypertension and history of Covid-19. She admitted to the facility on [DATE]. Facility provided wound list that indicated R49 has a current facility acquired unstageable pressure ulcer to her right heel that was identified on 09/18/2022. On 05/15/23 at 01:25 PM, observed R49 lying in bed on a pressure relieving mattress with right heel protector loosely in place. Observations made for remainder of 05/15/2023 through 05/18/2023 were of R49 sitting in wheelchair in same position with heels not being offloaded. On 05/16/2023 at 12:15 PM, V13 (Wound Care Coordinator) said R49 acquired the pressure ulcer to her right heel during the time she tested positive for Covid and was also having some mobility issues. V13 added that R49's wound measured 6 centimeters (cm) x 5 centimeters (cm) with no depth upon the initial identification. On 05/17/2023 at 02:42 PM, observed R49's wound care performed by V13 (Wound Care Coordinator) who first removed previous dressing; noted moderate amount of light to dark brown drainage visible throughout dressing. R49's right foot noted to be very dry and flaky with mild swelling to foot and ankle. V13 then performed resident's wound care and indicated the presence of new granulation and epithelial tissue with moderate amount of clear to light brown drainage and no current signs of infection. R49's physician wound care note dated 05/11/2023 showed, right heel with open stage 4 pressure injury with wound size post debridement documented as 1.5x3.5x0.7 (length x width x depth). R49's Medical Professional Progress Note dated 4/19/2023 12:50 showed, seen today for right heel wound. Heel was noted with swelling. Started on Augmentin empirically. Xray + right heel worsening ulcer without evidence of [Osteomyelitis] and Doppler negative. Wound culture ordered; results not available. R49's Skin Evaluation dated 03/15/2023 documents unstageable pressure wound to right heel with measurement of 3.0 x 2.5 x 0.3. Risk factors listed not limited to depression and psychotropic drug use. R49's care plan with last completion date of 3/14/2023 indicates that resident has an actual impairment to skin integrity related to right heel unstageable wound, date initiated 07/11/2022. Interventions indicated low risk with weekly skin checks and report abnormalities to the nurse (initiated 07/11/2022); off load heels as ordered (initiated 07/11/2022); turn and reposition at least every 2 hours and as needed (initiated 07/11/2022). No intervention for heel protectors noted. R49's Minimum Data Set, Section M dated 03/08/2023 indicates R49 has one or more unhealed pressure ulcers/injuries and is not on a turning/repositioning program. No documentation noted of heel protector use. R49's Skin Alteration Nursing Evaluation dated 9/21/2022 showed a new unstageable pressure wound to right heel that measured 6 centimeters (cm) x 5 centimeters (cm); no depth was documented. Per skin assessment evaluation, an unstageable wound indicates full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Last Skin Evaluation (Quarterly + Comprehensive) dated 07/11/2022 showed no current Braden pressure ulcer assessment score result. R49's Wound Specialist assessment dated [DATE] showed risk factors that contributed to and/or increased risk of resident's unstageable right heel wound as urinary incontinence, use of stool softener, and in need of assistance with activities of daily living (ADL's). Pressure relieving devices listed were: specialized air mattress (low air loss), heel protectors, and offload with green wedge. R49 has active physician orders to cleanse right heel with normal saline, pat dry, apply skin prep to peri wound, apply [calcium alginate] dressing to wound bed, and secure with dry dressing every day shift, every other day for wound care and as needed for soilage/dislodgement last revised 05/17/2023 and pressure relieving mattress. No order noted for heel protectors or offload with green wedge. Reviewed facility Skin Care Treatment Regimen policy last revised 07/28/2022 that reads in part: Policy Statement: it is policy to ensure prompt identification and documentation for residents with skin breakdown Procedures: 5. refer skin breakdown to the skin care coordinator. 6. residents unable to turn and reposition themselves will be turned and repositioned every 2 hours. 9. residents with stage III and/or IV pressure ulcer will be placed in specialized air mattresses like low air loss.

Based on observation, interview and record review, the facility failed to perform comprehensive pain assessments as scheduled to promote effective pain management; failed to administer pain medication as requested/needed by a resident to prevent the negative effect of uncontrolled pain on a resident's function and mood; and failed to follow their pain policy and procedure for 2 of 4 (R115, R129) residents reviewed for pain management in a sample size of 30. As a result, R115 was left in periods of unbareable pain level which causes him to cry out to staff for medication for pain relief. Findings include: 1. R115's face sheet showed he is a [AGE] year-old male with a past medical history not limited to: generalized osteoarthritis, anxiety, idiopathic chronic gout, calculus of the kidney and fatigue. He admitted to the facility on [DATE]. R115 with active physician orders for: Pain Assessment: Numeric Scale (0= No Pain; 1 to 3= Mild Pain; 4 to 7= Moderate Pain; 8 to 10= Severe Pain) every shift; tramadol oral tablet 50 milligrams (mg) give 1 tablet by mouth every 6 hours as needed for severe pain 4-10; gabapentin oral tablet 800mg, give 1 tablet by mouth three times a day for neuropathic pain; acetaminophen oral tablet 325mg give 2 tablet by mouth every 6 hours as needed for mild pain 1-3. R115's incomplete Admission Pain assessment dated [DATE] 12:03 showed he had pain or was hurting at any time in the last 5 days, and he frequently had moderate pain levels rated at 6/10 on numerical pain scale during those 5 days. Pain frequency, Pain effect on function, Pain intensities and indicators not completed. R115's care plan with last completion date of 04/24/2023 reads: I present with risk factors r/t acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history and present mental health symptoms (initiated 01/11/2023). Goal: I will be treated with respect, dignity and reside in the facility free of mistreatment (i.e., abuse/neglect (initiated 01/11/2023, target Date 04/14/2023); At risk for pain related to multiple diagnoses (initiated 01/09/2023). Interventions: Resident would like to be educated on overall pain management, especially on different pain-relieving methods and would like to receive pain relief upon request (initiated 01/09/2023). On 05/15/23 at 1:27 PM, R115 said V22 (Registered Nurse) is unpleasant to him, there's no consistency with his gabapentin and pain medication administration when she (V22) works because she doesn't administer his pain medications as requested which causes him to wait and cry in pain for her to bring my pain medicine. He said this has been ongoing since admission. R115 then said he has pain every day, most of the day and has asked for something stronger than acetaminophen, but he doesn't always receive it. R115 added that his pain level is usually 7-8 and doesn't always receive his medications when he needs them. R115 also said last week, V22 was his nurse and he had to wait 2-3 hours for pain medicine. R115 then said he feels sad and frustrated and can't even think right when he's in so much pain. R115 added that he fears retaliation for reporting his issues regarding his pain medications. Resident was observed to be visibly distraught and saddened during interview. On 05/15/23 at 01:32 PM, V12 (Licensed Practical Nurse) said R115 and his daughter both talked to her on Saturday regarding R115 having problems with a nurse (later identified as V22) about pain medication administration times. On 05/16/2023 at 12:06 PM, R115 rated his pain level on a numerical scale between 00-10 at 6-7. On 05/17/2023 at 01:00 PM, R115 rated his pain level on a numerical scale between 00-10 at 6. On 05/17/2023 at 3:40 PM, V16 (Regional Nurse Consultant) said R115 should have had a pain assessment done last month. V16 then said pain assessments should be done every shift for every resident, and if a resident is on pain medications, they should assess their pain level before and after administering pain medication then follow-up within an hour. V16 added that comprehensive pain assessments should be completed quarterly; said one will be completed for R115. On 05/17/2023 at 3:42 PM, V22 (Registered Nurse) said last Wednesday on the evening shift, R115 came out of his room and asked for his meds. She had told him he needed to wait because she was on the phone with the doctors' office. After the call, V22 said R115 was at her cart and said to her you always make me wait and rated his pain at 6-7; R115 always rates his pain at 6-7. V22 then said he sometimes asks for Tramadol because the acetaminophen doesn't work for him. V22 added that V2 (Director of Nursing) informed her on Monday that she will no longer care for R115 per resident request because of the Wednesday incident regarding delayed pain medication administration. On 05/17/2023 at 3:40 PM, V16 (Regional Nurse Consultant) provided last comprehensive/quarterly pain assessment that showed he had pain or was hurting at any time in the last 5 days, and he had severe pain levels rated at 7/10 on numerical pain scale during those 5 days. Assessment also showed R115's pain effected his mood, music and as needed (PRN) medication alleviate his pain. On 05/17/2023 at 3:59 PM, V21 (Physician) said R115 is alert and can make his needs known so, if he is voicing high levels of pain from 6-7, then he is not comfortable, and his pain is not being managed. She then added that it has not been reported to her of R115's uncontrolled pain. Reviewed R115's medication administration record (MAR) for March 2023 that showed he only received acetaminophen (used for mild pain rated 1-3) on the 29th and was not administered tramadol (used for severe pain 4-10) for the entire month. April 2023 MAR showed he was administered acetaminophen on the 10th, 11th and 19th, and was only administered tramadol on the 25th. May 2023 MAR showed he was administered acetaminophen on the 6th and 7th and had an increased amount of tramadol administrations on the 7th and 8th, and 10th through the 17th with minimal effectiveness noted. Reviewed Pain level Summary from 05/01/2023-05/17/2023 that indicated R115 rated his pain level at 5 or higher a total of 18 times. Reviewed Pain policy and procedure last revised 07/28/2022 that reads: Policy Statement: It is the policy of the facility to ensure all residents are assessed for pain in every situation where there is a potential for pain. Procedures: - After the administration of prn pain medication, the resident will be assessed for the effectiveness of the pain medication. If the resident is still unrelieved of pain despite pharmacologic and nursing measures, the resident's physician will be called to refer the lack of relief. 46066 2. R129 is a 55-year -old female admitted to the facility on [DATE] with diagnosis including but not limited to Anoxic Brain Damage, Neuromuscular Dysfunction of a Bladder, Gastrostomy Status, Colostomy Status, Aphasia, and Necrotizing Fasciitis. R129's Physician Order Sheet dated 03/01/2023 reads in part, Oxycodone HCL Oral Solution 5mg/5ml *Controlled Drug* Give 2.5ml by mouth every 6 hours as needed for moderate to severe pain. Per record review, R129's pain assessment reads pain level at 0 on each of three shifts in March, April, and May 2023 except for: 03/02/2023, 03/06/2023, 03/07/2023, 03/12/2023, 03/13/2023, 03/20/2023, 03/27/2023, 04/07/2023, 04/17/2023 R129's pain level assessed between 1-5. Per record review, R129's Controlled Drug Administration Record reads that R129 received schedule II controlled pain medication at least once a day in March, April, and May 2023 except for: 03/05/2023, 03/19/2023, 03/30/2023, 03/31/2023, 04/02/2023, 04/03/2023, 04/05/2023, 04/09/2023, 04/10/2023, 04/11/2023, 4/16/2023, 04/21/2023, 04/23/2023, 04/27/2023, 04/28/2023, and 04/29/2023. Per record review, R129's Medication Administration Record reads that R129 received schedule II controlled pain medication at least once a day in March, April, and May 2023 except for: 03/03/2023, 03/05/2023, 03/19/2023, 03/30/2023, 03/31/2023, 04/02/2023, 04/03/2023, 04/05/2023, 04/09/2023, 04/10/2023, 04/11/2023, 04/16/2023, 04/21/2023, 04/22/2023, 04/23/2023, 04/24/2023, 04/27/2023, 04/28/2023, 04/29/2023, and 05/01-06/2023. Per record review, neither R129's pain assessment, Controlled Drug Administration Record, nor Medication Administration Record for schedule II controlled pain medication align; multiple discrepancies noticed. R129's schedule II controlled pain medication should be given only on days with pain assessed at greater than 0. On 5/17/2023 at 1:18 PM Surveyor interviewed V17 (Registered Nurse/ Clinical Care Coordinator), V17 (RN/CCC) stated, R129 had some sort of traumatic experience at a dentist office. She suffered anoxic brain injury from that. She is on schedule II controlled pain medication. We know that R129 is in pain when she has facial grimacing, body guarding, or screaming. R129's family also said that her pain threshold is high. R129 is able to say when she is in pain, but because of her brain injury, there is some disconnect in communication. Residents are assessed for pain on every shift, and it is documented in resident's electronic health record. R129 would generally score 6-7 on pain scale. On 05/17/2023 at 02:14 PM Surveyor interviewed R129. R129 indicated that she is in some pain at the moment and that she is usually in pain. R129 does not recall any of the nurses asking about pain on the scale from one to 10. On 5/17/2023 at 3:48 PM Surveyor interviewed V21 (Attending Physician), V21 stated, R129 can articulate her needs and is appropriate to answer to scale pain. Facility Pain policy dated 07/28/2022 reads in part, It is the policy of the facility to ensure that all residents are assessed for pain in every situation where there is a potential for pain.

