Every finding on record at Living Center, The

Based on interview and record review, the facility failed to notify the resident's representative and/or physician of a change in condition or treatment for two residents (Residents #1 and #4). Resident #1 was treated with permethrin cream (a topical cream used to treat scabies and lice) on 07/04/26. Staff did not notify the resident's representative until 07/07/26 when the representative questioned the rash when he/she visited the resident at the facility. Resident #4, who had a history of verbal aggression, exhibited verbally aggressive behaviors directed towards another resident on 07/11/26. The facility did not notify the resident's representative or the physician of the resident's behaviors as directed in the resident's plan of care. The facility census was 65. Review of the facility policy titled Change in a Resident's Condition or Status, dated 09/19/26, showed the following:-Our facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status;-The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition;-A need to alter the resident's medical treatment significantly;-Unless otherwise instructed by the resident, the nurse supervisor/charge nurse will notify the resident's next of kin or representative when there is a significant change in the resident's physical, mental, or psychosocial status, there is a need to change the resident's room assignment;-Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical, mental condition or status;-The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 1. Review of Resident #1's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 05/08/26, showed the following:-Severe cognitive impairment;-Dependent on staff for toilet hygiene, lower body dressing, and personal hygiene; -Substantial to maximum assistance required from staff with bathing;-Partial to moderate assistance required from staff with upper body dressing;-No rashes present. Review of the resident's undated Face Sheet, revised 06/10/26, showed the resident the facility identified two family members as the resident's next of kin and responsible party. Review of the resident's shower sheet, dated 06/27/26, showed the following:-Visual assessment: redness, scratches and rashes to the resident's lower extremities and back;-The charge nurse signed the form. Review of the resident's Physician Order Sheet (POS), dated 07/04/26, showed the resident's physician ordered permethrin 5% topical cream on 07/04/26. Review of the resident's medical record showed no documentation staff notified the resident's family of the new physician orders received on 07/04/26 for permethrin cream or of the rash/suspected scabies (a tiny mite that burrows under the skin). Review of the resident's Progress Note, dated 07/07/26, showed the following:-Staff spoke with the resident's second next of kin via phone that morning. The resident's second next of kin was concerned the resident had not been treated for his/her rash;-Staff informed him/her the resident had been treated for the rash with permethrin cream on 07/04/26. During an interview on 07/28/26 at 2:15 P.M., the resident's second next of kin said the following:-He/She was aware the resident had been itching a lot, and the facility was trying to determine the cause of the itching around 06/25/26;-He/She visited the resident on 07/07/26 and noticed the resident had a severe rash, and the resident was scratching to the point of bleeding;-A family member of another resident who was visiting said they were testing residents for scabies;-Staff at the facility did not notify him/her of the resident's rash or treatment that started on 7/04/26 until he/she saw the rash and questioned the staff about it on 07/07/26;-He/She visited the resident routinely at the facility and was very upset no one had notified him/her of the rash, the medication changes and the potential diagnosis of scabies. During an interview on 07/28/26 at 11:40 A.M., the resident's first next of kin said the resident was itching a lot, and staff told him/her (could not recall when) the resident had been treated with a cream. He/She was not sure what the cream was for. Staff did not tell him/her they suspected the rash was scabies. 2. Review of Resident #4's undated Face Sheet showed the resident's family member was his/her first emergency contact. Review of the resident's quarterly MDS, dated [DATE], showed the following:-Diagnoses included cerebral vascular accident (stroke), hemiparesis (muscle weakness or partial loss of control of one side of the body) and traumatic brain injury (damage to the brain caused by an external physical force, such as a violent blow or bump or jolt to the head which disrupts normal brain function and ranges from mild to severe);-Cognitively intact;-Upper and lower extremity impairment on one side;-Verbal behaviors directed towards others occurred one to three days. Review of the resident's Care Plan, dated 06/5/26, showed the following:-Observe the resident's mood, pain, expressions, and abilities. Notify the nurse/primary care physician of any changes;-Observe the resident for worsening irritability and notify the primary care provider of any change. Review of the resident's Progress Note, dated 07/11/26, showed the following:-Resident #4 went up to another resident in the dayroom and said, What the fuck are you looking at fucker?-Staff told Resident #4 to go to his/her room. Resident #4 would not move away from the other resident, so staff told Resident #4 again he/she needed to go back to his/her room and his/her comment was inappropriate;-Resident #4 wheeled himself/herself back to his/her room;-Staff to keep the residents separated for safety; (Review showed no documentation staff notified the resident's family or physician of the resident's behavior.) During an interview on 08/10/26 at 8:30 A.M., the resident's family member said the following:-The facility did not notify him/her of the incident that occurred on 07/11/26;-He/She wanted staff to notify him/her when the resident exhibited any verbal behaviors. 3. During an interview on 7/28/26 at 5:00 P.M., the Administrator said staff should follow the facility policy regarding change in condition and document in the medical record when staff notified the family/representative or physician. She was not aware of the resident's verbal behaviors on 07/11/26. She expected staff to notify her and the resident's family of the resident's behaviors. She would have to look at the situation to see if they would notify the physician. 30719482749175

Based on interview and record review, the facility failed to ensure one resident (Resident #4), with a diagnosis of a traumatic brain injury (damage to the brain caused by an external physical force, such as a violent blow or bump or jolt to the head which disrupts normal brain function and ranges from mild to severe), in a review of 11 sampled residents, received appropriate treatment and services to attain their highest practicable mental and psychosocial well-being. Staff failed to implement individualized interventions based on the resident's behavioral symptoms and underlying causes and to communicate these interventions to staff in order to address the resident's verbally aggressive behaviors directed towards his/her previous roommate (Resident #5). The facility census was 65.Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, dated 12/2016, showed the following:-As a part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness;-The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior and cognition, including onset, duration, intensity and frequency of behavioral symptoms.-The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address modifiable factors that may have contributed to the resident's change in condition;-The IDT will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm;-Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, at a minimum, a description of the behavioral symptoms including the frequency, intensity, duration, outcomes, location and environment and any precipitating factors of the situations;-Targeted and individualized interventions for behavioral and/or psychosocial symptoms;-The rationale for the intervention and approaches;-Specific and measurable goals for targeted behaviors and how staff will monitor for effectiveness. 1. Review of Resident #4's Care Plan, revised 08/28/25, showed the following:-The resident came to the facility after a stroke affecting the resident's right side;-The resident had a history of brain injury and depression;-The resident got irritated with others at times; -The resident took medication for depression and anxiety;-Observe the resident's mood, pain, expressions, and abilities. Notify the nurse/primary care physician (PCP) of any changes;-Follow with a psychiatrist if needed. Review of the resident's Progress Note, 02/14/26 at 6:38 P.M., showed the resident was in the dining room and started to go after his/her roommate (Resident #5) who was also in the dining room. The resident was being verbally aggressive towards his/her roommate. The resident said the roommate stole his/her remote control. The charge nurse and the aide searched the resident's room and said the remote could not be found. The resident said he/she was going to beat the shit out of the roommate several times. Staff separated them for the remainder of the day. Registered Nurse (RN) Supervisor made aware. Review of the resident's Care Plan, last revised 8/25/25, showed it did not identify the resident's verbally aggressive behaviors directed towards his/her previous roommate after the incident on 02/14/26 and did not include specific interventions to address the resident's verbally aggressive behaviors. Review of the resident's Behavior Management Evaluation, dated 03/01/26 at 4:49 P.M. showed the following:-The resident was sitting in the dining room at lunch, when he/she saw his/her most recent roommate heading closer to dining room doors. The resident said, I want to beat him/her till he/she bleeds;-The charge nurse tried to deescalate the situation. The resident was determined to hurt the other resident. Staff notified the RN of the situation. Staff notified the resident's family who was okay with the resident going to the emergency room if he/she had another behavior. Review of the resident's Progress Note, dated 03/13/26 at 7:26 P.M., showed the Certified Nurse Aide (CNA) reported to the charge nurse that the resident was wheeling himself/herself to the dining room at the same time as another resident, who was his/her former roommate. The resident quickly wheeled himself/herself in front of the resident and blocked his/her way into the dining room. The other resident asked the resident how he/she was doing and the resident said bitch ass pussy while the CNA proceeded to push the resident in his/her wheelchair into the dining room. The resident said, of course you are wheeling him/her. Staff notified the family RN supervisor and the physician. The physician gave an order for the resident to go to the emergency room for psychiatric concerns. Review of the resident's Emergency Department Note, dated 03/13/26 6:41 P.M., showed the following:-The resident presented to emergency department. Staff reported the resident had been verbally aggressive to one resident (Resident #5) who was a previous roommate and they had been separated for the past week;-They moved the other resident to another room due to the inability to get along;-On arrival at the emergency room, the resident said he/she did not know why he/she was sent over. The resident said he/she got frustrated by the other resident, but he/she did not say anything aggressive tonight and only wheeled by the other resident. This appeared to be an acute anger reaction. The resident was administered hydroxyzine (antihistamine sometimes used to treat short-term anxiety) 25 milligrams (mg). Will discharge back to the facility with instructions to follow up with the primary care provider;-Diagnosis showed aggressive reaction;-Hydroxyzine 25 mg one tablet four times a day as needed (PRN). Return to the emergency department if symptoms worsen. Review of the resident's Care Plan, last revised 8/28/25, showed it did not identify the resident's verbally aggressive behaviors directed towards his/her previous roommate on 03/13/26 and did not include specific interventions to address the resident's verbally aggressive behaviors. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 05/30/26, showed the following:-Diagnoses included cerebral vascular accident (stroke), hemiparesis (muscle weakness or partial loss of control of one side of the body) and traumatic brain injury (damage to the brain caused by an external physical force, such as a violent blow or bump or jolt to the head which disrupts normal brain function and ranges from mild to severe);-Cognitively intact;-Upper and lower extremity impairment on one side;-Verbal behaviors directed towards others occurred one to three days out of seven. Review of the resident's Care Plan, last revised 06/05/26, showed the following:-The resident used a wheelchair for mobility;-The resident had a history of brain injury and depression. The resident may get irritated with others at times;-Sometimes the resident will get upset when he/she feels others are staring at him/her. Encourage the resident to move from the area;-The resident struggled with his/her limited abilities. Observe the resident's mood, pain, expression, and abilities. Notify the physician of any changes. Follow up with a psychiatrist if needed and approved. Observe the resident for worsening irritability, and notify the primary care provider;-The resident had poor safety awareness and was impulsive at times.(The resident's Care Plan, revised 06/05/26, did not identify the resident's verbally aggressive behaviors directed towards his/her previous roommate and did not include specific interventions to address the resident's verbally aggressive behaviors.) Review of the resident's Progress Note, dated 07/11/26, showed the following:-The resident went up to another resident (Resident #5) in the dayroom and said, What the fuck are you looking at fucker?-Staff told Resident #4 to go to his/her room. Resident #4 would not move away from the other resident, so staff told Resident #4 again he/she needed to go back to his/her room and his/her comment was inappropriate;-Resident #4 wheeled himself/herself back to his/her room;-Staff to keep the resident's separated for safety. During an interview on 08/10/26 at 8:30 A.M., the resident's family member said the following:-The resident had issues with his/her previous roommate (Resident #5). Staff moved the roommate out of the resident's room;-The resident continued to have very strong feelings towards his/her previous roommate;-He/She notified the physician in March 2026 about the resident's behaviors and the issues with his/her roommate. Staff did not notify the physician of the ongoing issue with the roommate;-The resident would hyper focus after incidents with his/her previous roommate and did not forget about the situation;-He/She did not feel staff were looking at the whole picture;During an interview on 7/28/26 at 11:15 A.M., Resident #5 said the following:-He/She had an issue with another resident (Resident #4) who had been his/her previous roommate. The other resident wanted his/her bed;-Staff moved him/her (Resident #5) to another room;-A while ago, Resident #4 put his/her fist up at him/her and said he/she was going to kick his/her (Resident #5's) ass. He/She also put his/her fist up towards Resident #4. He/She was not afraid, but he/she tried to ignore Resident #4. During an interview on 07/28/26 at 1:00 P.M., CNA I said the following: -A couple months ago, the resident cursed and threatened Resident #5. The two residents were moved to separate rooms. He/She was not aware of any further problems between the two residents;-There were no specific interventions or increased monitoring in place regarding the two residents as the issue was resolved. During an interview on 07/28/26 at 1:05 P.M., CNA H said the following:-He/She started working at the facility on 05/11/26;-A couple times, Resident #4 cursed and flipped off (an offensive/rude hand gesture) Resident #5;-Staff separated them and there were no more issues between the two residents;-There were no interventions in place as the issue was resolved. During an interview on 08/10/26 at 8:00 A.M., CNA J said the following:-There was an ongoing problem with the resident and Resident #5. He/She had concerns the resident would eventually act out or could become physical;-The resident cursed at Resident #5 when he/she was in a common area or in the hall. A few weeks ago, on 07/11/26, the resident got upset and tried to go after Resident #5;-He/She did not feel staff were documenting the ongoing issue between the two residents;-The communication was not good between the staff regarding the two residents at shift change or after there was an incident between the two residents;-Staff just tried to keep an eye on the two residents. There were no specific interventions in place. During an interview on 07/28/26 at 4:30 P.M., Licensed Practical Nurse (LPN) C said the following:-The resident always stayed in his/her room;-He/She was not aware of any issue involving the two residents on 07/11/26;-He/She was not aware the resident had verbally aggressive behaviors directed towards Resident #5. During an interview on 07/28/26 at 4:20 P.M., RN Supervisor A said he/she was not aware of any recent issues between the two residents or of the incident on 07/11/26. Staff should notify administration of any aggressive behavior. Staff should ensure the two residents were separated from each other and to assure the primary care physician was kept in the loop. During an interview on 07/28/26 at 4:15 P.M., the Care Plan Coordinator said the following:-The root cause for the resident's behaviors was the resident wanted a room to himself/herself;-The problem was resolved and the care plan did not need any specific interventions regarding the two residents as there was not an ongoing issue;-He/She was not aware of an incident on 07/11/26 between the two residents. During an interview on 07/28/26 at 1:45 P.M., the Administrator said the following:-The staff should know to keep the two residents separated in the dining room;-The interventions in general for Resident #4 were to remove him/her from the situation and allow him/her time to decompress. The root cause was other residents staring at him/her and one other time it was because the resident could not locate his/her remote control;-She would not expect there to be anything specific on the resident's care plan related to Resident #5. She did not want staff to think the only issue was between the resident and Resident #5;-She would not expect staff to update the care plan with specific interventions to address aggressive behaviors towards a specific resident;-She was not aware of an issue on 07/11/26 between the two residents. She would have expected staff to notify her if the resident had any verbal aggression. During an interview on 08/11/26 at 10:35 A.M., the resident's physician said the following:-The resident and Resident #5 did not get along and were separated;-She was not sure what happened that really caused the original issue between the two residents;-She assumed the two residents were staying away from each other;-Staff notified her on 07/28/26 of the incident that occurred on 07/11/26;-Staff should monitor the two residents like they did for any other residents. Staff did not need to do anything special for the residents unless the two residents were in proximity of each other;-The facility should follow any policies they had regarding behavioral health. 2749175

Based on observation, interview, and record review, the facility failed to ensure staff followed acceptable infection control practices when facility staff completed a central venous catheter (a long, thin flexible tube put into a large vein in the neck, chest or groin) dressing change and failed to ensure it was in accordance with the facility policy for one resident (Resident #3). The facility also failed to ensure Enhanced Barrier Precautions (EBP) were in place including posted signage to remind staff of the PPE requirements prior to entering the resident's room per facility policy. The facility census was 65 Review of the facility's policy titled Enhanced Barrier Precautions, dated 05/20/24, showed the following:-EBP will be used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning (putting on) of gowns and gloves for high contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms (MDRO, microorganisms predominately bacteria, that are resistant to one or more classes of antimicrobial agents) to staff hands and clothing. PPE at a minimum will include gloves, gown, mask and face protection (with risk of splash or spray during care);-Use of EBP included indwelling device care;-Signage will be posted in the area to remind staff of the PPE requirements. Review of the facility policy titled Central Venous Access Device Management, dated 10/23/24, showed the following:-Dressing changes are performed as a sterile procedure, change dressing at designated intervals depending on the type of dressing;-Replace transparent dressing at least every seven days and when the dressing was not intact or the dressing was loose or moist, drainage or blood was under the dressing or further assessment was needed. 