Every finding on record at Inn at Freedom Village, The

Based on record reviews and interviews the facility failed to ensure staff were competent to provide direct care to a resident with behaviors due to dementia for one (Resident #1) out of three residents sampled.Findings include: Review of Resident #1's admission Record dated 03/09/2026 showed Resident #1 was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinsonism, anxiety disorder, unspecified dementia with other behavioral disturbance. Resident #1 was admitted to the facility for short term rehabilitation. Resident #1 was successfully discharged home according to the plan on 3/3/2026. Review of a Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status Score of 09 which indicated Moderate cognitive impairment. Review of Resident #1's care plan did not reveal a plan of care to deal with Resident #1's behaviors related to dementia. Review of a nursing progress note dated 2/20/2026 showed, Patient combative with care tonight. Bowel movement smeared all over himself and bed. On 03/09/2026 at 12:02 PM, an interview was conducted with Staff G, Certified Nursing Assistant (CNA). Staff G said Staff H, CNA asked for assistance with Resident #1 as Resident #1 was agitated and she was having a hard time with him. Staff G, CNA said Resident # 1 was covered in feces. Staff G, CNA stated while trying to assist Resident #1, he grabbed her hands and bent her fingers. As they continued to care for him, when we rolled him over, he was trying to hit Staff H, CNA. Staff H took the pillow and put it over his arms telling him he was not going to be combative today. Staff G, CNA stated she was trying to explain to him that they were trying to clean him up. Staff G, CNA stated Resident #1 continuing to fight them. Staff H, CNA used the pillow to move the resident's arm out of the way. Staff H told him he was not going to be combative today while holding the pillow on his arms and proceeded to clean the resident up. Resident #1 told them he was not trying to be mean. Staff G stated this was her first time working with Resident # 1, so she was not familiar with his behavior. After Staff H held up the pillow Resident #1 calmed down. Staff G, CNA stated not being sure of what she had just witnessed. Staff G stated she had not seen this happen before with a pillow so she asked another CNA. The other CNA told her they must report the event to the nurse. Staff G stated she did not think she had to report the event to her nurse because she planned on asking the Director of Nurse (DON) when she arrived at work the next morning. Staff G stated the other CNA told her she had to follow chain of command. Staff G stated prior to the event she did not know if what Staff H did was right or not. Staff G stated the other CNA reported the situation to a nurse. O 03/09/2026 at 1:14 PM, an interview was conducted with Staff B, Registered Nurse, (RN)/Nurse Manager. Staff B, RN stated being notified by one of the nurses that Staff H, CNA used a pillow to lean on Resident #1 to prevent him from striking her. Staff B stated he had Staff H, CNA write a statement about what happened. Then Staff H, CNA was told to go to the administrator's office. Staff H, CNA reported that she used a pillow to hold Resident #1 arm down to prevent him from hitting her during care. Staff B stated certified nursing assistants are trained to notify the nurse, step away and reattempt if redirection is not successful when a resident is combative during care. Staff B stated the approach Staff H took was not according to training. On 03/09/2026 at 1:50 PM, an interview was conducted with Staff H, CNA. Staff H stated it was her first time taking care of Resident #1, so she was not aware of his behavior. Staff H stated she did not get a full report from the CNA who had him prior to her taking the assignment. She said she checked his Kardex. Staff H stated she changed Resident #1 at 1:00 AM. When checking on him later in the shift, around 3:00 AM, Resident #1 was covered in feces. Staff H stated she left the room to get Staff G to assist her with changing Resident #1. Staff H stated Resident #1 grabbed Staff G's wrist and was trying to hurt her, while we were trying to change him. Staff H stated that's why she went to get Staff G because when she went to change Resident #1 the first time he grabbed her wrist. This time as soon as he let go of Staff G's wrists, he swung at her with both of his arms, trying to hit her. Staff H stated that's when she took a pillow and leaned her right arm on Resident #1 to keep him from hitting them. She said she asked Resident #1 to stop hitting them. After a few seconds she tried to wipe Resident #1 using her left hand while at the same time using her right arm to hold the pillow against him, so he would not hit her. Staff H stated she held the Resident with the pillow for about 30 seconds. Then Staff G was able to put his pants on, and then she was able to put on his shirt. Then they assisted him to his chair. Staff H stated she did not know that she was not able to use a pillow to stop Resident #1 from hitting them, because she had always used this technique in other states. On 03/09/2026 at 2:25 PM, an interview was conducted with Staff I, CNA. Staff I stated Staff G and Staff H worked with her on the same unit. Staff G told her that she was in the room assisting Staff H with Resident #1. Resident #1 was being combative during care and Staff H took a pillow and to prevent him from hitting them. After they finished changing Resident #1. Staff I stated she told staff G they needed to report the event to the nurse immediately. On 03/09/2026 at 2:44 PM, an interview was conducted with the Nursing Home Administrator (NHA) and DON. The NHA stated the Assistant Director of Nurses (ADON) came to his office to tell him there was an event with a CNA and Resident #1. Based on his investigation when he interviewed Staff H, it was all clear she said that she put a pillow on the resident and she leaned on the pillow to keep him from hitting her. The NHA said they gave Staff H education on how to handle resident with behaviors properly and told her she should have stepped away to get the nurse. The NHA stated staff are provided with dementia education upon hire and annually. Review of the facility policy titled, Dementia Care: Managing Challenging Behaviors, not dated, showed: Section 3: Behavior Problems in People Living with Dementia Behaviors in Dementia. Interventions for Aggression: Agitation and aggression usually happen for a reason. If you can find the cause, you may be able to stop it. Some causes of aggression are: . Being pushed to complete ADLs . These things may lead to aggressive behaviors, such as hitting, biting, angry outbursts, yelling, screaming, and throwing things. You may choose to intervene by: . Reassuring and speaking calmly . Do not use restraints unless safety is an issue and then do so only according to your organization's policy. Always check with your supervisor before using restraints.

Based on interviews and record review, the facility did not ensure a controlled prescribed medication was available for one (#1) out of three residents.Findings included: A record review of Resident #1's admission Record showed an admit date of 02/14/2026 and a discharge date of 03/03/2026 to home. Upon further review, Resident #1 had diagnoses to include but not limited to Parkinsonism unspecified, anxiety disorder unspecified and unspecified dementia unspecified severity, with other behavioral disturbance. A record review of Resident #1's hospital discharge medications include the following but not limited to Clonazepam 0.5 mg (milligram) oral tablet one tablet by mouth daily as needed for anxiety. A record review of Resident #1's physician orders include but not limited to Clonazepam tablet 0.5 mg give one tablet by mouth every 24 hours as needed for anxiousness related to anxiety disorder unspecified for 14 days, ordered 02/14/2026. A record review of Resident #1's MDS (Minimum Data Set) dated 02/21/2026, Section C-Cognition showed a BIMS (Brief Interview for Mental Status) of 09 which indicated the resident had moderate impairment with thinking and memory. In Section I- Active Diagnoses, the MDS showed non-Alzheimer's dementia and anxiety disorder as active diagnoses. A record review of Resident 1's progress notes, dated 02/18/2026 at 16:52 (4:52 p.m.), showed the following entry: New Behavior Noted. Please see POC documentation. No new behavior noted, Staff A, RN/ADON (Registered Nurse/Assistant Director of Nursing). On 03/09/2026 at 1:37 p.m., an interview was conducted with Staff A, RN/ADON regarding progress note entry. Staff A, RN/ADON stated during their daily morning clinical meetings, the dashboard from the electronic medical records will display events from the night before such as orders for labs, new medications, vital signs, and many more. Staff A, RN/ADON stated the dashboard alert was initiated from a Certified Nursing Assistant (CNA) note dated 02/17/2026 at 02:00 a.m., in which Resident #1 was noted as agitated and hitting others. When asked what others meant, Staff A, RN/ADON stated staff members. Staff A, RN/ADON stated a follow-up would be warranted from the clinical team. Staff A stated they would talk to the CNAs and ask if there were any behaviors. Staff A stated the physician, maybe psych services would be notified and/or consulted if there were continued behaviors. Staff A stated the CNAs during the day shift were interviewed and the resident had no agitated/combative behaviors. A record review of Resident #1's progress notes, dated 02/20/2026 at 03:33 a.m. showed the following entry: Patient combative with cares [SIC] tonight. BM [bowl movement] smeared all over himself and bed. Does have an order for Clonazepam 0.5 mg prn but no script. Pharmacy called, awaiting call back [primary physician] made aware, entered by Staff F, RN. On 03/09/2026 at 2:25 p.m., a telephone interview was conducted with the facility's contracted pharmaceutical services. A pharmacist on staff for the pharmacy stated an electronic prescription for Clonazepam 0.5 mg to dispense 10 tablets was received on 02/20/2026 and the facility received the tablets on 02/21/2026. The pharmacist stated there were no earlier prescriptions for Clonazepam received/faxed/called to the pharmacy before 02/20/2026. A record review of the psychiatric advance nurse practitioner (ARNP) with a date of service of 02/20/2026 showed the following: Reason for referral/chief complaint: Dementia inappropriate behavior, resistive to receive care and/or treatment. History of present illness: Resident #1 presents being followed for psychotropic medication management. He has been struggling with resisting ADL (activities of daily living) care at HS (at night). He presents alert in NAD (no abnormality detected). He has no recollection of last night other than not wanting to be changed. A medication intervention may help to comfort him. Treatment plan- continue klonopin 0.5 mg po (oral) q (every) 24 hours PRN (as needed) x (for) 14 days as currently prescribed. On 3/09/2026 at 2:47 p.m., a telephone interview was conducted with Resident #1's psychiatric ARNP. The ARNP stated she had a telehealth visit with the resident on 02/20/2026 with a follow-up visit on 02/27/2026. The psych ARNP stated the resident may have benefited from the Clonazepam but overall stated, he did not like to be changed. The psych ARNP stated she ordered the Clonazepam on 02/21/2026. The ARNP stated she believes the discharging hospital would send the prescription over with the resident upon discharge but ultimately the facility should follow up with the orders. The ARNP stated the facility should try non- medicated interventions as well to calm the resident. On 3/09/2026 at 5:20 p.m., an interview was conducted with Staff B, RN/Nurse Manager of A wing and Staff C, LPN (Licensed Practical Nurse)/Staff Manager C wing. Both staff members stated, when a prescription for a controlled substance arrives with for a new admit or readmit, they would fax the prescription to the pharmacy, call the pharmacy to confirm the prescription was received and package up the prescriptions to be delivered to the pharmacy via the delivery representative upon arrival to the facility. Both Staff B, RN and Staff C, LPN stated they do not make a copy of the original prescription or the confirmation fax receipt in the resident's medical record. On 3/09/2026 at 5:26 p.m., an interview was conducted with Staff D, RN/weekend supervisor. Staff D, RN stated her normal process for new admits/readmits would be to fax controlled prescription(s) to the pharmacy, confirm pharmacy had received the fax and would make a copy of the resident's face sheet, prescription and confirmed fax receipt and place behind the physician orders in the hard chart. Staff D, RN reviewed Resident #1's medical record documents. Staff D, RN recalled signing the basic care plan with the resident's family member and showed the document for observation. However, Staff D, RN could not show a copy of the hard script (prescription) or a copy of the confirmed fax to pharmacy. Staff D, RN stated during morning clinical meetings, all new admits and readmits are screened for a secondary chart check by utilization of a clinical admission check list. On 3/09/2026 at 6:09 p.m., an interview was conducted with Staff E, RN. Staff E, RN confirmed she was assigned to the admission of Resident #1. Staff E, RN stated her normal process would be to fax the script over to the pharmacy, wait 30-45 minutes, call the pharmacy to verify confirmation script was received, the hard copy would be provided to the pharmacy delivery representative and put a copy of the script in the resident's chart. Staff E, RN stated if a prescription was not provided by the discharging hospital, she would contact the admitting physician a prescription would be needed. Staff E, RN stated the physician can send a prescription over via e-script. From there, Staff E, RN stated she would call the pharmacy to confirm the prescription was received and could get an authorization to pull the medication, if available, from their [electronic medication dispensing machine]. On 3/09/2026 at 4:16 p.m., an interview was conducted with Resident #1's primary attending physician (MD). The MD stated with Resident #1's behavior during the time of the event (02/20/2026), may not have benefitted from administering Clonazepam. The MD stated the resident may not have been receptive to taking an oral medication at the moment the behavior was present. The MD does not recall receiving a call from pharmacy regarding this medication of Clonazepam. The MD stated he would not hesitate to prescribe a controlled medication or any medication if needed. The MD stated he does not know why the medication was not available. The MD stated the nurses would contact him if a prescription was needed. The MD stated for Resident #1 he could not state what happened but added it would be a matter of minutes for him to place the prescription. A record review of the discharging hospital's history and physical showed a list of Resident #1's home medications with Clonazepam 0.5 mg one tablet as needed for anxiety listed. On 3/09/2026 at 3:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated when a new admit, the hospital may send the hard prescription for a controlled substance or if not, the nurses should contact the admitting physician to inform if a prescription would be needed. The DON stated the Clonazepam was appropriately reconciled by evidence of the medication in the Medication Administration Record and would contact the pharmacy to verify when the prescription was received. The DON returned to state the pharmacy had not originally received the prescription/order for Clonazepam. A record review of the Resident #1's progress notes showed the following: Resident discharged home today with family at side. All belongings and copy of discharge forms (including upcoming appt on Thursday) provided to resident. Signed discharge forms placed in resident's chart. Medication was also provided to resident along with the PRN Klonopin. Staff B, RN The facility provided a policy titled, Controlled Substances revised December 2012 which showed the following policy statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of scheduled II and other controlled substances.