Based on observation, interview and record review the facility failed to follow controlled medications count policy by failing to maintain an accurate count of schedule II controlled pain medication for 1 of 85 (R129) residents during the medication storage and labeling task. This failure has a potential to affect all 133 residents residing at the facility. Findings include: On 5/15/23 at 9:45 AM, V1 (Administrator) presented survey team with facility matrix showing 133 current residents. On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. R129's oxyCODONE HCl Oral Solution 5 MG/5ML (Oxycodone HCl) bottle - surveyor observed about half an inch of medication at the bottom of the bottle. Per R129's controlled drug administration record for schedule II controlled medication, last signed out amount on 05/07/2023 by V18 (Licensed Practical Nurse) was 165.5 milliliters. Surveyor requested V18 (LPN) to measure remaining schedule II controlled medication in the bottle; measured amount of remaining medication in the bottle was 16 milliliters; 149.5 milliliters discrepancy noticed. R129's Physician Order Sheet dated 03/01/2023 reads in part, Oxycodone HCL Oral Solution 5mg/5ml *Controlled Drug* Give 2.5ml by mouth every 6 hours as needed for moderate to severe pain. On 5/17/2023 at 9:54 AM Surveyor interviewed V2 (Director of Nursing), V2 (DON) stated, We're still doing the investigation. I talked to several nurses. Sometimes nurses miss to sign medical administration record and controlled drug administration sheet. I work every weekend and at least every other weekend I do spot checks in medication carts. There was no discrepancy noticed. Appropriate in-services are already started. Moving forward, Assistant Director of Nursing, MDS nurses, EMAR nurse, restorative nurse, and psychotropic nurse, will do narcotic count at least on the daily basis to check for any discrepancies. We never had issues like this before. V18 (Licensed Practical Nurse) mistook R129's medication for another liquid medication. V2 (DON) further indicated that V18's (LPN) mistake created the discrepancy in R129's schedule II controlled medication. On 5/17/2023 at 10:23 AM Surveyor interviewed V17 (Registered Nurse/ Clinical Care Coordinator), V17 (RN/CCC) stated, R129's schedule II controlled medication was at the appropriate line on the bottle when I signed it out on both 04/17/2023 and 04/30/2023. There was no discrepancy at the time. Surveyor asked V17 (RN/CCC) to clarify controlled medication administration process, V17 (RN/CCC) stated, If controlled medication is scheduled, it's scheduled, when it is to be given as needed, we assess pain and then we administer it. I look at the order, dose, last time was given, and I administer controlled medication to the appropriate resident, I then, sign it out on controlled drug administration sheet and in the Medication Administration Record. Surveyor asked how does V17 (RN/CCC) know the process of controlled medication administration, V17 (RN/CCC) said that nurses receive training upon hire and as needed during in-services. She does not remember when the last controlled medication administration in-service was, but she was hired in November of 2020. On 5/17/2023 at 11:01 AM Surveyor interviewed V18 (Licensed Practical Nurse), V18 (LPN) said that on the morning of 05/07/2023 R129 was yelling, and V18 (LPN) had to give her schedule II controlled pain medication. After V18 (LPN) gave R129 2.5 milliliters of medication, she recorded 23.5 milliliters on the first page of controlled drug administration sheet based on the mark on the bottle. Around 3:00 PM V18 (LPN) gave another dose of 2.5 milliliters to R129, and at that point, she discovered the second page of controlled drug administration sheet for R129's schedule II controlled medication. V18 (LPN) thought it was the second bottle and that's how she confused it with another liquid medication. Quantity values on the two bottles somewhat matched. When V18 (LPN) wanted to record the given amount of 2.5 milliliters, she realized remaining amount recorded on the controlled drug administration sheet was completely different, so she tried to match the number from previous sign out even though V18 (LPN) saw that there was less medication in the bottle than recorded. Surveyor asked what should V18 (LPN) have done when she noticed the discrepancy, V18 (LPN) said that when she saw the discrepancy, she should have checked the bottle to verify the difference. V18 (LPN) also said that she was trained pertaining to controlled medication administration upon hiring, which was in January 2021 and most recent in-service regarding nursing skills was in March 2023. On 5/17/2023 at 12:27 PM Surveyor interviewed V19 (Licensed Practical Nurse), V19 (LPN) stated, I don't know what happened. I always give R129 2.5ml of the schedule II controlled pain medication each morning. I don't remember how much was left in the bottle when I gave it last time (on 05/06/2023) but there are other nurses working on the floor. Surveyor asked what should be done if controlled medication discrepancy is discovered, V19 (LPN) said that if there is a discrepancy, the nurse should call another nurse or Director of Nursing to verify and then both have to count and sign. Pharmscript Controlled Substance Storage policy reads in part, Any discrepancy in controlled substance counts is reported to the Director of Nursing immediately. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, Director of Nursing notifies the administrator and consultant pharmacist immediately.

Based on observation, interview and record review, the facility failed to follow pharmacy medication storage and labeling policy and facility medication pass policy by not noting and implementing open date labels and failing to refrigerate new medication requiring refrigeration before opening. This applies to 6 of 85 (R22, R27, R61, R70, R76, and R121) residents' medications in three of five medication carts and one of one medication storage rooms during the medication storage and labeling task. Findings Include: On 05/16/23 at 10:10 AM Surveyor conducted inspection of the facility medication storage room. Surveyor observed opened and undated medication for: R61 - Ozempic (0.25 or 0.5 MG/DOSE) Subcutaneous Solution Pen-injector 2 MG/3ML (Semaglutide) - no open date On 05/16/23 at 10:19 AM Surveyor conducted inspection of Unit C medication cart. Surveyor observed opened and undated medications for: R22 - Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH (Fluticasone Furoate-Vilanterol) - no open date R61 - HumaLOG Solution 100 UNIT/ML (Insulin Lispro) - no open date R76 - Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine)- no open date On 05/16/23 at 10:56 AM Surveyor conducted inspection of Unit D medication cart. Surveyor observed opened and undated medications for: R70 - Trelegy Ellipta Aerosol Powder Breath Activated 100-62.5-25 MCG/INH (Fluticasone-Umeclidin-Vilant) - no open date R121- HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) - no open date On 05/16/23 at 11:47 AM Surveyor conducted inspection of Unit B medication cart. Surveyor observed unopened and inappropriately stored medication for: R27 - Latanoprost Solution 0.005 % eye drops - new, unopened, should be refrigerated when new and unopened On 5/17/2023 at 10:13 AM Surveyor interviewed V2 (Director of Nursing), V2 (DON) stated, You need to know the expiration date because medications like insulin are good for only 27 days. It is because of the effectivity of the medication. Other medications than insulin may also be no longer effective, that's why it's important to document expiration date upon opening. Facility Medication Pass policy dated 03/28/2023 reads in part, It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Insulin vials are to be discarded within 28 days after opening. Pharmscript Medication Label policy dated 11/19/2018 reads in part, Each prescription medication label includes Beyond Use (or expiration) date of mediation.

Based on observation, interview and record review the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 5 residents (R2) reviewed for abuse in the sample of 10. The findings include: The facility's Final Abuse Report dated 11/3/2022 documents on 10/31/22 V5 (LPN) reported to V1 (Administrator) R1 hit R2 on the back. V5 said he was in the hallway passing medications when he heard a commotion. He saw R1 walking down the hallway speaking loudly so he went to address the situation, before he could get to R1, R1 hit R2 on the back The local police interviewed R1 regarding the allegation of physical abuse toward R2. R1 stated she did hit R2 because she was mad at her because R2 told her to be quiet. On 11/18/22 at 9:10 AM, R2 was sitting in the hallway. She was observed interacting with staff in a pleasant manner. R2 said there was a woman who hit me. There was an argument she was talking about my family then she hit me a few times all over. It hurt and made me feel like sh-t. R2 said she better not come near me again. On 11/18/22 at 9:47 AM, V5 (Licensed Practical Nurse-LPN) said he was the nurse the day of the incident with R1 and R2. He heard both yelling and screaming in the hallway and he saw R1 hit R2 in the back. On 11/18/22 at 12:07 PM, R1 was observed in her room upset and crying. She said someone is following her. V12 (CNA supervisor) in the room. R1 stated I'm irritated and can't take it. She's following me referring to another resident. When V12 asked who is following her she said the person with the walker and white sweater. V12 said she's referring to R12 she likes to walk the halls. On 11/18/22 at 12:08 PM, V12 said R1 has behaviors she can get verbal and easily irritated. On 11/18/22 at 10:50 AM, V4 (Social Services) said R1 has verbal outburst and disorganized thinking. She was sent out after the incident for behaviors. If she hears loud noises, she can get agitated. It's abuse if another resident hits another resident. On 11/18/22 at 11:54 AM, V1 (Administrator) confirmed R1 made physical contact with R2. R1's face sheet shows she is a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set assessment dated [DATE] shows she's cognitively intact. R1's care plan dated through 2/2/23 shows she has verbally aggressive behaviors related to infective coping skills, mental/emotional illness, poor impulse control using profanity and racial slurs. R1 also has physically aggressive behaviors when agitated, attempting to push, shove, scratch, hit, slap, grab or otherwise harm another person with interventions to ask her calmly what is causing this upset behavior and assess her coping skills and support system. The facility's Abuse and Neglect Policy reviewed 10/24/22 states, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimation, or punishment. Abuse assumes intent to harm .Physical Abuse includes but not limited to infliction of injury .examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting and rough handling .

Based on interview and record review, the facility failed to prevent a resident from being abused by another resident as evidenced by (R5) physically assaulting another resident (R3) before staff intervened. This failure affected one of two residents (R3) reviewed for abuse. Findings include: R3 is a [AGE] year male currently residing at the facility with the following past medical history, [CONDITION(S)], [CONDITION(S)], anxiety disorder, major depressive disorder, unspecified [CONDITION(S)] without hepatic coma, major depressive disorder, [CONDITION(S)], alcohol abuse, essential primary hypertension, etc. On 7/12/2022 at 11:58 AM, R3 was observed in his room awake, alert and oriented, appears clean and dressed appropriately for the weather. R3 said that he remembers the day he had a physical altercation with another resident, (R5) he was walking down the hall and was between the door when R5 went towards his neck, staff intervened and separated them. Incident note documented in medical record states the following, around 3:30 pm, resident had an altercation with another male resident while in Section D Hallway, resident was allegedly punched on the face obtaining a small skin tear on his left eyelid area and upper lip. No bleeding noted. Both residents were separated and placed on 1:1 monitoring. Head to toe assessment done. (Physician) notified and gave order to send to (local hospital) for evaluation. No other visible injuries noted. Resident refused to go to the ER for evaluation despite encouragement. (POA) notified. R5 was sent out to the hospital for evaluation. R5 is a [AGE] year-old male who was admitted to the facility on [DATE], with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility admission evaluation dated 6/7/2022 documented the reason for admission as aggressive behavior. Facility (Minimum Data Set) MDS assessment dated [DATE] section C (Cognitive) coded R5 with a BIMs (Basic Interview for Mental Status) score of 3 (severe cognitive impairment), section G (functional status) of the same assessment coded R5 as indicating supervision with one-person physical assist for walking in room, on the corridor, locomotion on and off unit. Care plan dated 6/15/2022 states, Resident requires supervision to limited assistance with ADL's (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). R5 was sent out to the hospital for increased aggression on 6/16/2022 and was readmitted to the facility on [DATE], there was no revision, update or any additional intervention to R5's care plan for movement, wandering and anxiety. 7/14/2022 at 9:38 AM, V2 DON (Director of Nurses) said that R5 was assessed for aggression upon admission, he was very calm at the time, just pacing, the hospital said that he was stable. V2 added that R5 walks independently with a steady gait, he is set up only for food and transfer and does not require supervision. Facility abuse policy presented by V2 with an effective date of 1/17/2022 states in part that it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Under the section prevention, the policy states one of the steps as Identification, assessment, care planning for intervention, and monitoring of residents with needs and behaviors that might lead to conflicts or neglect.

Based on interview and record review, the facility failed to re-admit a resident who was originally admitted with history of aggression and was sent to the hospital for psychiatrist evaluation following a resident-to-resident altercation, failed to follow resident's discharge process as indicated in care plan for 1 of 5 residents (R5) reviewed for transfer and discharge. Findings include: R5 is a [AGE] year-old male who was admitted to the facility on [DATE] with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R5 was sent to the hospital for psychiatrist evaluation on 6/30/2022, following an altercation with another resident. R5 was the aggressor as documented in medical record. Nurse's note dated 6/30/2022 states resident picked up by two paramedics to hospital in stable condition for further evaluation. Facility admission/readmission assessment dated [DATE] stated that resident was admitted from acute hospital and the reason for admission was documented as aggressive behavior. R5 was sent to the hospital on 6/16/2022 for agitation, as documented in nurse's progress note; Resident picked up by ambulance accompanied by 2 paramedics. Resident sent with 3 original involuntary petitions, written notice for transfers to the hospital, notice of involuntary transfer or discharge and opportunity for hearing for nursing home residents, involuntary transfer or discharge request for hearing, and bed reserve policy. POA made aware and appreciative. Resident was readmitted to the facility on [DATE]. There is no documentation of resident being aware or any documents sent with resident for the 6/30/2022 transfer to the hospital. R5's care plan dated 6/7/2022 for movement, wandering and anxiety states in part, I am an adult living with dementia and mental health concerns .There is movement behavior on the unit consistent with anxiety and disorientation. My boundaries are poor, and my behavior may be interpreted as intrusive by my peers. I may walk/wander on the unit and approach doors on the main floor. I may not be able to comprehend the safety precautions that staff continually share/address with me. My awareness/insight may fluctuate .There is confusion and mal orientation at times. Goal: will remain safely engaged in activity focused care, a meaningful intervention, or social interaction without trying to leave the facility without a responsible escort. Facility Minimum Data Set (MDS) assessment dated [DATE] coded R5 as requiring supervision with one-person physical assist for walking in room, corridor, locomotion on and off unit. Care plan for R5 however, did not include any interventions (per assessment) for R5 to be supervised. All staff interviewed during the course of this survey stated that the incident was reported to them and there were no witnesses to the resident-to-resident altercation. R5's care plan for discharge potential and discharge planning dated 6/9/2022 states that resident's discharge potential and discharge planning needs have been assessed by the Interdisciplinary Team and D/C potential = fair. Goal: Resident and/or representative will meet with the social worker, nurse, and significant other(s) to identify post-discharge needs through next review. Interventions include, review resident's medical record, including medications and treatment recommendations. Discuss resident abilities and needs with nursing and the attending physician to determine what services resident will need in the community. 7/14/2022 at 9:38 AM, V2 (DON) said that the facility is not taking R5 back because he is too aggressive; he hit another resident. (R5) was assessed for aggression upon admission, he was very calm at the time, just pacing, the hospital said that he was stable. R5 hit another resident 2 days after he came back from the hospital. V2 added that R5 does not need staff supervision, he ambulates by himself with a steady gait, she added that residents are assessed for abuse upon admission, the facility does not do a separated assessment for aggressive behavior. The only documented abuse assessment for R5 was dated 6/30/2022, the date of the resident-to-resident altercation. 7/19/2022 at 12:35 PM, V2 said that the decision of not accepting R5 back to the facility is a team decision; his son was aware of the aggression, the social worker spoke to the hospital liaison and told them that the facility is not taking the resident back, they must find a more appropriate setting, facility was aware that resident was aggressive prior to admission. V2 added that the resident was sent out for aggression, he came back and two days later he hit another resident. V2 said that resident's care plan was updated with additional intervention to watch resident closely, involuntary discharge papers were given to paramedics. There was no information provided during the course of this survey or in R5's medical record to show that the facility made attempts to address the resident's aggression, which he was admitted with, or what efforts the facility made to accommodate the resident's needs prior to determining that they could no longer meet his care needs.

