Every finding on record at Lakewest Rehabilitation and Skilled Care

Based on record review, observation and interview, the facility failed to provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge from the facility for 1 of 5 residents (Resident #1) reviewed for transfer, discharge rights, and discharge summary. The Facility failed to provide sufficient preparation and orientation to ensure a safe and orderly transfer by not allowing the resident to return to the facility on [DATE], from the hospital after the resident had been cleared for return after psychological examination. DON failed to complete a discharge summary for Resident #1 with the right to appeal and failed to notify the Ombudsman. These failures could place residents at risk of disruption in their continuity of care.Findings included: Record review of Resident #1's Face Sheet dated 8/11/26 revealed that she was admitted to the facility on [DATE]. The face sheet did not reflect a discharge date . Resident #1 had the following diagnosis: Vascular Dementia, Moderate with Agitation (a reduction in cognitive skills caused by lowered blood flow to the brain), Bipolar Disorder (extreme mood swings) and Altered Mental Status. Record review of Resident #1's Care Plan dated 7/24/26 revealed Focus: [Resident #1] has impaired cognitive function and impaired thought processes (X) Rarely/never makes decisions (X) BIMS =3). Goal: [Resident #1] will be able to communicate basic needs on a daily basis through the review. Interventions: Communicate with the resident/family/caregivers regarding residents capabilities and needs. Focus: [Resident #1] resides in the transitional behavioral unit d/t history/current inappropriate/unmanageable behaviors. At risk for outburst, mood changes, decompensation of behavioral symptom. Bipolar Disorder, Dementia Pt says things like they are poisoning me and that she wants to get out of here [Resident #1] have outburst at times. Goal: [Resident #1] will display cooperative, calm and collected behaviors through the next review date. Interventions: Monitors/observe for early signs of agitation, mood shifts, or triggers and provide reorientation as needed. Record Review of Resident #1's MDS Nursing Home Discharge Item Set, dated 07/25/26 revealed that Resident #1 had a staff assessment for mental status in which Resident #1 was found to have a short-term memory problem, and was assessed for cognitive skills for daily decision making to be severely impaired. Resident #1's MDS also indicated that Resident #1 displayed Verbal Behavioral Directed towards others as occurring every one to three days. Resident #1 was listed as not displaying any Physical Behavioral symptoms towards others. Resident #1 was assessed as being independent in Eating, oral hygiene, Toileting hygiene, Shower/Bathing, Upper Body Dressing, and Putting on /Taking off Footwear. Resident #1 required Setup or Clean-up Assistance in the functional areas of Lower Body Dressing and Personal Hygiene. During an observation on 08/11/26 at 10:00 AM of the Secure Facility Behavioral Transitional Unit it was revealed that the unit required a code to egress the unit. The unit had 6 rooms; all 6 rooms were observable from the nurse station. 5 residents were observed occupying the Behavioral Transitional Unit. A nurse and a CNA were observed to be working in the unit. A large clear plastic bag full of clothing items was observed on Resident #1's bed in Resident #1's former room.In an interview on 08/11/26 at 10:30 AM Hospital SW A revealed that she had been the SW to try and facilitate sending Resident #1 back to the Facility from the hospital after Resident #1 had been cleared by the hospital psychiatrist. She stated that Resident #1 had indicated several times that she had wanted to return to her facility and had arranged for Resident #'1 transport back to the facility on 7/25/26 around 6:00PM, she stated that the transport had brought Resident #1 back to the hospital around 6:45 PM 7/25/26 and that it had been reported to her that the facility had refused to take Resident #1 back. Hospital SW A then stated that she had then called the facility to verify that they had refused to take Resident #1 back, and the facility had verified the refusal. In an interview on 08/11/26 at 10:52 AM Hospital SW B revealed that she had admitted Resident#1 to the Medication Secure Unit at her hospital on 7/25/26. She stated that during her admittance interview with Resident #1, Resident #1 had expressed that she had wanted to go back to her room at the facility and that she expressly did not want to go to her former Boarding Home. Hospital SW B further stated that there had been no reports of Resident #1 being verbally or physically aggressive to staff or other patients since she had been admitted to the hospital. In an interview on 08/11/26 at 12:11 AM Hospital NP revealed that she was the NP for the Behavioral Transitional Unit at the facility. She stated that Resident #1 had been a resident of the Behavioral Transitional Unit for around three months, and that she had not received any reports of Resident #1 being physically aggressive to other residents on the unit but Resident #1 could be verbally aggressive. She stated that she was not aware of Resident #1's current location but had assumed that she had been admitted to the Hospital Psych/Secure unit. In an interview on 08/11/26 at 1:23 PM Facility SW revealed that she had never seen Resident #1 be physically aggressive towards staff or other residents. She stated that she had not been told Resident #1 had been discharged . She stated that she thought Resident #1 had been transferred but stated she had not been told that either. She stated she had not produced a discharge letter for Resident #1. In an interview on 08/11/26 at 1:58 PM the DON revealed that she had interacted with Resident #1 many times, she stated That she had not witnessed or of any aggressive physical behavior by Resident #1 towards any staff or residents. She denied having any knowledge of where Resident #1 was currently residing. She stated she was unable to provide a discharge letter, discharge summary or Notice of Medicare Non-Coverage to the investigator. In an interview on 08/11/26 at 2:24 PM LVN C revealed that they had worked with Resident #1 for the last three months, she stated that Resident #1 could start yelling but was redirectable. She stated she had never seen Resident #1 be physically aggressive to staff or other Residents. He stated he had been surprised that Resident #1 was not there anymore, and he did not know where Resident #1 had gone too. In an interview on 08/11/26 at 2:40 PM LVN D revealed that she had worked with Resident #1 for the last three months. She stated that she had never seen or heard of Resident #1 being physically aggressive towards any staff or other residents. She stated that Resident #1 spoke loudly because Resident #1 was hard of hearing. She stated she had been surprised that Resident #1 was no longer at the facility, or where Resident #1 had transferred too, but her possessions are still in her room. Review of the facility policy titled Transfer and Discharge (including AMA) Revised 08/2023 read in part.4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and a manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis of the transfer or discharge.b. The effective date of transfer or dischargec. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.i.a discharge summary and plan of care should be prepared for the resident. Document in the medical record that written discharge instructions were given to the resident, and if applicable, the resident's representative.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 9 (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10) of 14 reviewed for Abuse.The facility failed to protect Residents #2, #3, #4, #5, #6, #7, #8, #9, #10 from physical and verbal abuse by another resident.An IJ was identified on 4-16-2026. The IJ template was provided to the facility on 4-16-2026 at 3:40 PM. While the IJ was removed on 4-17-2026, the facility remained out of compliance at a scope of pattern and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective measures. This failure placed residents at risk of subsequent abuse resulting in potential mental anguish, emotional distress, and physical harm. Findings included:Record review of Resident #1's admission Record, dated 4-15-2026, revealed a [AGE] year-old female with an original admission date of 4-26-2021 and a readmission date of 11-4-2025. Resident #1 had a primary diagnosis of dementia with psychotic disturbance (the presence of delusions or hallucinations in individuals with a diagnosed neurodegenerative [chronic loss of function in nerve cells] disorder) and secondary diagnoses of homicidal ideations (thoughts, fantasies, or plans about killing another person), paranoid schizophrenia (a chronic mental health disorder, characterized by intense, irrational delusions and hallucinations-often auditory centered on persecution or conspiracy), dementia with other behavioral disturbance (involves non-cognitive symptoms like agitation, aggression, depression, wandering, or social disinhibition) schizoaffective disorder (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions, disorganized speech) with major mood disorder, such as depression or bipolar mania), psychosis not due to a substance or known physiological condition, and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early, leading to daytime fatigue, irritability, and poor concentration). Review of Resident #1's Quarterly MDS dated [DATE], revealed Resident #1 re-entered the facility from an inpatient psychiatric facility with a BIMS score of 8 which indicated being mildly cognitively impaired. The D Mood section indicated Resident #1 often felt socially isolated. Section E Behavior section indicated Resident #1 rejected evaluation and care daily. Review of Resident #1's most recent Care Plan with an initial date of 5-24-2022 and revised on 2-9-2026 revealed she was physically aggressive to staff and residents having a pair of scissors being at risk for potential for harming herself and others. Resident #1 has attempted to use metal utensils to harm staff. On 10-7-2025 Resident #1 hit another resident, 10-8-2025 Resident #1 was physically aggressive to another resident, 1-21-2026 Resident #1 was physically aggressive toward another resident. Resident #1 was at risk for delirium initiated on 4-24-2022 stating the devil will tell her to do things, Resident #1 was resistive to care by refusing to take medications revised on 4-5-2023, Resident #1 had potential to be verbally aggressive yelling at staff because of ineffective coping skills revised on 5-19-2021, Resident #1 was physically aggressive to staff and residents because of poor impulse control by locking herself in other resident's bathroom revised on 6-20-2023, Resident #1 had aggressive behavior problems striking Residents initiated on 9-29-2024, Resident #1 was care planned to receive antipsychotic medication for mood & behavior management revised on 7-24-2022.Review of a Resident #1's Psychiatric Subsequent assessment dated [DATE], reflected a history of being confrontational, not compliant with medications, bizarre behavior, having schizoaffective disorder having a history of depression, symptoms of psychosis including auditory hallucinations, visual hallucinations, delusions, Alzheimer's disease with major depressive disorder, and paranoid schizophrenia. Current psychotropic medications included: Depakote Sprinkle, Trazodone, and Haldol injections. Resident #1 frequently refused medications and lag draws. Review of Resident #1's progress nurse notes reflected the following:1-23-2025 at 1:58 PM - Resident just came back from [mental] hospital stay due to negative behaviors. Resident had been making threats and taking things from other residents .5-8-2025 at 1:15 PM - Psychiatric service asked to see resident due to increase of behaviors. Resident yelling and screaming out loud at staff with any attempts to redirect her .5-13-2025 - 3:59 PM - .resident's refusal of valproic acid lab draw. Lab personnel will try again in the next round of blood draw.5-15-2025 - 4:00 PM - Psych in facility and due to resident's increased behaviors .5-28-2025 at 3:0016 AM - Resident #1 had a fall. Neighborhood portable x-ray personnel [were] in this facility for resident's ordered skull series x-ray. resident refused stating Get out, I told you I am a missionary; I don't go over what other people go through . The above skull series x-ray not performed at this time. resident refused.7-30-2025 at 7:47 PM - Resident stated she doesn't take meds nurse notified.7-31-2025 at 7:41 PM - [Resident] stated she doesn't take medication nurse notified.8-2-2025 at 12:20 PM - I am calling about [Resident #1] . Noncompliant with taking medications. This started on 07/28/2025. Since this started has stayed the same. The following makes this condition worse refusing medications . Resident noted to have behaviors of refusing meds and is hard to redirect . Resident noted to have more pacing in and out of room and verbal aggressiveness towards staff. Informed that resident has been refusing her medication saying she is not sick .8-5-2025 at 7:25 PM - Resident stated she doesn't take medications that nothing is wrong with her because she is a missionary.8-19-2025 at 1:40 PM - Patient noted with increased agitation yelling at another resident and noted to have verbal outburst when discussing boundaries and behaviors. Patient gets upset and yells at staff. Patient can be redirected at times but requires constant redirection.8-19-2025 at 1:40 PM - Resident #1 in the dining room and reported to be verbally aggressive with table mate .8-21-2025 at 12:03 PM - Resident #1 is noted to have increased agitation with anxiety, yells at staff, pacing and follows staff .8-25-2025 at 12:20 PM - Resident #1 is noted to have agitation and yells at staff, pacing .8-26-2025 at 1:25 PM - Resident #1 has been verbally aggressive with staff, yells out when redirected, then paces to her room .8-28-2025 at 5:20 PM - Resident #1 pacing and follows 1 staff and yells out with agitation when staff redirects her that she has to work. Tells staff. Shut up, you don't do nothing! .8-31-2025 at 3:52 PM - Resident #1 was observed entering another resident's room (313A) and removing clothing items from the closet . the resident became verbally and physically agitated. She raised her voice and yelled, stating, Y'all work for the devil and when God tells me to leave then I'll leave or when she tells me to leave then I will, but the rest of y'all can go to hell.9-5-2025 at 11:11 AM - Social Worker Note: and changing clothes multiple times per day. Resident #1 is currently being followed by [mental health professional]. She has also been noted to bother other residents and cross personal boundaries .10-7-2025 at 2:45 PM - ADON A witnessed resident from RM [ROOM NUMBER]A hit resident [Resident#6] on her left shoulder while passing by outside dining room across by nurse's station . [Resident #1] was verbally aggressive when asked why she hit the other and walked away to her room, refused assessment .10-8-2025 at 8:28 AM - NP notified . Patient noted to have physical aggressive behavior toward residents and staff. Refuses all medications and assistance from staff. While supervising the patient as a one on one, patient struck staff. Patient unable to be redirected; screaming and using profanity toward staff. Patient chasing staff member through dining room trying to strike at her. Patient redirected by staff x several attempts. Patient goes into her room and after 1-2 mins return to hallway yelling and screaming at staff and other patients trying to hit staff while screaming in their face .Police and 911 called .10-8-2025 at 9:01 AM - Resident #1 to be transferred to Psychiatric ER Hospital because of altered mental state with aggression and physical aggression .10-8-2025 at 10:45 AM - While supervising patient as a one on one, patient chased staff away, struck staff to her back. Patient unable to be redirected; screaming and using profanity toward staff. Patient chasing staff member through dining room trying to strike at her again. Patient redirected by staff x several attempts. Patient goes into her room and after 1-2 mins return to hallway yelling and screaming at staff and other patients trying to hit staff while screaming in their face .10-8-2025 at 11:01 AM - ADON A stated Patient needs cannot be met, facility attempts to meet the resident needs, and the service available are refused by patient x several attempts. Patient is a danger to the health and safety of other residents and individuals if failure to transfer or discharge is not implemented. Patient was transferred to [Psychiatric Hospital] at this time accompanied by police and non-emergency services .10-17-2025 at 8:25 AM - Resident #1 with verbal aggression, aide with nurse checking on her and yelled out to get out of her room, banged door behind them .10-21-2025 at 2:46 PM - Resident #1 pacing around. Continues on 1 on 1. Came to the nurse station and told this nurse that will not pray for the writer anymore shouting and spit, then left away from the nursing station .10-22-2025 at 10:30 PM - Police arrived at the facility at about 10pm to transport resident to [Psychiatric Hospital], visited the resident in her room. They walked out. One of the officers returned and told this nurse that they were not taking her because they did not have a mental warrant .11-27-2025 at 12:40 PM - Resident #1 refused all her morning meds and vitals, x 2 attempts with different nurse, resident replied, I am not taking those meds, i don't have any sickness to take them, i will follow what God told me . Resident #1 continued to be non-compliant with taking medications intermittently till 4-2026.1-19-2026 at 9:30 AM - Resident #1 is physically aggressive to a staff member, resident was being redirected from interfering with another patient's care. Yells out when redirected, has been non-compliant with taking her meds, verbally aggressive when redirected .1-21-2026 at 2:35 PM - Resident #1 became verbally hostile towards staff, pacing and yells back and calls staff fools when asked not to assist other residents .1-21-2026 at 4:29 PM - Resident #1 hit another resident and was seen walking from the hallway. Writer asked resident what happened, called writer ugly fool .1-22-2026 at 6:29 AM - Resident #1 would come out of room at times, early in the morning resident went down 400 hall and became verbally aggressive when being redirected off the hall, resident then went down the hall yelling and walked into dining room, then went in her bedroom and slammed the door 2 times.4-2-2026 at 5:43 PM - Resident #1 hit Resident #2 in the dining room. Resident #1 was asked what happened but told this nurse to go away .Record review of Resident #1's EMR assessment section, revealed 9 Internal Investigation Reports where Resident #1 abused other Residents. These reports are the following:7-30-2024 - Resident #1 slapped Resident #3 on her hand twice as Resident #3 was touching her [NAME] Box. 9-29-2024 - Resident #1 hit Resident #4 with a closed fist on Resident #4's right arm. Resident #4 said Resident #1 also hit two other Residents that day. 10-15-2024 - Resident #1 spit on Resident #5 and hit Resident #5 in the face.12-17-2024 - Resident #1 slapped Resident #5 on the face. 10-7-2025 - ADON A saw Resident #1 hit Resident #6 who was non-verbal. 10-8-2025 - Resident #1 hit Resident #7 unprovoked. Resident #7's progress notes revealed she was hit in the face by Resident #1, and it made her cry. Resident #7 was noted to be non-verbal and ADL dependent. 1-21-2026 - Resident #1 hit Resident #8 on her arm and was verbally abusive.4-1-2026 - Resident #1 hit Resident #2 with a closed fist.In an observation and interview on 4-15-2026 at 3:05 PM, Resident #1 was observed to be in a private room and ambulating by walking. Resident #1 said she touched Resident #2's arm but denied hitting her. Resident #1 said I do not take medicine because I am not sick! I'm a missionary and God protects me. God told me to stop taking medicine. In an observation and interview on 4-15-2026 at 3:19 PM, Resident #2 said Resident #1 tried to push Resident #2 in her wheelchair against her will when she told Resident #1 to stop. That is when Resident #1 punched Resident #2 in the arm. Resident #2 said she did not feel safe around Resident #1 and no Residents in the facility should feel safe around Resident #1. In an observation and interview on 4-15-2026 at 3:28 PM, Resident #8 said Resident #1 came into her bedroom, while she was asleep, and hit her with a closed fist in her chest. Resident #8 said Resident #1 told her to call your people, they were all going to hell, and my kids were all stupid. Resident #8 said she did not feel safe around Resident #1. In an interview on 4-15-2026 at 11:22 AM, the Activity Director said she witnessed Resident #1 punch, with a closed fist, Resident #2 in the dining room on 1-21-2026. The Activity Director said she believed Resident#1 should be placed in a secured unit somewhere else. In an interview on 4-15-2026 at 4:54 PM, the Staffing Coordinator said in October 2025 she witnessed Resident #1 physically assault Resident #7 by hitting her with a closed fist repeatedly with a punching motion. The Staffing Coordinator said Resident #7 was non-verbal and had the use of one arm. After the incident the Staffing Coordinator was one-on-one supervision for Resident #1 outside Resident #1's room. However, Resident #1 came charging out of her room toward the Staffing Coordinator in a threatening manner yelling I don't need no one to sit with me, you're going to hell. The Staffing Coordinator said Resident #1 started punching her with a closed fist in a downward pounding motion. The Staffing Coordinator then ran down the hallway, into the dining room, and then into the TV room when the IA intervened and blocked Resident #1 from attacking her. The Staffing Coordinator said Resident #1 seems to target Caucasian people.In an interview on 4-16-2026 at 11:15 AM, the Interim Administrator (Director of Operations of Momentum Skilled Services) said he had filled in as a temporary Administrator at the facility from September 2025 through 12-5-2025 and came back to the facility on 4-1-2026. The IA said the facility's procedure for dealing with aggressive behavior Resident #1 had was to have a psychologist do an assessment and have her medications reviewed to see if changes need to be made. The IA said the facility had problems with Resident #1 refusing to take medications. The IA said the other problem the facility had with Resident #1 was getting her moved to another type of facility because her social security funds ran out to pay for Medicaid. He stated no facility will take Resident #1 if she did not have insurance or money. The IA said, the facility had successfully handled Residents like Resident #1 in the past and he felt they could successfully handle Resident #1. The IA said the risk to other residents if the facility did not successfully manage Resident #1's behaviors was There can be all kinds of risk. What specific risk I cannot tell you. The IA said all residents had the right to feel free from abuse in their own homes. After showing, from the facility's own EMR, 9 separate times Resident #1 abused other residents, the IA said he didn't know why those residents were not protected because he was not here during the time those incidents occurred. The IA said the regular DON resigned on 4-7-2026. In an interview on 4-16-2026 at 11:45 AM, ADON B said she had worked at the facility for 7 years and had been an ADON for 1 year. ADON B said ADON A resigned yesterday 4-15-2026. ADON B said the procedure the facility followed when Resident #1 starts being aggressive was to do in-service training on abuse, follow standing orders, order psychiatric services, and follow what they recommend. ADON B did not believe the facility was adequately equipped to manage Resident #1's aggressive behaviors. ADON B said there has always been roundtable discussions as to whether Resident #1 should reside at the facility. She had always been told it was a money problem. Resident #1 would be sent to a psychiatric hospital, her guardian would then tell the facility if you will take Resident #1 back, I will get her discharged in 2 weeks. ADON B said however, discharge never occurred. ADON B said in 2-2026, she witnessed Resident #1 hit Resident #8, then hit the Staffing Coordinator and chase her throughout the facility. ADON B said she was assaulted by Resident #1 2 years ago when Resident #1 grabbed her close to her throat, broke a necklace around her throat, and scratched her chest. ADON B showed scars on her chest Resident #1 left from the attack. ADON B said the risk to other residents if the facility could not manage aggressive behaviors was harm to residents. ADON B said residents had a right to be free from abuse, had a right to feel safe in their own home, and felt the facility was not equipped to handle someone like Resident #1. ADON B said the last time in-service training on abuse was given at the facility was on 4-6-2026. In an interview on 4-16-2026 at 12:30 PM, the Corporate DON (CD) said the facility DON resigned the previous week. The CD said it depends on what type of aggressive behavior a resident exhibited to determine what action was needed. CD said if the aggression was verbal, the facility would respond in a calm manner and remove the stimuli. CD said if the aggression was physical, the facility would separate the aggressive residents from the other residents so no one would get hurt. The CD initially said she felt the facility could manage Resident #1's behaviors. However, after the CD saw the 9 facility internal reports of Resident #1's attacks on residents and realized Resident #1 had a diagnosis of Homicidal Ideations, the CD changed her response and said, no one with a Homicidal Ideation diagnosis should be residing in a nursing home environment. The CD said residents had a right to be free from abuse and feel safe in their own homes. The CD did not know why the Residents, in the 9 internal facility reports, were not protected. In an interview on 4-16-2026 at 12:36 PM, ADON A said the facility's procedures for dealing with aggressive behaviors were to start de-escalation and identify triggers. ADON A said when Resident #1 was acting out, a little too much, they tried to redirect her. However, when her behavior was too aggressive, the facility had to remove Resident #1 from the general population. ADON A said when she fully blows up, there is no stopping her. ADON A said the facility was not set up to handle the type of aggression Resident #1 would exhibit. ADON A said what typically happened was Resident #1 would hit someone and EMS would not respond because the incident was not medical, the police would come and say Resident #1 was a psychiatric issue and leave, and there was never any real change. ADON A said the process with Resident #1 has been a revolving door. ADON A said residents had a right to be free from abuse and feel safe in their own homes. In an observation and interview on 4-16-2026 at 5:20 PM, Resident #9 was lying in bed and needed a mechanical lift to transfer to a wheelchair. Resident #9 said she had been slapped by Resident #1 and did not feel safe around her. In an interview on 4-16-2026 at 5:30 PM, Resident #11 said he had witnessed Resident #1 verbally abuse residents and been taken to jail. In an observation and interview on 4-16-2026 at 5:55 PM, Resident #10 was observed lying in bed eating dinner. Resident #10 said being in the same facility as Resident #1 made her feel like beating the shit out of her. Resident #10 said being around Resident #1 disturbed her peace, made her feel like she did not live in a homelike environment, and not feel safe. Resident #10 said she had been verbally abused by Resident #1 and threatened with physical violence. In an interview on 4-17-2026 at 11:50 AM, the Social Worker (SW) said she had worked at the facility since 12-25-2025. After reviewing Resident #1's care plan, progress notes, and diagnoses, the SW said Resident #1 was not appropriate to reside at the facility. The SW said the facility was trying to discharge Resident #1 to another facility. In an interview on 4-17-2026 at 12:50 PM, CMA C had worked at the facility for 7 months and did not feel safe around Resident #1 because she did not want to get hit. CMA C said to be honest, the facility doesn't do anything to stop Resident #1 from hitting other residents. When she is on 1-to-1 supervision she will hit the one-on-one staff member. If Resident #1 gets bad they try to give her a shot of Haldol to try to calm her down, but she doesn't let staff give her medications either. She has seen her close to hitting someone. To her, Resident #1 knows what she is doing. Weekly she is combative. On 4-14-2026 she was last in-serviced on Abuse/neglect. Residents #2, #8, and #12 have told me they do not feel safe around Resident #1. An IJ was identified on 4-16-2026 at 3:40 PM. The Administrator was notified. The IJ template was provided to the Administrator on 4-16-2026 at 3:40 PM and a Plan of Removal was requested at that time.The facility's plan of removal (POR) was accepted on 4-17-2026 at 2:42 PM.Plan of RemovalName of facility: Lake [NAME] Rehabilitation CenterDate: 4/16/26F- 600 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Problem: The facility failed to protect residents from aggressive behaviors from Resident #1. Resident #1 on multiple occasions, verbally and physically attacked other residents.1. 4/16/16 Resident #1 immediately placed on 1:1 until alternative placement is secured. 2. 4/16/26 Psych services assessed the resident for inappropriate behaviors and medication adjustments as necessary.3. On 4/16/26 Residents #2 and #3 were immediately assessed by the IDON/designed without physical injuries noted. They were also assessed for mental anguish by the facility Social Worker and verbalized feeling safe. 4/16/264. Interviews were conducted with residents who were able to participate and answer questions. A skin assessment audit was initiated with residents who are nonverbal, and any issues identified were immediately corrected by the IDON/Designee. 4/16/265. The Interim Administrator and the Interim DON received 1:1 in-service on abuse, neglect, and reporting policy and procedures along with the company expectation to adhere to it by the Vice-President of Clinical Services. 4/16/266. On 4/16/26 The Social worker received a 1:1 in-service by the IADM on proper resident discharge planning for residents who are physically and verbally abusive towards other residents and timely follow up. Any concerns are immediately reported to the administrator 4/16/267. The ADON self-terminated employment by the facility on 4/16/268. The Facility [NAME] President of Clinical Services reviewed Abuse, neglect and Exploitation policy and procedure no changes were necessary. Completion 4/16/20269. The IDON nurse initiated and in-serviced on the corporate Compliance hotline to report any unresolved issues by the facility administration. Completion date 04/17/26 Interventions10. On 4/16/26 The IDON/designee immediately initiated and in-service with all facility staff regarding Resident Rights, Abuse and Neglect and expectations to keep residents free of abuse and reporting. Administrator/Abuse Coordinator will provide ongoing oversight, in-services and supervision of staff in order to assure that policies are implemented and followed as written. Completed 4/17/2611. 4/16/26 The Administrator and IDON provided a training presentation to the facility staff on abuse and neglect to include Definition of abuse, understanding abuse, signs and symptoms of abuse, resident to resident abuse and facility and staff responsibility on reporting. This presentation included a facility specific procedure on reporting and included examples of various types of abuse. Completed 4/17/2612. 4/16/26 4/16/26 Residents noted with aggressive or violent behaviors towards other residents will immediately put 1:1 until the facility can arrange alternative placement. If alternative placement can't be secured and if the residents' behaviors are persistent and not manageable at the facility, the facility will contact the local authorities for assistance, transfer to them back to the hospital/psych unit and will collaborate with the IDT to ensure alternative placement is secure regardless of payer source.13. 4/17/26 The facility referrals are reviewed by the IDT through [AI software] to ensure they have a place to discharge safely, and/or a responsible party and are appropriate for our community before they are admitted into the facility. Residents identified to have aggressive or violent behaviors are declined for admission. Residents with violent, aggressive and unmanageable behaviors are deemed not appropriate for admission as the facility is not well equipe to maintain residents who are consistently displaying aggressive and/or violent behaviors.14. On 4/16/26 the Administrator reviewed the grievances from the last 3 months; all grievances were addressed and up to date with no abuse concerns. Completion 4/17/26. Monitoring15. 4/16/26 Residents with behavior or changes in condition are monitored daily by staff during ADL care. Inappropriate behaviors are reported and assessed by their assigned nurse; assessment then is communicated to the resident physician for order and or interventions.16. 4/16/26 The IDON/IADM and designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with all facility staff. Immediate re-education will be completed by the IDON/IADM/designee if any staff is unable to answer appropriately the questions on the questionnaire. 4/17/2617. Staff will not be allowed to work until after completion of the questionnaire. Completed 4/17/26. 18. The IDON/IADM/IDT will review Incident and accidents during the morning meeting to ensure these are properly investigation and have appropriate interventions in place, any issues noted will be immediately addressed by the IDON/IADM or designed. 4/16/1619. 4/16/26 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Surveyor Monitoring:An interview on 04/17/26 at 12:30 PM with the Administrator revealed the facility did not have other residents who had aggressive behaviors toward other residents and only had a handful of residents who were sometimes combative or verbally aggressive with staff during care. Shortly after this interview, he provided a list of six residents who sometimes were combative or verbally aggressive with staff during care. Interviews with three residents who were listed as having combative or verbally aggressive behaviors with staff, and observations of all six of those residents revealed no concerns about these residents having aggressive or abusive behaviors toward other residents. Between 1:38 PM and 7:30 PM on 4-17-2026 staff covering all shifts and departments were interviewed about types of abuse, identifying possible abuse, procedures for de-escalating resident behaviors and managing resident to resident aggressive behaviors, reporting concerns related to possible abuse and neglect, and what to do if they felt administrative staff did not address reported issues. The following staff were interviewed, and all were found to be knowledgeable about the above procedures: ADON B, CMA C, CNA D, CNA E, LVN F, LVN G, CMA H (Staffing Coordinator), LVN I, CNA J, CNA K, LVN L, LVN M, CNA N, CNA O, CNA P, Dietary Manager, Cook, LVN Q, CNA R, CNA S, CNA T, CNA U, CNA V, LVN W, LVN X. An interview on 4-17-2026 at 6:00 PM, revealed the Corporate DON said the IJ was called because Resident #1 has put others at risk because other residents have rights. The DON said staff were in-serviced on de-escalating, resident rights, abuse and neglect with validation on how to report abuse, when, who to and what HHSC phone # is, and nursing did a change in condition one. How to initiate on the compliance hotline with corporate. Did a power point (PP) on who can cause abuse, who is at risk for abuse, details and examples. The DON said she and the IA would oversee monitoring, no changes to the abuse policy occurred, and the Abuse Coordinator was the IA. If the IA was not available, the Corporate DON would be the person staff would report abuse to. The Corporate DON said the facility would determine if it could manage certain behaviors by using an Artificial Intelligence (AI) software program that flags certain behaviors like aggression and restraints. The Corporate DON said the facility would ensure the safety of residents by removing stimulation that causes misbehaviors and will discharge residents whose behavior cannot be managed. An interview on 5-17-2026 at 6:30 PM, the IA said he believes the IJ was called because Resident #1's past events/behaviors and her medical condition. The IA said the in-services were on abuse/neglect, resident rights, de-escalating strategies, a power point presentation was given on abuse, and the corporate compliance phone line number. The IA and Corporate DON stated they would oversee the monitoring to ensure compliance with the POR. The IA said there were no changes to the facility's policies and procedures, he was the Abuse Coordinator, and a designee would be appointed if he was unavailable. The IA said the facility will use an AI software program that will alert red flags of certain types of behaviors that would be inappropriate for the facility to admit. This would help protect residents in the future and if residents who were already admitted don't get along with roommates, they would be moved. The IA said the nursing staff would oversee monitoring of resident's behaviors because they have behavior sheets to monitor medications. The CNAs would monitor combative behaviors and report them to the nurses. Review of the facility's EMRs for six residents (Residents #13, #14, #15, #16, #17, #18) who had combative behaviors or verbal aggression toward staff was reviewed, and no concerns related to abuse of residents were found. Review of the Plan of Removal documentation reflected:1. The Social Worker will discharge residents in a timely manner who have verbal or physical behaviors that cannot be managed2. A corporate compliance hotline phone # was given to staff to report when the facility administration fails in completing duties.3. Residents that portray aggressive or violent behaviors towards residents will immediately be put on 1:1 supervision until the facility can properly discharge them. 4. The facility referrals will be reviewed by the Interdisciplinary Team through the AI software program to ensure a proper discharge can be made and not accept residents who are not appropriate for the facility. An IJ was identified on 4-16-2026 at 3:40 PM. While the IJ was removed on 4-17-2026, the facility remained out of compliance at a scope of pattern and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective measures.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 3 of 8 Residents (Residents #6, #7, #8 ) reviewed for abuse and neglect. The facility failed to report to the Texas Health and Human Services Commission alleged abuse that occurred when Resident #1 physically and verbally abused Resident #6 on 10-7-2025, physically abuse Resident #7 on 10-8-2026, and physically and verbally abused Resident #8 on 1-21-2026. These failures could place residents at risk of abuse, neglect, pain, psychosocial harm, and a diminished quality of life. Findings included:Record review of Resident #1's Face Sheet, dated 4-15-2026, reflected a [AGE] year-old female with an original admission date of 4-26-2021 and a readmission date of 11-4-2025. Resident #1 had a primary diagnosis of dementia with psychotic disturbance (the presence of delusions or hallucinations in individuals with a diagnosed neurodegenerative [chronic loss of function in nerve cells] disorder) and secondary diagnoses of homicidal ideations (thoughts, fantasies, or plans about killing another person), paranoid schizophrenia (a chronic mental health disorder, characterized by intense, irrational delusions and hallucinations-often auditory centered on persecution or conspiracy), dementia with other behavioral disturbance (involves non-cognitive symptoms like agitation, aggression, depression, wandering, or social disinhibition) schizoaffective disorder (a chronic mental health condition combining schizophrenia symptoms (hallucinations, delusions, disorganized speech) with major mood disorder, such as depression or bipolar mania), psychosis not due to a substance or known physiological condition, and insomnia (a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking too early, leading to daytime fatigue, irritability, and poor concentration). Review of Resident #1's Quarterly MDS dated [DATE], revealed Resident #1 re-entered the facility from an inpatient psychiatric facility with a BIMS score of 8 which indicated being mildly cognitively impaired. The D Mood section indicated Resident #1 often felt socially isolated. Section E Behavior section indicated Resident #1 rejected evaluation and care daily. Review of Resident #1's most recent Care Plan with an initial date of 5-24-2022 and revised on 2-9-2026 revealed she was physically aggressive to staff and residents having a pair of scissors being at risk for potential for harming herself and others. Resident #1 has attempted to use metal utensils to harm staff. On 10-7-2025 Resident #1 hit another resident, 10-8-2025 Resident #1 was physically aggressive to another resident, 1-21-2026 Resident #1 was physically aggressive toward another resident. Resident #1 was at risk for delirium initiated on 4-24-2022 stating the devil will tell her to do things, Resident #1 was resistive to care by refusing to take medications revised on 4-5-2023, Resident #1 had potential to be verbally aggressive yelling at staff because of ineffective coping skills revised on 5-19-2021, Resident #1 was physically aggressive to staff and residents because of poor impulse control by locking herself in other resident's bathroom revised on 6-20-2023, Resident #1 had aggressive behavior problems striking Residents initiated on 9-29-2024, Resident #1 was care planned to receive antipsychotic medication for mood & behavior management revised on 7-24-2022.Review of Resident #1's progress nurse notes reflected the following:10-7-2025 at 2:45 PM - ADON A witnessed resident from RM [ROOM NUMBER]A hit resident [Resident#6] on her left shoulder while passing by outside dining room across by nurse's station . [Resident #1] was verbally aggressive when asked why she hit the other and walked away to her room, refused assessment .10-8-2025 at 8:28 AM - NP notified . Patient noted to have physical aggressive behavior toward residents and staff. Refuses all medications and assistance from staff. While supervising the patient as a one on one, patient struck staff. Patient unable to be redirected; screaming and using profanity toward staff. Patient chasing staff member through dining room trying to strike at her. Patient redirected by staff x several attempts. Patient goes into her room and after 1-2 mins return to hallway yelling and screaming at staff and other patients trying to hit staff while screaming in their face .Police and 911 called .10-8-2025 at 9:01 AM - Resident #1 to be transferred to Psychiatric ER Hospital because of altered mental state with aggression and physical aggression .10-8-2025 at 10:45 AM - While supervising patient as a one on one, patient chased staff away, struck staff to her back. Patient unable to be redirected; screaming and using profanity toward staff. Patient chasing staff member through dining room trying to strike at her again. Patient redirected by staff x several attempts. Patient goes into her room and after 1-2 mins return to hallway yelling and screaming at staff and other patients trying to hit staff while screaming in their face .10-8-2025 at 11:01 AM - ADON A stated Patient needs cannot be met, facility attempts to meet the resident needs, and the service available are refused by patient x several attempts. Patient is a danger to the health and safety of other residents and individuals if failure to transfer or discharge is not implemented. Patient was transferred to [Psychiatric Hospital] at this time accompanied by police and non-emergency services .1-21-2026 at 2:35 PM - Resident #1 became verbally hostile towards staff, pacing and yells back and calls staff fools when asked not to assist other residents .1-21-2026 at 4:29 PM - Resident #1 hit another resident and was seen walking from the hallway. Writer asked resident what happened, called writer ugly fool .Record review of Resident #1's EMR assessment section, revealed the facility filled out Internal Investigation Reports where Resident #1 abused Resident #6, #7, and #8. The reports stated: 10-7-2025 - ADON A saw Resident #1 hit Resident #6 who was non-verbal. 10-8-2025 - Resident #1 hit Resident #7 unprovoked. Resident #7's progress notes revealed she was hit in the face by Resident #1, and it made her cry. Resident #7 was noted to be non-verbal and ADL dependent. 1-21-2026 - Resident #1 hit Resident #8 on her arm and was verbally abusive.Record review of Resident #1's progress notes dated 10-7-2025 and 10-8-2025 revealed the Administrator and DON were notified of the incidents of Resident #1 striking Resident #6 and Resident #7. Record review of Resident #8's progress notes dated 1-21-2026 at 4:20 PM, revealed the DON was notified of Resident #1 striking Resident #8. Resident #6, #7, and #8's face sheet, care plan, MDS, and orders were not obtained. Record review of Resident #7's progress notes revealed Resident #7 died on 2-12-2026 from unrelated causes. In an interview and observation on 4-15-2026 at 3:05 PM, Resident #1 was observed in a private room ambulating on her own. Resident #1 denied hitting anyone and said she would be in jail if she hit anyone. In an interview and observation on 4-15-2026 at 3:28 PM, Resident #8 was observed to be in her room and said Resident #1 came into her room when she was asleep, hit her with a closed fist in her chest, and yelled your people and you are all going to hell and your kids are stupid. Resident #8 said Resident #1 still comes into her room and did not feel safe around her. In an interview and observation on 4-16-2026 at 5:53 PM, Resident #6 was observed to be lying in her bed, awake, and unresponsive to questions. In an interview on 4-16-2026 at 11:15 AM, the IA stated he was the Interim Administrator for the facility from [DATE] through [DATE]. The IA said he returned to the facility as the Interim Administrator on 4-1-2026. In an interview on 4-17-2026 at 6:30 PM, the IA said he did not know why abuse was not reported to Texas Health and Human Services Commission (THHSC) regarding Resident #6 and #7 in [DATE] and Resident #8 in [DATE]. The IA said the risk for not reporting abuse would be the abuse will continue happening. The IA said he expected abuse to be reported immediately. Record review of Resident #6's progress notes failed to show any documentation or assessment that she had been hit by Resident #1. Review of (THHSC) Long Term Provider Letter #PL 2024-14 (Replaces PL 2019-17), titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC), Provider Type: Nursing Facilities (NF), dated [DATE], stated: A NF must report to CII (Complaint and Incident Intake) the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect . Immediately, but not later than two hours after the incident occurs or is suspected.Review of TULIP (Texas Unified Licensure Information Portal) revealed no reports being filed from the facility for allegations of abuse or neglect concerning Residents #6, #7, or #8 during [DATE] or [DATE].

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for four of six residents (Resident #1, #2, #3, and #5) reviewed for the resident rights.The facility failed to ensure the call light system in Resident #1, #2, #3, and #5's room was in a position that was accessible to the residents on 03/05/26. This failure could place residents at risk of being unable to obtain assistance when needed, and help in the event of an emergency.Findings included:Record review of Resident #1's Face Sheet, dated 03/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses of a need for assistance with personal care and muscle weakness.Record review of Resident #1's Quarterly MDS Assessment, dated 02/10/26, reflected the Resident's BIMS (11) indicated a moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of a need for assistance with personal care and muscle weakness. Record review of Resident #1's Comprehensive Care Plan, dated 01/12/26, reflected Resident #1 was a fall risk and an intervention included the resident to have her call light with reach.During an observation on 03/05/26 at 08:10 a.m., Resident #1 was observed lying in bed and her call light was on the floor, under the bed.During an observation and interview on 03/05/26 at 08:20 a.m., CNA F was shown Resident #1's call light positioned under her bed. She stated the call light should be positioned within reach of the resident so she could call for help.2. Record review of Resident #2's Face Sheet, dated 03/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had a diagnosis of paralysis of the left side of her body.Record review of Resident #2's Quarterly MDS Assessment, dated 02/09/26, reflected the Resident's BIMS (15) indicated an intact cognitive response. The Quarterly MDS Assessment reflected a stroke, and paralysis of the left side of her body. Record review of Resident #2's Comprehensive Care Plan, dated 02/05/26, reflected Resident #2 required assistance to perform functional abilities in self-care and mobility and an intervention included to encourage resident to use call light.During an observation and interview on 03/05/26 at 08:11 a.m., Resident #2 was observed lying in bed and her call light was hanging on the lower portion of the left side rail, out of reach from the resident. The resident stated she was trying to get staff to help reposition her in bed, but did not know where her call light was located.3. Record review of Resident #3's Face Sheet, dated 03/05/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses of a lack of coordination and muscle weakness.Record review of Resident #3's Quarterly MDS Assessment, dated 02/19/26, reflected the Resident's BIMS (12) indicated a moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of unsteadiness on feet, and muscle weakness. Record review of Resident #3's Comprehensive Care Plan, dated 02/21/26, reflected Resident #3 required assistance to perform functional abilities in self-care and mobility and an intervention included to encourage resident to use call light.During an observation and interview on 03/05/26 at 08:13 a.m., Resident #3 was observed lying in bed and his call light was hanging on the lower portion of the left side rail, out of reach from the resident. He stated he did not know where his call light was and wanted it to contact staff.During an interview and observation on 03/05/26 at 08:15 a.m., LVN H was shown the locations of the call lights for Resident #2 and #3, and she stated the call lights needed to be in reach of the resident so they could contact staff for assistance. She stated it was everyone's responsibility to ensure the resident's call light was within reach of the resident.4. Record review of Resident #5's Face Sheet, dated 03/05/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses of lack of coordination and muscle weakness.Record review of Resident #5's Quarterly MDS Assessment, dated 01/02/26, reflected the Resident's BIMS (10) indicated a moderate cognitive impairment. The Quarterly MDS Assessment reflected the resident had active diagnoses of a need for assistance with personal care and muscle weakness. Record review of Resident #5's Comprehensive Care Plan, dated 01/01/26, reflected Resident #5 required assistance to perform functional abilities in self-care and mobility and an intervention included to encourage resident to use call light.During an observation and interview on 03/05/26 at 08:22 a.m., Resident #5 was observed lying in his bed. He stated he did not know where his call light was located. The call touch pad was located on the floor and out of reach of the resident.During an observation and interview on 03/05/26 at 08:27 a.m., CNA L was shown Resident #5's call touch pad on the floor. She stated she was not the CNA for that hall. She stated the call touch pad should be positioned near the resident so that he could press it if he needed help.During an interview on 03/05/26 at 12:19 p.m., Unit Manager C was informed of Residents #1, #2, #3, and #5's call light devices not being within reach of the residents, and she stated they should all be in reach of the resident so they could contact staff if they needed assistance. She stated all staff were to check for this when they completed their rounds.During an interview on 03/05/26 at 12:30 p.m., ADON A was informed of Residents #1, #2, #3, and #5's call light devices not within their reach, and she stated the call light needed to be within reach of the resident in case they need help. She stated it was all staff's responsibility to ensure call lights were in reach of resident.During an interview on 03/05/26 at 01:07 p.m., the DON was informed of Resident #1, #2, #3, and #5' call light devices not being within reach of the residents, and she stated they should all be within reach of the residents so they could contact staff if they needed assistance. She stated her nursing staff informed her of the findings. She stated everyone should check to ensure call lights were within reach of the resident.Record review of the facility's policy on Call Lights: Accessibility and Timely Response, revised 02/23, revealed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 6. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 6 residents (Resident #4 ) reviewed for care plan. The facility failed to ensure Resident #4's care plan reflected a plan of care for the resident's use of a BiPAP device. This failure could place residents at risk of not receiving necessary care and services.Findings included:Record review of Resident #4's Face Sheet, dated 02/18/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had a diagnosis of acute respiratory failure.Record review of Resident #4's Quarterly MDS Assessment, dated 02/21/26, reflected Resident #4's BIMS (15) indicated an intact cognitive response. The Quarterly MDS Assessment reflected the resident had active an diagnosis of acute respiratory failure.Record review of Resident #4's Comprehensive Care Plan, dated 02/23/26, revealed no care plan for the use of the BiPAP device. Record review of Resident #4's Physician orders, dated 03/05/26, reflected BiPAP settings 20/8 with O2 @ 2L at bedtime. During an interview on 03/05/26 at 12:19 p.m., Unit Manager C was informed of Resident #4 not care planned for the use of the BiPAP device, and she stated it should have been care planned. She stated she was not responsible for updating care plans. She stated it should be care planned because it shows what care the resident needed.During an interview on 03/05/26 at 12:30 p.m., ADON A stated the MDS Nurse, the ADON, the DON, and the Treatment Nurse updated care plans. She stated if a resident used a BiPAP machine, it should be care planned. She was informed of Resident #4 not being care planned for the use of the BiPAP device. She stated he should be care planned so his treatment could be monitored.During an interview on 03/05/26 at 12:51 p.m., the MDS Nurse, was informed of Resident #4 not being care planned for the use of the BiPAP device and she stated it should be care planned because if not, it could place him at respiratory distress. She stated the nurses should update the care plans, and since it was coded on her end, she should have updated his care plan.During an interview on 03/05/26 at 01:07 p.m., the DON was informed of Resident #4 not being care planned for the use of the BiPAP device, and she stated it should be care planned because it was a special device. She stated if the resident arrived to the facility with the device, the MDS nurse should have updated the care plan. She stated if the resident had new orders for the device while at the facility, it was the DON and ADON's responsibility. She stated not care planning the use of the device could result in missed care.Record review of the facility's policy, Comprehensive Care Plans, revised 04/2023, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Policy Explanation and Compliance Guidelines . 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of six residents (Resident #4) reviewed for respiratory care.The facility failed to ensure Resident #4's breathing treatment masks were properly stored in a bag when not in use on 03/05/26. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #4's Face Sheet, dated 02/18/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had a diagnosis of acute respiratory failure.Record review of Resident #4's Quarterly MDS Assessment, dated 02/21/26, reflected Resident #4's BIMS (15) indicated an intact cognitive response. The Quarterly MDS Assessment reflected the resident had an active diagnosis of acute respiratory failure.Record review of Resident #4's Physician orders, dated 03/05/26, revealed BiPAP settings 20/8 with O2 @ 2L at bedtime and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) mg/3ml 1 unit every 6 hours.During an interview and observation on 03/05/26 at 08:18 a.m., LVN H was shown by the Surveyor, Resident #4's BiPAP mask and Nebulizer mask on top of the nightstand unbagged. She stated the masks should be bagged when not in use to avoid infection.During an interview on 03/05/26 at 12:19 p.m., Unit Manager C was informed of Resident #4's BiPAP and Nebulizer mask being observed unbagged while not in use, and she stated they should have been bagged when not in use to avoid infections. She stated all department heads should check to ensure the masks were bagged and dated. During an interview on 03/05/26 at 12:30 p.m., ADON A was informed of Resident #4's BiPAP and Nebulizer mask not bagged when not in use. She stated the masks should be bagged to avoid any type of infection. She stated the nursing staff, and leadership should check to ensure masks were bagged.During an interview on 03/05/26 at 01:07 p.m., the DON was informed of Resident #4's BiPAP and Nebulizer masks not being bagged when not in use. She stated it should have been bagged when not in use to avoid the resident getting an infection. She stated the charge nurse was responsible for ensuring the items were bagged when completing her rounds.Record review of the facility's policy Oxygen Administration, revised 01/2025, reflected Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. PROCEDURES. e. Keep delivery devices covered in a antimicrobial bag when not in use.