1. Review of Resident #3's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff), dated 07/08/26, showed the following:-Diagnoses included renal insufficiency; -Moderate cognitive impairment;-Dependent on staff for toilet hygiene, showering/bathing, upper and lower body dressing;-The resident received dialysis in the last 14 days. Review of the resident's Care Plan, revised on 06/01/26, showed dialysis was on hold. Provide dialysis care to the port (vascular access located on the outside of the body) as ordered by the physician. Review of the resident's physician order sheet (POS), dated 07/28/26 at 10:54 A.M., showed the following:-Dressing to hemodialysis catheter (a central venous line) to be completed on Tuesday, Thursday and Saturday;-The resident and nurse were to wear a mask, cleanse area with alcohol wipes and cover with a 4x4 dressing and Tegaderm (a thin, waterproof, and sterile medical dressing). Observation on 7/28/26 at approximately 11:00 A.M. showed the following:-The resident's door had no signage indicating EBP was required and no accessible PPE (masks and gowns) available for staff upon entry to the resident's room;-Registered Nurse (RN) A entered the room, sanitized his/her hands, put on gloves and a mask, and put a mask on the resident;-RN A placed an unopened package of sterile gloves, an unopened drain sponge, an unopened Tegaderm and unopened alcohol pad directly on the resident's bedside table without cleaning the bedside table or placing a clean barrier on the bedside table; -RN A pulled back the resident's shirt and removed the old dressing that covered the resident's central venous catheter;-RN A removed his/her gloves, washed his/her hands, and put on another pair of gloves;-RN A placed a small paper towel at one end of the table. He/She picked up the unopened sterile gloves and dressing supplies from the unclean bedside table and placed them partially on the paper towel. The unopened alcohol pad remained on the unclean bedside table;-RN A opened the sterile gloves, drain sponge, and Tegaderm dressing;-RN A removed the exam gloves, and without washing or sanitizing his/her hands, put on the sterile gloves;-RN A picked up the alcohol pad from the unclean bedside table, opened it and swiped it back and forth around the central venous catheter;-While wearing the same gloves, he/she placed the drain sponge and the Tegaderm around the central venous catheter insertion site. During an interview on 7/28/26 at 1:10 P.M. and email correspondence on 08/06/26 at 2:10 P.M., RN A said the following:-The dialysis clinic did not specify a sterile dressing was required, just to make sure the resident and staff wore a mask, and staff cleaned the access with alcohol pads;-He/She should have cleaned the table before completing the dressing change. During an interview on 7/28/26 at 1:10 P.M., the Dialysis Nurse Manager said the following:-The resident had a central venous catheter that was surgically placed in the resident's right upper chest;-He/She was concerned with the resident's risk of infection as the central venous catheter had not been used in a month;-He/She expected the facility to maintain infection control precautions throughout the dressing change. Staff should ensure a clean field and change their gloves frequently throughout the dressing change. During an interview on 7/28/26 at 5:00 P.M., the Administrator said the following:-The facility should have EBP in place for the resident;-Staff should follow infection control precautions when providing the resident's dressing change;-She expected staff to place dressing supplies on a clean surface;-The facility should contact the hemodialysis clinic for specific directions on the dressing change. 3071948

Based on interview and record review, the facility failed to provide adequate supervision for one resident (Resident #1), in a review of seven sampled residents. Staff failed to monitor Resident #1, who was taken outside by staff, at approximately 1:27 P.M. to 3:30 P.M. The resident sat in the courtyard under the gazebo and self-propelled him/herself in the courtyard with temperatures between 78 degrees Fahrenheit (F) and 86 degrees F. When discovered by staff at approximately 3:30 P.M., the resident had wheeled himself/herself out from under the gazebo, had his/her back wheel of the wheelchair off of the sidewalk, had taken his/her shoes and socks off and had a red face and his/her skin was hot to touch. The resident was assessed and noted to have an elevated temperature of 101.3 degrees F (normal temperature is between 97.8 degrees F and 99.1 degrees F), had lethargy (sluggish, drowsy and lack of energy), was dry heaving and leaning to the right with reddened skin. The facility census was 64. The administrator was notified of the past noncompliance on 07/09/25 which occurred on 06/28/25. On 06/28/25, the facility began an investigation into the failure, in-serviced staff and put corrective measures in place. In-servicing was completed on 07/08/25. This deficiency was corrected on 07/08/25 as confirmed by the surveyor's investigation on 07/09/25. The facility did not have a policy related to heat precautions for outdoor activities prior to 06/28/25. 1. Review of wunderground weather data for 06/28/25 showed the following:-At 12:54 P.M., temperature 85 degrees F, dew point 70 degrees F, humidity 61 percent (%), winds: from the south at five miles per hour (mph) and condition: fair;-At 1:54 P.M., temperature 86 degrees F, dew point 71 degrees F, humidity 61%, winds: from the south at three mph and condition fair;-At 2:54 P.M., temperature 78 degrees F, dew point 71 degrees F, humidity 79%, winds from south southwest at 13 mph and condition mostly cloudy;-At 3:54 P.M., temperature 76 degrees F, dew point 71 degrees F, humidity 85%, winds from the south at 13 miles per hour (mph) and condition fair. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility, dated 06/17/25, showed the following:-Severely impaired cognition;-Mobility per wheelchair with substantial/maximum staff assistance for motivating wheelchair 50 feet and dependent on staff for motivating wheelchair 150 feet;-Substantial/Maximum staff assistance for transfer from sitting to lying, lying to sitting on the side of the bed, sit to stand and chair/bed-to-chair transfer;-Diagnoses included congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), hypertension (high blood pressure) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's care plan, last reviewed by the facility on 06/02/25, showed the following:-He/She has severely impaired cognition related to dementia with mood disturbances and needed staff to provide redirection;-Provide him/her with oversight to dependent help for one to two staff members for transfers;-Provide him/her with oversight to dependent help of one staff for mobility using his/her wheelchair. He/She will propel self at times. Review of the resident's nursing progress notes, in his/her electronic health record, dated 06/28/25, showed the following:-At 4:13 P.M., this nurse was notified as Certified Nursing Assistant (CNA) was bringing the resident in from the courtyard. Resident was dry heaving and lethargic looking, leaning to the right. Resident was assisted to bed and vital signs obtained as follows: blood pressure (B/P) 104/68 (normal B/P 90/60 to 120/80), pulse 63 (normal rate 60-100 beats per minute), temperature 38.5 Celsius (101.3 F - normal temperature between 36.5 degrees C and 37.3 degrees C, or 97.8 degrees F and 99.1 degrees F). Cooling cloths were immediately applied to the resident's neck, groin and arm pits. Clothing removed and cooling cloths applied to any reddened areas. Thighs were reddened as well as his/her ankles, arms and face. Registered Nurse (RN) notified as well as physician. After about 15 minutes the resident was able to respond to staff appropriately. Resident is taking small sips of cool water and able to keep it down. Received instructions from the physician to check vital signs every 30 minutes for four hours and push fluids;-At 11:57 P.M., resident's vital signs have remained within normal limits. Resident wakes when this nurse enters room, asks what medications he/she is taking and takes sips of water. Fluids encouraged each time staff enters room, voices no complaints. Review of the resident's nursing progress notes dated 06/29/25 at 9:19 A.M., showed the resident was awake and alert. Ate breakfast this morning and drank his/her Ensure. He/She answers questions appropriately. Vital signs: blood pressure 156/77, pulse 62 and temperature 36.3 Celsius (97.3 F). During an interview on 07/09/25 at 12:39 P.M., the resident said he/she liked to go outside and was unsure if he/she had any issues related to being outside too long on 06/28/25. He/She did not remember being outside on 06/28/25. 3. Review of the facility follow-up investigation report, for the 06/28/25 Facility Reported Incident (FRI), showed the following:-Additional/Updated information related to the reported incident: staff member took resident outside at 1:27 P.M. per resident request. Staff placed the resident in the shade under the gazebo. Once outside, staff assisted another resident back indoors to the bathroom and then to bed before returning to other duties on the floor. The resident remained outside for approximately two hours;-Facility reported to family on 06/28/25 at approximately 4:00 P.M.;-Summary of interview(s) with witness(es), documenting what the individual observed or knowledge of the alleged incident or injury, including a written statement, provided by CNA A on 6/28/25 at 6:00 P.M., which showed the staff member took the resident outside at 1:27 P.M. per resident request. Staff placed the resident in the shade under the gazebo. Once outside, staff assisted another resident back indoors to the bathroom and then to bed.-Conclusion: there was no intent of abuse or neglect discovered through the investigation process;-Corrective action(s) taken: facility has educated staff on 15-30 minute checks when residents are left outside unattended and to ensure other staff members are aware residents are outside. I.T. has ordered a camera and door alarm to be placed on door to allow increased monitoring of the courtyard and to alarm staff if a resident would go outside. These should be up and running by end of business day on 07/07/25. Staff education provided on 15-30 minute checks and designated times for residents to be outside when temperatures are above 90. Will encourage residents to go outside during the morning hours or late evening times. 4. During an interview on 07/09/25 at 2:26 P.M., CNA A said the following:-He/She took Resident #1 outside after lunch on 06/28/25 and placed him/her in the shade under the gazebo;-Another resident was outside and requested to go back inside;-He/She took the other resident inside and performed needed cares and then started doing other things as it was busy and he/she forgot Resident #1 was outside;-He/She could not remember if he/she told anyone Resident #1 was outside;-Resident #1 was outside for about two hours;-Resident #1, or any resident, should not be left outside for an extended period of time. During an interview on 07/09/25 at 2:40 P.M., CNA E said the following:-On 06/28/25, at about 3:30 P.M., he/she took a resident to the courtyard and another resident in the courtyard was concerned about Resident #1 and asked him/her to check on the resident;-Resident #1 was outside of the gazebo; the resident usually moved around in his/her wheelchair by him/herself when outside;-The back wheel of Resident #1's wheelchair was off the sidewalk and the resident had no socks or shoes on;-Resident #1 was very red in the face and his/her skin very hot to touch; he/she took the resident back inside the facility and called for help from the nurse;-Residents should not be left outside for extended periods of time;-All staff are responsible for checking on residents when they go outside. During an interview on 07/09/25 at 2:15 P.M., LPN C said the following:-On 06/28/25, he/she had just returned from lunch when CMT F brought Resident #1 in from the courtyard and said he/she needed help;-The resident was leaning to the right, was dry heaving and was very flushed in the face and arms;-Staff put the resident to bed and obtained vital signs; the resident had a temperature of 38.5 degrees Celsius (101.3 F);-The resident's skin was warm to the touch, the skin on his/her face, arms, ankles and thighs was red;-He/She instructed staff to remove the resident's clothing (a short sleeved light weight shirt and jean capris) and to apply cooling cloths to all the red areas, groin, armpits and head;-Within 15-20 minutes, the dry heaving had slowed down and within 30 minutes the resident had returned to baseline cognition and he/she sipped cool water;-The physician, RN and family were notified;-He/She received orders from the physician to check vital signs every 30 minutes for four hours and to encourage fluids;-Residents should not be left in the courtyard for extended periods of time when it was hot;-Every staff member was responsible for checking on residents when they were outside. During an interview on 07/09/25 at 2:59 P.M., LPN G said the following:-When staff got the resident inside, he/she observed the resident to be very hot to touch with a temperature of 103 degrees F. The resident was pale and red at the same time, lethargic, his/her clothes were soaked, he/she was dry heaving and had red arms, thighs, and face;-He/She assisted staff to put cool cloths on the resident;-It was everybody's responsibility to check on residents when they go outside. During an interview on 07/09/25 at 10:30 A.M. and 3:16 P.M., the Director of Nursing (DON) said the following:-Residents should not be left in the courtyard for extended periods of time without staff checking on the resident's well-being.