Based on observation, interview, and record review the facility failed to change gloves and perform hand hygiene after adjusting a face mask during the preparation of pureed foods; and failed to keep a scoop out of a bin of oatmeal. These failures have the potential to affect 132 residents receiving meals from the kitchen. Findings include: On 6/21/22 at 10:50 AM, during the initial tour of the kitchen there was a scoop in a bin of oatmeal in the dry storage room. V23 (Regional Director of Culinary Services) said, that should not be in there. I am trying to find a way to store the scoops outside of the bins. On 6/22/22 V22 (Cook) prepared pureed lunch items. At 9:46 AM and 9:48 AM, V22 tasted the collard greens. Each time V22 adjusted his face mask and continued the food prep without changing his gloves and performing hand hygiene. At 9:59 AM, V22 tasted the chicken and at 10:09 AM, V22 tasted the macaroni and cheese. Each time V22 adjusted his mask after tasting the food and returned to food prep without changing his gloves or performing hand hygiene. On 6/22/22 at 10:30 AM, V22 said, yes I should have changed my gloves. I just forgot. Thanks for telling me. At 10:32 AM, V23 said, he (V22) should have changed his gloves. The Diet Counts sheet dated 6/21/22 indicates that 132 residents were served food from the kitchen and nine residents (R25, R50, R78, R80, R98, R113, R114, R121, R136) received pureed diets.

Based on observation, interview, and record review the facility failed to keep call lights in reach for 5 of 32 residents (R83, R85, R88, R119, and R133) reviewed for accommodation of needs in the sample of 32. Findings include: 1. On 6/21/22 at 12:25 PM, R83 was seated in a wheelchair beside the bed on the right side of the bed. R83's call light was on the left side of the bed out of reach of R83. R88 was seated in a wheelchair on the left side of the bed next to the foot of the bed. R88's call light was on the bed behind the resident between the rail and the mattress out of R88's reach. On 6/21/22 at 12:32 PM, V7 LPN (Licensed Practical Nurse) said, the call light should be in reach at all times. The wheelchair should be in reach of the call light. On 6/23/22 at 10:35 AM, V2 DON (Director of Nursing) said, of course the call light should be in the residents' reach at all times. A Call Light Policy, reviewed 7/27/21, indicates 5. Be sure call lights are placed within reach of residents who are able to use it at all times. 2. R119 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan interventions indicated keep call light within reach. On 6/21/22 at 11:50 am, Observed R119 lying in bed. R119 said his bed feels like it's broken and it's uncomfortable. He said he cannot find his call light and his bed control. He said he has been lying in bed for more than a month. R84 (R119's mother visiting who is also a resident on another unit), concurred with his statement. R119 said that he did not inform the staff, but they saw him in this position and did not do anything. Surveyor called V2 and showed how R119 was positioned in bed. She said that the bed needs to be fixed. She said that she was not aware of his bed condition. R119 asked for his call light. V2 found his call light by bedside drawer away and unreachable from him. V2 said that his call light should be within his reach. V2 could not find the bed control. V2 said that the bed control should be available for positioning. 3. On 6/21/2022 at 11:40 am, R85 was observed in bed with the call light behind the dresser out of reach. On 6/21/2022 at 11:45 am, V8 CNA (Certified Nursing Assistant) said I thought I put the call light in reach and clipped the call light to the bed. On 6/21/2022 at 2:30 pm, R85's face sheet indicates R85 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/21/2022 at 11:55 am, R133 was observed in bed with the call light on the floor out of reach. On 6/21/2022 at 12:00 pm, V8 put R133's light in reach and clipped the call light to the bed. On 6/21/2022 at 2:40 pm, R133's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for call light intervention.

Based on observation, interview and record review the facility failed to review and revise/update the individualized care plan to meet the resident's needs. This deficiency affects four (R28, R32, R36, R119) residents in a sample of 32. Findings include: 1. R28 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Please refer to hand surgeon order dated 5/12/22. Care plan does not indicated use of splint for carpal tunnel syndrome. On 6/22/22 at 11:01 am, R28 said that she does not have hand splint, she never wears splint on both hands at night. She said she has carpel tunnel. Called V2 DON (Director of Nurses) to her room. V2 said that she does not have hand splint, it was ordered long time ago. V2 said she does not need it. V2 said she will call her physician to have it discontinued. No hand splint found in her room. Informed V2 that R28 care plan is not updated. V2 said that they will update her care plan. V2 said that care plan should be updated when there is new order or changes of order. On 6/24/22 at 11:10 am, V28 Care Plan Coordinator said that Residents' care plan is updated annually and quarterly when there is significant change of condition, new orders or new treatment. She said that she is aware of R28's bilateral splint order but the one who should update the care plan is V27 Restorative Nursing. On 6/24/22 at 11:30 am V27 Restorative Nurse said that she is aware that resident has order for bilateral hand splint but the resident is currently on Therapy services. She said that if the resident is on Therapy she does not update the care plan. 2. R32 and R36 are involved in resident-to-resident altercation on 6/21/22. Incident report initiated and in progress. Resident still residing in the facility. R32 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R36 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/23/22 at 1:12 pm, Reviewed R32 and R36's care plan with V2. Both care plans for presence of abuse factors were not updated. V2 said that care plan should be updated after abuse incident/allegations. She said she will inform the social service to update care plan interventions. 3. R119 is admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan does not indicate that he can take his own blood sugar test. On 6/21/22 at 12:30 pm, V11 [CONDITION(S)] Nurse said that R119 does his own blood sugar test, and the nurse will just ask him for result and document in MAR. Observed box of alcohol swab, box of lancet and small sharp container at bedside. R119 said that he takes his own blood sugar by himself without supervision. Reviewed copy of the care plan provided by V2 and informed her that R119's care plan was not updated. On 6/22/22, 1:30 pm, V2 presented printed copy of R119's care plan for Diabetes Mellitus. The facility inserted sentence in the care plan intervention that R119 may do his own blood sugar under staff supervision dated 11/23/20. Called attention of V2 and V11 Nursing Consultant of proper updating care plan intervention. V2 said she does not know who updated that care plan she provided to the surveyor. V11 said that current date should be entered when updating the care plan intervention. Facility's policy on Care plan indicates: Procedures: 5. These will be periodically reviewed and revised by a team of qualified person after each assessment.

Based on observation, interview and record review the facility failed to follow its policy on infection control by failure to perform hand hygiene, disinfect/sanitize medical equipment (Blood pressure) and medication tray after each resident contact when administering medication. This deficiency affects all nine (R1, R19, R25, R40, R52, R71, R83, R91 and R100) residents in the sample of 32 reviewed for infection control during medication administration. Findings include: On 6/21/22 at 12:18 pm, V10 LPN (Licensed Practical Nurse) prepares medications for R25 and placed it on disposable medication tray. V10 placed it on R25's bedside tray table without a liner. After giving meds, he took the tray back to the medication cart without disinfecting or sanitizing. On 6/21/22 at 12:34 pm, V10 prepares meds for R71 and placed it on the same disposable medication tray. V10 placed the tray on R71's bedside tray table without a liner. After giving meds, he took the tray back to the medication cart without disinfecting or sanitizing. On 6/21/22 at 12:50 pm, V7 LPN prepares medication for R91. V7 did not perform hand hygiene after giving medication. On 6/21/22 at 12:55 pm, V7 prepares medication for R40. V7 did not perform hand hygiene after giving medication. On 6/21/22 at 12:56 pm, V7 prepares medication for R83. V7 did not perform hand hygiene after giving medication. On 6/21/22 at 1pm, V7 prepares medication for R19. V7 did not perform hand hygiene after giving medication. On 6/21/22 at 1:04 pm, Informed V7 that surveyor observed she did not perform hand hygiene after each resident contact when administering medications. She denied it. Informed V7 that medication administration was observed by 2 surveyors. V7 did not respond. On 6/21/22 at 1:20 pm, V10 prepares medication for R100 and placed it on the disposable medication tray. V10 placed the tray on R100's bedside tray table without a liner. After giving medication, he took the tray back to the medication cart without disinfecting or sanitizing. On 6/21/22 at 1:24 pm, V10 prepares medication for R1 and placed it on the disposable medication tray. V10 placed the tray on R1's bedside tray table without a liner. After giving medication, he took the tray back to the medication cart without disinfecting or sanitizing. Surveyor informed V10 that he did not disinfect/sanitize disposable medication tray after each use. He said he only disinfects it when he is going into a isolation room. On 6/21/22 at 1:29 pm, V11 [CONDITION(S)] Nurse said that she just checked the Blood Pressure (BP) of R52 and obtained BP 130/74. V11 prepared medications for R52 and administered. She said she is done with her noon-time medication administration. At 1:45 pm, Observed V11 did not disinfect/sanitize portable BP equipment. She said that it should be sanitized/disinfected immediately after use. She said they use bleach wipes/disinfectant to clean it. On 6/21/22 at 4:50 pm, Informed V2 DON of above observation during medication administration. V2 said that hand hygiene should be performed before and after each resident medication administration. The disposable medication tray should be disposed after each resident use or disinfected after each resident use. The blood pressure equipment should be disinfected immediately after each use. Facility's policy on Medication Pass indicates: It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures Procedures: a. Follow hand hygiene procedure before and after each resident Facility's policy on Hand Hygiene indicates: Hand hygiene is important in controlling infections. Hand hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC guidelines in regard to hand hygiene. 1. Hand hygiene using alcohol-based hand rub is recommended during the following situations: a. Before and after direct resident contact. Facility's policy on medical care equipment, instrument and health IT devices infection control plan indicates: It is the policy of this facility to prevent and create/maintain a safe environment for the residents, their visitors and staff thru proper handling, cleaning and sanitizing of medical care equipment, instruments and or other related health IT devices. Procedures: 7. Nursing personnel shall wipe down/clean reusable equipment between residents using a facility approved cleaner/disinfectant. 12. Some medical equipment items shall be cleaned and sanitized with facility approved disinfectant agent between each resident use.

Based on observation, interview and record review, the facility failed to follow its policy on informing four of five residents (R19, R42, R56, and R122) on where to locate the facility's survey binder in a sample of 32 residents. Findings include: During a Resident Council meeting on 6/22/22 at 11:30 am, four out of five residents R19, R42, R56, and R122 stated that they did not know where to find the facility's survey binder. During an interview on 6/23/22 at 12:00 pm with V1 (Administrator), V1 stated that the residents should be able to locate the facility's survey binder. During an interview on 6/22/22 at 12:05 pm with V20 (Activity Director), V20 stated that the residents should know where to find the facility's survey binder. Facility document titled Residents' Rights for people in Long Term Care facilities from the Illinois Department of Aging includes; Your rights as a citizen and a facility resident . Your facility must let you see reports of all inspections by the Illinois Department of Public Health from the last five years and the most recent survey of your facility along with any corrective action plans from your facility .

Based on observation, interview and record review the facility failed to follow the physician's order for the care of a peripherally inserted central catheter (PICC) dressing, and wound care treatment for two of three resident's (R73, R92) reviewed for physician's order in the sample of 32. Findings include: 1. On 6/21/2022 at 10:30 am, R73 was observed in bed with a Peripherally Inserted Central Catheter (PICC) line in right arm with a date of 6/3/2022, R 73 said I want this out of my arm. V10 LPN (Licensed Practical Nurse) observed the PICC line dressing and said LPN's do not change PICC line dressing's only the Registered Nurse. V3 ADON (Assistant Director of Nursing) observed the PICC line dressing date and said I'll have to see what the policy says. V2 DON (Director of Nursing) said the PICC line dressing should be changed every week and as needed. On 6/22/2022 at 1:30 pm, R73's Physician order sheet dated June 2022 indicates a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An order dated 4/22/2022 to change Intravenous (IV) catheter and cap with transparent dressing on right upper arm as needed and every day shift every Sunday. A care-plan dated 4/28/2022 with IV interventions. 2. On 6/22/2022 at 12:00 pm, V13 RN (Registered Nurse) was observed administering wound care to R92 and stated on the right foot top and heel, I am applying Calcium Alginate and cleansing with normal saline and wrap with Kerlix, and the left medial leg and left foot I'm also applying Calcium alginate and cleansing with normal saline and wrap with kerlix. On 6/22/2022 at 1:30 pm, V13 was asked to read the physician order, V13 said I should have used Dakin's solution to the left foot, right heel, and right top of foot, I overlooked that order. On 6/22/2022 at 2:00pm V2 said I expect all nurses to follow the physician's order for wound-care. On 6/22/2022 at 2:00 pm, R92's face sheet with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Order dated June of 2022, date to start 6/16/2022 Dakin's (1/2 strength) Solution 0.25% (Sodium Hypochlorite) apply to per additional directions' topically every-day shift for wound care management cleanse the left foot, right heel, and right top of foot with normal saline, cover wound beds on each side with Dakin's 0.25% soaked gauze, wrap with kerlix, and secure with retention tape. Facility Policy: (revised 7/28/2021) Intravenous Therapy Policy statement: It is the facility's policy to ensure that intravenous policy and procedure are compliant to federal standard of care. Procedures: Dressing Change: b. All central line dressing (PICC lines, single and multi-lumen central catheters inserted in [MEDICATION(S)], jugular, or inguinal area) will be changed every 7 days and as needed prn. Facility Policy: Revised 7/28/2022 Policy Statement It is the policy of this facility to ensure prompt identification, documentation and to obtain appropriate topical treatment for residents with skin breakdown. Procedures 2. Routine daily wound care treatment/dressing change is administered by the wound care nurse of designee daily unless otherwise indicated by the patient's attending physician. a. Pressure Sore/ Stasis Ulcers/Arterial wounds