Based on observations, interviews, and record review the facility failed to ensure food service equipment was maintained in a safe operating condition in two of two kitchen freezers. Findings included: On 7/15/24 at 9:44 a.m. a kitchen tour was conducted with the Director of Dining Services and the Assistant Director of Dining Services/Certified Dietary Manager (CDM). At 9:54 a.m. an observation of the large walk-in freezer revealed ice build-up on the floor upon walking in. Further observation of the large walk-in freezer revealed ice build-up and condensation throughout the freezer to include on top of racks and boxes of food items. The large walk-in freezer revealed icicles and ice build-up on the ceiling and floor. Observations of the back of the large walk-in freezer, by the blower unit, revealed icicles and ice build-up. The Director of Dining Services stated there were work orders for the large walk-in freezer and small walk-in freezer, which is inside the refrigerator. He stated the door handle of the large walk-in freezer was not working properly and does not close all the way. He stated this allows air into the freezer contributing to the ice build-up. An observation of the door revealed it did not seal and close all the way. At 9:56 a.m. an observation of the small walk-in freezer, inside the refrigerator, revealed ice build-up on the right corner of the blowing unit, as well as on the top of the rack next to the blower unit. An observation of the rack next to the blower unit revealed a small ice mound. On 7/15/24, after the kitchen tour, the CDM provided three work orders. A review of the work order for the small walk-in freezer, created on 6/27/24 by the CDM, revealed the request was completed by Staff L, Maintenance. A review of the second work order for the small walk-in freezer, created on 7/7/24 by the CDM, revealed the request was completed by the Nursing Home Administrator (NHA). A review of the work order for the large walk-in freezer, created on 7/6/24, revealed the request was completed by the Maintenance Director on 7/10/24. On 7/16/24 at 10:09 a.m. an interview with the Sous-chef regarding the work orders revealed he was told last week, by the Maintenance Director and Staff K, Maintenance, the small walk-in freezer was fixed. A second observation, with the Sous-chef present, of the small walk-in freezer revealed ice build-up on the right corner of the blower unit and a small ice mound on top of the rack next to the blower unit. The Sous-chef stated he would follow up with maintenance. A second observation of the large walk-in freezer revealed ice build-up on the floor upon walking in. Further observation of the large walk-in freezer revealed ice build-up and condensation throughout the freezer to include on top of racks and boxes of food items. The large walk-in freezer revealed icicles and ice build-up on the ceiling and floor. Observations of the back of the large walk-in freezer, by the blower unit, revealed icicles and ice build-up. On 7/16/24 at 2:45 p.m. an interview was conducted with the CDM. A review of the work order for the small walk-in freezer created on 6/27/24 by the CDM revealed the request was completed by Staff L, Maintenance. The CDM stated Staff L scraped the ice build-up away and applied sealant to the gaps leaking air. He stated he created another work order on 7/7/24 due to air leaking from the ceiling panel still occurring. A review of the second work order for the small walk-in freezer, created on 7/7/24 by the CDM, revealed the request was completed by the NHA. He stated the NHA closed the order by mistake. A review of the work order for the large walk-in freezer, created on 7/6/24, revealed the request was completed by the Maintenance Director on 7/10/24. For the large walk-in freezer, the CDM provided an approved estimate proposal dated 7/10/24 from [Vendor name]. The CDM stated the proposal was approved, however, the vendor was waiting for parts. At the time of the interview, he did not have documentation of the communication from the vendor regarding the delay of parts. On 7/17/24 at 12:57 p.m. an interview with the CDM revealed he did not follow-up with the vendor until today regarding the parts for the large walk-in freezer. He provided evidence of communication with the vendor, dated 7/17/24 at 9:48 a.m., to include, The needed parts will arrive within 7 days. An ETA [estimated time of arrival] will be set when they come in . For the small walk-in freezer the CDM provided evidence of communication from the vendor to include, Your technician will arrive between [DATE]:00PM and [DATE]:00PM . He stated this was a text message sent today from the vendor. A review of a service request from the vendor for the small walk-in freezer, created by Staff K, revealed a created date of 7/17/24. A review of the facility Food and Beverage Clinical Services policy titled, Equipment Maintenance, revealed under policy, It is the policy of the community to maintain equipment according to manufacturer's directions. Further review of the policy revealed under procedure, 1. All food service equipment will be operated, maintained, serviced, and cleaned according to manufacturer's directions.

Based on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate for four Residents (#1, #6, #30, #24) out of 9 residents sampled for PASRR review. Findings included: 1. Review of the medical record for Resident #1 showed an admission to facility on 07/20/23 with diagnoses including unspecified dementia moderate with mood disturbance, dissociative and conversion disorder, major depressive disorder, and panic disorder. Review of the PASRR, dated 6/14/2023, showed on page two panic disorder not marked on section A. Mental Illness or suspected mental illness. Page 5 marked no diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation required. The box on page showed A level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an Serious Mental Illness, Intellectual Disability, or both. A Level II PASRR may only be terminated by the Level II PASRR evaluator in accordance with 42 CFR [Code of Federal Regulation] 483.128(m) (2) (i) or 42 CFR 483.128 (m) (2) (ii). Resident with a primary diagnosis of dementia and secondary diagnoses including major depressive disorder, panic disorder and dissociative and conversion disorder with no Level II PASRR. Review of physician orders revealed: - Ativan oral tablet 0.5 tablet by mouth every 6 hours as needed for anxiety. - Duloxentine Hydrochloride capsule delayed release particles 20 mg (milligrams) by mouth one time a day for depression related to major depressive disorder. - Levetiracetam oral tablet 250 mg by mouth four times a day related to unspecified dementia moderate with mood disturbance, dissociative and conversion disorder. A review of the Minimum Date Set (MDS), dated [DATE], revealed: - Section C: Cognitive Patterns: showed a Brief Interview for Mental Status (BIMS) score of 12 indicating no cognitive impairment. - Section I: Diagnoses marked included non-Alzheimers Dementia, anxiety, depression, dissociative and conversion disorder. - Section N: Medications marked yes for antianxiety, antidepressant. A review of the care plan, dated 04/26/24, revealed: - A focus Has impaired cognitive function/dementia or impaired thought processes. Interventions included Collaborate with hospice as needed. - A focus Uses psychotropic medications. She receives antidepressant medication for depression, anxiolytic for anxiety and hypnotic for sleep. Intervention included administer medications as ordered, and monitor/document for side effects and effectiveness. 2. Review of medical record for Resident #6 showed an admission to facility on 09/20/23 with diagnoses including unspecified dementia, mood disorder due to known physiological condition with depressive features, bipolar disorder II, anxiety disorder, major depressive disorder. A review of Pre-Admission Screening and Resident Review (PASRR), dated 09/23/23, showed no mental illness or suspected mental illness marked on page two section A, all boxes were left blank. Review of the physician orders revealed: - Paroxetine Hydrochloride oral tablet 20 mg, 1 tablet by mouth one time a day related to major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], revealed: - Section I Diagnoses included anxiety, depression, bipolar, and non-Alzheimer's dementia. - Section C a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. - Section N marked yes for antidepressant. Review of the care plan, dated 04/29/24, revealed: - A focus of Received antidepressant or dx of depression. Past attempt at GDR [gradual dose reduction] unsuccessful date initiated 12/08/22, revision on 03/28/23. Interventions including Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 12/08/2020. - A focus of Has depression related to disease process major depressive disorder. date initiated on 10/08/2020, revised on 12/17/2020. 3. Review of Resident #30's medical record showed an admission to facility on 07/28/17 with diagnoses including major depressive disorder, schizoaffective disorder bipolar type, vascular dementia mild with mood disturbance, and generalized anxiety disorder. Review of the physician orders revealed: - Quetiapine Fumarate oral tablet 25 mg. Give 12.5 mg by mouth at bedtime for schizoaffective disorder, bipolar type paranoia, mania symptoms, for failed dose decrease attempt. Review of the MDS, dated [DATE] revealed: - Section C Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impairment. - Section I diagnoses marked yes for anxiety disorder, depression, schizophrenia, and non-Alzheimer's dementia. - Section N marked yes for antipsychotics. Review of the care plan, dated 03/21/24, revealed: - A focus of Experiencing changes in psychosocial well-being, related to her diagnosis of schizoaffective disorder, bipolar type, psychosis. Date initiated 04/29/20, revision on 06/22/23. Interventions including clinical monitoring guidelines in the MAR to be filled out daily by nursing. - A focus of Potential to demonstrate physical behaviors related to dementia. Date initiated 10/12/20, revised on 03/22/23. Interventions including Assess and anticipate resident needs for food, thirst, toileting needs, comfort Review of PASRR, dated 07/25/17, showed no boxes marked on page 2 section A question MI [mental illness] or suspected MI. Section II on page 4, question #6 Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is an SMI or ID marked No. Question #7 Does the individual have validating documentation to support dementia or related neurocognitive disorder (including Alzheimer's disease marked Yes. The outlined box on page 4 reveals Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an SMI, ID, or both. A level II PASRR may only be terminated by the Level II PASRR evaluator in accordance with 42 CFR 483.128 (m)(2) (i) or 42 CFR 483.128(m) (2)(ii). No level II PASRR completed. 48223 4. Review of the Admission Record showed Resident #24 was admitted on [DATE] and readmitted on [DATE] with diagnoses of cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery; major depressive disorder recurrent severe with psychotic symptoms; Bipolar disorder, unspecified dementia, mood disorder due to known physiological condition; anxiety disorder, and other comorbidities. Review of Resident #24's PASRR Level I Assessment, dated 5/17/2021, did not reveal a qualifying mental health diagnosis marked in section I A. nor was the diagnosis of Dementia. A level II PASRR was not completed. An interview was conducted with the Social Service Coordinator (SSC) on 7/18/2024 at 11:47 AM. The SSC stated the Director of Social Services (SSD) completes PASRR's, and the SSD was out of the facility but was able to be reached by telephone. The SSC then proceeded to call the SSD. The SSD stated the Assistant Director of Nursing (ADON) reviews the PASRR upon resident admission, the ADON will bring PASRR to the Interdisciplinary Team (IDT) meeting if any questions arise after review. A determination is made if the PASRR needs correction. She stated the ADON will initiate the Level II PASRR if it is warranted. An interview was conducted with the ADON on 11/18/2024 at 11:58 AM. The ADON stated on admission she completes a chart review for history, medications, diagnoses, and PASRR. She stated a review of the PASRR is done ensuring the marked diagnoses match the diagnosis list and a resident warrants an updated PASRR if a diagnosis is not identified at the hospital when admitted to the facility. She stated in addition to new residents the order listing report is completed for all residents each morning to see if a new antipsychotic or antidepressant, etc was added. She stated if any are added then a review of the resident's PASRR is completed to determine if an updated PASRR is needed. The ADON stated the facility does not have a process in place to alert the staff when new diagnoses are added to a resident chart unless they receive new orders. The ADON reviewed Residents: #1, #6, #24 and #30 and confirmed 4 of 4 residents have a primary or secondary diagnoses of dementia and/or Alzheimer's, along with a mental illness or suspected mental illness that was marked yes on their PASRR's page 2 and none of the residents had Level II PASRR completed. The ADON stated, I should have put the Dementia or Alzheimer under question #7 on page 4 other, this would have prompted an update of the Level I and indicated a Level II PASRR be completed. Review of the facility's policies and procedures titled Admission Criteria, dated revised March 2019, revealed the following: Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation: . 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per Medicaid Pre-Admission Screening and Resident Review (PASRR) process. a. The facility conducts a level 1 PASRR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD. b. If the level one screen indicates that the individual may meet the criteria for AMD, ID, or RD., he or she is referred to the state PASRR representative for the level 2 (evaluation and determination) screening process. (1) The admitting nurse notifies the social services department when a resident is identified as having a possible (or event) MD, ID or RD. (2) The social worker is responsible for making referrals to the appropriate state designated authority. 3 c. Upon completion of the level 2 evaluation, the state PASRR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility appropriate. d. The state PASRR representative provides a copy of the report to the facility. e. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the resident that are outlined in the evaluation. f brought back. Once the decision is made, the state PASRR representative, the potential resident and his or her representative are notified.