-Every staff member was responsible for checking on the residents when they go outside. During an interview on 07/09/25 at 10:30 A.M. and 3:33 P.M., the administrator said the following:-She was called on 06/28/25 and informed that Resident #1 had been left in the courtyard in the sun and was overheated, had red skin, was dry-heaving, lethargic, leaning to the right and had a temperature;-All staff were responsible for checking on a resident that was outside at any time. During an interview on 07/09/25 at 1:00 P.M., the resident's physician said the following:-Staff notified about the heat related event with the resident on the day it occurred;-Staff told her the resident was found outside and seemed to be overheated;-The resident got overheated and could have had a heat related emergency;-According to documentation in the nursing notes, the resident exhibited some of the same symptoms of heat exhaustion;-She would expect all staff to follow the facility policy and check on residents outside in hot weather;-Resident #1 should not have been left outside for extended periods without staff checking on the resident. 1454636

Based on observation, interview, and record review, the facility failed to ensure two ice machines were free of a buildup of debris, failed to properly store an ice scoop in the serving kitchen, and failed to ensure the refreshment area ice machine was equipped with an adequate air gap. The facility also failed to safely store food items in two refrigerators in the serving kitchen. The facility census was 69. 1. Review of the facility policy, Infection Prevention and Control, Nutritional Services, dated May 2015, showed the following guidance for the Ice Machine in the Food Server Area: -Run the scoop through the dish machine and air dry daily. Store them in clean Ziploc bag; -Wipe the exterior of the machine with warm, sudsy water, rinse and sanitize weekly; -The vendor is responsible for cleaning ice machine quarterly; -Check the interior of the ice cabinet, lid and gaskets for any signs of mold or mildew between monthly vendor visits. If they're visible, follow the cleaning procedures. Observation on 07/15/24 at 10:33 A.M. in the dining room serving kitchen, showed an ice machine sat in an adjacent alcove. The ice scoop was not properly stored and sat on an exterior ledge on the side of the machine. A mild buildup of white flaky debris was on the exterior surface of the machine and directly under the scoop. A plastic ice machine scoop holder was mounted to the wall next to the ice machine and was empty. Inside the ice machine, the white plastic baffle had a mild buildup of dark-colored debris around the edges all the way around the baffle. The lowest portion of the baffle had a buildup of debris and came in direct contact with the accumulated ice Observation on 7/15/24 at 2:04 P.M. showed the ice machine's white plastic baffle had a mild buildup of dark-colored debris around the edges all the way around the baffle. The lowest portion of the baffle had a buildup of debris and came in direct contact with the accumulated ice. The ice scoop sat on the edge of the plastic holder on the wall, but directly touched the wall and wasn't stored in the wall holder. Observation on 7/16/24 at 8:55 A.M. showed the ice machine's white plastic baffle had a mild buildup of dark-colored debris around the edges all the way around the baffle. The metal scoop sat on the exterior ledge of the unit and made direct contact with the soiled exterior surface and was not stored in wall holder. Observation on 7/16/24 at 10:34 A.M. showed a small countertop combination ice machine/water dispenser unit sat in the central refreshment area near the nurse's station. The ice dispensing spout had a heavy buildup of white crusty and dark-colored debris. The drip tray below the spout had a heavy buildup of white crusty debris and brown-colored debris. The ice machine was not equipped with an air gap and the drain was directly connected to the nearby sink drain near the p-trap under the counter inside a cabinet. 2. Review of the facility policy, Infection Prevention and Control, Nutritional Services, dated May 2015, showed the following guidance for Refrigeration: -The nutritional services staff shall check and record temperatures daily. Any out-of-range temperatures will be reported to the maintenance department. Notification will be documented on the temperature log; -All foods that have been prepared for service, but not shredded or chopped, shall be covered, dated and discarded after three days, if not used. Review of the facility policy, Temperatures of Refrigerators and Freezers, Nutritional Services, dated June 2015, showed the following: -Temperatures shall be recorded and kept on file of all refrigerators and freezers; -A thermometer is located in each refrigerator where it can be easily read; -Refrigerator temperatures shall be 41 degrees Fahrenheit (F) or colder; -At any time any refrigerator or freezer is not within the acceptable range, it must be reported to maintenance immediately. Review of the Refrigerator/Freezer Temperature Log for the Tea/Water Refrigerator, dated July 2024, showed the following: -July 11: At 5:45 A.M., 44 degrees F; At 5:38 P.M., 46 degrees F; -July 12: At 5:35 A.M., 48 degrees F; No measurement documented for P.M.; -July 13: At 5:42 A.M., 45 degrees F; -July 14: At 5:31 A.M., 48 degrees F; -July 15: At 6:00 A.M., 60 degrees F; At 6:58 P.M., 60 degrees F; -July 16: At 5:27 A.M., 58 degrees F; No measurement documented for P.M. Observation on 7/15/24 at 10:38 A.M. showed a vertically stacked double reach-in refrigerator, labeled as TLC tea/water fridge sat in the serving kitchen. The outside analog gauge showed an internal temperature of +60 degrees F. A separate thermometer inside the unit showed a temperature of +54 degrees F. The refrigerator contained carafes of tea and water and a box of buttery spread. Observation on 7/15/224 at 2:06 P.M. showed the TLC tea/water fridge outside analog gauge showed an internal temperature of +60 degrees F. A separate thermometer inside the unit showed a temperature of +62 degrees F. The refrigerator contained carafes of tea and water and a box of buttery spread. The unit also had one clear pitcher with a green lid, labeled comfort care 7/15 with dark liquid inside. Two additional blue pitchers with blue lids were not labeled or dated and contained a dark liquid. Observation on 7/16/24 at 8:56 A.M. showed the TLC tea/water fridge outside analog gauge showed an internal temperature of +52 degrees F. A separate thermometer inside the unit showed a temperature of +48 degrees F. 3. Review of the Refrigerator/Freezer Temperature Log for the Kitchen Refrigerator (a separate unit used to store food items in the serving kitchen), dated July 2024, showed the following: -July 11: At 5:45 A.M., 44 degrees F; -July 12: At 5:32 A.M., 45 degrees F; -July 13: At 5:40 A.M., 45 degrees F; -July 14: At 5:30 A.M., 45 degrees F; -July 15: At 6:00 A.M., 46 degrees F; -July 16: At 5:26 A.M., 51 degrees F; No measurement documented for P.M. Observation on 7/15/24 at 10:49 A.M. showed an upright, three-door refrigerator located in the preparation area labeled as TLC kitchen fridge. The outside digital temperature display showed an internal temperature of +55 degrees F. A separate thermometer inside the unit showed a temperature of +50 degrees F. Perishable food items were located inside the refrigerator. Observation on 7/15/24 at 2:09 P.M. showed the the outside digital display showed an internal temperature of +60 degrees F. A separate thermometer inside the unit showed a temperature of +60 degrees F. The refrigerator contained eggs, trays of portioned salads, cottage cheese, produce, fruit, bulk ham salad, muffins, and bulk condiments. Observation on 7/16/24 at 8:57 A.M. showed the outside digital display showed an internal temperature of +52 degrees F. A separate thermometer inside the unit showed a temperature of +46 degrees F. The food items remained inside the refrigerator. During interview on 7/15/24 at 2:27 P.M., the Dietary Director said the refrigerator for tea/ice had started running higher temperatures over the weekend and she had asked staff to monitor the refrigerator more closely. She thought the broken air conditioning unit in the dining room/serving area kitchen may have affected the temperature in this refrigerator. She was unaware the temperature in the kitchen refrigerator (refrigerator used to store food items) was also running high. If staff found a refrigerator was not working properly, a request would be submitted to maintenance requesting a repair. During interview on 7/16/24 at 9:23 A.M., the Director of Facilities Maintenance said the following: -He was unaware that two refrigerators were not maintaining cold temperatures; -The broken air conditioning in the dining room/serving kitchen could be affecting the refrigerators; -He wasn't sure if there was a work order submitted for the tea/water refrigerator, but there may have been one for the three-door kitchen refrigerator (identified as TLC kitchen fridge) The three-door unit had some issues staying cold and had work done on it in the past; -Staff should put in a work order if units are not cooling properly; -A vendor cleaned the inside of the ice machine quarterly; -He was unaware of debris buildup on the inside of the unit; -The vendor was at the facility approximately one to two months ago. During interview on 7/16/24 at 11:05 A.M., the Dietary Supervisor said the following: -She had been the supervisor for two weeks; -She was aware of the warmer temperatures in the ice/tea refrigerator; -She wasn't aware the temperatures in the three-door refrigerator (identified as TLC kitchen fridge) were that high. She had only reported to one of the dietitians that the bottom seal on the 3-door unit needed to be replaced; -She was not aware there was an ice machine in the central refreshment area; -She was not aware that an ice machine was required to have an adequate air gap; -She was not aware the kitchen ice machine had a buildup of debris inside. She thought the vendor cleaned the unit; -The ice scoop should be stored in the wall-mounted scoop holder and not on the outside ledge. The scoop should be washed daily.