Based on observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 residents of 25 residents (Resident #17, Resident #89, Resident #57, Resident# 66, Resident #63) reviewed for ADLs.The facility failed to ensure:1. Residents #17, #57, and #63's fingernails were trimmed.2. Residents #89 and #66's fingernails were cleaned and trimmedThese failures could place residents who were dependent on staff for ADL care at a loss of dignity and a decreased quality of life.Findings include: 1. Record review of Resident #17's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old male with an admission date of 09/19/22. Resident #17 had a BIMS score of 15 which indicated he was cognitively intact. He required substantial to maximum assistance for personal hygiene, toileting, bathing and dressing and had not refused care. He had functional limitation in range of motion upper and lower extremities on one side extremities. He was frequently incontinent of bowel and bladder. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #17's care plan revised on 12/17/25 reflected, Functional Abilities: [Resident #17] requires assistance to perform functional abilities in Self Care and Mobility related to his history of cerebral vascular accident with left hemiplegia.Intervention.Provide the following self-care assistance.Personal Hygiene: dependent. In an observation and interview on 01/12/26 at 9:10 AM, Resident #17 was observed lying in bed. His nails on both hands were clean and approximately 1/2 an inch in length. He stated he needed them trimmed badly. He stated no one had offered to trim his nails. Resident had limited use of his left hand, and his wrist was turned downward approximately 90 degrees. Resident stated he did not like his nails that long and stated it had been over a month since anyone had trimmed his nails. On 01/12/26 at 2:15 PM, an observation and interview with Resident #17's nails was made with the DON. She stated his nails definitely needed trimming. She stated that the risk of long nails were skin tears, pressure wounds to the palm of his left hand, and increased infection. She stated the staff saw him every day, getting him up, dressing him, and the nurses perform weekly skin checks. She stated someone should had noticed his nails. Resident #17 stated no one offered to trim his nails. The DON stated she would ensure they were trimmed today (01/12/26) and would be putting in a new process to ensure all of the residents' nails were maintained properly. 2. Record review of Resident #89's quarterly MDS assessment, dated 11/21/25, reflected a [AGE] year-old male with an admission date of 12/21/22. Resident #89 had a BIMS score of 15 which indicated he was cognitively intact. He was dependent for personal hygiene, toileting, bathing, eating and dressing and had not refused care. He had functional limitation in range of motion of both upper extremities and one side lower extremities. He was always incontinent of bowel and bladder. Diagnoses included spinal stenosis of the cervical (neck) regions (narrowing of spaces with the spine that puts pressure on the spinal cord, often causing pain and weakness in the back, neck, arms or legs), and chronic obstructive pulmonary disease (inflammation and obstruction of the airways, making it hard to breath). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #89's care plan initiated on 11/19/24 reflected, [Resident #89] requires assistance to perform functional abilities in Self Care and Mobility as indicated by unsafe and poor quality in range of motion related to medically complex conditions .Intervention.Provide the following self-care assistance.Personal Hygiene: dependent. In an observation and interview on 01/12/26 at 1:00 PM, Resident #89 was observed lying in bed being fed lunch by a staff member. Resident's right arm was drawn up to his neck with his hand turned inward. His left hand was contracted with his second finger overlapping his first finger. Unable to determine the length of his nails due to a buildup of thick brown tinged skin with the appearance of snakeskin on his left hand. His nails were jagged and brown tinged. Resident #89 stated no one trimmed them in a while and they needed trimmed. On 01/12/26 at 2:15 PM, an observation and interview with Resident #89 nails was made with the DON. She stated his nails definitely needed trimming, but due to the condition of his hands, they may need to have the podiatrist look at them. She stated his hands definitely needed cleaning and lotion applied. She stated the staff should have alerted her to the condition of his hands. She stated someone should have noticed his nails and hands. The DON stated she would ensure they get his hands cleaned today and then determine if they would be able to trim his nails. In an observation and interview on 01/14/26 at 2:00 PM of Resident #89's hands revealed the buildup of dead; scaly skin had been removed from both his hands and under his nails revealing his nails to be approximately 1/2 inch long but clean. Resident #89 stated they had cleaned his hands and nails and filed his nails. He stated they looked much better. In a follow-up interview with the DON on 01/14/26 at 02:55 PM, she stated she had the CNAs wash Resident #89's hands and only file his nails. She stated she was going to have the treatment nurse cut them due to the severity of his contractures she did not feel comfortable having the CNAs cut his nails. 3. Record review of Resident #57's Annual MDS assessment dated [DATE] reflected, Resident #57 was a [AGE] year-old male with initial admission date of 04/26/2021 to the facility. His relevant diagnoses included: Hypertension (high blood pressure), non-traumatic brain dysfunction (causes damage to the brain by internal factors, such as a lack of oxygen, exposure to toxins, or pressure from a tumor), aphasia (impairment in a person's ability to comprehend or formulate language), and non-Alzheimer's dementia (Cognitive decline). He needed supervision from staff regarding personal hygiene. His BIMS score of 12 indicated Resident # 57's cognition was moderately impaired. He had functional limitation in the range of motion of his upper and lower extremities on one side. Record review of Resident #57's care plan revised on 05/22/2025 reflected, [Resident #57] requires assistance to perform functional abilities in Self Care and Mobility as evidenced by poor quality in functional range of motion related to Non-Traumatic Brain Dysfunction, Dementia. Goal: Intervention: Will have improvement in functional abilities in the following areas. Intervention: Provide the following self-care assistance.Personal Hygiene: supervision/ touching dependence. In an observation and interview on 1/11/2026 at 10:27 AM with Resident #57 revealed he was sitting in his room. Resident had long nails on both hands measuring about 0.5-0.7 inch long. Resident #57 stated that he would like his nails trimmed since he did not prefer long nails. He added that the staff had not offered to clip his nails. He stated that he had not alerted any staff regarding clipping his nails. In an observation and interview on 01/13/2026 at 11:00 AM, Resident # 57's nails on both hands were clipped. Resident #57 stated, they (Staff) came in yesterday to trim my nails. 4. Record review of Resident #66's quarterly MDS assessment dated [DATE] reflected, Resident #66 is a [AGE] year-old male with initial admission date to facility on 11/20/2023. His pertinent diagnoses included coronary artery disease (heart disease, characterized by the buildup of plaque in the coronary arteries), Hypertension (high blood pressure), Dementia (decline in cognitive function), Schizophrenia (serious mental health condition that affects how people think, feel and behave). He needed set up from staff for personal hygiene. He has a BIMS score of 14 which indicated Resident # 66 had intact cognition. Record review of Resident #66's care plan initiated on 01/12/2026 reflected, Focus: Behavior Problem: [Resident #66] has an unwanted behavior as evidenced by Refusing Care. Intervention: . Encourage resident to allow staff to trim nails. An observation and interview on 01/11/2026 at 10:56 AM revealed Resident #66 had long, discolored and dirty nails on both hands. Resident #66's nails had black discoloration beneath the nail bed and were about 0.3-0.5 inch long. Resident stated he would like his nails trimmed and cleaned. He stated that he had not informed any staff member regarding nailcare. 5. Record review of Resident #63's quarterly MDS assessment dated [DATE] reflected, Resident # 63 is a [AGE] year-old female with initial admission date to the facility on 7/22/2025. Her pertinent diagnoses included stroke (Decreased blood flow to the brain), hypertension (High blood pressure), Anemia (low blood count), Diabetes (high blood sugar), Hyperlipidemia (elevated lipid levels). She needed substantial assistance from staff for personal hygiene. She had a BIMS score of 8 which indicated Resident # 63's cognition was moderately impaired. Record review of Resident #63's care plan revised on 8/4/2025 reflected, Goal: Functional Abilities: [Resident #63] requires assistance to perform functional abilities in ADL Self Care and Mobility . Intervention I. Personal Hygiene: Substantial/Max. An observation and interview on 01/11/2026 at 10:45 AM reflected Resident #63 had long nails extending from the nail bed to the tip about 0.3-0.5 inch. Resident #63 stated that she would like her nails clipped. She also added that she did not remember if staff had offered nail care to her in the last few days. An observation and interview on 1/12/2026 at 9:05 AM with CNA P revealed she had been working at the facility since November 2024. She stated that CNAs were responsible for trimming and cleaning nails. She stated Nailcare was offered to residents on shower days and as needed. She added, for residents with diagnoses of diabetes, nurses were responsible for cutting nails. She stated that Residents #57, #66, and #63 had long nails, and they needed to be clipped. She stated that Resident #57 could be resistive to care sometimes, but she would offer nail care to him after the interview. She added the risk of not cleaning and cutting nails was the possibility of bleeding, skin infection, and loss of dignity. An interview on 1/12/2026 at 9:09 AM with LVN R, she stated she worked in the facility as a PRN nurse but was aware of resident care needs. She stated CNAs and Nurses were responsible for nail care. She added charge nurses were responsible for clipping nails for residents who were diabetics. She added that Resident #57 and Resident #66 could be resistive to care. However, nail care should still be offered to them on shower days and as needed. She stated that she had not heard of CNAs reporting any refusals to her for Residents #57 and #66 in the past few weeks. She stated the risk of not cutting and cleaning nails was lapses in infection control and decreased quality of life for residents. An interview on 01/12/2026 at 4:20 PM with the Nursing Manager revealed CNAs and nurses were responsible for nail care and should be offered on shower days and as needed. She added nurses were responsible for clipping nails for diabetic residents. She stated the risk of not cutting and cleaning nails was lapses in infection control and decreased quality of life for residents. She stated that if residents refused ADL care, it should be documented and the family and physician should be notified. In an interview on 1/12/2026 at 9:45 AM with the DON, she stated that her expectation was that ADL care should be performed on shower days and as needed. She stated that both CNAs and nurses were responsible for providing ADL care, including nail care. She also stated that nurses were responsible for clipping fingernails for diabetic residents. She stated if the resident refused, refusals should be reported to the charge nurse and documented. She stated that risk to residents with dirty, long fingernails could be skin irritation and loss of dignity. She stated that she ensured quality of care in residents by daily rounding on all residents. She stated the DON and other Nursing Management would be responsible for following up and ensuring those tasks were carried out. Review of the facility's policy titled, Activities of Daily Living revised on 1/2025 reflected, .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for four of seven Residents (Resident #17, Resident #8, Resident #89, and Resident #3) reviewed for quality of care.1. The facility failed to implement interventions to prevent further decline of Resident #17's contracture to his left wrist.2. The facility failed to implement interventions to prevent further decline of Resident #8's contracture to his left hand.3. The facility failed to implement interventions to prevent further decline of Resident #89's contracture to his left hand, right hand and shoulder. 4. The facility failed to implement interventions to increase range of motion for Resident #3's upper and lower extremities. This failure could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included:1. Record review of Resident #17's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old male with an admission date of 09/19/22. Resident #17 had a BIMS score of 15 which indicated he was cognitively intact. He required substantial to maximum assistance for personal hygiene, toileting, bathing and dressing and had not refused care. He had functional limitation in range of motion upper and lower extremities on one side extremities. He was frequently incontinent of bowel and bladder. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #17's care plan revised on 08/01/25 reflected, Cerebral Vascular Accident [Resident #17] has the diagnosis of Cerebral Vascular Accident with left side hemiparesis and is at risk for falls, contractures, over all wellbeing decrease.Interventions.Therapy to eval and screen as ordered and as needed. There were no interventions listed for the contractures. Record review of Resident #17's Skilled Therapy referral initiated by the Director of Rehab dated 12/16/25 reflected, Patient referred to nursing for hand contracture. Patient appropriate for left resting hand splint to be worn for max of 4-hour duration. Patient would benefit from left hand splint to be worn during breakfast and lunch mealtimes to encourage more independence with self-feeding. In an observation and interview on 01/12/26 at 9:10 a.m. Resident #17 was observed lying in bed. Resident had limited use of his left hand, and his wrist was turned downward approximately 90 degrees, and he was unable to straighten his wrist. He stated he had been trying to get a splint from therapy for a few months but stated nothing had happened. He stated he did not want his wrist to get worse. In an observation of Resident #17 and interview with OT L on 01/12/26 at 1:40 p.m. OT L assessed his left arm, wrist and hand and stated she thought he would benefit from therapy to improve his flexibility and decrease the pain. She stated he would benefit from a resting hand splint. She stated he was about the same as he was in December 2025 when they recommended a resting hand splint. 2. Record review of Resident #8's quarterly MDS assessment, dated 11/04/25, reflected a [AGE] year-old male with an admission date of 03/18/24. Resident #8 had a BIMS score of 15 which indicated his cognition was intact. He required substantial to maximum assistance for personal hygiene, toileting, bathing and dressing and had not refused care. He had functional limitations in range of motion upper and lower extremities on one side extremities. He was always incontinent of bowel and bladder. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #8's care plan revised on 11/03/25 reflected, [Resident #8] has a history of Cerebral Vascular Accident.Goal.Minimize the risk of complications for Cerebral Vascular Accident.Interventions.Keep positioning devices on and areas dry and clean to maintain proper alignment. An interview and observation with Resident #8 on 01/11/26, revealed resident lying in bed finishing lunch. His left hand was curled into a fist, and the resident was unable to straighten his fingers or open his hand. Resident #8 stated he had never had a splint or brace for his hand, and he needed one. He stated he had not gotten therapy since he had been here. In an observation of Resident #8 and interview with OT L on 01/12/26 at 2:00 p.m., OT L stated Resident #8's left hand would not be classified as a contracture because it was flaccid and had no tone, but he would benefit from a resting palm guard for comfort and positioning. 3. Record review of Resident #89's quarterly MDS assessment, dated 11/21/25, reflected a [AGE] year-old male with an admission date of 12/21/22. Resident #89 had a BIMS score of 15 which indicated he was cognitively intact. He was dependent for personal hygiene, toileting, bathing, eating and dressing and had not refused care. He had functional limitation in range of motion of both upper extremities and one side lower extremities. He was always incontinent of bowel and bladder. Diagnoses included spinal stenosis of the cervical (neck) regions (narrowing of spaces with the spine that puts pressure on the spinal cord, often causing pain and weakness in the back, neck, arms or legs), and chronic obstructive pulmonary disease (inflammation and obstruction of the airways, making it hard to breath). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #89's care plan with the last revision date of 12/03/25 on reflected, [Resident #89] requires assistance to perform functional abilities in Self Care and Mobility as indicated by unsafe and poor quality in range of motion related to medically complex conditions. There were no interventions to address the resident's contractures to his right arm and left hand. Record review of Resident #89's Skilled Therapy referral initiated by the Director of Rehab dated 12/16/25 reflected, Patient referred to nursing for hand contracture. Patient appropriate for left resting hand splint to be worn for max of 4-hour duration. Patient would benefit from left hand splint to be worn during breakfast and lunch mealtimes to encourage more independence with self-feeding. In an observation and interview on 01/12/26 at 1:00 p.m. Resident #89 was observed lying in bed being fed lunch by a staff member. Resident's right arm was drawn up to his neck with his hand turned inward. His left hand was contracted with his second finger overlapping his first finger. Resident was able to move his wrist slightly but was not able move his fingers. He stated he needed something done for his right hand because he would like to be able to use for more independence. He stated he had not had any exercise for his left hand. He stated he was not able to move his right arm or hand at all. In an observation of Resident #89 and interview with OT L on 01/12/26 at 2:05 p.m. OT L assessed Resident #89's left hand, right hand and right arm and stated he would benefit from therapy to improve his flexibility and decrease the pain. She stated he would benefit from a resting hand splint. She stated he was about the same as he was in December 2025 when they recommended a resting hand splint. 4. Review of Resident #3's Face sheet dated 1/13/26 reflected a [AGE] year-old female with an original admission date of 3/25/23 and a readmission date of 10/22/25. Review of Resident #3's Significant Change MDS assessment, dated 10/28/25, reflected her cognition was intact with a BIMs of 13. The resident had upper and lower extremity impairment on one side and used a walker. Resident #3 was dependent on staff for toileting, showering, lower body dressing and putting and taking off footwear. She also needed substantial assistance with upper body dressing and personal hygiene. Resident #3 had no therapy. Active diagnoses included Cerebrovascular Accident (commonly known as a stroke, where blood flow to a part of the brain is interrupted), Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body), Hemiplegia following Cerebral Infraction (paralysis or severe weakness of one side of the body due to brain damage), effusion left knee (excess fluid buildup in or around the knee joint) and pain in left knee. Review of Resident #3's Physical Therapy Evaluation & Plan of Treatment dated 8/15/25 reflected .Focus of plan of Treatment = Restoration.Assessment Summary: Clinical Impressions: Patient presents with left-sided hemiparesis, inability to grip with left hand, impairments in motor control, trunk control, postural control, activities tolerance, generalized strength, sitting balance and tolerance, and generalized coordination, thus negatively impacting performance of bed mobility and manual w/c mobility. Reason for Skilled Services: given the assessment above, patient will highly benefit from PT services in order to address the above impairments and allow patient improve bed mobility, Out of Bed frequency and maximize functional manual wheel chair propulsion to improve functional independent in the facility.Assessment Summary: Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for : Deep vein thrombosis(blood clot), falls, immobility, further decline in function, depression, dehydration, limited out of bed activity, muscle atrophy, pressure sores, decreased skin integrity, contracture (s) and compromised general health. Review of Resident #3's comprehensive care plan revised on 10/30/25, reflected, .Resident #3 has the diagnosis of Cerebral Vascular Accident with hemiparesis and is at risk for falls, contractures, over all wellbeing decrease. Left hemiparesis Date Initiated: 05/20/2025 Revision on: 05/20/2025 The resident will not experience signs and symptoms of a Cerebral Vascular Accident unaddressed X 90 days. Date Initiated: 05/20/2025 Revision on: 10/30/2025 Target Date: 11/11/2025 The resident will maintain current level of independence X 90 days. Date Initiated: 05/20/2025 Revision on: 10/30/2025 Target Date: 11/11/2025 . Therapy to eval and screen as ordered and as needed date initiated 5/20/25. Interview with Resident #3 on 01/11/2026 at 11:44 a.m. revealed she had been at the facility for a while and was there for therapy and had not had any therapy since her admission. She also stated no one had assisted her with any exercise. Resident #3 stated she would like to walk again and be more independent. Interview with LVN J 01/12/2026 at 2:23 p.m. revealed she had been Resident #3's nurse for several months. LVN J stated she was not completing restorative therapy with her. She stated therapy had not provided any exercises to do with Resident #3. She stated the risk of not having received any exercises or assistance from therapy would have been the resident could decline and become more contracted. An interview with the Director of Rehab on 01/12/2026 at 1:01 p.m. reflected Resident #3 was not on therapy. The Director of Rehab stated Resident #3 had been evaluated on 6/18/25 and 8/15/25 by therapy, and determined she needed therapy, but when it was submitted to the insurance, it was not approved. She stated the rehab department would reassess the resident whenever her payor source changed to see if they would be approved therapy. Resident #3 had not had therapy in the last year due to not being approved by her insurance. The Director of Rehab stated when the payor source denied therapy the next step would have been to notify the Administrator but did not know if this was done due to her not working at the facility when Resident #3's last evaluation was done. She stated they had not recommended restorative for her because they had not provided any therapy, therefore, they would not have recommended restorative care. She stated the risk to the resident of not receiving rehab was possible decline and/or lack of improvement in her ADLs. In an interview with the DON on 01/12/26 at 2:25 p.m., she stated she was not sure if the therapy department had a contracture management program. She stated she knew therapy was screening residents quarterly, and she would expect them to develop a plan for the management of those residents with contractures and communicate those plans with nursing. She stated there had been 3 Administrator and 2 Directors of Therapy since she had started in March 2025 which had impeded some of the communication between departments. She stated she knew that therapy was looking into some of the residents, but she was not sure if those residents were going to receive therapy or be handed back to nursing. She stated nursing had not received any instruction on education of splint placing for Resident #17 or Resident #89. In an interview on 01/13/26 at 7:35 a.m. with the Previous Administrator/Corporate Compliance, he stated he was the acting administrator from around the first of November 2025 until December 5th, 2025, when he handed off the building to the current Administrator. He stated sometime around the end of November 2025, he had requested the therapy department screen for contractures and to provide a list to them on what residents needed splints. He stated that was the last conversation he had with the therapy department before he handed off the building. He stated therapy was supposed to be screening every time a resident's quarterly assessment was completed. He stated they were provided with a list of the upcoming assessments and should be performing those screenings at the time of the MDS assessments. In an interview with MDS Nurse G on 01/13/26 at 10:00 a.m., she stated she was presented with a list, on 01/06/26, of all of the residents in the building who had contractures. She stated the therapy department had been discussing the outcome of the screenings in their morning meetings, but she was not sure what interventions they had determined needed to happen and for which residents. She stated contractures needed to be care planned with the necessary interventions to improve or prevent further decline from happening. In an interview with the Director of Rehab on 01/13/26 at 11:00 a.m., she stated her department had been requested to screen every resident in the building for contractures. She stated it took several weeks to get everyone screened. She stated they identified the residents who had contractures and needed splints. She stated she had submitted the request for the splints to be ordered to central supply, and her plan was once the splints arrived, they would follow up with the DON. She stated they had several residents who would benefit from therapy but did not have a payor source to cover it. She stated Resident #17 and Resident #89 were two of the residents who they had requested splints for. In an interview with the Administrator, DON and Director of Therapy on 01/13/26 at 12:05 p.m., the Administrator stated they had all met and discussed the steps which needed to be taken going forward. The Administrator stated once a resident was evaluated by therapy, and was determined to have a need for therapy, to assess and treat to establish the necessary interventions, they were to submit the evaluation to the payor source and if denied or if there was not a payor source, they were to immediately notify her so they could move forward with meeting the resident's needs. She stated the therapy department had been instructed to re-evaluate those residents who had been identified and put in the necessary orders and interventions to meet those residents' needs. Record review of the facility's policy titled, Prevention of Decline in Range of Motion, dated December 2025, reflected, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motions is unavoidable.Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion.Based on the comprehensive assessment, the facility will provide interventions, exercises, and/or therapy to maintain or improve range of motion.This includes, but is not limited to.Specialized rehabilitation, restorative, maintenance.braces or splints.Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner.

Based on observation, interview, and record review, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 24 residents (Resident #98, Resident #68, Resident #12, and Resident #17) and 1 of 4 linen closets (Linen Closet for Hall 100) and the facility's only laundry room observed for infection control. 1. The facility failed to ensure CNA D and LVN E utilized Enhanced Barrier Precautions during incontinence care for Resident # 98 on 01/11/26. 2. The facility failed to ensure LVN E utilized Enhanced Barrier Precautions, performed hand hygiene after glove changes during wound care, and prevent cross contamination of the treatment cart after completion of wound care for Resident # 98 on 01/11/26. 3. The facility failed to ensure CNA C and CNA B changed their gloves and performed hand hygiene while providing incontinence care for Resident #98, used enhanced barrier precautions, and perform hand hygiene before entering and leaving the resident's room on 01/12/26. 4. The facility failed to ensure CNA C performed hand hygiene and glove changes during incontinence care of Resident #17, and CNA C and CNA B performed hand hygiene before entering and leaving the resident's room on 01/12/26. 5. The facility failed to ensure LVN E performed hand hygiene and changed gloves during Fingerstick blood sugar, prevent cross contamination of Resident #68's insulin pen, follow the manufacturer's recommendations for disinfecting the glucometer after obtaining fingerstick blood sugars for Resident #68, and failed to prevent cross contamination of LVN E's medication cart on 01/11/26. 6. The facility failed to ensure Agency LVN K utilized Enhanced Barrier Precautions while performing G tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) medication administration for Resident # 12 on 01/11/26. 7. The facility staff failed to store residents' personal clothing away from clean linens in Linen Closet for hall 100. 8. The facility staff failed to appropriately secure and label bags of residents' clothing in the facility's laundry room on 1/12/27. These failures could place residents at risk of cross-contamination and the development of infection.Findings include: 1. Record review of Resident #98's Significant change MDS assessment dated [DATE] reflected [AGE] year-old female with an admission date of 09/07/23. She was always incontinent of bowel and bladder. Diagnosis included Parkinson's disease (disorder of the central nervous system that affects movement), dementia, and diabetes. Record review of Resident #98's admission Note dated 01/09/26, completed by LVN J, reflected, . readmitted for kidney infection, on cipro until 1/12/26. Foley 18FR (unit for sizing catheters), light pink color. Open area to coccyx, top of right thigh open area no depth, boggy heels, right heel more soft with a scab, MD notified of arrival An observation and interview on 01/11/26 at 10:14 a.m. revealed CNA D providing incontinent care to Resident #98. CNA D put on gloves, but no gown. Resident was observed to have a urinary catheter and a wound dressing above her anus. There was no signage posted to indicate the resident was on Enhanced Barrier precautions. The wound care dressing was covered in bowel movement, and CNA D stated she would have to get the Nurse to come and redress the wound. CNA D removed her gloves, washed her hands and left the room to go and get the nurse. CNA D and LVN E entered the room, washed their hands and put on gloves, but no gown. CNA D continued to provide incontinence care and with instruction from LVN E. She removed the wound care dressing, revealing a stage 3 pressure ulcer (involves full-thickness skin loss). LVN E stated the resident had just returned from the hospital on Friday (01/09/26) She stated she did not have a urinary catheter before she went to the hospital and believed she had the wound before, but stated she only worked the weekends, and was not sure. LVN E stated she would have the Treatment Nurse come and re-dress the wound, if she was here, if not, she would review the orders and re-dress the wound. Both staff removed their gloves, washed their hands, and left the room. An observation on 01/11/26 at 10:49 a.m. revealed LVN E was outside of Resident #98's room preparing the wound care treatment. She gathered a bottle of wound care cleanser, an open package of 4X4 gauze, collagen sheet (wound care dressing that promotes healing), and a dry dressing. LVN E entered the room and retrieved paper towels from the resident's bathroom and placed them on the Residents over bed table and laid out the wound care supplies. She then washed her hands and put on gloves but did not put on a gown. LVN E picked up the bottle of wound cleanser and sprayed the wound and pulled a few 4x4 gauze from the package of gauze and cleaned the wound. She removed her gloves, but did not perform hand hygiene, then applied the collagen dressing to the wound bed, changed gloves again with no hand hygiene, and covered the wound with a dry dressing. LVN E then removed her gloves, did not perform hand hygiene, and picked up the bottle of wound cleanser and the remaining unused 4x4 gauze and returned them to the top of the treatment caret. She re-entered the Resident's room and performed hand hygiene and returned to the cart and placed the bottle of wound cleanser and the 4x4's back into the treatment cart. In an interview with LVN E on 01/11/26 at 12:50 p.m., she stated Resident #98 should have been placed in Enhanced Barrier Precaution when she returned from the hospital on [DATE]. She stated any resident with a urinary catheter or wound had to be on enhanced barrier precautions, and she and the CNA should had worn a gown while providing care to Resident #98. She stated they did this to prevent the spread of multiple drug-resistant organisms to other residents. She stated she was supposed to perform hand hygiene after every glove change during wound care and just forgot. She stated she should had only taken in the supplies she needed, and by returning supplies to the cart, she had cross-contaminated the cart. She stated the Weekend Supervisor usually did the wound care on the weekends and the Treatment Nurse did the wound care during the week, but they were also responsible for wound care in their absence. She stated she would make sure the Enhanced Barrier Sign was posted. In an interview with CNA D on 01/11/26 at 1:18 p.m., she stated any resident with a catheter or wound was supposed to be in Enhanced Barrier Precautions which required them to wear a gown. She stated it was not posted outside of Resident #98's room, and she did not think to stop and go get a gown. She stated she had been trained on Enhanced Barrier Precautions and knew it was to prevent the spread of infection to other residents. In an observation on 01/12/26 at 09:30 a.m., CNA B and CNA C entered Resident #98's room. An Enhanced Barrier sign was posted outside of the room. Both staff put gloves on without performing hand hygiene, but neither staff put on a gown. CNA B unfastened the resident's brief and wiped across his pubic area, down each groin, but did not separate the labia and wipe down the middle or clean the catheter tube from the insertion site downward. CNA B did not remove her gloves or perform hand hygiene after cleaning the resident's front. Both staff assisted the Resident onto her side, and CNA C wiped from front to back to clean the anal area and then placed a clean brief under her without changing her gloves and performing hand hygiene. Both staff then rolled the resident back onto her back and fastened the brief. Both staff removed their gloves and left the room without performing hand hygiene. 2. Record review of Resident #17's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old male with an admission date of 09/19/22. He was frequently incontinent of bowel and bladder. Diagnoses included diabetes, cerebral vascular accident (stroke), and hemiplegia (paralysis on one side of the body). In an observation on 01/12/26 at 9:15 a.m., CNA C entered Resident #17 to perform incontinence care. CNA C entered the room and without performing hand hygiene put on gloves and unfastened the Residents brief and assisted the Resident to roll onto his left side revealing the resident was wet. CNA C then reached between the resident's legs and wiped downward with the penis and scrotum going toward the anal peri area with a few wipes. Wiped the anal area outward and then placed a clean brief under the resident, still wearing the same soiled gloves. CNA C assisted the resident back onto his back and fastened the brief. CNA B entered the room, put on gloves without performing hand hygiene and assisted with pulling the resident up in bed. CNA B removed her gloves and left the room without performing hand hygiene, while CNA C gathered the trash, removed her gloves and left the room without performing hand hygiene and walked down the hallway, deposited the trash in the soiled linen room, went to use the hand sanitizer in the hallway, which was empty, and then stepped into another resident's room and used the hand sanitizer on the wall. In an interview on 01/12/26 at 9:50 a.m. with CNA B and CNA C, they stated both stated they were supposed to sanitize their hands before and after providing care and acknowledged they had failed to do that. They both stated residents who had catheters were supposed to wear a gown when providing care and they had also failed to do that. CNA C stated she was not aware she had to change her gloves when going from dirty to clean during incontinence care. CNA B stated she knew she was supposed to change her gloves when going from dirty to clean and just failed to do it. They both stated they had received training on Enhanced Barrier Precautions, and were skills checked each year on hand hygiene. They stated the risk of not following infection control protocols was the spread of infection to other residents. 3. During a medication pass observation on 01/11/26 at 11:49 a.m., LVN E was at the medication cart preparing to check Resident # 68's blood sugar levels via a fingerstick blood sugar. LVN E retrieved a tray from the medication cart, wiped it down with a germicidal wipe, and then removed glucometer which was wrapped in a germicidal wipe from the top of medication cart. LVN E removed the wipe and placed the glucometer on the tray, along with several needles, a bottle of test strips, and the resident's Insulin pen. LVN E sanitized her hands, put on gloves and entered the resident's room. LVN E pricked the residents' fingers, obtained the blood sample for the blood glucose reading and placed the glucometer with the test strip still in it and the used lancet, on the tray next to the insulin pen and the unused needles. LVN E then attached a needle to the insulin pen, still wearing the same gloves she used to perform the finger stick blood sugar, primed the pen and dialed in the amount of insulin, and administered the insulin. LVN E then placed the pen back on the tray with the dirty glucometer, used lancet, and test strip, and returned to the medication cart where disposed of the lancet and test strip and returned to the medication cart and placed the glucometer on top of the medication cart. She then disposed of the needle and used test strip, removed her gloves, and performed hand hygiene. She then retrieved a germicidal wipe and wiped down the glucometer and the bottle of test strips and placed both of them back into the top of the medication cart without allowing them to air dry and returned the unused needles back into the top of the medication cart. In an interview and observation with LVN E on 01/11/26 at 12:52. p.m., LVN E retrieved the germicidal wipes from her medication cart, which revealed the amount of time an item needed to remain wet to achieve disinfection was 2 minutes. She stated she was not aware the glucometer had to air dry before placing it back in the cart. She stated she took Resident #68's insulin pen with her because he routinely received a set amount insulin regardless of the blood sugar readings. She stated she should have only taken in the supplies she needed and not the whole bottle of test strips. She stated any disposable items she did not use would be considered contaminate since it had been in the resident's room. She stated looking back, she should have completed the fingerstick blood sugar, removed her gloves and performed hand hygiene, before giving the insulin. She stated the risk was the spread of blood borne pathogens. 3. An observation on 01/11/26 at 02:58 p.m. of G-Tube medication administration revealed Agency LVN K at the medication cart outside of Resident #12's room. An Enhanced Barrier sign and a cart containing gowns were outside of the door. Agency LVN K prepared the medication for Resident #12, sanitized her hands and put on gloves, but did not put on a gown. Agency LVN K checked for residual, flushed the tube with water, and then administered the medication and flushed with water following the medication administration. Agency LVN K removed her gloves and performed hand hygiene and left the room. In an interview with Agency LVN K on 01/11/26 at 3:09 p.m., she stated any resident with a G-tube was required to be in Enhanced Barrier Precautions. She stated she should have worn a gown and just overlooked it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of MDRO's. 4. During an interview and observation with the Housekeeping Supervisor of the linen closets in the facility on 01/12/2026 at 2:36 p.m. revealed 6 clothing items were observed stored on the shelf with clean linens in the Linen Closet on Hall 100. The Housekeeping Supervisor was unable to state who put the clothing there or who it belonged to. He stated residents' clothing should not have been stored with the linens. He then grabbed the stack of clothes and held them until arriving in the laundry room and put the clothing in a yellow bin on the dirty side of the laundry room. He stated he did not know if the clothing was clean or dirty and therefore put it in the bin to be washed. The Housekeeper Supervisor stated he had never seen clothing in linen closets; clothing should not be stored in linen closets due to risk of cross contamination. Observation of the laundry room revealed two doors. The first door was the dirty side; this was where the dirty clothes were handled. On the floor on the dirty side were two wide open large clear plastic bags with clothes in them. The bags had no label on them and were about 75 percent full. The Housekeeping Supervisor stated the bags were not supposed to be wide open on the floor and should have been closed and labeled with the name of a resident they belonged to. The Housekeeping Supervisor further stated because he was unsure if the clothing was soiled with bodily fluids the bags should have been closed and put in the yellow barrel with the top on to avoid issues with cross contamination. If the clothing were from a resident with EBP the clothing would need to have been stored in a different bag. The Housekeeping Supervisor stated there could be a health risk to the residents due to the bags not being properly closed or labeled. In an interview with Laundry Staff A on 01/12/2026 at 2:59 p.m., it was revealed that all clothes and linens were transported to the laundry room in plastic bins and sealed bags. If the clothing was in a bag, it should have been labeled with the resident's name and tied. She stated she saw the bags of clothes in the laundry room when she started her shift at 2pm, but she did not know who they belonged to as they just showed up. She stated she believed they were dirty but not soiled because they did not look soiled. She stated the risk of having the clothes just thrown there with no name and opened, was it would affect residents getting their items back timely. She stated if they were soiled items there could be a risk of cross contamination especially if they belong to a resident who was on EBP. Laundry Staff A also stated clean linen should not have been stored with residents' clothing. There should not have been any residents' clothing in the linen closets. Interview with CNA O on 01/12/2026 at 3:24 p.m. revealed residents' dirty clothing was stored in a bag or personal laundry basket in the residents' rooms, and once they were full, the laundry was taken to the laundry room. Before dropping the bags off, she would put the name of the resident and room number on a piece of paper and place it in the bag. She then would take the bags to the laundry room and leave them outside the door, and the button to let laundry staff know she dropped off laundry. For rooms that had residents on EBP, they would put the laundry in the infection cardboard boxes, store them in the bathroom and would notify housekeeping staff to pick them up. The red bag held anything with blood and the yellow bins were for linen. She stated the risk to the residents of not properly securing the bags of dirty laundry and not labeling them, would have been the spread of illness. In an interview with ADON H on 01/14/2026 at 2:05 p.m., she revealed she was the infection preventionist for the facility. She stated any resident who had a G-tube, wound, or urinary catheter was supposed to be in enhanced barrier precautions. She stated the admitting nurse was responsible for ensuring the signage was posted and the supplies were available. She stated she had done extensive training with the staff, even going to the residents' room and having them read on the Enhanced Barrier Precaution sign what care level required them to wear a gown and gloves when providing care. She stated in addition, she had not only provided them with instruction but had done return demonstration with the staff on when they were to perform hand hygiene and gloves changes during wound care and incontinence care. She stated they had no excuse for not following infection protocol, and the risk was spreading infections. She also revealed soiled or dirty linen should have been bagged and closed, and residents' dirty laundry should have been bagged, closed and labeled. She stated the big yellow bins were for soiled linen and should always be covered. The risk to the residents when dirty clothing and linen were not properly closed and transported to the laundry room was cross contamination and infection. She stated Resident's clothing, regardless of whether it was clean or dirty, did not belong in the linen closets because there was a risk of cross contamination. In an interview with the DON on 01/14/2026 at 2:21 p.m., she stated any resident who had any type of indwelling medical device was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was supposed to be posted outside to the door, which explains what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with a g-tube required the use of gown and gloves. She stated the staff had received numerous trainings on the use of Enhanced Barrier Precautions. She stated staff were to change their gloves and sanitize their hands when going from dirty to clean. She stated staff were always required to perform hand hygiene before care and after care. She stated staff were always to change their gloves and perform hand hygiene after completing Fingerstick blood sugars, and before proceeding to Insulin administration. She stated they were never to return disposable items back the medication or treatment cart once they had been taken into a resident's room due to the risk of cross contamination. She stated to disinfect the glucometer, it had to stay wet for the designated amount of time the germicide used and remain on top of the med cart until dry, before placing it back in the cart. She stated when it was put back in the cart wet, it had not been effectively disinfected. As to the handling of soiled resident's clothing, she revealed the expectation of staff was they put residents' dirty clothing in bags with their names on them, tie the bag, and take them to the laundry. It was not okay for staff to place residents' laundry in the laundry room in an open bag without any labels. Not labeling the items could have delayed residents receiving their items back. She stated if clothing had blood or was from a resident diagnosed with c-diff, staff would use the biohazard bags to notify laundry staff the items were contaminated. She did not believe cross contamination was an issue with the bags opened on the floor, because residents that were on special precautions already had biohazard bags in their room, and they would not have their linens in regular bags. The DON stated linen closets should not have had residents' clothing or personal items stored in them. She stated personal items should not have been stored with clean linens because of the risk of cross-contamination if the clothing was dirty. She stated they trained on infection control, during their skills checks, and anytime they had any issues with infections in the building. She stated the risk of not adhering to the protocol was increased risk of infections. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated March 2024, reflected, Enhanced Barrier Precautions (EHPs) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.An order for enhanced barrier precautions will be obtained for resident with any of the following.Wounds.urinary catheters.feeding tubes.Implementation.Make gowns and gloves available immediately near or outside or inside of the resident's room.PPE for enhance barrier precautions is only necessary when performing high-contact care.High-contact resident care activities include.changing briefs or assisting with toileting.Device care or use.urinary catheters.feeding tubes.Wound Care. Record review of the facility's policy, Hand Hygiene, dated February 2023, reflected, All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, resident, and visitors.The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Hand hygiene.Hands are visibly soiled.Between resident contacts.After handling contaminated items.Before applying and after removing personal protective equipment (PPE), including gloves.Before and after handling clean or soiled dressings, linens, etc.When, during resident care, moving from a contaminated body site to a clean body site. Record review of the facility's policy, Glucometer Disinfection, dated January 2025, reflected, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to residents and employees.The glucometers will be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant.Procedure.Put on gloves. Obtain capillary blood glucose sampling.Remove and discard gloves, perform hand hygiene prior to exiting the room.Reapply gloves.Retrieve (2) disinfectant wipes from container.Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry.Perform hand hygiene. Record review of the facility's Laundry policy revised on 6/2025 reflected .1. Aligning with principles of standard precautions, staff shall consider all previously worn clothing and used linens as potentially contaminated.3. Soiled laundry shall be kept separate from clean laundry at all times. Record review of the facility's Safe and Homelike Environment policy revised on 7/2025 reflected .3. Housekeeping and maintenance services will provide as necessary to maintain a sanitary, orderly and comfortable environment. Record review of the facility's Infection Prevention and Control Program revised on 1/2024 reflected .12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times. c. Clean linen shall be delivered to resident care units on covered linen carts with covers down. d. Linen shall be stored on all resident care units on covered carts, shelves, in bins, drawers, or linen closets. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linen unless it is properly bagged.

Based on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 1 (Resident #65) of 7 residents reviewed for resident rights. The facility failed to ensure staff distributed unopened mail packages to Resident #65. This deficient practice could result in residents not receiving their mail in a timely manner and diminished quality of life. Findings included: Record review of Resident #65's face sheet dated 1/14/26 reflected a [AGE] year-old female with an original admission date of 2/25/21 and re-admission date of 9/12/25. Resident #65 had the following diagnoses: Major Depressive Disorder (a serious mood disorder, marked by persistent sadness) and Generalized Anxiety Disorder (a condition marked by excessive, persistent and hard to control worry). Record review of Resident #65's Quarterly MDS Assessment on 12/31/25 reflected she had a BIMs score of 15 which indicated intact cognition. An interview with Resident #65 on 01/11/2026 at 10:11 AM revealed she had been receiving her Amazon packages opened. The last time this occurred was around December 2025. An interview with the Business Office Manager on 1/14/26 at 10:13 AM revealed when the facility received resident mail, they would pass it out to the residents. However, if the mail was medical insurance claims or bank statements, she would open the mail, scan it to herself, and put it in the residents' file on the computer. Interview revealed she would have done that process for bank statements, and insurance mail for all residents at the facility. She would not give residents mail pertaining to bank statements or insurance forms, but would file it in a cabinet. All other mail would have been given to residents as long as they were cognitively alert. The Business Office Manager stated she opened all mail before distributing it for residents who were cognitively impaired, but would give cognitively intact residents their mail closed. She stated if a cognitively impaired resident had gotten a birthday card or gift card, she opened it and then gave it to the resident. When she had a question about whether the resident should have gotten their mail, she would have called the Administrator, but it was rare because she knew who everyone was. The Business Office Manager stated she had delivered closed Amazon packages to residents in the past. Interview with the Business Office Manager revealed the receptionist delivered packages to the residents. Interview revealed she was unaware of the policy on delivering packages to residents. An interview with the Receptionist on 1/14/26 at 10:24 AM revealed she received packages for residents from Amazon, and mail at her desk. She stated she would take the packages to the residents, but before she gave them to the residents, she would show them to the assigned nurse for that resident. Interview with the Receptionist revealed if it was in a soft envelope package, the nurse would feel for what it was and would inform her if she could give the package to the resident. If the package was a box, the nurse would open the box to make sure it was not medication or something the resident could not have, and then she would take it to the resident. She stated she delivered packages to Resident #65 and could not recall if they were open or closed when she delivered them. An interview with the DON on 01/14/2026 at 2:21 PM revealed nursing was not responsible for packages or mail to residents. Interview with the DON revealed she had not heard of any staff opening mail or packages. She was not aware of any policy related to nursing having to check mail or boxes before providing them to the residents. She stated staff opening residents' mail and packages affected the residents' rights to privacy. An interview with the Administrator on 1/14/26 at 4:18 PM revealed when mail was received by the receptionist, it should have been taken to the Business Manager and/or the Activities Director, sorted, and given to the residents. Interview with the Administrator revealed the residents' mail should not have been opened before delivery. There was no reason the facility should open all residents' mail. The residents should have received their Amazon packages closed as well. It was the residents' right to privacy with their mail. The Administrator stated she was unaware staff was opening Resident #65's mail packages. Record review of the facility's policy Communications Within and External to the Facility revised on 3/2025 did not reflect residents' rights to receive closed mail.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two of 25 (Residents #17 and #89) reviewed for comprehensive care plans. 1. The facility failed to include, in the care plan for Resident #17, his left wrist contracture and interventions to prevent further decline.2. The facility failed include, in the care plan for Resident #89, his contracture to his left hand, right hand and shoulder and interventions to prevent further decline of Resident #89'sThese failures could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life and care and did not represent a person-centered coordination of care.Findings included: 1. Record review of Resident #17's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old male with an admission date of 09/19/22. Resident #17 had a BIMS score of 15 which indicated his cognition was intact. He required substantial to maximum assistance for personal hygiene, toileting, bathing and dressing and had not refused care. He had functional limitations in range of motion upper and lower extremities on one side. He was frequently incontinent of bowel and bladder. Diagnoses included diabetes, cerebral vascular accident (stroke), and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7-day look back period. Record review of Resident #17's care plan revised on 08/01/25 reflected, a focus of Cerebral Vascular Accident. [Resident #17] has the diagnosis of Cerebral Vascular Accident with left side hemiparesis and is at risk for falls, contractures, over all wellbeing decrease.Interventions.Therapy to eval and screen as ordered and as needed. There were no interventions listed to address the contractures. Record review of Resident #17's Skilled Therapy referral initiated by the Director of Rehab dated 12/16/25 reflected, Patient referred to nursing for hand contracture. Patient appropriate for left resting hand splint to be worn for max of 4-hour duration. Patient would benefit from left hand splint to be worn during breakfast and lunch mealtimes to encourage more independence with self-feeding. In an observation and interview on 01/12/26 at 9:10 AM, Resident #17 was observed lying in bed. Resident had limited use of his left hand, and his wrist was turned downward approximately 90 degrees, and he was unable to straighten his wrist. He stated he had been trying to get a splint from therapy for a few months, but nothing had happened. He stated he did not want his wrist to get worse. In an observation of Resident #17 and an interview with OT L on 01/12/26 at 1:40 p.m., OT L assessed Resident #17's left arm, wrist and hand, and stated she thought he would benefit from therapy to improve his flexibility and decrease the pain. She stated he would benefit from a resting hand splint. She stated he was about the same as he was in December 2025 when they recommended a resting hand splint. 2. Record review of Resident #89's quarterly MDS assessment, dated 11/21/25, reflected a [AGE] year-old male with an admission date of 12/21/22. Resident #89 had a BIMS score of 15 which indicated his cognition was intact. He was dependent on staff for personal hygiene, toileting, bathing, eating and dressing and had not refused care. He had functional limitations in range of motion of both upper extremities and one side lower extremities. He was always incontinent of bowel and bladder. Diagnoses included spinal stenosis of the cervical (neck) regions (narrowing of spaces with the spine that puts pressure on the spinal cord, often causing pain and weakness in the back, neck, arms or legs), and chronic obstructive pulmonary disease (inflammation and obstruction of the airways, making it hard to breath). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7-day look back period. Record review of Resident #89's care plan with the last revision date of 12/03/25 on reflected, [Resident #89] requires assistance to perform functional abilities in Self Care and Mobility as indicated by unsafe and poor quality in range of motion related to medically complex conditions. There were no interventions to address the resident's contractures to his right arm and left hand. Record review of Resident #89's Skilled Therapy referral initiated by the Director of Rehab and dated 12/16/25 reflected, Patient referred to nursing for hand contracture. Patient appropriate for left resting hand splint to be worn for max of 4-hour duration. Patient would benefit from left hand splint to be worn during breakfast and lunch mealtimes to encourage more independence with self-feeding. In an observation and interview on 01/12/26 at 1:00 p.m., Resident #89 was observed lying in bed being fed lunch by a staff member. Resident's right arm was drawn up to his neck with his hand turned inward. His left hand was contracted with his second finger overlapping his first finger. Resident was able to move his wrist slightly but was not able to move his fingers. He stated he needed something done for his right hand, because he would like to be able to use for more independence. He stated he had not had any exercise for his left hand. He stated he was not able to move his right arm or hand at all. In an observation of Resident #89 and interview with OT L on 01/12/26 at 2:05 p.m., OT L assessed Resident #89's left hand, right hand, and right arm, and stated he would benefit from therapy to improve his flexibility and decrease the pain. She stated he would benefit from a resting hand splint. She stated he was about the same as he was in December 2025 when they recommended a resting hand splint. In an interview with CNA D on 01/11/26 at 10:00 a.m., she stated she was the restorative aide in the facility but also worked on the floor as a CNA. She stated her restorative care mainly consisted of doing weights on the residents. She stated the facility was big on getting weights. She stated she did not do any range of motion or placement of splints on residents. She stated therapy took care of the splints as far as she knew. In an interview with MDS Nurse G on 01/13/26 at 10:00 a.m., she stated she had only been with the facility since October 2025. She stated she was responsible for updating the comprehensive care plan when she completed the Annual, quarterly or significant change assessment. She stated she assumed the DON and ADONs updated the care plan when there were changes. She stated she was presented with a list on 01/06/26 of all of the residents in the building who had contractures but had not updated the care plans yet. She stated the therapy department had been discussing the outcome of the screenings in their morning meetings, but she was not sure what interventions they had determined needed to happen and for which residents. She stated contractures needed to be care planned with the necessary interventions to improve or prevent further decline from happening. She stated the care plan was supposed to be a comprehensive approach to what the needs of the resident were or what their wishes were. An interview with the DON on 01/12/26 at 2:25 p.m. p.m. revealed the MDS Coordinator, herself, and the ADONs were all responsible for updating the care plans. She stated all contractures should have been care planned with interventions in place. She stated if a resident had splints ordered, it should be placed in the physician's orders. The DON stated if a resident refused the required splint, then it should be documented on the care plan. She stated failing to have interventions in place, put residents at risk of further decline and decreased range of motion, and by not updating the care plan, they had no evidence of what attempts had been made to prevent a resident's decline. She stated she knew the therapy staff was supposed to be screening the residents every quarter and would expect if they determined the resident had a new contracture, they would develop a plan with interventions. She stated she knew they were looking at Resident #17 and Resident #89 for possible splints, but the contractures should have been care planned and updated with the interventions they put in place. Record review of the facility's policy, Comprehensive Care, revised April 2023, reflected, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Record review of the facility's policy titled, Prevention of Decline in Range of Motion, dated December 2025, reflected, Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motions is unavoidable.Based on the comprehensive assessment, the facility will provide interventions, exercises, and/or therapy to maintain or improve range of motion.This includes, but is not limited to.Specialized rehabilitation, restorative, maintenance.braces or splints.Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner.

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #39 and Resident #48) of 4 residents reviewed for wound treatment.1. The facility failed to provide care for Resident #39's wounds as identified on the resident's physician's orders on 1/9/2025.2. The facility failed to provide care for Resident #48's wound and obtain physician order for another wound that had reopened on 1/8/2025.These failures could place residents at risk for delayed wound healing or worsening of the exiting wound.Findings included:1.Record review of Resident 39's quarterly MDS assessment dated [DATE] reflected, Resident # 39 was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included: Stroke (Decreased blood flow to the brain), Anemia (low blood count), Hypertension (High blood pressure), Hyperlipidemia (elevated lipid levels in blood) , Hemiplegia (one sided weakness in a person's body), Chronic venous hypertension with ulcer of left/Right lower extremity (damaged valves or blockages cause blood to pool, leading to high pressure, skin changes, inflammation, and open sores (venous ulcers). Her BIMS score was 15 which indicated Resident #39's cognition was intact.Record review of Resident #39's care plan revised on 11/12/2025 reflected, Focus: [Resident #39] has a venous/stasis ulcer of the Right. Posterior Calf related to poor circulation and increased edema . Intervention: .Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated.Record review of Resident #39's care plan revised on 11/12/2025 reflected, Focus: [Resident #39] has a venous of the Left Lateral Leg related to poor circulation and increased edema . Intervention: .Evaluate wound for: Size, Depth, Margins: peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. Document progress in wound healing on an ongoing basis. Notify physician as indicated.Record Review of Resident #39's Physician Orders dated reflected dated 12/31/2025 reflected, Non-Pressure Rt. Posterior Leg/Calf cleanse wound bed with Nexodyn solution ( type of wound cleanser) or wound cleanser, pat dry, apply Xeroform, cover with gauze, Kerlix gauze and Coban. every Monday, Wednesday , Friday related to NONPRESSURE CHRONIC ULCER OF OTHER PART OF RIGHT LOWER LEG WITH FAT LAYER EXPOSED.Record Review of Resident #39's Physician Orders dated 12/31/2025 reflected, Non-Pressure Lower Lt Lateral Leg cleanse wound bed with Nexodyn solution or wound cleanser, pat dry, apply Xeroform, cover with ABD gauze, Kerlix gauze and Coban. every Monday, Wednesday, Friday related to CHRONIC VENOUS HYPERTENSION (IDIOPATHIC) WITH ULCER OF LEFT LOWER EXTREMITY .Record review of Resident #39 Treatment admission Record (TAR) for January 2026 reflected, Non-Pressure Rt. Posterior Leg/Calf cleanse wound bed with Nexodyn solution or wound cleanser, pat dry, apply Xeroform, cover with ABD gauze, Kerlix gauze and Coban . No administration of treatment was recorded on 01/09/2026.Record review of Resident #39 TAR for January 2026 reflected, Non-Pressure Lower Lt Lateral Leg cleanse wound bed with Nexodyn solution or wound cleanser, pat dry, apply Xeroform, cover with ABD gauze, Kerlix gauze and Coban . No administration of treatment was recorded on 01/09/2026.In an observation and interview on 01/11/2026 at 2:45 PM with Resident #39 revealed the date on wound care bandage on both lower extremities was 1/7/2026. Resident #39 stated that wound care was last performed on Wednesday 1/7/26. She stated that the Wound Care Nurse told her she would be on vacation on Friday 1/9/2026 (when wound care was expected to be performed next) and no other staff member had performed the wound care.An interview on 01/11/2026 at 2:51 PM with RN I revealed she worked as the Weekend Supervisor and performed wound care on the weekends. As needed for residents on the weekend. She stated she was aware that the Wound Care Nurse that usually worked in the facility from Monday through Friday, did not work on 1/9/2026. She stated that the assigned floor nurses were responsible for providing wound care to residents on 1/9/2026. She stated that she worked in the facility on 1/10/2026. She stated that she was not aware or informed by any staff that Resident #39 did not receive wound care on 1/9/2026 or over the weekend, until the surveyor brought it to her notice. She stated that she would look at Resident #39's wound care orders after the interview was completed. She stated that the risk of not performing wound care as ordered was worsening of wounds and delayed healing.In an observation on 1/12/2026 at 1:12 PM of Resident # 39's bilateral lower extremity wound care treatment with LVN F revealed Resident # 39 had a new bandage on the wound dated 1/11/2026. Resident #39 stated to LVN F that RN I performed wound care on both the wounds late evening on 1/11/2026. The dressing was dry and the wound was stable.An interview on 1/12/2026 at 1:59 PM with LVN F revealed she worked as the charge nurse on 1/9/26 from 6AM - 2PM. She stated she was aware that the Wound Care Nurse that usually worked in the facility from Monday through Friday, did not work on 1/9/2026 and she was responsible for performing wound care on residents. She stated that she got busy with care for other residents and could not complete the wound care. She asked the oncoming Nurse for 2-10 PM shift (LVN J) to perform wound care for Resident #39. She stated that the risk of not performing wound care, as ordered was worsening of wounds and delayed healing. An interview on 1/12/2026 at 2:16 PM with LVN J revealed she worked as the charge Nurse on 1/9/26 from 2 -10 PM. She stated that LVN F told her that Resident #39 needed wound care. However, she got busy in her shift, taking care of residents that she was not able to complete. She stated that she informed the oncoming Nurse, LVN T, that Resident #39's wound care was pending. She stated that the risk of not performing wound care as ordered was worsening of wounds and delayed healing.In a phone interview on 1/13/26 at 9:02 AM with LVN T revealed she worked as the charge nurse on 1/9/26 from 10 PM to 6 AM on 1/10/26. She stated that LVN J told her that Resident #39 needed wound care. However, she got busy in her shift taking care of other residents, and was not able to complete it. She stated that she informed RN I about Wound care was not performed on 1/9/26. She stated that the risk of not performing wound care as ordered was worsening of wounds and delayed healing.In an interview on 01/13/2026 at 10:07 AM with the DON, she stated that her expectation was that when the Wound Care Nurse wound nurse was not in the building, the floor nurses should be providing the ordered wound care and treatments. She stated that the floor nurses should have notified the physician about the missed treatment and obtained a PRN order for the same. She stared that the RN I called the physician to obtain PRN wound care order and provided wound care to Resident # 39 on 1/11/2026 after surveyor intervention. She stated that all the facility nurses were aware that the wound care nurse was not available in the facility from 1/8/26 through 1/12/2026. She stated that risk of not providing ordered wound care could result in deterioration of the wound and delayed healing process. 2. Record review of Resident 48's quarterly MDS assessment dated [DATE] reflected, Resident #48 was a[AGE] year-old male admitted to the facility on [DATE]. His pertinent diagnoses included: Stroke (Decreased blood flow to the brain), Cancer, Hypertension (high blood pressure), Respiratory failure (not enough oxygen in the blood). His BIMS score was 13 which indicated Resident #48's cognition was intact. Resident # 48 was on hospice services.Record review of Resident #48's care plan revised on 12/12/2025 reflected, Focus: [Resident #48] has a Skin Tear/potential for skin tear of the Left Lower Lateral Leg related to severe edema. Goal: [Resident #48] will be free from skin tears through the review date. Intervention: If skin tear occurs, treat per facility protocol and notify MD, family.Record Review of Resident # 48's progress noted dated 01/08/2026 at 15:44 written by LVN S reflected, per hospice nurse, [Resident # 48] has small open area to left shin/anterior side, already has dressing in place with xeroform and kerlix, [LVN S] sees no wound care orders in place, wound was healed out last week Monday/Tuesday, she said it must have happened after Tuesday 1/6/2026 , her visit with patient, she left wound care supplies, will let [Wound care nurse] know, in case orders need to be added, asked hospice nurse did she usually leave orders, she said [Wound care Nurse] normally just puts them in. Record review of Record review of Resident #48 TAR for January 2026 reflected no new orders or wound care treatment for left shin wound. An observation and interview on 1/13/25 at 12:50 PM with Resident #48, he stated that he had some wounds on his legs. He had a skin tear on the left shin that was red, but no dressing on it. He stated that the hospice nurse told him that his shin wound had opened up again. In an interview and record review on 1/13/26 at 1:15 PM with the Wound Care Nurse revealed she was on leave, and not in the facility from 1/8/26 to 1/12/2026. She stated that Resident #48 had a prior wound on left shin that had healed. She stated she was not aware that Resident #48 left side shin wound had opened up again until the hospice nurse met her on 1/13/26 and informed her. She stated that she was reading the progress note from LVN S dated 1/8/26 for the first time after this surveyor informed her. She stated that if the Hospice Nurse informed about a re-opened wound and Nurse could not find orders for it, her expectation was that floor nurse would call the physician for orders to treat it. She stated not addressing the wound in a timely manner or obtaining physician orders to treat the wound may lead to worsening of the wound and delayed wound healing.In a phone interview on 01/13/2026 at 1:35 PM with the Hospice Nurse, she stated that she had seen a skin tear on Resident # 48's left lower leg that had previously closed up on. She stated she visited Resident #48 on 1/6/26, and the wound had healed. On 1/8/26, when she visited Resident #48, she saw the wound had opened up and informed LVN S about the same. She stated that usually she would inform the Wound Care Nurse in the facility, but did not see the Wound care nurse on 1/8/2026. She stated that she visited Resident #48 on 1/13/26, and saw that Resident #48 did not receive any treatment for the skin tear. She stated that there was no change in the wound. She added that she met with the Wound care nurse in the facility on 1/13/26 and informed her about the new skin tear. She stated not addressing wounds promptly could lead to worsening of the wound and delayed healing.In an interview on 1/13/26 at 2:15 PM with LVN S stated she had just started working in the facility few days ago and was on training until Wednesday 1/7/26. She stated that she worked the 2 PM -10 PM shift at the facility on 1/8/2026. She stated that Hospice Nurse came to visit Resident #48 and found a wound that had reopened on Resident's left shin. She stated that she was made aware by the DON that the wound care nurse would not be available in the facility from 1/8/26-1/12/26. She stated that she should have called the physician to obtain new wound care orders for the reopened wound rather than waiting on the wound care nurse to come back to the facility. She stated that the risk to the residents, if the wound is not treated in a timely manner, was worsening of the wound.In a follow-up interview on 01/13/2026 at 2:28 PM with the DON, she stated that her expectation was that the nurses should follow up with the physician for any new wound for orders. She added if there was a new wound discovered, nurses should call the physician and have orders put in for treatment. She stated that the risk of not addressing the wound in a timely manner was worsening of the wound.Record review of the facility's policy titled, Wound Treatment Management revised May 2025 reflected, .1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2.In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse.

Based on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities for 1 (Resident #55) of 2 residents reviewed for prescription eyeglasses. The facility failed to follow up in a timely manner on prescription eyeglasses for Resident #55 after his eye exam was completed on 7/17/25. This deficient practice and failure could place residents at risk for worsening vision and decreased quality of life. Findings included: Record review of Resident #55's face sheet, dated 1/15/2026, revealed a [AGE] year-old male with an admission date of 3/7/22. Pertinent diagnoses included Chronic Kidney Disease, Unspecified Dementia (cognitive decline that severely impairs daily life), Major Depressive Disorder (a mood condition causing persistent sadness, loss of interest and affecting how you feel) and Adult Failure to Thrive (a syndrome of decline, marked by weight loss, poor appetite, inactivity and social withdrawal). Record review of Resident #55's Quarterly MDS assessment, dated 12/24/25, revealed a BIMS score of 15, which revealed intact cognition. Record review of Resident #55's active physician orders on 1/14/26, revealed no order for prescription eyeglasses. Record review of Resident #55's eye exam summary dated 7/17/25 reflected .Assessment:1. Cataract (the clouding of the eye's natural lens), mixed; Stable; Both eyes 2. Hyperopic astigmatism (a refractive error where one or both curves of the eye focus light behind the retina) and presbyopia (the loss of eyes' ability to focus on close-up objects); Stable; Both eyes; update recommended. Plan: 1. Monitor; Follow-Up: Comprehensive 07/17/2026 2. New bifocals; Follow-Up: Comprehensive 07/17/2026.New Glasses recommended? Yes, to be delivered upon approval. Action Required by Nursing Home Staff: Glasses required? Yes, encouraged full-time use for distance and reading. Record review of an email thread between the Social Worker and the eye care provider on 1/12/26 at 2:23pm reflected a request for an update on Resident #55's eye care services stating he had an eye refraction on 7/7/25. An interview with Resident #55 on 1/12/26 at 10:31am revealed he had gone to the optometrist a while ago and had not gotten his glasses. Resident #55 stated he had been waiting for several months for them to arrive. An interview with the Social Worker on 01/13/2026 at 4:06 PM revealed she had just followed up on Resident #55's eyeglasses that week because he asked her for his glasses. She stated it was her first follow up because she had only been working at the facility for a couple of weeks. The Social Worker then stated she did not know what attempts the previous social worker made to obtain Resident #55's eyeglasses. She stated she noted Resident #55 had been prescribed glasses in July of 2025. The Social Worker stated she delivered Resident #55's eyeglasses earlier in the day 01/13/26, as she had received them in the mail. She stated when residents needed an eye exam, she would fax their face sheet and an order from the doctor to see their vision provider. The vision provider came once per month and saw residents who were on their list and had been referred to them. If a resident needed glasses, the provider would send an authorization for the Social Worker to sign, and the provider would order the glasses and shipped them to the facility. She had no way to determine who was pending glasses prior to her employment with the facility, and only knew to follow up on the status of glasses if the resident had asked her. An observation and interview with Resident #55 on 1/14/26 at 10:20 am revealed he was wearing glasses and stated he had gotten his glasses yesterday. Resident #55 stated he waited for over 5 months for his glasses, and couldn't see good during that time. An interview with the DON on 01/14/2026 at 2:21 PM revealed Resident #55's need for glasses fell through the cracks with the previous social worker. The DON stated the Social Worker was responsible for following up with eye exams and glasses. She stated it would not have been good for residents to wait a long time for their glasses because it could affect their vision and their vision could worsen. An interview with the Administrator on 01/14/2026 at 4:28 PM revealed the expectation for a follow up on glasses for a resident who was pending to receive glasses would have been 3-4 weeks, not 6 months. She stated Social Services was responsible for the follow-up of any recommendations from the vision provider to include obtaining glasses for the resident. She stated the lapse of time between when Resident #55 saw the doctor to when he received the glasses, possibly put him at risk of more vision problems or even could have caused headaches. Record review of the Facility's Hearing and Vision Services policy revised on 12/2025 reflected .it is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated.2. Staff should refer to any identified need for hearing or vision services/appliances to the social worker/social service designee. 3. The social worker/social service designee is responsible for assisting residents and their families, in locating and utilizing any available resources.for the provision of the vision and hearing services the resident needs. 4. Once vision or hearing services have been identified, the social worker/social services designee will assist the resident by making appointments and arranging for transportation.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents (Resident #17 and Resident #98) reviewed for quality of care. 1. The facility failed to ensure CNA C provided appropriate perineal care for Resident #17 when she failed to clean the resident's penis downward and the pubic area on 01/12/26. 2.The facility failed to ensure CNA B provided appropriate catheter and perineal care for Resident #98, when she failed to separate the labia and wipe the catheter tubing from the insertion site downward while providing care on 01/12/26. These failures could place residents at risk for not receiving appropriate care to address their incontinence and could increase the risk of urinary tract infections. Findings included: 1. Record review of Resident #17's quarterly MDS assessment, dated 12/11/25, reflected a [AGE] year-old male with an admission date of 09/19/22. Resident #17 had a BIMS score of 15 which indicated his cognition was intact. He required substantial to maximum assistance for personal hygiene, toileting, bathing and dressing and had not refused care. He had functional limitations in range of motion upper and lower extremities on one side extremities. He was frequently incontinent of bowel and bladder. Diagnoses included diabetes, cerebral vascular accident (stroke) and hemiplegia (paralysis on one side of the body). He had not received occupational therapy (therapy that focuses on regaining dexterity and strength in fine motor skills) or restorative nursing services in the 7 days look back period. Record review of Resident #17's care plan revised on 12/17/25 reflected, Functional Abilities: [Resident #17] requires assistance to perform functional abilities in Self Care and Mobility related to his history of cerebral vascular accident with left hemiplegia.Intervention.Provide the following self-care assistance. Toilet Hygiene: Substantial/max assist . In an observation on 01/12/26 9:15 a.m. CNA C entered Resident #17's room to perform incontinence care. CNA C put on gloves and unfastened the Residents brief and assisted the Resident to roll onto his left side revealing the resident was wet. CNA C then reached between the resident's legs and wiped downward with the penis and scrotum going toward the anal peri area with a few wipes. Wiped the anal area outward and then placed a clean brief under the resident, still wearing the same soiled gloves. CNA C assisted the resident back onto his back and fastened the brief without cleaning his pubic area, the penile shaft, or scrotum. In an interview on 01/12/26 9:48 a.m. with CNA C, she stated she thought she did Resident #17's peri-care correctly because she wiped from his front toward his back. She stated she did not know she was supposed to hold the penis and wipe the penial shaft toward the scrotum. She stated she thought she had cleaned between his legs, but she did not clean the pubic area. She stated she had been checked off for incontinence care not long ago, but she did not remember those steps. She stated the risk of not performing correct incontinence care would be infection if it was not done right. 2. Record review of Resident #98's Significant change MDS assessment dated [DATE] reflected [AGE] year-old female with an admission date of 09/07/23. Resident had a BIMS score of 8 which indicated her cognition was moderately impaired. She was always incontinent of bowel and bladder. Her diagnosis included Parkinson's disease (disorder of the central nervous system that affects movement), dementia, and diabetes. Record review of Resident #98's admission Note dated 01/09/26, completed by LVN J, reflected, . readmitted for kidney infection, on cipro until 1/12/26. Foley 18FR (unit for sizing catheters), light pink color. Open area to coccyx, top of right thigh open area no depth, boggy heels, right heel more soft with a scab, MD notified of arrival In an observation on 01/12/26 at 09:30 a.m. CNA B and CNA C entered Resident #98's room, put on gloves, but no gown and told her they were there to get her changed. CNA B unfastened the resident's brief and wiped across his pubic area, down each side of the groin area, but did not separate the labia and wipe down the middle or clean the catheter tube from the insertion site downward. Both staff assisted the Resident onto her side, and CNA C wiped from front to back to clean the anal area and then placed a clean brief under her. Both staff then rolled the resident back onto her back and fastened the brief. In an interview on 01/12/26 at 9:50 a.m. with CNA B and CNA C, they both stated they were supposed to provide catheter care every time they provided incontinence care. CNA B stated I know what I did wrong. I did not go down the middle and wipe down the catheter tube. She stated the risk to the residents were urinary tract infections. She stated she had been skills checked on catheter care and knew the importance of doing it correctly. In an interview on 01/14/26 at 2:50 p.m. with ADON H, she stated she was also the infection preventionist for the building. She stated they did frequent training on infection control, and all of the staff were skilled checked, and had to do a return demonstration. She stated the staff knew the proper procedures; they just needed to follow them. She stated the risk of not following the procedures was increased risk of infection to the resident. In an interview with the DON on 01/14/26 at 2:55 p.m., she stated it was the expectation for all staff to provide timely and appropriate incontinent and catheter care. She stated she could attribute some of it to nerves, but they would do some re-education to ensure staff were following the correct procedures. She stated the risk of not performing correct peri-care or catheter care was increased risk of infection. She stated they did annual competency checks, but going forward, they needed to start doing spot checks while making rounds to see how the staff were providing care to the residents. Record Review of CNA B's Certified Nursing Skills Checklist, dated 07/28/25, reflected she was competent in infection control, peri-care and catheter care. Record Review of CNA C's Certified Nursing Skills Checklist, dated 09/09/25, reflected she was competent in infection control, peri-care and catheter care. Record review of the facility's policy titled, Perineal Care, dated January 2024, reflected, .Males.Assist resident to supine position.Gently raise penis.hold the shaft of the penis with one hand and was with the other. Begin cleansing tip of penis at urethral meatus using a circular motion and working outward.Cleanse the shaft of the penis, using downward stroked toward the scrotum. Use separate section of the washcloth or new disposable wipe with each stroke.Cleanse scrotum, using a clean portion of the washcloth, new washcloth or new disposable wipe with each stroke.Pat dry.Turn the resident on his. Clean and dry the bottom of the scrotum and the anal area.Remove gloves.perform hand hygiene. Record review of the facility's policy titled Catheter Care, dated March 2023, reflected, .Perform hand hygiene.Don gloves.Female: Gently separate the labia to expose the urinary meatus. Wipe front to back with a clean cloth moistened with water and perineal cleaner or moist wipes. Use a new part of the cloth/wipe or different cloth/wipe for each side. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as not to pull on the catheter.