Based on observation, interview and record review the facility failed to develop fall prevention interventions to include supervision to reduce or prevent the risk of falling for 1 of 3 residents (R55) in the sample of 29 residents reviewed for supervisions and fall preventions. This failure resulted in R55 having multiple falls with injury resulting in treatments at the local hospital for nasal bone fracture, non-displaced fracture of the third cervical vertebra, and injury to right upper extremity. Findings include: On 4/27/21 at 10:00am, R55 is up in the wheelchair in the corner of her room doing coloring using her left hand. She is alert and oriented to self but does not speaks English. She has right arm sling which not properly placed. The sling is not supporting the right elbow. She has right arm bandage which is loose and falling. She does not have 1:1 supervision/sitter. Her room is 3 rooms away from the nursing station. On 4/27/21 at 11:30am, Heard R18 (R55's roommate) yelling for help for R55 in the hallway. Observed R55 on the floor on her right side in front of her wheelchair with V2 DON ( Director of Nursing) and V17 Restorative Aide /Certified Nurse Assistant ( CNA). Surveyor left the room for the staff to assess R55. R55 was sent out to the hospital for evaluation via 911. On 4/27/21 at 4:49pm Telephone interview with V4 Family member stated that he is concern of R55's frequent and numerous falls since admissions. He is notified of fall incidents occurred but was not informed of plans to prevent from falling. R55's medical diagnosis listed in part as: Muscle wasting and atrophy, Fracture of nasal bone, Difficulty walking, Unsteadiness of feet, Abnormality of gait and mobility, Lack of coordination, [CONDITION(S)], Age related [CONDITION(S)]. R55's admission Fall assessment dated [DATE] score of 10 indicated high risk for fall. R55's Fall incident reports indicated: 4/27/21- 11:15am R55 was sitting on her bedside wheelchair coloring an activity book with no concerns. Around 11:30am writer ( V2 DON) rushed to R55's room after roommate called for help in the hallway. Observed R55 sliding slowly away from her wheelchair and falling o her right side with her forehead hitting the floor. Noted mild jerking movements on her upper body and a loss of consciousness for 5 seconds. R55 unable to give description. Head to toe assessment was done. No visible injuries noted. Neuro vital signs intact. Breathing well, no apparent distress. No incontinence, changes in ROM or complaint of pain. R55 became responsive after 5 seconds and was able to answer simple yes/no questions. 911 paramedics came and evaluated R55. Primary Care Physician notified and gave order to send to emergency room hospital for further treatment and evaluation. V4 Family member notified. Post incident investigation dated 4/27/21 completed by V8 Restorative Nurse indicated : Unwitnessed fall with injury. 4/27/21 at 11:15am. R55 was observed sliding slowly from her wheelchair and falling on her right side with her forehead hitting the floor. R55 was noted with mild jerking movement on her upper body and a loss of consciousness for 5 seconds. Interventions to address incident: R55 will have a sitter and will be moved to a room closer to the nurses' station for close monitoring. R55 will continue to get skilled therapy for PT/OT and restorative exercise for upper and lower extremities strengthening. R55 will continue to have bed/chair alarm to alert staff for unassisted transfer. Will refer to Physician to obtain and monitor lab/diagnostic work to check blood levels. Hospital discharged instruction dated 4/27/21 indicated: Diagnosis: Closed head injury, initial encounter; Other closed nondisplaced fracture of third cervical vertebral, initial encounter. Facility sent initial incident report to IDPH on 4/28/21 . R55's fall assessment dated [DATE] score of 20 indicated high risk for fall. 4/17/21 Fall incident report- At 12:30am R55 pulled the call light and CNA responded to the call light. R55 was sitting on the edge of her bed and she requested CNA to take her to the washroom. CNA was getting the wheelchair to R55, meanwhile R55 became restless and stood up from her bed and resident lost her balance and fell on the floor. R55 hit her face on the floor and started bleeding from her nose and mouth. Nurse applied pressure to her nose and cold pack to control bleeding. Neuro check initiated. 911 called immediately. Post incident investigation dated 4/17/21 completed by V8 Restorative Nurse indicated: Unwitnessed fall with injury. 4/17/21 at 12:30am, R55 requested CNA to take her to the washroom at around 12:30am, became restless and stood up from her bed and lost her balance, fell on the floor, hit her face on the floor. Alert and oriented x 1, confused, difficult to redirect, with impaired cognition. Interventions to address incident: R55 will have a sitter for close monitoring. R55 will have a sitter for close monitoring. R55 will continue to use a bed/chair alarm to alert staff for unassisted transfer. R55 will continue to get skilled therapy for PT/OT. On 4/22/21 Sitter discontinued as indicated in care plan. Hospital discharged instruction dated 4/17/21 indicated: Diagnosis: Closed head injury, initial encounter; Closed fracture of nasal bone, initial encounter; Elbow injury, right, initial encounter. Facility sent final incident report to IDPH indicated: Final investigation/Conclusion: Based on staff and resident interview, there was no abuse that took place. R55 was witnessed attempting to stand independently, lost balance and fell forward. R55 sustained a fracture to her nasal bone and came back with a sling on her right arm due to questionable fracture on the right elbow. X-ray as performed on 4/22/21 confirmed no fracture of dislocation on the right elbow. R55 was taken to hospital on 4/17/21 and was sent back to the facility that same day. Denies any pain. Care plan updated and interventions in place. R55's Fall assessment dated [DATE] score of 17 indicated high risk for fall. 3/14/21 Fall incident report- 1:45pm Nurse was at the nursing station documenting when a staff member approached and stated that R55 was on the floor, immediately the nurse rushed to the R55's room and observed her laying on the floor in a prone position. Bleeding noted from both of her nostrils. R55 unable to give description. Nursing assessment done. Vital signs done. Pressure applied to the nostrils, ice pack, applied to control bleeding. 911 called per facility's protocol. R55's primary care physician notified. R55's emergency contact notified. DON made aware. Hospital discharged instruction dated 3/14/21 indicated: Diagnosis: Closed fracture of nasal bone, initial encounter. Post incident investigation dated 3/15/21 completed by V8 Restorative Nurse indicated: Unwitnessed fall with injury. 3/14/21 at 1:45pm, Resident was observed by staff laying on floor in prone position beside her bed. Alert and oriented x 1, confused, difficult to redirect with impaired cognition. Interventions to address incident: R55 will place by the nurses' station once up in the chair for close monitoring. R55 will continue to have bed/chair alarm to alert staff for unassisted transfer. R55's Fall assessment dated [DATE] score of 21 indicated high risk for fall. 2/23/21 Fall incident- 12:21pm R55 was observed on the bathroom floor laying with her head on the floor. The roommate said she fell backwards and hit her head on the floor. Resident unable to give description. Head to toe assessment done, noted minimal bruise with mild bleeding on the back of the head. ROM ( Range of Motion) within baseline. 911 called. R55 is alert and oriented x 1. Confused and forgetful. Vital signs checked and recorded as T-97.9, RR-18, BP-117/72. R55 was assisted by 2 staff back to her bed via Hoyer lift. Pressure applied on head with gauze. Primacy care Physician notified and sent R55 to hospital. POA ( Power of attorney) and DON notified. Post incident investigation dated 2/23/21 completed by V8 Restorative Nurse indicated: R55 was observed in the bathroom floor, laying with her head on the floor. Alert and oriented x 1, confused and forgetful, R55 requires assistance in all her ADLs (toileting), should be in wheelchair for locomotion. Per roommate, she fell from the back and hit her head on the floor. Interventions to address incident: Sent to hospital for evaluation. R55 will use an ultra-low bed and bed/chair alarm upon return from the hospital to alert staff for unassisted transfer. R55 will be picked up for skilled therapy ( PT/OT/ST). Requested for Fall assessment after fall incident on 2/23/21. No document given. R55's Fall Care Plan initiated 2/23/21 indicated: 3/15/21- R55 will stay at nurses' station once up in chair for close monitoring. 4/17/21- R55 will have a sitter for close monitoring. She will continue to use bed/chair alarm. 4/22/21- Sitter discontinued. She will continue to get therapy for PT/OT and also with Restorative program/exercise for UE ( upper extremity)/LE (Lower extremity) strengthening. Care plan intervention was not implemented. On 4/27/21, R55 fell in her room. She is not placed by nursing station once up for close monitoring as indicated in her care plan dated 3/15/21. On 4/28/21 at 9:54am, Observed R55 up in wheelchair in the corner of her room with right arm sling not properly placed. The right elbow is not supported with the sling. V5 Resident Escort stated she is sent to watch her 1:1 since 7:30am. R55 has medical appointment today. On 4/28/21 at 10:15am, V6 Activity Aide translated conversation with R55 and R18. R55 stated that she has pain in her both arms. She stated she stood up and the wheelchair moved, and she fell . R18 ( R55's roommate) stated that R55 dropped her coloring pen, she tried to stand and pick it up. She instructed her not to stand up, but she does not listen to her . She called for help. Both R55 and R18 stated it happened during lunch time. On 4/28/21 at 12:13pm, V7 Therapy Supervisor/Occupational Therapist stated that she has treated R55 for occupational therapy for Certification period of 2/22/21 to 3/23/21 and 4/20/21 to 5/19/21. She did her initial evaluation on 2/22/21. She needs minimal assist for ADLs except toileting and bathing she needs moderate assistance for 1 person. Per record review, she lives with family at home. She ambulates with walker at home with supervision. She is high risk for fall due to poor cognition and impaired safety awareness. She had a fall incident on 2/23/21. After each fall incident Restorative nurse informed therapy to evaluate for changes in functional mobility. She was seen by PT and OT on 2/25/21. She is ambulating 20-30ft with minimal assist. No changes in assistance for hygiene and grooming. She had another fall on 3/14/21 causing nasal bone fracture. She was seen by PT and OT on 3/17/21. No changes in mobility. On 3/19/21, she added to her goal of locking her wheelchair because V8 Restorative nurse reported that from previous fall investigation indicated that R55 stood up without locking her wheelchair that causes her to fall. She was recertified for skilled therapy services for 3/24/21 to 4/22/21. R55 had another fall on 4/17/21 causing fractured right elbow. She was re-certified again on 4/20/21 to 5/19/21. R55 demonstrated significant functional decline after the fall resulting in fracture in RUE (right upper extremity) and inability to use RUE for assistance in functional mobility. She was progressing toward goals prior to fall but due to limited use of RUE, she is now requiring more assistance. Her functional assessment decline in the following areas: Bed mobility (from contact guard assist to moderate assistance), Transfer (from minimal assist to maximum assist), Ambulation (from walking 60 feet with minimal assist to 5 feet maximum assist). Hygiene to moderate assist. Toileting (from minimal assist to maximum assist). Dressing (from minimal assist to moderate assist). R55 remains a high risk for falls. She (V7) has not spoken to a family member of R55 regarding her progress or decline due to recent falls. She stated that usually nursing staff talk to the family. R55's therapy notes for 3/19/21 indicated goal upgrade: R55 will demonstrate ability to lock brakes with moderate assist and 75% verbal cues for initiation of tasks. Certification period 4/20/21 to 5/19/21 Physical therapy updated plan indicated: Summary of skilled services Patient progress: R55 demonstrates significant functional decline s/p fall resulting in fracture in RUE and inability to use RUE for assistance in functional mobility. R55 was progressing towards goals prior to fall but due to limited use of RUE, she now requires more assistance. Bed mobility- Moderate assistance, Transfers- Maximum assistance and Ambulation- Maximum assistance. On 4/28/21 at 12:48am, V8 Restorative Nurse/Fall Coordinator stated that a Fall assessment is done upon admission and after each fall incident. V8 does the Fall investigation and root- cause analysis. V8 updated the resident's individualized care plan based on root cause analysis to prevent from future falls. Care plan meeting with resident (if applicable) and family member to discuss plan of care to prevent future falls. V8 stated she spoke with R55's brother but did not document. V8 cannot recall date of conversation. She stated that she does need to call the family member for new fall prevention intervention after each fall. She stated that she updated R55's care plan after each fall. The sitter was discontinued on 4/22/21 but resident remains on therapy for PT/OT and Restorative program/exercises for UE (Upper extremities) /LE( lower extremities) strengthening. V8 did the fall investigation incident yesterday and implemented new interventions. She stated that fall could be prevented by providing a sitter and moving closer to the nursing station. V8 stated that she has not called or spoken to family regarding new interventions. Review R55's POS and care plan indicated that she is on AROM (active range of motion) program for bilateral upper and lower extremities. Nursing Rehab log indicated that from 4/17/21 to 4/27/21 AROM was done to both upper extremities. R55 has right arm sling due to right elbow injury secondary to fall incident on 4/17/21. She stated that she has not updated the POS ( Physician order sheet) and care plan. AROM cannot be done on right upper arm due to fracture and need to be immobilized. V9 Restorative Aide only performed it on Left upper arm. Review of R55's Restorative program log dated 4/27/21 done at 12:10pm for both walking and AROM. R55 had fall incident on 4/27/21 at 11:15am in her room and was sent out to the hospital. She stated that V9 RA did the exercises in the morning but documented in the afternoon. On 4/29/21 at 9:43am, Follow up request to V1 Administrator and V2 DON documents requested for R55 and policies from yesterday including the 1:1 monitoring log for R55. She stated she will ask V8 Restorative Nurse. On 4/29/21 at 10:29am Observed R55 up in wheelchair in the corner of her room with right arm brace. V5 Resident Escort/Sitter at bedside stated that the ortho doctor applied it yesterday when they went for medical appointment. She stated that she is assigned to monitor R55 today since 7:10am. Observed 1:1 monitoring log every hour binder started on 4/28/21 at bedside. V6 Activity Aide translated conversation with R55. R55 stated that she has pain on both arms but more pain on right upper arm and rubbed her right upper arm. On 4/29/21 at 1:50pm Interview with V8 Restorative Nurse at 2nd floor Nursing station. She stated that she did not have the monitoring log for R55 for 4/17/21 to 4/22/21, she just started the monitoring 1:1 log yesterday. Asked V8, for the list of residents on high fall risk or residents on fall prevention program in the unit to communicate with the staff. She stated she does not have the list on the unit but it's in her office. Requested copy of policy of fall prevention program. She stated the V2 DON has the policy. On 4/29/21 at 2:08pm, Follow up request for R55's documents and Facility's policy on fall prevention program. She stated they don't have Fall prevention program policy. That corporate only gave her a Fall occurrence policy. On 4/29/21 at 2:15pm Telephone interview with V10 Pyschiatrist, she stated that she has been seeing R55 regularly since admission. She is aware that she is high risk for falls and has multiple episodes of falls. She is not aware that 1:1 supervision/ sitter was discontinued on 4/22/21 as indicated in care plan. She is not aware that R55 has another fall on 4/27/21. She has not spoken to R55's family member and R55's Primary Care Physician. She stated fall could be prevented if she is on 24-hour supervision/1:1 monitoring /sitter. She is very impulsive. If they continue the 1:1 supervision/sitter she could be monitored, watched closely and fall could be prevented. R55's progress notes indicated V10 Psychiatrist visits and documentation on the following dates: 3/15/21- Plan: 12. Fall precautions: she fell over the weekend and was sent to the hospital, found to have nasal fracture, she has to see ENT in this regard. Fall precaution per facility protocol. PT, OT to improve strength, frequent visit by staff and call light within reach. 3/22/21- Plan: 12. Fall precautions: she fell over the weekend and was sent to the hospital, found to have nasal fracture, she has to see ENT in this regard. Fall precaution per facility protocol. PT, OT to improve strength, frequent visit by staff and call light within reach. 3/29/21- Plan: 12. Fall precautions: she fell over the weekend and was sent to the hospital, found to have nasal fracture, she has to see ENT in this regard. Fall precaution per facility protocol. PT, OT to improve strength, frequent visit by staff and call light within reach. 4/12/21-Plan: 12. Fall precautions: denies any pain in the nasal fracture area. Fall precaution per facility protocol. PT, OT to improve strength, frequent visit by staff and call light within reach. 4/19/21- Plan: 12. Fall precautions: Recurrent fall, fall precaution per facility protocol. She has sitter. Patient suffers from right arm fracture, no records available for review. Sling and ortho appointment on 4/28/21 she also has auto laryngology consult for recent nasal fracture. 4/26/21- Plan: 12. Fall precautions: Recurrent fall, fall precaution per facility protocol. She has sitter. Patient suffers from right arm fracture, no records available for review. Sling and ortho appointment on 4/28/21 she also has auto laryngology consult for recent nasal fracture. Facility's Fall Occurrence policy revised date 8/5/2020 indicated: Policy statement: it is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling Procedure: 8. The Fall coordinator will add the intervention in the resident's care plan Facility's Care plan policy revised date 8/5/2020 indicated: Procedures: These will be periodically reviewed and revised by a team qualified person after each assessment.