Based on interview and record review, the facility failed to ensure a Minimum Data Set (MDS), a federally mandated resident assessment completed by the facility staff, was completed no less than once every three months for one resident (Resident #34), of 20 sampled residents and four additional residents (Resident #13, #38, #48 and #54). The facility census was 69. 1. During an interview on 07/18/24 at 3:59 P.M., Registered Nurse (RN) A said the facility followed the Resident Assessment Instrument (RAI) manual to guide completion of all of the MDS assessments and the facility did not have a specific policy related to MDS completion. 2. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0, dated 2023, showed the following: -The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS; -Assessment Reference Date (ARD - item A2300)) refers to the specific endpoint for the observation (or look-back) periods in the MDS assessment process. The facility is required to set the ARD on the MDS Item Set or in the facility software within the required time frame of the assessment type being completed. This concept of setting the ARD is used for all assessment types (OBRA and PPS) and varies by assessment type and facility determination; -The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1; -For an admission assessment the completion date must be no later than the admitted +13 days; -The annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (significant change in status assessment) or an SCPA (significant correction in prior comprehensive assessment) has been completed since the most recent comprehensive assessment was completed; -The quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -For a quarterly or annual assessment, the MDS completion date (item Z0500B) must be no later than the ARD +14 days. 3. Review of Resident #34's MDS record showed the following: -Quarterly MDS assessment ARD of 08/22/23; -Completion date of 09/18/23, 27 days after ARD (13 days late); -Quarterly MDS assessment ARD of 11/21/23; -Completion date of 12/06/23, 15 days after ARD (1 day late); -Quarterly MDS assessment ARD of 02/20/24; -Completion date of 3/12/24, 21 days after ARD (7 days late); -Annual MDS assessment ARD of 05/21/24; -Completion date of 07/11/24, 51 days after ARD (37 days late). 4. Review of Resident #13's MDS record showed the following: -Quarterly MDS assessment ARD of 09/05/23; -Completion date of 10/03/23, 28 days after ARD (14 days late); -Quarterly MDS assessment ARD of 03/05/24; -Completion date of 3/21/24, 16 days after ARD (2 days late); -Annual MDS assessment ARD of 06/04/24; -Completion date of 07/19/24, 45 days after ARD (31 days late). 5. Review of Resident #38's MDS record showed the following: -Annual MDS assessment ARD of 09/05/23; -Completion date of 10/10/23, 35 days after ARD (21 days late); -Quarterly MDS assessment ARD of 06/04/24; -Completion date of 07/11/24, 37 days after ARD (23 days late). 6. Review of Resident #48's MDS record showed the following: -Quarterly MDS assessment ARD of 08/24/23; -Completion date of 09/18/23, 25 days after ARD (11 days late); -Annual MDS assessment ARD of 02/22/24; -Completion date of 3/21/24, 28 days after ARD (14 days late); -Quarterly MDS assessment ARD of 05/23/24; -Completion date of 07/09/24, 47 days after ARD (33 days late). 7. Review of Resident #54's MDS record showed the following: -Quarterly MDS assessment ARD of 08/24/23; -Completion date of 09/18/23, 25 days after ARD (11 days late); -Quarterly MDS assessment ARD of 11/23/23; -Completion date of 12/08/23, 15 days after ARD (1 day late); -Quarterly MDS assessment ARD of 02/22/24; -Completion date of 3/13/24, 20 days after ARD (6 days late); -Annual MDS assessment ARD of 05/21/24; -Completion date of 07/09/24, 49 days after ARD (35 days late). During an interview on 7/17/24 at 4:55 P.M., MDS coordinator #1 said the following: -She has been the MDS coordinator for a while; -She follows the RAI manual for the completion of an MDS; -MDS's are supposed to be completed within 14 days of the ARD date; -The RN signature for completion is supposed to be within 14 days of the ARD date; -She covered for MDS coordinator #2 during staff medical leave, and she covered on the floor during staff turnover, causing her to get behind on completing the MDS assessments. During an interview on 7/18/24 at 4:18 P.M., MDS coordinator #2 said the following: -She followed the RAI manual for the completion of an MDS; -The MDS assessments should be completed by day 14 once an ARD is set; -Her goal was to have the MDS completed by day 14 after the ARD date is set; -She just got back from an extended medical leave and recently returned to her role. During an interview on 7/18/24 at 4:11 P.M., the Director of Nursing (DON) said the following: -The only part of the MDS she completed was to sign off on the process once they were completed by the team; -She was unaware of what that time frame was for completion; -She was not familiar with the RAI manual as had never done a complete MDS; -She would expect an MDS to be completed in a timely manner; -She was unsure if the MDS assessments were getting done in the required time frame. During an interview on 7/18/24 at 4:23 P.M., the administrator said the following: -MDS coordinator #1 completes the MDS's for the long-term care residents and MDS coordinator #2 completes the MDS's for the skilled residents; -RN A has also been helping complete the MDS assessments during a staff medical leave; -She believed the skilled side MDS's had to be completed in 14 days and the long-term care side seven days after the opening date; -She recently found out the MDS's were not being completed on time; -She would expect staff to follow the RAI manual and to complete the assessments within the appropriate time frame.

Based on observation, interview, and record review, the facility failed to adequately document appropriate diagnoses of residents or resident behaviors to justify the implementation for continued use of antipsychotic medications (a type of psychiatric medication used to treat certain types of mental health problems, such as schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), for three residents (Resident #12, #34 and #56), and failed to complete a 14-day review for the PRN (as-needed) use of a benzodiazepine (a drug that produces sedation and hypnosis) for three residents (Resident #42, #57 and #63) in a review of 20 sampled residents. The facility census was 69. Review of the facility's policy, Antipsychotic Medication Use, dated (revised) December 2016, showed the following: -Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed; -Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction (GDR) and re-review; -Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective; -The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms and risks to the resident and others; -The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications; -The attending physician and the facility staff will identify acute psychiatric episodes, will differentiate them from enduring psychiatric conditions; -Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (DSMM, the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders), current or subsequent editions: -a. Schizophrenia; -b. Schizo-affective disorder; -d. Delusional disorder; -e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); -f. Psychosis in the absence of dementia; -For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: -b. Persistent or likely to reoccur without continued treatment; -Antipsychotic medications will not be used if the only symptoms are one or more of the following: -c. Restlessness; -e. Mild anxiety; -f. Insomnia; -k. Uncooperativeness; - Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record; -The need to continue PRN orders for psychotropic medications beyond 14 days require that the practitioner document the rationale for the extended order, the duration of the PRN order will be indicated in the order; -PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication; -The staff will observe, document and report to the attending physician, information regarding the effectiveness of any interventions, including antipsychotic medications in 30 days; -The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of www.drugs.com for Seroquel (generic name quetiapine) showed the following: -Seroquel is used to treat schizophrenia and to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder), a disease that causes episodes of depression, episodes of mania, and other abnormal moods); -Seroquel is used in combination with antidepressant medications to treat major depressive disorder in adults; -Seroquel may increase the risk of death in older adults with mental health problems related to dementia; -Potential adverse effects of Seroquel include somnolence (sleepiness), postural hypotension (a drop in the blood pressure when a person stands), motor and sensory instability, which may lead to falls, and consequently, fractures (broken bones) or other injuries. 1. Review of Resident #56's admission form, undated, showed the following: -He/She had a legal guardian; -Medical diagnoses of unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), unspecified severity, without behavioral disturbance, and insomnia. Review of the resident's physician orders (undated) showed an order for quetiapine (an antipsychotic medication) 25 milligrams (mg), oral tablet, one daily at bedtime (hs) for insomnia, start date 12/20/23. Review of the resident's care plan, dated 3/28/24, showed the following: -Behavior: the resident had a diagnosis of dementia and insomnia; -He/She had some of the following behavioral issues: agitation, medication refusals and poor safety awareness; -He/She usually exhibited Sundowner's (a state of confusion that occurs in the late afternoon and lasts into the night) and these were attributed to the diagnosis of dementia; -Goal: the resident will take his/her medications as prescribed over the next 90-day period; -Interventions: staff will encourage the resident to take his/her medication; -Staff will learn any triggers the resident may have to help guide the resident; -Staff will help keep others out of the resident's space unless invited; -Staff will report any changes in behaviors to charge nurse; -Behavior: the resident had a history of falls at home and since coming to the facility; -The resident was up often throughout the night but did not remember it; -Goal: the resident would be free from falls with injury over the next 90 days; -Interventions: monitor the resident and help him/her to the restroom throughout the day and night. Review of the resident's physician office/clinic note, dated 4/03/24, showed the physician documented the resident's psychiatric exam was cooperative, with appropriate mood and affect. Review of the resident's pharmacy note, dated 4/16/24 at 9:09 A.M., showed the consulting pharmacist documented the following: -The resident had an order for quetiapine 25 mg by mouth daily at bedtime since 12/20/23; -Consider a gradual dose reduction to quetiapine 12.5 mg by mouth at bedtime. (Review of the resident's medical record showed no documentation the