Every finding on record at Heritage Manor of Opelousas

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person-centered care plan for 2 (#1, #3) of 3 (#1, #2, #3) total sampled residents. This was evidenced by failing to:1.ensure physician orders to monitor a surgical incision for signs and symptoms of infection were implemented for Resident #1;2.apply palm protectors for Resident #3; and3.monitor and document the response to pain medication for Resident #3.Findings: Resident #1 1.Review of Resident #1's electronic health record revealed an admission date of 03/20/2026 with diagnoses that included, but were not limited to, status-post L2(level2)-ilium decompression and fusion, chronic kidney disease, atherosclerotic heart disease, transient ischemic attack, and cerebral infarction. Review of Resident #1's physician orders dated 03/20/2026 read in part. monitor surgery incision to back for signs and symptoms of infection. Review of Resident #1's nurses' notes revealed a note written by S11LPN on 03/20/2026 which read in part, surgical incision noted to midback. Further review of nurses' notes revealed another note written by S11LPN on 03/22/2026 which read in part, dressing to midback dry and intact. Review of S7TXN documentation dated 04/01/2026 read in part, surgical wound, new wound, present upon admission, number of staples was 36, measurement length 16.34 cm (centimeters) x 0.73 cm width x area 9.41 cm, surrounding tissue erythema redness of the skin. Further review of nurses' notes and wound care notes did not reveal further evidence of staff monitoring Resident #1's surgical incision. On 05/05/2026 at 9:36 a.m., a telephone interview was conducted with Resident #1 and his wife. Resident #1 stated staff had not been monitoring his incision. He added S7TXN had not been monitoring his surgical incision. Resident #1 stated that on 04/01/2026 was the first time S7TXN had observed his incision and completed wound care. On 05/05/2026 at 10:46 a.m., an interview was conducted with S2RNS. S2RNS stated she completed the admission assessment on Resident #1. She stated she had observed an aquacel dressing (a soft non-woven wound dressing) to the resident's lower back area. S2RNS stated she did not observe any writing on the outside of the dressing that indicated the dressing was not to be removed. She stated when residents were admitted with an aquacel dressing, staff did not remove the dressing. She stated S7TXN should have been monitoring the residents' incision. On 05/05/2026 at 11:10 a.m., an interview was conducted with S5LPN who stated she provided care to the resident while he was in the facility. S5LPN stated she remembered the resident had a physician order to monitor for signs and symptoms of infection. When asked if she had physically observed the incision on the resident's midback, she stated she had not. On 05/05/2026 at 12:50 p.m., an interview was conducted with S6LPN who stated she provided care to the resident on 03/23/2026. S6LPN stated she was aware of the physician order to monitor the surgical incision for signs and symptoms of infection. S6LPN confirmed she had not observed the surgical incision for signs and symptoms of infection. On 05/05/2026 at 3:23 p.m., a phone interview was conducted with S10PA, Resident #1's Physician Assistant, who stated when Resident #1 arrived at his post-surgical follow up appointment, he appeared pale and weak. S10PA stated when she removed the midback dressing it was awful. She stated fecal residue was observed on the surgical incision and the dressing was saturated with some brown colored substance. S10PA stated the dressing was so saturated with a brown substance that the glue from the dressing was stuck to the resident's skin and the dressing barely hung on. S10PA stated there was no writing on the dressing stating Do Not Touch. S10PA stated their office did not receive any calls from the facility to clarify the orders or request new orders for the care of the surgical incision. On 05/05/2026 at 3:45 p.m., an interview was conducted with S1DON and S5LPN. S1DON stated Resident #1's orders stated the dressing was not to be removed. When asked why she did not call the physician's office for clarification of the order, she stated the doctor should have been more specific when he wrote his orders. S1DON was asked again why she or her staff did not call the physician's office for clarification of the order, and she stated she worked with the physician for many years, and that was something he did many times before. S5LPN stated in hindsight, I should have called for clarification of the orders. She stated she did not physically observe the surgical incision for signs and symptoms of infection. Resident #3 2. Resident #3 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, aphasia following unspecified cerebrovascular disease, muscle weakness, cognitive communication deficit, delirium due to unknown physiological condition, and major depressive disorder. Review of Resident #3's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 05, indicating the resident's cognition was severely impaired. Review of Resident #3's MDS Section GG revealed Resident #3 was dependent on staff for eating, oral hygiene, toileting hygiene, shower/ bathe self, and upper and lower body dressing. Section GG also revealed Resident #3 had impairment on both sides upper and lower extremities. Review of Resident #3's care plan revealed resident was at risk for complications to left and right hand related to weakness, impaired mobility, and decline in dexterity: Notify MD of any change; Palm protector to left and right hand during the day, may have off at night. On 05/05/2026 at 9:23 a.m., an observation was conducted in Resident #3's room with her husband present. The resident's hands were contracted with fingers turned into her palms. Resident #3 had a piece of cloth in the palm of each of her hands, no palm protector was observed. On 05/05/2026 at 10:30 a.m., an interview, review of Resident #3's medical record, and observation of Resident #3 was conducted with S5LPN. S5LPN reviewed the resident's care plan and confirmed Resident #3 should have palm protectors in her hands. S5LPN then observed Resident #3's right and left hands. S5LPN confirmed there was a piece of cloth inside the palms of Resident #3's hands. S5LPN confirmed Resident #3 did not have palm protectors in her hands. On 05/05/2026 at 11:05 a.m., an interview and observation of Resident #3 was conducted with S1DON. S1DON confirmed there was a piece of cloth in the palms of Resident #3's hands. S1DON confirmed Resident #3 should have palm protectors in her hands. 3. Review of Resident #3's care plan revealed the resident was on a pain medication (Opioid): Administer analgesic medications as ordered by physician. Monitor/ document side effects and effectiveness q (every) shift, ask physician to review medication if side effects persist. Review of the Resident #3's electronic medical record physicians orders revealed an order for oxycodone HCL oral table 20 mg(milligrams) *controlled drug*; give one tablet by mouth three times a day for generalized pain with an order date of 03/30/2026. Review of Resident #3's medication administration record revealed the resident received oxycodone oral tablet 20 mg three times a day during the review period of 04/01/2026 through 05/04/2026. There was no evidence of monitoring for side effects and effectiveness q shift. On 05/05/2026 at 10:30 a.m., an interview and review of Resident #3's medical record was conducted with S5LPN. S5LPN confirmed Resident #3's care plan stated monitor/ document side effects and effectiveness every shift for Opioid medications and ask physician to review medication if side effects persist. S5LPN reviewed the electronic health record for Resident #3. S5LPN confirmed there was no documented evidence that Resident #3 was monitored/ documented for side effects and effectiveness of opioid medications that were given three times per day. On 05/05/2026 at 12:50 p.m., an interview and review of Resident #3's medical record was conducted with S1DON and S12CN. S1DON reviewed the electronic health record for Resident #3 and confirmed Resident #3 was administered opioid medication three times per day. S1DON confirmed there was no documentation of monitoring for side effects and effectiveness Q shift for Resident #3. S12CN reviewed Resident #3's electronic medical record and confirmed the care plan for Resident #3 read: Resident is on pain medication (Opioid): Administer analgesic medications as ordered by physician. Monitor/ document side effects and effectiveness every (Q) shift, ask physician to review medication if side effects persist. S12CN confirmed Resident #3's care plan should have been followed.

Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good personal hygiene and grooming for 2 (Resident#1, Resident#3) of 3 residents reviewed for ADLs. The facility failed to:1. provide personal hygiene for Resident #1, and2. Provide personal hygiene and nail care for Resident #3 Findings:Resident #1 Review of Resident #1's clinical record revealed he was admitted to the facility on [DATE] and had diagnoses of chronic pain syndrome, atherosclerotic heart disease, Bradycardia, status post L2 ilium decompression and fusion. Further review revealed a discharge date of 04/04/2026. Review of Resident #1's physician orders dated 03/20/2026 read in part, monitor surgery incision to back for signs and symptoms of infection, do not remove dressing every shift. Review of a facility document with no title, which recorded Certified Nursing Assistant (CNA) staff task performed for residents dated 03/01/2026 – 04/06/2026. Review of a section on the task document read in part bath day (Tuesday, Thursday, Saturday) partial/moderate assist. Further review of the document revealed no documented evidence Resident #1 was given a bath on 03/27/2026, 03/28/2026 and 03/30/2026. Review of Resident #1's admission MDS (Minimum Data Set) dated 03/27/2026 read in part.BIMS (Brief Interview for Mental Status) score was 12 which indicated his cognition was moderately intact, only moderate problems with thinking and memory. Functional Abilities: shower/bathe – partial/moderate assistance Personal hygiene – partial/moderate assistance On 05/05/2026 at 9:31 a.m., a phone interview was conducted with Resident #1 and his wife. Resident #1 stated during his stay in the facility, he did not receive bed baths or showers regularly. Resident #1 stated during his two weeks stay in the facility, he received a total of three baths. On 05/05/2026 at 10:25 a.m., a record review of the CNA task log and an interview was conducted with S3CNASUP. S3CNASUP stated when an X was documented on the task log, it meant the task was not completed. Further review of the task log revealed an X on 03/27/2026 and 03/30/2026. On 05/05/2026 at 10:30 a.m., an interview and record review was conducted with S4CNA. She stated she did not know Resident #1, and she had not provided any personal care to the resident during his stay in the facility. Further review of the bath log revealed S4CNA initials on 03/28/2026 and 04/04/2026. S4CNA stated she did not know how her initials were documented on the resident's task log because she had not provided any care to the resident. On 05/05/2026 at 1:00 p.m., a follow up interview was conducted with S3CNASUP. S3CNASUP was asked how she was ensuring that residents in the facility were receiving baths on their assigned days and as needed. She stated she believed staff were performing the tasks that they were documenting as complete. S3CNASUP was asked for more monitoring interventions, but she did not provide any further monitoring interventions prior to survey exit. Resident #3 Review of the facility's policy and procedure titled, Resident Quality of Care with a review date of 08/2024, revealed in part: 2. a. Bathing: iii. At the time of bath, all residents shall also receive, nail care, . 2. a. Bathing: iv. Partial bath – by resident, if able, assisted by staff, or performed completely by staff daily or as often as indicated by the physical condition of the resident. This shall include: washing face, hands,. nail care, skin care,. Review of Resident #3's Electronic Health Record (EHR) revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to aphasia following unspecified cerebrovascular disease, muscle weakness, cognitive communication deficit, delirium due to unknown physiological condition, and major depressive disorder. Review of Resident #3's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 02/11/2026, revealed the resident's Brief Interview for Mental Status (BIMS) score was 05, indicating her cognition was severely impaired. Further review of the MDS revealed that the resident was dependent on staff for personal hygiene. Review of Resident #3's care plan revealed in part, resident needs assist with ADLs (Activities of Daily Living): bathing: resident is dependent on staff for bathing/ showering; personal hygiene: resident is dependent on staff for personal hygiene. Review of resident #3's care plan did not reveal interventions for nail care. On 05/05/2026 at 9:23 a.m., an observation was made of Resident #3's nails and palms on both hands. The resident had long, untrimmed thumb fingernails with a black substance caked underneath the thumb fingernails. The other fingers and fingernails were curled into the palm of her hand. The fingers curled into the palm of her hands had a yellow film on them. The nails curled into the palm of her hands were yellow and brown and untrimmed. Resident #3's hands smelled of a foul and sour odor. Resident #3 was not interviewable. On 05/05/2026 at 10:30 a.m., an interview and observation of Resident #3 was conducted with S5LPN. S5LPN confirmed Resident #3's thumb fingernails were coated with a black cakey substance under the nails. S5LPN confirmed the other fingers and fingernails were yellow and brown. S5LPN confirmed that both hands smelled of a foul and sour odor. S5LPN confirmed resident #3's fingernails were long and untrimmed. Resident #3's thumb fingernail measured 1/4 of an inch in length. On 05/05/2026 at 11:05 a.m., an interview and observation of Resident #3 was conducted with S1DON. S1DON confirmed Resident #3's thumb fingernails were coated with a black cakey substance under the nails. S1DON confirmed the other fingers and fingernails curled into her palm were yellow and brown. S1DON confirmed both of Resident #3's hands smelled of a foul and sour odor. S1DON confirmed Resident #3's nails were long and untrimmed. Review of Resident #3's task log revealed that Resident #3 was given a bath on 05/01/2026 and on 05/04/2026 by S11CNA. On 05/05/2026 at 2:15 p.m., an interview was conducted with S11CNA. S11CNA confirmed that she bathed Resident #3 on 05/01/2026 and 05/04/2026 and she did not clean inside the resident's hands, clean under her nails, or provide nail care. On 05/05/2026 at 12:10p.m., an interview was conducted with S13RNS. S13RNS stated wound care nurses performed nail care for residents that are diabetic. S13RNS stated that if a resident is not diabetic, the certified nursing assistants would provide nail care when baths were given. Reviewed Resident #3's EHR. Resident #3 does not have a diagnosis of diabetes.

Based on record reviews and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards and practices by failing to ensure staff accurately documented baths for 1 (Resident #1) of 3 (#1, #2, #3) residents sampled for Activities of Daily Living (ADL) care. Findings:Review of Resident #1's electronic health record revealed an admission date of 03/20/2026 with diagnoses that included, but were not limited to, status-post L2(level2)-ilium decompression and fusion, and cerebral infarction. Further review of the electronic health record revealed the resident was discharged from the facility on 04/04/2026 at 5:26 p.m. Review of a facility task document with no title dated 03/01/2026 - 04/06/2026 revealed CNA (Certified Nursing Assistant) staff recorded the completion of specific task(s) performed for residents during the CNA staff's shifts. Review of a section on the task document read in part, bath day (Tuesday, Thursday, Saturday) partial/moderate assist. Further review of the document revealed S9CNA documented on 04/05/2026 and 04/06/2026 she had completed activities of daily living and provided care for Resident #1 when the resident had been discharged home. On 05/05/2026 at 10:55 a.m., an interview was conducted with S8SS. She confirmed Resident #1 had been discharged from the facility on 04/04/2026 at 5:26 p.m. On 05/05/2026 at 1:00 p.m., a record review and interview was conducted with S3CNASUP. She stated S9CNA worked the night shift. She added that S9CNA should not have documented that she provided care for Resident #1 when the resident was discharged from the facility on 04/04/2026. She confirmed this was inaccurate documentation.

Based on observation, interviews, and record review, the facility failed to store and process linens to prevent the spread of infection as evidenced by failing to ensure clean items were not stored in the soiled linen area of the laundry department. Findings: Review of the facility's policy titled, Infection Control Laundry Department, with a last reviewed date of 08/2021, read in part: Sorted linens must be kept in a designated area separate from clean linen. Review of the facility's policy titled, Laundry Instructions, with a last reviewed date of 07/2025, read in part: 6. Keep soiled linens separate from clean linens, in their proper place. On 09/24/2025 at 11:37 a.m., an observation was made of the laundry department with S6Laun (Laundry). S6Laun stated that no soiled linens could be stored in the clean area of the laundry department and no clean linens can be stored in the soiled linen area. An observation was then made of the soiled linen area of the laundry department. A shelf, next to the washing machines, was observed with the following items: 2 geri (geriatric) chair cushions, a pair of heel lift boots, 4 pairs of shoes, and 2 Hoyer lift pads. S6Laun stated that these items had been washed today and were clean. She stated that they allowed them to air dry in the soiled linen area because they had space to dry them there. On 09/24/2025 at 11:45 a.m., an interview and observation was conducted with S4HskSup (Housekeeping Supervisor). She stated that the above listed items were clean, but they stored them on the shelf in the soiled area because they did not have a place in the clean area to store the items. S4HskSup confirmed that clean items or linens were not supposed to be stored in the soiled linen area of the laundry department. On 09/24/2025 at 12:30 p.m., an interview was conducted with S5ADON/IP (Assistant Director of Nursing/Infection Preventionist). S5ADON/IP was asked if she was familiar with infection control practices regarding the storage of clean linens and items. She stated she was not familiar with laundry processes.

Based on record review, observation, and interview, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#78) out 2 (#1 and #78) resident investigated for ADLs. Findings: Review of Resident #78's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but not limited to, Parkinsonism unspecified and muscle weakness (generalized). Review of Resident #78's care plan read in part, resident needs assist with ADLs. Interventions included. Oral hygiene: resident needs supervision with oral hygiene. Review of the CNA's (Certified Nursing Assistant) electronic personal hygiene task charting for Resident #78 revealed that oral care should be provided q (every) shift (three times a day).On 09/23/2025 at 11:30 a.m., Resident #78 was observed lying in bed. An observation of the resident's oral cavity was conducted and revealed a white residue on her teeth and food particles were observed between her teeth.On 09/24/2025 at 11:00 a.m., an observation was made of Resident #78's oral cavity and revealed a white residue on her teeth and food particles were observed between her teeth. Resident #78 stated no one had brushed her teeth today. On 09/24/2025 at 11:21 a.m., an observation of Resident #78's oral cavity was conducted with S1DON (Director of Nursing). She agreed that Resident #78's teeth had a white residue and food particles between her teeth. S1DON asked Resident #78 had her teeth been cleaned today and the resident answered No.