Based on interview and record review, the facility failed to identify and intervene for a change in the resident's condition related to adverse side effects from medication. This failure resulted in (R185) experiencing symptoms including headache, loss of appetite, sensitivity to light, muscle weakness, and chest pain for a period of approximately two weeks and then being sent to local hospital. R185 was admitted to the local hospital due to [MEDICAL CONDITION] and died six days after admission. Findings include: R185 was a [AGE] year old female initially admitted to the facility on [DATE]. R185 had [DIAGNOSES REDACTED]. R185 was referred to V11 (Physician - Pain Specialist) by V9 (Primary Care Physician) for treatment of [REDACTED]. Review of medical record documents that R185 visited V11 on [DATE] for an initial consultation. Visit summary includes orders for three new medications to treat the back pain and [MEDICAL CONDITION]; [MEDICATION NAME] HCL 150mg oral capsule, 1 by mouth twice a day; [MEDICATION NAME] HCL 10mg oral capsule, 1 by mouth at bedtime; and Memantine HCL 5mg oral tablet, 1 by mouth twice a day. Nursing Progress Note entered by V17 (LPN) on [DATE] 1:21pm, reads: Physician (V9) was called X2 with no respond for medication to be clarification. Endorse to next shift to follow up. Interview with V17 on [DATE] at approximately 10:35am, stated that he didn't remember the specifics of the issue but that he did not enter the order to start the new medications (ordered from V11) because the patient was telling him that the instructions from the doctor were different than what was written on the order. He did not want to start new medications for the resident without first getting clarification; so he called V9 since he is the primary care physician, to get clarification on the medication orders. Physician order [REDACTED]. There are no instructions for monitoring of the resident or indication of how to identify signs and symptoms of possible adverse reactions to medication. As documented on pharmacy recommendations: [MEDICATION NAME] HCL may interact with (not limited to) medicines for depression, anxiety, or psychotic disturbances. Side effects that should be reported to doctor or health care professional as soon as possible, when taking [MEDICATION NAME] HCL include (but not limited to): chest pain, continued irregular heartbeats, and unusually weak or tired. Side effects that should be reported to doctor or health care professional as soon as possible, when taking Memantine can include (not limited to): dizziness. [MEDICATION NAME] HCL should not be taken with other medicines for mental depression; may interact with (not limited to) [MEDICAL CONDITION] medicine, and side effects that should be reported to doctor or health care professional as soon as possible include (not limited to): feeling faint or lightheaded, stiff muscles, trouble sleeping, and unusually weak or tired. Interview with V14 on [DATE] at approximately 4:00pm, stated that she called the primary care doctor to get clarification before entering the orders for the three new pain medications and spoke to the primary care doctors nurse practitioner, (V12 / Nurse Practitioner). V14 stated that she always calls the primary care physician for clarification on orders since the primary care is the one responsible for the resident's care. Interview with V11 on [DATE] at approximately 3:40pm, stated that he returned a call to the facility on [DATE] and that he left a message with the receptionist for the nurse (V14) to call him back regarding medications that he had prescribed for the patient. V11 stated that he likes to speak to the nurse directly so that they understand how the medications should be taken (one week apart to watch for side effects and to know if the medications are effective or not; these medications take time to build up in your system). I made it a point to speak to the nurse to explain that the medications should be started a week apart and that they (nurses) must look for signs that the patient is having a reaction to the medication for safety of the patient. Interview with V14 on [DATE] at approximately 4:00pm stated that she did not call V11 for clarification or ever speak to V11 regarding how to enter in the order for medications or instructions for administration. She just entered the order for all three medications to start on [DATE] after getting approval from V12. Progress note dated [DATE] 3:26pm, Per patient, she states that (V11) told her to start each medication, Nortriplyine, Memantine, and [MEDICATION NAME] HCL and see what are her side effects. (V11's) order (written order) doesn't state that way, instead, to take them all at once, no tapering dose. Per (V12), confirm with (V11) first. Called (V11's) office but no answer. Left a voice message. On [DATE] at 4:48pm, (V11's) phone record documents that (V11) called facility back in regards to voice mail message at 2:48pm, spoke to receptionist (V18), he stated that he will leave a message for someone to return the call, stated ok. Nursing Progress Note dated [DATE] at 10:02pm, documents, Writer called (V11) to clarify new orders he gave to resident in that a start date was needed. V11 informed writer, As long as medication start dates are one week apart from each other it does not matter which medication in started which week. There is no information in the progress note stating that the patient should be monitored for adverse reactions to the new medications. Per the facility Medication Administration Record [REDACTED]. Interview with V9 on [DATE] at approximately 1:55pm, when asked if he was ever contacted for clarification on orders or notified of resident not receiving medication as ordered he stated that he didn't recall since his nurse practitioner was the one who mostly saw the resident. V9 stated that he relies on the specialist to check the medications that the resident is taking and sometimes his medication list is not correct because he uses his own system, which doesn't interface with the facility's electronic record. When asked if he was aware of the new medications the resident was receiving, V9 stated that he tries to review the record when he's onsite at the facility and has to personally go in and catch any changes to medications, etc. V9 stated that he is working on getting better at signing the physician orders. There was no documentation in the record to show that V9 reviewed the new medications ordered by V11. Physician Visit Note dated [DATE] for V9; Current Medications listed do not include [MEDICATION NAME] HCL 150mg, [MEDICATION NAME] HCL 10mg, or Memantine HCL 5mg. Review of R185's Physician order [REDACTED]. Interview with V12 (Nurse Practitioner) on [DATE] at approximately 2:25pm, stated that she collaborates with V9 when new medications are ordered but could not specifically remember discussing the new medications ordered by V11 with V9. Order Note dated [DATE] at 1:34pm, Nortryptyline order has triggered the following drug protocol alerts/warning: Drug to Drug interaction with [MEDICATION NAME]-[MEDICATION NAME] Solution (moderate severity, cardiovascular adverse effects), [MEDICATION NAME] (severity level: severe, prolongation of the QT interval with possible development of cardiac arrhythmia, including torsades de pointes), [MEDICATION NAME] (severity level: severe, additive QT interval prolongation), [MEDICATION NAME] (moderate severity, [MEDICAL CONDITION] other cardiac arrhythmias), and [MEDICATION NAME] (severity level: severe, additive QT interval prolongation). Interview with V2 (Director of Nursing) on [DATE] at approximately 10:00am, was asked who should respond to order notes that come up in the EMR (electronic medical record) related to possible drug to drug interactions. V2 stated that the RN's (nurses) are responsible for reviewing the order notes and communicating the information to the physician and document their communication; the [MEDICAL CONDITION] nurse should also be making the physician aware of any order notes related to [MEDICAL CONDITION] medications and documenting the communication. Interview with V16 (RN - [MEDICAL CONDITION] Nurse) on [DATE] at approximately 10:40am, was asked if she had reviewed and communicated the order note related to the possible drug interactions with Nortryptyline (since it's an anti-depressant) that R185 was taking and she stated that she was sure she had but probably didn't document it. She stated that V10 (Psychiatrist) is very well aware of this patient since he's been seeing her for [AGE] years. There was no documentation provided during the course of the survey to indicate that the drug to drug interactions with the Nortryptyline had been reviewed or discussed as part of the interdisciplinary management of care. Review of facility Job Description: [MEDICAL CONDITION] Nurse dated ,[DATE] includes under Essential Functions: 4. Monitor patients on [MEDICAL CONDITION] medications quarterly/or as needed for possible drug reductions and identify/document in patient medical record the clinical reasons why reduction attempts clinically contraindicated or recommended. On [DATE] per (V9) telephone encounter document, the caller from the facility, (V14), stated that patient was complaining of weakness, headaches, and dizziness. No fever. On [DATE] per (V9) telephone encounter document, the nurse from the facility states that the patient is complaining of sore throat, sensitive to light, nausea, light headed. Nurse thinks that it may be because of one of the meds she started on within last 3 weeks or because of [MEDICATION NAME] decrease. Asking to speak to you (MD)? Action taken per (V9) is: This is likely due to [MEDICATION NAME] decrease. Which medication has been started? Also, ask nurse to send throat swab for strep and flu, as well as put patient in contact isolation (in case if this is a flu). Facility Response is: Patient was started on [MEDICATION NAME] HCL 150mg, Nortryptyline 10mg, [MEDICATION NAME] 5mg. Response by (V9) is: Please advise nurse to call psychiatrist to see if any of those medications may have caused symptoms. On [DATE], Facility Response: called to check if order received, was asked to call in 30 minutes. Called again, spoke with nurse. Patient scheduled to see Pain specialist on [DATE]. She is on [MEDICATION NAME] ER 60mg BID also [MEDICATION NAME] 15mg every 8 hours PRN (for additional pain). But at present time have no order for those present meds, was rejected by pain specialist unless seen in his office. They're asking if possible you can give order for it until [DATE]. Or asking if can speak with your for further actions. On [DATE], (V9) response is: Advise to call (V11) for all pain medication orders. Nursing Progress Note dated [DATE] at 7:36pm, Resident presented at beginning of writers shift with signs and symptoms of opioid withdrawal as evidenced by c/o nausea, sensitivity to light, and muscle pain. Resident also has c/o headache and dry cough. Vital signs presented as follows: HR 69, BP ,[DATE]/rr (respitatory rate) 17/o2 saturation 97 room air, temp 97.6. Resident recently has had 60 mg [MEDICATION NAME] d/c on [DATE], and 3 new medications started within the last month. Resident's PCP has been informed. New order for throat culture and flu swab. Please f/u on results. Nursing Progress Note dated [DATE] at 2:38pm, Received a call from (V9)'s office as per secretary (V9) will call back the facility to follow up with residents s/sx, and current orders. Informed secretary awaiting for strep throat results. Ask secretary if they can suggest another lab for flu test. Secretary informed writer, MD will call back the facility. Nursing Progress Note dated [DATE] at 6:23pm documented that resident is complaining of nausea, sensitivity to light, muscle pain, headache and dry cough. Follow up with lab in regards to throat culture and flu swab. Throat culture is pending and machine to test for flu is broken, and will not be fixed until Monday. Please follow up with MD and inquire about sending resident to immediate care facility. On [DATE] per facility lab results report, throat culture was done and was resulted negative on [DATE]. Health Status Note dated [DATE] at 12:00pm documents that resident was complaining of weakness, muscle pains, headache, stiff neck, bilateral axillary lymphadenitis and pain, sore throat, loss of appetite and occasional or on and off chest pain for more than a week. She wants to go to hospital if above signs and symptoms cannot be controlled. Pulse rate documented at 51 bpm. Nursing Progress Note dated [DATE] at 11:22pm documents that resident was complaining of weakness and generalized pain. Left a voicemail to the MD regarding overall condition of the resident. Endorsed resident's condition to next nurse on duty. Nursing Progress Note dated [DATE] at 5:28pm documents that resident complains of muscle weakness, sore throat, muscle aches, nausea, sensitivity to light, headache, and little appetite. POS dated (MONTH) (YEAR) includes order to start on [DATE] [MEDICATION NAME] 500mg by mouth one time only for cough. Start order on [DATE] for [MEDICATION NAME] 250mg by mouth one time a day for cough for 4 days. MAR indicated [REDACTED]. Order Note dated [DATE] documents that [MEDICATION NAME] Tablet 250mg has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction with [MEDICATION NAME] Suspension 156mg/ml, [MEDICATION NAME] HCL Tablet 4mg, [MEDICATION NAME] HCL Tablet 50mg, [MEDICATION NAME] HCL 150mg, [MEDICATION NAME] HCL Capsule 10mg; All interactions are listed as severe and list prolongation of the QT interval with possible development of cardiac arrhythmias, including torsades de pointes, when co-administered with [MEDICATION NAME]. Interview with V11 on [DATE] at approximately 9:40am stated that there are certain antibiotics, like [MEDICATION NAME], that can interfere with the metabolism of other medications. There is a sudden spike in all of the meds that are broken down in their pathway. When [MEDICATION NAME] is given with other medications it can cause a dramatic change in the plasma levels of all other medications; so some caution should be exercised when ordering the antibiotic. The patient should be flagged for closer monitoring when [MEDICATION NAME] is ordered. There is no documentation that was provided in the medical record to show that these risks were evaluated in determining the benefit to the resident prior to administration of [MEDICATION NAME] for cough. Nursing Progress Note dated [DATE] at 3:23pm documents that the resident continues to have complaints of muscle weakness, sore throat, muscle aches, nausea, sensitivity to light, headache and little appetite. Tylenol offered, but refused. Flu results are final and negative for flu. NP informed of final result. Nursing Progress Note dated [DATE] at 11:23pm documents, Resident received awake in bed disheveled and tired looking. Writer inquired as to if resident has been sleeping in which she informed she has not been for several days. Resident is AOx2 (alert and oriented X 2) in which an incorrect last name was given. Resident's VS are as follows: BP ,[DATE], HR 64, o2 97 room air RR 16 c/o ,[DATE] all over in muscles. Resident cont. to have c/o headache, sensitivity to light, no appetite, dizziness, muscle aches and pain. Resident ate 30% of dinner, and took only [MEDICATION NAME] and Ambien. Psychiatric doctor informed as well as PCP NP and resident's father. New order for UA and C/S. If test results are negative for infection NP wants an order for [REDACTED]. Nursing Progress Note dated [DATE] at 9:55am documents, At 9:55am, Writer went to resident's room to administer medicine to her roommate when writer overheard resident gasping for air; Writer immediately assessed patient. Observed resident lying completely flat on the bed. HOB was elevated for optimal breathing. Resident was non-responsive at this time. Writer immediately called for assistance, code blue initiated. Oxygen administered via face mask. IV 0.9% normal saline via peripheral line started on left arm. 911 called. CPR imitated until paramedics took over at 9:59am. MD informed. POA notified. DON and all departments aware. On [DATE], R185 was taken to local hospital and admitted with a [DIAGNOSES REDACTED]. R185 expired at the hospital on [DATE]. Cause of death as listed on death certificate was [MEDICAL CONDITIONS] (due to or as a consequence of) ventricular fibrillation (due to or as a consequence of) [MEDICAL CONDITION]. Interview with V9 on [DATE] at approximately 1:55pm, asked if he ever considered that the resident was having an adverse reaction to the additional medications that were started from the pain doctor and he stated that she (R185) was a very complicated case and he would assume that the specialist looked at her history and medications. V9 stated that he would refer psych medication interactions to the psychiatrist. Interview with V2 on [DATE] at approximately 10:00am, stated that all physicians have access to the facility's EMR and that V9 and V10 can review all of the current medications that the resident is taking. The primary care physician still needs to be aware of everything the patient is getting; even if they go to an outside specialist, they (specialist) are not contracted by us so it's still the primary care doctors' responsibility. Interview with V19 (Nurse Consultant) on [DATE] at approximately 11:56am, stated that the primary care physician should take the lead when it comes to the coordination of patient care. The nurse, nurse practitioners, and physicians need to all coordinate. If there are consultation orders, they need to be coordinated through the primary care physician. Interview with V10 on [DATE] at approximately 12:58pm, was asked if he was ever notified of the recurrent symptoms that R185 was having during the month of (MONTH) (YEAR), specifically after she started the three new medications for pain. V10 stated that he doesn't remember the specifics of her symptoms or of being notified about any signs and symptoms. Asked V10 if he specifically remembered getting a call on [DATE] (Based on telephone encounter with V9, who requested to Please advise nurse to call psychiatrist to see if any of those medications may have caused symptoms.) V10 stated, No, I don't specifically remember. V10 also stated that if he knew about the three new medications he would have made some special recommendations and excluded the new medications if they were exacerbating the symptoms; if there was an underlying medical issue, then the medications could be the issue .if the symptoms were acute and different then you must investigate it and not assume it's psychiatric. Interview with V11 on [DATE] at approximately 3:40pm, was asked if he was ever notified of resident symptomatic complaints (such as headache, sensitivity to light, and chest pain, among others as documented in nursing progress notes) that she was having during the month of (MONTH) (YEAR). V11 stated that he was never notified or updated on anything related to this patient. He only saw her when she came in for consultation on [DATE] and that he was not updated again on her status. He did not know that she had passed away until his office called to follow up. V11 stated that his office received a call from the facility on [DATE] and were told that she would not be going to her appointment because she had the flu; at this time the facility did not tell V11 that the resident was complaining of any signs and symptoms. V11 stated that if he had been made aware of any of the complaints from the resident since starting the new medications for pain, that he would have stopped all medications immediately. V11 stated that these signs and symptoms are significant and that there needs to be improved communication both ways and a better way to monitor patients. Facility policy for Physician order [REDACTED]. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director. Care Plan with initiation date of [DATE] includes (but not limited to) intervention: Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications; refusal to eat, dry mouth, depression, fatigue, [MEDICAL CONDITION], loss of appetite, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Based on observation, interview, and record review, the facility failed to enter physician orders [REDACTED]. R134 is a [AGE] year old male admitted to the facility on [DATE]. R134's [DIAGNOSES REDACTED]. Interview with R134 on [DATE] at 1:49pm, stated that he needs more light in his room because his vision is poor and getting worse .I can't see out of this eye (pointing to his left eye) and now this one is going bad too (pointing to the right eye), so now I can barely see. Resident stated that he has asked maintenance to give him brighter bulbs because at night he can barely see and has to hold on to the wall to use the bathroom. I've been asking to see an eye doctor since I got here and no one has seen me, one day someone came but he didn't explain anything to me or give me any medication or anything for my eyes. Resident also stated that he needs new glasses because his got lost and he has told the nurses about this but he is still waiting to see the eye doctor. At this time, surveyor did not observe any eye glasses in the resident's room. R134's admission MDS (Minimum Data Set) dated [DATE] documents that R134 has moderately impaired vision (ability to see in adequate light) and uses corrective lenses. Interview with V2 (Director of Nursing) on [DATE] at approximately 3:50pm, V2 provided Encounter Details report from optometrist visit with R134 on [DATE]. V2 was asked why it took so long for resident to be seen by optometrist if he has been in the facility since December. V2 stated that she was not sure what the delay was but that normally appointments are scheduled right away. If the optometrist cannot come to the facility, the resident will be taken to the office for the appointment. Review of Encounter Details with optometrist dated [DATE] documents, Assessment and Plan: RTC [DATE] for IOP Check Limited and started Latanoprost qhs OU (every night at bedtime, both eyes). Latanoprost is medication used to treat increased intra-ocular pressure, which can be related to [MEDICAL CONDITION]. Review of current POS (Physician order [REDACTED]. There are also orders dated [DATE], (MONTH) see optometrist. R134 was not seen by optometrist until [DATE] and there were no orders included for Latanoprost medication in the POS. During interview with V2 on [DATE] at approximately 3:50pm, V2 was asked why there are no orders in the POS for the Latanoprost drops that were ordered last month. V2 stated that after the optometrist sees the resident, the nurses are supposed to review the encounter sheet and enter in any new orders or recommendations that were made. V2 stated that she is not sure why the orders for the drops were not put in but that she will follow up on it. Care plan dated [DATE] includes: Focus - Resident have impaired visual function r/t Diabetes; Goal - Resident will show no decline in visual function through the next review date; Interventions (include): Ensure appropriate visual aids eyeglasses are available to support my participation in activities/ADL's and Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADL's, Decline in mobility, Sudden vision loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision.