Based on interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, respiratory therapy for 1 (Resident #3) of 3 residents reviewed for therapy services. The facility failed to provide physical therapy for Resident #3 after her PT evaluation, recommending therapy, was completed on 8/15/25. This failure could place residents at risk for decline in range of motion, decreased mobility, development of contractures, and a decline in quality of life. Findings included: Review of Resident #3's Face sheet dated 1/13/26 reflected a [AGE] year-old female with an original admission date of 3/25/23 and a readmission date of 10/22/25. Review of Resident #3's Significant Change MDS assessment, dated 10/28/25, reflected her cognition was intact with a BIMS score of 13. The resident had upper and lower extremity impairment on one side and used a walker. Resident #3 was dependent on staff for toileting, showering, lower body dressing, and putting and taking off footwear. She also needed substantial assistance with upper body dressing and personal hygiene. Resident #3 had no therapy. Active diagnoses included Cerebrovascular Accident (commonly known as a stroke, where blood flow to a part of the brain is interrupted), Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body), Hemiplegia following Cerebral Infraction (paralysis or severe weakness of one side of the body due to brain damage), effusion left knee (excess fluid buildup in or around the knee joint) and pain in left knee. Review of Resident #3's comprehensive care plan revised on 10/30/25, reflected, .Resident #3 has the diagnosis of CVA with hemiparesis and is at risk for falls, contractures, over all wellbeing decrease. Left hemiparesis Date Initiated: 05/20/2025 Revision on: 05/20/2025 The resident will not experience signs and symptoms of a CVA unaddressed X 90 days. Date Initiated: 05/20/2025 Revision on: 10/30/2025 Target Date: 11/11/2025 The resident will maintain current level of independence X 90 days. Date Initiated: 05/20/2025 Revision on: 10/30/2025 Target Date: 11/11/2025 . Therapy to eval and screen as ordered and as needed date initiated 5/20/25. Review of Resident #3's physician orders on 1/13/26 revealed no orders for restorative therapy or therapy. Review of Resident #3's Physical Therapy Evaluation & Plan of Treatment dated 8/15/25 reflected .Focus of plan of Treatment = Restoration.Assessment Summary: Clinical Impressions: Patient presents with left-sided hemiparesis, inability to rip with left hand, impairments in motor control, trunk control, postural control, activities tolerance, generalized strength, sitting balance and tolerance, and generalized coordination, thus negatively impacting performance of bed mobility and manual w/c mobility. Reason for Skilled Services: given the assessment above, patient will highly benefit from PT services in order to address the above impairments and allow patient improve bed mobility, OOB frequency and maximize functional manual w/c propulsion to improve functional independent in the facility.Assessment Summary: Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for : DVT, falls, immobility, further decline in function, depression, dehydration, limited out of bed activity, muscle atrophy, pressure sores, decreased skin integrity, contracture (s) and compromised general health. Record review of Nurse Practitioner Progress note for Resident #3 dated 9/22/25 reflected PROGRESS NOTE: REASON FOR FOLLOW UP:.Acute left lower extremity DVT. #History of multiple CVA complicated by debilitation and wheelchair-bound #Debility Patient reports compliance with medication at home no new focal neurological sinus symptoms noted -CVA with left-sided hemiplegia: -She is wheelchair dependent -Continue aspirin and Lipitor. -Previous echo showed normal EF, and patent foramen ovale is not demonstrated. -Fall precaution -Continue physical therapy. Record review of Nurse Practitioner Progress note for Resident #3 dated 10/6/25 reflected Progress Note: REASON FOR FOLLOW UP: . Acute left lower extremity DVT.#History of multiple CVA complicated by debilitation and wheelchair-bound #Debility -Patient reports compliance with medication at home no new focal neurological sinus symptoms noted -CVA with left-sided hemiplegia: -She is wheelchair dependent -Continue aspirin and Lipitor. -Previous echo showed normal EF, and patent foramen oval is not demonstrated. -Fall precaution -Continue physical therapy. Record review of Nurse Practitioner Progress note for Resident #3 dated 10/24/25 reflected Progress Note: REASON FOR FOLLOW UP. Acute left lower extremity DVT. ASSESSMENT & PLAN #Acute left lower extremity DVT as evident per the ultrasound Doppler Most likely secondary to sedentary lifestyle given left-sided residual weakness from prior stroke and obesity. - S/P heparin drip - Started on Eliquis - PT evaluation. Record review of Nurse Practitioner Progress note for Resident #3 dated 12/22/25 reflected Progress Note: REASON FOR FOLLOW UP:. Acute left lower extremity DVT. ASSESSMENT & PLAN. #History of multiple CVA complicated by debilitation and wheelchair-bound #Debility -Patient reports compliance with medication at home no new focal neurological sinus symptoms noted -CVA with left-sided hemiplegia: -She is wheelchair dependent -Continue aspirin and Lipitor. -Previous echo showed normal EF, and patent foramen oval is not demonstrated. -Fall Precaution-Continue physical therapy. Interview with Resident #3 on 01/11/2026 at 11:44 AM revealed she had been at the facility for a while, was there for therapy. Resident # 3 stated she had not had any therapy since her admission. Resident #3 stated she would like to walk again, and would like to have been more independent. Interview with LVN J on 01/12/2026 at 2:23 PM revealed she has been Resident #3's nurse for several months. LVN J stated she was not completing restorative therapy with her. She stated therapy had not provided any exercises to do with Resident #3. She stated the risk to the residents not having received any exercises or assistance from therapy would have been the resident could have gotten more contracted. Interview with the Director of Rehab on 01/12/2026 at 1:01 PM reflected Resident #3 was not in therapy. The Director of Rehab stated Resident #3 had been evaluated on 6/18/25 and 8/15/25 by therapy and determined she needed therapy, but when the evaluation was submitted to the insurance, it was not approved. She stated the rehab department would reassess resident whenever her payor source changed to see if they would approve therapy. Resident #3 had not had therapy in the last year due to not being approved by her insurance. The Director of Rehab stated when the payor source denied therapy, the next step would have been to notify the Administrator, but she did not know if this was done due to her not working at the facility when Resident #3's last evaluation was done. The risk of the resident not receiving rehab was possible decline and/or lack of improvement in her ADLs. Interview with CNA U on 01/13/2026 at 10:25 AM revealed she had worked with Resident #3 since she had arrived at the facility, and stated Resident #3 frequently complained about not having gotten therapy. She stated Resident #3 would ask for therapy, and therapy staff would tell her the insurance had not approved it. CNA U stated she had not been provided with any therapy exercises to do with Resident #3. In an interview with the Administrator, DON, and Director of Therapy on 01/13/26 at 12:05 p.m., the Administrator stated they had all met and discussed the steps which needed to be taken going forward. The Administrator stated once a resident was evaluated by therapy and was determined to have a need for therapy, to assess and treat to establish the necessary interventions, they were to submit the evaluation to the payor source, and if denied or if there was not a payor source, they were to immediately notify her so they could move forward with meeting the resident's needs. She stated the therapy department had been instructed to re-evaluate those residents, who had been identified, and put in the necessary orders and interventions to meet those residents' needs. Review of the facility's Specialized Rehabilitative Services revised September 2025 reflected Policy: The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan. These services will assist them in attaining, maintaining or restoring their highest practicable level of physical, mental functional and psycho-social wellbeing.5. Specialized rehabilitative services are considered a facility service and included within the scope of facility services: therefore, if services are not enumerated in the State plan, the facility will not charge Medicaid recipients for specialized rehabilitative services.

Based on observations, interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 22) of one resident reviewed for PASRR services. The facility did not initiate the application process for the Durable Medical Equipment / Customized Wheelchair for Resident #22 within twenty days, per PASRR recommendations made during the PASRR Care plan meeting held on 05/08/2025.This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being.Findings included:Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed she was a [AGE] year-old female with an initial admission date of 04/26/2021, diagnoses included unspecified intellectual disabilities (significant limitations in intellectual functioning and adaptive behaviors), Schizophrenia (a mental disorder disrupts thought process, perception, emotional responsiveness and social interactions), Diabetes Mellitus (Elevated blood sugar levels). Resident #22 had a BIMS score of 8 indicating moderate cognitive impairment. Resident #22 required substantial/maximal assistance with personal hygiene and partial/moderate assistance with chair/bed-to-chair, toilet transfers. Resident #22 used a manual wheelchair for ambulation, and she was frequently incontinent of urine and bowel.Record review of Resident #22's comprehensive care plan with a revision date of 01/15/2025 reflected she was at risk for falls and injury related to confusion, weakness and unsteady gait. Interventions: . Resident (Resident #22) needs prompt response for all requests for assistance. Encourage resident (Resident #22) to participate in activities of choice that promote exercise, physical activity for strength, improved mobility and socialization. Rehab screen/evaluate and treat as indicated for therapeutic exercise and safety measures. Care Plan Initiated date 05/19/2021 reflected Resident #22 was PASRR MI/ID positive and receives services through PASRR. Observation and interview with Resident #22 on 08/06/2025 at 10:17 AM, revealed she was sitting in her wheelchair in the front lobby area. Resident #22 stated the wheelchair was not comfortable to sit, hard to move the wheels with her hands, and she used her legs to roll it. Resident #22 stated she was waiting to get her new wheelchair. Record review of Resident #22's PASRR Comprehensive Service Plan Form dated 05/08/2025 revealed a quarterly meeting was held, attended by the Coordinator with PASRR program, Director of Rehab, social worker, and Resident #22. The Specialized Services Information section revealed a Customized Manual Wheelchair was added as a new service for Resident #22.Telephone interview on 08/06/2025 at 11:04 AM Resident #23's Coordinator with PASRR program revealed, a quarterly care plan meeting was held at the facility on 05/08/2025 was attended by the facility Director of Rehab, Social Worker and Resident #22, in that meeting a customized Manual Wheelchair was added as a new service for Resident #22. The Director of Rehab was responsible to initiate the application process within 20 days, as per the state regulation, to make sure Resident #22 received the new wheelchair in a timely manner. She stated she checked the status of the application, and it was not initiated within the 20 days from 05/08/2025, resident had not received the new wheelchair yet. She stated the wheelchair Resident #22 used at that time was big, and that increased the risk for falls.Interview on 08/06/2025 at 12:23 PM, the Director of Rehab revealed she was working at the facility since 2024. She stated Resident #22 currently used an inappropriate size wheelchair, which increased Resident #22's risk for falls and injuries. She stated she received a recommendation for a new customized wheelchair for Resident #22 through PASRR services during the quarterly care plan meeting held on 05/08/2025, attended by the Coordinator with PASRR program, Director of Rehab, social worker and Resident #22. Director of Rehab stated she was responsible to initiate the application process within 20 days from the date PASRR service was recommended (05/08/2025) as per the state regulations, but she initiated it on 07/31/2025, because she was not able to coordinate with all parties to finish the application process. She stated resident #22 did not have any falls from her wheelchair and at that time the application was pending state approval. The Director of Rehab stated she and her employees received in services on abuse, neglect, resident rights every month and after each incident. Interview on 08/06/2025 at 12:48 PM, Certified Occupational Therapy Assistant revealed it was important to have appropriate size wheelchair for all residents to ensure their safety, not having appropriate size wheelchair increased the risk for pressure sores, fall risk, mobility issues. He stated the Director of Rehab was responsible to order customized wheelchair timely as per the PASRR recommendation. He stated Resident #22 used a bariatric wheelchair which was taller, wider, heavier and due to that she was sitting at the edge of the seat to use her legs to move the wheelchair, she was not able to properly ambulate the wheelchair. He stated he received in services on abuse, neglect, resident rights within the past month. Interview on 08/06/2025 at 01:00 PM, Physical Therapy Assistant revealed Resident #22 used an inappropriate size wheelchair, which was too high for her to sit properly, and inappropriate size wheelchairs increased the risk of impaired skin integrity- can cause pressure sores, falls among residents. She stated the Director of Rehab was responsible to order and make sure the residents received customized wheelchair as per PASRR service recommendations. She stated she received in services on abuse, neglect, resident rights every month.Interview on 08/06/2025 at 01:13 PM, the Physical Therapist revealed it was important to have appropriate size wheelchair for residents with mobility issues and Resident #22 used a wheelchair which was higher off the ground, which made it difficult for resident to sit properly. He stated not having a proper size wheelchair increased the risk for pressure sores, falls, injuries, easy ambulation and poor participation in activities among residents. He stated Resident # 22 sat at the end of the chair to ambulate using her legs because it was difficult for her to use the hands to wheel the wheelchair. He stated PASRR services recommended a new customized wheelchair for resident and the Director of Rehab was responsible to order it, he stated he did not know the time frame to start the application process once the recommendation was received from PASRR services. He stated he received in services on abuse, neglect, resident rights every month.Interview on 08/06/2025 at 01:02 PM, the MDS nurse revealed he was working at the facility for 2 months and he was not aware that Resident #22 had a recommendation from PASRR services for a new customized wheelchair. He stated the wheelchair resident #22 used was bigger than what she needed, and the use of inappropriate size wheelchairs increased the risk for pressure sores, falls and overall safety among residents. He stated the Director of Rehab was responsible to order customized wheelchair as per the PASRR recommendation, he would collaborate with the social worker to monitor the PASRR related services. He stated he received in services on abuse, neglect, resident rights every month. Interview on 08/06/2025 at 03:20 PM, the DON revealed she expected all residents to have appropriate mobility, independence, positioning while using a wheelchair and not having the appropriate size wheelchair increased the risk for discomfort, falls and decreased mobility. She stated she did not deal with PASRR services, and the Director of Rehab or Social Worker was responsible to order the new customized wheelchair within a timely manner, as per PASRR recommendations. She stated she did not know the time frame to initiate the application for new wheelchair as per the PASRR services recommendation. She stated all the employees received in services every month on abuse, neglect, resident rights. Interview on 08/06/2025 at 03:37 PM, the Administrator revealed she learned from Resident #22 that she was going to get a new wheelchair. The Administrator stated the Director of Rehab was responsible to order customized wheelchairs and to make sure it was ordered timely as per the PASRR recommendation. She stated she did not know the time frame to initiate the application for new wheelchair as per the PASRR service recommendation. She stated the residents who did not have the proper size wheelchair were not able to live their full potential, not able to ambulate independently, and it would increase the risk for falls. Administrator stated she will put a system in place as an intervention to ensure all the PASRR service recommendations were carried out in a timely manner: MDS nurse must notify the administrator if any services were missing/delayed related to PASRR, social services to implement a tracking system to ensure PASRR services were up to date, make sure all care plans were in compliance with regulations, discuss and make sure all the records were up to date during the IDT meetings. Review of the facility policy with revised date of 1/2025, titled Resident Assessment- Coordination with PASARR Program reflected Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: . PASARR Level II- a comprehensive evaluation by the appropriate state designated authority (cannot be determined by the facility) that determines whether the individual has MD, ID or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning and transition of care.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for one (Resident room [ROOM NUMBER]) of three resident rooms reviewed. The facility failed to ensure Resident #1 swallowed and consumed all of her pills and supplements prior to leaving Resident #1 alone in her room on 06/13/25 with the medications. During a medication pass, medications must be under the direct observation of the person administering the medications. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion. Findings included: Record review of Resident #1's Face Sheet, dated 06/13/25, reflected a [AGE] year-old female, with an initial admission date of 08/09/23 and a re-admission date of 06/10/24. Resident #1 had a diagnosis of Paraplegia (paralysis of lower legs and body), Type 2 Diabetes (body does not produce enough insulin or cannot properly use insulin), Osteomyelitis (bone infection), Muscle Weakness, Cognitive Communication Deficit (Difficulties in communication), Schizoaffective Disorder (hallucinations, delusions and mood episodes), Bipolar Disorder (extreme shifts in mood, energy, and activity levels), Major Depressive Disorder (persistent sadness, loss of interest, and difficulty functioning), Anxiety Disorder (excessive fear and worry), Pruritis (itching of the skin), and Essential Hypertension (high blood pressure). Record review of Resident #1's Medication Administration Record dated for June 2025, dated 06/13/25, reflected Resident #1 received the following medications, as scheduled, on the morning of 06/13/25: Multivitamin Arginaid Oral Packet with 8 ounces of water (nutritional supplement) Aspirin Low Dose Oral Tablet 81 MG Citalopram Hydrobromide Oral Tablet 20 MG (for depressive episodes) Docusate Sodium Oral Capsule 100 MG (for constipation) Duloxetine HCL Oral Capsule Delayed Release Sprinkle 60 MG (for Major Depressive Disorder) Metformin HCL Oral Tablet 500 MG (for Diabetes) Movantik Oral Tablet 25 MG (for constipation) Seroquel Oral Tablet 100 MG (for Schizoaffective Disorder, Bipolar type) Gabapentin Oral Capsule 300 MG (for chronic pain) Hydroxyzine HCL Oral Tablet 25 MG (for Pruritis) Alprazolam Oral Tablet 1 MG (for Anxiety Disorder) Cyclobenzaprine HCL Oral Tablet 10 MG (for chronic pain) All of the above morning medications, scheduled for 7 AM or morning, were marked as given, as scheduled, on the Medication Administration Record by the Medication Aide. In an observation and interview on 06/13/25 at 1:17 PM, Resident #1 was laying in her bed, with her tray table next to her, on the left side. On the tray table were two small, clear cups, the resident's plate of lunch, and a cup of orange-yellowish colored liquid in a clear cup, with a wooden stick in it. One cup had one pill and the other cup had six pills. Resident #1 stated she did not know what all the pills were, but she stated one of the pills was Gabapentin (medication used generally to prevent seizures or nerve pain). Resident #1 stated the staff usually waited with her to swallow her medication. She stated the medication had been there since this morning and stated the Medication Aide just put the pills and Arginaid (liquid nutritional supplement) down and left the room. In an interview with the ADM and the DON on 06/13/25 at 2:08 AM, the DON stated the Staffing Coordinator told her there were pills on Resident #1's tray table. The DON stated she went to Resident #1's room and removed the pills. The DON stated she asked the Medication Aide if she watched Resident #1 take her pills or if she saw any pills on her tray table after she initially passed the medications, and the DON stated Medication Aide told her, she did not see any pills in Resident #1's room. The DON stated the risk of leaving pills in a resident's room and not ensuring the medication was taken was Resident #1 not receiving the medication as ordered, which could exacerbate a symptom. The ADM stated she agreed with the risks the DON mentioned. In an interview on 06/13/25 at 2:34 PM, the Medication Aide stated she was the staff member that passed medications on Resident #1's hall. She stated she thought she watched Resident #1 take all of her pills this morning. The Medication Aide stated she was trained to watch all residents to ensure they took their medication. She stated if a resident refused their medication, she was trained to take the medication back with her to the medication cart. The Medication Aide stated she did give the Arginaid to Resident #1, but it was around lunch time when she gave it to her. The Medication Aide stated the risk of leaving medications with the residents was another residents or family member could get the pills and take them. The Medication Aide stated it could be an overall health risk to the resident if the pills were not taken as ordered or if it was taken at the wrong time. Record review of the facility's policy titled, Medication Administration, with an original date of 12/2020 and a revision date of 01/2025 reflected the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 18. Observe resident consumption of medication.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 (Resident #2) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse on 05/14/25, when Resident #1 hit Resident #2 in the back of his head with his walking cane which caused 2 hematomas (localized collection of blood outside of blood vessels, often due to injury). An Immediate Jeopardy was identified on 06/10/2025. The IJ template was provided to the facility on [DATE] at 3:31 PM and signed by the ADM. While the IJ was removed on 06/11/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm from abuse. Findings included: Record review of Provider Investigation Report dated 05/14/2025 reflected under Investigation Summary: On 05/14/2025, the facility ADM received a call from [LVN B] that [Resident #2] was sent to the hospital because he was lethargic and slurring his words after being hit in the head by [Resident #1] with his cane. Upon arrival to the facility on [DATE], the ADM interviewed [LVN B] regarding an incident involving [Resident #2] and [Resident #1]. [LVN B] reported that the residents had been arguing about the temperature in their shared room. [Resident #2] said that the room was extremely hot and wanted the door open to allow airflow. In contrast, [Resident #1] preferred the door to remain closed. When [Resident #1] closed the door, [Resident #2] attempted to reopen it, at which point [Resident #1] struck [Resident #2] in the head. [LVN B] stated that nearby [CNA E] heard [Resident #2] yelling and entered the room to assess the situation. [CNA E] was informed of what had occurred, and the residents were immediately separated. [Resident #2] was assessed for injuries and found to have two hematomas on the back of his head. . Facility Investigation Findings: Confirmed. Record review of Resident #1's face sheet, dated 06/09/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses of Vascular Dementia (progressive cognitive disorder that damages brain tissue due to reduced blood flow), Mixed Receptive-Expressive Language Disorder (neurodevelopmental condition where an individual experiences difficulties with both understanding language and producing language), Communication Deficit (cognitive function issues with memory and functioning), Metabolic Encephalopathy (brain dysfunction resulting from metabolic problems) and generalized Muscle Weakness (reduction in muscle strength throughout the body). Record review of Resident #1's Annual MDS Assessment, dated 05/07/25, reflected Resident #1 had a BIMS score of 5, which indicated Resident #1's cognition was severely impaired. The MDS noted Resident #1 had no issues with mood or behavior. Record review of Resident #1's Care Plan, with an initial date of 07/18/24, reflected the following: Date Initiated: 07/18/2024 [Resident #1] has impaired cognitive function and impaired thought processes AEB:(x) BIMS = 5 Related to: CVA, Dementia Date Initiated: 05/14/2025 [Resident #1] has been physically aggressive (hitting roommate) r/t Dementia Record review of the progress notes in Resident #1's electronic record reflected the following: 05/14/25 17:22 (5:22 PM) Documented by LVN B [LVN A] was alerted to Room [#] at approximately 0310 hrs (3:10 AM). [CNA E] on the floor explained that she heard [Resident #2] in Room [#] screaming. [CNA E] went into the room and observed [Resident #1] standing over [Resident #2] with his cane meanwhile [Resident #2] was holding his head and saying [Resident #1] had hit him. [CNA E] immediately separated [Resident #1] from [Resident #2] by requesting him to go back to his side of the room and asked another [CNA F] to notify [LVN A] while she kept [Resident #2] company. Notify MD/Family: Family notified. MD notified. Admin notified. DON notified. Interventions: [Resident #1] was requested to go back to his side of the room. [Resident #1] complied. 05/14/2025 00:37 (12:37 AM) - Late entry Documented by SW [SW] spoke with [Resident #1] regarding the recent incident. Provided education on appropriate behavior, specifically emphasizing that physical aggression is not acceptable. [Resident #1] was informed about the impact of his actions and was reminded of the importance of maintaining respectful interactions with others. [Resident #1] does not recall initiating physical contact with [Resident #2]. A psychosocial assessment was completed to further evaluate [Resident #1]'s behavior and mental status. Record review of Resident #2's face sheet, dated 06/09/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #2 had diagnoses of Vascular Dementia (progressive cognitive disorder that damages brain tissue due to reduced blood flow), Encephalopathy (broad range of brain disorders that affect the brain's function and/or structure) and Major Depressive Disorder (persistent feelings of sadness, emptiness, and a loss of interest or pleasure in activities). Record review of Resident #2's Quarterly MDS Assessment, dated 03/23/25, reflected Resident #2 had a BIMS score of 9, which indicated Resident #2's cognition was moderately impaired. The MDS noted Resident #2 had no issues with mood or behavior. Record review of Resident #2's Care Plan, with an initial date of 10/06/23, reflected the following: Date Initiated: 10/26/2023/Revision on: 05/21/2025 [Resident #2] psychosocial well-being is affected d/t Recent admission and DX of CVA with Hemiplegia (condition that involves paralysis of one side of the body) and Vascular Dementia: 5/14/25 hit by roommate Record review of the progress notes in Resident #2's electronic record reflected the following: 05/12/2025 23:57 (11:57 PM) Documented by LVN A [Resident #2] complains of room being too hot and staff have continuously attempted to lower room temperature but it was reset back to 80 degree Fahrenheit of heat by [Resident #1]. [Resident #2] desired to switch room and was informed to wait in the morning to speak with administration. 05/13/2025 21:45 (9:45 PM) Documented by LVN A [Resident #2] is staying in hallway and not staying in room due to heat. 05/14/25 00:41 (12:41 AM) - Late entry Documented by SW Checked on [Resident #2] following an incident in which [Resident #1] struck [Resident #2] with a cane, resulting in a visible knot on his head. Assessed [Resident #2]'s condition and provided appropriate support. Educated [Resident #2] on the importance of maintaining personal boundaries by staying on his designated side of the room to help prevent future conflicts. A psychosocial assessment was completed to evaluate [Resident #2]'s emotional and psychological response to the incident. 05/14/25 03:40 AM Documented by LVN B Complete Vitals with Orthostatic BP: [LVN B] was alerted to Room [#] at approximately 0310 [03:10 AM] hrs. The [CNA E] on the floor explained that she heard [Resident #2] in Room [#] screaming. [CNA E] went into the room and observed [Resident #1] standing over [Resident #2] with his cane meanwhile [Resident #2] was holding his head and saying [Resident #1] had hit him. [CNA E] immediately separated [Resident #1] from [Resident #2] by requesting [Resident #1] to go back to his side of the room and asked another [CNA F] to notify [LVN B] while she kept [Resident #2] company. Notify MD/Family: Family notified. MD notified Administrator notified. DON notified. Interventions: Vitals were taken head to toe assessment completed and [Resident #2] sent to emergency room immediately for suspected head trauma. Record review of Resident #2's hospital record, dated 05/14/25, reflected Resident #2 was diagnosed with Acute head injury, initial encounter; degenerative arthritis of cervical spine; and Hypertension (the force of blood pushing against artery walls is consistently too high), unspecified type. CT Cervical Spine WO Contrast (Final Result): 1. No acute intracranial abnormality. 2. No acute fracture, traumatic malalignment, or evidence of ligamentous injury in the cervical spine. CT Head WO Contrast (Final Result): No evidence of acute infarction, intracranial hemorrhage, mass or mass effect, or abnormal extra-axial collection. Observation and interview on 06/09/25 at 11:20 AM with Resident #1 revealed he was sitting up in bed watching television. Resident #1 stated he felt safe and no one bothered him. Surveyor inquired about the incident that occurred with Resident #2 and Resident #1 continued to provide different accounts of what happened. Observation and interview on 06/09/25 at 11:50 AM with Resident #2 revealed he was in his room sitting in his wheelchair watching television. Resident #2 was observed to not have any visible injuries. Resident #2 stated he had adjusted well to his new room and he had not seen Resident #1. Resident #2 stated Resident #1 hit him on the back of the head with his cane. Resident #2 stated Resident #1 liked the room to be hot with the door closed. Resident #2 stated he was sitting on his bed and Resident #1 hit him from behind. Resident #2 stated after Resident #1 hit him, Resident #1 walked back to his bed. Resident #2 stated CNA E and LVN B brought him to the lobby and he was sent to the hospital. In an interview on 06/09/25 at 1:45 PM, LVN A stated on 05/12/25 at 11:57 PM, Resident #2 informed him the room was too hot and he wanted to move to another room. LVN A stated he spoke with Resident #1 about being understanding and Resident #1 agreed to lower the temperature. LVN A stated about 40 minutes later, Resident #1 had turned the temperature back up. LVN A stated the next morning (5/13/25), he spoke with the DOA and the DOA informed him that they did not have a room ready but he would try to find a room for Resident #2. LVN stated when he returned to work on 05/13/25, Resident #1 continued to turn up the temperature. LVN A stated moving Resident #2 to a different room would have prevented Resident #1 from striking Resident #2 in the head with his cane. LVN A stated the worst that could have happened was Resident #2 could have suffered a brain bleed, contusion (localized area of discoloration and swelling caused by damage to small blood vessels under the skin), or spinal damage. In an interview on 06/09/25 at 2:15 PM, the ADON stated Resident #1 and Resident #2 preferred the room to be hot. The ADON stated Resident #2 wanted to keep the door opened and Resident #1 wanted the door to remain closed. The ADON stated Resident #2 went to open the door again and Resident #1 hit him in the back of the head with his cane. The ADON stated after-hours, staff could have moved Resident #2 to a private room until Administration arrived in the morning. The ADON stated LVN A should had rectified the situation on 05/12/2025 by moving Resident #2 temporarily until a permanent room could be confirmed. A telephone interview with LVN B was attempted on 06/09/25 at 2:45 PM, but there was no answer and no return call during the investigation. In an interview on 06/09/25 at 3:00 PM, CNA E stated she was in another resident's room when she heard a loud scream coming from Room [#]. CNA E stated when she opened the door [Resident #1] was standing over [Resident #2] with his cane. CNA E stated Resident #2 tried to sit up while holding his head saying, [Resident #1] hit me in the head. CNA E stated she asked [Resident #1] to please have a seat on his side of the room which he complied. CNA E stated she remained with Resident #2 while CNA F went to let LVN B know he was needed right away. A telephone interview with CNA F was attempted on 06/09/25 at 3:15 PM, but there was no answer and no return call during the investigation. In an interview on 06/09/25 at 3:30 PM, the DOA stated LVN A informed him the morning of 05/13/25 that Resident #2 wanted a room change due to Resident #1 keeping the room too hot. The DOA stated Resident #2 liked the room warm, but Resident #1 made it too warm. The DOA stated unfortunately, the incident happened overnight before they relocated Resident #2 to a different room. The DOA stated he believed the incident would not have occurred if Resident #2 had been moved to a different room. In an interview on 06/09/25 at 3:55 PM, the ADM stated Resident #2 was fine with the temperature being high, but he wanted the door to remain opened and Resident #1 wanted the door to remain closed. The ADM stated if a resident requested to move rooms, they would match them with an appropriate roommate. The ADM stated on 05/12/25, she was not informed that Resident #2 requested to move to a new room. The ADM stated LVN A should have notified the DON or whomever was on call on 05/12/25 if it was a significant situation. The ADM stated it was a concern not reporting Resident #2's concerns immediately. The ADM stated LVN A entered a Progress Note, but she had not been informed. The ADM stated overnight staff could temporarily move a resident if an issue arose and then Administration would find a permanent room the next day. In an interview on 06/10/25 at 11:00 AM, the DON stated LVN B informed them that Resident #2 had struck Resident #1 in the back of the head with his cane. The DON stated due to Resident #2 being struck in the head, he was immediately sent out to the hospital for further assessment. The DON stated the Residents had been roommates for only 6 days and there had not been any concerns. The DON stated one day before the incident, Resident #2 informed LVN A that the room was too hot and LVN A documented it in Resident #2's Progress Notes and informed the DOA. The DON stated they discussed it during the morning meeting and started looking for a new room. The DON stated unfortunately, later that night the incident occurred before Resident #2 could be moved the next day. The DON stated Resident #2 could have suffered a more serious injury (laceration, contusion, concussion, brain injury, etc.). In an interview on 06/10/25 at 12:05 PM, the ADM stated based on Resident #2's preference and comfort they should have addressed it as soon as possible to minimize any escalating issues. The ADM stated Resident #2's injuries could have been much worse. The ADM stated she does not believe anything could have been done differently other than moving Resident #2 to a temporary room. Record review of the facility's incidents/accidents report from 03/09/25 to 06/09/25 reflected there were no other situations that involved Resident #1 or Resident #2. Record review of the facility's policy, titled, Abuse, Neglect and Exploitation with a revised date of 1/8/2023 , reflected: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The Administrator was notified of an Immediate Jeopardy (IJ) on 6/10/25 at 3:20 PM, due to the above failures and the IJ Template was provided at 3:31 PM. The facility's Plan of Removal (POR) was accepted on 6/11/25 at 11:10 AM and included: Plan of Removal 06/10/2025 (Facility Name) F- 600 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Problem: The facility failed to ensure all residents were free from abuse. The facility failed to ensure Resident 2 was free from abuse. 1. All Facility Staff was in-serviced on Room Change Request Staff Responsibility and Emergency Relocation Procedures conducted by the Administrator. Completion date 06/10/25 2. The Administrator received 1:1 in-service on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the Vice-President of Operations. The DON received 1:1 education on abuse, neglect and exploitation policy and procedures along with the company expectation to adhere to it by the corporate nurse. Completion date 06/10/25 3. On June 10, 2025, the Administrator conducted a one-on-one in-service with the Admissions Coordinator regarding the proper handling of room change requests and emergency relocations. The training focused on the importance of immediately notifying leadership (Administrator and/or DON) when a room change is being considered or required. In the event of an emergency situation (e.g., behavioral incidents, safety concerns, environmental hazards), the Admissions Coordinator was instructed to assist in temporarily relocating the resident to a safe room until a permanent solution can be arranged. All changes must be clearly documented in the resident's record, and appropriate departments (nursing, dietary, housekeeping, social services) must be notified. The Admissions Coordinator was also reminded that no permanent room changes are to be made without leadership approval, and all actions taken during an emergency must be reported by the end of the shift. The Admissions Coordinator is expected to maintain active communication with the interdisciplinary team and support a smooth, resident-centered transition process. Interventions 4. On June 10, 2025, the Administrator initiated a comprehensive in-service training with all facility staff. The training addressed the following critical areas: o Abuse and Neglect: Emphasis was placed on defining what constitutes abuse, the facility's zero-tolerance policy, and staff responsibilities in maintaining a safe and abusefree environment for all residents. o Facility Expectations: Staff were educated on their role in meeting resident needs. recognizing signs of abuse or neglect, and maintaining compliance with facility policies. Room Change Requests, Staff Responsibilities, and Emergency Relocation Procedures: Staff received instruction on how to properly handle room changes, communicate with interdisciplinary teams and families, and respond appropriately to emergency relocation situations to ensure resident safety and dignity. Expected Completion on 06/l 1 /2025 As part of this in-service, staff were informed that the Administrator also serves as the facility's Abuse Coordinator, responsible for reporting all allegations or suspicions of abuse, neglect, or exploitation to the appropriate authorities. The Administrator/Abuse Coordinator will provide ongoing supervision, training, and oversight to ensure consistent adherence to policies and procedures. Staff will not be permitted to provide direct resident care until all required in-service training is completed and documented. This requirement ensures that all personnel are properly educated and equipped to maintain a safe and compliant care environment, in alignment with both regulatory standards and facility expectations. 5. On 6/10/25 the Administrator reviewed the grievances from the last month, all grievances were addressed and up to date with no abuse, or roommate/room change request concerns. Completion 6/10/25. Monitoring 6. 6/10/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with nursing staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Completed 6/11/25. 7. Administrator, DON/designee will conduct round to ensure roommate compatibility and no abuse, neglect, or exploitation has occurred. 06/11/2025 8. 6/10/25 An impromptu QAPI meeting will conduct with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. 9. 06/10/2025 Facility's Hospital Partner [Name] was notified by the administrator of the potential for non-compliance and action plan implemented. On 06/11/25 at 11:15 AM, the investigator began monitoring to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy with the following: Observation and interview on 06/11/25 at 11:20 AM with Resident #2 revealed he was sitting in the common area listening to music. Resident #2 stated his room temperature remained good and he was not in any pain. Resident #2 stated he did not have any complaints and he still had not seen Resident #1. Observation and interview on 06/11/25 at 11:30 AM with Resident #1 revealed he was in his room sitting up in bed. Resident #1 stated he was okay. Resident #1 stated he had no concerns to report. In an interview on 06/11/25 at 11:45 AM, the MTD stated he received in-services yesterday by the ADM. He stated the ADM covered abuse and neglect, resident rights, reporting of abuse and neglect, room change requests, emergency relocation procedures and facility expectations. The MTD stated the in-services reviewed reporting of abuse and who the abuse coordinator was (the ADM). The MTD stated he was also instructed to stick with a situation until it was resolved. The MTD stated three types of abuse were emotional, physical, and verbal. The MTD stated the trainings were a re-fresher for him. In an interview on 06/11/25 at 11:55 AM, LVN C stated she received in-services yesterday by the ADM. LVN C stated the in-services covered abuse and neglect, resident rights, and both types of room changes (request or emergency). LVN C stated if the resident was in imminent danger or there was an environmental concern, a room change could be initiated immediately. LVN C stated if a resident complained about something, you must do your due diligence and make appropriate notifications, including to the ADM. LVN C stated she was reminded to follow-up with reported concerns and adhere to the chain of command to ensure issues got addressed. In an interview on 06/11/25 at 12:20 PM, the Receptionist stated she was in-serviced yesterday by the ADM and the DON. The Receptionist stated she was in-serviced on abuse and neglect, room changes and facility expectations. The Receptionist stated if a resident wanted to change rooms, you notified the ADM and the DON and they then addressed it. The Receptionist stated if residents were not getting along, staff should move one of the residents to an empty room and follow-up with the ADM and the DON. The Receptionist stated you reported all abuse and neglect concerns to the ADM as soon as you learned of it and submitted a written statement. In an interview on 06/11/25 at 12:40 PM, the AD stated he was in-serviced by the ADM yesterday on abuse and neglect, room changes (including emergency situations) and facility expectations. The AD stated if a Resident complained about their room assignment, you must inform the Charge Nurse so that the information could be charted. The AD stated you then reported it to the ADM and the DON. The AD stated staff must act immediately and follow through until the request was completed. The AD stated the facility's expectations were for staff to be more aware of what went on with Residents and report any type of situations that might cause an issue to escalate. In an interview on 6/11/25 at 1:10 PM, LVN D stated she was in-serviced today by the ADM on abuse and neglect, room changes, resident to resident altercations and facility expectations. LVN D stated if a Resident requested a room change, you would inform the ADM and the DON and they assessed the Residents for an appropriate match. LVN D stated if it was an emergency, you diffused the situation by temporarily moving one Resident to an empty room. LVN D stated you then needed to notify the ADM and the DON and they took over from there. LVN D stated they reviewed examples of abuse and neglect and completed a quiz. LVN D stated it was her job to adhere to the facility's policies. LVN D stated the trainings were a re-education for her. In an interview on 6/11/25 at 1:30 PM, the SW stated the ADM in-serviced her today regarding abuse and neglect, room changes and facility expectations. The SW stated the ADM and the DON must be informed of all room change requests. The SW stated staff relocated residents in an emergency and notified the ADM and the ADON. The SW stated they reviewed the various types of abuse and neglect and completed a quiz on how to identify, timeframes, and when and whom to report incidents. The SW stated staff was required to report anything that went wrong in the building. In an interview on 6/11/25 at 1:55 PM, CNA G stated she was in-serviced yesterday by the VP. CNA G stated she was reminded whom to report incidents. CNA G stated even if you did not see it, but someone told you about it, you were still required to report it. CNA G stated the ADM authorized all room changes. CNA G stated in an emergency, staff temporarily relocated a resident, but needed to inform the ADM and the DON so they could follow-up with a permanent location. CNA G stated she followed the facility's protocols and reported everything. In an interview on 6/11/25 at 2:20 PM, the DON stated she was in-serviced on 6/10/25 and 6/11/25 by the ADM and the VP. The DON stated if a resident requested to move to another room, regardless of which staff the Resident told, that staff member needed to inform the ADM and herself. The DON stated she and the ADM reviewed the Resident roster and confirmed compatibility or put the Resident in an empty room until they determined an appropriate match. The DON stated it was everyone's responsibility to report concerns. The DON stated staff should not stop at the supervisory level, they needed to also inform the DON and the ADM. The DON stated if staff witnessed an act of abuse or neglect, staff had the responsibility to intervene. The DON stated the in-services were a refresher. The DON stated the only thing she would do different was reiterate more regularly to staff to check on residents for any concerns. In an interview on 6/11/25 at 2:45 PM, HK M stated she was in-serviced today, by the DOH on abuse and neglect, room changes and facility expectations. HK M stated if a resident requested to move rooms, you informed the ADM and the DON so they could find a suitable roommate. HK M stated if there was an emergency, a resident was temporarily moved to an empty room. HK M stated staff needed to inform the DON and ADM as they finalized room assignments. HK M stated if you witnessed or someone told you about an act of abuse or neglect, it was still your responsibility to report the information to the ADM. HK M stated she did not learn anything new as she had worked in nursing homes for over 3 years. In an interview on 6/11/25 at 3:05 PM, the DOA stated the VP in-serviced him on 6/10/25 and the ADM in-serviced him on 6/11/25 on the same topics which included abuse and neglect, room changes, and facility expectations. The DOA stated the ADM and DON must always be informed of room changes. The DOA stated the decision would be based on the residents' characteristics and preferences. The DOA stated if there was an imminent threat, staff moved the resident out of harm's way and notified the ADM. The DOA stated the ADM was the abuse and neglect coordinator. The DOA stated they reviewed all the categories of abuse and neglect. The DOA stated he did not learn anything new, it was a refresher. The DOA stated the facility's expectations were to report everything regardless of if you witnessed it or someone else told you. In an interview on 6/11/25 at 3:25 PM, the DOH stated she was in-serviced on 6/10/25 and again on 6/11/25 by the ADM. The DOH stated she then in-serviced her staff on Wednesday morning, 6/11/25. The DOH stated regarding an emergency relocation of a resident, staff moved the resident to a temporary room and notified the DON and the ADM. The DOH stated the DON and the ADM then assigned a permanent room. The DOH stated they reviewed the different types of abuse and neglect. The DOH stated incidents were reported to the Nurse and the ADM. The DOH stated staff were required to report everything and to ensure all protocols and procedures were followed. In an interview on 6/11/25 at 3:40 PM, LA O stated she was in-serviced by the VP on yesterday (06/10/25) and today by the DOH on abuse and neglect, room changes, and facility expectations. LA O stated if a resident wanted to switch rooms, she informed the ADM and DON. LA O stated during an emergency, staff transferred the Resident immediately to a different room and reported it to the ADM and the DON to follow-up for a permanent room assignment. LA O stated they worked as a team and were required to follow all facility rules and expectations. LA O stated the in-services were a refresher for her as it was information she already knew. In an interview on 6/11/25 at 3:55 PM, DC L stated he was in-serviced on abuse and neglect, room changes and expectations by the ADM on 6/10/2025. DC L stated they reviewed various types of abuse and neglect and he completed a quiz. DC L stated whenever a resident was relocated to a different room, the ADM and the DON must be informed. DC L stated all incidents must be reported to the ADM. DC L stated everything was a refresher as he already knew the information. In an interview on 06/11/25 at 4:10 PM, the VP stated the ADM completed all in-services and he completed all the quizzes yesterday and today. The VP stated all staff completed a post-test and were quizzed verbally and on paper. The VP stated the in-services were ongoing until everyone had been in-serviced. The VP stated he in-serviced the ADM and DON on the evening of 6/10/25. The VP stated there were no new changes, just re-education. The VP stated they completed the same in-services again this morning, 6/11/25. The VP stated all room changes went through the ADM and anyone could make the request. The VP stated it was reiterated that you do not take the emergency out of a situation and you were expected to address the situation until completion (e.g., once a room request was started, you were expected to complete it, or re-assign the task to a different staff member). The VP stated they discussed all categories of abuse and neglect and provided examples. The VP stated he expected all staff, including administration to adhere to policy and to not deter. In an interview on 6/11/25 at 4:25 PM, the ADM stated she audited grievances and there were no reports related to abuse or altercations. The ADM stated she was in-serviced by the VP on 6/10/25 and 6/11/25 on abuse and neglect, room changes and facility expectations. The ADM stated the information was a re-education as they went over a thorough review of state and federal regulatory requirements, facility-specific protocols for reporting and investigating incidents, and expectations for leadership accountability. The ADM stated they would continue to educate and train staff to identify gaps or lapses in their training to ensure staff received what they needed so situations were addressed efficiently. The ADM stated staff now recognized what could happen if they did not act. The ADM stated moving forward, she would keep working with staff to come up with new processes as needed. The ADM stated a lot of in-services were completed online, so they planned to pull some of the trainings to go over as a group to ensure staff understood what they were reading. Record review of an in-service sign in sheet, dated 6/10/25, and titled Expectations of the ADM [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 (Resident #2) of 2 residents reviewed for resident rights. The facility failed to move Resident #2 to a temporary room on the nights of 5/12/2025 and 5/13/2025 when Resident #2 complained that the room was too hot. This failure could place residents at risk for living in an uncomfortable and unhomelike environment which could cause a diminished quality of life. Findings included: Record review of Resident #2 face sheet, dated 06/09/25, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. Resident #2 had diagnoses of Vascular Dementia (progressive cognitive disorder that damages brain tissue due to reduced blood flow), Encephalopathy (broad range of brain disorders that affect the brain's function and/or structure) and Major Depressive Disorder (persistent feelings of sadness, emptiness, and a loss of interest or pleasure in activities). Record review of Resident #2's Quarterly MDS Assessment, dated 03/23/25, reflected Resident #2 had a BIMS score of 9, which indicated Resident #2's cognition was moderately impaired. The MDS noted Resident #2 had no issues with mood or behavior. Record review of Resident #2's Care Plan, with an initial date of 10/06/23, reflected the following: Date Initiated: 10/26/2023: 05/21/2025 [Resident #2] has a history of Hypertension, treatment in place Record review of the progress notes in Resident #2's electronic record reflected the following: 05/12/2025 23:57 (11:57 PM) Documented by LVN A [Resident #2] complains of room being too hot and staff have continuously attempted to lower room temperature but it was reset back to 80 degree Fahrenheit of heat by [Resident #1]. [Resident #2] desired to switch room and was informed to wait in the morning to speak with administration. 05/13/2025 21:45 (9:45 PM) Documented by LVN A [Resident #2] is staying in hallway and not staying in room due to heat. Observation and interview on 06/09/25 at 11:50 AM with Resident #2 revealed he was in his room sitting in his wheelchair watching television. Resident #2 stated he had adjusted well to his new room. Resident #2 stated Resident #1 (his previous roommate) liked the room to be hot with the door closed. Resident #2 stated he agreed to the heat, but with the door closed, it was too hot for him. Resident #2 stated he would sometimes sit outside the room when it was too hot. Resident #2 stated he told LVN A he wanted to switch rooms (05/12/2025) and LVN A told him he would tell the ADM in the morning (05/13/2025). In an interview on 06/09/25 at 1:45 PM, LVN A stated on 05/12/25 at 11:57 PM, Resident #2 informed him the room was too hot and he wanted to move to another room. LVN A stated he spoke with Resident #1 about being understanding and Resident #1 agreed to lower the temperature. LVN A stated about 40 minutes later, Resident #1 had turned the temperature back up. LVN A stated the next morning (5/13/25), he spoke with the DOA and the DOA informed him that they did not have a room ready but he would try to find a room for Resident #2. LVN A stated when he returned to work on 05/13/25, Resident #1 continued to turn up the temperature. In an interview on 06/09/25 at 2:15 PM, the ADON stated Resident #1 and Resident #2 preferred the room to be hot. The ADON stated Resident #2 wanted to keep the door opened and Resident #1 wanted the door to remain closed. The ADON stated after-hours, staff could have moved Resident #2 to a private room until Administration arrived in the morning. The ADON stated LVN A should have rectified the situation on 05/12/2025 by moving Resident #2 temporarily until a permanent room could be confirmed. In an interview on 06/09/25 at 3:30 PM, the DOA stated LVN A informed him the morning of 05/13/25 that Resident #2 wanted a room change due to Resident #1 keeping the room too hot. The DOA stated Resident #2 liked the room warm, but Resident #1 made it too warm. The DOA stated prior to assigning roommates, himself, the SW, and the ADM's input made sure residents were compatible (mental status, social status, etc.). The DOA stated Resident #1 and Resident #2 both kept to themselves. The DOA stated there had not been an issue since Resident #1 relocated to the room on 05/08/2025. In an interview on 06/09/25 at 3:55 PM, the ADM stated Resident #2 was fine with the temperature being high, but he wanted the door to remain opened and Resident #1 wanted the door to remain closed. The ADM stated if a resident requested to move rooms, they would match them with an appropriate roommate. The ADM stated on 05/12/25, she was not informed that Resident #2 requested to move to a new room. The ADM stated LVN A should have notified the DON or whomever was on call on 05/12/25 if it was a significant situation. The ADM stated it was a concern not reporting Resident #2's request. The ADM stated overnight staff could temporarily move a resident if an issue arose and then administration would find a permanent room the next day. In an interview on 06/10/25 at 11:00 AM, the DON stated Resident #1 and Resident #2 had been roommates for only 6 days and there had not been any concerns. The DON stated Resident #2 informed LVN A that the room was too hot and LVN A documented it in Resident #2's Progress Notes and informed the DOA. The DON stated they discussed it during the morning meeting on 05/13/2025 and started looking for a new room. The DON stated as a Team, they now discussed room assignments in greater detail. The DON stated if a Resident requested to change rooms, they looked further into the possibility of concerns with compatibility. Record review of the facility's policy, titled, Resident Rights with a revised date of January 2025, reflected: Policy Explanation and Compliance Guidelines: . 11. The facility will ensure that all direct care and indirect care staff members, including contractors and volunteers, are educated on the rights of residents and the responsibility of the facility to properly care for its residents. Training topics will be appropriate to the individual's role. . Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. . 8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #24) of 5 residents reviewed for pharmacy services. The facility failed to correctly transcribe Resident #1's medication changes when he returned to the facility on [DATE] after hospitalization. The incorrectly transcribed medication was administered from 03/2025 to 05/13/25. These failures could place residents at risk for medication errors, ineffective relief from pain medication, and drug diversion of controlled substances. Findings included: Record review of Resident #1's admission record, dated 05/13/25 revealed a [AGE] year-old male with an initial admission of 08/31/24 and readmission of 03/20/25. His primary diagnosis was chronic obstructive pulmonary disease with acute exacerbation (a lung disease that blocks airflow and makes it difficult to breathe). His secondary diagnoses were respiratory failure with hypoxia (the body not receiving enough oxygen), constipation, unspecified pain, insomnia (difficulty sleeping) and anxiety disorder. Record review of Resident #1's re-entry MDS assessment dated [DATE] reflected Resident #1 readmitted to the facility on [DATE] from a short-term general hospital. The MDS revealed Resident #1 had a BIMS score of 15, indicating that he was cognitively intact. He could understand others and others could understand him. Record review of Resident #1's care plan initiated on 02/28/25 revealed Resident #1 had a behavior problem of calling 911. The interventions were to administer medications as ordered. To monitor/document side effects and effectiveness. Record review of Resident #1's hospital discharge after visit summary physician orders for dated 03/20/25 reflected Resident #1 was admitted to the hospital from [DATE] to 03/20/25. Further review of discharge summary reflected: - Albuterol 90 mcg/actuation HFA Inhaler. Inhale 2 puffs by mouth every 4 hours as needed for wheezing or shortness of breath. - Start; Bisacodyl Extended Release 5 mg tablet. Take 2 tablet by mouth one time a day (for constipation) - Buspirone 5 mg tablet. Take 5 mg by mouth 3 times a day (for anxiety disorder) - Change; Hydroxyzine HCL 25 mg 1 tablet by mouth three times a day as need for anxiety (PRN) Record review of Resident #1's active physician orders for April and May 2025 reflected : - Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT. 1 puff inhale orally every 4 hours as needed for wheezing- ordered 03/05/25. - Bisacodyl Oral Tablet Delayed Release 5 MG. Give 1 tablet by mouth one time a day for constipation- ordered 03/20/25. -BusPIRone HCl Oral Tablet 10 MG (Buspirone HCl). Give 1 tablet by mouth three times a day related to anxiety disorder, unspecified- ordered 03/20/25. -Hydroxyzine HCl Oral Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety- ordered 03/11/25. -Hydroxyzine HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day related to anxiety disorder, unspecified- ordered 03/11/25. Record review of Resident #1's MAR for April and May 2025 reflected medications were administered as facility transcribed. Hydroxyzine HCl Oral Tablet 25 MG Give 1 tablet by mouth three times a day was administered at 07:00 AM, 2:30 PM and 7:00 PM daily. Buspirone 10 mg was administered 07:00 AM, 2:30 PM and 7:00 PM daily. 1 tablet of Bisacodyl was administered in the mornings daily. 1 puff of Albuterol Sulfate HFA Inhalation Aerosol Solution 108 was last administered 5/6/25 PRN. Hydroxyzine HCl Oral Tablet 25 MG Give 1 tablet by mouth every 8 hours was administered 5/4/25, 5/5/25, 5/7/25, 5/9/25, 5/10/25, and 5/12/25. Record review of Resident #1's nurse progress notes did not reflect changes to medications by facility after hospital discharge and readmission on [DATE]. The hospital pharmacist was not available by phone for interview on 05/13/25. Record review of intake investigation dated 03/18/25, it was revealed by the hospital pharmacist that on many occasions Resident #1 was sent to the hospital without his medication list and when requested, the ADON said patient had visited [hospital name] ER the previous week, the medication list in our records should suffice. hospital pharmacist reported ADON declined to provide an updated list and abruptly ended the call. The hospital pharmacist reported I have observed that even when a patient has recently been seen at our facility, discrepancies in medication records from [facility name] can occur, potentially contributing to patient admissions or complicating existing health issues. She reported this recurring issue raises significant concerns, including: 1. Delays in patient care due to inaccessible or outdated medication information. 2. Compromised continuity of care when patients transition between facilities. 3. Potential harm to patients if medications, dosages, or administration instructions for high-risk conditions or medications are not accurately verified. In an observation and interview with Resident #1 on 05/13/24 at 11:00 AM, he stated, I am getting too much medication. Resident #1 said at times the medication made it hard for him to stay awake. He said, they give me a cup full of medicines and three inhalers at the same time. He said it was too much. Resident #1 stated that stuff can mess you up. He said that some nurses tell him the names of medications and other nurses say, your doctor prescribed them to you. He said he was aware that some medications were changed during his last hospital visit but he did not know which ones they were, or which medication was making him too sleepy to function . He said he would like to only get a few pills in the morning, and the rest spread out at different times intervals during the day so that he was not getting so much medication at once some of which made him not function well and all he wanted to do was sleep. Resident #1 was alert and oriented and did not appear groggy at time of interview and he was seated upright on the edge of his bed. Resident denied being sleepy at that time. He stated he had gotten his morning medications. In an interview with LVN B on 05/13/25 at 2:30 PM, it was revealed that LVN A, who readmitted Resident #1 on 03/20/25, no longer worked at the facility. LVN B said when a resident returned to the facility after hospital or out of facility to see a specialty, the admitting nurse would fax the new orders to the facility physician or NP. She said at that point the physician or NP would tell them Yes let us use the new orders or let us change them. She said it was the responsibility of the admitting nurse to enter correct medications and doses. She said if you don't understand an order or need clarity ask the physician or pharmacist to avoid medication errors and delay in care. LVN A that readmitted the Resident #1 on 03/20/25 and transcribed the medication, was no longer employed at the facility and no contact information was provided on 05/13/25. In an interview with the ADON on 05/13/25 at 3:56 PM, it was revealed that the hospital pharmacist had called the facility after Resident #1 went to the hospital [03/14/25] to ask for a medication list. The ADON said Resident #1 called 911 himself. She said Resident #1 does this a lot, he calls 911 before we have a chance to assess him. She said when the paramedics came to get him, the facility had not prepared paperwork to send with him to the hospital. The ADON said the process was that any resident being sent out via EMS got a face sheet, medication list and a progress note if needed. The ADON stated she tried to fax the medication list, but the nursing fax machine was not working. She said she tried to explain to the caller the fax issue, and she even tried to go over the medication list over the phone or by sending snap shots of Resident #1's medication list but the caller [hospital pharmacist] refused. The ADON stated the medication list was finally sent out using the fax machine in the administrators' office. The ADON said when a resident is readmitted the admission orders are sent to the physician by the admitting nurse and the physician signs off on the new orders or changes. The ADON did not state risk to the resident. In an interview with the facility receptionist on 05/13/25 at 4:20 PM, she stated the nursing staff use the main nursing station fax machine for physician orders, labs, and hospital referrals. She said she was not aware of the main nursing fax machine not working because only the nursing staff used it. In an interview with the DON on 05/13/25 at 4:44 PM, it was revealed that she was new to the facility. She said that the expectation was that when a resident was admitted or readmitted to the facility, the physician was notified and that if any changes were made for medication, the nurse was responsible for transcribing correctly into EMR. She said the expectation was that the correctly transcribed medication was then sent to pharmacy to be reviewed. The DON stated moving forward all new medication orders would be brought to the clinical nurse meeting the next day to make sure that it was all transcribed correctly. She said herself and ADON's will be monitoring and ensuring all orders are transcribed correctly. She said she would do an in-service. The DON said the potential risk was inaccurate medication dosage would prolong the existing bad symptoms . In an interview with the Administer on 05/13/15 at 6:14 PM, it was revealed that the expectations was that medication was entered and transcribed as ordered and if the nurse needed clarity to reach out to physician. She said the Clinical leadership was responsible for monitoring the orders to make sure they were accurate. She said the potential risk depended on medication for example a blood pressure medication could cause a lower BP . Review of the facility's policy Pharmacy Services, revision date 01/23 reflected the following: The facility will provide pharmaceutical services that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs Review of the facility's policy Medication Orders, revision date 04/23 reflected: 4. (b) Clarify the order. (f), Transcribe newly prescribed medications on the MAR