Based on observations, interviews, and record review, the facility failed to ensure hand hygiene was offered prior to meals to residents in the dining room during one (7/15/24) of one meal observations. Findings included: On 7/15/24 at 11:51 a.m. observations of the main dining room during the lunch meal revealed no hand hygiene was offered to residents prior to eating. There were sixteen resident in the dining room at the time of the observation. Residents were observed sitting down at their table of choice. Staff were observed assisting residents with positioning at the table. Staff were observed providing beverages and condiments to residents. At 12:29 p.m. staff started to provide each resident with their lunch meal. Observations of the main dining room from 11:51 a.m. to 12:40 p.m. revealed no hand hygiene was offered to the residents by the staff. On 7/18/24 at 9:48 a.m. an interview with Staff G, Certified Nursing Assistant (CNA) was conducted. She stated she typically assists in the dining area. She stated she provides hand hygiene when giving residents a bed bath, before they go in their wheelchair, and when they go to the bathroom. Staff G stated residents are offered hand sanitizer or assistance with washing their hands before meals. On 7/18/24 at 9:57 a.m. Staff I, CNA stated he washes resident's hands with a washcloth before they eat. He stated he typically assists residents who dine in their rooms. Staff I stated he doesn't know if staff provide hand hygiene to residents in the dining area. On 7/18/24 at 10:07 a.m. Staff H, Restorative Aide, stated she typically assists in the dining area. She stated staff offer [Vendor Name] wipes to resident's before and after they eat. Staff H stated staff assist residents with sitting at the table, obtaining their requests from the dining menu, and giving them beverages. She stated after providing the residents their beverages, is when staff provide the Sani-Hands wipes. An interview conducted on 07/18/24 at 10:31 a.m. with Resident #11 revealed she eats breakfast, lunch and dinner in the dining room. She stated she was not offered hand hygiene by staff prior to eating her breakfast this morning. She stated staff offer hand hygiene prior to meals, Once in a while. Resident #11 stated yesterday, on 7/17/24, she was provided hand hygiene by staff for one of three meals. She stated the staff gave her a wipe to clean her hands. During an interview on 7/18/2024 at 10:34 a.m. the Infection Preventionist (IP) stated it is an expectation hand hygiene is provided to residents before meals. The IP stated staff have received education on completing hand hygiene for the residents prior to meals. She stated hand hygiene was discussed during the facilities recent mock survey. The IP stated the facility has ordered hand Sani-Wipes to provide to residents prior to meals. She stated she doesn't think the CNAs are providing hand hygiene to residents. On 7/18/24 at 10:47 a.m. an interview with Resident #33 was conducted. The resident stated meals were eaten in the dining room, stated staff do not ask him if he wants to wash his hands before he eats. He stated, You have to be careful with germs in here. On 7/18/24 at 10:56 a.m. an interview with Resident #235, who typically eats meals in the dining room, the resident stated staff do not ask him about washing his hands before he eats. He stated, No one has offered me wet naps. A review of the facility's policy titled, Handwashing/Hand Hygiene, revised August 2019, includes the following policy statement: This facility considers hand hygiene the primary means to prevent the spread of infection. The Policy Interpretation and Implementation includes the following: .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . o. Before and after eating or handling food; .

Based on observations, interviews, and record reviews the facility failed to ensure privacy of personal health information on three medication carts (Wing A and Wing C) out of four medication carts observed. Findings included: On 7/17/24 at 11:09 a.m. the facility's nursing shift report form was observed unattended on top of one of two medication carts on the Wing A hallway. The cart was assigned to Staff E, Registered Nurse (RN). (Photographic Evidence Obtained). On 7/17/24 at 11:10 a.m. the facility's nursing shift report form was observed unattended on top of one of two medications carts in the Wing C hallway. The cart was assigned to Staff J, Licensed Practical Nurse (LPN). On 7/18/24 at 11:19 a.m. the facility's nursing shift report form was observed unattended on top of the second medication cart in the Wing C hallway. The cart was assigned to Staff J, LPN (Photographic Evidence Obtained). The facility's nursing shift report form observed unattended on the three medication carts contained the following resident personal health information (PHI): -Room number -Date and shift skin check is scheduled -Resident's name -Mobility device -Blood sugar checks -Additional information such as type of diet, oxygen use, urinary catheter, etc., On 7/17/24 at 4:33 p.m. an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated nursing staff are expected to cover up or turn over their nursing report form to prevent disclosure protected health information. A review of the facilities policy titled, HIPAA Privacy and Security Safeguarding and Storing Protected Health Information, effective 8/1/2020, revealed the following: Purpose: To provide guidelines for safeguarding of protected health information . Policy: The policy of this community is to ensure, to the extent possible, that Protected Health Information (PHI) is not intentionally or unintentionally use or disclose in a manner that would violate the HIPAA privacy rule Safeguards for written PHI 1. Documents containing PHI should be stored appropriately to reduce the potential for incidental use or disclosure. Documents should not be easily accessible to any unauthorized staff or visitors .

Based on interviews, and record review, the facility failed to report an alleged violation of abuse/neglect within the required timeframe, related to elopement for two residents (#43 and #281) out of the four residents sampled. Findings included: 1. Review of the Admission Record showed Resident #43 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including atrial fibrillation, hypertension, unspecified dementia, and other co-morbidities. A review of Section C: Cognitive Patterns on the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #43 had a Brief Interview Status (BIMS) score of 00 out of 15, indicating severely impaired cognition. Section G: Functional Status revealed Resident #43 needed the following assistance for activities of daily living: bed mobility, dressing, toilet use, and personal hygiene- being dependent; transfers- dependent; eating - supervision. A review of Resident #43's admission nursing evaluation showed the resident was not at risk for elopement. A review of a Progress Notes, dated 10/29/2023 at 2:20 PM, revealed the writer was alerted Resident #43 was in the parking lot. The nurse completed an evaluation, and the resident had no new concerns noted. The nurse completed an Elopement Risk Evaluation and determined Resident #43 was now at risk for elopement. The nurse contacted the physician and received new orders for urinalysis culture, sensitivity, and electronic monitoring device placement. All orders were carried out and the resident's care plan was updated as needed. 2. A review of the Admission Record showed Resident #281 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure with hypertensive heart disease, prostate cancer, atrial fibrillation, hypertension, Parkinson's disease, dementia, and other co-morbidities. A review of Section C: Cognitive Patterns of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #281 had a Brief Interview Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. Section G: Functional Status revealed Resident #281 needed the following assistance for activities of daily living: toileting - substantial/maximal assistance; bed mobility, dressing, transfers, and personal hygiene- being partial/moderate assistance; walking - dependent; eating - supervision. A review of Resident #281's admission nursing evaluation showed the resident was not at risk for elopement. Review of a Progress Note, dated 2/15/2024 at 3:45 PM, revealed the writer was alerted Resident #281 was in the parking lot. The nurse completed an evaluation, and the resident had no new concerns noted. The nurse completed an Elopement Risk Evaluation and determined Resident #281 was now at risk for elopement. The nurse contacted the physician and received new orders for an electronic monitoring device. All orders were carried out and the resident's care plan updated as needed. During an interview on 7/17/2024 at 10:25 AM the Nursing Home Administrator (NHA) and the Director of Nursing (DON) reviewed the elopement event of Resident #43 and Resident #281. The NHA stated elopements are not considered abuse or neglect therefore they are not reportable events for Day 1 and Day 5 abuse and neglect reporting. The facility submitted an Adverse Incident Form on 11/10/2023 for Resident #43, and 2/29/24 for Resident #281. Review of the facility's Policy and Procedures titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated revised September 2022, revealed the following: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation. Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, and misappropriation of resident property or injury of unknown sources suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The residents representative; d. Adult Protective Services(where state law provides jurisdiction and long term care); e. Law enforcement officials; f. The residents attending physician; g. The facilities medical director. 3. Immediately is defined as: a. Within two hours of an allegation involving abuse or results in serious bodily injury; Or b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. . Follow-Up Report: 1. Within five business days of the incident, the the chair will provide a follow-up investigation report. 2. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective action taken if the allegation was verified. 3. The follow up investigation report will provide as much information as possible at the time of submission of the report. 4. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation. Review of the facility's policies and procedures titled Abuse and Neglect - Clinical Protocols dated revised March 2018 revealed the following: Definitions - . 2. Neglect as defined at S483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on observations, interviews, and record review, the facility failed to provide nursing care according to standards related to properly dating skin care dressings one resident (#59) out of eight residents sampled. Findings included: Review of the Admission Record revealed Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include metabolic encephalopathy, Rhabdomyolysis (skeletal muscle breaks down rapidly), history of falls and other co-morbidities. On 7/15/2024 at 10:58 AM, Resident #59 was observed and interviewed lying in the bed. Resident #59's feet were at the foot board of the bed with undated dressings. (Photographic Evidence was Obtained). The resident stated the dressings had not been changed for a couple of days. On 7/16/2024 at 11:31 AM, Resident #59 was observed and interviewed. Resident #59's feet were at the foot board of the bed with undated dressings. The Resident stated the dressing had been changed. A review of Resident #59's active Physician Order Summary Report, dated 6/27/2024, showed: Right inner Foot and side of 1st toe: Clean with normal saline/wound cleaner. Pat dry and skin prep peri wound. Cover open area with Xeroform and secure with Allevyn/CDD. If resident has fragile skin, secure with kerlix roll gauze and stretch net, as needed for replacement if soiled or dislodged, and every Monday, Wednesday, and Friday for wound care. A review of the Treatment Administration Record (TAR), for July 2024, revealed treatment was provided on 7/12/2024 and 7/15/2024. During an interview on 7/17/2024 at 1:39 PM Staff M, Licensed Practical Nurse (LPN) stated nursing was responsible for wound care with residents when ordered. Staff M, LPN stated if a resident is seen with a dressing not dated, then the dressing needs to be changed according to the physician orders and dated, The stated the event would be reported to the Unit Manager or Director of Nursing (DON). During an interview on 7/18/2024 at 11:20 AM the DON stated when dressings/treatments are completed the nurses are expected to date and initial the treatment. The DON reviewed Resident #59's foot treatments and stated the dressing/treatment should have been dated. A review of the facility's policies and procedures titled Wound Care, revised October 2010, revealed the following: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: . 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. Be certain all clean items are on clean field. A review of the facility's policies and procedures titled Dressings, Dry/Clean, revised September 2013, revealed the following: . Steps in the Procedure: 10. Label tape or dressing with date, time and initials. Place on clean field. 17. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty eight medication administration opportunities were observed, and three errors were identified for three residents (#23, #29 and #39) out of five residents observed. These errors constituted a 10.71% medication error rate. Findings included: On 7/17/24 at 8:04 a.m. a medication administration observation was conducted with Staff D, Registered Nurse, (RN), for Resident #21. Staff D, RN administered the following medications: -Amlodipine 5 mg (milligrams) for high blood pressure. -Abilify 5 mg for depression. - Plavix 75 mg for clot prevention. - Vitamin D 1000 units, 2 tablets for vitamin supplement. - Colace 100 mg to prevent constipation -Cymbalta 25 mg for depression - Loratadine 10 mg for allergy relief. - Senokot 2 tablets for constipation. - Multiple Vitamins with minerals 1 tablet for wound healing. - Metoprolol Succinate Extended Release 50 mg for high blood pressure -Potassium Chloride Extended Release 20 MEQ (milliequivalent) for hypokalemia [low potassium]. - Montelukast Sodium (Singular)10 mg for chronic obstructive pulmonary disease (COPD). - Spironolactone 12.5 mg for high blood pressure. Review of Resident #21's June Medication Administration Record (MAR) showed Staff D, RN, administered medications as ordered. On 7/17/24 at 9:00 a.m. a medication administration observation was conducted with Staff E, RN for Resident #29. Staff E, RN obtained Resident #29's vital signs and administered the following medications: -Hydrochlorothiazide 25 mg for high blood pressure. - Metformin 500 mg for diabetes mellitus type 2. -Potassium Chloride extended release 20 milliequivalent (meq.) for supplement. -Sertraline HCl 25 mg (1/2 tablet) for depression. -Aspirin Tablet Delayed Release 81 mg for clot prevention. -Calcium Carbonate 600 mg for supplement. -Polysaccharide Iron Complex 1 capsule for anemia. -Vitamin B12 100 micrograms (mcg) for vitamin B12 deficiency. -Vitamin D25 (Cholecalciferol) 1000 units for Vitamin D deficiency. - Med Pass 2.0 supplement drink 60 milliliters (mils) Review of Resident #29's June MAR showed Vitamin D25 (Cholecalciferol) 3000 units was ordered. Staff E, RN administered Vitamin D25 (Cholecalciferol) 1000 units (Photographic Evidence Obtained). The nine additional medications was administered as ordered. On 7/17/24 at 9:11 a.m. medication administration observation was conducted with Staff E, RN, for Resident #234. Staff E, RN administered the following medications: -Escitalopram Oxalate 10 mg, 0.5 tablet by mouth for Depression. -Glucerna Shake 237 mls (milliliters) for supplement. Review of Resident #234's June MAR showed Staff E, RN administered medications as ordered. During an interview on 7/18/24 at 8:38 a.m. the Assistant Director of Nursing (ADON) said she expects the nursing staff to administer medications one hour before and up to one hour after the scheduled time. On 7/17/24 at 9:22 a.m. Resident #23's MAR was highlighted red Staff E, RN confirmed Ascorbic Acid (vitamin c) 250 mg was scheduled to be given at 8:00 a.m., had not been administered and would be given late. On 7/17/24 at 5:30 p.m. Resident #23's June MAR showed an order for ascorbic acid 250 mg one time a day with breakfast. Staff E, RN initialed the MAR showing the medication was administered on time. On 7/17/24 at 9:23 a.m. Resident #39's MAR was highlighted red Staff E, RN confirmed Metformin Hydrochloride (HCL) 500 mg was scheduled to be given at 8:00 a.m., had not yet been administered and would be given late. On 7/17/24 at 5:23 p.m. Resident #39's June MAR showed an order for Metformin HCL 500 mg for diabetes each morning with breakfast. Staff E, RN had initialed the MAR showing the medication was administered on time. Review of the facility's Administering Medications, revised April 2019, showed the following: Policy: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber's orders, including required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. .7. Medications are administered within one (1) hour of their prescribed time. .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time before giving the medication. .21 If a drug is .given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .

Based on observations, interviews, and record review, the facility failed to store medications safely and securely for one resident (#22) of thirty-two residents sampled. Findings included: An observation and interview with Resident #22 on 07/15/2024 at 11:28 AM revealed unsecured medications on Resident #22's bedside furniture including Tylenol, nasal spray and medicated powder. He said he takes Tylenol once in a while, he only takes a couple, no more than two and he lets the nurse know when he takes them. A review of Resident # 22's most recent Quarterly Minimum Data Set (MDS), with a date of 05/28/2024, revealed in section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. A review of Resident # 22's July 2024 physician orders revealed an order with a start date of 03/07/2024 and no end date for Acetaminophen 325 mg [milligram], Give two tablets by mouth every 4 hours as needed for mild pain NTE [not to exceed] 3 GMS [grams] 24hr [hour]. There was no order for self-administration of medications for Resident #22. A review of Resident #22's active care plans revealed no care plan indicating self-administration of medication was in place. An interview was conducted with Staff C, Licensed Practical Nurse, (LPN) on 07/18/2024 at 11:05 AM. She said if she found medications at the bedside, she would take the medications and tell the resident they are not allowed to have them. She would report it to a supervisor. An interview was conducted with the Director of Nursing (DON) on 07/18/2024 at 11:30 AM. She said the expectations for medications found at the bedside would be to get a lock box to store the medications in. She said the nurses would normally report it to her. She said if the patient were to self-administer, they would do an assessment and try to encourage the patient to give the medications to the nurse to be stored on the medication cart. A review of policy titled Self-Administration of Medications, dated February 2021, revealed the following: Policy: Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. The facility reorders self-administered medications in the same manner as other medications. A review of policy titled Storage of Medications, dated April 2007, revealed the following: Policy: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals and shall be locked when not in use .

Based on interviews and record review, the facility failed to ensure laboratory results were reported to the provider, and/or physician orders were followed up on for two residents (#333 and #336) out of three sampled for reporting laboratory test results. Findings include: 1. During an observation on 7/15/2024 at 11:00 a.m., Resident #333 was observed lying down in bed with his call light within reach. The resident was well-groomed with no signs of distress. A review of the medical record showed Resident #333 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including urinary tract infection, depression, unspecified, and chronic kidney disease, stage 3 B. Review of the Minimum Data Set (MDS), dated [DATE], showed the resident had a Brief Interview Mental Status (BIMS) score of 15, which indicated cognitively intact. Review of the medical record showed abnormal laboratory results for a CBC (completed blood count) and urinalysis were reported electronically to the facility on [DATE]. The medical record revealed the staff did not review the lab report, and the abnormal results had not been reported to the physician for review. 2. During an observation on 7/15/2024 at 11:20 a.m. Resident #336 was observed lying down on his bed, dressed well-groomed with no signs of distress. Review of the medical record showed Resident #336 was originally admitted to the facility on [DATE] with diagnoses to including chronic kidney disease, stage 3 A, Type 2 Diabetes Mellitus without Complications, and Depression. Review of the Minimum Data Set, dated dated [DATE], showed the resident had a Brief Interview Mental Status (BIMS) score of 15, which indicated cognitively intact. Review of the medical record showed abnormal laboratory results for a CBC were reported electronically to the facility on [DATE]. The medical record revealed the staff did not review the lab report and report the abnormal results to the physician for review. During an interview on 07/17/24 at 09:36 a.m., with the Assisted Director of Nurse, (ADON), she stated on admission a Complete Blood Count (CBC) and Complete Metabolic Panel (CMP) laboratory tests are ordered for each resident. Laboratory test orders are placed in the computer by the nursing staff. She stated the order is a reminder for the night shift nurse to complete the laboratory requisition form. The completed requisitions are placed in the laboratory binder used by the phlebotomist to identify residents with test orders. She stated laboratory tests results are available the following day unless the results are critical. For residents with critical lab values the laboratory staff calls the facility and notifies the nursing staff. For non-critical laboratory results the Physician Assistant (PA) reviews 80% of the test results daily. She stated for results not addressed by the PA the nursing staff notifies the resident's physician of the test results. The ADON confirmed on 7/13/2024 Resident #336's CBC results were not reviewed by the nursing staff and the staff had not notified the physician, and on 7/10/2024 Resident #333's CBC and urinalysis tests results were not reviewed by the nursing staff and the staff had not notified the physician. The ADON stated the facility has a new doctor who has remote access and the doctor may have reviewed the resident lab results and not document the test results were reviewed. She stated the facility's process for reporting laboratory test results is for the nurse to notify the doctor when the lab results are received. A review of the facility policy titled, Lab and Diagnostic Test Results- Clinical Protocol, revised November 2018, revealed the following: Option for Physician Notification: a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab result report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, etc. b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment needs review or clarification.

Based on record review and interviews, the facility failed to develop and implement a care plan to provide the level of assistance needed for one (#1) of three residents sampled for accidents. Resident #1 was assisted by one staff member with bed mobility during incontinence care resulting in a fall from the bed requiring a transfer to a higher level of care where she received treatment for her injuries of a nose fracture. Findings included: Review of Resident #1's admission record revealed an original admitted in 2017 and a most recent re-admitted [DATE] with diagnoses to include fracture of nasal bones, subsequent encounter for fracture with routine healing, fall from bed, muscle weakness, unspecified lack of coordination, and spinal stenosis of the lumbar region without neurogenic claudication. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/05/22, indicated Resident #1 needed extensive assistance with bed mobility requiring two person physical assistance with moving to and from a lying position, turning side to side, and positioning body while in bed. Review of Resident #1's care plan revealed a focus area first initiated on 07/25/17, and revised on 08/07/19 indicating resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) ADL and mobility/balance deficits, weakness, cognitive impairment. The goal dated 08/08/17 and revised on 08/04/22 revealed Resident #1 will maintain current level of function . The interventions included requires assistance to turn and reposition in bed and requires staff assistance with incontinence care as needed with an initiated and revision date of 06/29/22. The care plan did not include person centered information to show the level of assistance needed to safely care for the resident to maintain the resident's highest practicable physical well-being. Review of Resident #1 Kardex Report dated 06/20/22 revealed the resident required staff assistance to provide incontinence care as needed and required assistance to turn and reposition in bed. The Kardex did not indicate the level of assistance the resident required such as supervision, one person physical assistance, or two person physical assistance. Review of a progress note dated 06/21/22 at 7:21 a.m. revealed: Resident had a fall at 6:15 am. Assessment was done and skin tear on bridge of nose and cut above head was found. Resident was assisted back into bed after assessment. Vitals were completed with no abnormal findings at the time. Currently experiencing pain. Physician Assistant was notified of incident at 6:45 am. Ambulance was called at 7:15 for transfer to hospital. Review of the Change in Condition Evaluation dated 06/21/22 revealed Resident #1 had a change in condition relating to her falls. The evaluation indicated the resident did not have any changes to her mental status but had a functional change relating to a fall associated with a serious injury. The evaluation further indicated the resident's primary physician was notified of the change in condition. Review of the SNF/NF (Skilled Nursing Facility/Nursing Facility) to Hospital Transfer Form dated 06/21/22 revealed Resident #1 was sent out to the hospital. Review of a progress note dated 06/21/22 at 1:41 p.m. revealed Resident returned back from [hospital] around 12:35 pm via stretcher. Resident is alert and oriented to self, situation, and place. Able to make needs known to staff. Resident has bruising on the bridge of her nose and underneath both eyes. A laceration to the bridge of her nose and posterior scalp. Review of hospital records revealed Resident #1 returned to the hospital on 6/24/22 for symptoms unrelated to her fall but during her hospital stay Resident #1 had closed nasal reduction with internal and external splinting on 6/27/22. The hospital report further revealed displaced nasal fracture, status post fall [6/21/22]. Interview with Staff J, Certified Nursing Assistant (CNA) on 12/01/22 at 3:35 p.m. revealed that while she was changing Resident #1 on 6/21/22 she fell . She noted she was not sure how it happened because she did not leave the resident's side and had her hand on the resident the entire time. She stated she was standing on the resident's left side of the bed and the resident fell . She reported she was wiping Resident #1 and the resident was facing away from her. She stated the bed was raised to about her waist level. Staff J stated at the time of the incident she had her hand on the resident and was reaching to the bed side table for a wipe. Resident #1 fell . She thought it could have been due to the bed not being wide enough. She indicated after Resident #1 fell , she checked to make sure she was okay before getting a nurse to help assist her. She reported she was gone for about a couple of minutes. She indicated she had worked with Resident #1 previously and had always changed her by herself. She indicated the aide before her would get the report that would indicate if the resident was a one or two person assist. She indicated the report did not clarify whether Resident #1 was a one or two person assist and assumed it was one person. She stated to her knowledge Resident #1 was not a two person assist and it was not indicated on the Kardex. An interview on 12/01/22 at 10:39 a.m. with Staff C, CNA reported she asked for the report from the previous CNA and they did walking rounds and verbal report for hand-offs at shift change. She indicated if she didn't know the resident, she would ask the nurse or the previous CNA what level of assistance the resident needed. She noted sometimes the Kardex has the level of assistance needed, but sometimes it doesn't. An interview was conducted on 12/01/22 at 10:40 a.m. with Staff D, CNA, stating if she does not know the resident, she would go to the Kardex to get information on how much assistance they needed. She noted if the resident was new and was at the facility for rehab, sometimes she waits for therapy because they assess them to know how much assistance they needed. She stated she also can find out from the report from the shift before. She indicated they had in-services at the facility with therapy on how to safely perform transfers. She indicated she always gets somebody to help if she does not feel safe even if two people were not required. She stated above all, she wants to keep the residents and herself safe. Interview with Staff E, CNA, on 12/01/22 at 10:53 a.m. confirmed she was a permanent facility staff member. Stated she would check in the computer, the Kardex, to get information on how much assist needed for mobilizing a resident or would get the information in the report from the previous shift. She noted she would also ask the nurse. Interview with Staff H, CNA, on 12/01/22 at 5:30 p.m. confirmed she knew Resident #1 and had cared for her during the time period around the fall in June. She stated at that time, the resident could have been changed in the bed with one-person assistance because the resident could use her upper body and her enabler bar to pull herself over, but the resident did not have mobility from the waist down. She stated because the resident does not have mobility from the waist down and she was heavy, Staff H used two people for assisting this resident. She stated the determinations for how much assistance to provide depended on the skill and technique to some degree. Interview with Staff A, Restorative Aide, and Staff B, Restorative Aide, on 12/01/22 at 10:29 a.m. confirmed they were permanent facility staff. Staff B stated if a star was posted on a resident's door that meant they were a fall risk and would cue them that the resident needed assist of more than one person. Staff A and Staff B stated they consulted the Kardex on how much assistance was required for mobilization and transfers. They stated if they were uncertain about the assistance, they could ask the nurses or therapy and a second person was always available when needed. Interview with the MDS Coordinator on 12/01/22 at 12:30 p.m. revealed that Section G of the MDS was where it showed if a resident needed a one person, or two person assist with bed mobility. The 04/05/22 quarterly MDS completed for Resident #1 prior to the fall in June 2022 was presented to the MDS Coordinator. The MDS Coordinator confirmed a 2 person assist with bed mobility was needed. She indicated the information gathered from the CNA (Certified Nursing Assistant) documentation generated the POC (Point of Care) data that helped make the determination on the MDS to enter the level of assistance needed. She stated if the resident was on restorative or rehab, they would use that documentation as well. She revealed her process for reviewing the POC in the chart system and showed how the CNAs had documented the two-person assistance about the same amount of time as they had documented the one-person assistance. Based on that information, she felt that the two-person assistance was appropriate to be entered into the MDS. She indicated the system triggered based on the POC data but if it was felt that the trigger was not accurate, it could have been changed, and it would be indicated by a note. She confirmed she had not entered this note in the MDS but said based on review she felt a two-person assist was accurate, and she didn't see a note stating otherwise. The Director of Nursing (DON) was present during the interview and explained how the information was entered into the CNA tasks lists. The DON stated either the Unit Manager or the nurse could enter that information and with regards to Resident #1, if she's evaluated that she was definitely a 2-person assist they would put that on the task. The DON stated there was nothing anywhere indicating for the care of Resident #1 she needed a two-person assist. She further indicated no one had ever said that she was a two person assist and there was no documentation to alert them that she was a two person assist. The DON indicated when a resident first comes to the facility, therapy will evaluate but if a resident has been at the facility for a long time and always been a one person assist, they will remain that way unless some kind of decline or change comes into play. MDS Coordinator stated the MDS should be a reference and the plan of care development was a clinical thing done by the clinical team and she wasn't involved in that. She indicated regarding Resident #1, the seven day look back indicated she did not always need two persons for assist with bed mobility and that would not go into her care plan. The DON stated they also talk to the CNA's during the IDT (Interdisciplinary Team) meetings to get care information to aide in informing and developing the care plan. An interview on 12/01/22 at 5:42 p.m. with Resident #1's physician confirmed the resident had sustained a fall with a fractured nose. He confirmed the resident had a reduction under anesthesia while at the hospital. He noted the plastic surgeon conducted the reduction. He stated the aide was holding onto Resident #1 and she fell . He felt it was an accident. He stated he felt the one person was fine, and maybe she could have two persons, but he did not know. Review of the policy titled Care Plans, Comprehensive Person-Centered revised March 2022 revealed: Policy Statement A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency, and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made . 7. The comprehensive, person-centered care plan: .b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of relationship between the resident's problem areas and their causes, and relevant clinical decision making . 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and medical record review, the facility failed to ensure a care plan was revised/updated for one (#54) out of nine residents receiving hospice services related to advanced directives. Findings Include: On 05/17/22 at 10:05 a.m. Resident #54 was observed in his bedroom sitting up in his recliner. He was alert and receptive to an interview and confirmed he had recently started receiving hospice services but could not recall when he seen them last. He said he had been at the facility for a few weeks and denied any concerns. Medical record review was conducted of the Admission Record form, which indicated he had resided at the facility since 04/07/2022, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued record review revealed Hospice services were initiated on 04/19/2022. Review of Hospice care plan dated 04/19/2022 indicated Advanced Directives: Do Not Resuscitate. Review of the facility care plan revealed: -Focus: has an Advanced Directive and has documentation in his medical record related to (r/t) Full Code, Revision on 04/10/2022. -Goal: wishes will be honored and maintained through next review date, Revision on: 05/03/2022 Revision by: Minimum Data Sheet Coordinator (MDSC). -Interventions: Collaborate with Hospice as needed (PRN) Date Initiated: 05/03/2022. Created by: MDSC. Review of Physician orders dated 04/15/2022 showed: -Advanced Directive Status: Current and Verified. -Order Type: Advanced Directive. -Description: Do Not Resuscitate (DNR). Medical record review dated 04/27/22 revealed a Care Plan conference was held at the facility with the Hospice nurse present via phone conference. On 05/17/22 at 3:40 p.m. an interview was conducted with Staff Member C, MDSC. She stated the creation of the care plan interventions with Hospice PRN is the responsibility of the Social Worker. She stated the computer system assigns her name when the care plan is opened. On 05/17/2022 at 4:00 p.m. an interview was conducted with the Social Worker. She confirmed the focus of the care plan should have been updated. Review of the facility Policy titled Goals and Objectives, Care Plans revision date April 2009 showed: -Policy Statement: Care Plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. -Policy and Interpretation and Implementation: 1. Care plan goals and objectives as the desired outcome for a specific resident problem. 5. Goals and objectives are reviewed and or revised a. When there had been a significant change in the resident's condition; b. When the desired outcome has not been achieved, d. At least quarterly.