Based on record review and interview, the facility failed to ensure that the resident's physician timely addressed the resident's RP (Representative) and/or resident's request for pain medication for 1 (#78) of 1 resident out of final sample of 38 residents. Findings:Review of the facility's policy titled, Physician Responsibilities read in part, Physician Services.A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide orders for the resident's immediate care needs. Review of Resident #78's clinical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but not limited to, intervertebral disc disorders with radiculopathy, lumbar region, other intervertebral disc degeneration, lumbar region with discogenic back pain only, low back pain, unspecified. Further review of the resident's medical record revealed that she had a Stage 3 sacral pressure ulcer. Review of Resident #78's admission MDS (Minimum Data Set) dated 09/09/2025 under Section J-Health Conditions revealed that the resident occasionally experienced pain. Further review under Section M-Skin Conditions revealed that the resident had an unstageable pressure ulcer. Review of Resident #78's care plan revealed the resident was care planned for pain with interventions that include in part, notify physician as needed of any complications.observe the effectiveness of pain intervention as needed.Review of Resident #78's physician orders revealed an order dated 08/31/2025 for Acetaminophen (Tylenol) oral table-give 1000 mg (milligram) by mouth every 6 hours as needed for pain.Review of Resident #78's MAR (medication Administration Record) revealed from 09/02/2025 to 09/23/2025, the resident requested pain medication for an average pain of 6 to 7 out of 10. Further review of the MAR revealed that on 09/17/2025, the resident received pain medication for pain 9 out of 10. Review of the nurse's note dated 09/17/2025 read, Resident complains of pain and refused PRN (as needed) Tylenol. Resident stated that doesn't work. I need something else please. RP aware and voices concern. Notified (resident physician name) nurse, will notify MD (medical doctor) and return call. RP made aware. On 09/23/2025 at 11:15 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). She stated that today she talked with the resident's physician nurse to follow up on the resident's complaint of Tylenol being ineffective for the resident's sacral pain. S3LPN contacted the resident's physician office 3-4 times in the last 2 weeks to address the resident's pain management, but she had not received a call from the resident's physician. On 09/23/2025 at 11:32 a.m., Resident #78 was observed lying in bed with guests present. The female guest stated that she was the resident's former caregiver. She stated that the family had been trying to get a meeting with Resident #78's physician to address her lack of pain management. On 09/23/2025 at 12:00 p.m., a phone interview was conducted with resident's daughter. She stated that she had been trying to get a meeting with Resident #78's physician to discuss several issues, but no meeting was set up. She stated that she had been asking for something better than Tylenol for her mother since September 5th for her complaint of pain to her sacral wound, but the resident was still receiving Tylenol. She stated that she finally sent an email to the nursing home intake staff on 09/22/2025 to address the resident's ineffective pain management. On 09/23/2025 at 1:25 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated that she was made aware of the resident's daughter's concerns. She confirmed that the resident's daughter sent an email on 09/22/2025 requesting that the resident's physician order something different than Tylenol for the resident's pain. She confirmed she was made aware that Resident #78's physician had not addressed the resident's daughter and/or the resident's pain management request. She stated that she became aware about two days ago. She stated that in the past, the facility has had conversation about the resident's physician not returning calls timely and lack of communicating when they need him. On 09/23/2025 at 1:45 p.m., an interview was conducted with Resident #78's physician nurse. She confirmed that she sent a message to the resident's physician today regarding that the Tylenol was not effective to manage the resident's pain. She confirmed they received a fax from the nurse at the nursing home on [DATE] stating that the resident's daughter requested a non-narcotic medication for the resident's pain. She stated that she was not sure if the fax received on 09/17/2025 was addressed by the physician. On 09/23/2025 at 2:11 p.m., a phone call received from Resident #78's physician's Office Manager. She stated that the resident's physician was requesting to speak with the surveyor.There was no call received from Resident #78's physician by exit of the survey.

Based on record review and interview, the facility failed to follow the resident's plan of care for 1 (Resident #1) of 3 (#1, #2, #3) sampled residents. Findings: Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses that included but were not limited to Acute on Chronic Diastolic Heart Failure, Urinary Tract Infection, Chronic Kidney Disease, Unspecified Dementia, Cerebral Ischemia and Essential Hypertension Review of Resident #1's significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/10/2025 revealed she had a BIMS (Brief Interview for Mental Status) of 05, indicating she was severely, cognitively impaired. Review of Resident #1's Physician Order Summary Report for May 2025 revealed an order with a start date of 05/09/2025. The order read in part: Lotrisone cream twice daily to affected area for 7 days. (two times a day until 05/16/2025 at 18:59 [6:59 p.m.]). Review of Resident #1's MAR/TAR (Medication Administration Record/Treatment Administration Record) for May 2025 revealed 4 dosages of the Lotrisone cream was not given. There was no evidence the doses were given on 05/09/2025 (first dose p.m.), 05/11/2025 (p.m. dose), 05/14/2025 (p.m. dose) and 05/15/2025 (p.m. dose) anywhere in the resident's record. On 07/01/2025 at 4:00 p.m., an interview and record review was conducted with S1DON. A review of Resident #1's May 2025 physician's orders, nurse's notes and MAR/TAR was done. S1DON confirmed that Resident #1's had missed four doses of Lotrisone cream.

Based on interview, observations, and record reviews, the facility failed to ensure a cognitively impaired resident received adequate supervision during facility transportation which resulted in the resident falling from a wheelchair and sustaining a severe head injury for 1 (#2) of 3 (#2, #3, #R5) sampled residents with impaired cognition investigated for safe transportation via wheelchair. The deficient practice resulted in an Immediate Jeopardy for Resident #2 on 10/08/2024 at 10:00 a.m., when S2D (Driver) left Resident #2 unattended in her wheelchair on a sidewalk outside of an eye doctor's office while S2D moved the transportation van. Resident #2, who was cognitively impaired, fell from her wheelchair during this time, striking her head against the concrete pavement. Resident #2 was transferred to a local hospital (Hospital A) for evaluation on 10/08/2024 at 12:01 p.m. Hospital A's CT (computed tomography) report of the head dated 10/08/2024 at 12:19 p.m., showed the resident sustained post traumatic bilateral parenchymal and subarachnoid hemorrhages. Resident #2 was transferred from Hospital A to a second hospital (Hospital B) for further evaluation and treatment by a neurologist on 10/08/2024 at 3:11 p.m. where she was subsequently admitted for further treatment with coagulation and antihypertensive medication in the ICU (Intensive Care Unit) for three days. Resident #2 returned to the facility on [DATE]. The facility implemented an immediate corrective action plan on 10/08/2024 which was completed prior to the State Agency's investigation. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance on 10/09/2024, thus it was determined to be a Past Noncompliance citation. Findings: A request was made for a facility policy regarding supervising residents during transportation appointments. On 10/29/2024 at 1:47 p.m., S1DON (Director of Nursing) stated the facility did not have such policy. Review of the facility's Transportation Attendant Job Summary revealed; as a part of the responsibilities .maintain safety and comfort of residents as much as possible during transportation. Review of the medical records for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety Disorder, and Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #2's quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 09/24/2024, revealed the following, in part: -BIMS (Brief Interview for Mental Status) interview was unable to be conducted because the resident was never/rarely understood and could never/rarely make herself understood. She was indicated as having a memory problem for both long-term and short-term memory, and her cognitive skill for daily decision making were severely impaired. -Resident #2 utilized a wheelchair and required extensive physical assistance from two or more persons with transferring. Review of Resident #2's current care plan initiated 08/13/2024 revealed the following, in part: Problem: Resident is at risk for falls .Approaches: Cues/reminders as needed for safety. Review of Resident #2's MAR (Medication Administration Record) for October 2024 revealed she received Aspirin 81mg (an antiplatelet medication) and Apixaban 2.5mg (an anticoagulant medication) from 10/1/2024 until the date of her fall on 10/08/2024. Resident #2's Fall Incident Report dated 10/08/2024 revealed the following in part: Resident #2 went out on pass at 0810 (8:10 a.m.) to an appointment via facility transportation in stable condition. S2D called provider to report that resident slid out of chair and hit her head. Resident was driven back to facility at 1040 (10:40 a.m.) as directed by the provider for proper assessment. On assessment a large hematoma with dried blood was noted to right side of Resident #2's forehead. Ambulance was called and Resident #2 was transferred to Hospital A. Review of Resident #2's hospital records from Hospital A revealed a CT of Resident #2's head without contrast was performed. The results revealed a posttraumatic bilateral parenchymal and subarachnoid hemorrhage with a large right scalp hematoma. Resident #2 was transferred to Hospital B on 10/08/2024 for neurology consultation and treatment with IV (intravenous) coagulation and antihypertensive therapy under ICU monitoring. On 10/28/2024 at 1:30 p.m., an attempt was made to interview Resident #2. She did not respond to questioning and was unable to be interviewed. On 10/28/2024 at 10:11 a.m., an interview was conducted with S2D. S2D stated she transported Resident #2 in her wheelchair to an appointment in the facility's van on 10/08/2024. When the appointment was done, she wheeled Resident #2 outside and parked her in her wheelchair on the sidewalk at the van parking spot. S2D stated the van had to be moved to put the wheelchair lift gait down. S2D stated she locked Resident #2's wheelchair then left Resident #2 unattended for approximately one minute to move the van. She returned to find Resident #2 lying on her right side on the concrete with her wheelchair on its side and observed a raised area to the resident's right forehead beginning to form. She stated she immediately notified the facility and was instructed to return to the facility with Resident #2. On 10/29/2024 at 11:10 a.m., an interview was conducted with S1DON (Director of Nursing). S1DON stated she was notified by the nursing staff that an incident occurred during Resident #2's transportation where the resident fell out of her wheelchair. She stated that without having full knowledge of incident details, she instructed S2D to return to the facility with the resident so a nursing assessment could be performed. She stated Resident #2's nurse performed an assessment and immediately sent her to the hospital via ambulance services. On 10/29/2024 at 1:20 p.m., S1DON stated the facility administrator immediately suspended S2D for the day and suspended her from driving for a week. They gave a verbal reeducation to all drivers before the next scheduled resident appointment. They immediately removed the resident's wheelchair and ordered a high back chair with a seatbelt. In-services were started the following day (10/09/2024) and also started retraining on the van/transportation with competency demonstrations. She stated they identified other residents that could be affected as every resident that utilizes facility transportation and by monitoring resident transports of both ambulatory and wheelchair bound residents. On 10/30/2024 at 11:40 a.m., a follow up interview was conducted with S1DON. S1DON confirmed that all residents in a wheelchair require supervision during transportation. S1DON confirmed that Resident #2's cognition was severely impaired, and she was left unsupervised which led to Resident #2's injury. S1DON further confirmed S2D should not have left Resident #2 unattended at any point while providing transportation services. The facility implemented the following immediate corrective actions to correct the deficient practice which was completed prior to the State Agency's investigation. 10/08/2024 Corrective Action Plan 1. Immediate suspension of S2D from work and driving privileges for 1 week post incident. 2. Immediate verbal education provided to drivers after the incident occurred before the next facility transport. 3. Immediate removal of Resident #2's wheelchair. 4. Audit conducted of Resident #2's transportation needs was performed. Implemented high back wheelchair with seatbelt to be used for transportation only. 5. In-services conducted for all facility drivers regarding: Safe transportation of resident including safe loading and unloading procedures; what to do if a resident falls; residents should be supervised and not to left unattended; proper location where residents should wait for safe loading and unloading, accident prevention; and wheelchair securement. 6. Review of the transportation attendant's job summary conducted with S2D. 7. In-serviced drivers on company owned vehicle with return demonstration for competency. 8. Monitoring drivers for adherence to transportation procedures. 9. Conducted review of resident needs/concerns with information gathered from van drivers during monitoring. 10/09/2024 - All staff identified as being able to transport residents using the facility's van received re-education; monitoring was conducted and documented. Ongoing monitoring of the plan's effectiveness continued. On 10/28/2024 - 10/30/2024 throughout the days multiple facility transportation drivers were interviewed about the transportation process. All staff interviewed were knowledgeable about the process and providing supervision to residents while out on pass at all times. All staff members stated they had received multiple trainings that included slides, in-services, and a return demonstration for competency. They were able to accurately verbalize the contents of the training that was outlined in the facility's plan of corrective action. Two facility transportation drivers were observed loading wheelchair bound residents in the facility van for appointment transportation on 10/29/2024 and 10/30/2024. Facility van is noted to be in the facility breezeway with the wheelchair gait already in the lowered position while the residents were waiting inside of the facility. Both staff members explained the procedure prior starting. Both utilized wheelchair locks and safety belt during lift. Once in van, both staff members strapped the residents in using all provided seat belts. Neither resident was ever left unattended during the entire process. No concerns observed. Six random residents requiring wheelchair use and facility van transportation were interviewed regarding facility transportation on 10/29/2024 and 10/30/2024. None of the residents expressed complaints regarding the transportation services. All residents confirm they had never been left unattended during transportation. None of the residents expressed fear of utilizing the facility van. No concerns identified. There was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance on 10/09/2024, thus it was determined to be a Past Noncompliance citation.