Based on observation, interview and record review, it was determined the facility failed to ensure the medication error rate was less than 5%. Thirty-one opportunities were observed with a total of ten errors, resulting in a 32% error rate. Two (LVN C and MA D) of seven staff observed administering medication made errors. Two (Residents #14 and #23 ) of nine residents observed during the medication pass were affected. 1) LVN C failed to shake a [MEDICATION NAME] suspension (particles of [MEDICATION NAME] are mixed in a fluid but are not dissolved)prior to preparing it for administration for Resident #14. [MEDICATION NAME] is used to prevent [MEDICAL CONDITION] activity; 2) LVN C failed and shake a [MEDICATION NAME] suspension (particles of [MEDICATION NAME] are mixed in a fluid but are not dissolved) prior to preparing it for administration for Resident #14. [MEDICATION NAME] is used to prevent [MEDICAL CONDITION] activity; 3) LVN C administered 25 mg of [MEDICATION NAME] versus the physician-ordered 50 mg to Resident #14. [MEDICATION NAME] is used to prevent [MEDICAL CONDITION] activity; 4) LVN C failed to administer the physician ordered Artificial Tears to Resident #14; 5)LVN C failed to flush Resident #14's gastrostomy tube with 30 cc of water before and after the medication pass; 6) MA D failed to administer Resident #23's Folbic as ordered by the physician. MA D administered three separate medications that were the ingredients to Folbic instead of the Folbic; and at the wrong doses : MA D administered two 400 microgram tablets of Folic Acid which equaled 0.8 milligrams total. (1000 micrograms =1 milligram)Folbic contains 2.5 milligrams of Folic Acid. MA D administered 500 micrograms of Vitamin B-12 which equaled 0.5 milligrams. Folbic contains 2.0 milligrams of Vitamin B-12. MA D administered 100 milligrams of Vitamin B-6 to Resident #23. Folbic contains 25 milligrams of Vitamin B-6; 7) MA D failed to administer Resident #23's physician-ordered [MEDICATION NAME]; and 8) MA D failed to administer Resident #23's physician-ordered [MEDICATION NAME]/Levomefolate/[MEDICATION NAME]/HRB CB 122 as ordered by the physician. On 08/07/15, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/10/15, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. These failures by LVN C could affect the 12 residents on the 300 Unit for whom she passed medication including Resident #14. In addition, LVN C made three anticonvulsant medication errors for Resident #14, which greatly increased the possibility of [MEDICAL CONDITION] activity, brain damage, and even death. These failures by MA D could also affect the 37 residents on the 200 and 300 Units for whom she passed medication, including Resident #23. MA D stated she did not ask for direction when the Folbic was not available and instead administered the individual ingredients in Folbic at the wrong dosages. A medication aide is prohibited from calculating doses. Failure to follow this rule could lead to significant medication errors. Findings included: 1)During the morning medication pass on 08/06/15 at 8:23 AM, LVN C was observed to prepare medication for Resident #14 who received all nutrition and medication through a gastrostomy tube. LVN C placed the following medications into individual medication cups: Ten milliliters of [MEDICATION NAME] 100 mg/5 ml suspension (for [MEDICAL CONDITION] control) She did not shake the bottle before pouring the medication and the bottle had a label to shake well; Five milliliters of [MEDICATION NAME] 125 mg/5 ml suspension (for [MEDICAL CONDITION] control)She did not shake the bottle before pouring the medication and the bottle had a label to shake well; One 25 mg tablet of [MEDICATION NAME] (for [MEDICAL CONDITION] control); One 200 mg tablet of [MEDICATION NAME] (for [MEDICAL CONDITION] control); and One 20 mg-10 mg capsule of Nudexta ( According to Drugs.com, last updated 07/03/15, Nudexta is a combination of [MEDICATION NAME] and [MEDICATION NAME] which is used to treat the outbursts of crying/laughing associated with neurological disease including Pseudobulbar Affect.) Before altering the medication for [DEVICE] administration, LVN C was asked to count the number of capsules/tablets/liquid medications she had prepared. LVN C counted and stated there were five capsules/tablets/liquid medications. LVN C then opened the capsule and poured the contents into a medication cup with about 5 cc water; and crushed the tablets and added about 5 cc water to each medication cup. Then LVN C entered Resident #14's room and set the medications on the bedside table. LVN C stated the pump was not running and she had disconnected the [DEVICE] feeding at 7 AM to allow for down-time and the one hour time interval prior to administering [MEDICATION NAME]. LVN C then removed the piston plunger from a 60 cc syringe and placed the tip of the syringe into Resident #14's [DEVICE] port. LVN C did not check placement or flush Resident #14's [DEVICE] with 30 cc of water prior to the administration of the medications. LVN C gave all five medications, one right after the other; and after the last medication, she failed to flush the [DEVICE] with 30 cc of water. LVN C then left Resident #14's room and approached her medication cart. At that point the surveyor asked LVN C why she had not flushed with at least 30 cc of water before and after the medication administration. LVN C replied she had already given Resident #14 her scheduled 150 cc water flush earlier that morning and that was when she checked for residual and placement. LVN C added there was no order to flush before and after administering medication. LVN C was then asked to bring up Resident #14's orders on the medication cart computer screen. LVN C did and the surveyor pointed out the order to flush with 30 cc of water before and after medications. LVN C replied, oh. When asked why she did not shake the bottles of [MEDICATION NAME] and [MEDICATION NAME] before pouring, she replied, I didn't? LVN C was then asked if she had completed her morning medication pass for Resident #14. LVN C replied she was through with all of Resident #14's morning medications. 2)Upon reconciliation of the medication pass with Resident #14's most current undated physician orders [REDACTED]. LVN C did not administer this medication. The orders also reflected Resident #14 was to receive 50 milligrams of [MEDICATION NAME] twice daily. LVN C administered 25 mg. The orders also reflected Resident #14 was to have her [DEVICE] flushed with 30 cc of water before and after medications. LVN C failed to flush the [DEVICE] before or after medications were administered. 3. A review of Resident #14's [MEDICATION NAME] laboratory report dated 07/21/15 revealed the [MEDICATION NAME] level to be low at 8.2 micrograms per ml of blood. The therapeutic reference range reflected on the report was 10.0 - 20.0 micrograms per ml of blood. 4) A review of Resident #14's [MEDICATION NAME] laboratory report dated 07/21/15 revealed the [MEDICATION NAME] level to be low on the last three months: 07/21/15: 3.6 micrograms per ml of blood; 06/23/15: 2.6 micrograms per ml of blood; and on 05/26/15: 3.2 micrograms per ml of blood. The therapeutic reference range reflected on the report was 4.0 to 12.0 micrograms per milliliter of blood. 5)A review of Resident #14's 08/06/15 nurses notes revealed the physician was notified after the surveyor notified the DON and Administrator of the errors made by LVN C with Resident #14. This notification was done during an end-of day meeting on 08/06/15 at 4 PM. The notes further reflected the physician ordered [MEDICATION NAME] and [MEDICATION NAME] levels be drawn STAT. According to the laboratory results report dated 08/06/15, the levels were drawn at 8:55 PM on 08/06/15. The [MEDICATION NAME] level was normal at 16.8 micrograms per ml of blood. The [MEDICATION NAME] level was low at 3.8 micrograms per ml of blood. According to the 08/07/15 nurses notes, Resident #14's laboratory results were shared with the Nurse Practitioner at 8:22 AM. Review of the physician orders [REDACTED]. 6)According to the 12th edition of the Geriatric Dosage Handbook, page 1233 entitled Administration: Oral: Suspension: Shake well prior to use. 7)According to the online website updated 07/13/15, http://www.drugs.com/[MEDICATION NAME].html Shake the [MEDICATION NAME] oral suspension (liquid) well just before you measure a dose. 8) According to the American Society for [MEDICATION NAME] and Enteral Nutrition Practice Recommendations, published 01/27/09, Section VII, Medication Administration, page 40, Prior to administering medication, stop the feeding and flush the tube with at least 15 ml water. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe greater or equal to 30 ml in size. Flush the tube again with at least 15 ml water taking into account patient's volume Repeat with the next medication if appropriate. Flush the tube one final time with at least 15 ml of water. 9)According to the facility policy entitled General Dose Preparation and Medication Administration, Revised January 2013, and provided as the most current policy by facility administration: .5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: .5.8 Follow manufacturer administration guidelines (e.g., rotating [MEDICATION NAME] site, providing medication with fluids or foot, shaking medication prior to pouring ) 10) During the morning medication pass on 08/06/15 at 9:22 AM, MA D was observed to prepare medication for Resident #23. MA D placed the following medications in a medication cup: One 325 mg tablet of Aspirin (for personal history of a [MEDICAL CONDITION]); One 100 mg caplet of [MEDICATION NAME] (stool softener); One 325 mg of [MEDICATION NAME] (treats [MEDICAL CONDITIONS]); One 500 microgram tablet of Vitamin B-12 (treatment of [REDACTED].>One 100 mg of Vitamin B-6 (treat of vitamin deficiency); Two 2.5 mg tablets of [MEDICATION NAME] (treatment of [REDACTED].>Two 750 milligram tablets of Levetiracetam (used to treat [MEDICAL CONDITION]); and Two 400 microgram tablets of Folic Acid (treats [MEDICAL CONDITION] and folic acid deficiency). Prior to administering the medication to Resident #23, MA D was asked to count all the caplets/tablets in the medication cup. MA D counted and stated there were 11 caplets/tablets. MA D then administered the medication to Resident #23. After administering the medication, MA D asked if she had completed her morning medication pass for Resident #23. MA D replied she was through with all of Resident #23's morning medications. 11)Upon reconciliation of the medication pass with Resident #23's most current physician orders [REDACTED].#23: One Vitamin B6-B12-levomefolate-122cmb 10 mg-200 microgram-400 microgram tablet every morning (a vitamin/folic acid/herb combination); One 100 mg [MEDICATION NAME] tablet every morning (Vitamin B1); and One Folbic 2.5 mg-25 mg-2 mg tablet (Folic Acid/[MEDICATION NAME]/[MEDICATION NAME])one time daily. ([MEDICATION NAME] is Vitamin B12 and [MEDICATION NAME] is Vitamin B6). In addition there were no orders for the the 500 micrograms of B12, the 100 mg of B6 and the two 400 microgram tablets of Folic Acid MA D was observed to administer to Resident #23. 12)An IJ was identified on 08/07/15. The facility's Administrator and DON were notified at Noon on 08/07/15 of the IJ and a Plan of Removal was requested. 13) On 08/07/15 at 2:30 PM, ADON B stated she had counseled LVN C on all of the medication errors and she was being re-trained and assessed by the Staff Development Coordinator. 14)On 08/07/15 at 3:41 PM, MA D was interviewed and stated the Folbic had not been available since she was hired about one month ago. MA D stated she looked up Folbic and determined it was a combination of Vitamins B6, B12, and Folic Acid. MA D stated she did not consult with a nurse and decided on her own to give the individual tablets of B6, B12 and Folic Acid to Resident #23 instead of the physician ordered Folbic. When explained she gave 0.8 mg of Folic Acid instead of the ordered 2.5 mg; 100 mg of B6 instead of the ordered 25 mg; and 0.5 mg of Vitamin B12 instead of the ordered 2.0 mg, MA D stated she did not realize the difference. MA D stated, It is all on me. During this same interview with MA D, she stated she did not know why she did not give the Vitamin B6-B12-levomefolate-122cmb 10 mg-200 microgram-400 microgram tablet. When asked about the failure to give the [MEDICATION NAME], MA D stated she gave the it, [MEDICATION NAME] is B6. When explained that [MEDICATION NAME] was B1 and B6 was Pyrodoxine, MA D replied, Oh, okay. MA D stated she passed medication to all residents on the 200 and 300 halls who did not have a [DEVICE]. 15)The Plan of Removal was accepted on 08/07/15 at 6 PM: Plan of Removal 08/07/15 4:45 p.m. (version 4) · Resident #14 [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. LVN C failed to check placement of the Gastrostomy tube prior to medication administration, and failed to flush with 30 cc water before and after medication administration, failed to shake [MEDICATION NAME] and [MEDICATION NAME] liquid medication prior to administration. She failed to administer eye drops as ordered. [MEDICATION NAME] was not administered as ordered by the physician. medication orders [REDACTED] [MEDICATION NAME] 100 mg/5 ml oral suspension. 10 ml per gastrostomy tube three times a day. [MEDICATION NAME] 5 ml per gastrostomy tube every day. 125 mg/5 ml. [MEDICATION NAME] 50 mg disintegrating tablet, one tablet per gastrostomy tube twice daily. Resident #14 was assess on 08/06/15 by ADON B at approximately 3:24 PM. Stat labs reflected: 08/07/15 [MEDICATION NAME] level was 3.8 (normal 5 - 12) 08/07/15 [MEDICATION NAME] level was 16.8 (normal was 10 - 20) LVN C was counseled by ADON B on 08/07/15. LVN C had no explanation how this medication error occurred. · Resident #23 [AGE] year-old admitted [DATE] with [DIAGNOSES REDACTED]. MA D failed to administer Fobic as ordered. She administered three separate medications at the wrong dose that are the ingredients of Fobic, instead of the Fobic. MA D failed to administer [MEDICATION NAME] and [MEDICATION NAME]/levomefolate/[MEDICATION NAME]/hrb cb 122 as ordered by the physician. Resident #23 was assessed on 08/06/15 by ADON A at approximately 8 AM. medication orders [REDACTED] Folbic 2.5 mg-25 mg-2 mg one tablet everyday [MEDICATION NAME] 100 mg everyday [MEDICATION NAME]/levomefolate/[MEDICATION NAME]/hrb cb 122, one every morning. MA D was counseled by ADON A on 08/07/15. MA D was confused of the individual components of the medication, when asked how this medication occurred. · The facilities Medication Error Rate of 34% prompted the Immediate Jeopardy. · The Medical Director was notified by telephone of the IJ on 08'-7'15 at 3:15 per the Administrator. In-Services were initiated immediately for: Facility Nurse Management: Corporate Nurse Consultant and Clinical Educational Specialist completed inservice with the facility ADONs, ADON A, ADON B, Staff Development Coordinator, and the DON on 08/07/15 at 12:15 PM, on completing medication competencies with all licensed nursing staff and medication aides, on hire, prior to rolling a medication cart independently, after any medication error, and annually. This inservice was, Medication Administration-Avoiding Common Errors. This was completed on 08/07/15. Licensed Nurses: Were initiated an inservice, Medication Administration-Avoiding Common Errors/Placement and flushing of Gastrostomy Tube. This inservice was initiated by ADON B , ADON A, DON, and the Staff Development Coordinator on 08/07/15 at 12:35 PM. The current 6-2 licensed nurses were educated during their shift and will have a simulation medication pass, chosen at random by observer(either ADON B, ADON A, Staff Development Coordinator, and DON)on 08/07/15. This well be documented on a Medication Competency for Licensed Nurses. A post-test will be completed following the inservice by the attendees. The 2pm-10 pm shift nursing staff will be educated prior to the start of their shift on 08/07/15 by either ADON B, ADON A, DON, or the Staff Development Coordinator on 08/07/15 at 12:35 PM, and will have a medication competency completed prior to passing medications independently. A post-test will be completed following the inservice by the attendees. The 10 pm - 6 am nursing staff will be educated prior to the start of their shift on 08/07/15 by either ADON B, ADON A, DON, or the Staff Development Coordinator at 08/07/15 at 12:35 PM, and will have a medication competency completed prior to passing medications independently A post-test will be completed following the inservice by the attendees. Any remaining licensed nurses needing education will be provided with the education prior to their next scheduled shift, by ADON B, ADON A, the DON, or the Staff Development Coordinator and will have a medication competency completed prior to pushing a medication cart independently. A post-test will be completed following the inservice by the attendees. The DON will be responsible for ensuring and monitoring a list of staff that haven't been educated. Inservices were initiated immediately for: Medication Aides: Were initiated and inserviced on Medication Administration-Avoiding Common Errors. This inservice was initiated by ADON B, ADON A, the DON, and the Staff Development Coordinator on 08/07/15 at 12:35 pm. The current Medication Aides were educated during their shift and will have a simulation medication pass, chosen at random by the observer (either ADON B, ADON A, the Staff Development Coordinator, or the DON) on 08/07/15. A follow-up medication pass observation will be completed by the current 6-2 Medication Aides on 08/08/15. This will be documented on a Medication Competency for Medication Aides. A post-test will be competed following the inservice by the attendees. The 2pm-10 pm shift Medication Aides will be educated prior to the start of their shift on 08/07/15 by either ADON B, ADON A, the Staff Development Coordinator, or the DON on 08/07/15 at 12:35 pm, and will have a medication competency completed prior to passing medication independently. A post-test will be completed following the inservice by the attendees. The 10 pm-6 am Medication Aides will be educated prior to the start of their shift on 08/07/15 by either ADON B, ADON A, the Staff Development Coordinator, or the DON on 08/07/15 at 12:35 pm, and will have a medication competency completed prior to passing medication independently. A post-test will be completed following the inservice by the attendees. All PRN Medication Aides and Medication Aides on vacation will be inserviced and have a medication competency prior to their next scheduled shift by the DON, ADON B, or ADON A. All new hired licensed nurses and Medication Aides will have the above education included in department specific education by the DON, ADON B or ADON A, effective 08/07/15, and will have medication competency completed prior to rolling a medication care independently. The Corporate Nurse Consultant, Clinical Educational Specialist and the DON initiated review of all current residents (108)Medication Administration Records for dosage discrepancies. This was initiated on 08/07/15 and will be completed by 08/07/15. Ongoing monitoring of residents receiving nutrition via a feeding tube (A total of 6 residents have gastrostomy tubes). Five of the six have been assessed. One is not in the facility. This will be conducted by ADON B or ADON A twice weekly for thirty days, then once weekly for thirty days and then monthly thereafter. Results of the audit will be documented in the nurses' notes and reviewed at the weekly Standards of Care Meeting. ADON B or ADON A will notify the physician of any changes. A medical record review of all resident, who transferred to the hospital from 05/07/15 through 08/07/15, was initiated on 08/07/15 and will be completed by 08/07/15, to determine if any other resident was transferred to the hospital due to medication discrepancies. This will be completed by the DON. Nurse Management will conduct random medication pass observations weekly. Findings will be reviewed weekly in the Standards of Care Meeting an monthly in QAA meetings for the next 90 days. The Administrator and the DON are responsible for monitoring this Plan of Removal and ensuring its implementation. 16)On-site monitoring was conducted on 08/08/15 between the hours of 9:45 AM and 12 Noon; and on 08/09/15 between the hours of 1:45 PM and 4 PM. In addition, the monitoring continued on 08/10/15, when the team conducted the extended survey. Interviews conducted during on-site monitoring included staff from all shifts and weekend staff: The DON, Administrator, ADON A, ADON B, MA D, RN E, LVN F, Staff Development Coordinator, LVN R, MA S, LVN T, MA U, MA V, MA W, LVN X, MA Y, LVN Z, LVN AA, MA BB, LVN CC, LVN DD, LVN EE, LVN FF, LVN GG, LVN HH, MA II, and RN JJ. All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in the administration of medication via [DEVICE]; and suspensions. All medication aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications were not available and who they were to notify. 17)On 08/10/15 at 1:16 PM, the DON was interviewed and stated the pharmacist did random medication passes with a couple of staff and the Staff Development Coordinator also did random medication passes. The DON stated she could not explain the IJ cause as LVN D could not explain her performance. The DON stated she believed the correction would involve doing weekly or biweekly random medication passes with the Medication Aides and nurses, especially when passing medication through a [DEVICE]; assessing if the orientation process needed changing to ensure issues with medication skills were identified up front; and possibly checking nursing medication pass skills every six months. The DON checked with Human Resources and stated the hire date for LVN C was 09/24/15 and she worked only as needed. 18)On 08/10/15 at 1:41 PM, the Staff Development Coordinator was interviewed and stated she was hired in April 2014. The Staff Development Coordinator stated she had never conducted a medication pass with LVN C until 08/07/15, when she was instructed to train and observe LVN C. The Staff Development Coordinator stated she never conducted a pass with LVN C before this date because LVN C only worked as needed and was not always available. When asked how LVN C performed on 08/07/15, the Staff Development Coordinator stated she did not use a stethoscope when she checked for placement of a gastrostomy tube with a 10 cc bolus of air; and she forgot to flush the tube before giving medications. The Staff Development Coordinator stated she had never worked with MA D because she was just hired mid-July. 19)ADON A was asked for the punch time detail report for LVN C from 01/01/15 through current date and the report was provided by ADON A on 08/10/15 at 3:10 PM. This report was reviewed and revealed LVN C worked on the following number of days for each month: January 2015: 12 February 2015: 14 March 2015: 19 April 2015: 10 May 2015: 5 June 2015: 14 July 2015: 17; and August 2015: 3 as of 08/07/15. 20)A review of the Pharmacy Consultant Reports from January 2015 through August 2015 was conducted and revealed no evidence the pharmacist had ever observed LVN C during a medication pass. 21)At 2:35 PM on 08/10/15, the DON was asked to see if she could find any evidence the pharmacist had worked with LVN C. As of the exit on 08/10/15 at 5 PM, no evidence was provided. 22)the IJ was removed on 08/10/15 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. 23) A review of the list of residents on anticonvulsant medication was provided by the DON on 08/10/15 at 1:45 PM. This list reflected there were 14 residents who received anticonvulsant medications. 24)On 08/07/15 at 9:24 AM, ADON A provided a list of residents for whom LVN C passed medications. The list dated 08/07/15, reflected there were 11 residents in addition to Resident #14, totaling 12 residents. 25) A Resident Roster dated 08/09/15, there were 37 residents who did not have a gastrostomy tube who resided on the 200 and 300 Units; and for whom MA D passed medications.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #14) of nine residents reviewed during the medication pass was free of significant medication errors. 1) LVN C failed to shake a [MEDICATION NAME] suspension (particles of [MEDICATION NAME] are mixed in a fluid but are not dissolved)prior to preparing it for administration for Resident #14. [MEDICATION NAME] is used to prevent [MEDICAL CONDITION] activity; 2) LVN C failed and shake a [MEDICATION NAME] suspension (particles of [MEDICATION NAME] are mixed in a fluid but are not dissolved) prior to preparing it for administration for Resident #14. [MEDICATION NAME] is used to prevent [MEDICAL CONDITION] activity; 3) LVN C administered 25 mg of [MEDICATION NAME] versus the physician-ordered 50 mg to Resident #14. [MEDICATION NAME] is used to prevent [MEDICAL CONDITION] activity; These failures could affect the 12 residents on the 300 Unit for whom LVN C passed medication including Resident #14. In addition, LVN C made three anticonvulsant medication errors for Resident #14, which greatly increased the possibility of [MEDICAL CONDITION] activity, brain damage, and even death. On 08/07/15, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 08/10/15, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. Findings included: 1)During the morning medication pass on 08/06/15 at 8:23 AM, LVN C was observed to prepare medication for Resident #14 who received all nutrition and medication through a gastrostomy tube. The following were some of the medications LVN C placed into individual medication cups: Ten milliliters of [MEDICATION NAME] 100 mg/5 ml suspension (for [MEDICAL CONDITION] control) She did not shake the bottle before pouring the medication and the bottle had a label to shake well; Five milliliters of [MEDICATION NAME] 125 mg/5 ml suspension (for [MEDICAL CONDITION] control)She did not shake the bottle before pouring the medication and the bottle had a label to shake well; and One 25 mg tablet of [MEDICATION NAME] (for [MEDICAL CONDITION] control). When finished with administering the medication to Resident #14, LVN C then left the room and approached her medication cart. At that point she was asked by the surveyor why she did not shake the bottles of [MEDICATION NAME] and [MEDICATION NAME] before pouring, she replied, I didn't? LVN C was then asked if she had completed her morning medication pass for Resident #14. LVN C replied she was through with all of Resident #14's morning medications. 2)Upon reconciliation of the medication pass with Resident #14's most current undated physician orders [REDACTED].#14 was to receive 50 milligrams of [MEDICATION NAME] twice daily. LVN C administered 25 mg. 3. A review of Resident #14's [MEDICATION NAME] laboratory report dated 07/21/15 revealed the [MEDICATION NAME] level to be low at 8.2 micrograms per ml of blood. The therapeutic reference range reflected on the report was 10.0 - 20.0 micrograms per ml of blood. 4) A review of Resident #14's [MEDICATION NAME] laboratory report dated 07/21/15 revealed the [MEDICATION NAME] level to be low on the last three months as follows: 07/21/15: 3.6 micrograms per ml of blood; 06/23/15: 2.6 micrograms per ml of blood; and on 05/26/15: 3.2 micrograms per ml of blood. The therapeutic reference range reflected on the report was 4.0 to 12.0 micrograms per milliliter of blood. 5)A review of Resident #14's 08/06/15 nurses notes revealed the physician was notified after the surveyor notified the DON and Administrator of the errors made by LVN C with Resident #14. This notification was done during an end-of day meeting on 08/06/15 at 4 PM. The notes further reflected the physician ordered [MEDICATION NAME] and [MEDICATION NAME] levels be drawn STAT. According to the laboratory results report dated 08/06/15, the levels were drawn at 8:55 PM on 08/06/15. The [MEDICATION NAME] level was normal at 16.8 micrograms per ml of blood. The [MEDICATION NAME] level was low at 3.8 micrograms per ml of blood. According to the 08/07/15 nurses notes, Resident #14's laboratory results were shared with the Nurse Practitioner at 8:22 AM. Review of the physician orders [REDACTED]. 6)According to the 12th edition of the Geriatric Dosage Handbook, page 1233 entitled Administration: Oral: Suspension: Shake well prior to use. 7)According to the online website updated 07/13/15, http://www.drugs.com/[MEDICATION NAME].html Shake the [MEDICATION NAME] oral suspension (liquid) well just before you measure a dose. 8)An IJ was identified on 08/07/15. The facility's Administrator and DON were notified at Noon on 08/07/15 of the IJ and a Plan of Removal was requested. 9) On 08/07/15 at 2:30 PM, ADON B stated she had counseled LVN C on all of the medication errors and she was being re-trained and assessed by the Staff Development Coordinator. 10)The Plan of Removal was accepted on 08/07/15 at 6 PM: Plan of Removal 08/07/15 4:45 p.m. (version 4) · Resident #14 [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. LVN C failed to check placement of the Gastrostomy tube prior to medication administration, and failed to flush with 30 cc water before and after medication administration, failed to shake [MEDICATION NAME] and [MEDICATION NAME] liquid medication prior to administration. She failed to administer eye drops as ordered. [MEDICATION NAME] was not administered as ordered by the physician. medication orders [REDACTED] [MEDICATION NAME] 100 mg/5 ml oral suspension. 10 ml per gastrostomy tube three times a day. [MEDICATION NAME] 5 ml per gastrostomy tube every day. 125 mg/5 ml. [MEDICATION NAME] 50 mg disintegrating tablet, one tablet per gastrostomy tube twice daily. Resident #14 was assess on 08/06/15 by ADON B at approximately 3:24 PM. Stat labs reflected: 08/07/15 [MEDICATION NAME] level was 3.8 (normal 5 - 12) 08/07/15 [MEDICATION NAME] level was 16.8 (normal was 10 - 20) LVN C was counseled by ADON B on 08/07/15. LVN C had no explanation how this medication error occurred. · The facilities Medication Error Rate of 34% prompted the Immediate Jeopardy. · The Medical Director was notified by telephone of the IJ on 08'-7'15 at 3:15 per the Administrator. In-Services were initiated immediately for: Facility Nurse Management: Corporate Nurse Consultant and Clinical Educational Specialist completed inservice with the facility ADONs, ADON A, ADON B, Staff Development Coordinator, and the DON on 08/07/15 at 12:15 PM, on completing medication competencies with all licensed nursing staff and medication aides, on hire, prior to rolling a medication cart independently, after any medication error, and annually. This inservice was, Medication Administration-Avoiding Common Errors. This was completed on 08/07/15. Licensed Nurses: Were initiated an inservice, Medication Administration-Avoiding Common Errors/Placement and flushing of Gastrostomy Tube. This inservice was initiated by ADON B , ADON A, DON, and the Staff Development Coordinator on 08/07/15 at 12:35 PM. The current 6-2 licensed nurses were educated during their shift and will have a simulation medication pass, chosen at random by observer(either ADON B, ADON A, Staff Development Coordinator, and DON)on 08/07/15. This well be documented on a Medication Competency for Licensed Nurses. A post-test will be completed following the inservice by the attendees. The 2pm-10 pm shift nursing staff will be educated prior to the start of their shift on 08/07/15 by either ADON B, ADON A, DON, or the Staff Development Coordinator on 08/07/15 at 12:35 PM, and will have a medication competency completed prior to passing medications independently. A post-test will be completed following the inservice by the attendees. The 10 pm - 6 am nursing staff will be educated prior to the start of their shift on 08/07/15 by either ADON B, ADON A, DON, or the Staff Development Coordinator at 08/07/15 at 12:35 PM, and will have a medication competency completed prior to passing medications independently A post-test will be completed following the inservice by the attendees. Any remaining licensed nurses needing education will be provided with the education prior to their next scheduled shift, by ADON B, ADON A, the DON, or the Staff Development Coordinator and will have a medication competency completed prior to pushing a medication cart independently. A post-test will be completed following the inservice by the attendees. The DON will be responsible for ensuring and monitoring a list of staff that haven't been educated . All new hired licensed nurses and Medication Aides will have the above education included in department specific education by the DON, ADON B or ADON A, effective 08/07/15, and will have medication competency completed prior to rolling a medication care independently. The Corporate Nurse Consultant, Clinical Educational Specialist and the DON initiated review of all current residents (108)Medication Administration Records for dosage discrepancies. This was initiated on 08/07/15 and will be completed by 08/07/15. Ongoing monitoring of residents receiving nutrition via a feeding tube (A total of 6 residents have gastrostomy tubes). Five of the six have been assessed. One is not in the facility. This will be conducted by ADON B or ADON A twice weekly for thirty days, then once weekly for thirty days and then monthly thereafter. Results of the audit will be documented in the nurses' notes and reviewed at the weekly Standards of Care Meeting. ADON B or ADON A will notify the physician of any changes. A medical record review of all resident, who transferred to the hospital from 05/07/15 through 08/07/15, was initiated on 08/07/15 and will be completed by 08/07/15, to determine if any other resident was transferred to the hospital due to medication discrepancies. This will be completed by the DON. Nurse Management will conduct random medication pass observations weekly. Findings will be reviewed weekly in the Standards of Care Meeting an monthly in QAA meetings for the next 90 days. The Administrator and the DON are responsible for monitoring this Plan of Removal and ensuring its implementation. 11)On-site monitoring was conducted on 08/08/15 between the hours of 9:45 AM and 12 Noon; and on 08/09/15 between the hours of 1:45 PM and 4 PM. In addition, the monitoring continued on 08/10/15, when the team conducted the extended survey. Interviews conducted during on-site monitoring included staff from all shifts and weekend staff: The DON, Administrator, ADON A, ADON B, MA D, RN E, LVN F, Staff Development Coordinator, LVN R, MA S, LVN T, MA U, MA V, MA W, LVN X, MA Y, LVN Z, LVN AA, MA BB, LVN CC, LVN DD, LVN EE, LVN FF, LVN GG, LVN HH, MA II, and RN JJ. All nurses interviewed stated they had received the in-service training and post-tests. They were knowledgeable in the administration of medication via [DEVICE]; and suspensions. All medication aides who were interviewed stated they had received the in-service training and post-tests. They were knowledgeable in what to do if medications were not available and who they were to notify. 12)On 08/10/15 at 1:16 PM, the DON was interviewed and stated the pharmacist did random medication passes with a couple of staff and the Staff Development Coordinator also did random medication passes. The DON stated she could not explain the IJ cause as LVN D could not explain her performance. The DON stated she believed the correction would involve doing weekly or biweekly random medication passes with the Medication Aides and nurses, especially when passing medication through a [DEVICE]; assessing if the orientation process needed changing to ensure issues with medication skills were identified up front; and possibly checking nursing medication pass skills every six months. The DON checked with Human Resources and stated the hire date for LVN C was 09/24/15 and she worked only as needed. 13)On 08/10/15 at 1:41 PM, the Staff Development Coordinator was interviewed and stated she was hired in April 2014. The Staff Development Coordinator stated she had never conducted a medication pass with LVN C until 08/07/15, when she was instructed to train and observe LVN C. The Staff Development Coordinator stated she never conducted a pass with LVN C before this date because LVN C only worked as needed and was not always available. When asked how LVN C performed on 08/07/15, the Staff Development Coordinator stated she did not use a stethoscope when she checked for placement of a gastrostomy tube with a 10 cc bolus of air; and she forgot to flush the tube before giving medications. 14)ADON A was asked for the punch time detail report for LVN C from 01/01/15 through current date and the report was provided by ADON A on 08/10/15 at 3:10 PM. This report was reviewed and revealed LVN C worked on the following number of days for each month: January 2015: 12 February 2015: 14 March 2015: 19 April 2015: 10 May 2015: 5 June 2015: 14 July 2015: 17; and August 2015: 3 as of 08/07/15. 15)A review of the Pharmacy Consultant Reports from January 2015 through August 2015 was conducted and revealed no evidence the pharmacist had ever observed LVN C during a medication pass. 16)At 2:35 PM on 08/10/15, the DON was asked to see if she could find any evidence the pharmacist had worked with LVN C. As of the exit on 08/10/15 at 5 PM, no evidence was provided. 17)While the IJ was removed on 08/10/15 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, that is not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of the Plan of Removal. 18) A review of the list of residents on anticonvulsant medication was provided by the DON on 08/10/15 at 1:45 PM. This list reflected there were 14 residents who received anticonvulsant medications. 19)ADON A provided a list of residents for whom LVN C passed medications on 08/07/15 at 9:24 AM. The list dated 08/07/15, reflected there were 11 residents in addition to Resident #14, totaling 12 residents. 20)According to the Form CMS-672, Resident Census and Conditions of Residents, signed and dated by the facility MDS Coordinator H on 08/05/15, seven residents had gastrostomy tubes.

Based on observation, interview and record review, the facility failed to implement its policies and procedures that prohibit neglect of residents for one (Resident #1) of 14 residents reviewed for neglect. The facility failed to assess and recognize a change of condition and implement interventions necessary to prevent the complications of constipation resulting in a fecal impaction; and to recognize risk factors associated with possible side effects of narcotics, iron supplements and diuretics for Resident #1. Resident #1 was admitted to the facility on [DATE], with the medications [MEDICATION NAME]-[MEDICATION NAME] (narcotic) 5 mg-325 mg tablet every six hours, [MEDICATION NAME] (iron supplement) 325 mg one tablet to be given three times a day, and [MEDICATION NAME] (diuretic) 20 mg one tablet two times a day. She was transferred to the hospital on [DATE] for rectal bleeding, where she was diagnosed with [REDACTED]. The resident did not return to the facility until 07/28/14 (six days later). Resident #1 had readmission orders [REDACTED]. The orders did not include anything for constipation or a stool softener until surveyor intervention. Resident #1, who received her only hydration/nutrition via [DEVICE], was approximately 300 cc behind in receiving her tube feeding on 07/30/14, leaving her without needed fluids to keep her hydrated. An Immediate Jeopardy (IJ) was identified on 12:58 PM on 07/31/14. While the IJ was removed on 08/01/14 at 2:47 PM, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to assess and recognize the risk factors of side effects of narcotics, iron supplements and diuretics, and to implement and intervene in a timely manner to prevent constipation/fecal impaction, could affect the 64 residents on a pain management program, the 63 residents on a bowel training program, the 71 residents in a chair all or most of the time and the eight residents receiving tube feedings, which due to their medical needs and/or their inactivity placed them at risk for constipation which could result in severe complications such as fecal impaction, bowel rupture and death. Findings included: Resident #1's Face Sheet, dated 06/24/14, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 07/01/14, revealed on admission, Resident #1 had short-term and long-term memory deficit. Resident #1 rarely/never made herself understood. She sometimes had the ability to understand others. The resident's functional level for ADLs reflected she required the extensive physical assistance of two persons for bed mobility and transferring from the bed to wheelchair, dressing, personal hygiene, and bathing. She had urinary and bowel incontinence. She was Aphasic (unable to communicate verbally) and she received her only nutrition and liquids for hydration via feeding tube. The MDS assessment reflected she received scheduled pain medication. Resident #1's care plan, which was provided by facility staff as the residen'ts currrent care plan was undated. The care plan did not address constipation or bowel management, only incontinent care of bowel and bladder. Resident#1's Physician's Telephone Order, dated 06/24/14, noted by LVN T, was to start [MEDICATION NAME]/[MEDICATION NAME] 5 mg - 325 mg tablet, one tablet per [DEVICE] (a gastrostomy tube is a surgical procedure for inserting a tube through the abdomen wall and into the stomach) every six hours for pain. Resident#1's Medication Consolidated physicians order for admission on 06/24/14, reflected the following drug regimen: 1. [MEDICATION NAME] (iron supplement) 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] (diuretic) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg - 325 mg tablet, one tablet [DEVICE] every six hours. Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/article/ 8.htm)>:) revealed the following: Common side effects of Iron Supplements are constipation and diarrhea. With constipation, it was recommended to take a stool softener such as [MEDICATION NAME] sodium ([MEDICATION NAME]). Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/druginf/meds/a 8.htt>) revealed the following: [MEDICATION NAME], a 'water pill' is used to reduce the swelling and fluid retention caused by various medical problems. One of the common side effects is Constipation. Review of Resident #1's Medication Consolidated physicians order for admission on 06/24/14 revealed there was no stool softener or medication ordered for constipation. An interview was conducted on 08/01/14 at approximately 5:30 PM, with Resident #1's family member. The family member stated while he/she was at the facility visiting with Resident #1 (before the resident went to the hospital on [DATE]), the resident was crying and shaking. He/She stated the resident had a "real bad diaper rash." He/She stated he/she had asked the resident if her bottom was hurting her. He/She asked CNA N to put some cream on Resident #1's bottom because she had a "real bad diaper rash" and that was the reason she was moaning and crying. He/She stated when CNA N was positioning the resident to apply the cream, he/she saw Resident #1's rectal opening was stretched open about three inches and there was hard-looking feces in the "hole." At that time, he/she explained to CNA N the resident was severely constipated. He/She stated he/she went and got LVN T and told her what he/she had just seen and told her the resident was constipated and needed something to help her go to the bathroom. LVN T came back into the room and administered a clear liquid into her [DEVICE]. LVN T told him/her it was something for Resident #1's constipation. The next day he/she asked an LVN (unknown name) if Resident #1 had a bowel movement. The LVN stated she was not aware if the resident had a bowel movement. He/She stated he/she explained to the nurse the resident was constipated and needed something to help her go to the bathroom. He/She stated it was then a couple of days later when the resident were transferred to the hospital with rectal bleeding (07'/22/14). An interview was conducted on 07/31/14 at 10:28 AM with CNA R, who stated about two weeks ago (07/17/14), Resident #1 was constipated. CNA R said it was so painful for her trying to push out the stool. She was moaning and frowning. She stated she told her charge nurse, LVN T about it. CNA R stated LVN T spoke with the family member and told them she would give the resident some Milk of Magnesia for her constipation. When asked if the resident had a bowel movement, CNA R replied, "She passed a little ball." Interview conducted on 07/31/14 at 2:15 PM with LVN T, revealed Resident #1's family member told her the resident was constipated and had a hard time pushing out the stool. LVN T said she told the family member she would check and see if Resident #1 had routine medication ordered for constipation. LVN T stated when she checked, Resident #1 did not have medication ordered routine or PRN for constipation. LVN T stated, "The facility has a protocol for standing orders for constipation. I gave her 30 cc of Milk of Magnesia." When asked if she checked the resident or performed an assessment of the resident's rectum, she stated, "No." LVN T said Resident #1's family member was still in the room. When asked if she had followed up on the results of the Milk of Magnesia, LVN T replied, "No. It was at the end of my shift. I reported it to the oncoming nurse that I had given her the Milk of Magnesia." When asked if she had documented in the nurse's notes the date and time she had given the Milk of Magnesia, LVN T stated she did not document she had given the medication. When asked if she had written a one time order for the Milk of Magnesia, she replied "No. I know that I am supposed to notify the physician and obtain a telephone order, then document in the nurses notes that a prn medication had been given." The facility's Activities of Daily Living Management System report received from the DON on 07/30/ 14, dated from 06/28/14 through 07/29/14 for Resident #1 was reviewed. This system was used by the facility's CNAs to document the care and services provided for each resident. Review of the document for Resident #1's bowel movements revealed from the time of 06/28/14 through 07/21/14 (24 days), Resident #1 had no bowel movements for 12 days. 06/28/14 - small and normal BM 06/29/14 - medium, loose/watery BM 07/03/14 - small BM 07/05/14 - small normal BM 07/06/14 - small normal BM 07/07/14 - no BM 07/08/14 - no BM 07/09/14 - no BM 07/10/14 - no BM 07/11/14 - no BM 07/12/14 - no BM 07/13/14 - soft medium BM 07/14/14 - no BM 07/15/14 - no BM 07/16/14 - no BM 07/17/14 - normal medium BM 07/18/14 - small dry hard BM 07/19/14 - no BM 07/20/14 - no BM 07/21/14 - no BM The facility's 24-Hour Report, dated 07/19/14 reflected: Resident #1 was "constipated, give MOM (Milk of Magnesia), large BM (bowel movement)." Comment by LVN V. Review of Resident #1's MAR for July 2014 revealed from 07/11/14 through 07/21/14 (11 days), following complaints of pain, the resident complained of pain at a level of six to seven out of ten on eight days. On 07/31/14 at approximately 9:30 AM, an interview with the DON revealed the facility used the Wong-Baker pain rating scale. The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by the user. The faces range from a smiling face to a sad, crying face. A numerical rating is assigned to each face, of which there are six total. The face zero indicates no hurt, two is hurts a little bit, four is hurts little more, six is hurts even more, eight is hurts a whole lot, and number 10 is hurts worse. Review of Resident #1's Individual Control Drug Record revealed from 07/12/14 through 07/22/14 (11 days), the resident received [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg for pain every day but 07/19/14 for a total of 37 tablets. Resident#1 received a total of 37 tablets of [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg over a period of 11 days. Review of information retrieved on 08/08/14 and obtained from http://www.nlm.nih.gov/medlineplus/druginfo/meds/ revealed one of the side effects of [MEDICATION NAME] is constipation. Resident #1's emergency room Admission Record, dated 07/22/14 at 12:49 AM, reflected a physical exam was done and indicated, "Abdominal bowel sounds were decreased." Review of Resident #1's hospital History and Physical Notes, dated 07/22/14, revealed the following: "Studies/Imaging: CT (computerized tomography) abdomen/pelvis, 1. a large amount of fecal debris in the right colon including large amount of fecal debris in the rectal vault suggesting constipation and fecal impaction." Review of Resident #1's [MEDICATION NAME] Consultation, dated 07/22/14 revealed the following: "Procedure: Colonoscopy ...2. Severe Constipation - the patient was grossly constipated on admission, which was felt to be causative for the hematochezia (the passage of bright red blood in the stool). After significant bowel regimen and manual disimpaction she had multiple BMs. She should be on a strong outpatient bowel regimen to ensure no further constipation given the morbidity she faces when she is constipated. This was communicated in writing to her SNF (Skilled Nursing Home)." Review from Resident #1's hospital physician progress notes [REDACTED]. She was disimpacted x2. First disimpation (manual removal of impacted fecal matter from the rectum) with 900 ccs brown stool out, and 2nd disimpation with 1 liter out." Note: One liter equals approximately one quart (32 ounces). Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME].html revealed the following: "[MEDICATION NAME] (Polyethylene [MEDICATION NAME] electrolyte solution)... is a laxative that increaseS the amount of water in the intestinal tract to stimulate bowel movement." Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME]-of-magnesia.html revealed the following: "[MEDICATION NAME] of Magnesia is used as a laxative to treat occasional constipation." A confidential interview was conducted and it was revealed while Resident #1 was in the hospital, the doctor said she was going to have to digitally remove the stool from her rectum with her fingers because it was so hard and impacted, water was not working to remove the stool. He/She stated, a nurse came into the room to clean the resident after she had a bowel movement. At that point, Resident #1 looked at the nurse and with her one good hand, she grabbed the sheet and would not let the sheet out of her hand. She was crying and shaking her head back and forth saying, "No." Review of the Physician Discharge Instructions from the hospital, dated 07/28/14 at 4:21 PM, revealed the following: Resident #1's Plan of Care (instructions to SNF and future physicians). "Patient should have consistent bowel movements to prevent stool impaction - this was likely a root cause for the current (rectal) bleed." Review of Resident #1's hospital orders for Admission Physician orders [REDACTED]. 1. [MEDICATION NAME] 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg tablet, one tablet [DEVICE] every six hours as needed for pain. Do not exceed 3,000 mg for pain [MEDICATION NAME] from all sources in 24 hours. Note: the dosage was increased from 5 mg to 10 mg. 4. DiabetiSource 65 ml/hr per Peg Tube, down at 9:00 AM and up at 12:00 PM. (start date 07/21/14.) Resident #1's Admission Physician orders [REDACTED]. During initial tour on 07/29/14 at 9:09 AM, Resident #1 was observed in bed. LVN P said the resident was non-verbal, but was able to follow staff with her eyes. Resident #1 was given nothing by mouth due to her [MEDICAL CONDITION] (stroke) and she had difficulty moving her right arm and hand. She further stated Resident #1 required total care for all ADLs, and she was incontinent of bladder and bowel. The resident was non-ambulatory and wheelchair-bound. LVN P stated Resident #1 had just returned from the hospital on [DATE] at 1:50 AM, and had been sent to the hospital for rectal bleeding. She had a [DEVICE] for continuous feeding, which was connected to a feeding pump. Observation at that time revealed the formula infusing was DiabetiSource at the rate of 30 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM on 07/29/14 at the rate of 65 cc/hr. The bag had approximately 1400 cc of formula remaining in the bag. When LVN P was asked what the current rate was for the formula, she replied 65 cc/hr. When asked why the rate of the formula was at 30 cc/hr, LVN P, replied the night nurse reported to her she had changed the rate of the formula on the pump to 30 cc/hr because the resident had just returned from the hospital at 1:50 AM, and she was monitoring her. LVN P stated she had not had time to verify the formula or rate since her start of the shift. An interview conducted on 07/30/14 at 2:30 PM with the DON revealed she had contacted RN K, who had set Resident #1's feeding pump at 30 cc/hr. RN K would be coming into the facility to contact Resident #1's physician regarding the formula infusion rate of 30 cc/hr. RN K would enter a late entry for the reason she set the pump at 30 cc/hr instead of 65 cc/hr. The DON continued to state it was normal procedure to set the pump at a different rate after a new admit to monitor how the resident tolerated the feeding, but RN K should have received a physician order [REDACTED]. On return to Resident #1's room on 07/29/14 at 10:18 AM, observation revealed the resident was not in her room, and the feeding pump with the formula was hanging at the bedside with approximately 1350 cc of formula remaining in the bag. On 07/29/14 at 12:13 PM, Resident #1 was still not in her room. She was observed sitting in the small activity room outside the dining hall. On 07/30/14 at 7:45 AM, Resident#1 was observed resting quietly in bed. She had formula infusing via [DEVICE], which was connected to a feeding pump. The formula was DiabetiSource and it was infusing at the rate of 65 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM with a date of 07/29/14; there was approximately 250 cc of formula left in the bag. At that time, Resident #1 was approximately 360 cc behind of receiving her full amount of fluid and nutritional intake. The resident was NPO and received water and/or formula only via the [DEVICE]. When asked if she had notified the Dietitian Resident #1 was behind on her fluid intake for the day, LVN P replied she would notify the Dietitian. An interview conducted on 07/31/14 at 8:40 AM with CNA N revealed on 07/29/14 and 07/30/14, Resident #1 had loose small watery stools on both days. She stated she informed LVN P about Resident #1's loose stools. On 07/31/14 at approximately 8:55 AM, the surveyor interviewed the DON in regard to Resident #1's loose stools from 07/29/14 and 07/3014. The interview revealed the DON had not been notified about Resident #1's loose stools. An interview was conducted on 07/31/14 at approximately 9:35 AM with LVN P. When asked if she was aware of Resident #1's loose stools, she replied, "No one had mentioned to me that she had a loose, watery stool." LVN P was asked to check if CNA N had documented the loose watery stool on the Activity of Daily Living Management System. LVN P said, "Yes," the CNA had documented the loose, watery stool. When asked to explain how the system operated, LVN P replied, "If a resident has not had a bowel movement in three days, the system will have an alert show-up and we look at the alert." When asked what the sign and symptoms of constipation were, LVN P stated it was moaning grimacing, hard dried stool and blood in the stool. When asked what the side effects of narcotics were, she stated, "Constipation." When asked what the side effects of an Iron Supplement were, she stated, "Constipation." When asked what the side effects of [MEDICATION NAME] were, LVN P replied, "Dehydration." When asked what the effects of being dehydrated were, she stated, "Constipation." During an interview conducted on 07/31/14 at 10:15 AM with the DON, she told the surveyor she had contacted Advanced Nurse Practitioner Certification (ANPC) O on 07/31/14 at 9:07 AM following surveyor intervention. She said ANPC O stated it was normal for Resident #1 to have a loose, watery stool after a disimpaction. During an interview conducted on 07/31/14 at 9:30 AM with ADON Q, she stated she did not know if Resident #1 had a bowel movement since her return from the hospital. She was then asked how often a nurse reviewed the CNAs Activities of Daily living system. She replied nurses reviewed it at the end of each shift to check if the CNAs have done their documentation. ADON Q stated the nurse would only look at specific details if there was an alert. ADON Q then stated, for example, if a resident had not had a bowel movement in three day, an alert would pop up, and then the nurse would open up that alert. If the CNAs were charting a resident was having bowel movements, then the alert would not show up. It meant the resident was "okay." When asked what the side effects were for [MEDICATION NAME] pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." An interview was conducted on 07/31/14 at 9:15 AM with RN W. RN W told the surveyor the CNAs documented into the Activity Daily Management system when a resident had a bowel movement. If there was not an entry, an Alert sign would come on the screen and this would alert the nurse the resident had not had a bowel movement in three days. RN W stated, "If the resident has not had a bowel movement in three days, I will do an assessment; give a laxative or stool softer." When asked what the side effects were for [MEDICATION NAME] (a narcotic [MEDICATION NAME] with [MEDICATION NAME]) pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." Review of information retrieved on 08/04/14 and obtained from National Digestive Diseases Information Clearinghouse (NDDIC).<http://digestive.niddk.nih.gov/diseases/pubs/constipation/> revealed the following: "...Constipation is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry and small, making them painful or difficult to pass. People may feel bloated or have pain in their abdomen, the area between the chest and hips. ...Constipation is caused by stool spending too much time in the colon. The colon absorbs too much water from the stool, making it hard and dry. Hard, dry stool is more difficult for the muscles of the rectum to push out of the body. Common factors or disorders that lead to constipation are: Medications Neurological and metabolic disorders Diet low in fiber Lack of physical activity... Medications that can cause constipation include Pain medications, especially narcotics ...Iron supplements Diuretics ...Metabolic disorders, such as diabetes and [MEDICAL CONDITION], disrupt the process the body uses to get energy from food. ...Constipation is treated with the use of ...medications; stool softeners, [MEDICATION NAME], and [MEDICATION NAME]. Stool softeners help mix fluid into stools to soften them... ....complications of constipation... can lead to ...hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. Fecal impaction - occurs when hard stool packs the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition occurs most often in children and older adults...." Review of the Nursing Services Policy and Procedure, revised 2007, Bowel (lower Gastrointestinal Tract) Disorders, Clinical Protocol revealed: "Assessment and Recognition: 1. As part of the initial assessment, the staff and physician will help identify individuals with previous lower gastrointestinal tract conditions and symptoms for example, resident with a history of diarrhea, fecal incontinence, irritable bowel syndrome, pain with defecation, passing blood rectally, alteration in bowel monuments, ulcerative [MEDICAL CONDITION] or regional enteritis and those taking anti-diarrheal medication or medication related to bowel motility (abnormal intestinal contractions, such as spasms and intestinal paralysis). a. This should include a review of gastrointestinal problems during any recent hospitalization , results of previous [MEDICATION NAME] studies, endoscopies, etc... 2. In addition, the nurse shall asses and document/report the following: a. Vital signs b. Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistence, etc.) c. Change in mental status or mental consciousness d. Presence of fecal impaction e. Signs of dehydration... f. Abdominal assessment g. Digital rectal examination h. Onset, duration, frequency, severity of signs and symptom i. All current medications j. All active diagnoses k. Recent labs 3. The staff and the physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to, gastrointestinal erosion, bleeding, diarrhea, dysmotility (term used to describe diseases of the muscles of the gastrointestinal tract), etc...." Review of the facility's current Protocol for Standing Orders, dated 06/06/03 reflected: "1. MUST WRITE A TELEPHONE ORDER FOR WHATEVER PROTOCOL USED! Please write in communication book to let Dr./PA/NP (Doctor/Physician's Assistant/Nurse Practitioner) have knowledge. Effective: ...4. Constipation Protocol #1 Milk of Magnesia 30 cc PO Bid PRN Protocol #2 [MEDICATION NAME] 30 cc QD or BID PRN Protocol #3 Fleets Enema Q 72 hours PRN Protocol #4 [MEDICATION NAME] 100 mg tablet 1 PO QD." Review of the facility's current policy and procedure for Abuse Prohibition Management Program (undated) revealed the following: Screening, Training & Prevention Policy Policy: "Our Facility will not condone resident ...neglect ...by anyone, including staff members, other residents, consultants, volunteers, staff or toehr agencies serving the resident... To ensure that incidents of abuse are prevented, to the extent possible, the following procedures will be implemented. Procedures: Responsibilities: 1. The facility's Administrator, and in his/her absence, the Director of Nursing, will perfrom the duties of the Abuse prevention Coordinator. Duties include but are not limited to: ...d. Assuring that the timely identification, investigation and reporting of incidences of abuse occur... ...Prevention ...e. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as ...residents with communications disorders and residents who require heavy nursing care and/or are totally dependent on staff." Identification, Investigation & Reporting Policy Procedures: Identification: "...h. Neglect is a deprivation of life's necessities of foo, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." An IJ was identified on 07/31/14. On 07/31/14 at 12:58 PM. The Administrator, the DON, Corporate RN G, Corporate LVN H and the Regional Director of Operations were informed of the IJ, and a Plan of Removal for the IJ was requested. On 08/01/14 at 7:50 AM, an interview was conducted with the Administrator. When he was asked how he monitored his staff including the DON, to ensure the systems were effective, he stated he had constant communication with the DON and they reviewed all issues at their daily meetings. When the Administrator was asked why he thought the IJ had occurred, he stated if the systems were not working, it was because the staff was not following the policies. The Administrator stated the facility IT department was putting in an alert system to alert the nursing staff when a resident went on pain medications so they would do assessments for all issues, which might have an impact on the bowels. On 08/01/14 at 10:45 PM, an interview was conducted with the DON. She stated the computer system had an area where alerts would pop up for the nurses to review. The alerts came from the documentation the CNAs entered on the ADL Flow Sheets. The CNAs were to document on the sheets any bruises, skin tears, wounds, feedings with meal intake, methods of transfers, bathing, if it required one or two person assistance with ADLs, voiding, if they took the resident to the bathroom, changed a brief or if the resident had a Foley catheter (a thin, flexible, sterile tube that is inserted through the urethra and into the bladder to drain urine) and the number of stools to include the consistency and the amount. The DON further stated the nurses had to document their acknowledgement when the alert appeared for it to shut down and no longer provide an alert. She stated they might document the nurse was aware of the issue or what they had done if it was to assess or give medications. When the DON was asked how she monitored her staff to ensure they were following the policies and procedures correctly, she replied she had computer access to the ADL Flow Sheets the CNAs filled out. The DON said she would go in and review them to see if they were documenting on the residents correctly. The DON stated she and her ADONs provided the nursing staff with in-service trainings. When the DON was asked why the IJ had occurred, she stated she really did not know what to tell the surveyor what had caused the situation. The DON stated they were in the process of in-servicing all nurses, CNAs and medication aides on the signs and symptoms of constipation and fecal impactions, how to assess and recognize them and who to report it to. The in-services for the nurses included how to do daily assessments, medication reconciliations on new admissions and re-admissions from the hospital, and how to properly follow-up on all the alerts, which pop up on the computers. The staff was also being in-serviced on how to assess all residents, who were on routine pain medications or who had experienced an increase in the amount of pain medications they were receiving. She stated they had reviewed all residents on pain medications and for anyone who did not have an order for [REDACTED]. On 08/01/14 at 12:50 PM, an interview was conducted with the Medical Director, who was Resident #1's primary care physician. He stated he had been informed by the facility about the IJ yesterday (07/31/14). He stated the elderly get Toxic Mega Colon (abnormal dilation of the colon) very quickly especially if they were bedfast and received tube feedings. He stated they were working on this concern and were providing the staff with more training as to what they should observe for constipation and the importance of giving fluids. The facility's Plan of Removal was accepted on 08/01/14 at 2:38 PM and reflected the following: In-services were initiated immediately for: Facility ADONs: Corporate Nurse Consultant, LVN H educated the facility ADONs, ADON R and ADON Q, and Charge Nurse LVN S on 07/31/14 at 1:15 PM, on S/S (Signs/Symptoms) Constipation/ Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. Corporate Nurse Consultant LVN educated the Weekend RN Supervisor on 08/01/14 at 2:00 PM, on S/S Constipation/Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. A post-test will be completed following the in-service by the attendees. Licensed Nurses: S/S Constipation/Fecal Impaction, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. This In-service was initiated by ADON R on 07/31/14 at 11:40 AM. The 10:00 PM - 6:00 AM