Based on observation, interview, and medical record review, the facility failed to ensure care and services were provided to one (#74) out of twenty-five residents, as evidenced by not providing an antiemetic prior to transport to aid in the prevention of nausea and vomiting. Findings Include: On 05/16/22 at 12:31 p.m. Resident #74 was observed lying in his bed and was receptive to an interview. He said he was just put in bed after he returned from a doctor's appointment and was not feeling well. He stated while at the eye doctor, I got sick. They usually give me something before I go out, but it didn't work this time. He went on to state I get car sick if I don't sit in the front seat. I have ever since I was a kid. He stated, I can't eat I am too nauseated from the car ride. The resident stated, once my eyes are fixed, I need to see an ear doctor to clean out my ears. Review of Admission Record form revealed resident #74 has resided at the facility for two years and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nursing notes on 05/16/2022 did not reveal the resident had a change in condition related to nausea and vomiting. Review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/17/2022 at 9:50 a.m. Staff Member C Unit Manager (UM) confirmed she knew Resident #74 had got sick after transport to his appointment. She stated, He got his medication. On 05/17/2022 at 10:00 a.m. an interview was conducted with the Physician Assistant, who said he knew Resident #74. The Physician Assistant confirmed he was not aware the resident had nausea and vomiting when at his eye appointment on 05/16/2022. Review of medical record physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Needs follow up Intraocular lens implant (IOL) appointment on 6/6/2022 12:50 p.m. and will need to be medicated for his car sickness. The Progress Note did not contain a Physicians signature. On 05/18/2022 at 12:22 p.m. an interview was conducted with the Staff C, UM, and Staff B. Licensed Practical Nurse (LPN). Staff BS confirmed she was the nurse assigned to Resident #74, and stated, did I forget to sign it out? Staff B was observed reviewing the resident's MAR. On 05/18/22 12:38 p.m. an interview was conducted with Staff A, Certified Nursing Assistant (CNA). She confirmed she knew Resident # 74, and said she escorted him to his appointment on 05/16/2022 at 10:00 a.m. She said she was unaware if he had received his medications before he left. Staff A stated after we arrived at the MD office we had to wait in the sitting room for a short period of time. When it was time, we entered the examination room the resident told me he felt sick. I grabbed the garbage can and he threw up two times. Staff A said he gets motion sick from the drive. And after we returned to the facility, I took him to his bedroom. He threw up again. Staff A stated they usually give him something, so he doesn't get sick. But this time it didn't work. On 05/19/22 10:00 a.m. an interview was conducted with Staff B, LPN. She confirmed at that time she had not provided the resident his [MEDICATION(S)] prior to his appointment. She said, he was having pain after he was transferred into his wheelchair so, I gave him Tylenol. She then stated, he did not ask for the [MEDICATION(S)]. Staff B confirmed she has provided the resident [MEDICATION(S)] in the past prior transportation appointments, and confirmed she was aware transport makes the resident sick. Further review of an administration note dated 04/20/2022 at 8:09 a.m. showed: -[MEDICATION(S)] tablet 4 mg give 1 tablet every 6 hours as needed for nausea -Note Text: per resident request due to being transported to [hospital name] medical center. Review of an administration Note dated 05/02/2022 at 8:17 a.m. showed: -Created by staff B, [MEDICATION(S)] ([MEDICATION(S)]) tablet 4 mg give 1 tablet by mouth every 6 hours as needed for nausea and vomiting -Note Text: to prevent car sickness appt at 9 am. The note did not reflect the resident had requested the medication. On 05/19/22 at 1:15 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated, it was a PRN medication, and he needs to ask for it. On 05/19/2022 at 2:40 p.m. the Director of Social Services provided a copy of Resident #74 Brief Interview for Mental Status (BIMS) dated 04/28/2022. She confirmed the BIMS score of 15 indicted no cognitive deficit. She stated, I had overheard the resident gets dizzy when he goes to appointments. Motion Sickness: What is motion sickness? If you've ever been sick to your stomach on a rocking boat or a bumpy airplane ride, you know the discomfort of motion sickness. It doesn't cause long-term problems, but it can make your life miserable, especially if you travel a lot. Children from 5 to [AGE] years old, women, and older adults get motion sickness more than others do. Motion sickness is sometimes called airsickness, seasickness, or carsickness. What causes it? You get motion sickness when one part of your balance-sensing system (your inner ear, eyes, and sensory nerves) senses that your body is moving, but the other parts don't. Accessed from https://joubinkhorsandmd.com/conditions/hw-view.php?DOCHWID=uf4437. on 05/19/2022.

Based on observations, interview and record review the facility failed to appropriately maintain the kitchen equipment related to the range hood and 2 of 2 walk-in freezers. Findings included: Observations of the kitchen during the initial tour of 2/9/21 at 9:59 AM revealed that the range hood located over the range unit was noted with dust and grease build-up. Observation of the purple service sticker indicated that the unit was last cleaned by the vendor October 2020 and was due to be serviced again 1/21. (Photographic evidence obtained) Interview with the Certified Dietary Manager (CDM) at this time revealed that the vendor is scheduled to come and clean the hood now. Observations on 2/11/21 at 9:15 AM during the Comprehensive tour of the kitchen revealed that the Dessert walk-in freezer was noted to have built up ice around door and under the fans directly over food, and icicles dripping and hanging from fans and located over food. (Photographic evidence obtained). Continued inspection of the kitchen revealed that the Food walk-in freezer had ice build-up around door, and ice formed and dripping on the ceiling over food. Interview with the CDM at this time revealed that she is aware of the walk-in freezers having ice build-up and that she put in a work request via the tells system and that someone came to look at it but they are waiting for a part to be ordered. Review of the work history report for the walk-in freezers revealed that they were last inspected on 1/18/21. No documentation of any concerns. Review of the work request provided by the CDM revealed that in the 1st floor kitchen the freezer leak when thawing during the day creating large amounts of ice in the freezer and attached to the units. Created 1/25/21 at 8:56 AM, assigned to Maintenance Manager at 9:06 AM (Set to Vendor Name Work Orders), 9:20 due date removed by maintenance manger. 1/27 Updated status 8:36 AM by maintenance Manager (set closed ) priority was medium general maintenance. Review of the work request provided by the Maintenance Manager revealed that the 1st floor kitchen The freezer leak when thawing during the day creating large amounts of ice in the freezer and attached to the units. created 1/25/8:56 AM, assigned to Maintenance Manager at 9:06 AM (Set to Vendor Name Work Orders) , 9:20 due date removed by maintenance manger. 1/27 Updated status 8:36 AM by maintenance Manager (set closed ) priority was medium general maintenance, with the addition of 2/11 Updated priority 9:42 AM set to High Review of the Invoice from the vendor for heat and refrigeration invoice dated 1/26/21 indicating that they serviced the healthcare 1st floor kitchen larger freezer, with labor that included Found that the drain pan hanger had pulled out of unit, pulled up pan and put in new screw to hold pan, water now draining properly. There was no documentation provided that would indicate that the ice build-up in the 2 walk-in freezers were resolved. Interview on 2/11/21 10:25 AM with the Maintenance Manager revealed that when there is an issue with equipment in the kitchen the kitchen staff are to put in a work request via the work order system and then the work will be completed or the vendor called to complete the work. Once the work is completed it is documented on the work order system. He reported that the vendor for the walk-in freezer was here the day after the kitchen put in a work request and that work was completed. He reported that he was unaware that there was additional work as the additional work request was not put in until today. Review of the facility policy titled Kitchen Equipment-Operation and Care with a revised date of August 2014 revealed To ensure that kitchen equipment be operated and maintained with the greatest care to protect and prolong the useful life of the equipment.