Based on observation, interview and record review, the facility failed to maintain an effective infection control program in order to prevent the transmission of communicable diseases and infections as evidenced by failing to ensure: 1. a previously used insulin multi-dose pen that is designed for single patient use, was not used to administer insulin to another resident. 2. proper cleaning of glucometer between use 3. staff wore proper Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) while performing high contact resident care activity. 4. proper use and storage of PPE for used on residents in contact isolation. This deficient practice resulted in an Immediate Jeopardy (IJ) on 08/27/2024 at 11:17 a.m. when S27LPN (Licensed Practical Nurse) used Resident #6's previously used insulin multi-dose pen, designed for single patient use, to administer insulin to Resident #61. This deficient practice placed 6 residents who receive insulin by multi-dose pens at risk for potential exposure to blood-borne pathogens. S1ADM (Administrator) and S2DON (Director of Nursing) were notified of the Immediate Jeopardy on 08/27/2024 at 5:25 p.m. The Immediate Jeopardy was removed on 8/28/2024 at 12:55 p.m., after it was verified through observations, interviews, and record reviews that the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The facility had a census of 107 residents. Findings: 1. On 08/27/2024, a review of the facility's policy titled Injections with a last review date of 01/2024 read in part, Purpose: To administer medication via injection. Preparation .Verify the physician's order, comparing the medication label to the order verify the following: a. Right medication b. Right dosage c. Right route d. Right time e. Right resident Review of FDA (United States Food and Drug Administration) Drug Safety Communications, Safety Announcement dated 02/25/2015 revealed the following in part: FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients. Insulin pens and pens for other injectable diabetes medicines should never be shared among patients, even if the needle is changed. Sharing pens can result in the spread of serious infections from one patient to another. Pens must never be used for more than one patient because blood may be present in the pen after use. Sharing pens can lead to transmission of infections such as the human immunodeficiency virus (HIV) and hepatitis viruses. Pens should be clearly labeled with each patient's name or other identifying information. Verify the pen with the name of the patient and other patient identifiers to ensure the correct pen is used on the correct patient. Resident #61 admitted to the facility on [DATE] with diagnoses which included, but were not limited to Type 2 Diabetes Mellitus. A review of Resident #61's electronic health record (EHR) revealed a physician's order dated 12/21/2023 that read, Novolog (insulin) Flexpen syringe (single patient use), Accu-check (blood glucose monitor) AC (before meals) and HS (hour of sleep) to SS (sliding scale). A review of Resident #61's August 2024 Electronic Medication Administration Record (EMAR) revealed on 08/27/2024 at 11:00 a.m., she was administered 4 units of Novolog Flexpen by S27LPN. A review of Resident #6's EHR revealed a diagnosis of Type 2 Diabetes Mellitus. Further review revealed a physician's order dated 04/20/2017 that read, Novolog (insulin) Flexpen syringe (single patient use), Accu-check (blood glucose monitor) AC (before meals) and HS (hour of sleep). A review of Resident #6's August 2024 EMAR revealed she was administered Novolog Flexpen on 08/26/2024 at 4:00 p.m. and 8:00 p.m., also on 08/27/2024 at 6:00 a.m. and 11:00 a.m. On 08/27/2024 at 11:17 a.m., a observation was made of S27LPN during medication administration. S27LPN completed a blood glucose Accu-check on Resident #61 that read 163. S27LPN prepared 4 units of Novolog Flexpen according to the physician order. She stated the Novolog Flexpen was for Resident #61 and administered the injection. After S27LPN administered the injection, an observation of the Novolog Flexpen that was administered revealed a label which read Resident #6's name Novolog. S27LPN confirmed the Novolog Flexpen was labeled with Resident #6's name and that it was previously used to administer insulin to Resident #6. S27LPN confirmed she administered Resident #6's Novolog Flexpen to Resident #61. She stated she should have checked the label on the Novolog Flexpen prior to administration. S27LPN confirmed she should not have administered Resident #6's insulin to Resident #61. S27LPN further stated, There were too many insulin pens that were all bunched up and I just grabbed a Novolog Flexpen. On 08/27/2024 at 11:32 a.m., an interview was conducted with S2DON. She confirmed insulin pens are not to be used on another resident. During the interview, S27LPN entered the S2DON's office and informed her that she had administered Resident #6's previously used insulin pen to Resident #61. On 08/28/24 at 2:11 p.m., an interview was conducted with S3ICP. She confirmed that insulin flexpens are for single resident use only and are not to be shared due to the risk of blood-borne pathogen transmission and infections. 2. On 08/28/2024, a review of the policy titled Blood Glucose Quality Control with a last review date of 01/2024 read in part, Maintenance of Blood Glucose Monitoring Systems, Always clean the meter after each use. Gently wipe to clean and disinfect the surface of the meter with a disinfectant wipe per facility policy. On 08/27/2024 at 11:17 a.m., an observation was made of S27LPN (Licensed Practical Nurse) during medication administration. S27LPN completed a blood glucose check on Resident #61 and placed the uncleaned glucose monitor on the medication cart. After S27LPN administered Resident #61's insulin, she placed the uncleaned glucose monitor in the drawer. S27LPN confirmed she did not disinfect the blood glucose monitor after use. S27LPN stated that she only disinfects the monitor at the beginning and the end of the shift and did not disinfect the glucose monitor after use with each resident. On 08/27/2024 at 11:32 a.m., an interview was conducted with S2DON (Director of Nursing). She confirmed the blood glucose monitor should be disinfected after each use. On 08/28/24 at 2:11 p.m., an interview was conducted with S3ICP who confirmed blood glucose monitors are to be disinfected between all patient use and as needed when soiled. 41419 3. Review of the provider's policy and Ppocedure titled Enhanced Barrier Precautions, read in part Enhanced Barrier Precautions (EBP) involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) .Hand hygiene is recommended before and after resident contact .As part of Standard Precautions, gown and gloves should be removed and hand hygiene performed when moving to work with another resident. Resident #44 was admitted to the facility on [DATE] with diagnosis that included contracture of left and right hand. On 07/11/2024, resident had underwent placement of a PEG (percutaneous endoscopic gastrostomy) tube (indwelling medical device). On 08/28/2024 at 2:35 p.m., an observation was conducted in the room of Resident #44, which revealed a sign on the door that the resident was on Enhanced Barrier Precautions (EBP). Further observation revealed S13CNA (Certified Nursing Assistant) entered the resident's room, and asked if she needed assistance. S13CNA was observed assisting the resident without gloves or an isolation gown to locate her call bell and repositioned it for her. Further observation revealed S13CNA moved and adjusted the resident's blanket on her bed to locate the resident's hat. S13CNA then rubbed the resident's leg as she spoke with her. S13CNA exited Resident #44's room without sanitizing her hands, and entered another resident's room, and was observed with the water pitcher in her hand. On 08/28/2024 at 2:37 p.m., an interview was conducted with S13CNA who confirmed that she should have had gloves on while she assisted Resident #44, and sanitized her hands before entering another resident's room. On 08/28/2024 at 3:30 p.m., an interview was conducted with S3ICP (Infection Control Preventionist) who confirmed that S13CNA should have had gloves on while assisting Resident #44, and sanitized her hands before entering another resident's room. 20777 Record review of Resident #27's Care Plan read in part, Nutritional Status, PEG (Percutaneous Endoscopic Gastrostomy) Feeding and flush as ordered. Enhanced Barrier Precautions as Ordered. Record review of Resident #27's Physician Orders dated 04/16/2024 read in part, Enhanced Barrier Precautions: Gown and gloves to be worn during high contact resident care Activities ( .Feeding Tube). On 08/27/2024 at 11:45 a.m., an observation of Resident #27's room door revealed a sign on the outside that read in part, STOP . Enhanced Barrier Precautions .Providers and Staff must .Wear gloves and gown for the following High-Contact Resident Care Activities .Device Care or used: Feeding tube. Surveyor knocked on the door and S30LPN (Licensed Practical Nurse) responded. On entering the room, S30LPN was observed flushing Resident #27's PEG tube with water. She was wearing gloves and not wearing a gown. S30LPN was asked if Resident #27 was on Enhanced Barrier Precautions and she stated Yes. When asked if she should be wearing a gown to flush the residents PEG tube, she stated she should be wearing a gown. On 08/27/2024 at 12:09 p.m., an interview was conducted with S3ICP (Infection Control Preventionist) who confirmed that Resident #27 was on Enhanced Barrier Precaution for her PEG tube. S3ICP stated that staff should wear gown and gloves when flushing or cleaning the resident's PEG tube. 49784 Resident #72 was admitted to the facility on [DATE] with diagnosis including Pressure ulcer of sacral region, stage IV. Review of Resident #72's Physician Orders, in part, revealed an order dated 07/9/2024 for Enhanced Barrier Precautions: Gown and gloves to be worn during high contact activities (Hygiene, Toileting, Chronic Wound care). Review of Resident #72's Care Plan revealed the following: -Problem Onset 07/9/2024, Resident has a Pressure Ulcer- Stage 4 Pressure Ulcer to Sacral Region -Approaches, In part: Enhanced Barrier Precautions Followed On 08/27/24 at 2:30 p.m., an observation of wound care for Resident #72 was made, and an interview was conducted with S23CNA (Certified Nursing Assistant). Resident #72 was noted to have a sign on her door reading in part: Enhanced Barrier Precautions, Stop, Wear gloves and a gown for the following high- contact resident care activities: Changing briefs, wound care. S23CNA was observed assisting during wound care, turning Resident #72 and changing her brief without wearing a gown. On 08/28/24 at 2:25 p.m., an interview was conducted with S3ICP (Infection Control Preventionist). S3ICP confirmed that S23CNA should have been wearing a gown while assisting with wound care and changing a brief for Resident #72. 44418 4. On 8/27/2024 at 9:30 a.m., an observation was made of S7LPN (Licensed Practical Nurse) entering Resident #75's room to administer medication. She was not wearing any PPE. The resident was on contact precautions for an infection with Extended-Spectrum-Beta-Lactamase (ESBL). An interview was conducted with S7LPN when she exited the resident's room. She confirmed the signage on the door indicating the need for Enhance Barrier Precautions (EBP) because the resident had a catheter. She then acknowledged the Contact isolation signage and stated she was unaware of the resident's contact isolation status. On 08/27/2024 at 9:43 a.m., a second observation was made of S7LPN entering Resident #38's room with no PPE on, looking behind and donning PPE after entering room. The resident's door had signage, acknowledging the resident was on droplet precautions due to a positive COVID-19 diagnosis and there were no PPE available at the outside entrance of the room. On 08/27/2024 at 9:50 a.m., an interview was conducted with S7LPN, in which she stated that S3ICP (Infection Control Preventionist) informed her the PPE was to be kept inside the room for EBP (Enhanced Barrier Precautions) and any type of isolation residents. On 08/27/2024 at 3:29 p.m., an interview was conducted with S3ICP who stated she had been instructed by a corporate nurse to keep PPE inside residents' rooms rather than outside at the point of entry. S3ICP confirmed Resident #75 was on contact isolation precautions for ESBL and Resident #38 was on droplet precautions for a positive COVID-19 diagnosis.

Based on observation and interview, the facility failed to properly store drugs as evidenced by loose pills found in the bottom of medication cart drawers for 3 (Cart A, Cart B, and Cart C) of 3 medication carts checked for safe and secure storage. Findings: On 08/28/2024 a review of the facility's policy titled Medication Storage, with a last reviewed date of 01/2024, revealed in part, Policy Statement: There shall be storage areas provided that assure adequate space, equipment and security for medications within the facility, including .Medication rooms, refrigerators and medication/treatment carts shall be maintained in a clean and orderly manner per the facilities' policy and procedure. On 08/28/24 at 10:56 a.m., Cart A and Cart C were checked with S19LPN (Licensed Practical Nurse). Four loose pills were observed underneath the residents' medication blister packs of Cart A. These included: one white oblong tab (tablet), one white oval tab, one half of a green oval tab, and one pink and brown capsule. Eight pills were observed underneath residents' medication blister packs of Cart C. These included : two white round tabs, one orange round tab, one white rectangle tab, one yellow gel capsule, one pink round tab, one-half white round tab, and one half orange oval tab. On 08/28/24 at 11:53 a.m., Cart B was observed with S29LPN. One small green oval tab was observed underneath the residents' medication blister packs.

Based on record review and interviews, the facility failed to provide individual financial record to the resident through quarterly statements and/or upon request for 1 (#5) of 1 (#5) residents investigated for personal funds. The deficiency had the potential to affect a census of 107. Findings: On 08/28/2024, a review of the provider's policy titled General Resident Trust Fund Policies with a last reviewed date of 08/2021, read in part, quarterly statements shall be provided to all residents, or their resident representative within 30 days after the end of the quarter. Resident #5 was admitted to facility on 09/22/2023 with diagnoses that included Chronic Kidney Disease, Type 2 Diabetes Mellitus, Retention of Urine, and Paraplegia. Review of Resident #5's MDS (Minimum Data Set) dated 06/04/2024, revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating the resident was cognitively intact. On 08/26/2024 at 12:35 p.m., an interview was conducted with Resident #5 who stated that he had not received quarterly statements informing him of his account balance. On 08/28/2024 at 4:20 p.m., an interview was conducted with S14AA (Administrative Assistant) who stated Resident #5 had received his quarterly financial statements. S14AA was not able to provide evidence that Resident #5 was provided with quarterly financial statements. On 08/28/2024 at 4:30 p.m., an interview was conducted with S15AM (Accounts Manager) who stated the facility did not have any documented evidence that Resident #5 had received his quarterly financial statements. She further stated that she and S14AA were not trained to document when the resident's or the resident's representative financial statements were issued their quarterly financial statements. On 08/28/2024 at 5:05 p.m., a follow up interview was conducted with Resident #5, who was shown a copy of his financial statement for 03/30/2024 through 06/28/2024. The resident stated he had never seen a statement like what he was shown. He stated that he had requested a copy of his statement from S14AA, and she had not provided the information to him.

Based on interviews, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (#64) of 3 (#11, #64, and #69) residents sampled for pain. The facility failed to ensure Resident #64 who displayed verbal pain received the ordered interventions to alleviate pain. Findings: Record review revealed Resident #64 was admitted to the facility on [DATE]. She had diagnosis that included but were not limited to, Pain in Leg, Intervertebral Disc Degeneration in her Lumbar Region, Scoliosis, Angina Pectoris, Weakness, and Type 2 Diabetes Mellitus. Her BIMS (Brief Interview for Mental Status) was 10 (Moderate Cognitive Status). Record review of Resident #64's care plan read in part, Resident is at risk for pain. Administer meds as ordered. Notify MD (Medical Doctor) of any unrelieved pain. Record review of Resident #64's physician orders read in part, Tylenol 325 milligram tablet take one by mouth once every 6 hours as needed for pain. On 08/26/2024 at 12:53 p.m., an interview was conducted with Resident #64. She stated she had back pain that comes from her sciatic nerve and the nurse gives her Tylenol for the pain. On 08/27/2024 at 8:39 a.m., during a skin assessment with S22TN (Treatment Nurse) Resident #64 complained of back pain that was an 8 to 9 on the pain scale with 10 being the worst. She asked S22TN if she could ask her nurse to bring her some Tylenol for the pain. Resident #64 then stated she had asked the nurse for Tylenol for pain last night (08/26/2024) and the nurse did not bring her Tylenol. On 08/28/2024 at 11:02 a.m., S22TN was asked if she had notified S7LPN (Licensed Practical Nurse) on 08/27/2024 that Resident #64 had complained of pain. She stated she did notify S7LPN regarding the residents pain. Record review of Resident #64's MAR (Medication Administration Record) for August 2024 read in part, Tylenol 325 milligram take one tablet by mouth once every 6 hours as needed for pain. On 8/13/2024 at 12:22 p.m., the resident was administered her Tylenol for a pain level of 5. Resident #64 did not receive any Tylenol on 08/26/2024, or 08/27/2024. Record review of Resident #64's nurses notes dated 08/27/2024 revealed there was no notation that S22TN had notified S7LPN of the resident's pain or that S7LPN had administered Resident #64 Tylenol for pain. On 08/28/2024 at 11:17 a.m., an interview with S7LPN revealed she did not administer Resident #64 any Tylenol for pain on 8/27/2024. On 08/28/2024 at 3:00 p.m., an interview with S2DON (Director of Nursing) revealed that the nursing staff should manage the residents pain as ordered by the physician.

Based on observations and interview, the facility failed to ensure the cleanliness of a wheelchair for 1 (#33) out of 2 (#33 and #105) residents investigated for a safe, clean, comfortable and homelike environment, out of a total sample size of 39 residents. Findings: A review of the facility's policy titled Equipment and Supplies with a last reviewed date of 01/2024 read in part, 7. Resident Care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. Equipment will be cleaned and decontaminated according to manufacturer's recommendation. Resident #33 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia. On 08/26/24 at 10:00 a.m., Resident #33 was observed sitting in her room in her wheelchair. Resident #33's wheelchair was observed with a large amount of yellow food-like residue on the seat, the foot petal bars, and the wheels of the wheelchair. On 08/26/2024 at 11:00 a.m., an interview and observation was conducted with S29LPN (Licensed Practical Nurse) of Resident #33's wheelchair. S29LPN confirmed that the wheelchair was dirty and should be cleaned. S29LPN confirmed that that Resident #33's wheelchair should not have been in that condition.

Based on record review and interview, the facility failed to ensure that a MDS (Minimum Data Set) assessment was completed and submitted to CMS (Center for Medicare And Medicaid Services) in a timely manner, after a resident was discharged for 1 (#82) of 1 (#82) resident investigated for Resident Assessment out of a final sample of 39 residents. The deficient practice had the potential to affect 107 residents. Findings: Review of Resident #82's medical record revealed an admitted [DATE], and a discharge date of [DATE]. Further review of Resident #82's medical record revealed no documented evidence that a discharge assessment was opened, completed and/or transmitted since he was discharged . On 08/28/2024 at 4:39 p.m., an interview was conducted with S18MDS (Minimal Data Set). who confirmed Resident #82 was discharged home on 05/06/2024. She also confirmed the discharge assessment had not been opened, completed, or transmitted in greater than 120 days and should have been.

Based on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) was completed accurately for 1 (#56) out of 39 sampled residents. Findings: Review of Resident #56's clinical medical record revealed she was admitted to the facility on [DATE]. Her current diagnoses include, but where no limited to, Cerebral Infarction, Hemiplegia affecting right dominant side, Chronic Obstructive Pulmonary Disease and Muscle Weakness. Review of Resident #56's Significant Change MDS dated [DATE] revealed under Section P-Restraints, the resident was coded for the use of restraints. Review of the resident's active physician order as of 08/01/2024 revealed no order for restraints. On 08/26/2024 at 8:30 a.m., an interview and review of the residents MDS dated [DATE] was conducted with S9LPN/MDS (Licensed Practice/Minimum Data Set. She confirmed that she incorrectly coded the use of the bed rails as a restraint on the resident's MDS.

Based on record reviews, interviews and observations, the facility failed to develop and/or implement a resident centered comprehensive plan of care for 3 (#36, #76 and #105) out of 39 sampled residents as evidenced by failing to: 1. implement Resident #36's plan of care to apply bilateral heel protectors while in bed; 2 develop a plan of care for Resident #76 that addressed his significant weight loss; and 3. develop a plan of care to address Resident #105's Urinary Catheter and her diagnosis of Urinary Tract Infection. Findings: 1. Resident #36 Review of Resident #36's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Pressure Ulcer of Sacral Region Stage 4, Rash and other Nonspecific Skin Eruption, Unspecified, and Severe Protein-Calorie Malnutrition. Review of Resident #36's care plan revealed a problem onset on 04/02/2021 which read in part .Resident is at risk for further skin breakdown due to decline in mobility. This problem included a goal for the resident to have no new skin breakdown through next review date 10/16/2024, and an intervention for bilateral heel protectors while in bed. Review of Resident #36's August 2024 EMAR (Electronic Medical Record) revealed bilateral heel protectors while in bed signed by nurses as completed on 08/27/2024 at 6 a.m., 2 p.m. and 10 p.m., and on 08/28/2024 at 6 a.m. On 08/27/2024 at 9:40 a.m., Resident #36 was observed lying in bed with no bilateral heel protectors on. On 08/28/2024 at 08:33 a.m., an observation of Resident #36 and an interview was conducted with S21CNA (Certified Nursing Assistant). S21CNA confirmed that Resident #36 did not have bilateral heel protectors and stated that she should have been wearing the heel protectors. She further stated that she had worked with Resident #36 on 08/27/2024 from 6 a.m. to 2 p.m. and that the resident did not use the heel protectors and should have. S21CNA confirmed that she was aware that Resident #36 should have used bilateral heel protectors while in bed. On 08/28/2024 at 8:42 a.m., an interview, record review and observation of Resident #36 was conducted with S19LPN (Licensed Practical Nurse). S19LPN confirmed that Resident #36 was care planned for bilateral heel protectors, and was not wearing bilateral heel protectors and should have. 2. Resident #76 Review of Resident #76's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Vascular Dementia, Anxiety Disorder and Unspecified Sequelae of Cerebral Infarction. Review of Resident #76's Significant Change MDS (Minimal Data Set) with an ARD (Assessment Reference Date) of 06/12/2024 revealed a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and was not on a prescribed weight loss regimen. Review of Resident #76's resident centered comprehensive care plan revealed no evidence that his weight loss had been addressed. On 08/28/2024 at 2:31 p.m., an interview and record review was conducted with S17AN (Assessment Nurse). She confirmed that Resident #76 had a significant weight loss that was coded on his Significant Change MDS with an ARD of 06/12/2024. S17AN also confirmed that she had not addressed Resident #76's weight loss on his comprehensive care plan and stated she should have. 39319 3. Resident #105 Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnosis included in part, Urinary Tract Infection, Type 2 Diabetes Mellitus, Unspecified Hydronephrosis and Essential Hypertension. Review of the resident's 5-day PPS (Prospective Payment System) MDS (Minimum Data Set) assessment dated [DATE] revealed under Section H-Bladder and Bowel, the resident was coded for having an indwelling catheter. Further review revealed under Section I: Active Diagnosis, the resident was coded for have a UTI (urinary tract infection) in the last 30 days. Review of the resident's care plan revealed no evidence that the resident's urinary catheter and UTI was addressed in the care plan. On 08/28/2024 at 3:30 p.m., an interview conducted with S17ANAssessement Nurse). She confirmed that according to Resident 105's electronic clinical record, the resident did have a urinary catheter and had a UTI. Then, a review of the resident's care plan was conducted with S17AN. She confirmed the resident's urinary catheter and UTI was not addressed in her care plan and should have been.