Based on observation, interview and record review, the facility failed to implement its written policies and procedures that prohibit neglect of residents for one (Resident #1) of 14 residents reviewed for neglect. The facility failed to assess and recognize a change of condition and implement interventions necessary to prevent the complications of constipation resulting in a fecal impaction; and to recognize risk factors associated with possible side effects of narcotics, iron supplements and diuretics for Resident #1. Resident #1 was admitted to the facility on [DATE], with the medications [MEDICATION NAME]-[MEDICATION NAME] (narcotic) 5 mg-325 mg tablet every six hours, [MEDICATION NAME] (iron supplement) 325 mg one tablet to be given three times a day, and [MEDICATION NAME] (diuretic) 20 mg one tablet two times a day. She was transferred to the hospital on [DATE] for rectal bleeding, where she was diagnosed with [REDACTED]. The resident did not return to the facility until 07/28/14 (six days later). Resident #1 had readmission orders [REDACTED]. The orders did not include anything for constipation or a stool softener until surveyor intervention. Resident #1, who received her only hydration/nutrition via [DEVICE], was approximately 300 cc behind in receiving her tube feeding on 07/30/14, leaving her without needed fluids to keep her hydrated. An Immediate Jeopardy (IJ) was identified on 12:58 PM on 07/31/14. While the IJ was removed on 08/01/14 at 2:47 PM, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to assess and recognize the risk factors of side effects of narcotics, iron supplements and diuretics, and to implement and intervene in a timely manner to prevent constipation/fecal impaction, could affect the 64 residents on a pain management program, the 63 residents on a bowel training program, the 71 residents in a chair all or most of the time and the eight residents receiving tube feedings, which due to their medical needs and/or their inactivity placed them at risk for constipation which could result in severe complications such as fecal impaction, bowel rupture and death. Findings included: Review of the facility's current policy and procedure for Abuse Prohibition Management Program (undated) revealed the following: Screening, Training & Prevention Policy Policy: "Our Facility will not condone resident ...neglect ...by anyone, including staff members, other residents, consultants, volunteers, staff or toehr agencies serving the resident... To ensure that incidents of abuse are prevented, to the extent possible, the following procedures will be implemented. Procedures: Responsibilities: 1. The facility's Administrator, and in his/her absence, the Director of Nursing, will perfrom the duties of the Abuse prevention Coordinator. Duties include but are not limited to: ...d. Assuring that the timely identification, investigation and reporting of incidences of abuse occur... ...Prevention ...e. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as ...residents with communications disorders and residents who require heavy nursing care and/or are totally dependent on staff." Identification, Investigation & Reporting Policy Procedures: Identification: "...h. Neglect is a deprivation of life's necessities of foo, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." Review of the Nursing Services Policy and Procedure, revised 2007, Bowel (lower Gastrointestinal Tract) Disorders, Clinical Protocol revealed: "Assessment and Recognition: 1. As part of the initial assessment, the staff and physician will help identify individuals with previous lower gastrointestinal tract conditions and symptoms for example, resident with a history of diarrhea, fecal incontinence, irritable bowel syndrome, pain with defecation, passing blood rectally, alteration in bowel monuments, ulcerative [MEDICAL CONDITION] or regional enteritis and those taking anti-diarrheal medication or medication related to bowel motility (abnormal intestinal contractions, such as spasms and intestinal paralysis). a. This should include a review of gastrointestinal problems during any recent hospitalization , results of previous [MEDICATION NAME] studies, endoscopies, etc... 2. In addition, the nurse shall asses and document/report the following: a. Vital signs b. Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistence, etc.) c. Change in mental status or mental consciousness d. Presence of fecal impaction e. Signs of dehydration... f. Abdominal assessment g. Digital rectal examination h. Onset, duration, frequency, severity of signs and symptom i. All current medications j. All active diagnoses k. Recent labs 3. The staff and the physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to, gastrointestinal erosion, bleeding, diarrhea, dysmotility (term used to describe diseases of the muscles of the gastrointestinal tract), etc...." Review of the facility's current Protocol for Standing Orders, dated 06/06/03 reflected: "1. MUST WRITE A TELEPHONE ORDER FOR WHATEVER PROTOCOL USED! Please write in communication book to let Dr./PA/NP (Doctor/Physician's Assistant/Nurse Practitioner) have knowledge. Effective: ...4. Constipation Protocol #1 Milk of Magnesia 30 cc PO Bid PRN Protocol #2 [MEDICATION NAME] 30 cc QD or BID PRN Protocol #3 Fleets Enema Q 72 hours PRN Protocol #4 [MEDICATION NAME] 100 mg tablet 1 PO QD." Resident #1's Face Sheet, dated 06/24/14, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 07/01/14, revealed on admission, Resident #1 had short-term and long-term memory deficit. Resident #1 rarely/never made herself understood. She sometimes had the ability to understand others. The resident's functional level for ADLs reflected she required the extensive physical assistance of two persons for bed mobility and transferring from the bed to wheelchair, dressing, personal hygiene, and bathing. She had urinary and bowel incontinence. She was Aphasic (unable to communicate verbally) and she received her only nutrition and liquids for hydration via feeding tube. The MDS assessment reflected she received scheduled pain medication. Resident #1's care plan, which was provided by facility staff as the residen'ts currrent care plan was undated. The care plan did not address constipation or bowel management, only incontinent care of bowel and bladder. Resident#1's Physician's Telephone Order, dated 06/24/14, noted by LVN T, was to start [MEDICATION NAME]/[MEDICATION NAME] 5 mg - 325 mg tablet, one tablet per [DEVICE] (a gastrostomy tube is a surgical procedure for inserting a tube through the abdomen wall and into the stomach) every six hours for pain. Resident#1's Medication Consolidated physicians order for admission on 06/24/14, reflected the following drug regimen: 1. [MEDICATION NAME] (iron supplement) 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] (diuretic) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg - 325 mg tablet, one tablet [DEVICE] every six hours. Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/article/ 8.htm)>:) revealed the following: Common side effects of Iron Supplements are constipation and diarrhea. With constipation, it was recommended to take a stool softener such as [MEDICATION NAME] sodium ([MEDICATION NAME]). Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/druginf/meds/a 8.htt>) revealed the following: [MEDICATION NAME], a 'water pill' is used to reduce the swelling and fluid retention caused by various medical problems. One of the common side effects is Constipation. Review of Resident #1's Medication Consolidated physicians order for admission on 06/24/14 revealed there was no stool softener or medication ordered for constipation. An interview was conducted on 08/01/14 at approximately 5:30 PM, with Resident #1's family member. The family member stated while he/she was at the facility visiting with Resident #1 (before the resident went to the hospital on [DATE]), the resident was crying and shaking. He/She stated the resident had a "real bad diaper rash." He/She stated he/she had asked the resident if her bottom was hurting her. He/She asked CNA N to put some cream on Resident #1's bottom because she had a "real bad diaper rash" and that was the reason she was moaning and crying. He/She stated when CNA N was positioning the resident to apply the cream, he/she saw Resident #1's rectal opening was stretched open about three inches and there was hard-looking feces in the "hole." At that time, he/she explained to CNA N the resident was severely constipated. He/She stated he/she went and got LVN T and told her what he/she had just seen and told her the resident was constipated and needed something to help her go to the bathroom. LVN T came back into the room and administered a clear liquid into her [DEVICE]. LVN T told him/her it was something for Resident #1's constipation. The next day he/she asked an LVN (unknown name) if Resident #1 had a bowel movement. The LVN stated she was not aware if the resident had a bowel movement. He/She stated he/she explained to the nurse the resident was constipated and needed something to help her go to the bathroom. He/She stated it was then a couple of days later when the resident were transferred to the hospital with rectal bleeding (07'/22/14). An interview was conducted on 07/31/14 at 10:28 AM with CNA R, who stated about two weeks ago (07/17/14), Resident #1 was constipated. CNA R said it was so painful for her trying to push out the stool. She was moaning and frowning. She stated she told her charge nurse, LVN T about it. CNA R stated LVN T spoke with the family member and told them she would give the resident some Milk of Magnesia for her constipation. When asked if the resident had a bowel movement, CNA R replied, "She passed a little ball." Interview conducted on 07/31/14 at 2:15 PM with LVN T, revealed Resident #1's family member told her the resident was constipated and had a hard time pushing out the stool. LVN T said she told the family member she would check and see if Resident #1 had routine medication ordered for constipation. LVN T stated when she checked, Resident #1 did not have medication ordered routine or PRN for constipation. LVN T stated, "The facility has a protocol for standing orders for constipation. I gave her 30 cc of Milk of Magnesia." When asked if she checked the resident or performed an assessment of the resident's rectum, she stated, "No." LVN T said Resident #1's family member was still in the room. When asked if she had followed up on the results of the Milk of Magnesia, LVN T replied, "No. It was at the end of my shift. I reported it to the oncoming nurse that I had given her the Milk of Magnesia." When asked if she had documented in the nurse's notes the date and time she had given the Milk of Magnesia, LVN T stated she did not document she had given the medication. When asked if she had written a one time order for the Milk of Magnesia, she replied "No. I know that I am supposed to notify the physician and obtain a telephone order, then document in the nurses notes that a prn medication had been given." The facility's Activities of Daily Living Management System report received from the DON on 07/30/ 14, dated from 06/28/14 through 07/29/14 for Resident #1 was reviewed. This system was used by the facility's CNAs to document the care and services provided for each resident. Review of the document for Resident #1's bowel movements revealed from the time of 06/28/14 through 07/21/14 (24 days), Resident #1 had no bowel movements for 12 days. 06/28/14 - small and normal BM 06/29/14 - medium, loose/watery BM 07/03/14 - small BM 07/05/14 - small normal BM 07/06/14 - small normal BM 07/07/14 - no BM 07/08/14 - no BM 07/09/14 - no BM 07/10/14 - no BM 07/11/14 - no BM 07/12/14 - no BM 07/13/14 - soft medium BM 07/14/14 - no BM 07/15/14 - no BM 07/16/14 - no BM 07/17/14 - normal medium BM 07/18/14 - small dry hard BM 07/19/14 - no BM 07/20/14 - no BM 07/21/14 - no BM The facility's 24-Hour Report, dated 07/19/14 reflected: Resident #1 was "constipated, give MOM (Milk of Magnesia), large BM (bowel movement)." Comment by LVN V. Review of Resident #1's MAR for July 2014 revealed from 07/11/14 through 07/21/14 (11 days), following complaints of pain, the resident complained of pain at a level of six to seven out of ten on eight days. On 07/31/14 at approximately 9:30 AM, an interview with the DON revealed the facility used the Wong-Baker pain rating scale. The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by the user. The faces range from a smiling face to a sad, crying face. A numerical rating is assigned to each face, of which there are six total. The face zero indicates no hurt, two is hurts a little bit, four is hurts little more, six is hurts even more, eight is hurts a whole lot, and number 10 is hurts worse. Review of Resident #1's Individual Control Drug Record revealed from 07/12/14 through 07/22/14 (11 days), the resident received [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg for pain every day but 07/19/14 for a total of 37 tablets. Resident#1 received a total of 37 tablets of [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg over a period of 11 days. Review of information retrieved on 08/08/14 and obtained from http://www.nlm.nih.gov/medlineplus/druginfo/meds/ revealed one of the side effects of [MEDICATION NAME] is constipation. Resident #1's emergency room Admission Record, dated 07/22/14 at 12:49 AM, reflected a physical exam was done and indicated, "Abdominal bowel sounds were decreased." Review of Resident #1's hospital History and Physical Notes, dated 07/22/14, revealed the following: "Studies/Imaging: CT (computerized tomography) abdomen/pelvis, 1. a large amount of fecal debris in the right colon including large amount of fecal debris in the rectal vault suggesting constipation and fecal impaction." Review of Resident #1's [MEDICATION NAME] Consultation, dated 07/22/14 revealed the following: "Procedure: Colonoscopy ...2. Severe Constipation - the patient was grossly constipated on admission, which was felt to be causative for the hematochezia (the passage of bright red blood in the stool). After significant bowel regimen and manual disimpaction she had multiple BMs. She should be on a strong outpatient bowel regimen to ensure no further constipation given the morbidity she faces when she is constipated. This was communicated in writing to her SNF (Skilled Nursing Home)." Review from Resident #1's hospital physician progress notes [REDACTED]. She was disimpacted x2. First disimpation (manual removal of impacted fecal matter from the rectum) with 900 ccs brown stool out, and 2nd disimpation with 1 liter out." Note: One liter equals approximately one quart (32 ounces). Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME].html revealed the following: "[MEDICATION NAME] (Polyethylene [MEDICATION NAME] electrolyte solution)... is a laxative that increaseS the amount of water in the intestinal tract to stimulate bowel movement." Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME]-of-magnesia.html revealed the following: "[MEDICATION NAME] of Magnesia is used as a laxative to treat occasional constipation." A confidential interview was conducted and it was revealed while Resident #1 was in the hospital, the doctor said she was going to have to digitally remove the stool from her rectum with her fingers because it was so hard and impacted, water was not working to remove the stool. He/She stated, a nurse came into the room to clean the resident after she had a bowel movement. At that point, Resident #1 looked at the nurse and with her one good hand, she grabbed the sheet and would not let the sheet out of her hand. She was crying and shaking her head back and forth saying, "No." Review of the Physician Discharge Instructions from the hospital, dated 07/28/14 at 4:21 PM, revealed the following: Resident #1's Plan of Care (instructions to SNF and future physicians). "Patient should have consistent bowel movements to prevent stool impaction - this was likely a root cause for the current (rectal) bleed." Review of Resident #1's hospital orders for Admission Physician orders [REDACTED]. 1. [MEDICATION NAME] 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg tablet, one tablet [DEVICE] every six hours as needed for pain. Do not exceed 3,000 mg for pain [MEDICATION NAME] from all sources in 24 hours. Note: the dosage was increased from 5 mg to 10 mg. 4. DiabetiSource 65 ml/hr per Peg Tube, down at 9:00 AM and up at 12:00 PM. (start date 07/21/14.) Resident #1's Admission Physician orders [REDACTED]. During initial tour on 07/29/14 at 9:09 AM, Resident #1 was observed in bed. LVN P said the resident was non-verbal, but was able to follow staff with her eyes. Resident #1 was given nothing by mouth due to her [MEDICAL CONDITION] (stroke) and she had difficulty moving her right arm and hand. She further stated Resident #1 required total care for all ADLs, and she was incontinent of bladder and bowel. The resident was non-ambulatory and wheelchair-bound. LVN P stated Resident #1 had just returned from the hospital on [DATE] at 1:50 AM, and had been sent to the hospital for rectal bleeding. She had a [DEVICE] for continuous feeding, which was connected to a feeding pump. Observation at that time revealed the formula infusing was DiabetiSource at the rate of 30 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM on 07/29/14 at the rate of 65 cc/hr. The bag had approximately 1400 cc of formula remaining in the bag. When LVN P was asked what the current rate was for the formula, she replied 65 cc/hr. When asked why the rate of the formula was at 30 cc/hr, LVN P, replied the night nurse reported to her she had changed the rate of the formula on the pump to 30 cc/hr because the resident had just returned from the hospital at 1:50 AM, and she was monitoring her. LVN P stated she had not had time to verify the formula or rate since her start of the shift. An interview conducted on 07/30/14 at 2:30 PM with the DON revealed she had contacted RN K, who had set Resident #1's feeding pump at 30 cc/hr. RN K would be coming into the facility to contact Resident #1's physician regarding the formula infusion rate of 30 cc/hr. RN K would enter a late entry for the reason she set the pump at 30 cc/hr instead of 65 cc/hr. The DON continued to state it was normal procedure to set the pump at a different rate after a new admit to monitor how the resident tolerated the feeding, but RN K should have received a physician order [REDACTED]. On return to Resident #1's room on 07/29/14 at 10:18 AM, observation revealed the resident was not in her room, and the feeding pump with the formula was hanging at the bedside with approximately 1350 cc of formula remaining in the bag. On 07/29/14 at 12:13 PM, Resident #1 was still not in her room. She was observed sitting in the small activity room outside the dining hall. On 07/30/14 at 7:45 AM, Resident#1 was observed resting quietly in bed. She had formula infusing via [DEVICE], which was connected to a feeding pump. The formula was DiabetiSource and it was infusing at the rate of 65 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM with a date of 07/29/14; there was approximately 250 cc of formula left in the bag. At that time, Resident #1 was approximately 360 cc behind of receiving her full amount of fluid and nutritional intake. The resident was NPO and received water and/or formula only via the [DEVICE]. When asked if she had notified the Dietitian Resident #1 was behind on her fluid intake for the day, LVN P replied she would notify the Dietitian. An interview conducted on 07/31/14 at 8:40 AM with CNA N revealed on 07/29/14 and 07/30/14, Resident #1 had loose small watery stools on both days. She stated she informed LVN P about Resident #1's loose stools. On 07/31/14 at approximately 8:55 AM, the surveyor interviewed the DON in regard to Resident #1's loose stools from 07/29/14 and 07/3014. The interview revealed the DON had not been notified about Resident #1's loose stools. An interview was conducted on 07/31/14 at approximately 9:35 AM with LVN P. When asked if she was aware of Resident #1's loose stools, she replied, "No one had mentioned to me that she had a loose, watery stool." LVN P was asked to check if CNA N had documented the loose watery stool on the Activity of Daily Living Management System. LVN P said, "Yes," the CNA had documented the loose, watery stool. When asked to explain how the system operated, LVN P replied, "If a resident has not had a bowel movement in three days, the system will have an alert show-up and we look at the alert." When asked what the sign and symptoms of constipation were, LVN P stated it was moaning grimacing, hard dried stool and blood in the stool. When asked what the side effects of narcotics were, she stated, "Constipation." When asked what the side effects of an Iron Supplement were, she stated, "Constipation." When asked what the side effects of [MEDICATION NAME] were, LVN P replied, "Dehydration." When asked what the effects of being dehydrated were, she stated, "Constipation." During an interview conducted on 07/31/14 at 10:15 AM with the DON, she told the surveyor she had contacted Advanced Nurse Practitioner Certification (ANPC) O on 07/31/14 at 9:07 AM following surveyor intervention. She said ANPC O stated it was normal for Resident #1 to have a loose, watery stool after a disimpaction. During an interview conducted on 07/31/14 at 9:30 AM with ADON Q, she stated she did not know if Resident #1 had a bowel movement since her return from the hospital. She was then asked how often a nurse reviewed the CNAs Activities of Daily living system. She replied nurses reviewed it at the end of each shift to check if the CNAs have done their documentation. ADON Q stated the nurse would only look at specific details if there was an alert. ADON Q then stated, for example, if a resident had not had a bowel movement in three day, an alert would pop up, and then the nurse would open up that alert. If the CNAs were charting a resident was having bowel movements, then the alert would not show up. It meant the resident was "okay." When asked what the side effects were for [MEDICATION NAME] pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." An interview was conducted on 07/31/14 at 9:15 AM with RN W. RN W told the surveyor the CNAs documented into the Activity Daily Management system when a resident had a bowel movement. If there was not an entry, an Alert sign would come on the screen and this would alert the nurse the resident had not had a bowel movement in three days. RN W stated, "If the resident has not had a bowel movement in three days, I will do an assessment; give a laxative or stool softer." When asked what the side effects were for [MEDICATION NAME] (a narcotic [MEDICATION NAME] with [MEDICATION NAME]) pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." Review of information retrieved on 08/04/14 and obtained from National Digestive Diseases Information Clearinghouse (NDDIC).<http://digestive.niddk.nih.gov/diseases/pubs/constipation/> revealed the following: "...Constipation is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry and small, making them painful or difficult to pass. People may feel bloated or have pain in their abdomen, the area between the chest and hips. ...Constipation is caused by stool spending too much time in the colon. The colon absorbs too much water from the stool, making it hard and dry. Hard, dry stool is more difficult for the muscles of the rectum to push out of the body. Common factors or disorders that lead to constipation are: Medications Neurological and metabolic disorders Diet low in fiber Lack of physical activity... Medications that can cause constipation include Pain medications, especially narcotics ...Iron supplements Diuretics ...Metabolic disorders, such as diabetes and [MEDICAL CONDITION], disrupt the process the body uses to get energy from food. ...Constipation is treated with the use of ...medications; stool softeners, [MEDICATION NAME], and [MEDICATION NAME]. Stool softeners help mix fluid into stools to soften them... ....complications of constipation... can lead to ...hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. Fecal impaction - occurs when hard stool packs the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition occurs most often in children and older adults...." An IJ was identified on 07/31/14. On 07/31/14 at 12:58 PM. The Administrator, the DON, Corporate RN G, Corporate LVN H and the Regional Director of Operations were informed of the IJ, and a Plan of Removal for the IJ was requested. On 08/01/14 at 7:50 AM, an interview was conducted with the Administrator. When he was asked how he monitored his staff including the DON, to ensure the systems were effective, he stated he had constant communication with the DON and they reviewed all issues at their daily meetings. When the Administrator was asked why he thought the IJ had occurred, he stated if the systems were not working, it was because the staff was not following the policies. The Administrator stated the facility IT department was putting in an alert system to alert the nursing staff when a resident went on pain medications so they would do assessments for all issues, which might have an impact on the bowels. On 08/01/14 at 10:45 PM, an interview was conducted with the DON. She stated the computer system had an area where alerts would pop up for the nurses to review. The alerts came from the documentation the CNAs entered on the ADL Flow Sheets. The CNAs were to document on the sheets any bruises, skin tears, wounds, feedings with meal intake, methods of transfers, bathing, if it required one or two person assistance with ADLs, voiding, if they took the resident to the bathroom, changed a brief or if the resident had a Foley catheter (a thin, flexible, sterile tube that is inserted through the urethra and into the bladder to drain urine) and the number of stools to include the consistency and the amount. The DON further stated the nurses had to document their acknowledgement when the alert appeared for it to shut down and no longer provide an alert. She stated they might document the nurse was aware of the issue or what they had done if it was to assess or give medications. When the DON was asked how she monitored her staff to ensure they were following the policies and procedures correctly, she replied she had computer access to the ADL Flow Sheets the CNAs filled out. The DON said she would go in and review them to see if they were documenting on the residents correctly. The DON stated she and her ADONs provided the nursing staff with in-service trainings. When the DON was asked why the IJ had occurred, she stated she really did not know what to tell the surveyor what had caused the situation. The DON stated they were in the process of in-servicing all nurses, CNAs and medication aides on the signs and symptoms of constipation and fecal impactions, how to assess and recognize them and who to report it to. The in-services for the nurses included how to do daily assessments, medication reconciliations on new admissions and re-admissions from the hospital, and how to properly follow-up on all the alerts, which pop up on the computers. The staff was also being in-serviced on how to assess all residents, who were on routine pain medications or who had experienced an increase in the amount of pain medications they were receiving. She stated they had reviewed all residents on pain medications and for anyone who did not have an order for [REDACTED]. On 08/01/14 at 12:50 PM, an interview was conducted with the Medical Director, who was Resident #1's primary care physician. He stated he had been informed by the facility about the IJ yesterday (07/31/14). He stated the elderly get Toxic Mega Colon (abnormal dilation of the colon) very quickly especially if they were bedfast and received tube feedings. He stated they were working on this concern and were providing the staff with more training as to what they should observe for constipation and the importance of giving fluids. The facility's Plan of Removal was accepted on 08/01/14 at 2:38 PM and reflected the following: In-services were initiated immediately for: Facility ADONs: Corporate Nurse Consultant, LVN H educated the facility ADONs, ADON R and ADON Q, and Charge Nurse LVN S on 07/31/14 at 1:15 PM, on S/S (Signs/Symptoms) Constipation/ Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. Corporate Nurse Consultant LVN educated the Weekend RN Supervisor on 08/01/14 at 2:00 PM, on S/S Constipation/Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. A post-test will be completed following the in-service by the attendees. Licensed Nurses: S/S Constipation/Fecal Impaction, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. This In-service was initiated by ADON R on 07/31/14 at 11:40 AM. The 10:00 PM -

Based on observation, interview and record review, the facility failed to provide the necessary services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, for one (Resident #1) of 15 residents reviewed for quality of care. The facility failed to assess and recognize a change of condition and implement interventions necessary to prevent the complications of constipation resulting in a fecal impaction; and to recognize risk factors associated with possible side effects of narcotics, iron supplements and diuretics for Resident #1. Resident #1 was admitted to the facility on [DATE], with the medications [MEDICATION NAME]-[MEDICATION NAME] (narcotic) 5 mg-325 mg tablet every six hours, [MEDICATION NAME] (iron supplement) 325 mg one tablet to be given three times a day, and [MEDICATION NAME] (diuretic) 20 mg one tablet two times a day. She was transferred to the hospital on [DATE] for rectal bleeding, where she was diagnosed with [REDACTED]. The resident did not return to the facility until 07/28/14 (six days later). Resident #1 had readmission orders [REDACTED]. The orders did not include anything for constipation or a stool softener until surveyor intervention. Resident #1, who received her only hydration/nutrition via [DEVICE], was approximately 300 cc behind in receiving her tube feeding on 07/30/14, leaving her without needed fluids to keep her hydrated. An Immediate Jeopardy (IJ) was identified on 12:58 PM on 07/31/14. While the IJ was removed on 08/01/14 at 2:47 PM, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to assess and recognize the risk factors of side effects of narcotics, iron supplements and diuretics, and to implement and intervene in a timely manner to prevent constipation/fecal impaction, could affect the 64 residents on a pain management program, the 63 residents on a bowel training program, the 71 residents in a chair all or most of the time and the eight residents receiving tube feedings, which due to their medical needs and/or their inactivity placed them at risk for constipation which could result in severe complications such as fecal impaction, bowel rupture and death. Findings included: Resident #1's Face Sheet, dated 06/24/14, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 07/01/14, revealed on admission, Resident #1 had short-term and long-term memory deficit. Resident #1 rarely/never made herself understood. She sometimes had the ability to understand others. The resident's functional level for ADLs reflected she required the extensive physical assistance of two persons for bed mobility and transferring from the bed to wheelchair, dressing, personal hygiene, and bathing. She had urinary and bowel incontinence. She was Aphasic (unable to communicate verbally) and she received her only nutrition and liquids for hydration via feeding tube. The MDS assessment reflected she received scheduled pain medication. Resident #1's care plan, which was provided by facility staff as the residen'ts currrent care plan was undated. The care plan did not address constipation or bowel management, only incontinent care of bowel and bladder. Resident#1's Physician's Telephone Order, dated 06/24/14, noted by LVN T, was to start [MEDICATION NAME]/[MEDICATION NAME] 5 mg - 325 mg tablet, one tablet per [DEVICE] (a gastrostomy tube is a surgical procedure for inserting a tube through the abdomen wall and into the stomach) every six hours for pain. Resident#1's Medication Consolidated physicians order for admission on 06/24/14, reflected the following drug regimen: 1. [MEDICATION NAME] (iron supplement) 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] (diuretic) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg - 325 mg tablet, one tablet [DEVICE] every six hours. Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/article/ 8.htm)>:) revealed the following: Common side effects of Iron Supplements are constipation and diarrhea. With constipation, it was recommended to take a stool softener such as [MEDICATION NAME] sodium ([MEDICATION NAME]). Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/druginf/meds/a 8.htt>) revealed the following: [MEDICATION NAME], a 'water pill' is used to reduce the swelling and fluid retention caused by various medical problems. One of the common side effects is Constipation. Review of Resident #1's Medication Consolidated physicians order for admission on 06/24/14 revealed there was no stool softener or medication ordered for constipation. An interview was conducted on 08/01/14 at approximately 5:30 PM, with Resident #1's family member. The family member stated while he/she was at the facility visiting with Resident #1 (before the resident went to the hospital on [DATE]), the resident was crying and shaking. He/She stated the resident had a "real bad diaper rash." He/She stated he/she had asked the resident if her bottom was hurting her. He/She asked CNA N to put some cream on Resident #1's bottom because she had a "real bad diaper rash" and that was the reason she was moaning and crying. He/She stated when CNA N was positioning the resident to apply the cream, he/she saw Resident #1's rectal opening was stretched open about three inches and there was hard-looking feces in the "hole." At that time, he/she explained to CNA N the resident was severely constipated. He/She stated he/she went and got LVN T and told her what he/she had just seen and told her the resident was constipated and needed something to help her go to the bathroom. LVN T came back into the room and administered a clear liquid into her [DEVICE]. LVN T told him/her it was something for Resident #1's constipation. The next day he/she asked an LVN (unknown name) if Resident #1 had a bowel movement. The LVN stated she was not aware if the resident had a bowel movement. He/She stated he/she explained to the nurse the resident was constipated and needed something to help her go to the bathroom. He/She stated it was then a couple of days later when the resident were transferred to the hospital with rectal bleeding (07'/22/14). An interview was conducted on 07/31/14 at 10:28 AM with CNA R, who stated about two weeks ago (07/17/14), Resident #1 was constipated. CNA R said it was so painful for her trying to push out the stool. She was moaning and frowning. She stated she told her charge nurse, LVN T about it. CNA R stated LVN T spoke with the family member and told them she would give the resident some Milk of Magnesia for her constipation. When asked if the resident had a bowel movement, CNA R replied, "She passed a little ball." Interview conducted on 07/31/14 at 2:15 PM with LVN T, revealed Resident #1's family member told her the resident was constipated and had a hard time pushing out the stool. LVN T said she told the family member she would check and see if Resident #1 had routine medication ordered for constipation. LVN T stated when she checked, Resident #1 did not have medication ordered routine or PRN for constipation. LVN T stated, "The facility has a protocol for standing orders for constipation. I gave her 30 cc of Milk of Magnesia." When asked if she checked the resident or performed an assessment of the resident's rectum, she stated, "No." LVN T said Resident #1's family member was still in the room. When asked if she had followed up on the results of the Milk of Magnesia, LVN T replied, "No. It was at the end of my shift. I reported it to the oncoming nurse that I had given her the Milk of Magnesia." When asked if she had documented in the nurse's notes the date and time she had given the Milk of Magnesia, LVN T stated she did not document she had given the medication. When asked if she had written a one time order for the Milk of Magnesia, she replied "No. I know that I am supposed to notify the physician and obtain a telephone order, then document in the nurses notes that a prn medication had been given." The facility's Activities of Daily Living Management System report received from the DON on 07/30/ 14, dated from 06/28/14 through 07/29/14 for Resident #1 was reviewed. This system was used by the facility's CNAs to document the care and services provided for each resident. Review of the document for Resident #1's bowel movements revealed from the time of 06/28/14 through 07/21/14 (24 days), Resident #1 had no bowel movements for 12 days. 06/28/14 - small and normal BM 06/29/14 - medium, loose/watery BM 07/03/14 - small BM 07/05/14 - small normal BM 07/06/14 - small normal BM 07/07/14 - no BM 07/08/14 - no BM 07/09/14 - no BM 07/10/14 - no BM 07/11/14 - no BM 07/12/14 - no BM 07/13/14 - soft medium BM 07/14/14 - no BM 07/15/14 - no BM 07/16/14 - no BM 07/17/14 - normal medium BM 07/18/14 - small dry hard BM 07/19/14 - no BM 07/20/14 - no BM 07/21/14 - no BM The facility's 24-Hour Report, dated 07/19/14 reflected: Resident #1 was "constipated, give MOM (Milk of Magnesia), large BM (bowel movement)." Comment by LVN V. Review of Resident #1's MAR for July 2014 revealed from 07/11/14 through 07/21/14 (11 days), following complaints of pain, the resident complained of pain at a level of six to seven out of ten on eight days. On 07/31/14 at approximately 9:30 AM, an interview with the DON revealed the facility used the Wong-Baker pain rating scale. The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by the user. The faces range from a smiling face to a sad, crying face. A numerical rating is assigned to each face, of which there are six total. The face zero indicates no hurt, two is hurts a little bit, four is hurts little more, six is hurts even more, eight is hurts a whole lot, and number 10 is hurts worse. Review of Resident #1's Individual Control Drug Record revealed from 07/12/14 through 07/22/14 (11 days), the resident received [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg for pain every day but 07/19/14 for a total of 37 tablets. Resident#1 received a total of 37 tablets of [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg over a period of 11 days. Review of information retrieved on 08/08/14 and obtained from http://www.nlm.nih.gov/medlineplus/druginfo/meds/ revealed one of the side effects of [MEDICATION NAME] is constipation. Resident #1's emergency room Admission Record, dated 07/22/14 at 12:49 AM, reflected a physical exam was done and indicated, "Abdominal bowel sounds were decreased." Review of Resident #1's hospital History and Physical Notes, dated 07/22/14, revealed the following: "Studies/Imaging: CT (computerized tomography) abdomen/pelvis, 1. a large amount of fecal debris in the right colon including large amount of fecal debris in the rectal vault suggesting constipation and fecal impaction." Review of Resident #1's [MEDICATION NAME] Consultation, dated 07/22/14 revealed the following: "Procedure: Colonoscopy ...2. Severe Constipation - the patient was grossly constipated on admission, which was felt to be causative for the hematochezia (the passage of bright red blood in the stool). After significant bowel regimen and manual disimpaction she had multiple BMs. She should be on a strong outpatient bowel regimen to ensure no further constipation given the morbidity she faces when she is constipated. This was communicated in writing to her SNF (Skilled Nursing Home)." Review from Resident #1's hospital physician progress notes [REDACTED]. She was disimpacted x2. First disimpation (manual removal of impacted fecal matter from the rectum) with 900 ccs brown stool out, and 2nd disimpation with 1 liter out." Note: One liter equals approximately one quart (32 ounces). Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME].html revealed the following: "[MEDICATION NAME] (Polyethylene [MEDICATION NAME] electrolyte solution)... is a laxative that increaseS the amount of water in the intestinal tract to stimulate bowel movement." Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME]-of-magnesia.html revealed the following: "[MEDICATION NAME] of Magnesia is used as a laxative to treat occasional constipation." A confidential interview was conducted and it was revealed while Resident #1 was in the hospital, the doctor said she was going to have to digitally remove the stool from her rectum with her fingers because it was so hard and impacted, water was not working to remove the stool. He/She stated, a nurse came into the room to clean the resident after she had a bowel movement. At that point, Resident #1 looked at the nurse and with her one good hand, she grabbed the sheet and would not let the sheet out of her hand. She was crying and shaking her head back and forth saying, "No." Review of the Physician Discharge Instructions from the hospital, dated 07/28/14 at 4:21 PM, revealed the following: Resident #1's Plan of Care (instructions to SNF and future physicians). "Patient should have consistent bowel movements to prevent stool impaction - this was likely a root cause for the current (rectal) bleed." Review of Resident #1's hospital orders for Admission Physician orders [REDACTED]. 1. [MEDICATION NAME] 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg tablet, one tablet [DEVICE] every six hours as needed for pain. Do not exceed 3,000 mg for pain [MEDICATION NAME] from all sources in 24 hours. Note: the dosage was increased from 5 mg to 10 mg. 4. DiabetiSource 65 ml/hr per Peg Tube, down at 9:00 AM and up at 12:00 PM. (start date 07/21/14.) Resident #1's Admission Physician orders [REDACTED]. During initial tour on 07/29/14 at 9:09 AM, Resident #1 was observed in bed. LVN P said the resident was non-verbal, but was able to follow staff with her eyes. Resident #1 was given nothing by mouth due to her [MEDICAL CONDITION] (stroke) and she had difficulty moving her right arm and hand. She further stated Resident #1 required total care for all ADLs, and she was incontinent of bladder and bowel. The resident was non-ambulatory and wheelchair-bound. LVN P stated Resident #1 had just returned from the hospital on [DATE] at 1:50 AM, and had been sent to the hospital for rectal bleeding. She had a [DEVICE] for continuous feeding, which was connected to a feeding pump. Observation at that time revealed the formula infusing was DiabetiSource at the rate of 30 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM on 07/29/14 at the rate of 65 cc/hr. The bag had approximately 1400 cc of formula remaining in the bag. When LVN P was asked what the current rate was for the formula, she replied 65 cc/hr. When asked why the rate of the formula was at 30 cc/hr, LVN P, replied the night nurse reported to her she had changed the rate of the formula on the pump to 30 cc/hr because the resident had just returned from the hospital at 1:50 AM, and she was monitoring her. LVN P stated she had not had time to verify the formula or rate since her start of the shift. An interview conducted on 07/30/14 at 2:30 PM with the DON revealed she had contacted RN K, who had set Resident #1's feeding pump at 30 cc/hr. RN K would be coming into the facility to contact Resident #1's physician regarding the formula infusion rate of 30 cc/hr. RN K would enter a late entry for the reason she set the pump at 30 cc/hr instead of 65 cc/hr. The DON continued to state it was normal procedure to set the pump at a different rate after a new admit to monitor how the resident tolerated the feeding, but RN K should have received a physician order [REDACTED]. On return to Resident #1's room on 07/29/14 at 10:18 AM, observation revealed the resident was not in her room, and the feeding pump with the formula was hanging at the bedside with approximately 1350 cc of formula remaining in the bag. On 07/29/14 at 12:13 PM, Resident #1 was still not in her room. She was observed sitting in the small activity room outside the dining hall. On 07/30/14 at 7:45 AM, Resident#1 was observed resting quietly in bed. She had formula infusing via [DEVICE], which was connected to a feeding pump. The formula was DiabetiSource and it was infusing at the rate of 65 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM with a date of 07/29/14; there was approximately 250 cc of formula left in the bag. At that time, Resident #1 was approximately 360 cc behind of receiving her full amount of fluid and nutritional intake. The resident was NPO and received water and/or formula only via the [DEVICE]. When asked if she had notified the Dietitian Resident #1 was behind on her fluid intake for the day, LVN P replied she would notify the Dietitian. An interview conducted on 07/31/14 at 8:40 AM with CNA N revealed on 07/29/14 and 07/30/14, Resident #1 had loose small watery stools on both days. She stated she informed LVN P about Resident #1's loose stools. On 07/31/14 at approximately 8:55 AM, the surveyor interviewed the DON in regard to Resident #1's loose stools from 07/29/14 and 07/3014. The interview revealed the DON had not been notified about Resident #1's loose stools. An interview was conducted on 07/31/14 at approximately 9:35 AM with LVN P. When asked if she was aware of Resident #1's loose stools, she replied, "No one had mentioned to me that she had a loose, watery stool." LVN P was asked to check if CNA N had documented the loose watery stool on the Activity of Daily Living Management System. LVN P said, "Yes," the CNA had documented the loose, watery stool. When asked to explain how the system operated, LVN P replied, "If a resident has not had a bowel movement in three days, the system will have an alert show-up and we look at the alert." When asked what the sign and symptoms of constipation were, LVN P stated it was moaning grimacing, hard dried stool and blood in the stool. When asked what the side effects of narcotics were, she stated, "Constipation." When asked what the side effects of an Iron Supplement were, she stated, "Constipation." When asked what the side effects of [MEDICATION NAME] were, LVN P replied, "Dehydration." When asked what the effects of being dehydrated were, she stated, "Constipation." During an interview conducted on 07/31/14 at 10:15 AM with the DON, she told the surveyor she had contacted Advanced Nurse Practitioner Certification (ANPC) O on 07/31/14 at 9:07 AM following surveyor intervention. She said ANPC O stated it was normal for Resident #1 to have a loose, watery stool after a disimpaction. During an interview conducted on 07/31/14 at 9:30 AM with ADON Q, she stated she did not know if Resident #1 had a bowel movement since her return from the hospital. She was then asked how often a nurse reviewed the CNAs Activities of Daily living system. She replied nurses reviewed it at the end of each shift to check if the CNAs have done their documentation. ADON Q stated the nurse would only look at specific details if there was an alert. ADON Q then stated, for example, if a resident had not had a bowel movement in three day, an alert would pop up, and then the nurse would open up that alert. If the CNAs were charting a resident was having bowel movements, then the alert would not show up. It meant the resident was "okay." When asked what the side effects were for [MEDICATION NAME] pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." An interview was conducted on 07/31/14 at 9:15 AM with RN W. RN W told the surveyor the CNAs documented into the Activity Daily Management system when a resident had a bowel movement. If there was not an entry, an Alert sign would come on the screen and this would alert the nurse the resident had not had a bowel movement in three days. RN W stated, "If the resident has not had a bowel movement in three days, I will do an assessment; give a laxative or stool softer." When asked what the side effects were for [MEDICATION NAME] (a narcotic [MEDICATION NAME] with [MEDICATION NAME]) pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." Review of information retrieved on 08/04/14 and obtained from National Digestive Diseases Information Clearinghouse (NDDIC).<http://digestive.niddk.nih.gov/diseases/pubs/constipation/> revealed the following: "...Constipation is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry and small, making them painful or difficult to pass. People may feel bloated or have pain in their abdomen, the area between the chest and hips. ...Constipation is caused by stool spending too much time in the colon. The colon absorbs too much water from the stool, making it hard and dry. Hard, dry stool is more difficult for the muscles of the rectum to push out of the body. Common factors or disorders that lead to constipation are: Medications Neurological and metabolic disorders Diet low in fiber Lack of physical activity... Medications that can cause constipation include Pain medications, especially narcotics ...Iron supplements Diuretics ...Metabolic disorders, such as diabetes and [MEDICAL CONDITION], disrupt the process the body uses to get energy from food. ...Constipation is treated with the use of ...medications; stool softeners, [MEDICATION NAME], and [MEDICATION NAME]. Stool softeners help mix fluid into stools to soften them... ....complications of constipation... can lead to ...hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. Fecal impaction - occurs when hard stool packs the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition occurs most often in children and older adults...." Review of the Nursing Services Policy and Procedure, revised 2007, Bowel (lower Gastrointestinal Tract) Disorders, Clinical Protocol revealed: "Assessment and Recognition: 1. As part of the initial assessment, the staff and physician will help identify individuals with previous lower gastrointestinal tract conditions and symptoms for example, resident with a history of diarrhea, fecal incontinence, irritable bowel syndrome, pain with defecation, passing blood rectally, alteration in bowel monuments, ulcerative [MEDICAL CONDITION] or regional enteritis and those taking anti-diarrheal medication or medication related to bowel motility (abnormal intestinal contractions, such as spasms and intestinal paralysis). a. This should include a review of gastrointestinal problems during any recent hospitalization , results of previous [MEDICATION NAME] studies, endoscopies, etc... 2. In addition, the nurse shall asses and document/report the following: a. Vital signs b. Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistence, etc.) c. Change in mental status or mental consciousness d. Presence of fecal impaction e. Signs of dehydration... f. Abdominal assessment g. Digital rectal examination h. Onset, duration, frequency, severity of signs and symptom i. All current medications j. All active diagnoses k. Recent labs 3. The staff and the physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to, gastrointestinal erosion, bleeding, diarrhea, dysmotility (term used to describe diseases of the muscles of the gastrointestinal tract), etc...." Review of the facility's current Protocol for Standing Orders, dated 06/06/03 reflected: "1. MUST WRITE A TELEPHONE ORDER FOR WHATEVER PROTOCOL USED! Please write in communication book to let Dr./PA/NP (Doctor/Physician's Assistant/Nurse Practitioner) have knowledge. Effective: ...4. Constipation Protocol #1 Milk of Magnesia 30 cc PO Bid PRN Protocol #2 [MEDICATION NAME] 30 cc QD or BID PRN Protocol #3 Fleets Enema Q 72 hours PRN Protocol #4 [MEDICATION NAME] 100 mg tablet 1 PO QD." An IJ was identified on 07/31/14. On 07/31/14 at 12:58 PM. The Administrator, the DON, Corporate RN G, Corporate LVN H and the Regional Director of Operations were informed of the IJ, and a Plan of Removal for the IJ was requested. On 08/01/14 at 7:50 AM, an interview was conducted with the Administrator. When he was asked how he monitored his staff including the DON, to ensure the systems were effective, he stated he had constant communication with the DON and they reviewed all issues at their daily meetings. When the Administrator was asked why he thought the IJ had occurred, he stated if the systems were not working, it was because the staff was not following the policies. The Administrator stated the facility IT department was putting in an alert system to alert the nursing staff when a resident went on pain medications so they would do assessments for all issues, which might have an impact on the bowels. On 08/01/14 at 10:45 PM, an interview was conducted with the DON. She stated the computer system had an area where alerts would pop up for the nurses to review. The alerts came from the documentation the CNAs entered on the ADL Flow Sheets. The CNAs were to document on the sheets any bruises, skin tears, wounds, feedings with meal intake, methods of transfers, bathing, if it required one or two person assistance with ADLs, voiding, if they took the resident to the bathroom, changed a brief or if the resident had a Foley catheter (a thin, flexible, sterile tube that is inserted through the urethra and into the bladder to drain urine) and the number of stools to include the consistency and the amount. The DON further stated the nurses had to document their acknowledgement when the alert appeared for it to shut down and no longer provide an alert. She stated they might document the nurse was aware of the issue or what they had done if it was to assess or give medications. When the DON was asked how she monitored her staff to ensure they were following the policies and procedures correctly, she replied she had computer access to the ADL Flow Sheets the CNAs filled out. The DON said she would go in and review them to see if they were documenting on the residents correctly. The DON stated she and her ADONs provided the nursing staff with in-service trainings. When the DON was asked why the IJ had occurred, she stated she really did not know what to tell the surveyor what had caused the situation. The DON stated they were in the process of in-servicing all nurses, CNAs and medication aides on the signs and symptoms of constipation and fecal impactions, how to assess and recognize them and who to report it to. The in-services for the nurses included how to do daily assessments, medication reconciliations on new admissions and re-admissions from the hospital, and how to properly follow-up on all the alerts, which pop up on the computers. The staff was also being in-serviced on how to assess all residents, who were on routine pain medications or who had experienced an increase in the amount of pain medications they were receiving. She stated they had reviewed all residents on pain medications and for anyone who did not have an order for [REDACTED]. On 08/01/14 at 12:50 PM, an interview was conducted with the Medical Director, who was Resident #1's primary care physician. He stated he had been informed by the facility about the IJ yesterday (07/31/14). He stated the elderly get Toxic Mega Colon (abnormal dilation of the colon) very quickly especially if they were bedfast and received tube feedings. He stated they were working on this concern and were providing the staff with more training as to what they should observe for constipation and the importance of giving fluids. The facility's Plan of Removal was accepted on 08/01/14 at 2:38 PM and reflected the following: In-services were initiated immediately for: Facility ADONs: Corporate Nurse Consultant, LVN H educated the facility ADONs, ADON R and ADON Q, and Charge Nurse LVN S on 07/31/14 at 1:15 PM, on S/S (Signs/Symptoms) Constipation/ Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. Corporate Nurse Consultant LVN educated the Weekend RN Supervisor on 08/01/14 at 2:00 PM, on S/S Constipation/Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. A post-test will be completed following the in-service by the attendees. Licensed Nurses: S/S Constipation/Fecal Impaction, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. This In-service was initiated by ADON R on 07/31/14 at 11:40 AM. The 10:00 PM - 6:00 AM nursing staff will be educated prior to the start of their shift on 07/31/14 by LVN S. Any remaining nursing staff needing education will be provided with the education prior to their next scheduled shift. Nursing staff picking up their paycheck on 08/01/14, will be educated on the above by ADONs R and Q. A post-test will be completed following the in-service by the attendees. In-services were initiated immediately for: CNA/MA: S/S constipation and reporting to the Nurse, reporting to the ADON/DON when no response from the nurse after reporting to the nurse, Stop and Watch, and how to document consistency of the BM accurately. This In-service was initiated by ADON R on 07/31/14 at 11:40 AM. The second shift nursing staffs were educated on 07/31/14 by ADON R. The 10:00 PM - 6:00 AM nursing staff were educated prior to the start of their shift on 07/31/14 by LVN S. A post-test was completed following the in?-service by the attendees. Any remaining nursing staff needing education will be provided with the education prior to their next scheduled shift. Nursing staff picking up their paycheck on 08/01/14, will be educated on the above including the completion of the post-test at 2:30 PM on 08/01/14. Any weekend staff not educated during payday on 08/01/14, will be in-serviced by the Weekend RN Supervisor, prior to the start