Based on interview and record review, the facility failed to ensure the physician supervised the resident's medical care by the physician failing to consult with physician specialist regarding new medications for the resident and the possible adverse side effects of new medication when used in combination with residents existing medication regimen; the physician also failed to include instructions for monitoring of adverse side effects when adding new medication to regimen in conjunction with medications ordered by physician specialist. This failure resulted in (R185) experiencing symptoms including headache, loss of appetite, sensitivity to light, muscle weakness, and chest pain for a period of approximately two weeks and then being sent to local hospital. R185 was admitted to the local hospital due to [MEDICAL CONDITION] and died six days after admission. Findings include: R185 was a [AGE] year old female initially admitted to the facility on [DATE]. R185 had [DIAGNOSES REDACTED]. R185 was referred to V11 (Physician - Pain Specialist) by V9 (Primary Care Physician) for treatment of [REDACTED]. Review of medical record documents that R185 visited V11 on [DATE] for an initial consultation. Visit summary includes orders for three new medications to treat the back pain and [MEDICAL CONDITION]; [MEDICATION NAME] HCL 150mg oral capsule, 1 by mouth twice a day; [MEDICATION NAME] HCL 10mg oral capsule, 1 by mouth at bedtime; and Memantine HCL 5mg oral tablet, 1 by mouth twice a day. Nursing Progress Note entered by V17 (LPN) on [DATE] 1:21pm, reads: Physician (V9) was called X2 with no respond for medication to be clarification. Endorse to next shift to follow up. Interview with V17 on [DATE] at approximately 10:35am, stated that he didn't remember the specifics of the issue but that he did not enter the order to start the new medications (ordered from V11) because the patient was telling him that the instructions from the doctor were different than what was written on the order. He did not want to start new medications for the resident without first getting clarification; so he called V9 since he is the primary care physician, to get clarification on the medication orders. Physician order [REDACTED]. There are no instructions for monitoring of the resident or indication of how to identify signs and symptoms of possible adverse reactions to medication. As documented on pharmacy recommendations: [MEDICATION NAME] HCL may interact with (not limited to) medicines for depression, anxiety, or psychotic disturbances. Side effects that should be reported to doctor or health care professional as soon as possible, when taking [MEDICATION NAME] HCL include (but not limited to): chest pain, continued irregular heartbeats, and unusually weak or tired. Side effects that should be reported to doctor or health care professional as soon as possible, when taking Memantine can include (not limited to): dizziness. [MEDICATION NAME] HCL should not be taken with other medicines for mental depression; may interact with (not limited to) [MEDICAL CONDITION] medicine, and side effects that should be reported to doctor or health care professional as soon as possible include (not limited to): feeling faint or lightheaded, stiff muscles, trouble sleeping, and unusually weak or tired. Interview with V14 on [DATE] at approximately 4:00pm, stated that she called the primary care doctor to get clarification before entering the orders for the three new pain medications and spoke to the primary care doctors nurse practitioner, (V12 / Nurse Practitioner). V14 stated that she always calls the primary care physician for clarification on orders since the primary care is the one responsible for the resident's care. Interview with V11 on [DATE] at approximately 3:40pm, stated that he returned a call to the facility on [DATE] and that he left a message with the receptionist for the nurse (V14) to call him back regarding medications that he had prescribed for the patient. V11 stated that he likes to speak to the nurse directly so that they understand how the medications should be taken (one week apart to watch for side effects and to know if the medications are effective or not; these medications take time to build up in your system). I made it a point to speak to the nurse to explain that the medications should be started a week apart and that they (nurses) must look for signs that the patient is having a reaction to the medication for safety of the patient. Interview with V14 on [DATE] at approximately 4:00pm stated that she did not call V11 for clarification or ever speak to V11 regarding how to enter in the order for medications or instructions for administration. She just entered the order for all three medications to start on [DATE] after getting approval from V12. Progress note dated [DATE] 3:26pm, Per patient, she states that (V11) told her to start each medication, Nortriplyine, Memantine, and [MEDICATION NAME] HCL and see what are her side effects. (V11's) order (written order) doesn't state that way, instead, to take them all at once, no tapering dose. Per (V12), confirm with (V11) first. Called (V11's) office but no answer. Left a voice message. On [DATE] at 4:48pm, (V11's) phone record documents that (V11) called facility back in regards to voice mail message at 2:48pm, spoke to receptionist (V18), he stated that he will leave a message for someone to return the call, stated ok. Nursing Progress Note dated [DATE] at 10:02pm, documents, Writer called (V11) to clarify new orders he gave to resident in that a start date was needed. V11 informed writer, As long as medication start dates are one week apart from each other it does not matter which medication in started which week. There is no information in the progress note stating that the patient should be monitored for adverse reactions to the new medications. Per the facility Medication Administration Record [REDACTED]. Interview with V9 on [DATE] at approximately 1:55pm, when asked if he was ever contacted for clarification on orders or notified of resident not receiving medication as ordered he stated that he didn't recall since his nurse practitioner was the one who mostly saw the resident. V9 stated that he relies on the specialist to check the medications that the resident is taking and sometimes his medication list is not correct because he uses his own system, which doesn't interface with the facility's electronic record. When asked if he was aware of the new medications the resident was receiving, V9 stated that he tries to review the record when he's onsite at the facility and has to personally go in and catch any changes to medications, etc. V9 stated that he is working on getting better at signing the physician orders. There was no documentation in the record to show that V9 reviewed the new medications ordered by V11. Physician Visit Note dated [DATE] for V9; Current Medications listed do not include [MEDICATION NAME] HCL 150mg, [MEDICATION NAME] HCL 10mg, or Memantine HCL 5mg. Review of R185's Physician order [REDACTED]. Interview with V12 (Nurse Practitioner) on [DATE] at approximately 2:25pm, stated that she collaborates with V9 when new medications are ordered but could not specifically remember discussing the new medications ordered by V11 with V9. Order Note dated [DATE] at 1:34pm, Nortryptyline order has triggered the following drug protocol alerts/warning: Drug to Drug interaction with [MEDICATION NAME]-[MEDICATION NAME] Solution (moderate severity, cardiovascular adverse effects), [MEDICATION NAME] (severity level: severe, prolongation of the QT interval with possible development of cardiac arrhythmia, including torsades de pointes), [MEDICATION NAME] (severity level: severe, additive QT interval prolongation), [MEDICATION NAME] (moderate severity, [MEDICAL CONDITION] other cardiac arrhythmias), and [MEDICATION NAME] (severity level: severe, additive QT interval prolongation). Interview with V2 (Director of Nursing) on [DATE] at approximately 10:00am, was asked who should respond to order notes that come up in the EMR (electronic medical record) related to possible drug to drug interactions. V2 stated that the RN's (nurses) are responsible for reviewing the order notes and communicating the information to the physician and document their communication; the [MEDICAL CONDITION] nurse should also be making the physician aware of any order notes related to [MEDICAL CONDITION] medications and documenting the communication. Interview with V16 (RN - [MEDICAL CONDITION] Nurse) on [DATE] at approximately 10:40am, was asked if she had reviewed and communicated the order note related to the possible drug interactions with Nortryptyline (since it's an anti-depressant) that R185 was taking and she stated that she was sure she had but probably didn't document it. She stated that V10 (Psychiatrist) is very well aware of this patient since he's been seeing her for [AGE] years. There was no documentation provided during the course of the survey to indicate that the drug to drug interactions with the Nortryptyline had been reviewed or discussed as part of the interdisciplinary management of care. Review of facility Job Description: [MEDICAL CONDITION] Nurse dated ,[DATE] includes under Essential Functions: 4. Monitor patients on [MEDICAL CONDITION] medications quarterly/or as needed for possible drug reductions and identify/document in patient medical record the clinical reasons why reduction attempts clinically contraindicated or recommended. On [DATE] per (V9) telephone encounter document, the caller from the facility, (V14), stated that patient was complaining of weakness, headaches, and dizziness. No fever. On [DATE] per (V9) telephone encounter document, the nurse from the facility states that the patient is complaining of sore throat, sensitive to light, nausea, light headed. Nurse thinks that it may be because of one of the meds she started on within last 3 weeks or because of [MEDICATION NAME] decrease. Asking to speak to you (MD)? Action taken per (V9) is: This is likely due to [MEDICATION NAME] decrease. Which medication has been started? Also, ask nurse to send throat swab for strep and flu, as well as put patient in contact isolation (in case if this is a flu). Facility Response is: Patient was started on [MEDICATION NAME] HCL 150mg, Nortryptyline 10mg, [MEDICATION NAME] 5mg. Response by (V9) is: Please advise nurse to call psychiatrist to see if any of those medications may have caused symptoms. On [DATE], Facility Response: called to check if order received, was asked to call in 30 minutes. Called again, spoke with nurse. Patient scheduled to see Pain specialist on [DATE]. She is on [MEDICATION NAME] ER 60mg BID also [MEDICATION NAME] 15mg every 8 hours PRN (for additional pain). But at present time have no order for those present meds, was rejected by pain specialist unless seen in his office. They asking if possible you can give order for it until [DATE]. Or asking if can speak with your for further actions. On [DATE], (V9) response is: Advise to call (V11) for all pain medication orders. Nursing Progress Note dated [DATE] at 7:36pm, Resident presented at beginning of writers shift with signs and symptoms of opioid withdrawal as evidenced by c/o nausea, sensitivity to light, and muscle pain. Resident also has c/o headache and dry cough. Vital signs presented as follows: HR 69, BP ,[DATE]/rr (respiratory rate) 17/o2 saturation 97 room air, temp 97.6. Resident recently has had 60 mg [MEDICATION NAME] d/c on [DATE], and 3 new medications started within the last month. Resident's PCP has been informed. New order for throat culture and flu swab. Please f/u on results. Nursing Progress Note dated [DATE] at 2:38pm, Received a call from (V9)'s office as per secretary (V9) will call back the facility to follow up with residents s/sx, and current orders. Informed secretary awaiting for strep throat results. Ask secretary if they can suggest another lab for flu test. Secretary informed writer, MD will call back the facility. Nursing Progress Note dated [DATE] at 6:23pm documented that resident is complaining of nausea, sensitivity to light, muscle pain, headache and dry cough. Follow up with lab in regards to throat culture and flu swab. Throat culture is pending and machine to test for flu is broken, and will not be fixed until Monday. Please follow up with MD and inquire about sending resident to immediate care facility. On [DATE] per facility lab results report, throat culture was done and was resulted negative on [DATE]. Health Status Note dated [DATE] at 12:00pm documents that resident was complaining of weakness, muscle pains, headache, stiff neck, bilateral axillary lymphadenitis and pain, sore throat, loss of appetite and occasional or on and off chest pain for more than a week. She wants to go to hospital if above signs and symptoms cannot be controlled. Pulse rate documented at 51 bpm. Nursing Progress Note dated [DATE] at 11:22pm documents that resident was complaining of weakness and generalized pain. Left a voicemail to the MD regarding overall condition of the resident. Endorsed resident's condition to next nurse on duty. Nursing Progress Note dated [DATE] at 5:28pm documents that resident complains of muscle weakness, sore throat, muscle aches, nausea, sensitivity to light, headache, and little appetite. POS dated (MONTH) (YEAR) includes order to start on [DATE] [MEDICATION NAME] 500mg by mouth one time only for cough. Start order on [DATE] for [MEDICATION NAME] 250mg by mouth one time a day for cough for 4 days. MAR indicated [REDACTED]. Order Note dated [DATE] documents that [MEDICATION NAME] Tablet 250mg has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction with [MEDICATION NAME] Suspension 156mg/ml, [MEDICATION NAME] HCL Tablet 4mg, [MEDICATION NAME] HCL Tablet 50mg, [MEDICATION NAME] HCL 150mg, [MEDICATION NAME] HCL Capsule 10mg; All interactions are listed as severe and list prolongation of the QT interval with possible development of cardiac arrhythmias, including torsades de pointes, when co-administered with [MEDICATION NAME]. Interview with V11 on [DATE] at approximately 9:40am stated that there are certain antibiotics, like [MEDICATION NAME], that can interfere with the metabolism of other medications. There is a sudden spike in all of the meds that are broken down in their pathway. When [MEDICATION NAME] is given with other medications it can cause a dramatic change in the plasma levels of all other medications; so some caution should be exercised when ordering the antibiotic. The patient should be flagged for closer monitoring when [MEDICATION NAME] is ordered. There is no documentation that was provided in the medical record to show that these risks were evaluated in determining the benefit to the resident prior to administration of [MEDICATION NAME] for cough. Nursing Progress Note dated [DATE] at 3:23pm documents that the resident continues to have complaints of muscle weakness, sore throat, muscle aches, nausea, sensitivity to light, headache and little appetite. Tylenol offered, but refused. Flu results are final and negative for flu. NP informed of final result. Nursing Progress Note dated [DATE] at 11:23pm documents, Resident received awake in bed disheveled and tired looking. Writer inquired as to if resident has been sleeping in which she informed she has not been for several days. Resident is AO (alert and Oriented) x2 in which an incorrect last name was given. Resident's VS are as follows: BP ,[DATE], HR 64, o2 97 room air RR 16 c/o ,[DATE] all over in muscles. Resident cont. to have c/o headache, sensitivity to light, no appetite, dizziness, muscle aches and pain. Resident ate 30% of dinner, and took only [MEDICATION NAME] and Ambien. Psychiatric doctor informed as well as PCP NP and resident's father. New order for UA and C/S. If test results are negative for infection NP wants an order for [REDACTED]. Nursing Progress Note dated [DATE] at 9:55am documents, At 9:55am, Writer went to resident's room to administer medicine to her roommate when writer overheard resident gasping for air; Writer immediately assessed patient. Observed resident lying completely flat on the bed. HOB was elevated for optimal breathing. Resident was non-responsive at this time. Writer immediately called for assistance, code blue initiated. Oxygen administered via face mask. IV 0.9% normal saline via peripheral line started on left arm. 911 called. CPR imitated until paramedics took over at 9:59am. MD informed. POA notified. DON and all departments aware. On [DATE], R185 was taken to local hospital and admitted with a [DIAGNOSES REDACTED]. R185 expired at the hospital on [DATE]. Cause of death as listed on death certificate was [MEDICAL CONDITIONS] (due to or as a consequence of) ventricular fibrillation (due to or as a consequence of) [MEDICAL CONDITION]. Interview with V9 on [DATE] at approximately 1:55pm, asked if he ever considered that the resident was having an adverse reaction to the additional medications that were started from the pain doctor and he stated that she (R185) was a very complicated case and he would assume that the specialist looked at her history and medications. V9 stated that he would refer psych medication interactions to the psychiatrist. Interview with V2 on [DATE] at approximately 10:00am, stated that all physicians have access to the facility's EMR and that V9 and V10 can review all of the current medications that the resident is taking. The primary care physician still needs to be aware of everything the patient is getting; even if they go to an outside specialist, they (specialist) are not contracted by us so it's still the primary care doctors' responsibility. Interview with V19 (Nurse Consultant) on [DATE] at approximately 11:56am, stated that the primary care physician should take the lead when it comes to the coordination of patient care. The nurse, nurse practitioners, and physicians need to all coordinate. If there are consultation orders, they need to be coordinated through the primary care physician. Interview with V10 on [DATE] at approximately 12:58pm, was asked if he was ever notified of the recurrent symptoms that R185 was having during the month of (MONTH) (YEAR), specifically after she started the three new medications for pain. V10 stated that he doesn't remember the specifics of her symptoms or of being notified about any signs and symptoms. Asked V10 if he specifically remembered getting a call on [DATE] (Based on telephone encounter with V9, who requested to Please advise nurse to call psychiatrist to see if any of those medications may have caused symptoms.) V10 stated, No, I don't specifically remember. V10 also stated that if he knew about the three new medications he would have made some special recommendations and excluded the new medications if they were exacerbating the symptoms; if there was an underlying medical issue, then the medications could be the issue .if the symptoms were acute and different then you must investigate it and not assume it's psychiatric. Interview with V11 on [DATE] at approximately 3:40pm, was asked if he was ever notified of resident symptomatic complaints (such as headache, sensitivity to light, and chest pain, among others as documented in nursing progress notes) that she was having during the month of (MONTH) (YEAR). V11 stated that he was never notified or updated on anything related to this patient. He only saw her when she came in for consultation on [DATE] and that he was not updated again on her status. He did not know that she had passed away until his office called to follow up. V11 stated that his office received a call from the facility on [DATE] and were told that she would not be going to her appointment because she had the flu; at this time the facility did not tell V11 that the resident was complaining of any signs and symptoms. V11 stated that if he had been made aware of any of the complaints from the resident since starting the new medications for pain, that he would have stopped all medications immediately. V11 stated that these signs and symptoms are significant and that there needs to be improved communication both ways and a better way to monitor patients. Facility policy for Physician order [REDACTED]. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director. Care Plan with initiation date of [DATE] includes (but not limited to) intervention: Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications; refusal to eat, dry mouth, depression, fatigue, [MEDICAL CONDITION], loss of appetite, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person.