Based on interview and record review, the facility failed to ensure a medical record for one resident (#129) was complete and accurate of 3 sampled. Findings Included: Review of Resident #129's medical certification for medicaid long-term care services and patient transfer form reflected the resident was admitted to the facility on 2 liters of continuous oxygen and [CONDITION(S)](continuous positive airway pressure). Review of the facility physician orders reflected oxygen at 2 liters per nasal cannula discontinued on 1/11/21, the date of admission. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing admission data collection dated 1/11/21 revealed, Resident #129 oxygen saturation of 95% on 1/11/21 at 8:12 p.m., on oxygen via nasal cannula. Review of the comprehensive nursing note dated 1/12/21 at 10:49 p.m. in section F. respiratory, checked as no oxygen. Review of the comprehensive nursing note dated 1/12/21 at 2:38 p.m. in section F. respiratory, checked as oxygen at 2 liters per minute via nasal cannula. Review of the comprehensive nursing note dated 1/14/21 at 2:50 a.m. in section F. respiratory, checked as no oxygen. Review of the comprehensive nursing note dated 1/14/21 at 10:39 a.m. in section F respiratory, checked as no oxygen. Review of the comprehensive nursing note dated 1/16/21 at 6:29 p.m. in section F respiratory, checked as oxygen at 2 liters per minute via nasal cannula. Review of the nursing progress notes dated 1/17/21 at 2:54 a.m. reflected the resident oxygen level at 93% with 3 liters of oxygen. Patient refusing to keep the [CONDITION(S)] machine in place. However, oxygen remains on via nasal cannula. Physician called due to resident having cold sweats and shirt soaked. Review of the nursing progress notes dated 1/17/21 at 7:43 p.m. reflected the resident was talking to his daughter on the phone at approximately 6:40 p.m. the resident when an LPN left the room and asked the RN to speak with the daughter on the phone at daughter's request. The resident was seen prior by the CNA after eating at 6:00 p.m. The resident's hands were cool with normal color. Oxygen in place at 2 liters via nasal cannula with oxygen saturation at 93%. The daughter requested transfer to hospital and nurse complied. Review of Minimum Data Set, dated dated dated [DATE], section O, did not reflect that the resident was on oxygen prior to admission or as a resident. Review of the resident's record did not reflect a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 2/11/21 at 8:12 a.m. with the Director of Nursing (DON) she stated the resident was admitted on [DATE] and was alert with confusion and would call out but was redirected. Resident #129 had a [CONDITION(S)] and his daughter was concerned about his diet and wanted him upgraded. The daughter also changed his physician to the medical director. The DON confirmed the resident was on oxygen but that was not reflected in the record or physician orders as expected. The DON confirmed the record was incomplete and did not contain the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] During a phone interview with the Medical Director on 2/12/21 at 12:15 p.m. he stated the resident's care was transferred to his team after 1/13/21 and they saw the resident on 1/15/21 and ordered labs and urinalysis. The resident did have a chest x ray and was started on antibiotics for a temperature and cough. He was on oxygen at the time. Review of the facility policy for oxygen administration dated 10/10, 3 pages reflected: Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Documentation: After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record. 1. the date and time that the procedure was performed. 2. the name and title of the individual who performed the procedure. 3. the rate of oxygen flow, route and rationale. 4. the frequency and duration of the treatment. 6. all assessment date obtained before, during, and after the procedure. Review of the admission assessment and follow up procedure revealed, Role of the nurse dated 9/12, 3 pages reflected: 12. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observations, interview and record review the facility failed to implement care the resident care plans for 2 of 25 (#18, #49) sampled residents related to posey application for #18, and documentation of meals for #49. Findings included: 1. Review of Resident #18's record revealed that he was admitted the facility on 10/1/19, and has [DIAGNOSES REDACTED]. Review of the physician orders revealed a order for Place posey 6 inch spiral foot elevator to left ankle to assist with prevention of further skin/joint integrity decline. Monitor frequently for skin integrity, circulation and ROM (range of motion). When in bed & in wheelchair. May remove for transfers, the order was dated 10/22/2020. Review of the care plan dated 9/4/20, with a revision date of 2/10/21 related to right heel and right lateral foot with unavoidable Right 2nd toe, revealed that it included an intervention to Place Posey 6 inch spiral foot elevator to left ankle to assist with prevention of further skin/joint integrity decline. Monitor frequently for skin integrity, circulation and ROM. When out of bed Observations 2/09/21 at 1:43 PM of the resident lying in bed revealed that there was no Posey present while the resident was in bed. Observations 2/10/21 at 8:35 AM revealed that Resident #18 was sitting up in bed with Staff G, Certified Nursing Assistant (CNA) feeding him his morning meal. Continued observation of the resident revealed that there was no Posey in place on the residents left ankle. Interview with Staff G at this time, she reported that the resident is supposed to wear the soft boots all the time for his skin. She was unable to verbalize if the resident uses any other devices. She reported that she was unsure because she floats and does not have a set assignment. Interview on 2/11/21 at 12:54 PM with the Director of Therapy revealed that the resident is on restorative care for passive ROM, and has soft boots for wounds on the foot. She reported that the resident does have a Posey for use on his left leg to prevent contractures and skin breakdown. She reported that at times the resident is non-compliant and attempting to cross his legs, and at one point the resident was on hospice and the residents wife would come for [MEDICATION NAME] visits and she would take the posey off or put it on or move it. The Therapy Director reported that the posey was ordered jointly from therapy and nursing to also aid in wound healing. At this time this surveyor went to the resident's room to find the Posey with the Therapy Director present. The resident was not in his room and the Posey could not be located in his room. Observations on 2/11/21 at 1:06 PM of Resident #18 revealed him being wheeled to his room by Staff H, CNA with Staff B, Licence Practical Nurse (LPN) and the Therapy Director present. The Posey was noted to be on the residents left leg above the knee. Interview with Staff B, LPN at this time revealed that the resident is to have the posey on at all times. The Therapy Director was present in the room and noted that the Posey was on the residents left thigh above the knee, she was noted to adjust the posey by turning it counter clockwise but leaving it above the knee, as she verbalized that the resident continued to try to cross his legs. Interview on 2/11/21 at 1:13 PM with Staff H, CNA revealed that the resident is to have on his Posey everyday while in bed and in the wheelchair. She reported that she put it on this morning when she provided care to the resident. Interview on 2/11/21 at 1:15 PM with the DON and the Wound nurse, revealed that the resident has vascular issues and likes to cross his legs. The Wound nurse reported that the posey is for the knees and the ankles and should be on at all times. He reported that the Posey helps circulation and prevent legs from crossing all the time and should be placed around the ankle. Observations of Resident #18 on 2/11/21 at 1:20 PM with the Wound nurse present revealed that the resident had the Posey placed above his left knee. Interview with the Wound nurse at this time revealed that the Posey should be around the ankle, and that it should not be around his thigh. 2. Review of Resident #49's record revealed that this resident was admitted to the facility on [DATE] with a re-admission date of [DATE], and has [DIAGNOSES REDACTED]. Observations of Resident #49 on 2/09/21 at 11:34 AM revealed the resident seated in his wheelchair in his room in front of his over-bed table which had his morning meal on it, which consisted of 1 slice of French toast, bacon, ham, syrup, milk, vanilla shake, Orange Juice, water. The resident was sitting with his head hanging down and sleeping and none of his breakfast had been eaten. (photographic evidence obtained) Observations on 2/09/21 at 11:39 AM Staff G, CNA noted to remove his meal tray out of the room. She was not observed to encourage the resident to eat the meal and she did not offer him any alternative. Observations on 2/09/21 at 12:30 PM revealed the residents mid-day meal tray was on his over-bed table, which consisted of spaghetti, meat sauce, green beans, roll, Ice cream, milk, water, Juice, house shake. The resident was noted to be asleep in his bed with his head covered with the sheets. Interview with Staff G, CNA at this time revealed that the resident wanted to go back in the bed, but she was getting someone to help her get him up now. She reported that he feeds himself. Observations on 2/09/21 at 1:15 PM revealed that Resident #49 was still in bed with sheets over his head and his mid-day meal was still on his over-bed table untouched. Observations on 2/09/21 at 1:52 PM revealed that Resident #49's midday meal tray was still on his over-bed table untouched, (photographic evidence obtained) while the resident was noted to still be in his bed with covers over his head. Observations of Resident #49 on 2/10/21 at 8:30 AM revealed that the resident was alert but hard of hearing. He reported that his bandage is covering his [MEDICAL CONDITION] and that he has [MEDICAL CONDITION] and that he is a Bleeping mess It was noted that his morning meal tray was on his over bed table and consisted of eggs, potatoes, toast, corn hash, Orange Juice, strawberry shake, coffee, milk, water. The resident was noted to drink all fluids and asked for more fluids. He kept stating I want more to drink. An interview with the resident's aide Staff G at this time revealed that she was unsure if the resident is offered anything else if he does not eat his meal. She simply reported that he doesn't want anything, but was not observed to encourage the resident to eat his meal or to offer an alternate. At this time she told the resident that she will get him another tray. Review of the care plan related to the resident being at a nutritional risk with an initiated date of 12/30/20 and a revision date of 2/9/21 revealed interventions that included Monitor meal intake with each meal Review of the CNA documentation of percentage of meal eaten revealed that on 2/9/21 the resident ate 26%-50% of his morning and midday meals and refused his evening meal; On 2/10/21 the resident ate 26%-50% of his morning and midday meal and ate 0-25% of his evening meal; On 2/11/21 the resident at 51%-75% of his morning and midday meal and refused his evening meal. Interview on 2/12/21 at 11:27 AM with the Registered Dietician (RD) and the Dietetic Technician, Registered (DTR) revealed that the resident's weight was stable, that staff report that he does not eat well but may drink at times. She reported that supplements are helping to maintain his weights and they will continue to monitor. Interview on 2/12/21 at 1:06 PM with the DTR revealed that the staff should be documenting % correctly so that they can make appropriate interventions. She reported that the percentages documented do not reflect the actual amounts the resident ate. She reported that she will in-service the staff on documenting %. She confirmed that the % documented does not reflect the same as the actual amounts eaten. 3. Review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revision date of December 2016 revealed that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the reside's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on record review, observation and interviews, the facility did not ensure that assistance was provided for dental services to meet the needs of one resident (Resident #13) out of 25 sampled residents. Findings included: Record review of Resident #13 medical record revealed that she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) (3.0)-V1.1 dated 10/28/2020 Section D, titled Staff Interview #8 Making Decisions Regarding Task of Daily Life revealed a score of 3, indicated that the resident's cognition was severely impaired. Observation on 02/09/21 at 12:26 p.m. revealed Resident # 13 being fed by staff. The food on her tray appeared to be pureed or of soft consistency. Resident #13 had no teeth or dentures in place. During an interview on 2/09/2021 at 12:27 p.m. with staff E Certified Nurse's Assistant (CNA) present at time of observation. The CNA stated that Resident #13's dentures were loose, and they may have been sent out for repairs. During an interview with Staff F License Practical Nurse (LPN), unit manager on 2/11/2021 at 1:50 p.m., she stated that she needed to check to see what happened to Resident #13's denture. She proceeded to Resident #13's room and entered the bathroom. Upon observation a denture was observed in a blue denture cup. Upon closer observation, the denture appeared to be an upper denture. Staff F stated she was not sure what has happened Resident #13's lower denture and confirmed that she should have been wearing her denture. An interview was conducted on 2/11/2021 at 2:00 p.m. with the Social Worker. She stated that she recently assumed responsibility as the Social Worker beginning in December of 2020, and she is not aware of any reports, services or follow up with the dentist related to Resident #13's denture. During an interview with the Director of Nursing (DON) on 2/11/2021 at 2:15 p.m., the DON stated that she is not aware of Resident #13 missing lower denture. Review of care plan dated 8/21/2020 related to Resident #13 missing denture. The care plan revealed that Resident #13 lower denture was missing, and that social service was aware. A review of Dental Services Provider, [DIAGNOSES REDACTED]. Patient has upper denture and no lower denture Patient will not respond if she wants a new set of dentures. No follow up needed. During a follow up interview with the DON on 2/12/2021 at 8:20 a.m., the DON stated that the unit manager usually follows up with recommendations for the residents. She stated that she will check to find out if there were any follow up information available for Resident #13. The DON confirm that the facility should have followed up with Resident #13's Responsible Party (RP) based on the Dental Service Provider recommendation, due to Resident severely impaired cognition. During an interview on 2/12/2021 at 9:15 a.m. with Resident #13's Responsible Party (RP) she stated that she had brought Resident's dentures (upper and lower) to the facility upon her admission to the facility. The RP stated that she noticed the lower denture missing either June or July of 2020 and has been communicating with the Social Worker and the Charge Nurse about replacing the lower denture. She was told how much it would cost to replace the denture and she agreed to pay the cost, but the facility has not followed up with her. Resident #13's RP stated that she would love Resident to get her lower denture, for her to be able to eat regular food (consistency). Review physician order dated 12/15/2020 revealed Resident #13 diet as Controlled Carbohydrate Diet (CCHO)Puree (Level1). Review Nutrition Risk Review dated 10/26/2020, revealed diet: CCHO, Texture Modified and on 1/4/21 revealed diet as CCHO, pureed consistency. Review progress note dated 11/19/2020, which stated that Residents #13's denture had been missing while in Health Center, and she had refused follow up with the dentist on 10/21/2020 per social services. Review social services notes dated 10/21/2020 stated that resident refused to see the dentist. Nurses note dated 10/21/2020 also confirmed that resident refused to go to see the dentist. Record review did not reveal that social service contacted Resident #13 RP due to her refusal to follow up with the dentist or to see the dentist. A review of Resident #13 Inventory of personal effects dated 4/23/2020, revealed that Resident #13 was admitted with full upper and lower dentures. Review of the Complaint/Grievance log dated 8/19/2020, revealed a report for Resident #13 lost lower denture. Record review of the facility policy and procedure titled, Dental Services, last revised December 2016 revealed: #6. Social services representative will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan if eligible. #9. Lost or damage dentures will be replaced at the resident's expense unless an employee or contractor of the facility is responsible for accidentally or intentionally damaging dentures. #10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting dental services: and the reason for the delay.