Based on observation, interview and record review, the facility Administrator and the DON failed to ensure the facility was administered in a manner which enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, enatl and psychosocial well-being of each resident for one (Resident #1) of 15 residents reviewed for neglect and quality of care. The Administrator failed to ensure the facility's policy and procedure for abuse/neglect prohibition was implemented. The Administrator and the DON did not monitor and apprise care and services being provided to Resident #1 to ensure: --The resident was assessed and her change of condition was recognized; --Failed to recognize the risk factors associated with side effects of narcotic [MEDICATION NAME], iron supplements and diuretics; --Interventions were implemented to prevent the complications of constipation resulting in a fecal impaction. --When the resident returned from the hospital on [DATE], interventions were implemented at that time to prevent a recurrency of constipation/fecal impaction. --When the resident returned from the hospital on [DATE], the resident received adequate hydration via her [DEVICE]. An Immediate Jeopardy (IJ) was identified on 12:58 PM on 07/31/14. While the IJ was removed on 08/01/14 at 2:47 PM, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to assess and recognize the risk factors of side effects of narcotics, iron supplements and diuretics, and to implement and intervene in a timely manner to prevent constipation/fecal impaction, could affect the 64 residents on a pain management program, the 63 residents on a bowel training program, the 71 residents in a chair all or most of the time and the eight residents receiving tube feedings, which due to their medical needs and/or their inactivity placed them at risk for constipation which could result in severe complications such as fecal impaction, bowel rupture and death. Findings included: Resident #1's Face Sheet, dated 06/24/14, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessment, dated 07/01/14, revealed on admission, Resident #1 had short-term and long-term memory deficit. Resident #1 rarely/never made herself understood. She sometimes had the ability to understand others. The resident's functional level for ADLs reflected she required the extensive physical assistance of two persons for bed mobility and transferring from the bed to wheelchair, dressing, personal hygiene, and bathing. She had urinary and bowel incontinence. She was Aphasic (unable to communicate verbally) and she received her only nutrition and liquids for hydration via feeding tube. The MDS assessment reflected she received scheduled pain medication. Resident #1's care plan, which was provided by facility staff as the residen'ts currrent care plan was undated. The care plan did not address constipation or bowel management, only incontinent care of bowel and bladder. Resident#1's Physician's Telephone Order, dated 06/24/14, noted by LVN T, was to start [MEDICATION NAME]/[MEDICATION NAME] 5 mg - 325 mg tablet, one tablet per [DEVICE] (a gastrostomy tube is a surgical procedure for inserting a tube through the abdomen wall and into the stomach) every six hours for pain. Resident#1's Medication Consolidated physicians order for admission on 06/24/14, reflected the following drug regimen: 1. [MEDICATION NAME] (iron supplement) 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] (diuretic) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] (narcotic [MEDICATION NAME]) 5 mg - 325 mg tablet, one tablet [DEVICE] every six hours. Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/article/ 8.htm)>:) revealed the following: Common side effects of Iron Supplements are constipation and diarrhea. With constipation, it was recommended to take a stool softener such as [MEDICATION NAME] sodium ([MEDICATION NAME]). Review of information retrieved on 08/04/14 and obtained from Medline Plus (<http://www.nlm.nih.gov/medlineplus/druginf/meds/a 8.htt>) revealed the following: [MEDICATION NAME], a 'water pill' is used to reduce the swelling and fluid retention caused by various medical problems. One of the common side effects is Constipation. Review of Resident #1's Medication Consolidated physicians order for admission on 06/24/14 revealed there was no stool softener or medication ordered for constipation. An interview was conducted on 08/01/14 at approximately 5:30 PM, with Resident #1's family member. The family member stated while he/she was at the facility visiting with Resident #1 (before the resident went to the hospital on [DATE]), the resident was crying and shaking. He/She stated the resident had a "real bad diaper rash." He/She stated he/she had asked the resident if her bottom was hurting her. He/She asked CNA N to put some cream on Resident #1's bottom because she had a "real bad diaper rash" and that was the reason she was moaning and crying. He/She stated when CNA N was positioning the resident to apply the cream, he/she saw Resident #1's rectal opening was stretched open about three inches and there was hard-looking feces in the "hole." At that time, he/she explained to CNA N the resident was severely constipated. He/She stated he/she went and got LVN T and told her what he/she had just seen and told her the resident was constipated and needed something to help her go to the bathroom. LVN T came back into the room and administered a clear liquid into her [DEVICE]. LVN T told him/her it was something for Resident #1's constipation. The next day he/she asked an LVN (unknown name) if Resident #1 had a bowel movement. The LVN stated she was not aware if the resident had a bowel movement. He/She stated he/she explained to the nurse the resident was constipated and needed something to help her go to the bathroom. He/She stated it was then a couple of days later when the resident were transferred to the hospital with rectal bleeding (07'/22/14). An interview was conducted on 07/31/14 at 10:28 AM with CNA R, who stated about two weeks ago (07/17/14), Resident #1 was constipated. CNA R said it was so painful for her trying to push out the stool. She was moaning and frowning. She stated she told her charge nurse, LVN T about it. CNA R stated LVN T spoke with the family member and told them she would give the resident some Milk of Magnesia for her constipation. When asked if the resident had a bowel movement, CNA R replied, "She passed a little ball." Interview conducted on 07/31/14 at 2:15 PM with LVN T, revealed Resident #1's family member told her the resident was constipated and had a hard time pushing out the stool. LVN T said she told the family member she would check and see if Resident #1 had routine medication ordered for constipation. LVN T stated when she checked, Resident #1 did not have medication ordered routine or PRN for constipation. LVN T stated, "The facility has a protocol for standing orders for constipation. I gave her 30 cc of Milk of Magnesia." When asked if she checked the resident or performed an assessment of the resident's rectum, she stated, "No." LVN T said Resident #1's family member was still in the room. When asked if she had followed up on the results of the Milk of Magnesia, LVN T replied, "No. It was at the end of my shift. I reported it to the oncoming nurse that I had given her the Milk of Magnesia." When asked if she had documented in the nurse's notes the date and time she had given the Milk of Magnesia, LVN T stated she did not document she had given the medication. When asked if she had written a one time order for the Milk of Magnesia, she replied "No. I know that I am supposed to notify the physician and obtain a telephone order, then document in the nurses notes that a prn medication had been given." The facility's Activities of Daily Living Management System report received from the DON on 07/30/ 14, dated from 06/28/14 through 07/29/14 for Resident #1 was reviewed. This system was used by the facility's CNAs to document the care and services provided for each resident. Review of the document for Resident #1's bowel movements revealed from the time of 06/28/14 through 07/21/14 (24 days), Resident #1 had no bowel movements for 12 days. 06/28/14 - small and normal BM 06/29/14 - medium, loose/watery BM 07/03/14 - small BM 07/05/14 - small normal BM 07/06/14 - small normal BM 07/07/14 - no BM 07/08/14 - no BM 07/09/14 - no BM 07/10/14 - no BM 07/11/14 - no BM 07/12/14 - no BM 07/13/14 - soft medium BM 07/14/14 - no BM 07/15/14 - no BM 07/16/14 - no BM 07/17/14 - normal medium BM 07/18/14 - small dry hard BM 07/19/14 - no BM 07/20/14 - no BM 07/21/14 - no BM The facility's 24-Hour Report, dated 07/19/14 reflected: Resident #1 was "constipated, give MOM (Milk of Magnesia), large BM (bowel movement)." Comment by LVN V. Review of Resident #1's MAR for July 2014 revealed from 07/11/14 through 07/21/14 (11 days), following complaints of pain, the resident complained of pain at a level of six to seven out of ten on eight days. On 07/31/14 at approximately 9:30 AM, an interview with the DON revealed the facility used the Wong-Baker pain rating scale. The Wong Baker Faces Pain Scale combines pictures and numbers to allow pain to be rated by the user. The faces range from a smiling face to a sad, crying face. A numerical rating is assigned to each face, of which there are six total. The face zero indicates no hurt, two is hurts a little bit, four is hurts little more, six is hurts even more, eight is hurts a whole lot, and number 10 is hurts worse. Review of Resident #1's Individual Control Drug Record revealed from 07/12/14 through 07/22/14 (11 days), the resident received [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg for pain every day but 07/19/14 for a total of 37 tablets. Resident#1 received a total of 37 tablets of [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg over a period of 11 days. Review of information retrieved on 08/08/14 and obtained from http://www.nlm.nih.gov/medlineplus/druginfo/meds/ revealed one of the side effects of [MEDICATION NAME] is constipation. Resident #1's emergency room Admission Record, dated 07/22/14 at 12:49 AM, reflected a physical exam was done and indicated, "Abdominal bowel sounds were decreased." Review of Resident #1's hospital History and Physical Notes, dated 07/22/14, revealed the following: "Studies/Imaging: CT (computerized tomography) abdomen/pelvis, 1. a large amount of fecal debris in the right colon including large amount of fecal debris in the rectal vault suggesting constipation and fecal impaction." Review of Resident #1's [MEDICATION NAME] Consultation, dated 07/22/14 revealed the following: "Procedure: Colonoscopy ...2. Severe Constipation - the patient was grossly constipated on admission, which was felt to be causative for the hematochezia (the passage of bright red blood in the stool). After significant bowel regimen and manual disimpaction she had multiple BMs. She should be on a strong outpatient bowel regimen to ensure no further constipation given the morbidity she faces when she is constipated. This was communicated in writing to her SNF (Skilled Nursing Home)." Review from Resident #1's hospital physician progress notes [REDACTED]. She was disimpacted x2. First disimpation (manual removal of impacted fecal matter from the rectum) with 900 ccs brown stool out, and 2nd disimpation with 1 liter out." Note: One liter equals approximately one quart (32 ounces). Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME].html revealed the following: "[MEDICATION NAME] (Polyethylene [MEDICATION NAME] electrolyte solution)... is a laxative that increaseS the amount of water in the intestinal tract to stimulate bowel movement." Review of information retrieved on 08/04/14 and obtained from www.drug.com/mtm/[MEDICATION NAME]-of-magnesia.html revealed the following: "[MEDICATION NAME] of Magnesia is used as a laxative to treat occasional constipation." A confidential interview was conducted and it was revealed while Resident #1 was in the hospital, the doctor said she was going to have to digitally remove the stool from her rectum with her fingers because it was so hard and impacted, water was not working to remove the stool. He/She stated, a nurse came into the room to clean the resident after she had a bowel movement. At that point, Resident #1 looked at the nurse and with her one good hand, she grabbed the sheet and would not let the sheet out of her hand. She was crying and shaking her head back and forth saying, "No." Review of the Physician Discharge Instructions from the hospital, dated 07/28/14 at 4:21 PM, revealed the following: Resident #1's Plan of Care (instructions to SNF and future physicians). "Patient should have consistent bowel movements to prevent stool impaction - this was likely a root cause for the current (rectal) bleed." Review of Resident #1's hospital orders for Admission Physician orders [REDACTED]. 1. [MEDICATION NAME] 325 mg tablet, one tablet [DEVICE] three times per day. 2. [MEDICATION NAME] ([MEDICATION NAME]) 20 mg tablet, one tablet, two times per day. 3. [MEDICATION NAME]/[MEDICATION NAME] 10 mg - 325 mg tablet, one tablet [DEVICE] every six hours as needed for pain. Do not exceed 3,000 mg for pain [MEDICATION NAME] from all sources in 24 hours. Note: the dosage was increased from 5 mg to 10 mg. 4. DiabetiSource 65 ml/hr per Peg Tube, down at 9:00 AM and up at 12:00 PM. (start date 07/21/14.) Resident #1's Admission Physician orders [REDACTED]. During initial tour on 07/29/14 at 9:09 AM, Resident #1 was observed in bed. LVN P said the resident was non-verbal, but was able to follow staff with her eyes. Resident #1 was given nothing by mouth due to her [MEDICAL CONDITION] (stroke) and she had difficulty moving her right arm and hand. She further stated Resident #1 required total care for all ADLs, and she was incontinent of bladder and bowel. The resident was non-ambulatory and wheelchair-bound. LVN P stated Resident #1 had just returned from the hospital on [DATE] at 1:50 AM, and had been sent to the hospital for rectal bleeding. She had a [DEVICE] for continuous feeding, which was connected to a feeding pump. Observation at that time revealed the formula infusing was DiabetiSource at the rate of 30 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM on 07/29/14 at the rate of 65 cc/hr. The bag had approximately 1400 cc of formula remaining in the bag. When LVN P was asked what the current rate was for the formula, she replied 65 cc/hr. When asked why the rate of the formula was at 30 cc/hr, LVN P, replied the night nurse reported to her she had changed the rate of the formula on the pump to 30 cc/hr because the resident had just returned from the hospital at 1:50 AM, and she was monitoring her. LVN P stated she had not had time to verify the formula or rate since her start of the shift. An interview conducted on 07/30/14 at 2:30 PM with the DON revealed she had contacted RN K, who had set Resident #1's feeding pump at 30 cc/hr. RN K would be coming into the facility to contact Resident #1's physician regarding the formula infusion rate of 30 cc/hr. RN K would enter a late entry for the reason she set the pump at 30 cc/hr instead of 65 cc/hr. The DON continued to state it was normal procedure to set the pump at a different rate after a new admit to monitor how the resident tolerated the feeding, but RN K should have received a physician order [REDACTED]. On return to Resident #1's room on 07/29/14 at 10:18 AM, observation revealed the resident was not in her room, and the feeding pump with the formula was hanging at the bedside with approximately 1350 cc of formula remaining in the bag. On 07/29/14 at 12:13 PM, Resident #1 was still not in her room. She was observed sitting in the small activity room outside the dining hall. On 07/30/14 at 7:45 AM, Resident#1 was observed resting quietly in bed. She had formula infusing via [DEVICE], which was connected to a feeding pump. The formula was DiabetiSource and it was infusing at the rate of 65 cc/hr. The current 1500 cc bag of formula reflected the bag had started infusing at 4:00 AM with a date of 07/29/14; there was approximately 250 cc of formula left in the bag. At that time, Resident #1 was approximately 360 cc behind of receiving her full amount of fluid and nutritional intake. The resident was NPO and received water and/or formula only via the [DEVICE]. When asked if she had notified the Dietitian Resident #1 was behind on her fluid intake for the day, LVN P replied she would notify the Dietitian. An interview conducted on 07/31/14 at 8:40 AM with CNA N revealed on 07/29/14 and 07/30/14, Resident #1 had loose small watery stools on both days. She stated she informed LVN P about Resident #1's loose stools. On 07/31/14 at approximately 8:55 AM, the surveyor interviewed the DON in regard to Resident #1's loose stools from 07/29/14 and 07/3014. The interview revealed the DON had not been notified about Resident #1's loose stools. An interview was conducted on 07/31/14 at approximately 9:35 AM with LVN P. When asked if she was aware of Resident #1's loose stools, she replied, "No one had mentioned to me that she had a loose, watery stool." LVN P was asked to check if CNA N had documented the loose watery stool on the Activity of Daily Living Management System. LVN P said, "Yes," the CNA had documented the loose, watery stool. When asked to explain how the system operated, LVN P replied, "If a resident has not had a bowel movement in three days, the system will have an alert show-up and we look at the alert." When asked what the sign and symptoms of constipation were, LVN P stated it was moaning grimacing, hard dried stool and blood in the stool. When asked what the side effects of narcotics were, she stated, "Constipation." When asked what the side effects of an Iron Supplement were, she stated, "Constipation." When asked what the side effects of [MEDICATION NAME] were, LVN P replied, "Dehydration." When asked what the effects of being dehydrated were, she stated, "Constipation." During an interview conducted on 07/31/14 at 10:15 AM with the DON, she told the surveyor she had contacted Advanced Nurse Practitioner Certification (ANPC) O on 07/31/14 at 9:07 AM following surveyor intervention. She said ANPC O stated it was normal for Resident #1 to have a loose, watery stool after a disimpaction. During an interview conducted on 07/31/14 at 9:30 AM with ADON Q, she stated she did not know if Resident #1 had a bowel movement since her return from the hospital. She was then asked how often a nurse reviewed the CNAs Activities of Daily living system. She replied nurses reviewed it at the end of each shift to check if the CNAs have done their documentation. ADON Q stated the nurse would only look at specific details if there was an alert. ADON Q then stated, for example, if a resident had not had a bowel movement in three day, an alert would pop up, and then the nurse would open up that alert. If the CNAs were charting a resident was having bowel movements, then the alert would not show up. It meant the resident was "okay." When asked what the side effects were for [MEDICATION NAME] pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." An interview was conducted on 07/31/14 at 9:15 AM with RN W. RN W told the surveyor the CNAs documented into the Activity Daily Management system when a resident had a bowel movement. If there was not an entry, an Alert sign would come on the screen and this would alert the nurse the resident had not had a bowel movement in three days. RN W stated, "If the resident has not had a bowel movement in three days, I will do an assessment; give a laxative or stool softer." When asked what the side effects were for [MEDICATION NAME] (a narcotic [MEDICATION NAME] with [MEDICATION NAME]) pain medication, she replied, "Constipation." When asked what the side effects were for Iron Supplements, she replied, "Constipation." When asked what [MEDICATION NAME] was used for, she replied it was a diuretic. When asked what the side effects could be from a diuretic, she stated, "Dehydration." Then she was asked what the effects could be from dehydration, and she replied, "Constipation." Review of information retrieved on 08/04/14 and obtained from National Digestive Diseases Information Clearinghouse (NDDIC).<http://digestive.niddk.nih.gov/diseases/pubs/constipation/> revealed the following: "...Constipation is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry and small, making them painful or difficult to pass. People may feel bloated or have pain in their abdomen, the area between the chest and hips. ...Constipation is caused by stool spending too much time in the colon. The colon absorbs too much water from the stool, making it hard and dry. Hard, dry stool is more difficult for the muscles of the rectum to push out of the body. Common factors or disorders that lead to constipation are: Medications Neurological and metabolic disorders Diet low in fiber Lack of physical activity... Medications that can cause constipation include Pain medications, especially narcotics ...Iron supplements Diuretics ...Metabolic disorders, such as diabetes and [MEDICAL CONDITION], disrupt the process the body uses to get energy from food. ...Constipation is treated with the use of ...medications; stool softeners, [MEDICATION NAME], and [MEDICATION NAME]. Stool softeners help mix fluid into stools to soften them... ....complications of constipation... can lead to ...hemorrhoids, anal fissures, rectal prolapse, and fecal impaction. Fecal impaction - occurs when hard stool packs the intestine and rectum so tightly that the normal pushing action of the colon is not enough to expel the stool. This condition occurs most often in children and older adults...." Review of the Nursing Services Policy and Procedure, revised 2007, Bowel (lower Gastrointestinal Tract) Disorders, Clinical Protocol revealed: "Assessment and Recognition: 1. As part of the initial assessment, the staff and physician will help identify individuals with previous lower gastrointestinal tract conditions and symptoms for example, resident with a history of diarrhea, fecal incontinence, irritable bowel syndrome, pain with defecation, passing blood rectally, alteration in bowel monuments, ulcerative [MEDICAL CONDITION] or regional enteritis and those taking anti-diarrheal medication or medication related to bowel motility (abnormal intestinal contractions, such as spasms and intestinal paralysis). a. This should include a review of gastrointestinal problems during any recent hospitalization , results of previous [MEDICATION NAME] studies, endoscopies, etc... 2. In addition, the nurse shall asses and document/report the following: a. Vital signs b. Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount, consistence, etc.) c. Change in mental status or mental consciousness d. Presence of fecal impaction e. Signs of dehydration... f. Abdominal assessment g. Digital rectal examination h. Onset, duration, frequency, severity of signs and symptom i. All current medications j. All active diagnoses k. Recent labs 3. The staff and the physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking medications that are used to treat, or that may cause or contribute to, gastrointestinal erosion, bleeding, diarrhea, dysmotility (term used to describe diseases of the muscles of the gastrointestinal tract), etc...." Review of the facility's current Protocol for Standing Orders, dated 06/06/03 reflected: "1. MUST WRITE A TELEPHONE ORDER FOR WHATEVER PROTOCOL USED! Please write in communication book to let Dr./PA/NP (Doctor/Physician's Assistant/Nurse Practitioner) have knowledge. Effective: ...4. Constipation Protocol #1 Milk of Magnesia 30 cc PO Bid PRN Protocol #2 [MEDICATION NAME] 30 cc QD or BID PRN Protocol #3 Fleets Enema Q 72 hours PRN Protocol #4 [MEDICATION NAME] 100 mg tablet 1 PO QD." Review of the facility's current policy and procedure for Abuse Prohibition Management Program (undated) revealed the following: Screening, Training & Prevention Policy Policy: "Our Facility will not condone resident ...neglect ...by anyone, including staff members, other residents, consultants, volunteers, staff or toehr agencies serving the resident... To ensure that incidents of abuse are prevented, to the extent possible, the following procedures will be implemented. Procedures: Responsibilities: 1. The facility's Administrator, and in his/her absence, the Director of Nursing, will perfrom the duties of the Abuse prevention Coordinator. Duties include but are not limited to: ...d. Assuring that the timely identification, investigation and reporting of incidences of abuse occur... ...Prevention ...e. The assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as ...residents with communications disorders and residents who require heavy nursing care and/or are totally dependent on staff." Identification, Investigation & Reporting Policy Procedures: Identification: "...h. Neglect is a deprivation of life's necessities of foo, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident." An IJ was identified on 07/31/14. On 07/31/14 at 12:58 PM. The Administrator, the DON, Corporate RN G, Corporate LVN H and the Regional Director of Operations were informed of the IJ, and a Plan of Removal for the IJ was requested. On 08/01/14 at 7:50 AM, an interview was conducted with the Administrator. When he was asked how he monitored his staff including the DON, to ensure the systems were effective, he stated he had constant communication with the DON and they reviewed all issues at their daily meetings. When the Administrator was asked why he thought the IJ had occurred, he stated if the systems were not working, it was because the staff was not following the policies. The Administrator stated the facility IT department was putting in an alert system to alert the nursing staff when a resident went on pain medications so they would do assessments for all issues, which might have an impact on the bowels. On 08/01/14 at 10:45 PM, an interview was conducted with the DON. She stated the computer system had an area where alerts would pop up for the nurses to review. The alerts came from the documentation the CNAs entered on the ADL Flow Sheets. The CNAs were to document on the sheets any bruises, skin tears, wounds, feedings with meal intake, methods of transfers, bathing, if it required one or two person assistance with ADLs, voiding, if they took the resident to the bathroom, changed a brief or if the resident had a Foley catheter (a thin, flexible, sterile tube that is inserted through the urethra and into the bladder to drain urine) and the number of stools to include the consistency and the amount. The DON further stated the nurses had to document their acknowledgement when the alert appeared for it to shut down and no longer provide an alert. She stated they might document the nurse was aware of the issue or what they had done if it was to assess or give medications. When the DON was asked how she monitored her staff to ensure they were following the policies and procedures correctly, she replied she had computer access to the ADL Flow Sheets the CNAs filled out. The DON said she would go in and review them to see if they were documenting on the residents correctly. The DON stated she and her ADONs provided the nursing staff with in-service trainings. When the DON was asked why the IJ had occurred, she stated she really did not know what to tell the surveyor what had caused the situation. The DON stated they were in the process of in-servicing all nurses, CNAs and medication aides on the signs and symptoms of constipation and fecal impactions, how to assess and recognize them and who to report it to. The in-services for the nurses included how to do daily assessments, medication reconciliations on new admissions and re-admissions from the hospital, and how to properly follow-up on all the alerts, which pop up on the computers. The staff was also being in-serviced on how to assess all residents, who were on routine pain medications or who had experienced an increase in the amount of pain medications they were receiving. She stated they had reviewed all residents on pain medications and for anyone who did not have an order for [REDACTED]. On 08/01/14 at 12:50 PM, an interview was conducted with the Medical Director, who was Resident #1's primary care physician. He stated he had been informed by the facility about the IJ yesterday (07/31/14). He stated the elderly get Toxic Mega Colon (abnormal dilation of the colon) very quickly especially if they were bedfast and received tube feedings. He stated they were working on this concern and were providing the staff with more training as to what they should observe for constipation and the importance of giving fluids. The facility's Plan of Removal was accepted on 08/01/14 at 2:38 PM and reflected the following: In-services were initiated immediately for: Facility ADONs: Corporate Nurse Consultant, LVN H educated the facility ADONs, ADON R and ADON Q, and Charge Nurse LVN S on 07/31/14 at 1:15 PM, on S/S (Signs/Symptoms) Constipation/ Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. Corporate Nurse Consultant LVN educated the Weekend RN Supervisor on 08/01/14 at 2:00 PM, on S/S Constipation/Fecal Impaction, Hydration, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. A post-test will be completed following the in-service by the attendees. Licensed Nurses: S/S Constipation/Fecal Impaction, Medication Reconciliation on admission and upon return from the hospital, assessment of residents after a report from the CNA/MA or other staff. This In-service was initiated by ADON R on 07/31/14 at 11:40 AM. The 10:00 PM - 6:00 AM nursing staff will be educated prior to the start of their shift on 07/31/14 by LVN S. Any remaining nursing staff needing education will be provided with the education prior to their next scheduled shift. Nursing staff picking up their paycheck on 08/01/14, will be educated on the above by ADONs R and Q. A post-test will be completed following the in-service by the attendees. In-services were initiated immediately for: CNA/MA: S/S consti

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one (Resident #7) of 14 residents reviewed for pain management. The facility staff failed to reorder and ensure delivery of Resident #7's [MEDICATION NAME]es for his pain. Resident #7 required three trips to the ER due to his severe, unrelieved pain on 08/15/13, 08/18/13 and 08/21/13 and was admitted to the hospital on [DATE] for pain evaluation. An Immediate Jeopardy (IJ) was identified on 08/22/13. While the IJ was removed on 08/23/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to ensure pain medication was reordered timely and to assess the resident for pain could affect the 52 residents, including Resident #7, who had either routine or PRN pain medication ordered by their physician and placed them at risk for unrelieved pain and discomfort. This could result in decreased nutritional intake, unplanned weight loss, alteration in sleep patterns, decreased socialization, serious medical complications, and a delay for appropriate interventions to be implemented and could result in the need for increased medication and possible admission to the hospital for pain relief treatment. Findings included: Resident #7's hospital H & P dated 08/22/13 reflected the resident was a [AGE] year-old male, who had undergone back surgery in May 2013 following a back injury after a fall at another hospital. The resident subsequently developed progressive lower extremity weakness and underwent a [MEDICATION NAME] laminectomy (cutting out the vertebral arch usually to remove a herniated disk) in June 2013 and was found to have Osteo[DIAGNOSES REDACTED] (inflammation of the bone and marrow usually caused by infection)." Resident #7's Physical, Medicine and Rehabilitation Progress notes dated 08/05/13 reflected the resident had [MEDICAL CONDITION] secondary to an [MEDICATION NAME] Abscess at T6-T9, status [REDACTED]. (Diskitis is an inflammation of the vertebral disk space.) Resident #7's care plan dated 07/26/13 addressed the problem of the resident experiencing pain frequently related to his [DIAGNOSES REDACTED]. Interventions included to turn and reposition the resident every two hours, place a pillow between his legs and behind his back when he was lying on his side and to give medication as ordered for his pain and report to the physician if the resident's medication was not effective. Resident #7's physician orders [REDACTED]. A [MEDICATION NAME] Patch is used to relieve moderate to severe chronic pain, which cannot be controlled by the use of other pain medications. The physician's orders [REDACTED]. The facility-contracted Pharmacy's Proof of Delivery manifests for 07/25/13 through 08/21/13 reflected on 07/27/13 at 8:00 PM, the pharmacy delivered five [MEDICATION NAME] 100 mcg/hr patches and five [MEDICATION NAME] 25 mcg/hr patches to the facility for Resident #7. The individual Control Drug Record for the [MEDICATION NAME]es for Resident #7 was reviewed. The five [MEDICATION NAME] 100 mcg patches and the five [MEDICATION NAME] 25 mcg patches were delivered by the pharmacy on 07/27/13 according to the Control Drug Record. The following dates and times were when the [MEDICATION NAME]es were signed out and initialed as given: 07/28/13 at 8:00 AM 08/01/13 at 8:00 AM 08/04/13 at 8:00 AM 08/07/13 at 8:00 AM 08/10/13 at 8:00 AM. Resident #7's MDS assessment dated [DATE] reflected he was admitted to the facility on [DATE]. The MDS assessment reflected Resident #7 was alert and oriented, with no signs or symptoms of [MEDICAL CONDITION], no behaviors and had a BIMS score of 15, which indicated he was cognitively intact. Resident #7 was also assessed as requiring extensive assistance by two staff for bed mobility, transfers, toileting and bathing. He required extensive assistance of one staff for dressing and personal hygiene and only set-up help for eating. [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #7 received scheduled pain medication and PRN pain medications. The MDS assessment also included an interview with Resident #7, in which he stated he had experienced pain within the last 5 days, it was frequent and it limited his day-to-day activities. Resident #7 stated his pain was an 8 on a pain scale of 0-10 with 10 being the most severe pain. At 10:00 AM on 08/20/13, Resident #7 was observed receiving physical therapy during initial rounds. Resident #7 was identified as being alert and oriented, incontinent of bowel, having a Foley catheter in place, required assistance with ADLs, was a two-person transfer and fed himself. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. Review of the MARs for July and August 2013 revealed Resident #7 received the [MEDICATION NAME]es on 07/28/13 and was due to have another set of patches applied on 07/31/13, but it was not documented as being administered until 08/01/13 (missed dose). MA A had signed out and administered the [MEDICATION NAME]es on 07/27/13, 08/04/13, 08/07/13 and 08/10/13, which was the last day the patches were available. MA B had signed out and administered the [MEDICATION NAME]es on 08/01/13 and had also signed out and administered the [MEDICATION NAME]es on 08/13/13. However, with only five doses delivered to the facility for Resident #7 on 07/27/13, the last ones would have been used on 08/10/13. The MARS reflected documentation of six doses, but there were only five doses of patches delivered and available for application. At 10:50 AM on 08/22/13, an interview was conducted with MA B. She stated she could not explain why she documented she had applied the [MEDICATION NAME]es to Resident #7 on 08/13/13 when there were no patches available. At 9:30 AM on 08/22/13, an interview was conducted with MA A. She confirmed she had applied the last of the [MEDICATION NAME]es for Resident #7 on 08/10/13. MA A stated she told LVN E Resident #7 did not have any more [MEDICATION NAME]es. At 10:30 AM on 08/22/13, an interview was conducted with LVN E. She stated she was not aware Resident #7 had no [MEDICATION NAME]es, and added MA A had not told her there were no more [MEDICATION NAME]es for the resident. Resident #7's MAR for August 2013 reflected there was a section to document a pain assessment every shift. The MAR indicated [REDACTED]. The staff wrote an "H" for each shift from the night shift on 08/15/13 through the evening and day shifts on 08/21/13, not restarting the pain assessments when Resident #7 returned to the facility on [DATE]. There was no documentation on the August 2013 MAR from 08/16/13 to the present to indicate staff assessed the resident's level of pain and documented it. At 1:40 PM on 08/22/13, an interview was conducted with ADON D. She stated the "H" on the MARs meant the medication or treatment was on hold. She said when a resident was sent to the hospital, all medications and treatments were put on hold and marked with an "H." ADON D stated with the facility's computer system, they had to go in and reactivate each medication and treatment individually. The system did not automatically reactivate everything on the MARs. ADON D stated the pain assessment order was not reactivated, so the "H " meant the pain assessments were not done. Review of Resident #7's nurses' notes dated from 07/31/13 through 08/21/13 revealed when the nurse administered a PRN medication for the residdent's pain, they documented the date and time and what PRN medication was given. There was a follow-up notation whether or not the medication was effective. The location and/or severity of the pain was not always included. There were only three days when the location of the pain and the severity of the pain was documented, which were 08/15/13, 08/18/13 and 08/21/13, the days he was sent to the hospital. At 9:20 AM on 08/23/13, the Corporate RN brought the survey team the Daily Skilled Nurses Notes for Resident #7 dated from 08/11/13 through 08/21/13. The Corporate RN confirmed the survey team did not have computer access to these Daily Skilled Nurses Notes. The Corporate RN also stated it was the facility's policy to conduct pain assessments each shift. She also provided a copy of the record from when MA A tried to re-order Resident #7's [MEDICATION NAME]es on 08/10/13. The Corporate RN stated something was wrong on the pharmacy side and the [MEDICATION NAME]es did not get re-ordered until 08/21/13, when the licensed nurse re-ordered it. The Corporate RN confirmed the triplicate prescription for the [MEDICATION NAME]es had refills, and they should have been refilled on 08/10/13. The Texas DADS Licensing Standards for Medication Aides Handbook with a revision date of "12-1" reflected the following: "TAC 95.105 Allowable and Prohibited Practices of a Permit Holder ...(b) A permit holder under Health and Safety Code, Chapter 242, Subchapter N, may not: ...(9) order a resident's medications from a pharmacy;...." At 4:10 PM on 08/23/13, an interview was conducted with the Weekend RN Supervisor. She stated she had never worked with Resident #7 personally but had made rounds on him. The Weekend RN Supervisor said she did not have any knowledge Resident #7's [MEDICATION NAME]es were not available, and no one had reported it to her. At 2:10 PM on 08/23/13, an interview was conducted with CNA G. She stated she had taken care of Resident #7 and was familiar with him. She stated his level of pain seemed to increase the last few days, and he was complaining more about his pain. At 2:20 PM on 08/23/13, an interview was conducted with LVN H. He stated he was not aware and had not been informed there were no [MEDICATION NAME]es available for Resident #7. The nurses' notes reflected at 11:51 AM on 08/15/13, Resident #7 was given two Tylenol 325 mg tablets, and at 12:13 PM on 08/15/13, Resident #7 received one [MEDICATION NAME] (narcotic [MEDICATION NAME]) tablet. Resident #7's nurses' notes dated 08/15/13 at 12:46 PM reflected the following: "Resident c/o severe back pain at the site where he had a surgical incision. [MEDICATION NAME] 10/325 mg (narcotic pain medication), 1 tab po given as ordered. Rechecked later Resident stated pain medication not effective. PA ...notified via voice mail. Awaiting call back. Will continue to monitor." Resident #7's nurses' notes dated 08/15/13 at 4:30 PM reflected the following: "Resident c/o severe back pain not relieved with [MEDICATION NAME] or APAP. [MEDICATION NAME] (anti-anxiety) given due to c/o increased anxiety. APAP given at this time, resident repositioned to alternating sides and stated it was effective. Drsg to incision site done by tx nurse CDI No drainage noted. Afebrile. Resd voiced he would like to go to the hospital if pain meds do not work." The nurses' notes dated 08/15/13 at 4:50 PM reflected Resident #7's family had arrived and requested the resident be sent to the ER for his back pain. The transport ambulance was called and reported pick-up time would be in 30 minutes. The family stated that was too long and requested 911 be called. 911 was called and the resident was picked up within 3 minutes and transported to the hospital. At 2:40 PM on 08/23/13, an interview was conducted with LVN F. She stated she worked on 08/15/13. She said Resident #7 was complaining of severe back pain and he had been given all his pain medications. His family reported he was crying and requested he be sent to the hospital. LVN F said Resident #7's family also reported to her the last time this happened, he had an infection, "Osteo[DIAGNOSES REDACTED]." Review of the ambulance Patient Care Report dated 08/15/13 at 4:51 PM revealed Resident #7 had been transported to the hospital for complaints of back pain. The severity of his back pain was assessed as a 9 on a pain scale of 0 to 10 with 10 being the worst pain. The Report reflected Resident #7's vital signs at the time the ambulance picked him up from the facility were as follows: Heart Rate: 105 bpm (normal is 72 bpm; Blood Pressure: 156/72; and Respiratory Rate: 18 respirations a minute. The Report reflected Resident #7 informed the paramedics he had been having back pain for about a week, and the pain had progressively been getting worse. He stated he was not ambulatory and the pain began when he was just lying in bed. Resident #7 told the paramedics it was a constant pain and was a 9 on a pain scale of 0 to 10. The ER report dated 08/15/16 reflected Resident #7 arrived at the hospital at 5:01 PM on 08/15/13 and was discharged back to the facility at 12:21 AM on 08/16/13. The resident's chief complaint was back pain. The ER report reflected an assessment of the resident's systems: "Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea and constipation. [MEDICAL CONDITION]: Positive for flank pain. Negative for dysuria, urgency, frequency and hematuria. Musculoskeletal: Positive for back pain. Negative for joint pain." The [DIAGNOSES REDACTED]. Neuritis is an inflammation of a nerve or a group of nerves which is characterized by pain, loss of reflexes, and atrophy of the affected muscles. Radiculitis is an inflammation involving a spinal nerve root resulting in pain and hyperesthesia (increased sensitivity to sensory stimuli, such as pain or touch). According to the ER report dated 08/15/13, Resident #7 received two doses of [MEDICATION NAME] 4 mg IV at 7:00 PM and again at 11:30 PM. The facility nurses' notes dated 08/16/13 at 12:48 AM reflected Resident #7 returned from the hospital with no new orders. The nurses' notes dated 08/18/13 at 9:35 PM reflected the following: "Patient noted uncomfortable, c/o feeling impacted, staff administered supp. As ordered, resident continued getting anxious, stated that his ribs are hurting, and will need stronger pain pill, vital signs checked. Noted stable. [MEDICATION NAME] administered at this time. Staff notified PA... He stated to give patient extra dose of [MEDICATION NAME] for pain added that he will come to facility tomorrow to assess patient." The nurses' notes dated 08/18/13 at 6:02 AM reflected, "Pt was c/o pain. Pain meds had been given 30 minutes prior. Departing nurse said pt had been stating that he was gonna call 911 if he didn't get med. Pt did call 911 and (family member) was notified of pt going out (to ER) on his own. (The facility had not called 911.)" The ER record dated 08/18/13 reflected Resident #7 was admitted to the ER at 11:08 PM on 08/18/13 and discharged back to the facility at 2:15 AM on 08/19/13. The resident's complaint was abdominal pain and constipation. The ER record reflected Resident #7 stated his pain had started two days ago and was located in the generalized abdominal region and the quality of pain was cramping. The pain was at a severity level of 7 on a 0 to 10 pain scale, and the pain was moderate. The abdominal region was normal in appearance and had normal bowel sounds. There was some tenderness but no rebound and no guarding. An abdominal series was conducted, and there was no bowel obstruction noted. NP C saw Resident #7 on 08/18/13 and documented the resident had gone to the hospital a few days ago for intractable back pain and was sent back to the facility after being treated with IV [MEDICATION NAME]. The NP documented he wanted to continue Resident #7's current pain medication regimen. Resident #7's nurses' notes dated 08/19/13 at 2:00 AM reflected the resident had returned from the hospital with an order for [REDACTED]. NP C saw Resident #7 again on 08/20/13 and again documented to continue the resident's current pain medication regimen. At 8:30 AM on 08/23/13, an interview was conducted with NP C. He stated the resident had a history of [REDACTED].#7 had not been receiving the [MEDICATION NAME], he would have discontinued it. NP C stated he offered the resident extra narcotics, but Resident #7 did not want them. He wanted to go to the hospital to get IV medications. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. The nurses' notes dated 08/21/13 at 2:53 PM reflected Resident #7 was complaining of severe pain and told facility staff he wanted to go to the ER. The facility notified NP C, and he approved the transfer. Resident #7's family was notified via voice mail.and the resident left the facility and was transported by ambulance with the paramedics. The Incident/Accident Report dated 08/22/13 reflected on 08/21/13, MA A reported Resident #7 was out of [MEDICATION NAME]es, and they had not been available since 08/10/13. At the time of MA A's report, it was noted Resident #7 was at the hospital. At the time of his discharge, his pain level was a 10, using a pain scale from 0 to 10, with 10 indicating severe pain. The Report reflected 911 was called, and the resident was sent to the ER. The Incident/Accident Report reflected the Nurse Practitioner was notified at 2:00 PM on 08/21/13 of the unavailability of the [MEDICATION NAME] Patches. The [MEDICATION NAME]es were re-ordered on [DATE] and delivered to the facility on [DATE]. The Report reflected the NP ordered Resident #7 to have a pain management consult upon his return to the facility. At 9:30 AM on 08/23/13, Resident #7 was interviewed at the hospital. He stated he was not feeling well. Resident #7 stated he had not had a new [MEDICATION NAME] in about two weeks. He said he kept asking facility staff when was he going to get a new patch, and they kept telling him, "It's been ordered but it has not come in yet." Review of the facility-contracted Pharmacy's Proof of Delivery manifests dated from 07/28/13 to current revealed [MEDICATION NAME]es were not delivered to the facility for Resident #7 until 08/21/13, the day he was admitted to the hospital. The hospital ER notes dated 08/21/13 reflected Resident #7's chief complaint was back pain with lower extremity tremor, and he had been given [MEDICATION NAME] 100 mcg on route to the hospital. The notes further reflected Resident #7 had a fever, elevated white blood cell count and Diskitis in the [MEDICATION NAME] spine with spinal cord compression. The neurosurgeon advised the resident he might need reconstruction of his spine for stability and needed to be admitted to the hospital for an MRI of the spine and IV antibiotics. The hospital H & P dated 08/22/13 reflected Resident #7 developed excruciating back pain associated with fevers and chills and this prompted his transfer to the hospital on [DATE]. His MRI revealed he has osteo[DIAGNOSES REDACTED] at his previous levels of decompression with [MEDICATION NAME] kyphosis and cord compression. There was no surgical intervention at that point. The Internal Medicine physician's consult report dated 08/22/13 reflected the following: Vertebral osteo[DIAGNOSES REDACTED] with cord compression [DIAGNOSES REDACTED]. The physician would arrange for a bone biopsy, blood cultures and start antibiotics after that and control his pain and Diabetes. The facility's most current policy and procedure for Pain assessment dated as revised August 2002 reflected the following: "Purpose The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: 1. A comprehensive pain assessment will be completed as part of the initial nursing assessment with development of a pain management program as indicated. 2. The comprehensive pain assessment will be reviewed quarterly and with a significant change in status. 3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. 4. Pain will be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours. Steps in the procedure: 1. Wash and dry your hands thoroughly. 2. Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. 3. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes and accompanying signs and symptoms. 4. Determine appropriate type of pain medication as ordered by the physician. 5. If no pain medication is ordered, notify the physician and obtain an order. 6. Medicate the resident as the physician ordered. 7. Do follow-up assessment within 2 hours after administration... Documentation: The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. Daily assessment of pain. 4. All assessment data obtained during the procedure including location of pain, level of pain using the pain scale and type of pain relief used. 5. 2-hour reassessment of pain and the resident's response to the pain relief used...." The facility's current pharmacy policy and procedures regarding reordering, changing and discontinuing orders, revised on 05/01/10, reflected the following: Procedure for "2.3 Facsimile Orders: Reorders can be faxed to the pharmacy, if permitted by Applicable Law, on the Refill Order Form set forth in Appendix 12: Refill/Reorder Form. 2.4 Electronic orders ("e-Refill"): Authorized Facility staff may use Omniview to electronically reorder resident medications. 2.4.2 Facility staff should re-order medications using an electronic list of residents and medications due or by use of barcode technology. 2.4.2 Facility staff should use a barcode scanner to read prescription numbers from the labels of orders they wish to reorder and transmit them electronically to the Pharmacy. 2.4.3 Facility staff should review the transmitted re-orders for status and potential issues and Pharmacy response. 2.4.4 Omniview will indicate if the re-order is confirmed, if Pharmacy follow-up is required, or an invalid prescription number has been entered into the system. 2.4.4.1 If Omniview indicates that a Pharmacy follow-up is required, Pharmacy will contact the Facility; and 2.4.4.2 If Omniview indicated that an invalid prescription number has been entered into the system. Facility staff should check the accuracy of the resident's name and prescription number. 2.4.5 Facility staff should use Omniview to review the status of open orders for follow-up with the Pharmacy." An IJ was identified on 08/22/13. On 08/22/13 at 5:00 PM, the Administrator, the DON, the Corporate RN, and the Corporate SW were informed of the IJ and a Plan of Removal for the IJ was requested. At 4:30 PM on 08/23/13, an interview was conducted with the Administrator. When asked how he monitored his staff to ensure the systems were effective, he stated he attended the Standards of Care weekly meeting where they track and trend all issues with the residents including those on pain management programs, and he would independently review the pain assessments himself to ensure they were being done. When the Administrator was asked why he thought the IJ had occurred, he stated it was the newness of the electronic system, the lack of staff training and their lack of knowledge how to use it. He stated the initial training for the computer was an on-line computer training with a question and answer session. He stated with all new staff, there would be orientation of actual hands-on computer training with knowledgeable staff. He added they had implemented the MAR indicated [REDACTED]. Training and oversight of the implementation of the plan of removal would be discussed in the weekly Standards of Care meetings and the QA meetings. At 4:45 PM on 08/23/13, an interview was conducted with the DON. When asked how she thought the IJ had occurred, she responded it was a lack of training of the staff for the new computer system, which created some problems. The DON added there were some glitches to work out. The system had only been in place for about 20 days. She also stated the MA should have followed up with her nurse when the [MEDICATION NAME]es did not come in when she had re-ordered them. If she had told the nurse, then she would have expected the nurse to call the pharmacy and find out what had happened and get the medication refilled. She added they now had a system in place, which allowed only the nurses to order or re-order narcotics. It will be the MAs' responsibility to notify the charge nurses when the medication was getting low. The nurse will click on the medication refill in the computer, fax the refill to the pharmacy, call the pharmacy to make sure they got the refill request and then, if the medication was not delivered or re-filled, the nurse was to notify the ADONs, and they will call the pharmacy to see what the problem was and get the medication delivered. The DON added they had now implemented a MAR indicated [REDACTED]. She had also has implemented a weekly audit of all pain assessments on the residents, which would be tracked and trended in the Standards of Care meetings and QA. The facility's Plan of Removal, dated 08/23/13 was accepted on 08/23/13 at 5:10 PM and reflected the following: 1. Medication carts were audited for the availability of prescribed pain medications on 08/22/13 between the hours of 5:15 PM and 11:00 PM. The audits were conducted by Nurse Consultant I, ADON D, LVN J, ADON K and the Weekend RN Supervisor. The outcome of the audit revealed there were no missing medications. There was no need to contact the physician or the pharmacy as a result. 2. The medication for Resident #7 was re-ordered via the EMR on 08/10/13. Due to a glitch in the EMR, the pharmacy never received the refill order. However, the resident continued receiving [MEDICATION NAME] (narcotic pain medication). 3. All residents have been physically assessed for pain by a licensed staff member. If pain was at a level needing to be addressed, a PRN pain medication was offered if the resident had one ordered or the physician was contacted to obtain an order for [REDACTED]. The outcome of the pain assessments revealed there were no irregularities. 4. Licensed Nurses and Medication Aides have been re-educated on: --Assessments for pain --Ordering/Re-ordering of narcotics --Escalation (increase) of the process for missing medications In-servicing began with the 2:00 PM - 10:00 PM shift at 7:30 PM on 08/22/13 by Corporate R, Nurse Consultant I and the DON. ADON D conducted the 10:00 PM - 6:00 AM shift from 10:00 PM to 10:45 PM. The DON conducted the training for the 6:00 AM - 2:00 PM shift on 08/23/13 from 6:00 AM - 6:45 PM and another training for the on-coming 2:00 PM - 10:00 PM shift from 2:00 PM - 2:45 PM on 08/23/13. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date of training is 08/27/13. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by the DON. Attachment 2 is the in-service sign-in sheets, including who presented the training, the content and the post-test. 5. Implementation of a weekly Medication Cart audit will begin no later than 08/30/13. This tool (attachment 3) will be completed by then 10:00 PM - 6:00 AM shift charge nurses and submitted to the ADON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed as having arrived. The facility ADONs, ADON D and ADON K will weekly conduct random audit form checks against the medication carts. 6. Med Error report (attachment 4) was completed on the one allegedly affected resident (Resident #7), which included physician notification. Completed by 5:00 PM today (08/23/13). 7. Weekly monitoring of pain assessments will be conducted by the DON, ADON D and ADON K using the HER Audit, which reviews assessments, unprocessed medication and order accuracy. These audits will be on-going and reviewed weekly at the Standards of Care meeting and results followed up at the monthly QI/PI to address trends and/or irregularities. 8. An off cycle QA meeting was held on 08/22/13 at 5:45 PM on the concerns identified and plans to address and correct identified issues. The Medical Director was informed of the IJ and the Plan of Removal. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/irregularities. Attendees at the Standards of Care Meeting: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager. QI/PI attendees: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager, Maintenance Director, Dietary Service Manager, the Administrator and the Medical Director. 9. Policy of re-ordering of narcotics and PRN follow up documentation. When a routine medication is due to be re-ordered, the MA and/or the charge nurse will click on the "Reorder" button in LG (computer system). There is an interface with LG and the pharmacy, which automatically alerts the pharmacy of the need to refill and send the medication. If the medication has been re-ordered too soon, the pharmacy will send the facility a message via LG to alert them the medication was not sent. If a narcotic has to be re-filled, the MA will alert the charge nurse of the need to refill the narcotic medication. Only a licensed nurse will be re-filling narcotic medication re-orders. MAs will not re-order narcotics. The nurse will click the "Reorder" button in LG, fax the order, and call the pharmacy to ensure they received the order request. If a narcotic needs a new prescription, then the nurse will notify the ADONs or the Weekend Supervisor (agents for physicians) to get the order. If a STAT medication does not arrive within four hours, the ADON on call will be notified to contact the pharmacy. Medications are delivered twice daily from the pharmacy. STAT medications are delivered within four hours. Medications ordered will be verified they arrived using then LG medication confirmation tracking. Medications not confirmed will be called to the pharmacy within two hours to confirm delivery time. 10. Th

Based on observation, interview and record review, the facility failed to ensure three (Residents #7, #21 and #22) of 22 residents reviewed for medications were free of any significant medication errors. 1) The facility failed to reorder and ensure delivery of Resident #7's [MEDICATION NAME]es for his pain resulting in three missed doses, and three trips to the ER due to his severe, unrelieved pain on 08/15/13, 08/18/13 and 08/21/13. He was admitted to the hospital on [DATE] for pain evaluation. An Immediate Jeopardy (IJ) was identified on 08/22/13. While the IJ was removed on 08/23/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. The failure of the facility to ensure Resident #7's physician-ordered [MEDICATION NAME] was available and the resident was appropriately assessed for pain resulted in the resident having unrelieved severe pain and discomfort, which required three hospitalization s to address his pain from 08/15/13 through 08/21/13. These failures to ensure pain medication was reordered timely and to assess the resident for pain could affect the 52 residents, including Resident #7, who had either routine or PRN pain medication ordered by their physician and placed them at risk for unrelieved pain and discomfort. This could result in decreased nutritional intake, unplanned weight loss, alteration in sleep patterns, decreased socialization, serious medical complications, and a delay for appropriate interventions to be implemented and could result in the need for increased medication and possible admission to the hospital for pain relief treatment. Non-Immediate Jeopardy examples: 2) The facility failed to accurately transcribe medication orders to the current computer printed physician orders [REDACTED].#21's [MEDICATION NAME] (Anticonvulsant). These failures placed the facility's 96 residents, including Residents #21 and #22) at risk for medication errors, which could result in a worsening of their medical conditions and the need for further treatment and possible hospitalization . Findings included: Resident #7's hospital H & P dated 08/22/13 reflected the resident was a [AGE] year-old male, who had undergone back surgery in May 2013 following a back injury after a fall at another hospital. The resident subsequently developed progressive lower extremity weakness and underwent a [MEDICATION NAME] laminectomy (cutting out the vertebral arch usually to remove a herniated disk) in June 2013 and was found to have Osteo[DIAGNOSES REDACTED] (inflammation of the bone and marrow usually caused by infection)." Resident #7's Physical, Medicine and Rehabilitation Progress notes dated 08/05/13 reflected the resident had [MEDICAL CONDITION] secondary to an [MEDICATION NAME] Abscess at T6-T9, status [REDACTED]. (Diskitis is an inflammation of the vertebral disk space.) Resident #7's care plan dated 07/26/13 addressed the problem of the resident experiencing pain frequently related to his [DIAGNOSES REDACTED]. Interventions included to turn and reposition the resident every two hours, place a pillow between his legs and behind his back when he was lying on his side and to give medication as ordered for his pain and report to the physician if the resident's medication was not effective. Resident #7's physician orders [REDACTED]. A [MEDICATION NAME] Patch is used to relieve moderate to severe chronic pain, which cannot be controlled by the use of other pain medications. The physician's orders [REDACTED]. The facility-contracted Pharmacy's Proof of Delivery manifests for 07/25/13 through 08/21/13 reflected on 07/27/13 at 8:00 PM, the pharmacy delivered five [MEDICATION NAME] 100 mcg/hr patches and five [MEDICATION NAME] 25 mcg/hr patches to the facility for Resident #7. The individual Control Drug Record for the [MEDICATION NAME]es for Resident #7 was reviewed. The five [MEDICATION NAME] 100 mcg patches and the five [MEDICATION NAME] 25 mcg patches were delivered by the pharmacy on 07/27/13 according to the Control Drug Record. The following dates and times were when the [MEDICATION NAME]es were signed out and initialed as given: 07/28/13 at 8:00 AM 08/01/13 at 8:00 AM 08/04/13 at 8:00 AM 08/07/13 at 8:00 AM 08/10/13 at 8:00 AM. Resident #7's MDS assessment dated [DATE] reflected he was admitted to the facility on [DATE]. The MDS assessment reflected Resident #7 was alert and oriented, with no signs or symptoms of [MEDICAL CONDITION], no behaviors and had a BIMS score of 15, which indicated he was cognitively intact. Resident #7 was also assessed as requiring extensive assistance by two staff for bed mobility, transfers, toileting and bathing. He required extensive assistance of one staff for dressing and personal hygiene and only set-up help for eating. [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #7 received scheduled pain medication and PRN pain medications. The MDS assessment also included an interview with Resident #7, in which he stated he had experienced pain within the last 5 days, it was frequent and it limited his day-to-day activities. Resident #7 stated his pain was an 8 on a pain scale of 0-10 with 10 being the most severe pain. At 10:00 AM on 08/20/13, Resident #7 was observed receiving physical therapy during initial rounds. Resident #7 was identified as being alert and oriented, incontinent of bowel, having a Foley catheter in place, required assistance with ADLs, was a two-person transfer and fed himself. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. Review of the MARs for July and August 2013 revealed Resident #7 received the [MEDICATION NAME]es on 07/28/13 and was due to have another set of patches applied on 07/31/13, but it was not documented as being administered until 08/01/13 (missed dose). MA A had signed out and administered the [MEDICATION NAME]es on 07/27/13, 08/04/13, 08/07/13 and 08/10/13, which was the last day the patches were available. MA B had signed out and administered the [MEDICATION NAME]es on 08/01/13 and had also signed out and administered the [MEDICATION NAME]es on 08/13/13. However, with only five doses delivered to the facility for Resident #7 on 07/27/13, the last ones would have been used on 08/10/13. The MARS reflected documentation of six doses, but there were only five doses of patches delivered and available for application. At 10:50 AM on 08/22/13, an interview was conducted with MA B. She stated she could not explain why she documented she had applied the [MEDICATION NAME]es to Resident #7 on 08/13/13 when there were no patches available. At 9:30 AM on 08/22/13, an interview was conducted with MA A. She confirmed she had applied the last of the [MEDICATION NAME]es for Resident #7 on 08/10/13. MA A stated she told LVN E Resident #7 did not have any more [MEDICATION NAME]es. At 10:30 AM on 08/22/13, an interview was conducted with LVN E. She stated she was not aware Resident #7 had no [MEDICATION NAME]es, and added MA A had not told her there were no more [MEDICATION NAME]es for the resident. Resident #7's MAR for August 2013 reflected there was a section to document a pain assessment every shift. The MAR indicated [REDACTED]. The staff wrote an "H" for each shift from the night shift on 08/15/13 through the evening and day shifts on 08/21/13, not restarting the pain assessments when Resident #7 returned to the facility on [DATE]. There was no documentation on the August 2013 MAR from 08/16/13 to the present to indicate staff assessed the resident's level of pain and documented it. At 1:40 PM on 08/22/13, an interview was conducted with ADON D. She stated the "H" on the MARs meant the medication or treatment was on hold. She said when a resident was sent to the hospital, all medications and treatments were put on hold and marked with an "H." ADON D stated with the facility's computer system, they had to go in and reactivate each medication and treatment individually. The system did not automatically reactivate everything on the MARs. ADON D stated the pain assessment order was not reactivated, so the "H " meant the pain assessments were not done. Review of Resident #7's nurses' notes dated from 07/31/13 through 08/21/13 revealed when the nurse administered a PRN medication for the residdent's pain, they documented the date and time and what PRN medication was given. There was a follow-up notation whether or not the medication was effective. The location and/or severity of the pain was not always included. There were only three days when the location of the pain and the severity of the pain was documented, which were 08/15/13, 08/18/13 and 08/21/13, the days he was sent to the hospital. At 9:20 AM on 08/23/13, the Corporate RN brought the survey team the Daily Skilled Nurses Notes for Resident #7 dated from 08/11/13 through 08/21/13. The Corporate RN confirmed the survey team did not have computer access to these Daily Skilled Nurses Notes. The Corporate RN also stated it was the facility's policy to conduct pain assessments each shift. She also provided a copy of the record from when MA A tried to re-order Resident #7's [MEDICATION NAME]es on 08/10/13. The Corporate RN stated something was wrong on the pharmacy side and the [MEDICATION NAME]es did not get re-ordered until 08/21/13, when the licensed nurse re-ordered it. The Corporate RN confirmed the triplicate prescription for the [MEDICATION NAME]es had refills, and they should have been refilled on 08/10/13. The Texas DADS Licensing Standards for Medication Aides Handbook with a revision date of "12-1" reflected the following: "TAC 95.105 Allowable and Prohibited Practices of a Permit Holder ...(b) A permit holder under Health and Safety Code, Chapter 242, Subchapter N, may not: ...(9) order a resident's medications from a pharmacy;...." At 4:10 PM on 08/23/13, an interview was conducted with the Weekend RN Supervisor. She stated she had never worked with Resident #7 personally but had made rounds on him. The Weekend RN Supervisor said she did not have any knowledge Resident #7's [MEDICATION NAME]es were not available, and no one had reported it to her. At 2:10 PM on 08/23/13, an interview was conducted with CNA G. She stated she had taken care of Resident #7 and was familiar with him. She stated his level of pain seemed to increase the last few days, and he was complaining more about his pain. At 2:20 PM on 08/23/13, an interview was conducted with LVN H. He stated he was not aware and had not been informed there were no [MEDICATION NAME]es available for Resident #7. The nurses' notes reflected at 11:51 AM on 08/15/13, Resident #7 was given two Tylenol 325 mg tablets, and at 12:13 PM on 08/15/13, Resident #7 received one [MEDICATION NAME] (narcotic [MEDICATION NAME]) tablet. Resident #7's nurses' notes dated 08/15/13 at 12:46 PM reflected the following: "Resident c/o severe back pain at the site where he had a surgical incision. [MEDICATION NAME] 10/325 mg (narcotic pain medication), 1 tab po given as ordered. Rechecked later Resident stated pain medication not effective. PA ...notified via voice mail. Awaiting call back. Will continue to monitor." Resident #7's nurses' notes dated 08/15/13 at 4:30 PM reflected the following: "Resident c/o severe back pain not relieved with [MEDICATION NAME] or APAP. [MEDICATION NAME] (anti-anxiety) given due to c/o increased anxiety. APAP given at this time, resident repositioned to alternating sides and stated it was effective. Drsg to incision site done by tx nurse CDI No drainage noted. Afebrile. Resd voiced he would like to go to the hospital if pain meds do not work." The nurses' notes dated 08/15/13 at 4:50 PM reflected Resident #7's family had arrived and requested the resident be sent to the ER for his back pain. The transport ambulance was called and reported pick-up time would be in 30 minutes. The family stated that was too long and requested 911 be called. 911 was called and the resident was picked up within 3 minutes and transported to the hospital. At 2:40 PM on 08/23/13, an interview was conducted with LVN F. She stated she worked on 08/15/13. She said Resident #7 was complaining of severe back pain and he had been given all his pain medications. His family reported he was crying and requested he be sent to the hospital. LVN F said Resident #7's family also reported to her the last time this happened, he had an infection, "Osteo[DIAGNOSES REDACTED]." Review of the ambulance Patient Care Report dated 08/15/13 at 4:51 PM revealed Resident #7 had been transported to the hospital for complaints of back pain. The severity of his back pain was assessed as a 9 on a pain scale of 0 to 10 with 10 being the worst pain. The Report reflected Resident #7's vital signs at the time the ambulance picked him up from the facility were as follows: Heart Rate: 105 bpm (normal is 72 bpm; Blood Pressure: 156/72; and Respiratory Rate: 18 respirations a minute. The Report reflected Resident #7 informed the paramedics he had been having back pain for about a week, and the pain had progressively been getting worse. He stated he was not ambulatory and the pain began when he was just lying in bed. Resident #7 told the paramedics it was a constant pain and was a 9 on a pain scale of 0 to 10. The ER report dated 08/15/16 reflected Resident #7 arrived at the hospital at 5:01 PM on 08/15/13 and was discharged back to the facility at 12:21 AM on 08/16/13. The resident's chief complaint was back pain. The ER report reflected an assessment of the resident's systems: "Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea and constipation. [MEDICAL CONDITION]: Positive for flank pain. Negative for dysuria, urgency, frequency and hematuria. Musculoskeletal: Positive for back pain. Negative for joint pain." The [DIAGNOSES REDACTED]. Neuritis is an inflammation of a nerve or a group of nerves which is characterized by pain, loss of reflexes, and atrophy of the affected muscles. Radiculitis is an inflammation involving a spinal nerve root resulting in pain and hyperesthesia (increased sensitivity to sensory stimuli, such as pain or touch). According to the ER report dated 08/15/13, Resident #7 received two doses of [MEDICATION NAME] 4 mg IV at 7:00 PM and again at 11:30 PM. The facility nurses' notes dated 08/16/13 at 12:48 AM reflected Resident #7 returned from the hospital with no new orders. The nurses' notes dated 08/18/13 at 9:35 PM reflected the following: "Patient noted uncomfortable, c/o feeling impacted, staff administered supp. As ordered, resident continued getting anxious, stated that his ribs are hurting, and will need stronger pain pill, vital signs checked. Noted stable. [MEDICATION NAME] administered at this time. Staff notified PA... He stated to give patient extra dose of [MEDICATION NAME] for pain added that he will come to facility tomorrow to assess patient." The nurses' notes dated 08/18/13 at 6:02 AM reflected, "Pt was c/o pain. Pain meds had been given 30 minutes prior. Departing nurse said pt had been stating that he was gonna call 911 if he didn't get med. Pt did call 911 and (family member) was notified of pt going out (to ER) on his own. (The facility had not called 911.)" The ER record dated 08/18/13 reflected Resident #7 was admitted to the ER at 11:08 PM on 08/18/13 and discharged back to the facility at 2:15 AM on 08/19/13. The resident's complaint was abdominal pain and constipation. The ER record reflected Resident #7 stated his pain had started two days ago and was located in the generalized abdominal region and the quality of pain was cramping. The pain was at a severity level of 7 on a 0 to 10 pain scale, and the pain was moderate. The abdominal region was normal in appearance and had normal bowel sounds. There was some tenderness but no rebound and no guarding. An abdominal series was conducted, and there was no bowel obstruction noted. NP C saw Resident #7 on 08/18/13 and documented the resident had gone to the hospital a few days ago for intractable back pain and was sent back to the facility after being treated with IV [MEDICATION NAME]. The NP documented he wanted to continue Resident #7's current pain medication regimen. Resident #7's nurses' notes dated 08/19/13 at 2:00 AM reflected the resident had returned from the hospital with an order for [REDACTED]. NP C saw Resident #7 again on 08/20/13 and again documented to continue the resident's current pain medication regimen. At 8:30 AM on 08/23/13, an interview was conducted with NP C. He stated the resident had a history of [REDACTED].#7 had not been receiving the [MEDICATION NAME], he would have discontinued it. NP C stated he offered the resident extra narcotics, but Resident #7 did not want them. He wanted to go to the hospital to get IV medications. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. The nurses' notes dated 08/21/13 at 2:53 PM reflected Resident #7 was complaining of severe pain and told facility staff he wanted to go to the ER. The facility notified NP C, and he approved the transfer. Resident #7's family was notified via voice mail.and the resident left the facility and was transported by ambulance with the paramedics. The Incident/Accident Report dated 08/22/13 reflected on 08/21/13, MA A reported Resident #7 was out of [MEDICATION NAME]es, and they had not been available since 08/10/13. At the time of MA A's report, it was noted Resident #7 was at the hospital. At the time of his discharge, his pain level was a 10, using a pain scale from 0 to 10, with 10 indicating severe pain. The Report reflected 911 was called, and the resident was sent to the ER. The Incident/Accident Report reflected the Nurse Practitioner was notified at 2:00 PM on 08/21/13 of the unavailability of the [MEDICATION NAME] Patches. The [MEDICATION NAME]es were re-ordered on [DATE] and delivered to the facility on [DATE]. The Report reflected the NP ordered Resident #7 to have a pain management consult upon his return to the facility. At 9:30 AM on 08/23/13, Resident #7 was interviewed at the hospital. He stated he was not feeling well. Resident #7 stated he had not had a new [MEDICATION NAME] in about two weeks. He said he kept asking facility staff when was he going to get a new patch, and they kept telling him, "It's been ordered but it has not come in yet." Review of the facility-contracted Pharmacy's Proof of Delivery manifests dated from 07/28/13 to current revealed [MEDICATION NAME]es were not delivered to the facility for Resident #7 until 08/21/13, the day he was admitted to the hospital. The hospital ER notes dated 08/21/13 reflected Resident #7's chief complaint was back pain with lower extremity tremor, and he had been given [MEDICATION NAME] 100 mcg on route to the hospital. The notes further reflected Resident #7 had a fever, elevated white blood cell count and Diskitis in the [MEDICATION NAME] spine with spinal cord compression. The neurosurgeon advised the resident he might need reconstruction of his spine for stability and needed to be admitted to the hospital for an MRI of the spine and IV antibiotics. The hospital H & P dated 08/22/13 reflected Resident #7 developed excruciating back pain associated with fevers and chills and this prompted his transfer to the hospital on [DATE]. His MRI revealed he has osteo[DIAGNOSES REDACTED] at his previous levels of decompression with [MEDICATION NAME] kyphosis and cord compression. There was no surgical intervention at that point. The Internal Medicine physician's consult report dated 08/22/13 reflected the following: Vertebral osteo[DIAGNOSES REDACTED] with cord compression [DIAGNOSES REDACTED]. The physician would arrange for a bone biopsy, blood cultures and start antibiotics after that and control his pain and Diabetes. The facility's most current policy and procedure for Pain assessment dated as revised August 2002 reflected the following: "Purpose The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: 1. A comprehensive pain assessment will be completed as part of the initial nursing assessment with development of a pain management program as indicated. 2. The comprehensive pain assessment will be reviewed quarterly and with a significant change in status. 3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. 4. Pain will be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours. Steps in the procedure: 1. Wash and dry your hands thoroughly. 2. Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. 3. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes and accompanying signs and symptoms. 4. Determine appropriate type of pain medication as ordered by the physician. 5. If no pain medication is ordered, notify the physician and obtain an order. 6. Medicate the resident as the physician ordered. 7. Do follow-up assessment within 2 hours after administration... Documentation: The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. Daily assessment of pain. 4. All assessment data obtained during the procedure including location of pain, level of pain using the pain scale and type of pain relief used. 5. 2-hour reassessment of pain and the resident's response to the pain relief used...." The facility's current pharmacy policy and procedures regarding reordering, changing and discontinuing orders, revised on 05/01/10, reflected the following: Procedure for "2.3 Facsimile Orders: Reorders can be faxed to the pharmacy, if permitted by Applicable Law, on the Refill Order Form set forth in Appendix 12: Refill/Reorder Form. 2.4 Electronic orders ("e-Refill"): Authorized Facility staff may use Omniview to electronically reorder resident medications. 2.4.2 Facility staff should re-order medications using an electronic list of residents and medications due or by use of barcode technology. 2.4.2 Facility staff should use a barcode scanner to read prescription numbers from the labels of orders they wish to reorder and transmit them electronically to the Pharmacy. 2.4.3 Facility staff should review the transmitted re-orders for status and potential issues and Pharmacy response. 2.4.4 Omniview will indicate if the re-order is confirmed, if Pharmacy follow-up is required, or an invalid prescription number has been entered into the system. 2.4.4.1 If Omniview indicates that a Pharmacy follow-up is required, Pharmacy will contact the Facility; and 2.4.4.2 If Omniview indicated that an invalid prescription number has been entered into the system. Facility staff should check the accuracy of the resident's name and prescription number. 2.4.5 Facility staff should use Omniview to review the status of open orders for follow-up with the Pharmacy." An IJ was identified on 08/22/13. On 08/22/13 at 5:00 PM, the Administrator, the DON, the Corporate RN, and the Corporate SW were informed of the IJ and a Plan of Removal for the IJ was requested. At 4:30 PM on 08/23/13, an interview was conducted with the Administrator. When asked how he monitored his staff to ensure the systems were effective, he stated he attended the Standards of Care weekly meeting where they track and trend all issues with the residents including those on pain management programs, and he would independently review the pain assessments himself to ensure they were being done. When the Administrator was asked why he thought the IJ had occurred, he stated it was the newness of the electronic system, the lack of staff training and their lack of knowledge how to use it. He stated the initial training for the computer was an on-line computer training with a question and answer session. He stated with all new staff, there would be orientation of actual hands-on computer training with knowledgeable staff. He added they had implemented the MAR indicated [REDACTED]. Training and oversight of the implementation of the plan of removal would be discussed in the weekly Standards of Care meetings and the QA meetings. At 4:45 PM on 08/23/13, an interview was conducted with the DON. When asked how she thought the IJ had occurred, she responded it was a lack of training of the staff for the new computer system, which created some problems. The DON added there were some glitches to work out. The system had only been in place for about 20 days. She also stated the MA should have followed up with her nurse when the [MEDICATION NAME]es did not come in when she had re-ordered them. If she had told the nurse, then she would have expected the nurse to call the pharmacy and find out what had happened and get the medication refilled. She added they now had a system in place, which allowed only the nurses to order or re-order narcotics. It will be the MAs' responsibility to notify the charge nurses when the medication was getting low. The nurse will click on the medication refill in the computer, fax the refill to the pharmacy, call the pharmacy to make sure they got the refill request and then, if the medication was not delivered or re-filled, the nurse was to notify the ADONs, and they will call the pharmacy to see what the problem was and get the medication delivered. The DON added they had now implemented a MAR indicated [REDACTED]. She had also has implemented a weekly audit of all pain assessments on the residents, which would be tracked and trended in the Standards of Care meetings and QA. The facility's Plan of Removal, dated 08/23/13 was accepted on 08/23/13 at 5:10 PM and reflected the following: 1. Medication carts were audited for the availability of prescribed pain medications on 08/22/13 between the hours of 5:15 PM and 11:00 PM. The audits were conducted by Nurse Consultant I, ADON D, LVN J, ADON K and the Weekend RN Supervisor. The outcome of the audit revealed there were no missing medications. There was no need to contact the physician or the pharmacy as a result. 2. The medication for Resident #7 was re-ordered via the EMR on 08/10/13. Due to a glitch in the EMR, the pharmacy never received the refill order. However, the resident continued receiving [MEDICATION NAME] (narcotic pain medication). 3. All residents have been physically assessed for pain by a licensed staff member. If pain was at a level needing to be addressed, a PRN pain medication was offered if the resident had one ordered or the physician was contacted to obtain an order for [REDACTED]. The outcome of the pain assessments revealed there were no irregularities. 4. Licensed Nurses and Medication Aides have been re-educated on: --Assessments for pain --Ordering/Re-ordering of narcotics --Escalation (increase) of the process for missing medications In-servicing began with the 2:00 PM - 10:00 PM shift at 7:30 PM on 08/22/13 by Corporate R, Nurse Consultant I and the DON. ADON D conducted the 10:00 PM - 6:00 AM shift from 10:00 PM to 10:45 PM. The DON conducted the training for the 6:00 AM - 2:00 PM shift on 08/23/13 from 6:00 AM - 6:45 PM and another training for the on-coming 2:00 PM - 10:00 PM shift from 2:00 PM - 2:45 PM on 08/23/13. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date of training is 08/27/13. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by the DON. Attachment 2 is the in-service sign-in sheets, including who presented the training, the content and the post-test. 5. Implementation of a weekly Medication Cart audit will begin no later than 08/30/13. This tool (attachment 3) will be completed by then 10:00 PM - 6:00 AM shift charge nurses and submitted to the ADON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed as having arrived. The facility ADONs, ADON D and ADON K will weekly conduct random audit form checks against the medication carts. 6. Med Error report (attachment 4) was completed on the one allegedly affected resident (Resident #7), which included physician notification. Completed by 5:00 PM today (08/23/13). 7. Weekly monitoring of pain assessments will be conducted by the DON, ADON D and ADON K using the HER Audit, which reviews assessments, unprocessed medication and order accuracy. These audits will be on-going and reviewed weekly at the Standards of Care meeting and results followed up at the monthly QI/PI to address trends and/or irregularities. 8. An off cycle QA meeting was held on 08/22/13 at 5:45 PM on the concerns identified and plans to address and correct identified issues. The Medical Director was informed of the IJ and the Plan of Removal. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/irregularities. Attendees at the Standards of Care Meeting: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager. QI/PI attendees: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager, Maintenance Director, Dietary Service Manager, the Administrator and the Medical Director. 9. Policy of re-ordering of narcotics and PRN follow up documentation. When a routine medication is due to be re-ordered, the MA and/or the charge nurse will click on the "Reorder" button in LG (computer system). There is an interface with LG and the pharmacy, which automatically alerts the pharmacy of the need to refill and send the medication. If the medication has been re-ordered too soon, the pharmacy will send the facility a message via LG to alert them the medication was not sent. If a narcotic has to be re-filled, the MA will alert the charge nurse of the need to refill the narcotic medication. Only a licensed nurse will be re-filling narcotic medication re-o