Based on observation, record reviews, and interviews, the facility failed to ensure nursing staff demonstrated competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (# 61, #78) residents out of 39 sampled residents. The facility failed to ensure staff demonstrated competency for: 1. safe injection practices when S27LPN used Resident #61's used multi-dose insulin pen designed for single patient use to administer insulin to Resident #6; and 2. correct application of Resident #78's bed bolsters by CNAs (certified nursing assistants). The facility had a census of 107 residents. Findings: 1. On 08/28/2024, a review of the facility's policy titled Injections with a last reviewed date of 01/2024 read in part, Purpose: To administer medication via injection. Procedure: 2. Verify the physician's order, comparing the medication label to the order verify the following: a. Right medication, b. Right dosage, c. Right route, d. Right time, e. Right resident. Resident #61was admitted to the facility on [DATE] with diagnoses which included but were not limited to, Type 2 Diabetes Mellitus. A review of Resident #61's electronic health record (EHR) revealed a physician's order dated 12/21/2023 that read, Novolog Flexpen syringe (multi-dose insulin pen device designed for single patient use), Accu-check (blood glucose monitor) AC (before meals) and HS (hour of sleep) to SS (sliding scale). A review of Resident #61's August 2024 Electronic Medication Administration Record (EMAR) revealed on 08/27/2024 at 11:00 a.m., she was administered 4 units of Novolog Flexpen by S27LPN. A review of Resident #6's EHR revealed a diagnosis of Type 2 Diabetes Mellitus. Further review revealed a physician's order dated 04/20/2017 that read, Novolog Flexpen syringe, Accu-check AC and HS. On 08/27/2024 at 11:17 a.m., an observation was made of S27LPN during medication administration. S27LPN completed a blood glucose check on Resident #61 that read 163. S27LPN prepared 4 units of Novolog Flexpen according to the physician order. She stated the Novolog Flexpen was for Resident #61 and administered the injection. After S27LPN administered the injection, an observation of pharmacy label on the Novolog Flexpen revealed it was labeled with Resident #6's name. S27LPN confirmed the Novolog Flexpen was labeled with Resident #6's name and that it had been previously used to administer insulin to Resident #6. S27LPN confirmed she administered Resident #6's Novolog Flexpen to Resident #61. She stated she should have checked the label prior to administration and should not have administered Resident #6's insulin to Resident #61. S27LPN further stated, There were too many insulin pens that were all bunched up and I just grabbed a Novolog Flexpen. On 08/27/2024 at 11:32 a.m., an interview was conducted with S2DON. She confirmed insulin pens were not to be used on another resident. During the interview, S27LPN entered the S2DON's office and informed her that she had administered Resident #6's previously used insulin pen to Resident #61. S2DON stated S27LPN knew that she should have verified the resident's name on the label of the insulin pen. S2DON further stated she conducted an in-service on 08/06/2024 with the nurses, including S27LPN, regarding medication administration. 49784 2. Resident #78 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Hemiplegia following Cerebral Infarction with the Right Dominant Side Affected, and Unspecified Dementia. Review of the Resident #78's Care Plan revealed the following: Problem Onset 07/26/2022, In part: Falls, Resident is at Risk for Falls due to SP (Stroke Progression) CVA (Cardiovascular Accident) with right sided weakness Approaches, In part: 06/26/2024 Bed Bolsters; 8/19/2024 for fall on0 08/15/2024. Staff to ensure that bolsters are in proper position. Review of Nursing Note for Resident #78, on 8/20/2024 at 6:45 a.m., by S9LPN, revealed in part: CNA reported resident found on floor at 0120. Code green called. Upon entering room noted bed in lowest position, floor mats in place, one bed bolster in place noted other one wasn't secured correctly after further evaluation. Neuros started, increase supervision and tighten bed bolster correctly. On 08/27/24 at 12:48 p.m., and interview was conducted with S3ICP. S3ICP stated that she was responsible for investigating falls. She stated that Resident #78 had bolsters on both sides of the bed to assist with fall prevention. She stated that on 8/20/2024, a CNA had admitted she did not know how to apply the bolsters correctly, resulting in Resident 78#'s fall on 8/20/2024. She stated she did not remember who the CNA was that was involved in the fall on 8/20/2024. She stated S9LPN reported that she educated the CNA after the fall on 8/20/2024 on proper use of the bolsters. She stated that these findings were the result of her investigation. On 08/27/24 at 05:15 p.m., an interview and observation of Resident #78's bed bolster was conducted with S10CNA while the resident was in bed. S10CNA confirmed that left bed bolster was not clipped. She stated that she was not assigned to Resident #78 at that time, but stated she did care for her at times. She stated that she was familiar with using the bolsters but had never been educated on the proper use of them. On 08/28/24 at 01:42 p.m. an interview and observation was conducted with S11CNA. S11CNA stated she was assigned to Resident #78 at that time. She stated that she had never been educated on the proper use of the bolsters. On 08/28/24 at 1:50 p.m. an interview was conducted with S2DON (Director of Nursing). S2DON stated that she was unaware of any staff education on bolsters and that S12CNAS (Certified Nursing Assistant Supervisor) was responsible for keeping records of all CNA education. On 08/28/24 at 01:55 p.m. an interview was conducted with S12CNAS. S12CNAS stated that she believed some of the CNA's were in-serviced on the bolsters but not all of them. She further stated that she personally had not conduced any bolster in-services. She confirmed that the facility had no documentation of staff being educated on the use of the bolsters for Resident #78.

Based on observation, record review and interviews the facility failed to provide oral care for 1 (#64) of 4 (#44, #56, #64, #91) residents reviewed for ADL's (Activities of Daily Living) from a sample of 39 Residents. Findings: Record review revealed Resident #64 was admitted to the facility on [DATE] and had a BIM (Brief Mental Exam) of 10. She had a diagnosis of Muscle weakness and required extensive assistance with all ADL's. Record review of Resident #64's Care Plan revealed the C.N.A.'s were to assist Resident #64 with maintaining good oral hygiene daily. On 08/26/24 at 12:48 p.m., an observation revealed Resident #64 had a white milky substance between her upper and lower teeth. At this time Resident #64 stated she has been in the facility going on 2 months and during this time the staff have not provided her with oral care in the morning. On 08/27/24 9:12 a.m., another observation revealed Resident #64 had a white milky substance between her upper and lower teeth. At this time Resident #64 stated no one had assisted her to brush her teeth after breakfast. On 08/27/24 at 9:13 a.m., an interview with S7LPN revealed Resident #64 required staff to assist her with brushing her teeth. At this time S7LPN observed Resident #64's oral Cavity and stated the residents teeth were nasty and needed to be cleaned. On 8/27/24 at 9:29 a.m., an interview with S24 C.N.A. revealed Resident #64 was a total assist and needed the C.N.A.s to brush her teeth daily. On 08/027/24 at 12:48 p.m., an interview with S17 AN (Assessment Nurse) revealed Resident #64 required extensive assistance with ADL's (Activities of Daily Living) and it was the C.N.A.'s responsible to provide oral hygiene for the resident daily.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 ( Resident #31 and #54) of 3 (Resident #31, Resident #54 and Resident #359) investigated for respiratory care by failing to properly store: 1. Resident #31's nebulizer mask, and 2. Resident #54's BiPAP (Bilevel Positive Airway Pressure) mask Findings: 1. Resident #31 Review of Resident #31's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included, but not limited to, Chronic Obstructive Pulmonary Disease with Exacerbation, Chronic Systolic Heart Failure and Shortness of Breath. Review of Resident #31's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/30/2024 revealed a BIMS (Brief Interview for Mental Status) of 14, indicating he was cognitively intact. Review of Resident #31current physician's orders read in part, Pulmicort 0.5 mg/2ml (milligram/milliliter) respule - Give 2 ml per neb (nebulizer) tx (treatment) twice a day. Brovana 15 mcg/2ml (microgram/milliliter) solution - Give 2 ml per neb tx twice a day. On 08/26/2024 at 09:15 a.m., during an interview with Resident #31, an observation was made of Resident #31's nebulizer mask on his bedside table open to air. Resident #31 stated that the nurses administered his nebulizer treatments and that the mask was never stored in a bag. On 08/26/2024 at 10:15 a.m., a second observation was made of Resident #31's mask on his bedside table open to air. On 08/26/2024 at 12:45 p.m., an interview and observation was with conducted with S19LPN (Licensed Practical Nurse). S19LPN confirmed that Resident #31's nebulizer mask was on his bedside table opened to air and not stored properly. 46169 2. Resident #54 A review of Resident #54's electronic health record revealed she admitted to the facility on [DATE] with diagnoses that included but were not limited to Chronic Obstructive Pulmonary Disorder, Pleural Effusion, Pneumonia, and Acute Pulmonary Edema. A review of Resident #54's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 06/25/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating her cognition was intact. Section O: Special Treatments, Procedures and Programs was checked for Non-invasive Mechanical Ventilator, Bi-level Positive Airway Pressure (BiPAP). A review of Resident #54's August 2024 physician's orders that included but were not limited to, BiPap at bedtime (settings 12/6), Cleanse BiPap mask with soap and water daily after use. On 08/26/2024 at 10:48 a.m., an observation was conducted in Resident #54's room. Resident #54's BiPap mask was observed on the night stand, not in use, open to air and not stored in a bag. Further observation of the BiPap mask revealed spots of a dried dark red substance inside the mask. On 08/26/2024 at 10:55 a.m., an observation and interview was conducted with S25LPN (Licensed Practical Nurse). S25LPN confirmed Resident #54's BiPap mask had spots of dried dark red substance inside the mask was open to air and not stored appropriately. She confirmed the mask should have been cleaned and placed in a bag.

Based on record review and interview, the facility failed to facilitate the resident's and if applicable, the resident representatives' participation in the care planning process for 1 (#5) of 2 (#5, and #76) residents investigated for care planning out of a total sample of 39 residents. Findings: Review of Resident #5's medical records revealed he was admitted to the facility on [DATE] and he was his own representative. Review of the resident's MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, indicating he was cognitively intact. Review of S16SS (Social Services) notes dated 11/02/2023 read in part .the residents daughter was having phone trouble, but left her P.O Box address so that she could also be contacted by the facility via mail. On 08/26/2024 at 12:35 p.m., an interview was conducted with Resident #5, in which he stated that he had not been invited to attend any care plan meetings. On 08/27/2024 at 4:15 p.m., an interview and review of a copy of the mailing envelope was conducted with S16SS. She stated she mailed the care plan meeting invitation to Resident #5's daughter. The copy of the mailing envelope was addressed to Resident #5 with his home address, but on closer observation the address was different from the one provided to the facility by the resident's daughter on 11/02/2023. On 08/27/2024 at 4:20 p.m., further review of Resident #5's hard chart revealed no evidence that quarterly care plan meetings had been conducted after 01/04/2024. On 08/27/2024 at 4:30 p.m., an interview was conducted with S16SS, who failed to provide documented evidence that care plan meetings were being conducted quarterly, or that the resident's daughter had been invited to the quarterly meetings.

Based on record review, and interview, the facility failed to ensure a resident was free from accident hazards during a mechanical lift transfer for 1 (#3) of 4 (#1,#3, #4, and #5) sampled residents who required two-person transfer with a mechanical (Vander) lift, of a total of 5 (#1, #2, #3, #4, and #5) sampled residents. This deficient practice resulted in an actual harm for Resident #3 on 11/18/2022 at 5:15 a.m. when S4CNA attempted to transfer Resident #3, utilizing a mechanical lift, from a bed to a wheelchair without the assistance of another person. Resident #3 fell from the lift and sustained a laceration to the back of his head during the attempted transfer. He was sent to the emergency room for evaluation, received 3 staples to the back of his head and returned to the facility in stable condition. The facility implemented and completed corrective actions prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's policy titled Mechanical Lift was conducted and revealed, in part: 12. Ensure resident and staff safety at all times. 13. Have co-worker stabilize the resident and assist in moving the resident's legs as the lift is in operation. A review of the Transfer Criteria for the Vander-Lift 600 (mechanical lift) revealed in Part: Warning, although one person can perform patient transfers, certain patients or situations may require the help of additional staff members. For example, patients with unpredictable behavior due to dementia may require additional help if their behavior poses a risk of injury to themselves or to staff. Resident #3's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included left sided hemiparesis related to cerebral infarction, unspecified lack of coordination, cerebral infarction, Parkinson's, involuntary abnormal movements, restlessness and agitation, muscle wasting and atrophy, and unspecified psychosis. Review of Resident #3's physician orders revealed and order with a start date of 06/04/2019 to use a lift transfer with 2 staff assistance. Review of Resident #3's Minimum Data Sheet (MDS) dated [DATE] section C revealed a Brief Interview Mental Score (BIMS) of 9, indicating moderate cognitive impairment. Under section G functional status, the resident was coded a 3 for transfers requiring 2 person physical assistance when transferring between surfaces such as bed and chair or wheelchair. Review of the care plan revealed resident required total lift with 2 staff assistance. Review of the resident's nurse notes dated 11/18/22 at 5:15 a.m. revealed resident fell while being transferred from bed to chair. Laceration noted to back of head MD (medical doctor) and RP (responsible party) notified. Review of Resident 3's emergency room Clinical Summary report dated 11/18/22 at 07:47 a.m. revealed a diagnosis of accidental fall with contusion of head. Reason for exam revealed trauma and resident on aspirin. Review of the second emergency room Clinical Summary report dated 11/18/2022 at 12:43 p.m. revealed a diagnosis of scalp laceration. Review of a nurse's note, dated 11/18/22 at 8:49 p.m., revealed Resident returned from hospital at 2:45 p.m., alert to self and place, denies pain at this time, 3 staples intact to back of head, to be removed in 5 days, sister at bedside . On 12/27/22 at 10:15 a.m., during an interview Resident #4 stated he was anxious to get up and did not keep his arms in the sling during the transfer when he hurt his head. He confirmed there was only one person using the sling to get him out of the bed. During an interview on 12/27/22 at 10:30 a.m., S4CNA confirmed she didn't wait for help to come to transfer Resident #3 from his bed to his wheelchair using the mechanical lift and he sustained a head laceration. S4CNA stated she had been trained to use 2 people when transferring a resident with the lift and should not have attempted the transfer without another staff assisting regardless of the resident getting impatient or getting in a hurry. Several observations were made of 2 staff using the mechanical lift, safely as ordered between 12/27/2022 and 12/28/22 and no problems were identified. Several interviews were conducted with the care provider staff that use the lift who confirmed they were trained to always have 2 or more staff working together with every resident that required the use of mechanical lift transfers. On 12/28/22 at 09:10 a.m., during an interview S1QA, S2DON, and S3ADON confirmed all care staff that use a lift must have 2 staff assistance, and all staff that have been in the facility since the incident have been retrained on safe transfers of residents using the mechanical lift. The facility has implemented the following actions to correct the deficient practice: 1. The resident who fell was assessed for injuries. Orders received to send to the emergency department. Resident received staples to the back of his head and returned to the facility. Neuro checks were initiated and resident was placed on acute observation with no negative outcome. 2. The residents in the facility who are transferred with the wrong sling size or not according to their plan of care have the potential to be affected by the alleged deficient practice. Education started within the facility regarding sling sizes and changes in resident's weight. 3. The Certified Nursing Assistants were in-serviced on using the correct lift pad. Continuing education to be done until compliance is achieved. All CNA staff in-serviced on lift policy and procedures utilizing 2 person assist during transfers. In-services were complete and compliance was achieved on 11/21/22. 4. Director of Nursing / Assistant Director of Nursing / QI nurse will perform Q&A sessions with demonstration with CNA's regarding the lift policy 6 times a week for 3 months to ensure that they are following the policy. Any negative findings will result in a progressive form of disciplinary action. The subcommittee will review weekly for three months.