Based on interview and record review, the facility failed to clarify new orders for medication prior to administration, including instructions for monitoring of potential side effects; failed to have communication between the primary care provider and other provider specialists related to changes to the medication regimen and appearance of signs and symptoms; failed to use an interdisciplinary evaluation in considering that new medications were the underlying cause of signs and symptoms. This failure resulted in (R185) experiencing symptoms including headache, loss of appetite, sensitivity to light, muscle weakness, and chest pain for a period of approximately two weeks and then being sent to local hospital. R185 was admitted to the local hospital due to [MEDICAL CONDITION] and died six days after admission. Findings include: R185 was a [AGE] year old female initially admitted to the facility on [DATE]. R185 had [DIAGNOSES REDACTED]. R185 was referred to V11 (Physician - Pain Specialist) by V9 (Primary Care Physician) for treatment of [REDACTED]. Review of medical record documents that R185 visited V11 on [DATE] for an initial consultation. Visit summary includes orders for three new medications to treat the back pain and [MEDICAL CONDITION]; [MEDICATION NAME] HCL 150mg oral capsule, 1 by mouth twice a day; [MEDICATION NAME] HCL 10mg oral capsule, 1 by mouth at bedtime; and Memantine HCL 5mg oral tablet, 1 by mouth twice a day. Nursing Progress Note entered by V17 (LPN) on [DATE] 1:21pm, reads: Physician (V9) was called X2 with no response for medication to be clarified Endorse to next shift to follow up. Interview with V17 on [DATE] at approximately 10:35am, stated that he didn't remember the specifics of the issue but that he did not enter the order to start the new medications (ordered from V11) because the patient was telling him that the instructions from the doctor were different than what was written on the order. He did not want to start new medications for the resident without first getting clarification; so he called V9 since he is the primary care physician, to get clarification on the medication orders. Physician order [REDACTED]. There are no instructions for monitoring of the resident or indication of how to identify signs and symptoms of possible adverse reactions to medication. As documented on pharmacy recommendations: [MEDICATION NAME] HCL may interact with (not limited to) medicines for depression, anxiety, or psychotic disturbances. Side effects that should be reported to doctor or health care professional as soon as possible, when taking [MEDICATION NAME] HCL include (but not limited to): chest pain, continued irregular heartbeats, and unusually weak or tired. Side effects that should be reported to doctor or health care professional as soon as possible, when taking Memantine can include (not limited to): dizziness. [MEDICATION NAME] HCL should not be taken with other medicines for mental depression; may interact with (not limited to) [MEDICAL CONDITION] medicine, and side effects that should be reported to doctor or health care professional as soon as possible include (not limited to): feeling faint or lightheaded, stiff muscles, trouble sleeping, and unusually weak or tired. Interview with V14 on [DATE] at approximately 4:00pm, stated that she called the primary care doctor to get clarification before entering the orders for the three new pain medications and spoke to the primary care doctors nurse practitioner, (V12 / Nurse Practitioner). V14 stated that she always calls the primary care physician for clarification on orders since the primary care is the one responsible for the resident's care. Interview with V11 on [DATE] at approximately 3:40pm, stated that he returned a call to the facility on [DATE] and that he left a message with the receptionist for the nurse (V14) to call him back regarding medications that he had prescribed for the patient. V11 stated that he likes to speak to the nurse directly so that they understand how the medications should be taken (one week apart to watch for side effects and to know if the medications are effective or not; these medications take time to build up in your system). I made it a point to speak to the nurse to explain that the medications should be started a week apart and that they (nurses) must look for signs that the patient is having a reaction to the medication for safety of the patient. Interview with V14 on [DATE] at approximately 4:00pm stated that she did not call V11 for clarification or ever speak to V11 regarding how to enter in the order for medications or instructions for administration. She just entered the order for all three medications to start on [DATE] after getting approval from V12. Progress note dated [DATE] 3:26pm, Per patient, she states that (V11) told her to start each medication, Nortriplyine, Memantine, and [MEDICATION NAME] HCL and see what are her side effects. (V11's) order (written order) doesn't state that way, instead, to take them all at once, no tapering dose. Per (V12), confirm with (V11) first. Called (V11's) office but no answer. Left a voice message. On [DATE] at 4:48pm, (V11's) phone record documents that (V11) called facility back in regards to voice mail message at 2:48pm, spoke to receptionist (V18), he stated that he will leave a message for someone to return the call, stated ok. Nursing Progress Note dated [DATE] at 10:02pm, documents, Writer called (V11) to clarify new orders he gave to resident in that a start date was needed. V11 informed writer, As long as medication start dates are one week apart from each other it does not matter which medication in started which week. There is no information in the progress note stating that the patient should be monitored for adverse reactions to the new medications. Per the facility Medication Administration Record [REDACTED]. Interview with V9 on [DATE] at approximately 1:55pm, when asked if he was ever contacted for clarification on orders or notified of resident not receiving medication as ordered he stated that he didn't recall since his nurse practitioner was the one who mostly saw the resident. V9 stated that he relies on the specialist to check the medications that the resident is taking and sometimes his medication list is not correct because he uses his own system, which doesn't interface with the facility's electronic record. When asked if he was aware of the new medications the resident was receiving, V9 stated that he tries to review the record when he's onsite at the facility and has to personally go in and catch any changes to medications, etc. V9 stated that he is working on getting better at signing the physician orders. Review of R185's Physician order [REDACTED]. There was no documentation in the record to show that V9 reviewed the new medications ordered by V11. Physician Visit Note dated [DATE] for V9; Current Medications listed do not include [MEDICATION NAME] HCL 150mg, [MEDICATION NAME] HCL 10mg, or Memantine HCL 5mg. Interview with V12 (Nurse Practitioner) on [DATE] at approximately 2:25pm, stated that she collaborates with V9 when new medications are ordered but could not specifically remember discussing the new medications ordered by V11 with V9. Order Note dated [DATE] at 1:34pm, Nortryptyline order has triggered the following drug protocol alerts/warning: Drug to Drug interaction with [MEDICATION NAME]-[MEDICATION NAME] Solution (moderate severity, cardiovascular adverse effects), [MEDICATION NAME] (severity level: severe, prolongation of the QT interval with possible development of cardiac arrhythmia, including torsades de pointes), [MEDICATION NAME] (severity level: severe, additive QT interval prolongation), [MEDICATION NAME] (moderate severity, [MEDICAL CONDITION] other cardiac arrhythmias), and [MEDICATION NAME] (severity level: severe, additive QT interval prolongation). Interview with V2 (Director of Nursing) on [DATE] at approximately 10:00am, was asked who should respond to order notes that come up in the EMR (electronic medical record) related to possible drug to drug interactions. V2 stated that the RN's (nurses) are responsible for reviewing the order notes and communicating the information to the physician and document their communication; the [MEDICAL CONDITION] nurse should also be making the physician aware of any order notes related to [MEDICAL CONDITION] medications and documenting the communication. Interview with V16 (RN - [MEDICAL CONDITION] Nurse) on [DATE] at approximately 10:40am, was asked if she had reviewed and communicated the order note related to the possible drug interactions with Nortryptyline (since it's an anti-depressant) that R185 was taking and she stated that she was sure she had but probably didn't document it. She stated that V10 (Psychiatrist) is very well aware of this patient since he's been seeing her for [AGE] years. There was no documentation provided during the course of the survey to indicate that the drug to drug interactions with the Nortryptyline had been reviewed or discussed as part of the interdisciplinary management of care. Review of facility Job Description: [MEDICAL CONDITION] Nurse dated ,[DATE] includes under Essential Functions: 4. Monitor patients on [MEDICAL CONDITION] medications quarterly/or as needed for possible drug reductions and identify/document in patient medical record the clinical reasons why reduction attempts clinically contraindicated or recommended. On [DATE] per (V9) telephone encounter document, the caller from the facility, (V14), stated that patient was complaining of weakness, headaches, and dizziness. No fever. On [DATE] per (V9) telephone encounter document, the nurse from the facility states that the patient is complaining of sore throat, sensitive to light, nausea, light headed. Nurse thinks that it may be because of one of the meds she started on within last 3 weeks or because of [MEDICATION NAME] decrease. Asking to speak to you (MD)? Action taken per (V9) is: This is likely due to [MEDICATION NAME] decrease. Which medication has been started? Also, ask nurse to send throat swab for strep and flu, as well as put patient in contact isolation (in case if this is a flu). Facility Response is: Patient was started on [MEDICATION NAME] HCL 150mg, Nortryptyline 10mg, [MEDICATION NAME] 5mg. Response by (V9) is: Please advise nurse to call psychiatrist to see if any of those medications may have caused symptoms. On [DATE], Facility Response: called to check if order received, was asked to call in 30 minutes. Called again, spoke with nurse. Patient scheduled to see Pain specialist on [DATE]. She is on [MEDICATION NAME] ER 60mg BID also [MEDICATION NAME] 15mg every 8 hours PRN (for additional pain). But at present time have no order for those present meds, was rejected by pain specialist unless seen in his office. They asking if possible you can give order for it until [DATE]. Or asking if can speak with your for further actions. On [DATE], (V9) response is: Advise to call (V11) for all pain medication orders. Nursing Progress Note dated [DATE] at 7:36pm, Resident presented at beginning of writers shift with signs and symptoms of opioid withdrawal as evidenced by c/o nausea, sensitivity to light, and muscle pain. Resident also has c/o headache and dry cough. Vital signs presented as follows: HR 69, BP ,[DATE]/rr17/o2 97 room air, temp 97.6. Resident recently has had 60 mg [MEDICATION NAME] d/c on [DATE], and 3 new medications started within the last month. Resident's PCP has been informed. New order for throat culture and flu swab. Please f/u on results. Nursing Progress Note dated [DATE] at 2:38pm, Received a call from (V9)'s office as per secretary (V9) will call back the facility to follow up with residents s/sx, and current orders. Informed secretary awaiting for strep throat results. Ask secretary if they can suggest another lab for flu test. Secretary informed writer, MD will call back the facility. Nursing Progress Note dated [DATE] at 6:23pm documented that resident is complaining of nausea, sensitivity to light, muscle pain, headache and dry cough. Follow up with lab in regards to throat culture and flu swab. Throat culture is pending and machine to test for flu is broken, and will not be fixed until Monday. Please follow up with MD and inquire about sending resident to immediate care facility. On [DATE] per facility lab results report, throat culture was done and was resulted negative on [DATE]. Health Status Note dated [DATE] at 12:00pm documents that resident was complaining of weakness, muscle pains, headache, stiff neck, bilateral axillary lymphadenitis and pain, sore throat, loss of appetite and occasional or on and off chest pain for more than a week. She wants to go to hospital if above signs and symptoms cannot be controlled. Pulse rate documented at 51 bpm. Nursing Progress Note dated [DATE] at 11:22pm documents that resident was complaining of weakness and generalized pain. Left a voicemail to the MD regarding overall condition of the resident. Endorsed resident's condition to next nurse on duty. Nursing Progress Note dated [DATE] at 5:28pm documents that resident complains of muscle weakness, sore throat, muscle aches, nausea, sensitivity to light, headache, and little appetite. POS dated (MONTH) (YEAR) includes order to start on [DATE] [MEDICATION NAME] 500mg by mouth one time only for cough. Start order on [DATE] for [MEDICATION NAME] 250mg by mouth one time a day for cough for 4 days. MAR indicated [REDACTED]. Order Note dated [DATE] documents that [MEDICATION NAME] Tablet 250mg has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction with [MEDICATION NAME] Suspension 156mg/ml, [MEDICATION NAME] HCL Tablet 4mg, [MEDICATION NAME] HCL Tablet 50mg, [MEDICATION NAME] HCL 150mg, [MEDICATION NAME] HCL Capsule 10mg; All interactions are listed as severe and list prolongation of the QT interval with possible development of cardiac arrhythmias, including torsades de pointes, when co-administered with [MEDICATION NAME]. Interview with V11 on [DATE] at approximately 9:40am stated that there are certain antibiotics, like [MEDICATION NAME], that can interfere with the metabolism of other medications. There is a sudden spike in all of the meds that are broken down in their pathway. When [MEDICATION NAME] is given with other medications it can cause a dramatic change in the plasma levels of all other medications; so some caution should be exercised when ordering the antibiotic. The patient should be flagged for closer monitoring when [MEDICATION NAME] is ordered. There is no documentation that was provided in the medical record to show that these risks were evaluated in determining the benefit to the resident prior to administration of [MEDICATION NAME] for cough. Nursing Progress Note dated [DATE] at 3:23pm documents that the resident continues to have complaints of muscle weakness, sore throat, muscle aches, nausea, sensitivity to light, headache and little appetite. Tylenol offered, but refused. Flu results are final and negative for flu. NP informed of final result. Nursing Progress Note dated [DATE] at 11:23pm documents, Resident received awake in bed disheveled and tired looking. Writer inquired as to if resident has been sleeping in which she informed she has not been for several days. Resident is AOx2 in which an incorrect last name was given. Resident's VS are as follows: BP ,[DATE], HR 64, o2 97 room air RR 16 c/o ,[DATE] all over in muscles. Resident cont. to have c/o headache, sensitivity to light, no appetite, dizziness, muscle aches and pain. Resident ate 30% of dinner, and took only [MEDICATION NAME] and Ambien. Psychiatric doctor informed as well as PCP NP and resident's father. New order for UA and C/S. If test results are negative for infection NP wants an order for [REDACTED]. Nursing Progress Note dated [DATE] at 9:55am documents, At 9:55am, Writer went to resident's room to administer medicine to her roommate when writer overheard resident gasping for air; Writer immediately assessed patient. Observed resident lying completely flat on the bed. HOB was elevated for optimal breathing. Resident was non-responsive at this time. Writer immediately called for assistance, code blue initiated. Oxygen administered via face mask. IV 0.9% normal saline via peripheral line started on left arm. 911 called. CPR imitated until paramedics took over at 9:59am. MD informed. POA notified. DON and all departments aware. On [DATE], R185 was taken to local hospital and admitted with a [DIAGNOSES REDACTED]. R185 expired at the hospital on [DATE]. Cause of death as listed on death certificate was [MEDICAL CONDITIONS] (due to or as a consequence of) ventricular fibrillation (due to or as a consequence of) [MEDICAL CONDITION]. Interview with V9 on [DATE] at approximately 1:55pm, asked if he ever considered that the resident was having an adverse reaction to the additional medications that were started from the pain doctor and he stated that she (R185) was a very complicated case and he would assume that the specialist looked at her history and medications. V9 stated that he would refer psych medication interactions to the psychiatrist. Interview with V2 on [DATE] at approximately 10:00am, stated that all physicians have access to the facility's EMR and that V9 and V10 can review all of the current medications that the resident is taking. The primary care physician still needs to be aware of everything the patient is getting; even if they go to an outside specialist, they (specialist) are not contracted by us so it's still the primary care doctors' responsibility. Interview with V19 (Nurse Consultant) on [DATE] at approximately 11:56am, stated that the primary care physician should take the lead when it comes to the coordination of patient care. The nurse, nurse practitioners, and physicians need to all coordinate. If there are consultation orders, they need to be coordinated through the primary care physician. Interview with V10 on [DATE] at approximately 12:58pm, was asked if he was ever notified of the recurrent symptoms that R185 was having during the month of (MONTH) (YEAR), specifically after she started the three new medications for pain. V10 stated that he doesn't remember the specifics of her symptoms or of being notified about any signs and symptoms. Asked V10 if he specifically remembered getting a call on [DATE] (Based on telephone encounter with V9, who requested to Please advise nurse to call psychiatrist to see if any of those medications may have caused symptoms.) V10 stated, No, I don't specifically remember. V10 also stated that if he knew about the three new medications he would have made some special recommendations and excluded the new medications if they were exacerbating the symptoms; if there was an underlying medical issue, then the medications could be the issue .if the symptoms were acute and different then you must investigate it and not assume it's psychiatric. Interview with V11 on [DATE] at approximately 3:40pm, was asked if he was ever notified of resident symptomatic complaints (such as headache, sensitivity to light, and chest pain, among others as documented in nursing progress notes) that she was having during the month of (MONTH) (YEAR). V11 stated that he was never notified or updated on anything related to this patient. He only saw her when she came in for consultation on [DATE] and that he was not updated again on her status. He did not know that she had passed away until his office called to follow up. V11 stated that his office received a call from the facility on [DATE] and were told that she would not be going to her appointment because she had the flu; at this time the facility did not tell V11 that the resident was complaining of any signs and symptoms. V11 stated that if he had been made aware of any of the complaints from the resident since starting the new medications for pain, that he would have stopped all medications immediately. V11 stated that these signs and symptoms are significant and that there needs to be improved communication both ways and a better way to monitor patients. Facility policy for Physician order [REDACTED]. Provision of care, treatment and services administered by the facility to the patient must be approved by the attending physician unless these treatment and services are governed by the facility's clinical policy and procedures as approved by the medical director. Care Plan with initiation date of [DATE] includes (but not limited to) intervention: Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications; refusal to eat, dry mouth, depression, fatigue, [MEDICAL CONDITION], loss of appetite, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person.