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, administering and disposition of all drugs and biologicals to meet the needs of three (Residents #7, #21 and #22) of 22 residents, whose records were reviewed for pharmacy services. 1) The facility failed to reorder and ensure delivery of Resident #7's Fentanyl patches for his pain resulting in three missed doses, and three trips to the ER due to his severe, unrelieved pain on 08/15/13, 08/18/13 and 08/21/13. He was admitted to the hospital on [DATE] for pain evaluation. An Immediate Jeopardy (IJ) was identified on 08/22/13. While the IJ was removed on 08/23/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. The failure of the facility to ensure Resident #7's physician-ordered Fentanyl pain patch was available and the resident was appropriately assessed for pain resulted in the resident having unrelieved severe pain and discomfort, which required three hospitalization s to address his pain from 08/15/13 through 08/21/13. These failures to ensure pain medication was reordered timely and to assess the resident for pain could affect the 52 residents, including Resident #7, who had either routine or PRN pain medication ordered by their physician and placed them at risk for unrelieved pain and discomfort. This could result in decreased nutritional intake, unplanned weight loss, alteration in sleep patterns, decreased socialization, serious medical complications, and a delay for appropriate interventions to be implemented and could result in the need for increased medication and possible admission to the hospital for pain relief treatment. Non-Immediate Jeopardy examples: 2) The facility failed to accurately transcribe medication orders to the current computer printed physician orders [REDACTED].#21's Dilantin (Anticonvulsant). These failures placed the facility's 96 residents, including Residents #21 and #22) at risk for medication errors, which could result in a worsening of their medical conditions and the need for further treatment and possible hospitalization . Findings included: Resident #7's hospital H & P dated 08/22/13 reflected the resident was a [AGE] year-old male, who had undergone back surgery in May 2013 following a back injury after a fall at another hospital. The resident subsequently developed progressive lower extremity weakness and underwent a thoracic laminectomy (cutting out the vertebral arch usually to remove a herniated disk) in June 2013 and was found to have Osteo[DIAGNOSES REDACTED] (inflammation of the bone and marrow usually caused by infection)." Resident #7's Physical, Medicine and Rehabilitation Progress notes dated 08/05/13 reflected the resident had [DIAGNOSES REDACTED] secondary to an Epidural Abscess at T6-T9, status [REDACTED]. (Diskitis is an inflammation of the vertebral disk space.) Resident #7's care plan dated 07/26/13 addressed the problem of the resident experiencing pain frequently related to his [DIAGNOSES REDACTED]. Interventions included to turn and reposition the resident every two hours, place a pillow between his legs and behind his back when he was lying on his side and to give medication as ordered for his pain and report to the physician if the resident's medication was not effective. Resident #7's physician orders [REDACTED]. A Fentanyl Transdermal Patch is used to relieve moderate to severe chronic pain, which cannot be controlled by the use of other pain medications. The physician's orders [REDACTED]. The facility-contracted Pharmacy's Proof of Delivery manifests for 07/25/13 through 08/21/13 reflected on 07/27/13 at 8:00 PM, the pharmacy delivered five Fentanyl 100 mcg/hr patches and five Fentanyl 25 mcg/hr patches to the facility for Resident #7. The individual Control Drug Record for the Fentanyl patches for Resident #7 was reviewed. The five Fentanyl 100 mcg patches and the five Fentanyl 25 mcg patches were delivered by the pharmacy on 07/27/13 according to the Control Drug Record. The following dates and times were when the Fentanyl patches were signed out and initialed as given: 07/28/13 at 8:00 AM 08/01/13 at 8:00 AM 08/04/13 at 8:00 AM 08/07/13 at 8:00 AM 08/10/13 at 8:00 AM. Resident #7's MDS assessment dated [DATE] reflected he was admitted to the facility on [DATE]. The MDS assessment reflected Resident #7 was alert and oriented, with no signs or symptoms of delirium, no behaviors and had a BIMS score of 15, which indicated he was cognitively intact. Resident #7 was also assessed as requiring extensive assistance by two staff for bed mobility, transfers, toileting and bathing. He required extensive assistance of one staff for dressing and personal hygiene and only set-up help for eating. [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #7 received scheduled pain medication and PRN pain medications. The MDS assessment also included an interview with Resident #7, in which he stated he had experienced pain within the last 5 days, it was frequent and it limited his day-to-day activities. Resident #7 stated his pain was an 8 on a pain scale of 0-10 with 10 being the most severe pain. At 10:00 AM on 08/20/13, Resident #7 was observed receiving physical therapy during initial rounds. Resident #7 was identified as being alert and oriented, incontinent of bowel, having a Foley catheter in place, required assistance with ADLs, was a two-person transfer and fed himself. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. Review of the MARs for July and August 2013 revealed Resident #7 received the Fentanyl patches on 07/28/13 and was due to have another set of patches applied on 07/31/13, but it was not documented as being administered until 08/01/13 (missed dose). MA A had signed out and administered the Fentanyl patches on 07/27/13, 08/04/13, 08/07/13 and 08/10/13, which was the last day the patches were available. MA B had signed out and administered the Fentanyl patches on 08/01/13 and had also signed out and administered the Fentanyl patches on 08/13/13. However, with only five doses delivered to the facility for Resident #7 on 07/27/13, the last ones would have been used on 08/10/13. The MARS reflected documentation of six doses, but there were only five doses of patches delivered and available for application. At 10:50 AM on 08/22/13, an interview was conducted with MA B. She stated she could not explain why she documented she had applied the Fentanyl patches to Resident #7 on 08/13/13 when there were no patches available. At 9:30 AM on 08/22/13, an interview was conducted with MA A. She confirmed she had applied the last of the Fentanyl patches for Resident #7 on 08/10/13. MA A stated she told LVN E Resident #7 did not have any more Fentanyl patches. At 10:30 AM on 08/22/13, an interview was conducted with LVN E. She stated she was not aware Resident #7 had no Fentanyl patches, and added MA A had not told her there were no more Fentanyl patches for the resident. Resident #7's MAR for August 2013 reflected there was a section to document a pain assessment every shift. The MAR indicated [REDACTED]. The staff wrote an "H" for each shift from the night shift on 08/15/13 through the evening and day shifts on 08/21/13, not restarting the pain assessments when Resident #7 returned to the facility on [DATE]. There was no documentation on the August 2013 MAR from 08/16/13 to the present to indicate staff assessed the resident's level of pain and documented it. At 1:40 PM on 08/22/13, an interview was conducted with ADON D. She stated the "H" on the MARs meant the medication or treatment was on hold. She said when a resident was sent to the hospital, all medications and treatments were put on hold and marked with an "H." ADON D stated with the facility's computer system, they had to go in and reactivate each medication and treatment individually. The system did not automatically reactivate everything on the MARs. ADON D stated the pain assessment order was not reactivated, so the "H " meant the pain assessments were not done. Review of Resident #7's nurses' notes dated from 07/31/13 through 08/21/13 revealed when the nurse administered a PRN medication for the residdent's pain, they documented the date and time and what PRN medication was given. There was a follow-up notation whether or not the medication was effective. The location and/or severity of the pain was not always included. There were only three days when the location of the pain and the severity of the pain was documented, which were 08/15/13, 08/18/13 and 08/21/13, the days he was sent to the hospital. At 9:20 AM on 08/23/13, the Corporate RN brought the survey team the Daily Skilled Nurses Notes for Resident #7 dated from 08/11/13 through 08/21/13. The Corporate RN confirmed the survey team did not have computer access to these Daily Skilled Nurses Notes. The Corporate RN also stated it was the facility's policy to conduct pain assessments each shift. She also provided a copy of the record from when MA A tried to re-order Resident #7's Fentanyl patches on 08/10/13. The Corporate RN stated something was wrong on the pharmacy side and the Fentanyl patches did not get re-ordered until 08/21/13, when the licensed nurse re-ordered it. The Corporate RN confirmed the triplicate prescription for the Fentanyl patches had refills, and they should have been refilled on 08/10/13. The Texas DADS Licensing Standards for Medication Aides Handbook with a revision date of "12-1" reflected the following: "TAC 95.105 Allowable and Prohibited Practices of a Permit Holder ...(b) A permit holder under Health and Safety Code, Chapter 242, Subchapter N, may not: ...(9) order a resident's medications from a pharmacy;...." At 4:10 PM on 08/23/13, an interview was conducted with the Weekend RN Supervisor. She stated she had never worked with Resident #7 personally but had made rounds on him. The Weekend RN Supervisor said she did not have any knowledge Resident #7's Fentanyl patches were not available, and no one had reported it to her. At 2:10 PM on 08/23/13, an interview was conducted with CNA G. She stated she had taken care of Resident #7 and was familiar with him. She stated his level of pain seemed to increase the last few days, and he was complaining more about his pain. At 2:20 PM on 08/23/13, an interview was conducted with LVN H. He stated he was not aware and had not been informed there were no Fentanyl pain patches available for Resident #7. The nurses' notes reflected at 11:51 AM on 08/15/13, Resident #7 was given two Tylenol 325 mg tablets, and at 12:13 PM on 08/15/13, Resident #7 received one Robaxin (narcotic analgesic) tablet. Resident #7's nurses' notes dated 08/15/13 at 12:46 PM reflected the following: "Resident c/o severe back pain at the site where he had a surgical incision. Norco 10/325 mg (narcotic pain medication), 1 tab po given as ordered. Rechecked later Resident stated pain medication not effective. PA ...notified via voice mail. Awaiting call back. Will continue to monitor." Resident #7's nurses' notes dated 08/15/13 at 4:30 PM reflected the following: "Resident c/o severe back pain not relieved with Norco or APAP. Lorazepam (anti-anxiety) given due to c/o increased anxiety. APAP given at this time, resident repositioned to alternating sides and stated it was effective. Drsg to incision site done by tx nurse CDI No drainage noted. Afebrile. Resd voiced he would like to go to the hospital if pain meds do not work." The nurses' notes dated 08/15/13 at 4:50 PM reflected Resident #7's family had arrived and requested the resident be sent to the ER for his back pain. The transport ambulance was called and reported pick-up time would be in 30 minutes. The family stated that was too long and requested 911 be called. 911 was called and the resident was picked up within 3 minutes and transported to the hospital. At 2:40 PM on 08/23/13, an interview was conducted with LVN F. She stated she worked on 08/15/13. She said Resident #7 was complaining of severe back pain and he had been given all his pain medications. His family reported he was crying and requested he be sent to the hospital. LVN F said Resident #7's family also reported to her the last time this happened, he had an infection, "Osteo[DIAGNOSES REDACTED]." Review of the ambulance Patient Care Report dated 08/15/13 at 4:51 PM revealed Resident #7 had been transported to the hospital for complaints of back pain. The severity of his back pain was assessed as a 9 on a pain scale of 0 to 10 with 10 being the worst pain. The Report reflected Resident #7's vital signs at the time the ambulance picked him up from the facility were as follows: Heart Rate: 105 bpm (normal is 72 bpm; Blood Pressure: 156/72; and Respiratory Rate: 18 respirations a minute. The Report reflected Resident #7 informed the paramedics he had been having back pain for about a week, and the pain had progressively been getting worse. He stated he was not ambulatory and the pain began when he was just lying in bed. Resident #7 told the paramedics it was a constant pain and was a 9 on a pain scale of 0 to 10. The ER report dated 08/15/16 reflected Resident #7 arrived at the hospital at 5:01 PM on 08/15/13 and was discharged back to the facility at 12:21 AM on 08/16/13. The resident's chief complaint was back pain. The ER report reflected an assessment of the resident's systems: "Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea and constipation. Genitourinary: Positive for flank pain. Negative for dysuria, urgency, frequency and hematuria. Musculoskeletal: Positive for back pain. Negative for joint pain." The [DIAGNOSES REDACTED]. Neuritis is an inflammation of a nerve or a group of nerves which is characterized by pain, loss of reflexes, and atrophy of the affected muscles. Radiculitis is an inflammation involving a spinal nerve root resulting in pain and hyperesthesia (increased sensitivity to sensory stimuli, such as pain or touch). According to the ER report dated 08/15/13, Resident #7 received two doses of Morphine Sulfate 4 mg IV at 7:00 PM and again at 11:30 PM. The facility nurses' notes dated 08/16/13 at 12:48 AM reflected Resident #7 returned from the hospital with no new orders. The nurses' notes dated 08/18/13 at 9:35 PM reflected the following: "Patient noted uncomfortable, c/o feeling impacted, staff administered supp. As ordered, resident continued getting anxious, stated that his ribs are hurting, and will need stronger pain pill, vital signs checked. Noted stable. Norco administered at this time. Staff notified PA... He stated to give patient extra dose of Norco for pain added that he will come to facility tomorrow to assess patient." The nurses' notes dated 08/18/13 at 6:02 AM reflected, "Pt was c/o pain. Pain meds had been given 30 minutes prior. Departing nurse said pt had been stating that he was gonna call 911 if he didn't get med. Pt did call 911 and (family member) was notified of pt going out (to ER) on his own. (The facility had not called 911.)" The ER record dated 08/18/13 reflected Resident #7 was admitted to the ER at 11:08 PM on 08/18/13 and discharged back to the facility at 2:15 AM on 08/19/13. The resident's complaint was abdominal pain and constipation. The ER record reflected Resident #7 stated his pain had started two days ago and was located in the generalized abdominal region and the quality of pain was cramping. The pain was at a severity level of 7 on a 0 to 10 pain scale, and the pain was moderate. The abdominal region was normal in appearance and had normal bowel sounds. There was some tenderness but no rebound and no guarding. An abdominal series was conducted, and there was no bowel obstruction noted. NP C saw Resident #7 on 08/18/13 and documented the resident had gone to the hospital a few days ago for intractable back pain and was sent back to the facility after being treated with IV Morphine. The NP documented he wanted to continue Resident #7's current pain medication regimen. Resident #7's nurses' notes dated 08/19/13 at 2:00 AM reflected the resident had returned from the hospital with an order for [REDACTED]. NP C saw Resident #7 again on 08/20/13 and again documented to continue the resident's current pain medication regimen. At 8:30 AM on 08/23/13, an interview was conducted with NP C. He stated the resident had a history of [REDACTED].#7 had not been receiving the Fentanyl patch, he would have discontinued it. NP C stated he offered the resident extra narcotics, but Resident #7 did not want them. He wanted to go to the hospital to get IV medications. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. The nurses' notes dated 08/21/13 at 2:53 PM reflected Resident #7 was complaining of severe pain and told facility staff he wanted to go to the ER. The facility notified NP C, and he approved the transfer. Resident #7's family was notified via voice mail.and the resident left the facility and was transported by ambulance with the paramedics. The Incident/Accident Report dated 08/22/13 reflected on 08/21/13, MA A reported Resident #7 was out of Fentanyl patches, and they had not been available since 08/10/13. At the time of MA A's report, it was noted Resident #7 was at the hospital. At the time of his discharge, his pain level was a 10, using a pain scale from 0 to 10, with 10 indicating severe pain. The Report reflected 911 was called, and the resident was sent to the ER. The Incident/Accident Report reflected the Nurse Practitioner was notified at 2:00 PM on 08/21/13 of the unavailability of the Fentanyl Patches. The Fentanyl patches were re-ordered on [DATE] and delivered to the facility on [DATE]. The Report reflected the NP ordered Resident #7 to have a pain management consult upon his return to the facility. At 9:30 AM on 08/23/13, Resident #7 was interviewed at the hospital. He stated he was not feeling well. Resident #7 stated he had not had a new Fentanyl patch in about two weeks. He said he kept asking facility staff when was he going to get a new patch, and they kept telling him, "It's been ordered but it has not come in yet." Review of the facility-contracted Pharmacy's Proof of Delivery manifests dated from 07/28/13 to current revealed Fentanyl patches were not delivered to the facility for Resident #7 until 08/21/13, the day he was admitted to the hospital. The hospital ER notes dated 08/21/13 reflected Resident #7's chief complaint was back pain with lower extremity tremor, and he had been given Fentanyl 100 mcg on route to the hospital. The notes further reflected Resident #7 had a fever, elevated white blood cell count and Diskitis in the thoracic spine with spinal cord compression. The neurosurgeon advised the resident he might need reconstruction of his spine for stability and needed to be admitted to the hospital for an MRI of the spine and IV antibiotics. The hospital H & P dated 08/22/13 reflected Resident #7 developed excruciating back pain associated with fevers and chills and this prompted his transfer to the hospital on [DATE]. His MRI revealed he has osteo[DIAGNOSES REDACTED] at his previous levels of decompression with thoracic kyphosis and cord compression. There was no surgical intervention at that point. The Internal Medicine physician's consult report dated 08/22/13 reflected the following: Vertebral osteo[DIAGNOSES REDACTED] with cord compression [DIAGNOSES REDACTED]. The physician would arrange for a bone biopsy, blood cultures and start antibiotics after that and control his pain and Diabetes. The facility's most current policy and procedure for Pain assessment dated as revised August 2002 reflected the following: "Purpose The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: 1. A comprehensive pain assessment will be completed as part of the initial nursing assessment with development of a pain management program as indicated. 2. The comprehensive pain assessment will be reviewed quarterly and with a significant change in status. 3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. 4. Pain will be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of analgesic medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours. Steps in the procedure: 1. Wash and dry your hands thoroughly. 2. Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. 3. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes and accompanying signs and symptoms. 4. Determine appropriate type of pain medication as ordered by the physician. 5. If no pain medication is ordered, notify the physician and obtain an order. 6. Medicate the resident as the physician ordered. 7. Do follow-up assessment within 2 hours after administration... Documentation: The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. Daily assessment of pain. 4. All assessment data obtained during the procedure including location of pain, level of pain using the pain scale and type of pain relief used. 5. 2-hour reassessment of pain and the resident's response to the pain relief used...." The facility's current pharmacy policy and procedures regarding reordering, changing and discontinuing orders, revised on 05/01/10, reflected the following: Procedure for "2.3 Facsimile Orders: Reorders can be faxed to the pharmacy, if permitted by Applicable Law, on the Refill Order Form set forth in Appendix 12: Refill/Reorder Form. 2.4 Electronic orders ("e-Refill"): Authorized Facility staff may use Omniview to electronically reorder resident medications. 2.4.2 Facility staff should re-order medications using an electronic list of residents and medications due or by use of barcode technology. 2.4.2 Facility staff should use a barcode scanner to read prescription numbers from the labels of orders they wish to reorder and transmit them electronically to the Pharmacy. 2.4.3 Facility staff should review the transmitted re-orders for status and potential issues and Pharmacy response. 2.4.4 Omniview will indicate if the re-order is confirmed, if Pharmacy follow-up is required, or an invalid prescription number has been entered into the system. 2.4.4.1 If Omniview indicates that a Pharmacy follow-up is required, Pharmacy will contact the Facility; and 2.4.4.2 If Omniview indicated that an invalid prescription number has been entered into the system. Facility staff should check the accuracy of the resident's name and prescription number. 2.4.5 Facility staff should use Omniview to review the status of open orders for follow-up with the Pharmacy." An IJ was identified on 08/22/13. On 08/22/13 at 5:00 PM, the Administrator, the DON, the Corporate RN, and the Corporate SW were informed of the IJ and a Plan of Removal for the IJ was requested. At 4:30 PM on 08/23/13, an interview was conducted with the Administrator. When asked how he monitored his staff to ensure the systems were effective, he stated he attended the Standards of Care weekly meeting where they track and trend all issues with the residents including those on pain management programs, and he would independently review the pain assessments himself to ensure they were being done. When the Administrator was asked why he thought the IJ had occurred, he stated it was the newness of the electronic system, the lack of staff training and their lack of knowledge how to use it. He stated the initial training for the computer was an on-line computer training with a question and answer session. He stated with all new staff, there would be orientation of actual hands-on computer training with knowledgeable staff. He added they had implemented the MAR indicated [REDACTED]. Training and oversight of the implementation of the plan of removal would be discussed in the weekly Standards of Care meetings and the QA meetings. At 4:45 PM on 08/23/13, an interview was conducted with the DON. When asked how she thought the IJ had occurred, she responded it was a lack of training of the staff for the new computer system, which created some problems. The DON added there were some glitches to work out. The system had only been in place for about 20 days. She also stated the MA should have followed up with her nurse when the Fentanyl patches did not come in when she had re-ordered them. If she had told the nurse, then she would have expected the nurse to call the pharmacy and find out what had happened and get the medication refilled. She added they now had a system in place, which allowed only the nurses to order or re-order narcotics. It will be the MAs' responsibility to notify the charge nurses when the medication was getting low. The nurse will click on the medication refill in the computer, fax the refill to the pharmacy, call the pharmacy to make sure they got the refill request and then, if the medication was not delivered or re-filled, the nurse was to notify the ADONs, and they will call the pharmacy to see what the problem was and get the medication delivered. The DON added they had now implemented a MAR indicated [REDACTED]. She had also has implemented a weekly audit of all pain assessments on the residents, which would be tracked and trended in the Standards of Care meetings and QA. The facility's Plan of Removal, dated 08/23/13 was accepted on 08/23/13 at 5:10 PM and reflected the following: 1. Medication carts were audited for the availability of prescribed pain medications on 08/22/13 between the hours of 5:15 PM and 11:00 PM. The audits were conducted by Nurse Consultant I, ADON D, LVN J, ADON K and the Weekend RN Supervisor. The outcome of the audit revealed there were no missing medications. There was no need to contact the physician or the pharmacy as a result. 2. The medication for Resident #7 was re-ordered via the EMR on 08/10/13. Due to a glitch in the EMR, the pharmacy never received the refill order. However, the resident continued receiving Norco (narcotic pain medication). 3. All residents have been physically assessed for pain by a licensed staff member. If pain was at a level needing to be addressed, a PRN pain medication was offered if the resident had one ordered or the physician was contacted to obtain an order for [REDACTED]. The outcome of the pain assessments revealed there were no irregularities. 4. Licensed Nurses and Medication Aides have been re-educated on: --Assessments for pain --Ordering/Re-ordering of narcotics --Escalation (increase) of the process for missing medications In-servicing began with the 2:00 PM - 10:00 PM shift at 7:30 PM on 08/22/13 by Corporate R, Nurse Consultant I and the DON. ADON D conducted the 10:00 PM - 6:00 AM shift from 10:00 PM to 10:45 PM. The DON conducted the training for the 6:00 AM - 2:00 PM shift on 08/23/13 from 6:00 AM - 6:45 PM and another training for the on-coming 2:00 PM - 10:00 PM shift from 2:00 PM - 2:45 PM on 08/23/13. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date of training is 08/27/13. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by the DON. Attachment 2 is the in-service sign-in sheets, including who presented the training, the content and the post-test. 5. Implementation of a weekly Medication Cart audit will begin no later than 08/30/13. This tool (attachment 3) will be completed by then 10:00 PM - 6:00 AM shift charge nurses and submitted to the ADON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed as having arrived. The facility ADONs, ADON D and ADON K will weekly conduct random audit form checks against the medication carts. 6. Med Error report (attachment 4) was completed on the one allegedly affected resident (Resident #7), which included physician notification. Completed by 5:00 PM today (08/23/13). 7. Weekly monitoring of pain assessments will be conducted by the DON, ADON D and ADON K using the HER Audit, which reviews assessments, unprocessed medication and order accuracy. These audits will be on-going and reviewed weekly at the Standards of Care meeting and results followed up at the monthly QI/PI to address trends and/or irregularities. 8. An off cycle QA meeting was held on 08/22/13 at 5:45 PM on the concerns identified and plans to address and correct identified issues. The Medical Director was informed of the IJ and the Plan of Removal. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/irregularities. Attendees at the Standards of Care Meeting: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager. QI/PI attendees: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager, Maintenance Director, Dietary Service Manager, the Administrator and the Medical Director. 9. Policy of re-ordering of narcotics and PRN follow up documentation. When a routine medication is due to be re-ordered, the MA and/or the charge nurse will click on the "Reorder" button in LG (computer system). There is an interface with LG and the pharmacy, which automatically alerts the pharmacy of the need to refill and send the medication. If the medication has been re-ordered too soon, the pharmacy will send the facility a message via LG to alert them the medication was not sent. I

Based on observation, interview and record review, it was determined the Administrator and DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for one (Resident #7) of fourteen residents reviewed for pain management. 1) The Administrator failed to ensure staff received appropriate training to ensure they were fully knowledgeable about the use of the computer. The Administrator failed to supervise the DON to ensure she was monitoring staff for compliance with assessing residents for pain and reordering pain medications to ensure availability for the resident. 2) The DON failed to implement the facility's current policy and procedure for Pain Assessment and ensured facility staff: --Conducted pain assessments at regular intervals and as necessary. --Evaluated the effectiveness of [MEDICATION NAME] medication in relieving pain. --Assessed pain, includinng the onset and duration, loaction, severity, alleviating and aggravating factors, possible causes and accompanying signs and symptoms. --Medicated the resident as ordered by the physician and conducted a follow-up assessment within two hours of administration of the pain medication. 3) The DON failed to ensure facility staff were fully trained in the use of the new computer system as evidenced by the facility staff's failure to re-order and confirm Resident #7 had [MEDICATION NAME]es available as ordered. Resident #7 required three trips to the ER due to his severe, unrelieved pain on 08/15/13, 08/18/13 and 08/21/13 and was admitted to the hospital on [DATE] for pain evaluation and treatment. An Immediate Jeopardy (IJ) was identified on 08/22/13. While the IJ was removed on 08/23/13, the facility remained out of compliance at a severity level of "Actual harm that is not Immediate Jeopardy" and a scope of "pattern," because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal. These failures to ensure pain medication was reordered timely and to assess the resident for pain could affect the 52 residents, including Resident #7, who had either routine or PRN pain medication ordered by their physician and placed them at risk for unrelieved pain and discomfort. This could result in decreased nutritional intake, unplanned weight loss, alteration in sleep patterns, decreased socialization, serious medical complications, and a delay for appropriate interventions to be implemented and could result in the need for increased medication and possible admission to the hospital for pain relief treatment. Findings included: Resident #7's hospital H & P dated 08/22/13 reflected the resident was a [AGE] year-old male, who had undergone back surgery in May 2013 following a back injury after a fall at another hospital. The resident subsequently developed progressive lower extremity weakness and underwent a [MEDICATION NAME] laminectomy (cutting out the vertebral arch usually to remove a herniated disk) in June 2013 and was found to have Osteo[DIAGNOSES REDACTED] (inflammation of the bone and marrow usually caused by infection)." Resident #7's Physical, Medicine and Rehabilitation Progress notes dated 08/05/13 reflected the resident had [MEDICAL CONDITION] secondary to an [MEDICATION NAME] Abscess at T6-T9, status [REDACTED]. (Diskitis is an inflammation of the vertebral disk space.) Resident #7's care plan dated 07/26/13 addressed the problem of the resident experiencing pain frequently related to his [DIAGNOSES REDACTED]. Interventions included to turn and reposition the resident every two hours, place a pillow between his legs and behind his back when he was lying on his side and to give medication as ordered for his pain and report to the physician if the resident's medication was not effective. Resident #7's physician orders [REDACTED]. A [MEDICATION NAME] Patch is used to relieve moderate to severe chronic pain, which cannot be controlled by the use of other pain medications. The physician's orders [REDACTED]. The facility-contracted Pharmacy's Proof of Delivery manifests for 07/25/13 through 08/21/13 reflected on 07/27/13 at 8:00 PM, the pharmacy delivered five [MEDICATION NAME] 100 mcg/hr patches and five [MEDICATION NAME] 25 mcg/hr patches to the facility for Resident #7. The individual Control Drug Record for the [MEDICATION NAME]es for Resident #7 was reviewed. The five [MEDICATION NAME] 100 mcg patches and the five [MEDICATION NAME] 25 mcg patches were delivered by the pharmacy on 07/27/13 according to the Control Drug Record. The following dates and times were when the [MEDICATION NAME]es were signed out and initialed as given: 07/28/13 at 8:00 AM 08/01/13 at 8:00 AM 08/04/13 at 8:00 AM 08/07/13 at 8:00 AM 08/10/13 at 8:00 AM. Resident #7's MDS assessment dated [DATE] reflected he was admitted to the facility on [DATE]. The MDS assessment reflected Resident #7 was alert and oriented, with no signs or symptoms of [MEDICAL CONDITION], no behaviors and had a BIMS score of 15, which indicated he was cognitively intact. Resident #7 was also assessed as requiring extensive assistance by two staff for bed mobility, transfers, toileting and bathing. He required extensive assistance of one staff for dressing and personal hygiene and only set-up help for eating. [DIAGNOSES REDACTED]. The MDS assessment further reflected Resident #7 received scheduled pain medication and PRN pain medications. The MDS assessment also included an interview with Resident #7, in which he stated he had experienced pain within the last 5 days, it was frequent and it limited his day-to-day activities. Resident #7 stated his pain was an 8 on a pain scale of 0-10 with 10 being the most severe pain. At 10:00 AM on 08/20/13, Resident #7 was observed receiving physical therapy during initial rounds. Resident #7 was identified as being alert and oriented, incontinent of bowel, having a Foley catheter in place, required assistance with ADLs, was a two-person transfer and fed himself. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. Review of the MARs for July and August 2013 revealed Resident #7 received the [MEDICATION NAME]es on 07/28/13 and was due to have another set of patches applied on 07/31/13, but it was not documented as being administered until 08/01/13 (missed dose). MA A had signed out and administered the [MEDICATION NAME]es on 07/27/13, 08/04/13, 08/07/13 and 08/10/13, which was the last day the patches were available. MA B had signed out and administered the [MEDICATION NAME]es on 08/01/13 and had also signed out and administered the [MEDICATION NAME]es on 08/13/13. However, with only five doses delivered to the facility for Resident #7 on 07/27/13, the last ones would have been used on 08/10/13. The MARS reflected documentation of six doses, but there were only five doses of patches delivered and available for application. At 10:50 AM on 08/22/13, an interview was conducted with MA B. She stated she could not explain why she documented she had applied the [MEDICATION NAME]es to Resident #7 on 08/13/13 when there were no patches available. At 9:30 AM on 08/22/13, an interview was conducted with MA A. She confirmed she had applied the last of the [MEDICATION NAME]es for Resident #7 on 08/10/13. MA A stated she told LVN E Resident #7 did not have any more [MEDICATION NAME]es. At 10:30 AM on 08/22/13, an interview was conducted with LVN E. She stated she was not aware Resident #7 had no [MEDICATION NAME]es, and added MA A had not told her there were no more [MEDICATION NAME]es for the resident. Resident #7's MAR for August 2013 reflected there was a section to document a pain assessment every shift. The MAR indicated [REDACTED]. The staff wrote an "H" for each shift from the night shift on 08/15/13 through the evening and day shifts on 08/21/13, not restarting the pain assessments when Resident #7 returned to the facility on [DATE]. There was no documentation on the August 2013 MAR from 08/16/13 to the present to indicate staff assessed the resident's level of pain and documented it. At 1:40 PM on 08/22/13, an interview was conducted with ADON D. She stated the "H" on the MARs meant the medication or treatment was on hold. She said when a resident was sent to the hospital, all medications and treatments were put on hold and marked with an "H." ADON D stated with the facility's computer system, they had to go in and reactivate each medication and treatment individually. The system did not automatically reactivate everything on the MARs. ADON D stated the pain assessment order was not reactivated, so the "H " meant the pain assessments were not done. Review of Resident #7's nurses' notes dated from 07/31/13 through 08/21/13 revealed when the nurse administered a PRN medication for the residdent's pain, they documented the date and time and what PRN medication was given. There was a follow-up notation whether or not the medication was effective. The location and/or severity of the pain was not always included. There were only three days when the location of the pain and the severity of the pain was documented, which were 08/15/13, 08/18/13 and 08/21/13, the days he was sent to the hospital. At 9:20 AM on 08/23/13, the Corporate RN brought the survey team the Daily Skilled Nurses Notes for Resident #7 dated from 08/11/13 through 08/21/13. The Corporate RN confirmed the survey team did not have computer access to these Daily Skilled Nurses Notes. The Corporate RN also stated it was the facility's policy to conduct pain assessments each shift. She also provided a copy of the record from when MA A tried to re-order Resident #7's [MEDICATION NAME]es on 08/10/13. The Corporate RN stated something was wrong on the pharmacy side and the [MEDICATION NAME]es did not get re-ordered until 08/21/13, when the licensed nurse re-ordered it. The Corporate RN confirmed the triplicate prescription for the [MEDICATION NAME]es had refills, and they should have been refilled on 08/10/13. The Texas DADS Licensing Standards for Medication Aides Handbook with a revision date of "12-1" reflected the following: "TAC 95.105 Allowable and Prohibited Practices of a Permit Holder ...(b) A permit holder under Health and Safety Code, Chapter 242, Subchapter N, may not: ...(9) order a resident's medications from a pharmacy;...." At 4:10 PM on 08/23/13, an interview was conducted with the Weekend RN Supervisor. She stated she had never worked with Resident #7 personally but had made rounds on him. The Weekend RN Supervisor said she did not have any knowledge Resident #7's [MEDICATION NAME]es were not available, and no one had reported it to her. At 2:10 PM on 08/23/13, an interview was conducted with CNA G. She stated she had taken care of Resident #7 and was familiar with him. She stated his level of pain seemed to increase the last few days, and he was complaining more about his pain. At 2:20 PM on 08/23/13, an interview was conducted with LVN H. He stated he was not aware and had not been informed there were no [MEDICATION NAME]es available for Resident #7. The nurses' notes reflected at 11:51 AM on 08/15/13, Resident #7 was given two Tylenol 325 mg tablets, and at 12:13 PM on 08/15/13, Resident #7 received one [MEDICATION NAME] (narcotic [MEDICATION NAME]) tablet. Resident #7's nurses' notes dated 08/15/13 at 12:46 PM reflected the following: "Resident c/o severe back pain at the site where he had a surgical incision. [MEDICATION NAME] 10/325 mg (narcotic pain medication), 1 tab po given as ordered. Rechecked later Resident stated pain medication not effective. PA ...notified via voice mail. Awaiting call back. Will continue to monitor." Resident #7's nurses' notes dated 08/15/13 at 4:30 PM reflected the following: "Resident c/o severe back pain not relieved with [MEDICATION NAME] or APAP. [MEDICATION NAME] (anti-anxiety) given due to c/o increased anxiety. APAP given at this time, resident repositioned to alternating sides and stated it was effective. Drsg to incision site done by tx nurse CDI No drainage noted. Afebrile. Resd voiced he would like to go to the hospital if pain meds do not work." The nurses' notes dated 08/15/13 at 4:50 PM reflected Resident #7's family had arrived and requested the resident be sent to the ER for his back pain. The transport ambulance was called and reported pick-up time would be in 30 minutes. The family stated that was too long and requested 911 be called. 911 was called and the resident was picked up within 3 minutes and transported to the hospital. At 2:40 PM on 08/23/13, an interview was conducted with LVN F. She stated she worked on 08/15/13. She said Resident #7 was complaining of severe back pain and he had been given all his pain medications. His family reported he was crying and requested he be sent to the hospital. LVN F said Resident #7's family also reported to her the last time this happened, he had an infection, "Osteo[DIAGNOSES REDACTED]." Review of the ambulance Patient Care Report dated 08/15/13 at 4:51 PM revealed Resident #7 had been transported to the hospital for complaints of back pain. The severity of his back pain was assessed as a 9 on a pain scale of 0 to 10 with 10 being the worst pain. The Report reflected Resident #7's vital signs at the time the ambulance picked him up from the facility were as follows: Heart Rate: 105 bpm (normal is 72 bpm; Blood Pressure: 156/72; and Respiratory Rate: 18 respirations a minute. The Report reflected Resident #7 informed the paramedics he had been having back pain for about a week, and the pain had progressively been getting worse. He stated he was not ambulatory and the pain began when he was just lying in bed. Resident #7 told the paramedics it was a constant pain and was a 9 on a pain scale of 0 to 10. The ER report dated 08/15/16 reflected Resident #7 arrived at the hospital at 5:01 PM on 08/15/13 and was discharged back to the facility at 12:21 AM on 08/16/13. The resident's chief complaint was back pain. The ER report reflected an assessment of the resident's systems: "Gastrointestinal: Negative for nausea, vomiting, abdominal pain, diarrhea and constipation. [MEDICAL CONDITION]: Positive for flank pain. Negative for dysuria, urgency, frequency and hematuria. Musculoskeletal: Positive for back pain. Negative for joint pain." The [DIAGNOSES REDACTED]. Neuritis is an inflammation of a nerve or a group of nerves which is characterized by pain, loss of reflexes, and atrophy of the affected muscles. Radiculitis is an inflammation involving a spinal nerve root resulting in pain and hyperesthesia (increased sensitivity to sensory stimuli, such as pain or touch). According to the ER report dated 08/15/13, Resident #7 received two doses of [MEDICATION NAME] 4 mg IV at 7:00 PM and again at 11:30 PM. The facility nurses' notes dated 08/16/13 at 12:48 AM reflected Resident #7 returned from the hospital with no new orders. The nurses' notes dated 08/18/13 at 9:35 PM reflected the following: "Patient noted uncomfortable, c/o feeling impacted, staff administered supp. As ordered, resident continued getting anxious, stated that his ribs are hurting, and will need stronger pain pill, vital signs checked. Noted stable. [MEDICATION NAME] administered at this time. Staff notified PA... He stated to give patient extra dose of [MEDICATION NAME] for pain added that he will come to facility tomorrow to assess patient." The nurses' notes dated 08/18/13 at 6:02 AM reflected, "Pt was c/o pain. Pain meds had been given 30 minutes prior. Departing nurse said pt had been stating that he was gonna call 911 if he didn't get med. Pt did call 911 and (family member) was notified of pt going out (to ER) on his own. (The facility had not called 911.)" The ER record dated 08/18/13 reflected Resident #7 was admitted to the ER at 11:08 PM on 08/18/13 and discharged back to the facility at 2:15 AM on 08/19/13. The resident's complaint was abdominal pain and constipation. The ER record reflected Resident #7 stated his pain had started two days ago and was located in the generalized abdominal region and the quality of pain was cramping. The pain was at a severity level of 7 on a 0 to 10 pain scale, and the pain was moderate. The abdominal region was normal in appearance and had normal bowel sounds. There was some tenderness but no rebound and no guarding. An abdominal series was conducted, and there was no bowel obstruction noted. NP C saw Resident #7 on 08/18/13 and documented the resident had gone to the hospital a few days ago for intractable back pain and was sent back to the facility after being treated with IV [MEDICATION NAME]. The NP documented he wanted to continue Resident #7's current pain medication regimen. Resident #7's nurses' notes dated 08/19/13 at 2:00 AM reflected the resident had returned from the hospital with an order for [REDACTED]. NP C saw Resident #7 again on 08/20/13 and again documented to continue the resident's current pain medication regimen. At 8:30 AM on 08/23/13, an interview was conducted with NP C. He stated the resident had a history of [REDACTED].#7 had not been receiving the [MEDICATION NAME], he would have discontinued it. NP C stated he offered the resident extra narcotics, but Resident #7 did not want them. He wanted to go to the hospital to get IV medications. At approximately 2:50 PM on 08/21/13, Resident #7 was observed in his room with the paramedics in attendance. Resident #7 was observed to be grimacing and told the surveyor he was having severe back pain. The paramedics started an IV on the resident and then transported him to the hospital. The nurses' notes dated 08/21/13 at 2:53 PM reflected Resident #7 was complaining of severe pain and told facility staff he wanted to go to the ER. The facility notified NP C, and he approved the transfer. Resident #7's family was notified via voice mail.and the resident left the facility and was transported by ambulance with the paramedics. The Incident/Accident Report dated 08/22/13 reflected on 08/21/13, MA A reported Resident #7 was out of [MEDICATION NAME]es, and they had not been available since 08/10/13. At the time of MA A's report, it was noted Resident #7 was at the hospital. At the time of his discharge, his pain level was a 10, using a pain scale from 0 to 10, with 10 indicating severe pain. The Report reflected 911 was called, and the resident was sent to the ER. The Incident/Accident Report reflected the Nurse Practitioner was notified at 2:00 PM on 08/21/13 of the unavailability of the [MEDICATION NAME] Patches. The [MEDICATION NAME]es were re-ordered on [DATE] and delivered to the facility on [DATE]. The Report reflected the NP ordered Resident #7 to have a pain management consult upon his return to the facility. At 9:30 AM on 08/23/13, Resident #7 was interviewed at the hospital. He stated he was not feeling well. Resident #7 stated he had not had a new [MEDICATION NAME] in about two weeks. He said he kept asking facility staff when was he going to get a new patch, and they kept telling him, "It's been ordered but it has not come in yet." Review of the facility-contracted Pharmacy's Proof of Delivery manifests dated from 07/28/13 to current revealed [MEDICATION NAME]es were not delivered to the facility for Resident #7 until 08/21/13, the day he was admitted to the hospital. The hospital ER notes dated 08/21/13 reflected Resident #7's chief complaint was back pain with lower extremity tremor, and he had been given [MEDICATION NAME] 100 mcg on route to the hospital. The notes further reflected Resident #7 had a fever, elevated white blood cell count and Diskitis in the [MEDICATION NAME] spine with spinal cord compression. The neurosurgeon advised the resident he might need reconstruction of his spine for stability and needed to be admitted to the hospital for an MRI of the spine and IV antibiotics. The hospital H & P dated 08/22/13 reflected Resident #7 developed excruciating back pain associated with fevers and chills and this prompted his transfer to the hospital on [DATE]. His MRI revealed he has osteo[DIAGNOSES REDACTED] at his previous levels of decompression with [MEDICATION NAME] kyphosis and cord compression. There was no surgical intervention at that point. The Internal Medicine physician's consult report dated 08/22/13 reflected the following: Vertebral osteo[DIAGNOSES REDACTED] with cord compression [DIAGNOSES REDACTED]. The physician would arrange for a bone biopsy, blood cultures and start antibiotics after that and control his pain and Diabetes. The facility's most current policy and procedure for Pain assessment dated as revised August 2002 reflected the following: "Purpose The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. General Guidelines: 1. A comprehensive pain assessment will be completed as part of the initial nursing assessment with development of a pain management program as indicated. 2. The comprehensive pain assessment will be reviewed quarterly and with a significant change in status. 3. Continuing assessment of the pain management program will occur daily and will focus on the effectiveness of the program and the comfort level of the resident. 4. Pain will be assessed and documented at regular intervals, as necessary and in accordance with the pain management program. Evaluation of the effectiveness of [MEDICATION NAME] medication in relieving pain to a level that is acceptable to the resident will occur within 2 hours. Steps in the procedure: 1. Wash and dry your hands thoroughly. 2. Ask the resident if he/she is experiencing any pain. Note the location of pain and the level of pain using the pain assessment tool identified by facility protocol. 3. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes and accompanying signs and symptoms. 4. Determine appropriate type of pain medication as ordered by the physician. 5. If no pain medication is ordered, notify the physician and obtain an order. 6. Medicate the resident as the physician ordered. 7. Do follow-up assessment within 2 hours after administration... Documentation: The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. Daily assessment of pain. 4. All assessment data obtained during the procedure including location of pain, level of pain using the pain scale and type of pain relief used. 5. 2-hour reassessment of pain and the resident's response to the pain relief used...." The facility's current pharmacy policy and procedures regarding reordering, changing and discontinuing orders, revised on 05/01/10, reflected the following: Procedure for "2.3 Facsimile Orders: Reorders can be faxed to the pharmacy, if permitted by Applicable Law, on the Refill Order Form set forth in Appendix 12: Refill/Reorder Form. 2.4 Electronic orders ("e-Refill"): Authorized Facility staff may use Omniview to electronically reorder resident medications. 2.4.2 Facility staff should re-order medications using an electronic list of residents and medications due or by use of barcode technology. 2.4.2 Facility staff should use a barcode scanner to read prescription numbers from the labels of orders they wish to reorder and transmit them electronically to the Pharmacy. 2.4.3 Facility staff should review the transmitted re-orders for status and potential issues and Pharmacy response. 2.4.4 Omniview will indicate if the re-order is confirmed, if Pharmacy follow-up is required, or an invalid prescription number has been entered into the system. 2.4.4.1 If Omniview indicates that a Pharmacy follow-up is required, Pharmacy will contact the Facility; and 2.4.4.2 If Omniview indicated that an invalid prescription number has been entered into the system. Facility staff should check the accuracy of the resident's name and prescription number. 2.4.5 Facility staff should use Omniview to review the status of open orders for follow-up with the Pharmacy." An IJ was identified on 08/22/13. On 08/22/13 at 5:00 PM, the Administrator, the DON, the Corporate RN, and the Corporate SW were informed of the IJ and a Plan of Removal for the IJ was requested. At 4:30 PM on 08/23/13, an interview was conducted with the Administrator. When asked how he monitored his staff to ensure the systems were effective, he stated he attended the Standards of Care weekly meeting where they track and trend all issues with the residents including those on pain management programs, and he would independently review the pain assessments himself to ensure they were being done. When the Administrator was asked why he thought the IJ had occurred, he stated it was the newness of the electronic system, the lack of staff training and their lack of knowledge how to use it. He stated the initial training for the computer was an on-line computer training with a question and answer session. He stated with all new staff, there would be orientation of actual hands-on computer training with knowledgeable staff. He added they had implemented the MAR indicated [REDACTED]. Training and oversight of the implementation of the plan of removal would be discussed in the weekly Standards of Care meetings and the QA meetings. At 4:45 PM on 08/23/13, an interview was conducted with the DON. When asked how she thought the IJ had occurred, she responded it was a lack of training of the staff for the new computer system, which created some problems. The DON added there were some glitches to work out. The system had only been in place for about 20 days. She also stated the MA should have followed up with her nurse when the [MEDICATION NAME]es did not come in when she had re-ordered them. If she had told the nurse, then she would have expected the nurse to call the pharmacy and find out what had happened and get the medication refilled. She added they now had a system in place, which allowed only the nurses to order or re-order narcotics. It will be the MAs' responsibility to notify the charge nurses when the medication was getting low. The nurse will click on the medication refill in the computer, fax the refill to the pharmacy, call the pharmacy to make sure they got the refill request and then, if the medication was not delivered or re-filled, the nurse was to notify the ADONs, and they will call the pharmacy to see what the problem was and get the medication delivered. The DON added they had now implemented a MAR indicated [REDACTED]. She had also has implemented a weekly audit of all pain assessments on the residents, which would be tracked and trended in the Standards of Care meetings and QA. The facility's Plan of Removal, dated 08/23/13 was accepted on 08/23/13 at 5:10 PM and reflected the following: 1. Medication carts were audited for the availability of prescribed pain medications on 08/22/13 between the hours of 5:15 PM and 11:00 PM. The audits were conducted by Nurse Consultant I, ADON D, LVN J, ADON K and the Weekend RN Supervisor. The outcome of the audit revealed there were no missing medications. There was no need to contact the physician or the pharmacy as a result. 2. The medication for Resident #7 was re-ordered via the EMR on 08/10/13. Due to a glitch in the EMR, the pharmacy never received the refill order. However, the resident continued receiving [MEDICATION NAME] (narcotic pain medication). 3. All residents have been physically assessed for pain by a licensed staff member. If pain was at a level needing to be addressed, a PRN pain medication was offered if the resident had one ordered or the physician was contacted to obtain an order for [REDACTED]. The outcome of the pain assessments revealed there were no irregularities. 4. Licensed Nurses and Medication Aides have been re-educated on: --Assessments for pain --Ordering/Re-ordering of narcotics --Escalation (increase) of the process for missing medications In-servicing began with the 2:00 PM - 10:00 PM shift at 7:30 PM on 08/22/13 by Corporate R, Nurse Consultant I and the DON. ADON D conducted the 10:00 PM - 6:00 AM shift from 10:00 PM to 10:45 PM. The DON conducted the training for the 6:00 AM - 2:00 PM shift on 08/23/13 from 6:00 AM - 6:45 PM and another training for the on-coming 2:00 PM - 10:00 PM shift from 2:00 PM - 2:45 PM on 08/23/13. All nurses and medication aides not in attendance will be re-educated prior to the start of their shift. Expected completion date of training is 08/27/13. In addition, this training has been added to the orientation process for licensed nurses and medication aides presented by the DON. Attachment 2 is the in-service sign-in sheets, including who presented the training, the content and the post-test. 5. Implementation of a weekly Medication Cart audit will begin no later than 08/30/13. This tool (attachment 3) will be completed by then 10:00 PM - 6:00 AM shift charge nurses and submitted to the ADON upon completion each week and will be on-going. Any medication issues identified will be addressed immediately. All ordered medications will be confirmed as having arrived. The facility ADONs, ADON D and ADON K will weekly conduct random audit form checks against the medication carts. 6. Med Error report (attachment 4) was completed on the one allegedly affected resident (Resident #7), which included physician notification. Completed by 5:00 PM today (08/23/13). 7. Weekly monitoring of pain assessments will be conducted by the DON, ADON D and ADON K using the HER Audit, which reviews assessments, unprocessed medication and order accuracy. These audits will be on-going and reviewed weekly at the Standards of Care meeting and results followed up at the monthly QI/PI to address trends and/or irregularities. 8. An off cycle QA meeting was held on 08/22/13 at 5:45 PM on the concerns identified and plans to address and correct identified issues. The Medical Director was informed of the IJ and the Plan of Removal. All audits will be reviewed weekly at the Standards of Care meeting, and results followed up at the monthly QI/PI to address trends and/irregularities. Attendees at the Standards of Care Meeting: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager. QI/PI attendees: ADON D, LVN J, ADON K, the DON, the SW, Rehab Manager, Maintenance Director, Dietary Service Manager, the Administrator and the Medical Director. 9. Policy of re-ordering of narcotics and PRN follow up documentation. When a routine medication is due to be re-ordered, the MA and/or the charge nurse will click on the "Reorder" button in LG (computer system). There is an interface with LG and the pharmacy, which automatically alerts the pharmacy of the need to refill and send the medicat