Based on record reviews and interviews, the facility failed to ensure a resident's environment remained as free of accident hazards as possible for 1 (#2) of 4 (#1-#4) sampled residents requiring two-person transfer with the use of an assistive device (mechanical lift). The facility failed to ensure staff transferred Resident (#2) with two-person transfer with use of lifter as identified in the plan of care. This failure resulted in a harm on 05/31/2020 at 12:20 PM, when Resident #2, who required 2-person assistance for transfers with a mechanical lifter, was dropped to the floor when one CNA (Certified Nursing Assistant) attempted to transfer the resident from his chair to the bed without additional staff present to assist. After the fall, Resident #2 was transferred to the local hospital where he was diagnosed with [REDACTED]. The facility implemented corrective action which was completed prior to the State Agency's investigation, thus it was determined Past Noncompliance. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review the resident's quarterly MDS (Minimum Data Set) dated 05/05/2020 revealed a BIMS (Brief Interview for Mental Status) score of 00, which indicated severe mental impairment. Further review of the MDS revealed that Resident #2 required extensive assistance with 2-person assistance for transfer. A review of the facility's Lifting Policy revealed that a plan of care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff. Further review revealed that dots are used to identify the type of lift and will be color coded as follows: .RED-total lift-1 or more person transfer. A review of the Nurse Data Collection and Screening form dated 05/05/2020 revealed under the Fall Risk Screening that Resident #2's transfer ability required extensive/total assistance and a fall risk score of 13, which indicated that Resident #2 was high risk for falls. Review of Resident #2's plan of care revealed that the resident was at risk for falls due to a history of falls and an intervention that included assist with all transfers; RED with use of lifter and staff x 2. Review of the nurse's note dated 05/31/2020 at 3:31 PM, which read that at 12:20 PM, the CNA reported that while transferring the resident with a mechanical lifter from gerichair to bed, she noticed that Resident #2 was crooked and attempted to fix him properly. However, she thought he was okay then continued the transfer the resident. The CNA noticed that Resident #2 was about to fall but realized it was too late to catch him and he flipped out of the lifter pad and hit his head on the end of the lifter. Upon assessment, the nurse observed bright red blood coming from a laceration to the back of his head approximately 2 cm long with swelling at the site. Resident #2 was transferred to the ER (emergency room ). Review of the nurse's note dated 05/31/2020 at 4:24PM, reflected that at 3:30 PM, Resident #2 had seven staples to the scalp laceration with swelling. Review of the ER discharge summary dated 05/31/2020 revealed a [DIAGNOSES REDACTED]. Review of a statement written by S4CNA, dated 05/31/2020, revealed that S4CNA was transferring Resident #2 from his chair to his bed using a mechanical lifter and she noticed that Resident #2 was a little crooked. After she fixed the resident properly, she continued to lift Resident #2 up with the mechanical lifter and noticed that he was about to fall but it was too late to catch him. Resident #2 slipped out the lifter pad and hit his head on the lifter. S4CNA picked the resident up from off the floor and placed him onto the bed. She then noticed blood on his pillow and that Resident #2 had a gash on the back of his head. Review of a document from the Louisiana Workforce Commission entitled, Separation Notice revealed that S4CNA was terminated on 06/01/2020 for violation of company policy. Further review of a document entitled, Termination Report revealed that S4CNA was terminated on 06/01/2020 for improper lifting of resident which caused harm to resident/violation of company policy. An interview was conducted on 10/21/2020 at 1:00 PM with S2DON. S2DON confirmed that Resident #2 required assistance with transfers utilizing a mechanical lifter. She stated that all residents who required transfer assistance with a mechanical lifter require that 2 staff members be present during the transfer. S1DON confirmed that S4CNA should not have attempted to transfer Resident #2 without another staff member present. An interview was conducted on 10/22/2020 at 1:00 PM with S3LPN (Licensed Practical Nurse). S3LPN stated that S4CNA summoned her to Resident #2's room. She stated that when she entered into the resident's room, S4CNA informed her that she was transferring the resident from the geri-chair to the bed and he slipped out of the sling of the mechanical lifter and fell . S3LPN stated that she conducted an assessment on Resident #2 and found that Resident #2 had a bump on the back of his head with redness with a small amount of blood noted. S3LPN stated that S4CNA admitted that she had transferred Resident #2 alone. She confirmed that any resident that needs to be transferred with a lifter requires two staff present during the transfer. On 10/20/2020 at 2:25 PM, an observation was made of Resident #1 being transferred with a lifter and 2 person assistance. There were no issues with transfer technique. A review of the facility's list of physician's orders [REDACTED]. A review of in-service sign in sheets and competencies dated 06/01/2020 through 06/19/2020 revealed that all nursing staff were in-serviced and deemed competent by return demonstration. A review of an additional in-service, dated 09/18/2020, revealed that the ADON conducted an in-service on the facility's lifter policy and use of the lift by staff. A review of the 2 person transfer assistance with a lifter acknowledgement form revealed that new hires signed the form to indicate that they understood the policy. A review of the monitoring forms completed by the DON and the ADON revealed that nursing personnel and CNAs were monitored for proper lift technique from June 2020 through 10/21/2020. These monitoring audits consisted of return demonstration by nursing personnel for proper lift technique. Further review revealed that no negative findings were discovered during the audits. Monitoring and return demonstrations of lift use continues. An interview was conducted on 10/21/2020 at 2:45 PM with S5CNA who stated that the CNAs are trained upon hire on the use of lifters. She stated that whenever the mechanical lifter was used to transfer a resident, two staff must be present during the transfer. An interview was conducted on 10/22/2020 at 3:00 PM with S6CNA who stated that anytime that the mechanical lifter was used to transfer a resident, two staff must be present during the transfer. The facility implemented the following plan of action to correct the deficiency: 1. The corrective actions taken for the resident: a. The resident's physician was notified of the fall on 5/31/2020 and the resident was sent to the ER for evaluation and treatment. A neurological observation was conducted upon the resident's return to the facility for the next 72 hours. b. S4CNA was dismissed on 6/1/2020 for failing to follow company policy due to improper lifting of residents. 2. All residents who required the use of a lift for transfers had the potential to be affected. All nursing and CNA staff were in-serviced by the DON and ADON from 06/01/2020 to 06/19/2020 on the proper use of a lift. Staff competencies were evaluated by return demonstration. 3. To ensure continued compliance, monitoring of staff for use of the lifter will be ongoing. 4. The DON or Designee will continue to monitor nursing personnel for proper lift technique 3 x weekly for 3 months. Any negative findings will be addressed immediately. The QA subcommittee will review any findings weekly. 5. The facility's actions to correct the deficient practice that occurred on 05/31/2020 was corrected on 06/19/2020.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for a resident with a [DIAGNOSES REDACTED].#2) of 5 sampled residents. The facility failed to: 1. Notify the physician to inform him that the resident was refusing to take the ordered [MEDICATION NAME] because she was having loose stools; 2. Failed to educate the resident on the importance of taking [MEDICATION NAME], a laxative, as the physician ordered for the treatment of [REDACTED]. This resulted in an actual harm to resident #2 on 12/23/16 at 10:56 pm, when the resident kept pushing and pushing resulting in a very painful bowel movement. The resident had refused to take an ordered laxative for 4 days because of loose stools. The physician was not notified of the resident's refusal to take the laxative because having loose stools. Hospital record read, apparently, had a fecal impaction which passed which resulted in a possible tear with lower GI (gastrointestinal) bleed resulting in acute blood loss [MEDICAL CONDITION]. As a result of the lower GI bleed, the resident was admitted to the hospital for monitoring and transfusion of packed red cells. Findings: Resident #2. Review of the resident ' s face sheet revealed documentation that the resident was admitted to the facility on [DATE]. The resident ' s admitting [DIAGNOSES REDACTED]. Also, the resident ' s [DIAGNOSES REDACTED]. Review of the resident ' s physician's order [REDACTED]. The order was noted to be discontinued on 12/30/16. Review of the resident ' s care plan revealed that it addressed the resident ' s constipation and history of irregular bowel movements. Also, the care plan addressed that the resident's physician would be notified of any complications. Review of the resident ' s MAR (medication administration record) for December 2016 revealed that the nurse documented on the MAR on 12/19/16, 12/20/16, 12/21/16, and on 12/22/16 that [MEDICATION NAME], a laxative, was not administered. Review of the resident ' s nurse ' s notes revealed no documentation concerning the resident being constipated or documentation that the resident was having loose stools on the following days, 12/19/16 at 2:25 am, 12/20/16 at 12:17 pm, 12/21/16 at 9:37 pm. Review of the resident ' s clinical records revealed that there was no documentation of nurse's notes for 12/22/16. Review of the resident ' s nurse ' s notes dated 12/23/16 at 10:56 pm revealed, 1010pm Resident was having a BM (bowel movement) and nurse noted blood and stool in diaper. (The physician) called and new order to send to (hospital) for eval and treat. Review of the resident ' s hospital history and physical notes dated 12/24/16 revealed, DATE OF ADMIT: 12/23/2016 Reason for Admission: Lower GI Bleed. History of Present Illness: The patient is a very pleasant [AGE] year old black female who is a resident at the nursing home . She does have a history of constipation. Apparently, had a fecal impaction which passed which resulted in a possible tear with lower GI bleed resulting in acute blood loss [MEDICAL CONDITION]. The patient was seen in the emergency room last night and admitted for monitoring and transfusion of packed red cells . VITAL SIGNS: At time of presentation showed a blood pressure of 81/60 . EXTREMITIES: .The patient was passing bright red blood per rectum . PLAN: The patient had received a total of 2 units of packed red cells IV. She is currrently undergoing another transfusion of 2 units of packed red cells ____ third unit I am also going to hold her antihypertensive medications in the setting of her low blood pressure readings Surgery has been consulted Review of the resident's nurse's notes dated 12/27/16 at 4:29 pm revealed that the resident had returned back to the facility after being hospitalized from [DATE] to 12/27/16. On 1/4/17 at 1:25 pm, the resident stated that around the time before she was admitted to the hospital that she was having stomach pain for approximately 2 days. The resident stated that she reported the complaints of stomach pain to the nurse, but the nurse did not do anything. The resident stated that she did not refuse to take the [MEDICATION NAME] and that she told the nurse that she did not want to take the [MEDICATION NAME] on the days that she went to [MEDICAL TREATMENT], which was on Mondays, Wednesdays, and Fridays. The resident stated that on the night that she went to the hospital, that she was having difficulty having a bowel movement. The resident stated that the nurse knew that she was having difficulty having a bowel movement. The resident stated that she does not remember the nurse ' s name. The resident stated that the nurse did not check her stomach and that she does not remember if the nurse checked her for an impaction. The resident stated that she was having difficulty and that she kept pushing and pushing and that it was very painful for her to have a bowel movement. The resident stated that it felt like she was pushing a big knot out of her bottom. The resident stated that when she passed the bowel movement that it felt like her bottom fell out. The resident stated that she let S5CNA (certified nursing assistant) know that she finished having a bowel movement. The resident stated that S5CNA came in the room and pulled the covers and then pulled the covers back up and told her that she would be right back. The resident stated that S5CNA and the nurse came in and pulled the covers. The resident stated that the nurse said, we got to get her out of here . The resident stated then the nurse and S5CNA began cleaning her up and she saw all the blood that was in the diaper. The resident stated that after she was all cleaned up, she was taken to the hospital. The resident stated that after that she was very weak from all the bleeding from her bottom. The resident stated that she was given 4 units of blood while in the hospital. On 1/4/17 at 2:10 pm, S5CNA stated the resident was cognitive. S5CNA stated that the resident didn ' t have a good bowel movement for about 3 to 4 days around the time of her hospital admission. S5CNA stated that the resident was backed up for a few days and was only passing gas and little bitty stools. S5CNA stated that you could tell that the resident really needed to have a bowel movement. S5CNA stated that she reported the resident ' s bowel movement results to S2LPN (licensed practical nurse). S5CNA stated that that the resident was bed bound and was getting more constipated. S5CNA stated that she documented yes on the BM (bowel movement) records even though the resident ' s bowel movements were not good. S5CNA stated that on the night the resident was sent to the hospital, the resident had a bowel movement. S5CNA stated that the resident told her that it felt like a brick was in her bottom. S5CNA stated that when the resident called to let her know she had a bowel movement, she saw a lot of blood in the resident ' s diaper. S5CNA stated that she called S2LPN to assess the resident. S5CNA stated that when the nurse saw all the blood in the resident ' s diaper that the nurse began getting the resident ready to be sent to the hospital. S5CNA stated that she does not remember the nurse examining the resident prior to the resident having the bowel movement. S5CNA stated that she has not observed or witnessed the resident refusing to take her laxatives or any medications. On 1/4/17 at 2:30 pm, S2LPN stated that the resident was cognitive. Also, S2LPN stated that the resident has a history of constipation. S2LPN stated that the resident was getting [MEDICATION NAME] routinely for constipation. S2LPN stated that to her knowledge, the resident was having bowel movements. S2LPN stated that when she asked the CNAs if the resident had a bowel movement that she does not ask the CNA to describe the size or consistency of the bowel movement. S2LPN stated that the resident did not complain of stomach pain to her. S2LPN stated that on the night the resident was sent to the hospital on [DATE], that the resident had a bowel movement around 8:00 pm. S2LPN stated that S5CNA told her that the resident had a bowel movement with blood in the diaper. S2LPN stated that she did not see the diaper, because S5CNA had already threw the diaper away. S2LPN stated that on the same night when the resident went to the hospital on [DATE], the resident ' s daughter went to tell her that her mother, resident#2, had a bowel movement. S2LPN stated that they went in the resident's room with S5CNA to change the resident. S2LPN stated that was when she saw in the resident ' s diaper that the resident was having a bowel movement and passing blood at the same time. S2LPN stated that she sent the resident to the hospital because of the bleeding. S2LPN stated that she did not check the resident for an impaction and she stated that she did not give the resident an enema. S2LPN stated that the resident was refusing to take the [MEDICATION NAME] and confirmed that she documented on the MAR on 12/19/16, 12/20/16, 12/21/16, and on 12/22/16 that the [MEDICATION NAME] was not administered. S2LPN stated that the resident refused the [MEDICATION NAME] because she was having loose stools on 12/19/16, 12/20/16, 12/21/16, and on 12/22/16. Also, S2LPN confirmed that she did not notify the physician that the resident was refusing the [MEDICATION NAME] because of loose stools. On 1/5/17 at 12:15 pm, S3LPN stated that the resident was cognitive. S3LPN stated that the resident complained to her about being constipated on Thursday, 12/22/16. S3LPN stated that the resident told her that she was constipated and that she really needed to have a bowel movement. S3LPN stated that she checked the physician's order [REDACTED]. S3LPN stated that S6CNA told her that the resident had a good bowel movement that spread towards the front of the diaper. S3LPN stated that the resident probably did tell her that her stomach was hurting and that she really needed to have a bowel movement. S3LPN stated that she did not do anything differently for the resident and that she did not call the physician. On 1/5/17 at 12:25 pm, S6CNA stated that the resident had a large, loose bowel movement that spread up to her stomach. S6CNA stated the resident had the bowel movement while she was giving the resident a bed bath. S6CNA stated that she reported the large bowel movement to S3LPN. S6CNA confirmed that she did not tell the nurse that the large bowel movement was loose. On 1/4/17 at 3:40 pm, S1DON (Director of Nurses) stated that S2LPN had informed her that the resident was refusing the [MEDICATION NAME] but did not tell her why the resident refused the [MEDICATION NAME]. S1DON stated that S2LPN should have notified the physician that the resident was refusing the [MEDICATION NAME] because she was having loose stools.