Based on interview and record review, the facility failed to ensure that proper equipment was used and right number of staff was utilized during transfer for 1 of 4 residents ( R11 ) reviewed for mechanical transfers. This failure resulted in R11 twisting her left leg in the mechanical lift and going to the hospital with [DIAGNOSES REDACTED]. Findings include: R11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R11's care plan initiated on 1/11/13 indicated use of full body mechanical lift with 2 staff during transfers. R11's Quarterly Restorative Functional assessment dated [DATE] also indicated that a full body mechanical lift using 2 or more staff is appropriate for R11's transfer. This was confirmed on 1/22/13 at 10:51 AM by E5, Restorative Nurse who did R11's functional assessment on 1/11/13. E5 said that the full body mechanical lift is appropriate for R11 because R11 has no upper body strength to hold on to a sit-to-stand lift. An undated Facility document, Mechanical Lift Transfer, states under Procedure, "5. There will always be 2 staff to assist the resident. 1 staff will control the lift as the other will guide resident and support back and neck to transfer surface." Additionally, facility's Resident Handling Policy " Limited Lift ", also undated, indicated that residents transfer status will be placed in resident's room to inform staff of the appropriate transfer to use. Fall Interview Form dated 1/12/13 indicated that at 12:10 PM, E3, Certified Nurse Aide (CNA) transferred R11 using a mechanical lift by himself when R11 slid from the pad and was eased to the floor. E3 stated that R11's left leg got caught in the machine and twisted. R11's 1/12/13 nurses note indicated that at 12:10 PM, R11 was crying and complaining of left hip pain while on the floor waiting for 911 to transfer her to the hospital. On 1/22/13 at 11:01 AM, E4, CNA team leader said that when he came to the room, R11 was on the floor and E3,CNA, did not say what happened. E4 said that E3 knew that for any mechanical lift ( full body and sit-to-stand lift ), a 2 person assist is needed. E4 continued that in R11's head board, an instruction to use a full body lift not sit-to-stand lift with 2 staff assistance is needed during R11's transfers. E4 said that E3 never asked him for help during R11's transfer. E4 also said that E3 used a sit-to-stand lift instead of a full body mechanical lift. On 1/23/13 at 1:15 PM, E7, Nurse said that E3 explained that he transferred R11 using a sit-to-stand lift by himself on 1/12/13 and R11 slid off the sling and was eased down the floor. E7 said that E3 added that R11's leg got caught in the sit-to-stand lift. E7 also said that E3 admitted that he was trained to have 2 staff present during mechanical transfer, but did not answer why he did not ask for help and did R11's transfer by himself on 1/12/13. On 1/22/13 at 10:40 AM, E2, Director of Nursing said that she fired E3 because E3 did not follow instructions to use a full body mechanical lift with 2 staff assistance for R11. R11's care plan initiated on 1/14/13 indicated that R11 was admitted to the hospital with [REDACTED].