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practical physical well-being for two (Residents #1 and #2) of six residents reviewed with indwelling urinary catheters and change of condition. 1) Facility failed to conduct a thorough assessment and intervene in a timely manner when Resident #1 had a change in condition. Resident #1 had diminished urinary output, which was minimal to nothing by [DATE]. Changing the resident's indwelling catheter on the [DATE], resulted in a large amount of blood draining from the catheter. Resident #1 was sent to the ER and admitted to the hospital on [DATE]. Facility failed to notify the physician and/or NP when Resident #1 had decreased urinary output. Facility staff failed to monitor and accurately document Resident #1's urinary output. 2) Facility staff failed to thoroughly assess and intervene in a timely manner when Resident #2 stopped eating and drinking and developed left-sided weakness on [DATE]. Resident #2 was admitted to the ICU on [DATE]. These failures to conduct thorough assessments when Residents #1 and #2 began to exhibit signs and symptoms other than normal could affect any of the facility's 96 residents, who may present with abnormal signs and symptoms, which are not appropriately assessed and could result in a delay in treatment and care issues, resulting in acute conditions requiring hospitalization and could result in death. Findings included: 1) Resident #1's MDS assessment, dated [DATE], reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment also reflected his cognition was severely impaired. Resident #1 had an indwelling catheter and was incontinent of bowel. Resident #1 needed the extensive assistance of one person for personal hygiene. Review of Resident #1's Comprehensive Plans of Care, dated [DATE], reflected the following approach with every problem: Keep Family/Responsible Part of Resident and MD informed of resident's progress. Review of the Skilled Daily Nurses Note for Daily ADL Charting, dated [DATE], (no time), reflected the resident had an output of 175 cc (six ounces) concentrated yellow urine. Review of the Skilled Daily Nurses Note for Daily ADL Charting from the 2:00 PM - 10:00 PM shift, dated [DATE], reflected Resident #1's Foley catheter was patent with 100 cc of concentrated yellow urine. Fluids were offered, but the resident refused. Review of the Skilled Daily Nurses Note for Daily ADL Charting, dated [DATE], (no time), reflected Resident #1 refused snacks/fluids and had an output of 150 cc (five ounces) concentrated urine "yellow-amber in color." Review of the Skilled Daily Nurses Note for Daily ADL Charting, dated [DATE], timed for the 2:00 PM - 10:00 PM shift, reflected Resident #1 was noted to have decreased urinary output. Fluids were offered multiple times, but the resident refused. Review of Resident #1's Daily Skilled Nursing Notes dated from [DATE] through [DATE], revealed the licensed nurses had not indicated any of the choices on the checklist for urine, which included: Color, Clarity, Odor, Testing and I & O. The area to be used for comments also did not include a description of Resident #1's urine or his decreasing output. Resident #1's Nurse's Notes, dated [DATE] (no time), reflected: "...Resident not having any urine output. Noted ABD (abdomen) distended. New foley replaced. Observed 800 cc bloody urine (with) 911 called. DON aware. Left message with MD and PA." Review of a second Nurse's Note, dated [DATE] at 3:00 AM, reflected it was reported to the nurse Resident #1 had 10 cc urine output. The nurse attempted to flush the Foley catheter, but it was "clogged." The nurse replaced the Foley catheter and had a return of 700 cc of bloody urine. The nurse's supervisor and the MD were notified and Resident #1 was sent to the ER for "further evaluation due to the amount of blood in urine." Attempts to contact LVN A, Resident #1's staff nurse on the 10:00 PM to 6:00 AM shift on [DATE], were unsuccessful. Resident #1's Physician Telephone Orders, dated [DATE], reflected to "Send Resident to Hospital to Be Further Evaluated For Bloody urine." Review of Resident #1's Transfer Form, dated [DATE], reflected Resident #1 was transferred to the hospital due to having the resident's Foley catheter changed and then had an output of "bloody" urine. Review of the ER Provider Notes, dated [DATE], reflected Resident #1 was transported "from nursing home with hematuria. EMS says patient was found in deplorable conditions on bed with no sheet. Per nursing home staff, patient had indwelling foley and had not had output for 3 days. They replaced the Foley and (Resident #1) had a large output of bloody fluid. At that point they clamped the foley and called EMS." The ER Notes further reflected Resident #1's problems included the following: "[MEDICAL CONDITION], clogged Foley, and bladder hemorrhage likely due to [MEDICAL CONDITION]." Review of Hospital Progress Notes, dated [DATE], reflected Resident #1 was pronounced deceased at 1:08 PM on [DATE]. During an interview on [DATE] at 9:30 AM with CNA B, the CNA told the surveyor she worked with Resident #1 on the 10:00 PM to 6:00 AM shift. The surveyor told the CNA she had not seen documentation of Resident #1's urine for the night shift and asked if the resident had any urine output. CNA B informed the surveyor of Resident #1's urine output: [DATE] - 50 cc dark yellow urine (ten teaspoons); [DATE] - very little urine, could not remember the amount ; [DATE] - no urine; [DATE] - 150 cc very dark yellow urine (five ounces); and [DATE] - no urine On [DATE], during an interview with CNA B, she stated the DON came to the facility between 2:00 AM and 3:00 AM. CNA B stated she and the DON went to Resident #1's room at about 4:00 AM. CNA B stated the DON saw Resident #1's urine collection bag and asked CNA B if the resident had any urine output. CNA B said the DON asked her if she had told the charge nurse, LVN A, and CNA B said she told the DON, but she had not told LVN A. CNA B said the DON told her (CNA B) the charge nurse (LVN A) needed to know, but she (CNA B) was busy answering call lights and could not get to the charge nurse. However, someone else told LVN A, because the LVN told her (CNA B) she needed to assist the LVN with the replacement of Resident #1's Foley catheter. CNA B said when LVN A "pulled" Resident #1's catheter out, Resident #1 was grimacing and screamed, "Oh!" CNA B told the surveyor when LVN A re-inserted the Foley catheter, "the blood" came through the catheter and the end of the resident's penis, filling up the collection bag. CNA B stated Resident #1's gown and bed linen became completely soaked with blood. CNA B added LVN A stated, "Oh my gosh!" CNA B said the DON came in, saw the bloody urine, started cleaning up the resident, and someone called 911. The emergency ambulance arrived in the facility and transferred Resident #1 to the hospital. Interview on [DATE] at 3:00 PM with the DON, revealed she went into the facility to do skin assessments during the 10:00 PM to 6:00 AM shift. The DON stated between 2:00 AM to 4:00 AM, she went to Resident #1's room and observed 10 cc of dark urine in his urinary drainage bag. The DON stated she went and got the charge nurse to check the Foley catheter. The DON said she was doing skin assessment rounds when LVN A told her she changed Resident #1's Foley and there was blood in his drainage bag. The DON said when she went to Resident #1's room, she saw a large amount of blood in his drainage bag. On [DATE] at 1:29 PM, during a telephone interview with NP K, the surveyor asked if she was aware of Resident #1's decreased urinary output. NP K stated the facility did not notify her about Resident #1's decreased urinary output. NP K was queried if she assessed Resident #1 when she was in the facility, and NP K replied, "If you want to talk to me, come to my office," and she hung up the telephone. During an interview on [DATE] at 9:30 AM with RN F, Resident #1's urinary output was discussed. RN F stated Resident #1 had urinary output on [DATE], [DATE], [DATE], [DATE],[DATE], and [DATE]. RN F stated she interviewed facility staff, who worked with Resident #1, and they said Resident #1 had urinary output, but they did not record it. RN F handed the surveyor documents with handwritten statements from staff, who provided care for Resident #1. The following written statements were provided: CNA J - Resident #1 had approximately 400 cc (13 ounces) clear yellow urine with no odor on [DATE]. LVN R - Resident #1 had approximately 400 cc (13 ounces) clear yellow urine with no odor on [DATE]. LVN S - On [DATE], Resident #1 had 150 cc (five ounces) of clear, concentrated yellow urine. CNA B - Resident #1 had urine output on [DATE]. "I emptied his foley (sic) before my shift ended." No amount or description of urine was given. LVN T - Resident #1 had 160 cc (five plus ounces) of dark yellow urine with no odor. Taber's Cyclopedic Medical Dictionary, Edition 21, F.A, Davis Company, Copyright 2009, page 2415, reflected normal urine output is from 1,000 - 3,000 ml/day (one to three liters/day) and is yellow to amber in color. 2) Resident #2's MDS assessment, dated [DATE], reflected Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment also reflected Resident #2 was moderately impaired cognitively. Resident #2's Physical Therapy Treatment Notes reflected the following: [DATE] - Set food tray in front of Resident #2; however, she was unable to feed herself. [DATE] - Resident #2 demonstrated difficulty initiating movement and following directions. [DATE] - Resident #2 demonstrated poor activity tolerance and effort during exercise. Resident #2's first attempt at sit to stand exercise with two person assist not successful. Family spoken to regarding Resident #1's session that day, and advised the family member to speak with the nursing staff and physician for more information (about the resident). [DATE] - Resident #1 participated in transfer from sit to stand using grab bar needing minimal assist of two and moderate assist of one. Resident #2 pivoted to the commode needing minimum assistance of one person. [DATE] - CNA assisted Resident #2 with the resident's transfer from the edge of the bed to the wheelchair, needing maximum assistance to dependence on two staff for transfer. BP of ,[DATE]. [DATE] - Resident #2 performed very poorly during transfers. CNA staff needed assistance to assure safe transfer. [DATE] - Resident #2 required maximum to total assist with rolling from side-to-side and positioning. Nursing staff was spoken to regarding Resident #2's lethargy and her BP was taken, which was ,[DATE]. No further treatment was provided. Resident #2's Occupational Therapy Daily Treatment Notes reflected the following: [DATE] - Resident #2 was at times disoriented and appeared confused. Nursing staff had reported same behavior. [DATE] - Resident #2 required maximum assist from two staff with transfer from the wheelchair to the bed. Resident #2 was showing signs of right-side neglect, unable to perform purposeful movement with extremities of right sight: Resident #1 was ignoring objects on the right side. Occupational Therapy Assistant (OTA) G was interviewed on [DATE] at 3:28 PM. She stated she remembered and worked with Resident #2. OTA G stated when she provided treatment to Resident #2 in February - [DATE], Resident #2 was able to really progress. OTA G stated when she started providing therapy to her in [DATE], Resident #2 was very different, very lethargic, could not follow commands and was confused. OTA G stated Resident #2 began to change after being on therapy for five days. On [DATE], the resident could not transfer and was not able to use her legs. OTA G stated Resident #2 was no longer able to hold a cup and was not able to use her left side. OTA G stated CNA D spoke to her (OTA G) about Resident #2's change of condition. Review of Resident #2's Emergency Department Notes, dated [DATE], reflected the resident presented to the ER with complaints of possible stroke. Family arrived and told the ER staff Resident #2 was not herself and had not been herself since [DATE], when she did not recognize her family members and did not speak. Family stated she had been nonverbal since then. Resident was responding to name and voice only. Resident #2's physical examination revealed she was slumped to the right. She opened her eyes when her name was called, otherwise she did not answer questions or follow commands. Admitting [DIAGNOSES REDACTED]. Resident #2 was admitted to ICU. The hospital's Death Summary, dated [DATE] for Resident #2, reflected the time of her death was at 10:49 PM on [DATE]. [DIAGNOSES REDACTED]. During an interview on [DATE] at 10:15 AM, CNA D stated she had worked with Resident #2. CNA D stated when Resident #2 was readmitted to the facility in [DATE], the resident was confused and could not feed herself or go to the bathroom. CNA D stated on [DATE], Resident #2 was not doing too well. CNA D said she was not eating and was not as alert as she was previously. CNA D stated she told LVN M, who checked her blood sugar and vitals and told the CNA Resident #2 was "fine." CNA D said Resident #2 acted more confused and stopped drinking on [DATE]. Interview on [DATE] at 1:15 PM with CNA H, revealed she worked with Resident #2 once before when she came to the facility, but said when Resident #2 was readmitted this last time, she was in "bad shape." Resident #2 could eat and drink a little bit. CNA H said therapy tried to encourage her and took her to the assisted dining room to eat and someone had to help her, but CNA H said the resident wanted to stay in bed and could not eat. CNA H stated a couple of days before she went to the hospital, she was "going down." The resident would say she wanted to exercise, but therapy could not get her up. CNA H said on [DATE], she told the charge nurse Resident #2 was not eating and drinking and was very weak, but CNA H could not remember the name of the charge nurse. Interview on [DATE] at 11:55 AM with CNA I, revealed she was at the facility when Resident #2 went to the hospital. Resident #2 had a change of condition on [DATE]. CNA I stated that morning ([DATE]), when she asked Resident #2 a question, she was not answering and was holding food in her mouth. CNA I said she went and told LVN C Resident #2 was not eating and talking. CNA I said she worked with Resident #2 on her second day here in the facility, she was stronger and putting food in her mouth and would tell the CNA, "I don't want it any more." Interview on [DATE] at 10:07 AM with LVN C, revealed he was Resident #2's charge nurse on [DATE]. LVN C stated when he made rounds at 5:50 AM, she was okay. The LVN said at 10:10 AM, he noticed changes in Resident #2. She was still alert, but not as much as she had been. LVN C stated the Medication Aide came and told him she had changed. The Medication Aide told him Resident #2 had some food in her mouth and was not able to swallow the food. LVN C stated he called the PA, but the PA did not return the call. LVN C said then the therapist came to work with Resident #2 and he (LVN C) told the therapist the resident could not get up and the resident did her therapy on the bed. LVN C stated Resident #2 said she was "okay." LVN C he called the PA again at 2:00 PM with no response. LVN C stated he checked on the resident at about 2:00 PM and when he spoke to her, Resident #2 answered, but her speech was not clear. LVN C said he checked her BP and it was low. LVN C said he then called Resident #2's family and told them he was sending her to the hospital. LVN C stated he called Resident #2's physician and he did not return his call. LVN C stated he went ahead and called Resident #2's family member and then sent Resident #2 to the emergency room . 3) Review of the facility's current undated policy and procedure on change of condition revealed: "Facility staff will assess, record, and report any significant change in Resident condition to attending physician to ensure appropriate care and treatment... Licensed nursing staff will assess and report change of Resident's condition to physician/physician extender in a timely manner... Changes in condition include: [MEDICAL CONDITION], decrease or no urine output, decrease or no p.o. intake... Charge nurse will notify the attending physician/extender of any significant change of condition. The Resident's responsible party will also be notified of change of condition. Observation and notification will be documented in the clinical record... Any of the above scenarios would require documentation in the Resident's chart and responsible party notification as well." Review of the Facility's Policy and Procedure on urinary care, dated [DATE] revealed: "1. Observe the Resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly, report it to your supervisor... 2. Should the resident indicate that his or her bladder is full or that he or she needs to void (urinate) report it immediately to your supervisor... 3. Check the urine for unusual appearance (color, blood, etc.)... 4. The urinary bag must be held in position lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder... 5. Check the Resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. 6. Notify the supervisor immediately in the event of hemorrhage (bleeding) or if the catheter is filled up... 7. Maintain an accurate record of the Resident's daily output, per facility's policy and procedure... 9. Unless specifically ordered by the physician, do not apply a clamp to any catheter... 10. Determine if changes in daily urinary catheter procedure have been made and review of care plan or receipt of oral instruction from nursing supervisor, physician orders, etc.)... 11. Be sure catheter tubing and drainage bag are kept off the floor... 12. Empty the collection bag at least every 8 hours... 14. Observe the resident for signs and symptoms of urinary tract infection and [MEDICAL CONDITION]. Report findings to supervisor immediately. Report to the supervisor any complaints... 18. Report to the supervisor any complaints the resident may have of burning, tenderness, or pain in the urinary area...." Form CMS 672, Resident Census and Residents Conditions, dated [DATE] and signed by the DON, reflected a census of 96 residents. .

Based on observation, interview and record review, it was determined the facility failed to ensure six (Residents #1, #2, #3, #4, #5, and #6) of 23 residents who were Diabetic and reviewed for pharmacy services, were free of significant medication errors. 1) LVN A held Resident #1's routine [MEDICATION NAME] 70/30 insulin scheduled for 8:00 AM on 04/02/12 without a physician's orders [REDACTED]. The available insulin should have been discarded on 03/28/12 and the resident did not receive the needed insulin at that time. 2) Resident #6 had a physician's orders [REDACTED]. On 04/02/12, the available insulin should have been discarded on 03/28/12, so Resident #6 did not received her scheduled insulin that morning. Resident #6's [MEDICATION NAME]was ordered on [DATE] at 3:00 PM and it was not delivered from the pharmacy in time for her 5:00 PM scheduled dose. 3) Resident #4 had routine [MEDICATION NAME]100 units/ml inject 10 units sq every night at bedtime. LVN F did not administer the insulin because the insulin was expired. LVN F also stated the resident's blood sugar was 90 and she thought the insulin should have been held due to his blood sugar. 4) Resident #3 had an elevated blood sugar of 264 and required coverage with [MEDICATION NAME] R insulin. There was no insulin available for the resident. 5) LVN F documented insulin was administered to Resident #5 on 04/02/12 at 11:30 AM, but LVN F said she did not give the insulin. 6) Resident #2 had an elevated blood sugar of 209 and required coverage with [MEDICATION NAME] R insulin. The available insulin should have been discarded on 03/28/12 and the resident did not receive the needed insulin at that time. An Immediate Jeopardy (IJ) was identified on 04/02/12 at 4:04 PM. While the IJ was removed on 04/04/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because the facility was still monitoring the Plan of Removal. These failures could affect the facility's 23 Diabetic residents, including Residents #1, #2, #3, #4, #5 and #6, by placing them at risk for inadequate control of blood sugar levels which could result in a Diabetic coma, shock or death. Findings included: A) Review of the website, http://www.rxlist.com/[MEDICATION NAME]-70-30-drug.htm, retrieved on 04/17/12 revealed the following information about [MEDICATION NAME] 70/30 insulin: "...The dosage is based on your medical condition and response to therapy. Measure each dose very carefully because even small changes in the amount of insulin may have a large effect on your blood sugar levels...Use this medication regularly as directed by your doctor to get the most benefit from it...It is very important to follow your insulin regimen exactly. Do not miss any doses of insulin. Discuss specific instructions with your doctor now in case you miss a dose of insulin in the future...." Review of the website, <http://www.drugs.com/mtm/[MEDICATION NAME]-r.html>, retrieved on 04/17/12 revealed the following information about Regular insulin: "...Insulin is a hormone that is produced in the body. It works by lowering levels of glucose (sugar) in the blood. Insulin regular is a short-acting form of insulin...Use exactly as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label...." Review of the website, http://www.rxlist.com/[MEDICATION NAME]-r-drug/clinical-pharmacology.htm, retrieved on 04/17/12 revealed the following about [MEDICATION NAME]-R insulin: "[MEDICATION NAME] R is a short-acting insulin. When injected subcutaneously, the glucose-lowering effect of [MEDICATION NAME] R begins approximately 30 minutes post-dose, is maximal between 1.5 and 3.5 hours post-dose and terminates approximately 8 hours post-dose...How should I take [MEDICATION NAME] R? ? [MEDICATION NAME] R comes in 10 mL vials for use with a syringe <http://www.rxlist.com/script/main/art.asp?articlekey=9462>. ? Take [MEDICATION NAME] R exactly as prescribed. ? Your healthcare provider will tell you how much [MEDICATION NAME] R to take and when to take it. ?Do not make any changes to your dose or type of insulin unless you are told to do so by your healthcare provider. ? The effects of [MEDICATION NAME] R usually start working within about 30 minutes after your injection and usually lasts for up to 8 hours...." Review of Resident #1's Record of admitted d 03/02/12 revealed she was admitted to the facility on [DATE]. Review of Resident #1's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. Resident #1's Treatment Record dated 02/01/12 through 02/29/12 reflected her blood sugar results ranged from as low as 51 on 02/06/12 at 6:30 AM to as high as 454 on 02/24/12 at 4:00 PM. The back of Resident #1's Treatment Record reflected an entry dated 02/29/12 which indicated Resident #1's routine 70/30 insulin was held because her blood sugar result at 6:30 AM that day was 74. Resident #1's Treatment Record reflected on 02/29/12 the resident's [MEDICATION NAME] 70/30 insulin 30 units was not administered. The Record also reflected the next time her blood sugar was tested was on 02/29/12 at 11:30 AM, and the result was 286 and she was given six units of insulin. According to the Treatment Record, Resident #1's blood sugar was next tested on [DATE] at 4:00 PM the result was 364 and she received 10 units of insulin. Review of Resident #1's March 2012 physician's orders [REDACTED]. The physician's orders [REDACTED]. The Orders reflected [MEDICATION NAME] R 100 units/ml vial, inject sq as directed per sliding scale: 0-150 units = 0 insulin, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 = 10 units, 401-450 =12 units, 451 and greater give 12 units and call the physician. A Physician's Telephone Order dated 03/23/12 reflected to check Resident #1's blood sugar at 2:00 AM daily. Resident #1's undated Treatment Record, which the staff were using for April 2012, reflected on 04/01/12 at 2:00 AM her blood sugar result was 71 and she did not receive any insulin. Resident #1's Treatment Record reflected on 04/01/12 at 6:00 AM her blood sugar result was 62 and her routine [MEDICATION NAME] 70/30 insulin 30 units, which was scheduled for 8:00 AM, was held by the nurse because of the blood sugar result. Resident #1's Daily Skilled Nurses Notes dated 04/01/12 reflected her blood sugar result was 67 and the nurse gave the resident orange juice with sugar and the resident tolerated it well. The Notes also reflected the resident's blood sugar was tested 30 minutes later and it was 138. Resident #1's undated Treatment Record reflected on 04/01/12 the next time her blood sugar was tested was at 11:00 AM, and the result was 205 and she received four units of insulin, at 4:00 PM her blood sugar result was 347 and she received eight units of insulin, at 8:00 PM her blood sugar result was 393 and she received 10 units of insulin. Resident #1's Treatment Record also reflected on 04/02/12 her blood sugar result was 43 at 2:00 AM and she was given orange juice with a sugar packet in it and did not receive any insulin. The Treatment Record reflected on 04/02/12 at 6:00 AM her blood sugar result was 116. An interview with LVN A on 04/02/12 at 11:38 AM revealed she checked Resident #1's blood sugar that day at 6:30 AM and the result was 116. She stated she did not administer Resident #1's routine [MEDICATION NAME] 70/30 insulin because the resident did not require sliding scale coverage with the regular insulin. Further interview with LVN A on 04/02/12 at 12:56 PM revealed she did not administer Resident #1's routine [MEDICATION NAME] 70/30 Insulin 30 units, which was scheduled for 8:00 AM. When LVN A was asked why she did not give the resident her scheduled insulin, LVN A replied because Resident #1's blood sugar was 116. LVN A was asked to find the physician's orders [REDACTED]. LVN A stated there was no order. LVN A told the surveyor, "In most cases she's low (blood sugar) in the morning, maybe if I had given it (insulin), it (blood sugar) may have been in the 50's or 60's in the PM." LVN A said she worked with Resident #1 last weekend and her blood sugar was very low. The surveyor asked LVN A if she notified the physician when she made the decision to hold the scheduled insulin and/or to inform him of her findings of the blood sugar levels. She stated she had not called the physician. On 04/02/12 at 11:38 AM LVN A was observed to check the blood glucose level of Resident #1. The measured reading was 294. LVN A at that time said, "She is going to get six units of Regular Insulin." LVN A pulled out a vial of insulin dated 02/29/12 and said she had to get a newer one because the insulin she was expired. LVN A went and looked in the medication refrigerator and said she was unable to locate any other available insulin at that time. LVN A told the surveyor she was going to inform her supervisor she did not have any insulin for Resident #1. LVN A stated, because the resident's blood sugar was 116 on 04/02/12 at 6:30 AM and the resident did not require sliding scale coverage with the regular insulin, she was unaware she only had expired insulin available. ADON B instructed LVN A to continue to obtain the blood sugar levels on the other residents scheduled for a blood sugar check, while she looked into the regular insulin for Resident #1. Resident #1's undated Treatment Record reflected on 04/02/12 at 11:00 AM her blood sugar result was 294. An interview with LVN A on 04/02/12 at 12:13 PM revealed she called Resident #1's attending physician's physician assistant. LVN A stated the physician's assistant told her to give Resident #1 water for now and recheck her blood sugar when the insulin arrived. The surveyor heard LVN A on the phone with the physician's assistant and LVN A did not ask the physician's assistant if the resident's lunch needed to be held until the insulin was available. On 04/02/12 at 1:00 PM the resident's insulin arrived from the pharmacy. On 04/02/12 at 1:06 PM, Resident #1's blood sugar was tested again and the result was 353. Resident #1 was given 10 units of insulin at that time. Resident #1's undated Treatment Record reflected on 04/02/12 her blood sugar result at 4:00 PM was 380 and she received 10 units of insulin, and at 8:00 PM her blood sugar result was 311 and she received eight units of insulin. The Treatment Record reflected Resident #1's blood sugar result on 04/03/12 at 2:00 AM was 93 and she did not receive any insulin, at 6:00 AM her blood sugar result was 132 and she did not receive any insulin, at 11:00 AM her blood sugar result was 370 and she received eight units of insulin, at 4:00 PM her blood sugar result was 204 and she received four units of insulin, at 8:00 PM her blood sugar result was 401 and she received 12 units of insulin. Resident #1's Treatment Record reflected on 04/04/12 at 2:00 AM her blood sugar result was 237 On 04/02/12 at 1:31 PM, the Administrator removed LVN A from her nursing duties. B) Review of the website, http://www.[MEDICATION NAME].com/default.aspx, retrieved on 04/17/12 revealed the following on [MEDICATION NAME] Insulin: "[MEDICATION NAME]? is a man-made long-acting insulin that is used to control high blood sugar in adults and children with diabetes mellitus...." Review of the website, http://www.rxlist.com/[MEDICATION NAME]-drug/medication-guide.htm, retreived on 04/17/12 revealed the following: "...Take [MEDICATION NAME] exactly as your healthcare provider told you to take it...? Your healthcare provider will tell you how much [MEDICATION NAME] to take and when to take it. ? If you forget to take your dose of [MEDICATION NAME], your blood sugar may go too high ([MEDICAL CONDITION]). If high blood sugar ([MEDICAL CONDITION]) is not treated it can lead to serious problems, like loss of consciousness (passing out), coma <http://www.rxlist.com/script/main/art.asp?articlekey=2803> or even death...." Review of Resident #6's Record of admitted d 03/02/12 revealed she was admitted on 11/02/11. A review of Resident #6's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. Resident #6's March 2012 physician's orders [REDACTED]. The physician's orders [REDACTED]. The Orders reflected if the resident was responsive and blood sugar was 50-70, to give four to eight ounces of orange juice with a sugar packet and monitor blood sugar until the result was greater than 100. Resident #6's Orders reflected to hold the insulin or diabetic medications for finger stick blood sugar less than 100 until the resident ate. The Orders reflected if the resident was unresponsive or the blood sugar was less than 50 to inject ___ (the Orders did not specify what to inject) one mg sq as needed for blood sugar less than 60 and one mg every shift every 15 minutes times 2 and call 911. On 04/02/12 at 12:40 PM, the surveyor requested to see what insulin was stored on LVN A's medication cart. The following insulin was available: two vials of [MEDICATION NAME] R, dated 02/29/12 for Resident #1, one vial of [MEDICATION NAME] R dated 02/29/12 for Resident #6, one vial of [MEDICATION NAME]dated 02/29/12 for Resident #6 and one vial of [MEDICATION NAME] R dated 02/29/12. LVN A said, "These are all expired." Review of Resident #6's April 2012 MAR indicated [REDACTED]. The surveyor asked LVN A at that time, what vial of [MEDICATION NAME]she had used for the 8:00 AM scheduled dose for Resident #6. LVN A told the surveyor she did not administer that 8:00 AM dose. The surveyor asked her why she charted it had been administered. LVN A replied, "No comment." The surveyor then asked LVN A if she notified the physician when she did not administer the scheduled insulin. She stated she did not, but she had no further comment. An interview was conducted with LVN D, who was assigned to the 100 hall, on 04/02/12 at 5:32 PM. The surveyor asked if she had any resident who was scheduled to receive insulin on her shift. She identified Resident #6. LVN D said the resident was scheduled to receive [MEDICATION NAME]at 5:00 PM, but she did not have any available. LVN D told the surveyor she ordered the insulin at 3:00 PM, but it had not been delivered yet. During an interview with LVN D on 04/02/12 at 7:15 PM, she told the surveyor the [MEDICATION NAME]that was scheduled for 5:00 PM for Resident #6 had arrived. She said she was going to contact the attending physician for a directive. She said the insulin was now two hours late and the resident was also scheduled to have her blood sugar checked at 8:00 PM and had orders for sliding scale coverage. Following the physician contact, she told the surveyor the physician said to hold the [MEDICATION NAME]. A review of Resident #6's physician's orders [REDACTED]. The Order reflected to recheck Resident #6's blood sugar at 8:00 PM and give according to the sliding scale. The Order also reflected the [MEDICATION NAME] was on hold due to not being available. C) Review of Resident #4's Record of admitted d 01/26/12 revealed he was admitted to the facility on [DATE]. Review of Resident #4's MDS assessment dated [DATE] revealed his [DIAGNOSES REDACTED]. Review of Resident #4's March 2012 physician's orders [REDACTED]. The Orders also reflected a sliding scale for [MEDICATION NAME] R 100 units/ml and his fingerstick blood sugar should be checked twice daily. A telephone interview was conducted with LVN E on 04/04/12 at 12:45 PM. The surveyor requested additional information regarding her entry on the MAR for 04/02/12 at 8:00 PM. LVN E told the surveyor she only had expired [MEDICATION NAME] available. In addition she stated she used her nursing judgement to not administer the [MEDICATION NAME]because the resident's blood sugar was only 90. The surveyor asked her if she notified the physician when she held the scheduled insulin. LVN E stated she did not notify the resident's physician. Resident #4's April 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The initials of LVN E were circled for 8:00 PM. D) Review of Resident #2's Record of admitted d 11/28/11 revealed she was admitted to the facility on [DATE]. Review of Resident #2's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. The MDS assessment reflected she was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Resident #2's March 2012 physician's orders [REDACTED]. The Orders also reflected to give the resident orange juice and monitor BS >100. Resident #2's physician's orders [REDACTED].= 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 =10 units, 401-450 = 12 units, 451-500 = 14 units, and if greater than 501 call MD. LVN A was observed on 04/02/12 at 11:48 AM as she obtained the blood sugar level of Resident #2. Resident #2's blood sugar was 209 according to the reading. The surveyor asked LVN A if she had the needed insulin for Resident #2. LVN A replied, "She is usually low." The surveyor asked LVN A again if she had the ordered insulin for the resident if the resident required it based on her blood sugar result. LVN A pulled out a vial of [MEDICATION NAME] R insulin dated 02/29/12. The surveyor asked her what the date on the side of the bottle meant. She said it was the date the bottle was opened and the bottle had to be discarded after 28 days. On 04/02/12 at 12:21 PM, LVN A called Resident #2's attending physician and requested a return call. LVN A told the surveyor Resident #2's physician stated, "We can't let her stay like that. Get it from someone else." Resident #2's blood sugar was tested again on 04/02/12 at 1:15 PM and the result was 236. Resident #2 received four units of insulin at that time. E) Review of Resident #3's Record of admitted d 11/25/11 revealed she was admitted on [DATE]. Review of Resident #3's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #3 required limited assistance with bed mobility, dressing and personal hygiene. The assessment also reflected she required supervision with transfers, ambulation in the corridor and on and off the unit, eating and for toileting. Resident #3's March 2012 physician's orders [REDACTED]. The Orders also reflected the following sliding scale for [MEDICATION NAME] R 100 units/ml to be injected sq: 0-150 = 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 = ten units, 401- 450 = 12 units, 451-500 = 14 units, and if greater than 501 notify the Physician Assistant or Nurse Practitioner or Physician. The Orders reflected if the blood sugar result was 60 give orange juice and recheck. LVN A was observed on 04/02/12 at 11:56 AM as she obtained the blood sugar level of Resident #3. The measured reading was 264. Review of Resident #3's current physician's orders [REDACTED]. According to the physician's orders [REDACTED]. LVN A looked on the medication cart at that time and informed the surveyor she did not have any insulin for Resident #3. LVN A also looked in the medication refrigerator at that time and was unable to locate any insulin labeled for Resident #3. LVN A then went to LVN C, who worked on a different hall. She asked LVN C if she had any insulin on her cart. LVN C told her she had insulin for her residents. LVN A then asked if she could have some of the insulin, because she did not have any for Resident #3. LVN C informed her she could not use insulin belonging to another resident. LVN A said, "It's an emergency." LVN A then turned to the surveyor and asked the surveyor if it was okay to use another resident's insulin. The surveyor informed her the surveyor could not advise her as to what she needed to do. LVN C told LVN A she (LVN A) needed to notify Resident #3's physician. On 04/02/12 at 12:27 PM, LVN A stated she was placing a call to Resident #3's attending physician to inform him there was no insulin available for the resident. Resident #3's blood sugar was tested again on 04/02/12 at 1:26 PM and the result was 199. Resident #3 was given two units of insulin at that time. F) An interview with the Administrator on 04/02/12 at 2:38 PM revealed she was not sure who was responsible for ensuring residents' insulins were not expired. The Administrator stated she was not sure of the system, but she would find out. G) An interview with ADON B on 04/02/12 at 2:40 PM revealed staff were to write the date the vial of insulin was opened on the vial. She stated someone was not as caring as he/she needed to be. ADON B stated the nurses probably the other did it. H) Review of http://facts-about-diabetes.com/is-insulin-that-expires-in-a-month-still-good/ retrieved on 04/18/12 revealed, "...Problems Associated with Expired Insulin...Injectible insulin is less forgiving with expiration dates due to the issues of crystallization and degradation. Expiration dates are not pulled out of a hat and in the case of crystallization and degradation, disregarding said expiry dates could result not only in insulin's loss of potency, but also in fatal harm, since degradants usually turn into toxic materials after expiring. (This applies to a large number of injectible medicines as well) Even if the expired insulin is not toxic and has just lost a large part of its potency, it can still be harmful for diabetics specially those who are afflicted with type 1 diabetes mellitus...[DIAGNOSES REDACTED] is a serious health problem that is caused by too much sugar in the bloodstream for long periods of time. This affliction normally damages the vessels and organs that supply blood, and can lead to [MEDICAL CONDITIONS], kidney diseases and visual problems as well as permanent brain damage. [DIAGNOSES REDACTED] also has immediate effects that mimic an [MEDICAL CONDITION] attack both in severity and look, which can result in improper treatment if misdiagnosed ." I) An IJ was identified on 04/02/12 at 4:04 PM in the area of Quality of Care and the Administrator, Regional Director of Operations, RN O, and Social Worker P were informed of the IJ at that time and a Plan of Removal was requested. J) An interview with the Interim DON on 04/04/12 at approximately 10:45 AM revealed she thought the IJ occurred because the DON went out on medical leave and staff did not have anyone to answer to. She also stated there was a lack of leadership and people need to be held accountable. K) During an interview with the Medical Director on 04/03/12 at 9:56 AM, the surveyor asked if it would be his expectations that staff notify him when they made a nursing decision to hold a scheduled dose of insulin. He said it sounded as if an inservice would be beneficial to educate the nurses on long acting insulin. Regarding notification, he said they would be developing protocols regarding physician notification versus contacting a physician assistant. The surveyor asked the Medical Director if he was aware the nurse held a scheduled 8:00 AM dose of [MEDICATION NAME] 70/30 insulin for Resident #1, based on a blood sugar reading of 116, which was obtained one and half hours earlier on 04/02/12. He said he was not aware of that and again, he believed education regarding long term insulin versus short acting insulin was needed. L) Review of Resident #5's Record of admitted d 01/06/12 revealed an admission date of [DATE]. According to the Record of Admission, the resident's [DIAGNOSES REDACTED]. Resident #5's March 2012 physician's orders [REDACTED]. The Orders also reflected to inject [MEDICATION NAME] R 100 units/ml sq per the following sliding scale: 0-150 = 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301- 350 = eight units, 351-400 = 10 units, 401-450 = 12 units, 451-500 = 14 units, and if over 501 notify Physician, Physician Assistant or the Nurse Practitioner. Review of Resident #5's April 2012 MAR indicated [REDACTED]. Documentation on this MAR indicated [REDACTED]. The orders reflected four units of [MEDICATION NAME] R insulin were to be administered for a blood sugar measurement between 201- 250. An entry by LVN F reflected two units of [MEDICATION NAME] R insulin were administered at that time but not the four units, according to the physician ordered sliding scale. LVN G was the 2:00 PM to 10:00 PM nurse on duty at the time of this review. The surveyor asked LVN G if he could show the surveyor the [MEDICATION NAME] R insulin that was available for Resident #5. LVN G opened the drawer of the medication cart at that time cart and was unable to locate any insulin for Resident #5. At that time, LVN F, who worked the 6:00 AM to 2:00 PM shift, wanted to know if there was a problem. The surveyor reviewed Resident #5's April 2012 MAR indicated [REDACTED]. She also looked on the medication cart at that time and was unable to locate any insulin for Resident #5. LVN F then told the surveyor she obtained the insulin from the Emergency Kit (E kit) in the refrigerator. (The E-Kit contained a variety of insulin for emergency use and had been newly implemented on 04/02/12.) The surveyor asked LVN F if she would show the surveyor the Emergency Kit. LVN F and the surveyor went to the medication room and LVN F pulled out the Emergency insulin box from the refrigerator. LVN F said that was the box she got the insulin from. The surveyor asked her how she was able to use the insulin from the Emergency box, when the seal had not been broken. LVN F at that time said, "I was pretty sure I got it from the E-Kit." LVN F said she wanted to look again in the medication cart. She said the insulin had to be there. No insulin was located. On 04/03/12 at 3:02 PM, LVN F told the surveyor she just remembered she had not administered the insulin because it was discontinued. She said she forgot to circle her initials to indicate she did not administer the insulin. A review of Resident #5's March 2012 physician's orders [REDACTED]. During an interview with LVN G on 04/04/12, at approximately 3:00 PM, he said he contacted Resident #5's physician for clarification, because he was certain the blood sugar checks with sliding scale coverage had been discontinued. LVN G said he did receive a new order to discontinue the sliding scale on 04/03/12. M) The Plan of Removal was accepted on 04/03/12 at 10:44 AM and reflected the following: "Licensed Nurse was removed from her assignment and suspended pending facility investigation at 1:30 PM, April 2, 2012. An allegation of Neglect has been self-reported to DADS at 3:00 PM, April 2, 2012: In-serviced licensed staff on: Diabetics with Insulin Order for sliding scale: parameters for calling the physician if < or > Need of Emergency orders when < (to be identified by physician) this includes OJ, Gel [MEDICATION NAME] injections, IVs. Use of insulin 'E-kit' when > than (to be identified by the physician.) MAR documentation: Initials, results, units given, site Dating: date vial when opened, good for 28 days Tool implemented for checking medication cart for expired medications. Assessment of resident, documentation, and notification The consulting RN provided In-service to the 2-10 staff at 2:10 PM, April 2, 2012, and the 6-2 PM shift at 2:30 PM, April 2, 2012. the consulting RN has trained the Staffing Coordinator (LVN) at 6:00 PM, April 2, 2012 on said inservice to be provided to the 10 PM-6:00 AM shift at 10:00 PM this evening, April 2, 2012. All nurses will be in-serviced prior to scheduled shift by Friday, April 6, 2012. Nurses are on a four days on, two days off schedule. The nurses currently in-serviced are on duty thru April 5, 2012. New on coming nurses will be inserviced prior to the start of their shift. The consulting RN and facility ADONs will randomly conduct at least four insulin medication pass competencies each day through Friday, April 6, 2012. 100% audit of all medication carts will be completed by 11:00 PM on April 2, 2012 by Two ADONs from a sister facility and two facility LVNs, to ensure that all medications are available and removal of any and all expired medications. Any medication identified as not available, the physician will be contacted for further recommendation, along with notifying the DON, and the medication will be 'STAT' ordered from the pharmacy for delivery that day. Implemented the use of a Medication Cart/Medication Room weekly audit tool. This tool will be completed by facility charge nurse and submitted to the ADON upon completion each week. Any medication issues identified will be addressed immediately. The facility ADONs will weekly randomly audit forms against the medication carts. 100% audit of medication room for expired medication. The facility ADON, LVN completed this at 5:00 PM on April 2, 2012. Med error reports have been completed on the three identified residents, which included physician notification. This was completed at 5:00 PM on April 2, 2012. The interim DON has completed an assessment of all resident receiving insulin, including an off cycle blood glucose check, to ensure each resident is stable. All residents receiving insulin have been assessed as of 5:30 PM on April 2, 2012. As of 7:25 PM, April 2, 2012, all insulin's are in the facility and admini

Based on observation, interview and record review, it was determined the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing and administering of medications for seven (Residents #1, #2, #3, #4, #5, #6, and #8) of 23 Diabetic residents reviewed for pharmacy services. 1) LVN A held Resident #1's routine Novolin 70/30 insulin scheduled for 8:00 AM on 04/02/12 without a physician's orders [REDACTED]. The available insulin should have been discarded on 03/28/12 and the resident did not receive the needed insulin at that time. The April 2012 MAR for Resident #1 indicated LVN A administered 70/30 insulin to Resident #1, but she did not administer it. 2) Resident #6 had a physician's orders [REDACTED]. On 04/02/12, the available insulin should have been discarded on 03/28/12, so Resident #6 did not received her scheduled insulin that morning. Resident #6's Levemir insulin was ordered on [DATE] at 3:00 PM and it was not delivered from the pharmacy in time for her 5:00 PM scheduled dose. Resident #6's April 2012 MAR indicated [REDACTED]. Resident #6's physician's orders [REDACTED]. 3) Resident #4 had routine Levemir insulin 100 units/ml inject 10 units sq every night at bedtime. LVN F did not administer the insulin because the insulin was expired. LVN F also stated the resident's blood sugar was 90 and she thought the insulin should have been held due to his blood sugar. 4) Resident #3 had an elevated blood sugar of 264 and required coverage with Novolin R insulin. There was no insulin available for the resident. 5) LVN F documented insulin was administered to Resident #5 on 04/02/12 at 11:30 AM, but LVN F said she did not give the insulin. LVN F said the physician discontinued the fingerstick blood sugar checks, but there was not a physician's orders [REDACTED]. 6) Resident #2 had an elevated blood sugar of 209 and required coverage with Novolin R insulin. The available insulin should have been discarded on 03/28/12 and the resident did not receive the needed insulin at that time 7) Insulin orders for Resident #8 did not specify the specific type of insulin to be used for the sliding scale coverage. An Immediate Jeopardy (IJ) was identified on 04/02/12. While the IJ was removed on 04/04/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because the facility was still monitoring the Plan of Removal. These failures had the potential to affect the 23 residents with Diabetes, including Residents #1, #2, #3, #4, #5, #6 and #8, by placing them at risk for inadequate control of blood sugars leading to diabetic coma, shock and death. Findings included: A) Review of the website, http://www.rxlist.com/humulin-70-30-drug.htm, retrieved on 04/17/12 revealed the following information about Humulin 70/30 insulin: "...The dosage is based on your medical condition and response to therapy. Measure each dose very carefully because even small changes in the amount of insulin may have a large effect on your blood sugar levels...Use this medication regularly as directed by your doctor to get the most benefit from it...It is very important to follow your insulin regimen exactly. Do not miss any doses of insulin. Discuss specific instructions with your doctor now in case you miss a dose of insulin in the future...." Review of the website, <http://www.drugs.com/mtm/novolin-r.html>, retrieved on 04/17/12 revealed the following information about Regular insulin: "...Insulin is a hormone that is produced in the body. It works by lowering levels of glucose (sugar) in the blood. Insulin regular is a short-acting form of insulin...Use exactly as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label...." Review of the website, http://www.rxlist.com/novolin-r-drug/clinical-pharmacology.htm, retrieved on 04/17/12 revealed the following about Novolin-R insulin: "...Novolin R is a short-acting insulin. When injected subcutaneously, the glucose-lowering effect of Novolin R begins approximately 30 minutes post-dose, is maximal between 1.5 and 3.5 hours post-dose and terminates approximately 8 hours post-dose...How should I take Novolin R? ? Novolin R comes in 10 mL vials for use with a syringe <http://www.rxlist.com/script/main/art.asp?articlekey=9462>. ? Take Novolin R exactly as prescribed. ? Your healthcare provider will tell you how much Novolin R to take and when to take it. ?Do not make any changes to your dose or type of insulin unless you are told to do so by your healthcare provider. ? The effects of Novolin R usually start working within about 30 minutes after your injection and usually lasts for up to 8 hours...." Review of Resident #1's Record of admitted d 03/02/12 revealed she was admitted to the facility on [DATE]. Review of Resident #1's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. Resident #1's Treatment Record dated 02/01/12 through 02/29/12 reflected her blood sugar results ranged from as low as 51 on 02/06/12 at 6:30 AM to as high as 454 on 02/24/12 at 4:00 PM. The back of Resident #1's Treatment Record reflected an entry dated 02/29/12 which indicated Resident #1's routine 70/30 insulin was held because her blood sugar result at 6:30 AM that day was 74. Resident #1's Treatment Record reflected on 02/29/12 the resident's Novolin 70/30 insulin 30 units was not administered. The Record also reflected the next time her blood sugar was tested was on 02/29/12 at 11:30 AM, and the result was 286 and she was given six units of insulin. According to the Treatment Record, Resident #1's blood sugar was next tested on [DATE] at 4:00 PM the result was 364 and she received 10 units of insulin. Review of Resident #1's March 2012 physician's orders [REDACTED]. The physician's orders [REDACTED]. The Orders reflected Novolin R 100 units/ml vial, inject sq as directed per sliding scale: 0-150 units = 0 insulin, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 = 10 units, 401-450 =12 units, 451 and greater give 12 units and call the physician. A Physician's Telephone Order dated 03/23/12 reflected to check Resident #1's blood sugar at 2:00 AM daily. Resident #1's undated Treatment Record, which the staff were using for April 2012, reflected on 04/01/12 at 2:00 AM her blood sugar result was 71 and she did not receive any insulin. Resident #1's Treatment Record reflected on 04/01/12 at 6:00 AM her blood sugar result was 62 and her routine Novolin 70/30 insulin 30 units, which was scheduled for 8:00 AM, was held by the nurse because of the blood sugar result. Resident #1's Daily Skilled Nurses Notes dated 04/01/12 reflected her blood sugar result was 67 and the nurse gave the resident orange juice with sugar and the resident tolerated it well. The Notes also reflected the resident's blood sugar was tested 30 minutes later and it was 138. Resident #1's undated Treatment Record reflected on 04/01/12 the next time her blood sugar was tested was at 11:00 AM, and the result was 205 and she received four units of insulin, at 4:00 PM her blood sugar result was 347 and she received eight units of insulin, at 8:00 PM her blood sugar result was 393 and she received 10 units of insulin. Resident #1's Treatment Record also reflected on 04/02/12 her blood sugar result was 43 at 2:00 AM and she was given orange juice with a sugar packet in it and did not receive any insulin. The Treatment Record reflected on 04/02/12 at 6:00 AM her blood sugar result was 116. An interview with LVN A on 04/02/12 at 11:38 AM revealed she checked Resident #1's blood sugar that day at 6:30 AM and the result was 116. She stated she did not administer Resident #1's routine Novolin 70/30 insulin because the resident did not require sliding scale coverage with the regular insulin. Further interview with LVN A on 04/02/12 at 12:56 PM revealed she did not administer Resident #1's routine Novolin 70/30 Insulin 30 units, which was scheduled for 8:00 AM. When LVN A was asked why she did not give the resident her scheduled insulin, LVN A replied because Resident #1's blood sugar was 116. LVN A was asked to find the physician's orders [REDACTED]. LVN A stated there was no order. LVN A told the surveyor, "In most cases she's low (blood sugar) in the morning, maybe if I had given it (insulin), it (blood sugar) may have been in the 50's or 60's in the PM." LVN A said she worked with Resident #1 last weekend and her blood sugar was very low. The surveyor asked LVN A if she notified the physician when she made the decision to hold the scheduled insulin and/or to inform him of her findings of the blood sugar levels. She stated she had not called the physician. On 04/02/12 at 11:38 AM LVN A was observed to check the blood glucose level of Resident #1. The measured reading was 294. LVN A at that time said, "She is going to get six units of Regular Insulin." LVN A pulled out a vial of insulin dated 02/29/12 and said she had to get a newer one because the insulin she was expired. LVN A went and looked in the medication refrigerator and said she was unable to locate any other available insulin at that time. LVN A told the surveyor she was going to inform her supervisor she did not have any insulin for Resident #1. LVN A stated, because the resident's blood sugar was 116 on 04/02/12 at 6:30 AM and the resident did not require sliding scale coverage with the regular insulin, she was unaware she only had expired insulin available. ADON B instructed LVN A to continue to obtain the blood sugar levels on the other residents scheduled for a blood sugar check, while she looked into the regular insulin for Resident #1. Resident #1's undated Treatment Record reflected on 04/02/12 at 11:00 AM her blood sugar result was 294. An interview with LVN A on 04/02/12 at 12:13 PM revealed she called Resident #1's attending physician's physician assistant. LVN A stated the physician's assistant told her to give Resident #1 water for now and recheck her blood sugar when the insulin arrived. The surveyor heard LVN A on the phone with the physician's assistant and LVN A did not ask the physician's assistant if the resident's lunch needed to be held until the insulin was available. On 04/02/12 at 1:00 PM the resident's insulin arrived from the pharmacy. On 04/02/12 at 1:06 PM, Resident #1's blood sugar was tested again and the result was 353. Resident #1 was given 10 units of insulin at that time. Resident #1's undated Treatment Record reflected on 04/02/12 her blood sugar result at 4:00 PM was 380 and she received 10 units of insulin, and at 8:00 PM her blood sugar result was 311 and she received eight units of insulin. The Treatment Record reflected Resident #1's blood sugar result on 04/03/12 at 2:00 AM was 93 and she did not receive any insulin, at 6:00 AM her blood sugar result was 132 and she did not receive any insulin, at 11:00 AM her blood sugar result was 370 and she received eight units of insulin, at 4:00 PM her blood sugar result was 204 and she received four units of insulin, at 8:00 PM her blood sugar result was 401 and she received 12 units of insulin. Resident #1's Treatment Record reflected on 04/04/12 at 2:00 AM her blood sugar result was 237 On 04/02/12 at 1:31 PM, the Administrator removed LVN A from her nursing duties. B) Review of the website, http://www.levemir.com/default.aspx, retrieved on 04/17/12 revealed the following on Levemir Insulin: "...Levemir? is a man-made long-acting insulin that is used to control high blood sugar in adults and children with diabetes mellitus...." Review of the website, http://www.rxlist.com/levemir-drug/medication-guide.htm, retreived on 04/17/12 revealed the following: "...Take LEVEMIR exactly as your healthcare provider told you to take it...? Your healthcare provider will tell you how much LEVEMIR to take and when to take it. ? If you forget to take your dose of LEVEMIR, your blood sugar may go too high (hyperglycemia). If high blood sugar (hyperglycemia) is not treated it can lead to serious problems, like loss of consciousness (passing out), coma <http://www.rxlist.com/script/main/art.asp?articlekey=2803> or even death...." Review of Resident #6's Record of admitted d 03/02/12 revealed she was admitted on 11/02/11. A review of Resident #6's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. Resident #6's March 2012 physician's orders [REDACTED]. The physician's orders [REDACTED]. The Orders reflected if the resident was responsive and blood sugar was 50-70, to give four to eight ounces of orange juice with a sugar packet and monitor blood sugar until the result was greater than 100. Resident #6's Orders reflected to hold the insulin or diabetic medications for finger stick blood sugar less than 100 until the resident ate. The Orders reflected if the resident was unresponsive or the blood sugar was less than 50 to inject ___ (the Orders did not specify what to inject) one mg sq as needed for blood sugar less than 60 and one mg every shift every 15 minutes times 2 and call 911. On 04/02/12 at 12:40 PM, the surveyor requested to see what insulin was stored on LVN A's medication cart. The following insulin was available: two vials of Novolin R, dated 02/29/12 for Resident #1, one vial of Novolin R dated 02/29/12 for Resident #6, one vial of Levemir insulin dated 02/29/12 for Resident #6 and one vial of Novolin R dated 02/29/12. LVN A said, "These are all expired." Review of Resident #6's April 2012 MAR indicated [REDACTED]. The surveyor asked LVN A at that time, what vial of Levemir insulin she had used for the 8:00 AM scheduled dose for Resident #6. LVN A told the surveyor she did not administer that 8:00 AM dose. The surveyor asked her why she charted it had been administered. LVN A replied, "No comment." The surveyor then asked LVN A if she notified the physician when she did not administer the scheduled insulin. She stated she did not, but she had no further comment. An interview was conducted with LVN D, who was assigned to the 100 hall, on 04/02/12 at 5:32 PM. The surveyor asked if she had any resident who was scheduled to receive insulin on her shift. She identified Resident #6. LVN D said the resident was scheduled to receive Levemir insulin at 5:00 PM, but she did not have any available. LVN D told the surveyor she ordered the insulin at 3:00 PM, but it had not been delivered yet. During an interview with LVN D on 04/02/12 at 7:15 PM, she told the surveyor the Levemir insulin that was scheduled for 5:00 PM for Resident #6 had arrived. She said she was going to contact the attending physician for a directive. She said the insulin was now two hours late and the resident was also scheduled to have her blood sugar checked at 8:00 PM and had orders for sliding scale coverage. Following the physician contact, she told the surveyor the physician said to hold the Levemir. A review of Resident #6's physician's orders [REDACTED]. The Order reflected to recheck Resident #6's blood sugar at 8:00 PM and give according to the sliding scale. The Order also reflected the Levemir was on hold due to not being available. C) Review of Resident #4's Record of admitted d 01/26/12 revealed he was admitted to the facility on [DATE]. Review of Resident #4's MDS assessment dated [DATE] revealed his [DIAGNOSES REDACTED]. Review of Resident #4's March 2012 physician's orders [REDACTED]. The Orders reflected if the resident was unresponsive, AMS or had a BS less than 50 inject 1 mg (the medication to be injected was not specified) IM or sq as needed for BS less than 60 and the remainder of the order was unreadable. Resident #4's March 2012 physician's orders [REDACTED].= 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351- 400 = 10 units, 401-450 = 12 units, 451-500 = 14 units and if greater than 500 notify the Physician, the Physician Assistant or the Nurse Practitioner. The Orders also reflected Glucagon one mg kit, inject one mg as needed. On 04/04/12 at 9:01 AM, a review of Resident #4's April 2012 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The initials of LVN E were circled for 8:00 PM. A telephone interview was conducted with LVN E on 04/04/12 at 12:45 PM. The surveyor requested additional information regarding her entry on the MAR for 04/02/12 at 8:00 PM. LVN E told the surveyor she only had expired Levemir available. In addition she stated she used her nursing judgement to not administer the Levemir insulin because the resident's blood sugar was only 90. The surveyor asked her if she notified the physician when she held the scheduled insulin. LVN E stated she did not notify the resident's physician. D) Review of Resident #2's Record of admitted d 11/28/11 revealed she was admitted to the facility on [DATE]. Review of Resident #2's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. The MDS assessment reflected she was totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. Resident #2's March 2012 physician's orders [REDACTED]. The Orders also reflected to give the resident orange juice and monitor BS >100. Resident #2's physician's orders [REDACTED].= 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 =10 units, 401-450 = 12 units, 451-500 = 14 units, and if greater than 501 call MD. LVN A was observed on 04/02/12 at 11:48 AM as she obtained the blood sugar level of Resident #2. Resident #2's blood sugar was 209 according to the reading. The surveyor asked LVN A if she had the needed insulin for Resident #2. LVN A replied, "She is usually low." The surveyor asked LVN A again if she had the ordered insulin for the resident if the resident required it based on her blood sugar result. LVN A pulled out a vial of Novolin R insulin dated 02/29/12. The surveyor asked her what the date on the side of the bottle meant. She said it was the date the bottle was opened and the bottle had to be discarded after 28 days. On 04/02/12 at 12:21 PM, LVN A called Resident #2's attending physician and requested a return call. LVN A told the surveyor Resident #2's physician stated, "We can't let her stay like that. Get it from someone else." Resident #2's blood sugar was tested again on 04/02/12 at 1:15 PM and the result was 236. Resident #2 received four units of insulin at that time. E) Review of Resident #3's Record of admitted d 11/25/11 revealed she was admitted on [DATE]. Review of Resident #3's MDS assessment dated [DATE] revealed her [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #3 required limited assistance with bed mobility, dressing and personal hygiene. The assessment also reflected she required supervision with transfers, ambulation in the corridor and on and off the unit, eating and for toileting. Resident #3's March 2012 physician's orders [REDACTED]. The Orders also reflected the following sliding scale for Novolin R 100 units/ml to be injected sq: 0-150 = 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301-350 = eight units, 351-400 = ten units, 401- 450 = 12 units, 451-500 = 14 units, and if greater than 501 notify the Physician Assistant or Nurse Practitioner or Physician. The Orders reflected if the blood sugar result was 60 give orange juice and recheck. LVN A was observed on 04/02/12 at 11:56 AM as she obtained the blood sugar level of Resident #3. The measured reading was 264. Review of Resident #3's current physician's orders [REDACTED]. According to the physician's orders [REDACTED]. LVN A looked on the medication cart at that time and informed the surveyor she did not have any insulin for Resident #3. LVN A also looked in the medication refrigerator at that time and was unable to locate any insulin labeled for Resident #3. LVN A then went to LVN C, who worked on a different hall. She asked LVN C if she had any insulin on her cart. LVN C told her she had insulin for her residents. LVN A then asked if she could have some of the insulin, because she did not have any for Resident #3. LVN C informed her she could not use insulin belonging to another resident. LVN A said, "It's an emergency." LVN A then turned to the surveyor and asked the surveyor if it was okay to use another resident's insulin. The surveyor informed her the surveyor could not advise her as to what she needed to do. LVN C told LVN A she (LVN A) needed to notify Resident #3's physician. On 04/02/12 at 12:27 PM, LVN A stated she was placing a call to Resident #3's attending physician to inform him there was no insulin available for the resident. Resident #3's blood sugar was tested again on 04/02/12 at 1:26 PM and the result was 199. Resident #3 was given two units of insulin at that time. F) Review of Resident #5's Record of admitted d 01/06/12 revealed an admission date of [DATE]. According to the Record of Admission, the resident's [DIAGNOSES REDACTED]. Resident #5's March 2012 physician's orders [REDACTED]. The Orders also reflected to inject Novolin R 100 units/ml sq per the following sliding scale: 0-150 = 0 units, 151-200 = two units, 201-250 = four units, 251-300 = six units, 301- 350 = eight units, 351-400 = 10 units, 401-450 = 12 units, 451-500 = 14 units, and if over 501 notify Physician, Physician Assistant or the Nurse Practitioner. Review of Resident #5's April 2012 MAR indicated [REDACTED]. Documentation on this MAR indicated [REDACTED]. The orders reflected four units of Novolin R insulin were to be administered for a blood sugar measurement between 201- 250. An entry by LVN F reflected two units of Novolin R insulin were administered at that time but not the four units, according to the physician ordered sliding scale. LVN G was the 2:00 PM to 10:00 PM nurse on duty at the time of this review. The surveyor asked LVN G if he could show the surveyor the Novolin R insulin that was available for Resident #5. LVN G opened the drawer of the medication cart at that time cart and was unable to locate any insulin for Resident #5. At that time, LVN F, who worked the 6:00 AM to 2:00 PM shift, wanted to know if there was a problem. The surveyor reviewed Resident #5's April 2012 MAR indicated [REDACTED]. She also looked on the medication cart at that time and was unable to locate any insulin for Resident #5. LVN F then told the surveyor she obtained the insulin from the Emergency Kit (E kit) in the refrigerator. (The E-Kit contained a variety of insulin for emergency use and had been newly implemented on 04/02/12.) The surveyor asked LVN F if she would show the surveyor the Emergency Kit. LVN F and the surveyor went to the medication room and LVN F pulled out the Emergency insulin box from the refrigerator. LVN F said that was the box she got the insulin from. The surveyor asked her how she was able to use the insulin from the Emergency box, when the seal had not been broken. LVN F at that time said, "I was pretty sure I got it from the E-Kit." LVN F said she wanted to look again in the medication cart. She said the insulin had to be there. No insulin was located. On 04/03/12 at 3:02 PM, LVN F told the surveyor she just remembered she had not administered the insulin because it was discontinued. She said she forgot to circle her initials to indicate she did not administer the insulin. A review of Resident #5's March 2012 physician's orders [REDACTED]. During an interview with LVN G on 04/04/12, at approximately 3:00 PM, he said he contacted Resident #5's physician for clarification, because he was certain the blood sugar checks with sliding scale coverage had been discontinued. LVN G said he did receive a new order to discontinue the sliding scale on 04/03/12. G) An interview with the Administrator on 04/02/12 at 2:38 PM revealed she was not sure who was responsible for ensuring residents' insulins were not expired. The Administrator stated she was not sure of the system, but she would find out. H) An interview with ADON B on 04/02/12 at 2:40 PM revealed staff were to write the date the vial of insulin was opened on the vial. She stated someone was not as caring as he/she needed to be. ADON B stated the nurses probably the other did it. I) Review of http://facts-about-diabetes.com/is-insulin-that-expires-in-a-month-still-good/ retrieved on 04/18/12 revealed, "...Problems Associated with Expired Insulin...Injectible insulin is less forgiving with expiration dates due to the issues of crystallization and degradation. Expiration dates are not pulled out of a hat and in the case of crystallization and degradation, disregarding said expiry dates could result not only in insulin's loss of potency, but also in fatal harm, since degradants usually turn into toxic materials after expiring. (This applies to a large number of injectible medicines as well) Even if the expired insulin is not toxic and has just lost a large part of its potency, it can still be harmful for diabetics specially those who are afflicted with type 1 diabetes mellitus...[DIAGNOSES REDACTED] is a serious health problem that is caused by too much sugar in the bloodstream for long periods of time. This affliction normally damages the vessels and organs that supply blood, and can lead to heart diseases, strokes, kidney diseases and visual problems as well as permanent brain damage. [DIAGNOSES REDACTED] also has immediate effects that mimic an epilepsy attack both in severity and look, which can result in improper treatment if misdiagnosed ." J) An IJ was identified on 04/02/12 at 4:04 PM in the area of Quality of Care and the Administrator, Regional Director of Operations, RN O, and Social Worker P were informed of the IJ at that time and a Plan of Removal was requested. K) An interview with the Interim DON on 04/04/12 at approximately 10:45 AM revealed she thought the IJ occurred because the DON went out on medical leave and staff did not have anyone to answer to. She also stated there was a lack of leadership and people need to be held accountable. L) Review of the Record of admitted d 02/27/12 for Resident #8 revealed she was admitted on [DATE] and her [DIAGNOSES REDACTED]. Review of Resident #8's Physician's admission orders Insulin R 100 U/ml/sliding scale. Inject Sub Q (subcutaneous) as needed prn." The specific type of insulin to be used was not ordered and the dosage of the insulin was not specified. The order further failed to specify parameters as to the prn ( as needed). The nurses signature as having obtained these orders was the signature of the Interim DON. Observation on 04/03/12 at 2:50 PM of the insulin available for Resident #8 revealed it was Novolin R. There was an undated MAR for Resident #8 in the current book used for the medication pass. An entry on this undated MAR for 04/02/12 reflected a blood sugar result of 127 was entered on the 6:00 AM to 2:00 PM shift and two units of insulin were administered, but the entry did not specify the type of insulin administered. A blood sugar level of 139 was documented on 04/03/12 for the 6:00 AM to 2:00 PM shift, but the amount and type of insulin administered was unreadable. An interview was conducted with the Interim DON on 04/03/12 at 4:04 PM. The surveyor asked the Interim DON to review the handwritten order and clarify for the surveyor what specific insulin had been ordered for the sliding scale coverage. The Interim DON acknowledged the order required clarification as to the type of insulin the physician desired to be used for the sliding scale coverage. M) During an interview with the Medical Director on 04/03/12 at 9:56 AM, the surveyor asked if it would be his expectations that staff notify him when they made a nursing decision to hold a scheduled dose of insulin. He said it sounded as if an inservice would be beneficial to educate the nurses on long acting insulin. Regarding notification, he said they would be developing protocols regarding physician notification versus contacting a physician assistant. The surveyor asked the Medical Director if he was aware the nurse held a scheduled 8:00 AM dose of Novolin 70/30 insulin for Resident #1, based on a blood