Based on record review and staff interview, the facility failed to ensure pharmaceutical services to meet the needs of each resident by failing to ensure accurate administration of medications ordered by physicians for 3 of 4 residents review for accurate medication administration. (#1, #3, and #10) Findings: 1. Resident #1: A review of Resident #1's Physician order [REDACTED]. Prilosec 40 mg and lactulose 30 ml were ordered every day. There was no documented evidence that the Prilosec and lactulose were administered on 8/12/11. Reglan 5 mg was ordered, but no documented evidence was found of Reglan being administered on 8/17/11 at 11:00 AM. Ambien 5 mg was ordered every night, but there was no documented evidence the Ambien was administered on 8/9/11 or 8/19/11. Seroquel XR 50 mg was ordered every night. There was no documented evidence the Seroquel XR was administered on 8/4/11, 8/5/11, 8/8/11, 8/9/11, 8/10/11, 8/11/11, 8/13/11, 8/16/11 or 8/19/11. On 8/22/11 at 11:00 AM, LPN S9 confirmed there was no documented evidence that Resident #1 was administered the above noted medications. 2. Resident #3: According to Resident #3's August 2011 MAR (Medication Administration Record), Resident #3 did not receive the following medications as ordered: Lortab 5-500 routinely ordered (pain medication) was not administered on 8/10/11 at 9:00 PM or on 8/21/11 at 1:00 PM. A Haldol Decanoate 50 mg IM shot that was ordered every 2 weeks was not administered on 8/10/11 at 6:00 am. Lasix 20 mg ordered every day was not administered on 8/21/11 at 9:00 am. Carafate 1 gm/10ml suspension 10 ml ordered twice every day was not administered on 8/14/11 at 5:00 PM. Geodon 80 mg ordered two times every day was not administered on 8/16/11 at 8:00 am. Ativan 1 mg ordered three times per day was not administered on 8/10/11 at 9:00 PM or on 8/14/11 at 9:00 PM. An interview was conducted with LPN S10 on 8/23/11 at 9:39 am. She confirmed that Resident #3's MAR had the missing signatures for the medications listed above and stated that she would have to assume that, "if it wasn't documented, that it wasn't given." An interview was conducted with LPN S11 on 8/23/11 at 11:10 am. She confirmed that Resident #3's MAR had missing signatures for the above dates and times and stated that she, "would have to assume the medications were not given." An additional interview was conducted with LPN S11 on 8/23/11 at 11:37 am. She stated that she first became aware of Resident #3's Haldol not being administered on 8/10/11 at 9:30 am and completed an incident report. She stated that the nurse that was caring for the resident on that date (8/10/11 at 9:00 am) could not recall whether she had administered the medication or not. A review of the Incident Report dated 8/23/11 at 9:51 am (this was after the missing documentation was pointed out to the staff by this surveyor) for Resident #3 indicated the signature was missing for the Haldol administration on 8/10/11, "it is assumed that medication was not administered." Both the MD and family were both notified and documentation revealed that there was no harm caused to the resident. 3. Resident #10: A review of Resident #10's MAR revealed no initials to indicate the administration of the following ordered medications: Xalatan 0.005% eye drops on 8/8/11, 8/9/11, and 8/10/11; Lipitor 40 mg on 8/8/11, 8/9/11, and 8/10/11; Megestrol 20 mg the 9:00 PM dose on 8/8/11, 8/9/11, and 8/10/11; Scopolamine transdermal patch which was to be replaced every 72 hours at 6:00 AM had no initials on 8/9/11 and 8/12/11; Iron tablet 325 mg on 8/11/11; Flunisolide 25 mg nasal spray on 8/11/11, and Caltrate 600 mg on 8/19/11. A Duragesic (Fentanyl) 25 mcg pain patch was ordered on [DATE] and was to be changed every 72 hours. There was an initial on 8/17/11, then on 8/20/11 an initial was placed and circled (this indicates the medication was held), then another initial was placed on 8/21/11. There was no documented explanation on the MAR or in the clinical record of the discrepancy with the pain medication. On 8/22/11 at 2:10 PM, A comparison was made of Resident #10's available medications located in the medication cart to Resident #10's August 2011 MAR with RN Consultant S3. Metoprolol tartrate 25 mg (antihypertensive medication) blister packet was located in the cart with a start date of 8/15/11 written next to the first blister opened. There was a total of 9 tablets missing, but according to Resident #10's MAR, 14 Metoprolol Tartrate 25 mg tablets had been administered between 8/15/11 and 8/22/11, which indicated 5 tablets had not been administered that had been signed out. A blister packet of Tramadol HCL 50 mg (pain medication) was initialed as started on 8/11/11. There were 11 tablets missing from the blister packet of pain medication, but according to Patient #10's MAR, only 8 tablets had been administered which indicated there were 3 tablets too many missing from the blister packet. A blister packet of Lipitor 40 mg tablets with a start date of 8/13/11 revealed 8 tablets were administered, but according to the MAR, 9 tablets had been administered since 8/13/11. A count of the Fentanyl pain patches revealed a closed box of 5 patches and an opened box with 2 out of 5 patches left. According to Physician order, there should have been 3 pain patches left in the opened box. The narcotic count sheet had fentanyl patches signed out on 8/17/11, 8/20/11 and 8/21/11. There was no way to verify if the other medications on the MAR were given accurately, due to either being community containers or no start date indicated on the blister packets. On 8/22/11 at 2:45 PM, a telephone interview was conducted with LPN S12. She stated that on 8/20/11, the nurse had not documented on the MAR that she had applied Resident #10's Fentanyl pain patch. She revealed the patch she had found on him did not have the date and time, so she changed the patch. On the MAR, it was not signed off and she accidentally initialed the wrong date, circled it, and then signed the correct date. She stated she was supposed to have documented this incident in the nurses notes, but did not. LPN S12 stated she did not have a witness to what occurred regarding the pain patch not having a date and time or that she removed it and replaced it with another. She confirmed she had not performed an incident report yet. There was no documented evidence explaining the incident regarding the discrepancy between the ordered pain medication and the delivered pain medication. A review of Resident #10's nurses notes dated 8/23/11 at 9:05 AM, read: late entry for 8/21/11 6:00 AM. Removed Fentanyl patch from resident. New patch applied. After application of new patch, discovered resident had new Fentanyl patch applied 8/20/11 at 6:00 AM. ... This written account of the incident was slightly different than the explanation given during a telephone interview with the same nurse on 8/22/11 at 2:45 PM.

Based on observation, record review, and staff interview, the facility failed to ensure each resident receive the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial well-being by failing to: 1. a. ensure ordered [MEDICATION NAME] as needed for chest pain was provided for Resident #64's complaints of chest pain resulting in continued chest pain from 09:05 AM when first reported until 10:25 AM (1 hour and 20 minutes) when the Resident was transported to the emergency room , b. ensure Resident #64 was thoroughly assessed including acquiring vital signs and oxygen saturation after complaining of chest pain and shortness of breath c. identify concerns with the procedure/mechanism to assure that all medication orders were processed consistently and accurately through the stages of ordering, receiving, and administering medication. These failures resulted in Resident #64's continued chest pain and subsequent transfer to the emergency room . The resident was in Immediate Jeopardy beginning on 6/24/11 at 9:05 AM when she first complained of chest pain and was not given [MEDICATION NAME]. The Immediate Jeopardy continued until 10:25 AM when she was transferred to the emergency room , from there she was admitted to the hospital with [REDACTED]. The Immediate Jeopardy Situation was lifted on 6/24/11 at 10:25 AM, when Resident #64 was transferred to the hospital. The deficient practice remains at the level of actual harm for Residents #64. The facility also failed to: 1. ensure Resident #64's arthritis pain was reported to nurses/Physician, ensure accurate pain assessments were performed and interventions provided resulting in the Resident's inability to attend all of the activities she would like to attend, 2. ensure Resident #91's contracture pain was reported to nurses, ensure nurses assess current pain management interventions for effectiveness, ensure Passive Range of Motion was provided which led to a progression of contractures with increase in pain level, 3. ensure availability of routinely administered [MEDICATION NAME] Pain medication for Resident #49 from 5/11/11 to 5/13/11 resulting in the Mentally Retarded Resident #49 with pain screenings dated 4/6/11 and 6/24/11 revealed she had indicators of possible pain observed daily with a 5/10 on the pain scale having no Rountinely ordered [MEDICATION NAME] pain medication for 2 days (6 doses). The deficient practice is a pattern of actual harm for 3 of 4 sampled residents reviewed for pain out of a total of 12 sampled residents triggered for pain. (#64, #91, and #49) Findings: 1. Resident #64 is a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #64's 6/21/11 Physician visit note read: Current Complaints - shortness of breath, [MEDICAL CONDITION], chest pain/pressure, lower leg pain, [MEDICAL CONDITION]. History of Present illness - SOB ongoing with onset days ago; [MEDICAL CONDITION] ongoing; chest pain/pressure sudden in onset...Active Problem: Benign Hypertension, [MEDICAL CONDITION] Hypertension, Tricuspid Regurgitation, [MEDICAL CONDITIONS], [DIAGNOSES REDACTED], moderate and Cardiovascular Disease - comment - Stents X3, Aortic Valve, moderate stenosis, severe regurgitation, moderate to severe tricuspid regurgitation, [MEDICAL CONDITION] hypertension. Plan: Discontinue [MEDICATION NAME] and [MEDICATION NAME] due to [MEDICAL CONDITION] side effects. [MEDICATION NAME] 40 mg daily, get records from Jennings. Patient had 3 stents. Echocardiogram, Appointment with Cardiologist... Corresponding Physician order [REDACTED]. This order was signed by the Physician on 6/21/11. On 6/24/11 at 09:50 AM, an interview was conducted with Resident #64. She stated her neck was really hurting today, she felt SOB, and had chest pain. This Surveyor walked out of the room and spoke directly with LPN S6. LPN S6 stated that Resident #64 told her she was SOB and having chest pain along with the neck pain. LPN S6 stated "I gave her the inhaler and that did not resolve the chest pain, so she is being sent to the hospital because I do not have any Nitro ([MEDICATION NAME]) ordered to give her." The LPN stated this all happened around 09:45 AM. On 6/24/11 at 11:00 AM, DON RN S2 confirmed Resident #64 had an order dated 6/21/11 at 3:30 PM for [MEDICATION NAME] as needed for chest pain. After reviewing Resident #64's current MAR (medication administration record), DON RN S2 confirmed that [MEDICATION NAME] was not listed and was not given to the resident for her chest pain that morning before being sent to the emergency room . On 6/24/11 at 11:50 AM, a telephone interview was conducted with LPN S15. LPN S15 confirmed she had forgotten to sign the orders off and forgot to list the [MEDICATION NAME] on the MAR. LPN S15 stated she was new and was just getting used to all of "this". She stated she just had "so much to do." LPN S15 indicated she had listed the [MEDICATION NAME] on the 24 hour nursing report and reported it to the night nurse LPN S20. LPN S15 indicated LPN S20 was supposed to check the orders from the day to see if everything was accurate. DON RN S2 was in the room during the telephone interview and confirmed the pharmaceutical procedure to assure that all medication orders were processed consistently and accurately included the LPN who received the physician order [REDACTED]. He confirmed LPN S15 failed to transcribe the Physician ordered [MEDICATION NAME] as needed for chest pain onto Resident #64's MAR, and the night LPN S20 also failed to ensure the medication [MEDICATION NAME] had been placed on the MAR. A review of the Nurses notes dated 6/24/11 at 09:05 AM signed by the ADON S1 read: ..."I'm having Chest Pain" Pain 4/10 (pain scale) and denies SOB or nausea at present. Oxygen at 2 liters per nasal cannula (O2 2L NC). Reported to LPN S6. She resumed care. Still no return call from Dr. -- Nurse states message waiting. At 09:50 AM, another nurse charted the following: Resident being sent out to --- emergency room (ER) for evaluation and treatment due to complaints of SOB and chest pain per nursing judgment. VS - Temperature 98.1, Pulse 58, respirations 24, and Blood Pressure 164/66. Per LPN S6 lung sounds clear upon auscultation. Report given to --- ER and attempted to notify.... 10:00 AM Ambulance called for transfer. 10:25 AM left via stretcher with --- ambulance in stable condition. Between 09:05 AM and 09:50 AM, no blood pressure, pulse, temperature, oxygen saturation, or presence of [MEDICAL CONDITION] were documented. No oxygen saturation values or assessment of [MEDICAL CONDITION] were documented in the clinical record between 09:05 AM and 10:25 AM when the resident left the nursing home. On 6/24/11 at 12:05 PM, ADON S1 confirmed she was the person who assessed Resident #64 at 9:05 AM. She confirmed that she did not perform vital signs for the resident and that the resident did not complain of SOB at that time. ADON S1 stated she informed LPN S6 and LPN S6 sent the aide to take Resident #64's vital signs. On 6/24/11 at 12:10 PM, LPN S6 confirmed the CNA S19 took Resident #64's vital signs for her. At that time, the DON RN S2 and ADON S1 was questioned about the resident complaining only of chest pain at 09:05 AM, and then the complaint progressed to chest pain with SOB at 09:50 AM, the DON RN S2 stated that LPN S6 had not had a chance to chart. A late entry was then placed in the nurse notes timed 09:15 AM which read: summoned to room Resident voiced she was SOB and complained of chest pain. Respirations 20 breaths per minute, but according to an earlier interview at 09:50 AM with LPN S6, she stated the incident was at approximately 09:45 AM. On 6/24/11 at 12:15 PM, CNA S19 stated that she took Resident #64's vital signs right before she went to the hospital. After reviewing the VS from Resident #64's 6/24/11 09:50 nurses notes, CNA S19 confirmed those were the vital signs she had taken. A review of Resident #64's Ambulance record read: Chief Complaint Chest Pain/SOB. Narrative read: Patient [AGE] year old female complaining of chest pain and SOB according to the nursing home staff. Upon EMS contact .... complaint of chest pain X "A long Time" and SOB X "A long Time". Initial Sats (oxygen saturation) at 93% on 2L/M via nasal cannula. Increased patient's oxygen ... At 2:40 PM on 6/24/11, a visit was made to the emergency room to interview Resident #64. Resident #64 stated her chest pain had subsided about 30 minutes prior to the visit. The emergency room Nurse stated Resident #64 had not told her anything about chest pain, but indicated the ER Physician had ordered a cardiac work up and EKG. The Emergency Department Triage note dated 6/24/11 revealed Resident #64's history was supplied by the patient's nursing home record and by the patient's ambulance record, but there was no documentation of the reported chest pain from Ambulance record or nursing home record. According to the emergency room Physical examination dated 6/24/11, Resident #64 had distended jugular veins, generalized rhonchi, breath sounds decreased on the left side and breath sounds decreased on the right side. 3+ [MEDICAL CONDITION] of lower extremities. At 10:44 AM, Resident #64's pulse Oximetry result was 88%. A cardiac Panel was included in the blood work drawn. A chest X-ray revealed prominent vessels with cephalization suggestive of early fluid overload. An ECG dated 6/24/1 at 11:31 AM read: Abnormal ECG - Sinus Rhythm with left axis deviation, late precordial r/s transition, left ventricular hypertrophy, and baseline wander in leads II, III, aVF. Resident #64 was admitted to the hospital with [REDACTED]. A review of Resident #64's nurses notes dated 11/29/10 at 1:30 PM revealed: Resident has been complaining of pain to neck, bilateral arms and legs ... 12/2/10 a late entry - resident lying in bed complained of back pain ...On call Physician ordered [MEDICATION NAME] along with two 500 mg Tylenol to be given, immediately, then continue with [MEDICATION NAME] as needed. 12/3/10 at 01:00 AM, complained of unrelieved back pain. [MEDICATION NAME] 50 mg administered at 02:00 AM stated the pain was relieved at 03:00 AM called nurses station stated pain started again. On call Physician notified. Order received for [MEDICATION NAME] 50 mg ever 6 hours. The order was unclear due to Resident #64 already receiving [MEDICATION NAME] 50 mg every 6 hours. Report given to oncoming nurse, will continue to make attempts to contact Physician for a new order for pain medications. 06:30 AM (3 1/2 hours after complaining of no relief) Another dose of [MEDICATION NAME] 50 mg administered. Stated little relief. 12/4/10 at 8:00 PM [MEDICATION NAME] 7.5 mg administered for complaints of back pain. A review of Resident #64's January Physician orders [REDACTED]. The resident was transferred to a psychiatric facility on 12/27/10 and was readmitted to the nursing home on 1/6/11 with no pain medication reordered. There was no documented evidence the nurse who transcribed Resident #64's readmit orders contacted the physcian for clarification regarding the omitted pain medications. A review of Resident #64's pain screen dated 1/19/11 revealed the following assessments: Resident had not been on scheduled pain medication regimen, had not received any PRN (as needed) pain medications (there were no pain medications reordered), had not received non-medication intervention, had not complained of pain or recent change in pain, and staff should not conduct an assessment for pain. The day after this assessment on 1/20/11, Resident #64 complained of neck pain, and the Physician ordered [MEDICATION NAME] 3 times a day as needed for neck pain. On 6/20/11 at 1:57 PM, Resident #64 stated she had arthritis pain in her hands, hips and neck. She indicated the medication they give her for pain did not work. Resident #64 revealed she does not have any relief. She stated she felts the pain has kept her from attending all of the activities she would like to participate in. On 6/23/11 at 12:30 PM, an interview was conducted with Resident #64 and MDS coordinator S13. When the MDS Coordinator S13 asked Resident #64 how she was doing, the resident answered "Oh my hand, my arthritis is really really hurting me." MDS Coordinator S13 confirmed Resident #64's right hand/wrist was swollen. The MDS coordinator S13 asked Resident #64 to squeeze her hand and indicated her right hand grasp was weak. Resident #64 also stated her knees hurt from arthritis. Resident #64 informed MDS Coordinator S13 they hurt all of the time. She stated her pain was a 10 on the pain scale (0 being no pain and 10 being the worst pain). Resident #64 stated she told the nurse about the arthritis pain. At that time, LPN S14 denied Resident #64 informed her she was in pain. On 6/23/11 at 1:50 PM, CNA S4 stated Resident #64 complained of arthritis pain in her knees and hands all of the time, "pretty much every day." CNA S4 revealed she informed Resident #64's nurse about the pain. On 6/23/11 at 2:10 PM, DON RN S2 revealed CNA S4 should have documented the complaints of pain in the ADL jot sheets, and had the nurse co-sign the entry to indicate she was informed. There were no documented entries. CNA S4 stated she did not know she was supposed to write the complaints of pain in the jot sheet, but confirmed again that she told the nurse each time Resident #64 complained of pain. 2. Resident #91: Resident #91 is a [AGE] year old male with [DIAGNOSES REDACTED]. On 6/20/11 at 2:20 PM, Resident #91 stated he has arthritis pain in both knees, his hands and his neck. He was noted with his neck bent forward and to the left side. A review of Resident #91's Comprehensive Plan of Care with a goal date of 9/1/11 revealed the CNAs were to provide the required passive range of motion (PROM) exercises while providing care. There was no documentation addressing contractures or pain associated with contractures in the Plan of Care. During an observation and interview with Resident #91 on 6/20/11 at 2:57 PM, his neck was noted bent forward and to the left. He was unable to bend it back. After explaining PROM, he stated that no one moved his neck for him or any other parts of his body. A review of Resident #91's June 2011 Physician order [REDACTED]. On 6/22/11 at 11:15 AM, CNAs S3 and S9 gave Resident #91 a bed bath. They did not perform any passive range of motion while providing this care. During the bath, Resident #91 told the CNAs that he needed something for pain and they told him they would tell his nurse. At 12:15 PM, LPN S14 was asked by the Administrator S18 if the aides had reported to her that Resident #91 was in pain and requested pain medication. She stated no, they had not told her anything. LPN S14 indicated she had administered [MEDICATION NAME] to Resident #91 that morning and would not have given him anything else because it was ordered every 6 hours. When asked if the Resident had Tylenol or anything else ordered for pain, she stated she did not know. The Administrator S18 stated that LPN S14 should have called the doctor if the pain medication that was ordered was not effective. On 6/22/11 at 2:40 PM, Restorative CNA S11 revealed she does not provide restorative services for Resident #91. He was not on her list. On 6/22/11, a new Physician order [REDACTED]. A review of Resident #91's physician progress notes [REDACTED]. Present illness: Complained of pain to legs... Assessment: ...Bilateral foot drop. Plan: Ask PT (Physical Therapy) to evaluate for assistive devices for foot drop... There were no new orders to increase Resident #91's pain medication. Nurses Notes dated 4/7/11 at 3:15 PM - Returned from Dr. --- New order noted per NP S12. Patient has bilateral foot drop. Ask PT to evaluate for devices for foot drop. 3:30 PM Clarification order: D/C order for PT to evaluate for device for bilateral foot drop due to nonambulatory. Occupational Therapy (OT) notes dated 5/18/11 and 5/20/11 revealed Resident #91 continues to be bedbound. Patient does not qualify for skilled OT services at this time, and patient is bedbound, total assist all care and mobility. The PT screening dated 3/3/11 revealed Resident #91 was dependant for bed mobility, transfers, and had impaired active range of motion. There was no documentation of location or severity of contractures on any of the above screenings. On 6/22/11 at 2:45 PM, Physical Therapy Assistant (PTA) S10 revealed they did not have orders for PT for Resident #91. He indicated the resident was screened by Physical Therapy each quarter. PTA S10 thought Resident #91 would need at least PROM to maintain his level of movement and does not decline, and had recommended Multi-Podus Boots. On 6/22/11 at 4:10 PM, a telephone interview was conducted with NP S12. He confirmed PTA S10 had recommended Multi-Podus Boots. NP S12 stated he must have forgotten to write the order. He revealed that since Resident #91 had been admitted to the facility, his neck contracture had gotten worse, and the neck pain had gotten worse as it progressed. The NP S12 confirmed this statement when read back to him. On 6/24/11 at 09:15 AM, Resident #91 stated his pain had gotten worse since he had been admitted to the nursing home, so he figured his neck contracture had gotten worse. Resident #91 did say the new pain medication he received on 6/23/11 really helped the pain. He stated to this surveyor, with a tear running down his face, "I really want to thank you for all you have done for me." 3. Resident #49: Resident #49 is a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident # 49 's Annual MDS (Minimum Data Set) dated 4/7/2011 reveals a BIMS (Brief Interview for Mental Status) score of 1, which indicates severely impaired. A review of Resident #49 's physician's orders [REDACTED]. Resident #49 's New Physician 's Orders revealed the following: On 5/11/11, the Pain medication [MEDICATION NAME] was being increased to 7.5 mg three times per day. A second New physician's order [REDACTED]. A third New physician's order [REDACTED]. On 5/12/11, Resident #49's New physician's order [REDACTED]. According to Resident #49 ' s May 2011 MAR (medication administration record), the last dose of [MEDICATION NAME] 5/500 Resident #49 received was on 5/10/11 at 5:00 PM, and the first dose of [MEDICATION NAME] 7.5/500 mg was not given until 5/13/11 at 9:00 am, which indicated Resident #49 failed to receive any of the routinely ordered pain medication [MEDICATION NAME] for 2 days. During an interview on 6/23/11 at 3:48 pm, S2DON confirmed that Resident #49 was prescribed [MEDICATION NAME] for pain and that neither [MEDICATION NAME] 5/500mg nor [MEDICATION NAME] 7.5/500 mg dosages were available for administration on 5/11/11 (three doses) or on 5/12/11 (three doses). S2DON confirmed that Resident #49 was seen by her physician in the facility on 5/11/11 but a hardcopy prescription was not obtained that day. S2 DON stated that in order to obtain the [MEDICATION NAME] from the pharmacy, a hardcopy prescription must be faxed to the pharmacy for a controlled drug. A review of Resident #49's Pain Screen dated 4/6/11 reads: Indicators of possible pain observed daily. During a telephone interview on 6/24/11 at 10:04 am with S16 Pharmacist, she confirmed that Resident #49 ' s prescription for [MEDICATION NAME] 5/500 mg three times per day was initially filled on 2/9/11 with 2 refills, and the last card of [MEDICATION NAME] 5/500 mg delivered to the facility would have indicated that there were no refills. She further stated that on the blister pack for the [MEDICATION NAME], there would be 8 days of medication left on the card when the facility should attempt to obtain a new prescription. S16 Pharmacist stated that the pharmacy sent a request to the facility on [DATE] for a new prescription for [MEDICATION NAME], as it should have been sent to them by 5/10/11 for Resident #49 not to miss a dose of [MEDICATION NAME]. S16 Pharmacist further stated that S17LPN called in [MEDICATION NAME] 7.5 mg po tid, but did not have a prescription with the physician's DEA number and the quantity of [MEDICATION NAME] being prescribed and because [MEDICATION NAME] is a schedule 3 narcotic, the pharmacy was unable to fill it without the prescription. She stated that [MEDICATION NAME] is listed as a schedule 3 narcotic, which can be faxed to pharmacy or phoned in to pharmacy by the physician or a designated agent of the physician. S16 Pharmacist further clarified that the prescription must include the physician's DEA number and the quantity of the medication. S16 Pharmacist further stated that they contacted the physician 's office for a prescription on 5/11/11, but did not receive the order from the physician until 5/12/11 at 2:21 pm and the medication should have been received at the facility on 5/12/11 at 9:25 pm, according to the delivery sheet.