Based on observation, interviews, and policy review, the facility did not appropriately secure medications in four (A Wing North, A Wing South, Center Hall, and North Hall) of four medication carts. Findings included: On 02/11/21 at 12:35 p.m. an observation of the A Wing South medication cart included two (2) loose tablets in the second drawer from the top of the medication cart. Staff A, Licensed Practical Nurse (LPN), confirmed the presence of the unsecured white tablets. On 02/11/21 at 10:31 a.m., an observation of the A Wing North medication cart included in the second drawer ¼ of a green tablet, one (1) white tablet and ½ of a white tablet in loose, and in the third drawer one loose white capsule. Staff B, (LPN) confirmed the presence of the unsecured tablets. On 02/11/21 at 12:55 p.m. an observation of the medication cart on Center Hall included in the second drawer one (1) white capsule, ¼ pink tablet and ¼ white tablet. Staff C, Registered Nurse, (RN) confirmed the presence of the unsecured tablets. On 02/11/21 at 01:15 p.m., an observation was conducted of the medication cart on the North Hall which included 2 oval white tablets and ½ white loose tablets in the second drawer from the top of the medication cart. The second drawer on the side of the medication cart, in the narcotic box included a ½ white loose tablet. Staff C, (RN) confirmed the presence of the unsecured tablets. On 02/11/21 at 1:32 p.m., an interview with the Director of Nursing (DON) was conducted. The DON was informed of observations made of four of four medication carts. The DON indicated there should not be unsecured pills in any medication carts. She stated My expectation is that if the nurses find unsecured medications, they should immediately destroy them, if they find unsecured narcotics in the narcotic box then they must bring those loose pills to me and I will destroy them , and record it properly. (Photographic Evidence Obtained.) A review of the facility policy titled, Storage of Medications, with a revision date of April 2007 Page 33, read: Policy Statement -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 1. Drugs and biologicals shall be stored in the packaging, containers, or other dispensing systems in which they are received.

Based on observation, interview, record review and facility policy review, the facility failed to store food in accordance with professional standards for food service safety by not ensuring opened and unopened food items in the main kitchen storage areas were labeled, dated or removed by the discard date. Findings included: On [DATE] at 9:25 a.m. an initial tour of the kitchen was conducted. The Dietary Director, Dietetic Technician Registered (DTR) and the Executive Chef were present. During the tour on [DATE] at 9:57 a.m., six items in the walk-in refrigerator were not labeled, not dated or uncovered. The items included: 1.One metal baking tray of seasoned chicken with no plastic wrap covering the tray and undated and placed on a storage cart. (Photographic evidence obtained). 2. Premade ham sandwiches in a plastic covered metal pan not dated or labeled. (Photographic evidence obtained). 3. One 16 ounce container of Low Sodium Vegetable Base was opened and undated (Photographic evidence obtained), 4. One 16 ounce container of Chicken Base Paste was opened and undated (Photographic evidence obtained) 5. A pitcher of ice tea with the date of [DATE] written on top of very loose plastic wrap placed in pan of melted ice water. The DTR stated the ice tea had an expired time of use. 6. An opened bag of shredded cabbage was undated. (Photographic evidence obtained). The DTR verified the items observed were either not dated, not labeled or not covered. On [DATE] at 10:10 a.m., the tour of the dry storage area revealed (4) 6 pounds/10 ounces cans of sliced peaches and (1) 6 pounds/9 ounces can of fruit cocktail not dated (Photographic evidence obtained). An interview was conducted on [DATE] at 8:41 a.m. with Staff C, Cook. She stated that she had training on labeling about a month ago. The in-service had to do with labeling items and the other in-service was about the dining services and the carbohydrate diet. She stated, You must label and date all items. She stated cooked food goes on the top shelf and uncooked food goes on the bottom shelf. An interview was conducted on [DATE] at 9:00 a.m. with Staff D, Dining Room Supervisor. She stated she assisted with unloading food supplies from the delivery truck, putting away stock, and labeling everything when it came in. She assisted with prep in cooling products down, labeling, and storing them. She stated, They try to do monthly in-services on labeling and storage as much as possible. On [DATE] at 1:06 p.m., an interview was conducted with the DTR. She verified and stated her expectation was for all items to be labeled, dated when they arrive, and placed in the appropriate storage areas. She stated she used signage to remind staff of protocols to follow in each work area. A review of the facility's policy and procedure titled, Labeling-DS-04.028, for of all product types and last revised ,[DATE] revealed the Policy Overview was that, All food items must be labeled and dated before storing. The Policy Detail stated, 1. All food items upon receipt from food vendors must have a date marked before putting in any storage (dry, refrigerator, freezer, pantry). This should be done even if the food items has a use by or sell by date marked by the manufacturer, 2. All prepared items (i.e. leftovers or prepared for next meal) must have a label with the name of item, date prepared, by whom, and date of discard., 3. It is recommended to use approved labels.

Based on interview, record review and policy review the facility did not ensure residents received the correct dosage of medication which resulted in a significant medication error for 1 (#2) of 6 residents sampled for medication review. A physician order [REDACTED]. The resident became unresponsive on the 6th day and was hospitalized for [REDACTED]. Findings included: 1. Review of Resident #2's medical record from the facility revealed a Situation Background Assessment Recommendation (SBAR) Communication Form dated 02/10/16 at 10:15 a.m. documenting the resident was unresponsive, vital Signs on 02/10/16 at 09:56 a.m.: Blood pressure 116/56, Pulse 57, Respirations 16, Oxygen saturation 95%. The Resident's mental status changes included: new or worsening behavior, decreased consciousness, unresponsiveness. Her functional status change included: very hard to arouse. Resident became unresponsive sitting in a chair at the nurses' station. Resident was assisted back to her room and was assisted back to bed. Some response was noted but she was very sluggish. Resident was transferred to the hospital. The daughter was notified at 09:55 a.m. and the physician was notified at 09:35 a.m. Review of Resident #2's hospital record on 02/10/16 at 11:50 a.m. revealed patient was found to be unresponsive at the nursing home. She had just prior been given [MEDICATION NAME] for agitation. She has had other episodes of falls. There is not one known to have happened today. Further review of hospital record revealed on 02/11/16 at 05:23 a.m. the resident's primary physician documented, patient presented at the (ER) emergency room from nursing home after an episode of unresponsiveness at the nurses' station. I was called by the nurses' station and informed of the change. Pt remains pleasantly confused today and per nursing did well with one dose of [MEDICATION NAME] after becoming agitated. Apparently, yesterday (02/10/16) she became unresponsive after receiving [MEDICATION NAME] 0.5 mg by mouth. This has occurred in the past but was related to a urinary tract infection. Further review revealed on 02/15/16 at 05:08 a.m. the resident's primary physician documented, admitted on [DATE] with altered mental status secondary to medication overdose with antipsychotics. Patient had all medications discontinued with adjustment and titration of medications. She improved with more alertness and taking PO (by mouth) improved compared to admission. [MEDICATION NAME] and [MEDICATION NAME] as well as [MEDICATION NAME] discontinued. She has been ordered to have [MEDICATION NAME] at a reduced dose as well as [MEDICATION NAME] at a reduced dose. Continue to adjust medications as inpatient-she is better-eating 75% of food- continue current meds-patient is more alert but remains confused, will discharge to nursing facility today. Review of the facility ' s investigation of Resident #2 ' s change in condition showed that on 02/10/16 at approximately 10:00 a.m. the resident was sitting in her wheelchair behind the nurses' station next to a nurse when she became unresponsive to verbal stimuli. She was returned to her room and assisted to bed. At this point she did start to respond but remained lethargic. The physician was called and orders received to send the resident to the hospital for an evaluation. The daughter was notified of the incident. A chart review was completed and a medication error was discovered which may have contributed to the resident's episode of unresponsiveness. On 01/15/16 [MEDICATION NAME] DR 250 mg TID was ordered. On 02/04/16 a new order was written to change the dose to [MEDICATION NAME] DR 500 mg BID. The first order for [MEDICATION NAME] was not discontinued resulting in the resident receiving 1750 mg of [MEDICATION NAME] per day instead of the ordered dose of 1000 mg per day. Analysis and Corrective Action included the nurse received corrective action for the medication error. Licensed nurses received an in-service on, Nursing Responsibilities Regarding Taking New Orders. The facility is addressing the issue in the QAPI (Quality Assurance Performance Improvement) meeting on 02/19/16. The resident returned from the hospital on [DATE]. Her physician performed a medication review and adjustment with the goal of preventing a repeat of this incident. Resident #2 was an [AGE] year old female admitted to the facility originally on 04/29/15 and readmitted on [DATE] per the face sheet. Her [DIAGNOSES REDACTED]. Record Review of Resident #2's Quarterly Minimum Data Set ((MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 99 (chooses not to participate or chose not to answer). It also revealed her behaviors included: physical behaviors directed at others occurred 1 to 3 days; verbal behaviors occurred 1 to 3 days; rejection of care occurred 1 to 3 days; and she wandered 4 to 6 days. Her functional status assessment indicated she required limited assistance for bed mobility, transfers, walking in her room, and toileting. She required extensive assistance for dressing and personal hygiene. The MDS revealed the medication assessment included: antianxiety medications, antidepressants, and antibiotics. Review of the record of the Resident ' s psychiatrist progress note dated 2/4/2016 showed that the resident's medications included [MEDICATION NAME] 250 mg DR three times a day. The treatment recommendation was change [MEDICATION NAME] DR to 500 mg in a.m. and bedtime. Review of Resident #2's physician telephone orders showed the following: 01/15/16 ordered by the psychiatrist Change [MEDICATION NAME] Delayed Release (DR) to 250 mg three TID (three times a day) and on 02/04/16 at 7:30 p.m. ordered by the psychiatrist ¿¿ (increase change) [MEDICATION NAME] DR to 500 mg twice a day BID a.m. and HS (in the morning and at bedtime) for [MEDICAL CONDITION] disorder with [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. The nurses documented the medication was given at 0900, 1300, and 1800 on 02/01, 02, 03, 04, 05, 06, 07, 08, 09 and at 0900 on 02/10/16. Review of the MAR indicated [REDACTED]. The nurses documented the medication was given at 0900 and 2100 on 02/05, 06, 07, 08, 09 and 0900 on 02/10/16. Further review of the MAR for 2/1/16 through 2/10/16 showed the resident received [MEDICATION NAME] DR 20 mg daily for depression, [MEDICATION NAME] 25 mg three times for agitated behavior related to [MEDICAL CONDITION] disorder; [MEDICATION NAME] 2.5 mg three times for behaviors related to [MEDICAL CONDITION], [MEDICATION NAME] 5 mg twice for behaviors related to [MEDICAL CONDITION]; Trazadone 25 mg twice for behaviors; Trazadone 100 mg three times for severe depression; and [MEDICATION NAME] 0.5 mg by mouth 18 times for anxiety. The Resident received [MEDICATION NAME] 0.5 mg on 02/10/16 at 08:38 a.m. Review of the Geriatric Dosage Handbook 12th Edition showed that [MEDICATION NAME] is used to treat [MEDICAL CONDITION] disorders and certain psychiatric conditions (manic phase of [MEDICAL CONDITION] disorder). Side effects include but are not limited to: somnolence (sleepiness, the start of feeling drowsy, ready to fall asleep), weakness and dizziness. Older adults may be more sensitive to the side effects of the drug due to decreased elimination. Older adults with dementia show a high incidence of somnolence. Symptoms of overdose include coma, deep sleep, restlessness and hallucinations. A review of the Drug Information Handbook For Nursing, dated 2007, showed [MEDICAL CONDITION] of [PHONE NUMBER] mg/day in divided doses. Review of the Geriatric Dosage Handbook 12th Edition showed that [MEDICATION NAME] DR is an antidepressant; side effects include somnolence and dizziness. Review of the Geriatric Dosage Handbook 12th Edition showed [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder; side effects include agitation, dizziness and somnolence. Review of the Geriatric Dosage Handbook 12th Edition showed [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION] disorder; side effects include somnolence, dizziness, [MEDICAL CONDITION] and weakness. Review of the Geriatric Dosage Handbook 12th Edition showed Trazadone is used to treat depression; side effects include dizziness, headache and sedation. Review of the Geriatric Dosage Handbook 12th Edition showed [MEDICATION NAME] is used to treat anxiety disorders; side effects include sedation and respiratory depression. 2. During an interview on 02/23/16 at 11:33 a.m. with the Director of Nursing (DON), Risk Manager, (RM), Assistant Director of Nursing (ADON) and Nursing Home Administrator (NHA), they stated that the resident was sitting at the nurses' station in her wheelchair in the a.m. of 02/10/16 and had an episode of unresponsiveness. She responded to verbal stimuli, was breathing and had a pulse. She was then taken to her room and 911 was called as well as her daughter and the physician. The resident was sent to the hospital. The ADON reviewed her medications and discovered an order given by the psychiatrist for a change in the [MEDICATION NAME]. The resident was getting [MEDICATION NAME] 250 mg TID. The psychiatrist wrote another order for [MEDICATION NAME] 500 mg BID. The floor nurse did not discontinue the TID dosage in the computer system. The resident was receiving 750 mg at 9 a.m., 250 mg at lunch time 250 mg at dinner and 500 mg at bedtime. They stated that on interview with several nurses; the nurses told the RM that they questioned the nurse that entered the order, but she said that was the order. When the nurses were asked why they did not look in the chart, they stated they should have, but just didn't. The ball was dropped. They stated that the daughter came to the facility and spoke with the ADON and NHA regarding the situation and wanted to know how the medication error happened. They stated that they explained the events to the daughter. They stated that the resident's primary care physician (PCP) is now managing all her medications. The facility offered the daughter a new psychiatric service but she declined, wanting the PCP to manage her mother's medications. They stated that the resident required almost one on one services except when she was sleeping. The resident was admitted with the [DIAGNOSES REDACTED]. She began falling in January 2016 and psychiatric service was ordered to address her impulsive and combative behaviors. We want to protect her as well as others. The RM stated that the incident was reported to AHCA (Agency for Health Care Administration) as an adverse incident on 02/10/16, the day the resident went to the hospital, and an investigation was started that day. They interviewed the nurses and asked why they did not catch the medication error. The nurses were in-serviced regarding taking proper orders and a QAPI was started. They stated that they re-educated the nurses to use critical thinking skills and address the patient as a whole and not just their individual medication pass. They were educated on telephone orders and to repeat back the order to verify the order. They were in-serviced on when a medication dosage is changed the prior medication must be discontinued and a new medication and dosage inputted into the computer system. They stated that the pharmacy consultant did a 100% review of all residents on psychiatric medications for accuracy of medications and dosages. They stated that a new process was implemented; any time a change in psychiatric medication occurs the ADON will review those order slips daily. During an interview on 02/23/16 at 1:45 p.m. the pharmacy manager stated that they had received a [MEDICATION NAME] order on 02/05/16 for 500 mg BID; he also stated that the pharmacy had discontinued the [MEDICATION NAME] order for 250 mg TID. He stated that anything they do in the pharmacy does not feed back to the facility. He stated that the facility is responsible for inputting any paper orders they receive from the physician into the facility computer system. He stated that the facility nurse should have contacted the physician and clarified the order if they had questions. During an interview on 02/23/16 at 4:30 p.m. the pharmacy consultant that visits the facility stated that the pharmacy cannot see the facility's computer system. The facility is responsible for their e-mar (Electronic Medication Administration Record). 3. Review of the facility's policy titled, Administering Medications, dated April 2013, showed that if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Review of the facility's policy titled, Medication Errors, dated August 2015, showed a medication error is defined as the preparation or administration of drugs or biologicals which are not in accordance with the Health Care Provider orders, manufacturer specifications, or accepted professional standards and principles of the professional (s) providing services. An example of a medication error includes: wrong dose. When a resident receives a new medication, the medication order should be reviewed for the following: the dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and /or manufacturer ' s specifications for use.