Based on observation, record review and staff interview, the facility failed to provide pharmaceutical services to meet the needs of each resident including an effective procedure/mechanism in place to assure that all medication orders were processed consistently and accurately to provide needed medications in a timely manner by failing to: 1. a. ensure physician ordered Nitroglycerin as needed for chest pain was transcribed onto the MAR (medication administration record) resulting in a failure to administer Nitroglycerin to Resident #64 after complaints of chest pain on 6/24/11. Resident #64's chest pain continued from 09:05 AM when first reported until 10:25 AM (1 hour and 20 minutes) when the Resident was transported to the emergency room , b. ensure staff follow procedure/mechanism to assure that all medication orders were processed consistently and accurately through the stages of ordering, receiving, and administering medication. These failures resulted in an Immediate Jeopardy Situation for Resident #64 beginning on 6/24/11 at 9:05 AM when she first complained of chest pain, and continued until 10:25 AM when she was transferred to the emergency room , from there she was admitted to the hospital with [REDACTED]. The Immediate Jeopardy Situation was lifted on 6/24/11 at 10:25 AM, when Resident #64 was transferred to the hospital. The deficient practice remains at the level of actual harm for Residents #64. Also, the facility failed to provide pharmaceutical services to meet the needs of each resident by failing to: 2. ensure verification with Physician when pain medications were not reordered on readmit for Resident #64 who was experiencing pain and indicated the pain kept her from attending all of the activities she would like, 3. ensure availability of routinely administered Lortab Pain medication for Resident #49 from 5/11/11 to 5/13/11 resulting in the Mentally Retarded Resident #49 with pain screenings dated 4/6/11 and 6/24/11 revealed she had indicators of possible pain observed daily with a 5/10 on the pain scale having no Rountinely ordered Lortab pain medication for 2 days, and ensure availability of Nexium and Prilosec for Resident #49 resulting in missed doses, 4. ensure availability of routinely administered Klonopin (Benzodiazepine) for Resident #68 resulting in 4 missed doses which induced severe shaking causing an inability of Resident #68 to button her own blouse. The deficient practice is a pattern of actual harm for 3 of 12 sampled residents reviewed for medication regimen out of a total of 27 residents. (#64, #49, and #68) Findings: 1. Resident #64 is a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #64's 6/21/11 Physician visit note read: Current Complaints - shortness of breath, edema, chest pain/pressure, lower leg pain, insomnia. History of Present illness - SOB ongoing with onset days ago; edema ongoing; chest pain/pressure sudden in onset...Active Problem: Benign Hypertension, Pulmonary Hypertension, Tricuspid Regurgitation, Chronic Obstructive Pulmonary Disease (COPD), [DIAGNOSES REDACTED], moderate and Cardiovascular Disease - comment - Stents X3, Aortic Valve, moderate stenosis, severe regurgitation, moderate to severe tricuspid regurgitation, pulmonary hypertension. Plan: Discontinue Omeprazole and Norvasc due to edema side effects. Lasix 40 mg daily, get records from Jennings. Patient had 3 stents. Echocardiogram, Appointment with Cardiologist... On 6/24/11 at 09:50 AM, an interview was conducted with Resident #64. She stated her neck was really hurting today, she felt SOB, and had chest pain. This Surveyor walked out of the room and spoke directly with LPN S6. LPN S6 stated that Resident #64 told her she was SOB and having chest pain along with the neck pain. LPN S6 stated "I gave her the inhaler and that did not resolve the chest pain, so she is being sent to the hospital because I do not have any Nitro (nitroglycerin) ordered to give her." The LPN stated this all happened around 09:45 AM. A review of Resident #64's MD orders revealed an order for [REDACTED]. On 6/24/11 at 11:00 AM, DON RN S2 confirmed Resident #64 had an order dated 6/21/11 at 3:30 PM for nitroglycerin as needed for chest pain. After reviewing Resident #64's current MAR (medication administration record), DON RN S2 confirmed that Nitroglycerin was not listed and was not given to the resident for her chest pain that morning before being sent to the emergency room . On 6/24/11 at 11:50 AM, a telephone interview was conducted with LPN S15. LPN S15 confirmed she had forgotten to sign the orders off and forgot to list the Nitroglycerin on the MAR. LPN S15 stated she was new and was just getting used to all of "this". She stated she just had "so much to do." LPN S15 indicated she had listed the nitroglycerin on the 24 hour nursing report and reported it to the night nurse LPN S22. LPN S15 indicated LPN S20 was supposed to check the orders from the day to see if everything was accurate. DON RN S2 was in the room during the telephone interview and confirmed the pharmaceutical procedure to assure that all medication orders were processed consistently and accurately included the LPN who received the physician order [REDACTED]. He confirmed LPN S15 failed to transcribe the Physician ordered Nitroglycerin as needed for chest pain onto Resident #64's MAR, and the night LPN S22 also failed to ensure the medication Nitroglycerin had been placed on the MAR. A review of the Nurses notes dated 6/24/11 at 09:05 AM signed by the ADON S1 read: ..."I'm having Chest Pain" Pain 4/10 (pain scale) and denies SOB or nausea at present. Oxygen at 2 liters per nasal cannula (O2 2L NC). Reported to LPN S6. She resumed care. Still no return call from Dr. -- Nurse states message waiting. At 09:50 AM, another nurse charted the following: Resident being sent out to --- emergency room (ER) for evaluation and treatment due to complaints of SOB and chest pain per nursing judgment. VS - Temperature 98.1, Pulse 58, respirations 24, and Blood Pressure 164/66. Per LPN S6 lung sounds clear upon auscultation. Report given to --- ER and attempted to notify.... 10:00 AM Ambulance called for transfer. 10:25 AM left via stretcher with --- ambulance in stable condition. Between 09:05 AM and 09:50 AM, no blood pressure, pulse, temperature, oxygen saturation, or presence of edema were documented. No oxygen saturation values or assessment of edema were documented in the clinical record between 09:05 AM and 10:25 AM when the resident left the nursing home. On 6/24/11 at 12:05 PM, ADON S1 confirmed she was the person who assessed Resident #64 at 9:05 AM. She confirmed that she did not perform vital signs for the resident and that the resident did not complain of SOB at that time. ADON S1 stated she informed LPN S6 and LPN S6 sent the aide to take Resident #64's vital signs. On 6/24/11 at 12:10 PM, LPN S6 confirmed the CNA S21 took Resident #64's vital signs for her. At that time, the DON RN S2 and ADON S1 was questioned about the resident complaining only of chest pain at 09:05 AM, and then the complaint progressed to chest pain with SOB at 09:50 AM, the DON RN S2 stated that LPN S6 had not had a chance to chart. A late entry was then placed in the nurse notes timed 09:15 AM which read: summoned to room Resident voiced she was SOB and complained of chest pain. Respirations 20 breaths per minute, but according to an earlier interview at 09:50 AM with LPN S6, she stated the incident was at approximately 09:45 AM. On 6/24/11 at 12:15 PM, CNA S21 stated that she took Resident #64's vital signs right before she went to the hospital. After reviewing the VS from Resident #64's 6/24/11 09:50 nurses notes, CNA S21 confirmed those were the vital signs she had taken. A review of Resident #64's Ambulance record read: Chief Complaint Chest Pain/SOB. Narrative read: Patient [AGE] year old female complaining of chest pain and SOB according to the nursing home staff. Upon EMS contact .... complaint of chest pain X "A long Time" and SOB X "A long Time". Initial Sats (oxygen saturation) at 93% on 2L/M via nasal cannula. Increased patient's oxygen ... At 2:40 PM on 6/24/11, a visit was made to the emergency room to interview Resident #64. Resident #64 stated her chest pain had subsided about 30 minutes prior to the visit. The emergency room Nurse stated Resident #64 had not told her anything about chest pain, but indicated the ER Physician had ordered a cardiac work up and EKG. The Emergency Department Triage note dated 6/24/11 revealed Resident #64's history was supplied by the patient's nursing home record and by the patient's ambulance record, but there was no documentation of the reported chest pain from Ambulance record or nursing home record. According to the emergency room Physical examination dated 6/24/11, Resident #64 had distended jugular veins, generalized rhonchi, breath sounds decreased on the left side and breath sounds decreased on the right side. 3+ pitting edema of lower extremities. At 10:44 AM, Resident #64's pulse Oximetry result was 88%. A cardiac Panel was included in the blood work drawn. A chest X-ray revealed prominent vessels with cephalization suggestive of early fluid overload. An ECG dated 6/24/1 at 11:31 AM read: Abnormal ECG - Sinus Rhythm with left axis deviation, late precordial r/s transition, left ventricular hypertrophy, and baseline wander in leads II, III, aVF. Resident #64 was admitted to the hospital with [REDACTED]. 2. Resident #64: A review of Resident #64's nurses notes dated 11/29/10 at 1:30 PM revealed: Resident has been complaining of pain to neck, bilateral arms and legs ... 12/2/10 a late entry - resident lying in bed complained of back pain ...On call Physician ordered Tramadol along with two 500 mg Tylenol to be given, immediately, then continue with Tramadol as needed. 12/3/10 at 01:00 AM, complained of unrelieved back pain. Tramadol 50 mg administered at 02:00 AM stated the pain was relieved at 03:00 AM called nurses station stated pain started again. On call Physician notified. Order received for Tramadol 50 mg ever 6 hours. The order was unclear due to Resident #64 already receiving Tramadol 50 mg every 6 hours. Report given to oncoming nurse, will continue to make attempts to contact Physician for a new order for pain medications. 06:30 AM (3 1/2 hours after complaining of no relief) Another doses of Tramadol 50 mg administered. Stated little relief. 12/4/10 at 8:00 PM Lortab 7.5 mg administered for complaints of back pain. A review of Resident #64's January Physician orders [REDACTED]. The resident was transferred to a psychiatric facility on 12/27/10 and was readmitted to the nursing home on 1/6/11 with no pain medication reordered. There was no documented evidence the nurse who transcribed Resident #64's readmit orders contacted the physician for clarification regarding the omitted pain medications. On 6/20/11 at 1:57 PM, Resident #64 stated she had arthritis pain in her hands, hips and neck. She indicated the medication they give her for pain did not work. Resident #64 revealed she does not have any relief. She stated she felts the pain has kept her from attending all of the activities she would like to participate in. On 6/23/11 at 12:30 PM, an interview was conducted with Resident #64 and MDS coordinator S13. When the MDS Coordinator S13 asked Resident #64 how she was doing, the resident answered "Oh my hand, my arthritis is really really hurting me." MDS Coordinator S13 confirmed Resident #64's right hand/wrist was swollen. The MDS coordinator S13 asked Resident #64 to squeeze her hand and indicated her right hand grasp was weak. Resident #64 also stated her knees hurt from arthritis. Resident #64 informed MDS Coordinator S13 they hurt all of the time. She stated her pain was a 10 on the pain scale (0 being no pain and 10 being the worst pain). Resident #64 stated she told the nurse about the arthritis pain. At that time, LPN S14 denied Resident #64 informed her she was in pain. On 6/23/11 at 1:50 PM, CNA S4 stated Resident #64 complained of arthritis pain in her knees and hands all of the time, "pretty much every day." CNA S4 revealed she informed Resident #64's nurse about the pain. On 6/23/11 at 2:10 PM, DON RN S2 revealed CNA S4 should have documented the complaints of pain in the ADL jot sheets, and had the nurse co-sign the entry to indicate she was informed. There were no documented entries. CNA S4 stated she did not know she was supposed to write the complaints of pain in the jot sheet, but confirmed again that she told the nurse each time Resident #64 complained of pain. 3. Resident #49: Resident #49 is a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident # 49 's Annual MDS (Minimum Data Set) dated 4/7/2011 reveals a BIMS (Brief Interview for Mental Status) score of 1, which indicates severely impaired. A review of Resident #49 ' s Physician order [REDACTED]. A review of Resident #49 ' s MAR (Medication Administration Record) for June 2011 reveals initials for Nexium 40 mg capsule 1 po Q Day for June 1,2011 through June 9, 2011. Beginning June 10, 2011, there are no initials for Nexium 40 mg capsule 1 po Q Day with " hold until available " written on the MAR. A review of Resident # 49 ' s Physician order [REDACTED]. A review of Resident #49 ' s New physician's order [REDACTED]. A review of Resident #49 ' s MAR for May 2011 indicates that the first dose of Nexium 40 mg 1 po Q Day was given on 5/7/11. A further review of Resident #49 ' s physician's order [REDACTED]. A review of Resident # 49 ' s New physician's order [REDACTED]..Increase Lortab to 7.5 mg tid. A review of Resident #49 ' s New physician's order [REDACTED]. A review of Resident #49 ' s New physician's order [REDACTED]. A review of Resident #49 ' s New physician's order [REDACTED]. According to Resident #49 ' s MAR for May, 2011, the last dose of Lortab 5-500 tablet 1 po tid was given on 5/10/11 at 5:00 pm and the first dose of Lortab 7.5/500 mg tablet 1 po tid was not given until 5/13/11 at 9:00 am. This indicated Resident #49 did not receive any pain medication for 2 days due to the medication not being available. During an interview on 6/23/11 at 3:48 pm, S2DON confirmed that Resident #49 was prescribed Lortab for pain and that neither Lortab 5/500mg 1 po tid nor Lortab 7.5/500 mg 1 po tid dosage was available for three doses on 5/11/11 and 3 doses on 5/12/11. S2DON confirmed that Resident #49 was seen by her physician in the facility on 5/11/11 but a hardcopy prescription was not obtained that day. S2 DON stated that in order to obtain the Lortab from the pharmacy, a hardcopy prescription must be faxed to the pharmacy for a controlled drug. S2 DON also confirmed that Resident #49 ' s Prilosec DR 40 mg capsule 1 po Q Day was not given 4/30/11 through 5/6/2011. S2DON confirmed that Nexium 40 mg 1 po Q Day was not ordered until 5/6/2011, with the first dose being given on 5/7/11. S2 DON further stated that Resident #49 ' s insurance did not cover Prilosec so Nexium was ordered for Esophageal Reflux. When S2DON was questioned about a current physician's orders [REDACTED].", S2 DON stated that he was unsure of the status of the Nexium or the reason it was on hold and that he was not aware that Resident #49 was not receiving the medication. A review of Resident # 49 ' s Physician order [REDACTED]. A review of Resident #49 ' s MAR (Medication Administration Record) for April 2011 reveals initials that are circled on 4/30/11 for Prilosec DR 40 mg capsule 1 po Q Day. During an interview on 6/23/11 at 3:48 pm, S2DON confirmed that the initials with a circle around them on the MAR indicate that the drug was not administered. A review of Resident #49 ' s New physician's order [REDACTED]. A review of Resident #49's Pain Screen dated 4/6/11 reads: Indicators of possible pain observed daily with a 5/10 on the pain scale. During a phone interview on 6/24/11 at 10:04 am with S16 Pharmacist,she confirmed that Resident #49 ' s prescription for Lortab 5/500 mg po tid was initially filled on 2/9/11 with 2 refills and that the last card of Lortab 5/500 mg delivered to the facility would have indicated that there were no refills. She further stated that on the blister pack for the Lortab, there would be 8 days of medication left on the card when the facility should be attempting to obtain a new prescription. S16Pharmacist stated that the pharmacy sent a request to the facility on [DATE] for a new prescription for Lortab, as it should have been sent to them by 5/10/11 for Resident #49 to not miss a dose of Lortab. S16 Pharmacist further stated that S17LPN called in Lortab 7.5 mg po tid but did not have a prescription with the physician's DEA number and the quantity of Lortab being prescribed and because Lortab is a schedule 3 narcotic, the pharmacy was unable to fill it without the prescription. She stated that Lortab is listed as a schedule 3 narcotic, which can be faxed to pharmacy or phoned in to pharmacy by the physician or a designated agent of the physician. S16 Pharmacist further clarified that the prescription must include the physician's DEA number and the quantity of the medication. S16Pharmacist further stated that they contacted the physician 's office for a prescription on 5/11/11, but did not receive the order from the physician until 5/12/11 at 2:21 pm and the medication should have been received at the facility on 5/12/11 at 9:25 pm, according to the delivery sheet. Regarding the Prilosec, S16Pharmacist said that Prilosec was last filled on 3/15/11 and the blister pack for Prilosec should have had "no refills" indicated on the blister pack. She further stated that the medications are not automatically refilled and the facility notifies the pharmacy of which non-narcotic medications that need to be filled by either fax or phone call. S16Pharmacist stated that the Prilosec was rejected by the insurance and a Medicaid Denial form was faxed to the facility on [DATE]. She further stated that a second fax of the Medicaid Denial Form was sent to the facility on [DATE], but there was no response from the facility until Nexium was called in to the pharmacy by the facility on 5/6/11. S16 Pharmacist stated that " reorder " was marked Resident #49 ' s blister pack for Nexium when there were 8 doses remaining. S16Pharmacist further stated that the fax for the next month of Nexium was not received by the pharmacy until 6/14/11 and was filled and sent to the facility on [DATE]. During an interview with LPN S17 on 6/24/11 at 11:30 am, she presented a blister pack for Nexium 40 mg capsule give 1 capsule by mouth every day dated 6/14/11 with 10 pills missing from the pack. LPN S17 stated that she did receive Resident #49's Nexium and began giving it on 6/15/11 but that she did not transcribe it onto the MAR. She further stated that she should have written it on the MAR and put her initials on each day that the medication was given, but that she had not. During an interview on 6/24/11 at 12:10 pm, S2DON stated that upon researching the location of Resident #49 ' s blister pack of Nexium 40 mg capsules that should have been received by the facility on 6/14/11, it was discovered that the blister pack of Nexium 40 mg capsules was with Resident #49's other medications in the medication cart. S2DON stated that 10 of the Nexium 40 mg capsules were missing from Resident #49 ' s blister pack and he assumed that meant that the Nexium was administered to Resident #49, but the medication was not written on the June 2011 MAR. S2DON confirmed there were no initials documenting that the medication was given from June 15, 2011 through June 23, 2011. S2DON confirmed that there were 30 capsules of Nexium 40 mg on Resident #49 ' s monthly blister pack and if the Nexium was started on May 7, 2011, then the 30th pill of the pack should have been given on June 5, 2011. S2DON confirmed that there were initials on Resident # 49 ' s June 2011 MAR as if Nexium 40 mg capsules were given on June 6, June 7, June 8, and June 9, 2011. S2DON further confirmed that the second blister pack of Nexium was not received until 6/14/2011 with the first dose of the Nexium from this blister pack being given on 6/15/11. When asked why Resident #49 ' s second blister pack of Nexium was not requested from the pharmacy until 6/14/11, he stated that he did not know but that Resident #49 should not have had missed doses of Nexium. 4. Resident #68: Resident #68 is an [AGE] year old female with [DIAGNOSES REDACTED]. According to her June 2011 Physician orders, she has been receiving the antianxiety medication Klonopin since 3/8/11. On 6/22/11 at 10:00 AM the resident was sitting on a chair attempting to button the bottom portion of her blouse. Her arms and hands were visibly shaking. The resident was asked why she was shaking this morning she stated "I did not get my medicine this morning". The resident was asked if she was able to finish dressing herself, and she said she could not button her blouse because she was shaking so much. The resident stated she was shaking since she had gotten up that morning. On 6/22/11 at 10:10 AM (S19)LPN was asked if the resident #68 was given her medication this morning and she said she was given everything except her klonopin. When asked why the resident did not receive the medication Klonopin, she stated that the pharmacy was called, but it was never delivered. The nurse was then asked when the last time the resident received her klonopin she replied Monday ( 6/20/11) On 6/22/11 at 11:00 AM (S19) LPN was interviewed. She stated that Resident #68 missed 4 doses of Klonopin. She stated that the pharmacy should have been called on the 14th. According to the resident's MAR the last dose was given June 20th at 8:00 PM which indicated she missed 4 doses between 6/21/11 and 6/22/11. According to the Spring 2011 MPR Pharmacists' edition, Klonopin has a warning/precaution to avoid abrupt cessation. Based on observation and interview, it was determined that the facility did not maintain clean and orderly medication carts. This failure affected 3 of 4 medication carts and residents on 5 of the 6 Halls and could cause possible medication administration errors. On 6/24/2011 at 3:50pm, medication carts were checked. Observations revealed Hall 200 and Hall 100-300 medication carts had sticky liquid drawers. The two nurses passing medication (S#15 and S#23) confirmed the observations upon interview. Observations revealed on Hall 100-300 medication cart and 500-600 medication cart, the nose drops and eye drops were stored together and not stored separately.

Based on observation and staff interview, the facility failed to promote care for resident's in a manner that enhanced each resident's sense of dignity and self worth, as evidenced by 1. the failure to keep Resident #91's water within reach but within view and failure to respond in a timely manner to requests for water resulting in the resident stating "I mostly just stop asking" for water when he was thirsty (apathy), 2. the failure of the CNAs to acknowledge and respond to the request to have Resident #91's teeth brushed, the failure to recognize that Resident #91 would be cold when undressed and wet during a bed bath while the air conditioning was blowing cold air and set at 61 degrees, and by failing to respond to Resident #91's request for pain medication and inform the nurse, the CNAs dehumanized the resident by treating him like an object instead of a person, and 3. the failure to respond to Resident #91's verbal requests for increased activities, failure to individualize his activities according to his past interests, and failure to "notice" he could not see his television when lying on his left side resulted in a significant decline from former social patterns as according to his activity screen for 1 of 1 residents reviewed for dignity out of a total of 27 sampled residents. (#91) Findings: Resident #91 is a [AGE] year old male with [DIAGNOSES REDACTED]. A review of Resident #91's Comprehensive Plan of Care revealed the CNAs were to place frequently used items within reach and visual field of resident due to a [DIAGNOSES REDACTED]. to comfortable position in chair that prevents rising. There was no problem of decreased activity addressed in the care plan. On 6/20/11 at 2:20 PM, Resident #91 was noted in his bed with the side rails up. A pitcher/glass with ice water was noted on Resident #91's nightstand out of his reach. He stated that the staff do not give him water between meals. He revealed he sees the glass of water there sometimes, but he cannot get it. He has called and asked the staff for water, telling them that he was thirsty, and they say they will come and give him some water, but it takes them a long time. "Maybe 2 hours, so I mostly just stop asking." This apathy voiced by Resident #91 was in response to the failure of the staff to keep the water within reach or provide timely assistance to the resident as requested. On 6/21/11 at 09:45 AM, Resident #91 was noted dressed in a hospital gown facing the window. His head was bent to the front and slightly left with no support. His feet had heel protectors with pillows underneath the heels, and the sheets were tightly pulled over his toes. Due to the pillow under his heels and no pillow underneath his knees, the knees were hyperextend. CNA S3 was asked about his position, and she stated that was how they were supposed to position him. On 6/22/11 at 10:30 AM, an observation was made of Resident #91 in bed with Activities Director S8. Aides had just finished changing his position and left the room. His water pitcher was noted on the nightstand out of his reach. The TV remote control was on the bedside table next to the wall away from the bed and out of the resident's reach. The Activities Director S8 confirmed these were out of the resident's reach. At that time, the Resident indicated he was thirsty and the water was out of his reach. The Activities Director S8 moved the bedside table to the resident and placed the water on it. He tried to lift the pitcher up to drink from it, and it was too heavy. She brought the water with straw to the Resident's mouth, and he drank approximately 1/3 of the pitcher at one time. Smiling, Resident #91 commented thank you and that the water was very good. On 6/20/11 at 2:44 PM, Resident #91 stated that the staff have to brush his teeth for him and they only brush them approximately every 4 weeks. On 6/22/11 at 11:15 AM, CNAs S3 and S9 gave Resident #91 a bed bath. When they were getting the supplies ready, the resident asked if they would brush his teeth. They never brushed his teeth. When they started bathing the resident, they did not turn the air off, it was set on 61 degrees and was blowing cold air in the room. The Resident appeared cold and this surveyor asked the resident if he was cold. He stated, yes he was cold and he would love the air cut off. He told the aides during the bath that he needed something for pain and they told him they would tell his nurse. The CNAs confirmed they were finished providing Resident #91's care. At 12:15 PM, LPN S14 was asked by the Administrator S18 if the aides informed her Resident #91 was in pain and requesting medication. She stated no, they had not told her anything. By the failure of the CNAs to acknowledge and respond to the request to have his teeth brushed, failure to recognize that Resident #91 would be cold when undressed and wet during a bed bath while the air conditioning was blowing cold air and set at 61 degrees, and by failing to respond to Resident #91's request for pain medication by informing the nurse, the CNAs dehumanized the resident by treating him like an object instead of a person. A review of Resident #91's Quarterly MDS dated [DATE] revealed the following: Vision impaired - sees large print, but not regular print in newspapers/books and does not have contacts, glasses, or magnifying glass. Section F - Preferences for Customary Routine and Activities was left blank. A review of Resident #91's Activity Screening dated 3/8/11 revealed his interest/activity preferences were card/table games, cooking, religious activities, gardening, movies, bingo, socials/parties, music, TV/Radio, reading. Enjoys being outdoors when the weather permits, prefers small groups, attention span - attentive, and participation - active and needs assistance to/with activities. Social Service Director documented: His religion is Christian and belong to --- Previous occupation - states he worked as a chief engineer. Speaks English only. Past interest include watching television programs such as news, soap operas, Western movies, etc. He also likes sporting events such as boxing and football games. States the Saints are his favorite team to support. he likes to listen to Jazz music. He used to play games such as Dominoes and Bingo. He also used to like to read the newspaper daily. Activity Plan - Will inform resident of all scheduled group activities. Will assist to and from activities of his choice. Will provide activity calendar in his room. Staff and volunteers will visit with him daily. Will encourage participation in group activities. On 6/20/11 at 2:17 PM, Resident #91 stated he does not go to any activities because they never get him up. He has been trying to get them to at least put him in the chair beside his bed. The resident was dressed in a hospital gown, facing the window (blinds not open), and was unable to see the television. When asked if the organized activities at the facility meet his interests, he stated yes, but he does not get to go to any. On 6/22/11 at 10:20 AM, Activity Director S8 stated that Resident #91 has a volunteer go into his room every day and visit, and he was gotten up twice a week in his Geri Chair. On 6/22/11 at 10:30 AM, an observation of Resident #91 was made with Activity Director S8. The resident was noted in bed. He informed the Activity Director he would like to attend more activities. The Resident revealed when on his left side, he could not see his television, and since that was his main source of entertainment, he got very bored. Activity Director S8 was asked if she had been aware when Resident #91 was on his left side, he could not see the television, and she stated she had not noticed that, but now that it was mentioned, she could understand due to his neck contracture to the left, he would not be able to see it. On 6/23/11 at 9:55 AM, Social Service S7 revealed that Resident #91 had an appointment with the eye doctor on 7/21/11 at 10:00 AM. She was asked if the Resident was ever offered Magnifying glasses to read the paper, since it was documented as one of his favorite things to do in the activity notes, and she stated no. Social Service S7 looked in her drawer and had several pairs of glasses, she also stated that he may be able to use a magnifying glass. On 6/23/11 at 12:00 PM, Social Service S7 stated she gave Resident #91 a pair of glasses and the newspaper. She stated he put the glasses on and was able to read the paper. "He was so excited. He was grinning from ear to ear," and thanked her. On 6/23/11 at 09:25 AM, CNA S4 revealed that Resident #91 does not get up very often, he gets out of bed maybe 2 times per week. CNA S4 stated she knew Resident #91 wanted to get up more. He is usually up in the Geri chair when he goes to the shower, that is when he goes to the dining room. Not everyone gets him up. It depends on who is working with him. By failing to respond to Resident #91's verbal requests for increased activities, failure to individualize his activities according to his past interests, and failure to "notice" he could not see his television when lying on his left side resulted in a significant decline from former social patterns.