Based on observation, interview, record review and policy review the facility did not ensure the supervision necessary to prevent a fall resulting in a fracture for 1 (#1) of three residents sampled for falls in regards to a transfer lift. Staff did not use the lift correctly which resulted in a fall with injuries that required hospitalization and follow up education on use of the transfer lift for less than 7% of the care providing staff members. Findings include: 1. Resident #1 was a [AGE] year old female admitted to the facility originally on 1/29/2015, and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed her Functional Status assessment was; transfers require extensive assistance with 2+persons. Review of her medical record Nurse's Notes revealed: 5/15/2015 CNAs witnessed fall while operating the (Arjo) lift. Further review of the record revealed a Nursing Home to Hospital transfer form with the notation of Reason for transfer: FALL-Head. An interview was conducted on 6/9/2015 at approximately 2:00 p.m., with Employee A, CNA. She stated that on 5/15/2015 she and Employee B were transferring Resident #1 from her bed to her wheelchair using a lift. They raised the resident in the sling over the bed and the machine stopped working. They lowered the Resident to the bed and replaced the battery on the machine. They then raised the resident again and when the resident's body was moved out over the floor she fell out of the top of the sling head first on to the floor. She hit her head. She stated that the sling came off the lift machine, one of the upper sling arms came off the lift machine. She confirmed they were using the Arjo lift. An interview was conducted on 6/10/2015 at 1:30 p.m., with Employee B, CNA. She stated that on 5/15/2015 she and Employee A put Resident #1 in the sling and raised her off the bed using the (Arjo) lift, then the lift machine needed a new battery so we lowered her to the bed and replaced it. When we lifted her up again and pulled the machine out to move her over to the wheelchair one side of the sling came off the lift and she fell . The plastic snaps on the left side of the sling were warped and loose; they hold the sling onto the lift. The plastic snaps on the right side were tight, maybe the plastic got warped in the laundry. A review of the medical record revealed a 5/20/2015 progress note written by Resident #1's primary physician: female patient that is readmitted after a short hospitalization . She presented at the ER after a fall from a lift, and hit her bead and back, CT (cat scan) chest reported no acute intrathoracic process identified, acute fracture of the T12 vertebral body, CT brain showed a scalp hematoma on the left with no evidence of an acute intra or extra axial hemorrhage, Neuro (neurologist) was consulted and recommended conservative management with pain medications. During this morning encounter patient stated doing fine, but complained of sharp back pain as 6 on 1/10 scale, according to nursing she has been complaining of back pain more often since she got readmitted from the hospital. She is currently on Dilaudid every 6 hours and fentanyl patch every 72 hours. Will change the Dilaudid to every four hours and monitor. Review of Resident #1's medical record revealed a Physical Therapy Evaluation and Plan of treatment dated 5/19/2015: referred to therapy secondary to recent fall resulting in T12 compression fracture with increased pain, decreased sitting balance, abnormal muscle tone of BLE (bilateral lower extremities), decreased activity tolerance. During a phone interview on 6/12/2015 at 11:02 a.m., with the physical therapist who conducted her evaluation on 5/19/2015 he stated that the resident's functional ability after the fall was unchanged in comparison to her status before the fall which was that she required extensive assistance for many functions. He also stated he was not able to complete her bed mobility assessment due to extreme pain. The therapist stated he questioned the resident and she denied having changes in her functional abilities since the fall. An interview was conducted with the Resident's primary physician on 6/10/2014 at 10:00 a.m. by phone. He stated that he is not sure the fall caused the compression fracture, it may have but it may not have. Her pain level is back to baseline now. An interview was conducted on 6/8/2015 at 1:28 p.m. with Resident #1. She was seated in her room in a wheelchair next to her bed. She was alert and had recently finished her lunch. When asked about the fall during a transfer she stated they say I fell from the lift but I fell from the bed, they were helping me get out of bed. I have pain and cannot get therapy. How am I going to get up from the chair if I don ' t get therapy? An observation was conducted on 6/9/2015 at 9:43 a.m. of the staff transferring the resident with a lift. Staff members A, B and E, CNAs performed the transfer. They placed a sling under the resident, moved the Arjo lift over the resident and clipped the sling onto the lift. They raised the resident into the air using the lift, moved the lift back to position the resident over her wheelchair and lowered her to the chair. They ensured the sling was clipped to the lift before raising it. They used correct technique and communicated appropriately with the resident during the transfer. An interview was conducted on 6/9/2015 at 1:30 p.m., with the Administrator, the DON, the ADON and the Risk Manager. They confirmed that the resident fell out of a sling during a transfer and was sent to the hospital. They stated that the lift was an Arjo brand lift with slings that attach using plastic clips that fit over a knob. They stated they had never had a problem with the Arjo lifts before but are ordering all new lifts that have a locking clip on the slings to prevent them from falling off. They stated that all lifts in the facility were removed from service temporarily after the accident, all slings were inspected and the representative from the lift company visited the facility to inservice the nurses and CNAs. The Risk Manager stated that training on lifts is done on hire and periodically. An interview was conducted on 6/10/2015 at 11:08 a.m. with the DON she stated that the Arjo representative told the facility they were the wrong slings with grey clips and should have been using slings with black clips. She stated that they removed all the slings with grey clips. An inspection of the slings present in the facility at that time revealed only slings with black clips, none with grey clips. A review of the inservice records provided by the facility revealed a Hoyer and Sara (two types of lifts, Arjo is a Hoyer type lift) Competency dated 5/18/2015, 10:00 a.m. to 11:00 a.m. The inservice was signed by 17 staff, 14 CNAs and 3 LPNs. Review of a list of active employees provided by the facility revealed 66 CNAs and 47 nurses. The DON on 6/10/2015 confirmed that 17 out of 113 current care providers attended the competency training on lifts. She stated that the representative for the company was only present in the facility for one day. A review of the Policy and Procedure Safe Lifting and Movement of Residents 2001 MED-PASS, Inc. October 2009, provided by the facility revealed: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 4. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts, lateral boards and mechanical lifting devices. 6. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 10. Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. A review of the annual training on transfers conducted in the previous 12 months provided by the facility revealed no training on lift transfers. The DON reviewed the training records on 6/10/2015 and confirmed that the facility had not conducted training on lifts in the past 12 months. An interview was conducted on 6/18/2015 at 8:39 a.m. by phone with Adam Sitzmann. He stated that he has worked for ArjoHuntleigh for three years. He was called by the facility on Friday 5/15/2015 and informed of a fall from a lift. He went to the facility on [DATE] to inservice staff. He was not sure but believes there were approximately 25 staff members in the training that day. He said he left a video with the management staff to train the remaining employees. He stated that there was nothing wrong with the lift or the sling involved in the fall. The sling had no rips or tears and there were no problems with the clips. He stated that all the slings in the facility were fine, even the older ones. He said that the facility had a few older slings with gray clips, but they also were in good condition. Newer slings have black clips. He stated that it is recommended that the facility change out the slings every few years. The facility disposed of the slings with the grey clips. He was asked what he thought caused the fall and he stated that he thinks they must have hooked the sling on incorrectly because he found nothing wrong with the sling. He believes the lifts are to be inspected once a year by the Arjo company, and stated the facility has the responsibility to inspect the slings for rips or tears. Review of the ArjoHuntleigh Passive Clip Slings Instructions for use information, October 2014 provided by the facility ' s Arjo Representative revealed: Clip Attachment and Detachment, Attach the Clips (5 steps), 1. Place the clip on the spreader bar lug, 2. Pull the strap down, 3. Make sure the lug is locked at the top end of the clip, 4. Make sure the strap is not squeezed in between the clip and the spreader bar. 5. Make sure the straps are not twisted.