resident's physician had been notified of the recommendation or a response given.) Review of the resident's nursing progress notes, from 4/25/24 through 4/30/24, showed no documentation of behaviors related to the resident's diagnosis of dementia without behavioral disturbance. Review of the resident's Medication Administration Record (MAR), for the month of May 2024, showed staff administered quetiapine (Seroquel) 25 mg oral at hs (bedtime) daily at 09:00 P.M. from 5/01/24 through 5/30/24 with no diagnosis listed. Review of the resident's physician office/clinic note, dated 5/01/24, showed the physician documented the resident's psychiatric exam was cooperative, with appropriate mood and affect. Review of the resident's Note to Attending Physician/Prescriber, dated 5/17/24, showed the consulting pharmacist documented the following: -The resident had an order for quetiapine 25 mg by mouth daily at bedtime since 12/20/23 for insomnia; -Consider a gradual dose reduction to quetiapine 12.5 mg by mouth at bedtime. Review of the resident's Note to Attending Physician/Prescriber, dated 5/17/24, showed the resident's attending physician's response to the consulting pharmacist was that she disagreed due to the resident still gets up at night. Review of the resident's nursing progress notes, dated 5/17/24 at 4:27 P.M., showed staff documented the following: -The resident was found on the floor at the foot of the bed without his/her shoes on; -The resident said his/her stomach hurt, and he/she was trying to go to the bathroom; -The call light was not on at the time of the fall; -The resident had multiple skin tears on the right hand, right thumb, palm, index finger, middle finger and ring finger; -Staff notified the resident's physician. Review of the resident's physician office/clinic note, dated 5/29/24, showed the physician documented the resident's psychiatric exam was cooperative, with appropriate mood and affect. Review of the resident's nursing progress notes, for the month of May 2024, showed documentation of behaviors related to the resident's diagnosis of dementia without behavioral disturbance. Review of the resident's MAR for the month of June 2024, showed staff administered quetiapine 25 mg oral at hs daily at 09:00 P.M. from 6/01/24 through 6/30/24 with no diagnosis listed. Review of the resident's nursing progress notes, for the month of June 2024, showed no documentation of behaviors related to the resident's diagnosis of dementia without behavioral disturbance. Review of the resident's physician office/clinic note, dated 6/06/24, showed the physician documented the resident's psychiatric exam was cooperative, with appropriate mood and affect. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 6/18/24, showed the following: -Severe cognitive impairment; -No hallucinations or delusions; -Independent in mobility; -One fall in the last month prior to admission; -Received an antipsychotic on a routine basis; -Last GDR attempted on 05/17/24; -GDR not documented by a physician as clinically contraindicated. Review of the resident's pharmacy note, dated 6/21/24 at 2:51 P.M., showed the consulting pharmacist documented the following: -The resident has an order for quetiapine 25 mg by mouth daily at bedtime since 12/20/23; -Consider a gradual dose reduction to quetiapine 12.5 mg. by mouth at bedtime. (Review of the resident's medical record showed no documentation the resident's physician had been notified of the recommendation or a response given.) Review of the resident's MAR for the month of July 2024, showed staff administered quetiapine 25 mg oral at hs daily at 09:00 P.M. from 7/01/24 through 7/31/24 with no diagnosis listed. Observation on 7/15/24 at 12:00 P.M. showed the resident sat quietly in a chair at the dining room table and was smiling. Observation on 7/15/24 at 3:30 P.M. showed the resident sat quietly in his/her recliner while his/her family visited. Observation on 7/16/24 at 12:10 P.M. showed the resident sat quietly at the dining room table and fed himself/herself. Review of the resident's Note to Attending Physician/Prescriber, dated 7/17/24, showed the consulting pharmacist documented the following: -The resident had an order for quetiapine 25 mg by mouth daily at bedtime since 12/20/23 for insomnia; -Consider a gradual dose reduction to quetiapine 12.5 mg by mouth at bedtime. Review of the resident's Note to Attending Physician/Prescriber, dated 7/17/24, showed the resident's attending physician's response to the consulting pharmacist was that she disagreed due to the resident was stable. Review of the resident's nursing progress notes, from 7/1/24 through 7/17/24, showed no documentation of behaviors related to his/her diagnosis of dementia without behavioral disturbance. During an interview on 7/15/24 at 3:35 P.M., the resident's family member said the following: -He/She was not aware of any behavior issues with the resident; -The resident would get up at night, he/she figured it was to go to the bathroom, but that was not something new; -He/She was not aware of the resident's medications or what they were for. During an interview on 7/17/24 at 7:30 P.M., Licensed Practical Nurse (LPN) C said the following: -He/She was not aware of any behavior issues with the resident; -The resident will sometimes go to the facility door after his/her family leaves, but does not try to elope and does not become agitated. During an interview on 7/18/24 at 11:00 A.M., LPN D said the following: -The resident did not have any behaviors, more like anxiety at times, and would pace more, especially after the resident's family would leave after visiting; -The resident could be easily redirected. Observation on 7/18/24 at 11:00 A.M., showed the resident sat quietly in a recliner in his/her room and would smile when spoken to. 2. Review of Resident #12's face sheet showed the following: -He/She admitted to the facility on [DATE]; -Diagnoses included advanced dementia and anxiety disorder. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognition was severely impaired; -The resident did not show any behaviors/hallucinations/delusions in the previous seven days; -Diagnoses included dementia and anxiety; -His/Her medication regimen included the use of an antipsychotic medication; -GDR last attempted on 4/3/23 and was documented by the physician as contraindicated. Review of a pharmacist to physician communication sheet, dated 3/20/24, showed the following: -Pharmacist requested GDR for quetiapine (an antipsychotic medication) 25 mg by mouth daily for dementia with anxiety; -Consider GDR to quetiapine 12.5 mg daily; -If a GDR is contraindicated, a rationale is documented for why an attempted dose reduction would impair the resident's function or cause psychiatric instability -Evaluate diagnosis associated with medication as anxiety was not an acceptable diagnosis for quetiapine. The resident's diagnosis list did contain dementia, but was listed as without behaviors; -Physician documented he/she disagreed with recommendations on 3/25/24 without an explanation/rationale given. Review of the resident's care plan, last reviewed on 6/26/24, showed the following: -His/Her diagnoses included advanced dementia; -He/She had behavioral issues which consisted of agitation with staff, refusal of medication, and poor safety awareness; -Staff were to encourage him/her to take medications; -He/She took antipsychotic medication for anxiety and sleep; -Have pharmacy review his/her medication monthly; Review of the resident's physician's orders, dated July 2024, showed the following: -Diagnoses included dementia without behavioral disturbances, psychiatric disturbances, mood disturbances, anxiety, and Alzheimer's dementia; -Quetiapine 25 mg by mouth every day (original order dated 1/1/20). Review of the resident's medical record showed no documentation the physician provided a psychiatric diagnoses to support the use of the antipsychotic medication, and no justification for continued use of the medication at the current dose (originally ordered on 1/1/20). 3. Review of Resident #34's undated note to attending physician/prescriber showed the following GDR requests was made: -Fluoxetine (an antidepressant medication) 20 mg daily for treatment of anxiety since 6/12/22; -Risperidone (an antipsychotic medication) 0.25 mg twice a day (BID) since 6/11/22 (decreased from three times a day (TID) on 6/22/22) -On 2/8/24, the physician documented he/she disagreed with the GDR recommendation, but did not give a rationale as to why he/she disagreed. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognition was severely impaired; -No psychosis/hallucinations/delusions in the previous seven days; -Diagnoses include nontraumatic brain dysfunction, Alzheimer's disease, dementia, anxiety, and depression; -Medications included use of antipsychotics and antidepressants with indication for use; -Last attempted gradual dose reduction (GDR) was on 2/17/22; -Physician documented GDR was clinically contraindicated on 2/8/24. Review of the resident's psychiatry note, dated 6/7/24, showed the following: -Diagnoses included Alzheimer's disease with behavioral disturbances, depression, dementia, insomnia, and social withdrawal; -He/She mumbled and did not answer most questions during the assessment; -Risperidone (an antidepressant medication) 0.25 mg twice a day (BID); -Fluoxetine (an antidepressant medication) 20 mg once daily; -No documented behaviors; -Continue current medications as ordered. Review of the resident's physician's progress note, dated 6/8/24, showed the following: -Diagnoses included Alzheimer's disease with behavioral disturbances, depression, dementia, insomnia, and social withdrawal; -He/She did not talk much; -Staff reported he/she seemed to be doing well and they had no concerns; -Risperidone 0.25 mg BID; -Fluoxetine 20 mg once daily; -Continue current medications as ordered. Review of the residents' care plan, last reviewed on 6/26/24, showed the following: -The resident spent most of the time in his/her room; -Impaired cognition related to dementia and memory issues; -He/She had times where he/she wanted to lay in his/her bed and sleep; -He/She had chronic back pain which could cause behavioral issues; -He/She seldom communicated his/her needs; -He/She used antidepressant and antipsychotic medications to treat depression, anxiety, and feeling others are trying to cause him/her ill will; -Interventions included to follow with psychiatric physician as needed and approved, and pharmacy to review medications monthly. Review of the resident's physician orders, dated July 2024, showed the following -Risperidone 0.25 mg; 1 tablet BID for treatment of mood disorder (6/22/22); -Fluoxetine 20 mg 1 PO daily for treatment of anxiety (6/12/22). Review of the resident's medical record showed no documentation of a physician justification for continued use of the medications at the current dose (originally ordered June 2022). Review of the resident's MAR dated July 2024 showed the following: -Staff administered risperidone 0.25 mg BID from 7/1/24 through 7/17/24; -Staff administered fluoxetine 20 mg daily from 7/1/24 through 7/17/24 Observation of the resident on 7/17/24 at 12:50 P.M. showed he/she lay in his/her bed with eyes closed. Observation of the resident on 7/17/24 at 2:00 P.M., showed he/she lay in his/her bed with eyes closed. During an interview on 7/17/24 at 2:00 P.M., Certified nursing assistant (CNA) B said that the resident did not like to come out of his/her room. 4. Review of Resident #63's face sheet showed the following: -admitted [DATE]; -Diagnoses included anxiety. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition was severely impaired; -Diagnoses included dementia and anxiety; -No documented behaviors, delusions, and/or hallucinations in the previous seven days; -Medication regimen included use of antipsychotics, antidepressants, and antianxiety medications. Review of the resident's care plan, dated 6/7/24, showed he/she admitted with orders for as needed (PRN) antianxiety medications for his/her mood/delusions/agitation/and sleep. Review of resident's nursing progress note, dated 6/28/24 at 1:30 P.M., showed the resident's physician wanted to continue PRN lorazepam for anxiety for another 30 days and would review the medication again at that time. Review of the resident's physician's orders, dated 6/28/24, showed an order for lorazepam (anti anxiety medication) 0.5 mg every four hours PRN anxiety. Review of the resident's medical record showed no documented rationale by the physician for extended use of PRN lorazepam beyond 14 days. Review of the resident's physician's orders, dated July 2024, showed an order for lorazepam 0.5 mg every four hours PRN anxiety for 30 days (original order dated 6/28/24). Review of the resident's MAR dated July 2024 showed staff administered PRN lorazepam 0.5 mg on 7/4/24 at 12:07 A.M. and 10:38 A.M., on 7/5/24 at 8:21 A.M., on 7/6/24 at 7:00 P.M., on 7/7/24 at 7:14 P.M., on 7/8/24 at 7:02 P.M., on 7/12/24 at 7:27 P.M., on 7/13/24 at 7:55 P.M., and on 7/14/24 at 7:37 P.M. 5. Review of Resident #42's face sheet showed the following: -Admission to the facility on [DATE]; -Diagnoses include non-Hodgkin's lymphoma (cancer that starts in the lymphatic system) and epilepsy (seizure disorder). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Has had no behaviors; -Inattention and disorganized thinking is present but fluctuates; -Takes a daily anti-anxiety; -Is on hospice care. Review of the resident's May 2024 physician orders showed an order for lorazepam (a medication used to treat anxiety) 0.5 mg every 4 hours PRN for anxiety for 30 days, with a start date of 4/19/24 and a stop date of 5/19/24. Review of the resident's care plan, updated 5/03/24, showed the following: -He/She takes and anti-anxiety medication for seizures and has a PRN anxiety medication for comfort; -Have pharmacy review his/her medications monthly. Review of the resident's nursing progress notes PRN psychotropic review, dated 5/17/24 at 7:12 A.M., showed nursing staff documented the resident's physician reviewed the resident's PRN lorazepam order for anxiety and end of life comfort measures. The physician would like to continue medication for another 30 days and will re-evaluate the medication again at that time. Review of the resident's medical record showed no documentation, from the physician, regarding his/her rationale for extending the use of the resident's PRN Lorazepam beyond the 14 day stop date. Review of the resident's May 2024 MAR showed an entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 5/17/24 and an end date of 6/17/24. Review of the resident's monthly medication regimen review (MRR), dated 5/21/24, showed comments of no recommendations at this time. Review of the resident's May 2024 MAR showed no PRN lorazepam administered during the month of May. Review of the resident's June 2024 physician orders showed an order for lorazepam 0.5 mg every 4 hours PRN for anxiety for 30 days, with a start date of 5/17/24 and a stop date of 6/16/24. Review of the resident's nursing progress notes PRN psychotropic review, dated 6/15/24 at 3:01 P.M., showed nursing staff documented the resident's physician reviewed the resident's PRN lorazepam order for anxiety and end of life comfort measures. The physician would like to continue medication for another 30 days and will re-evaluate the medication again at that time. Review of the resident's medical record showed no documentation, from the physician, regarding his/her rationale for extending the use of the resident's PRN lorazepam beyond the 14 day stop date. Review of the resident's June 2024 MAR showed an entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 6/14/24 and an end date of 7/14/24. Review of the resident's MRR, dated 6/21/24, showed comments of no recommendations at this time. Review of the resident's June 2024 MAR showed staff administered PRN lorazepam one time on 6/26/24, during the month of June. Review of the resident's nursing progress notes PRN psychotropic review, dated 7/14/24 at 3:40 P.M. showed nursing staff documented the resident's physician reviewed the resident's PRN lorazepam order for anxiety and end of life comfort measures. The physician would like to continue medication for another 30 days and will re-evaluate the medication again at that time. Review of the resident's medical record showed no documentation, from the physician, regarding his/her rationale for extending the use of the resident's PRN Lorazepam beyond the 14 day stop date. Review of the resident's July 2024 physician orders showed an order for lorazepam 0.5 mg every 4 hours PRN for anxiety for 30 days, with a start date of 7/14/24 and a stop date of 8/13/24. Review of the resident's MRR, dated 7/17/24, showed comments of no recommendations at this time. Review of the resident's July 2024 MAR, from 7/1/24 through 7/18/24, showed no PRN lorazepam administered during the month of July. Review of the resident's medical record on 7/18/24 showed there was no documented rationale by the physician for the extended use of PRN Lorazepam beyond the 14 day stop date. 6. Review of Resident #57's face sheet showed the following: -Admission on 7/10/23; -Diagnoses include anxiety disorder and basal cell carcinoma (skin cancer) of the skin. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No delirium or behaviors present; -Takes daily anti-anxiety and antidepressant medication. Review of the resident's May 2024 physician orders showed the following: -An order for lorazepam 0.5 mg twice a day for restless/comfort with a start date of 7/17/23; -An order for lorazepam 0.5 mg every 4 hours as needed for anxiety for 30 days, with a start date of 4/12/24 and a stop date of 5/12/24. Review of the resident's nursing progress notes PRN psychotropic review, dated 5/10/24 at 3:10 P.M. showed nursing staff documented the resident's physician reviewed the resident's PRN lorazepam order for anxiety and end of life comfort measures. The physician would like to continue medication for another 30 days and will review medication again at that time. Review of the resident's medical record showed no documentation from the physician, regarding his/her rationale for extending the use of the resident's PRN Lorazepam beyond the 14 day stop date. Review of the resident's May 2024 MAR showed the following: -Administration of lorazepam 0.5 mg twice a day each day of May; -An entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 4/12/24 and an end date of 5/10/24; -An entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 5/10/24 and an end date of 6/07/24. Review of the resident's MRR, dated 5/21/24, showed comments of no recommendations at this time. Review of the resident's May 2024 MAR showed no PRN lorazepam administered during the month of May. Review of the resident's June 2024 physician orders showed the following: -An order for lorazepam 0.5 mg twice a day for restless/comfort with a start date of 7/17/23; -An order for lorazepam 0.5 mg every 4 hours PRN for anxiety for 30 days, with a start date of 5/10/24 and a stop date of 6/09/24. Review of the resident's nursing progress notes PRN psychotropic review, dated 6/07/24 at 4:19 P.M. showed nursing staff documented the resident's physician reviewed the resident's PRN lorazepam order for anxiety and end of life comfort measures. The physician wants to continue medication for another 30 days and will review medication again at that time. Review of the resident's medical record showed no documentation, from the physician, regarding his/her rationale for extending the use of the resident's PRN Lorazepam beyond the 14 day stop date. Review of the resident's June 2024 MAR showed the following: -Administration of lorazepam 0.5 mg twice a day each day of June; -An entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 5/10/24 and an end date of 6/07/24; -An entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 6/07/24 and an end date of 7/07/24. Review of the resident's MRR, dated 6/21/24, showed comments of no recommendations at this time. Review of the resident's care plan, updated 6/28/24, showed the following: -He/She takes and anti-anxiety medication for his/her anxiety/comfort in his/her end of life; -Have pharmacy review his/her medications monthly. Review of the resident's June 2024 MAR showed no as needed lorazepam administered during the month of June. Review of the resident's nursing progress notes PRN psychotropic review, dated 7/07/24, at 12:56 P.M., showed nursing staff documented the resident's physician reviewed the resident's PRN lorazepam order for anxiety and end of life comfort measures. The physician wants to continue medication for another 30 days and will review medication again at that time. Review of the resident's medical record showed no documentation, from the physician, regarding his/her rationale for extending the use of the resident's PRN lorazepam beyond the 14 day stop date. Review of the resident's July 2024 physician orders showed the following: -An order for lorazepam 0.5 mg twice a day for restless/comfort with a start date of 7/17/23; -An order for lorazepam 0.5 mg every 4 hours PRN for anxiety for 30 days, with a start date of 7/07/24 and a stop date of 8/06/24. Review of the resident's July 2024 MAR showed the following: -Administration of lorazepam 0.5 mg twice a day each day of July (up to the end of annual survey on 7/18/24); -An entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 6/07/24 and an end date of 7/07/24; -An entry for lorazepam 0.5 mg every 4 hours PRN for 30 days for a diagnosis of anxiety with a start date of 7/07/24 and an end date of 8/06/24; -No as needed lorazepam administered during the month of July. Review of the resident's MRR, dated 7/17/24, showed comments of no recommendations at this time. Review of the resident's medical record on 7/18/24 showed there was no documented rationale by the physician for the extended use of PRN Lorazepam beyond the 14 day stop date. During an interview on 7/18/24 at 4:11 P.M., the Director of Nurses (DON) said the following: -A PRN medication, like an anti-anxiety or antipsychotic, should have a stop date of 14 days; -The attending physician should document in the progress notes why he/she did not want to stop a PRN anti-anxiety or antipsychotic medication and/or why they wanted to continue the medication; -The consulting pharmacist would send the GDRs to her and she would print those and given them to the RN supervisors; the RN supervisors would then review those with the physician, get new orders if necessary and give them back to the DON; -The RN supervisor and the DON were responsible for following up on the GDRs; -An antipsychotic medication should have an appropriate medical diagnosis as an indication for its use; -If a diagnosis for an antipsychotic is not appropriate, the consulting pharmacist should let the physician know; -She would expect the physician to address an inappropriate medical diagnosis for an antipsychotic being used by a resident; -The licensed staff who entered the anti-anxiety or antipsychotic medication order would be responsible for ensuring there is an appropriate medical diagnosis; -If there was a question about the diagnosis, then that staff person would ask the physician for clarification. During an interview on 7/18/24 at 4:23 P.M., the Administrator said the following: -A PRN anti-anxiety or

Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of 20 sampled residents, remained free from misappropriation of property when Certified Nurse Aide (CNA) F took the resident's cellular phone and made charges of approximately $200 to the resident's online shopping account without the resident's knowledge. The facility census was 69. On 7/3/24 at 4:08 P.M., the administrator was notified of the past noncompliance which occurred on 6/25/24. On 6/25/24, the administrator became aware of the violation of misappropriation of the resident's phone and charges made to the resident's online shopping account by CNA F. Upon discovery, the facility canceled the contract with CNA F through the contracting company, conducted an investigation, and notified appropriate parties. Staff reviewed the facility misappropriation policy, and all facility staff were educated on the facility misappropriation policy. CNA F was terminated. The deficiency was corrected on 6/26/24. Review of the facility's Abuse Prevention Program, revised 5/12/22, showed the following: -It is the policy of the facility to ensure that all alleged violations of misappropriation of resident property are reported to the administrator and to other officials immediately, not later than 24 hours if the events caused the allegation do not involve abuse and do not result in seriously body injury in accordance with state law through established procedure; -Misappropriation of resident property Is the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of the resident's belongings or money without the resident's consent. For the purpose of this program, theft has the same definition as misappropriation of resident property. 1. Review of Resident #1's face sheet showed the following: The resident readmitted to the facility on [DATE]: The resident was his/her own responsible party. Review of a copy of an email sent from the wireless cellular phone provider to Resident #1, dated 6/23/24 at 5:59 A.M., showed the wireless cellular phone account password was successfully changed. Review of a screenshot from the resident's online shopping app account, dated 6/25/24, showed the addition of Certified Nurse Aide (CNA) F's home address was added to the account for delivery. Review of the police report, dated 6/30/24, showed the following: -The law enforcement officer had probable cause to believe CNA F committed one or more criminal offenses; -On 6/25/24, at approximately 12:53 P.M., the police department received a call in reference to a resident's cell phone possibly being stolen; -The facility administrator said the resident had a cell phone which went missing sometime between the night of 6/23/24 and the following morning, 6/24/24; -The administrator said the resident's family member, the resident, and staff, had been searching for the phone, but it was not located; -The resident's family member noticed the resident's password for his/her cellular phone account had been changed via an email on 6/24/24; -The resident's family member visited the resident on the evening of 6/24/24, and asked about the phone. The resident realized it was missing; -The family member said searching the room provided nothing and the phone was no longer able to be tracked with the Find my Phone app; -The family member checked the resident's online accounts and found activity on the resident's online shopping account with an order placed by CNA F to be delivered to CNA F's address; -The family member said the cell phone was an iPhone SE20, black in color with a pink phone case. It was worth between $600 and $700; -The family member said due to the resident's declining health, he/she made decisions for the resident. During a phone interview on 7/3/24 at 11:08 A.M. and 7/9/24 at 8:51 A.M., the resident's family member said the following: -He/She received an email message from the resident's cellular phone service provider stating the account password was changed; -The family member no longer had access to the resident's cellular phone account; -The family member still had access to the online shopping account that the resident had on his/her phone; -A new name and address was added to the account for CNA F; -CNA F added several items to purchase on the resident's online shopping app, equaling approximately $200.00. - --He/She found the items in the cart before the transaction was completed, so it was canceled before the transaction was made. Review of the facility's staffing sheet, dated 6/23/24, showed CNA F worked from 7:00 P.M. to 7:00 A.M. on the resident's hall. During an interview on 7/3/24 at 4:00 P.M., Certified Medication Technician (CMT) E said the resident's family member came to the facility at approximately 9:00 A.M. on 6/25/24 and reported he/she had received emails from the wireless cellular phone provider regarding the resident's cell phone. The password had been changed, but not by the resident or the family member. During an interview on 7/3/24 at 2:45 P.M., the resident said he/she did not know who took his/her cell phone and didn't know how long it had been missing before he/she noticed. No one previously asked him/her to use the phone. He/She just wanted to use it one day and it was gone. During an interview on 7/3/24 at 10:30 A.M. and 3:40 P.M., the administrator said the resident's family member, reported the phone missing on 6/25/24 to Certified Medication Technician (CMT) E. CMT E started the investigation. The agency CNA F worked for was notified of the misappropriation and that he/she was not to return to the facility. MO238161

Based on interview and record review, the facility failed to ensure all allegations of abuse were reported immediately, but no later than two hours after the allegation was made, for one resident (Resident #2), in a review of five sampled residents. Resident #2 reported staff threw him/her into the sink while assisting the resident in the bathroom on 9/17/23. The facility failed to report the allegation of abuse to the state survey agency. The facility census was 67. Review of the facility policy, Abuse Prevention Policy, dated 5/12/22, showed the following: -The residents had the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility prohibited mistreatment, neglect or abuse of the residents; -The facility must ensure all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property were reported immediately to the administrator and to other officials immediately, but no later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury in accordance with state law through established procedure (including the State survey and certification agency); -This would be done by orienting and training employees on how to deal with stress and difficult situations, how to recognize and report occurrences of mistreatment, neglect and abuse. Establishing an environment that promoted resident sensitivity, resident security and prevention of mistreatment. Immediately protect residents involved in identified reports of possible abuse, implement systems to investigate all repots and allegations of mistreatment promptly and aggressively making the necessary changes to prevent future occurrences, filing accurate and timely investigative reports; -The administrator assumed the responsibility of the overall coordination and implementation of the abuse prevention program policy and procedure; -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish, or deprivation by and individual, including a caretaker of goods or services that were necessary to attain or maintain physical, mental and psychological well-being; -Physical abuse was hitting, slapping, pinching, kicking, etc. It also included controlling behavior through corporal punishment. 1. Review of Resident #2's nurses' notes, dated 9/14/23 at 12:24 P.M., showed the resident was admitted following hospitalization for a fractured right hip with surgical repair from a fall at home, history of stroke with left sided weakness. The resident required one staff member assist with gait belt transfers to the wheelchair and was occasionally incontinent of bowel and bladder. He/She was alert and oriented, answered questions appropriately with clear speech. Review of the resident's baseline care plan, dated 9/14/23, showed the following: -Diagnosis of weakness, fractured hip with surgical repair. Staff should provide a safe environment, properly use devices, monitor condition, and provide comfort and care; -The resident required assistance with toileting and hygiene. Staff should encourage participation in Activities of Daily Living (ADLs), maintain safety precautions, and toilet as needed; -The resident had problems with safety and required staff assistance with transfers, balance, ambulation and fall prevention. Staff should assist with transfers and utilize a gait belt, assist with ambulation, and monitor for falls. -Staff should monitor for unsteady gait and loss of balance and provide a wheelchair or walker for mobility. Review of the resident's nurses' notes, dated 9/17/23 at 6:33 A.M., showed Licensed Practical Nurse (LPN) C documented certified nurse assistant (CNA) staff said staff took the resident to the bathroom in a wheelchair and transferred the resident to the toilet. Staff cleaned the resident, and transferred him/her back into the wheelchair. The resident said the staff members threw him/her into the sink. LPN C spoke with the resident who said CNA A picked him/her up and threw him/her into the sink. During interview on 9/20/23 at 2:00 P.M., CNA A said sometime early in the morning on 9/17/23, he/she assisted the resident to the bathroom. After providing incontinence care, he/she attempted to transfer the resident to the wheelchair. The resident started to sit on the feces soiled toilet seat, and CNA A quickly pivoted the resident to the wheelchair. The resident sat down hard in the wheelchair. The resident went down fast and hard. The resident said the staff threw him/her into the sink and became irate. CNA A did not throw the resident into the sink or wall area. CNA A and CNA B reported the incident to LPN C. During interview on 9/20/23 at 1:45 P.M., CNA B said the following: -Early on the morning of 9/17/23, he/she and CNA A took the resident to the toilet. -While transferring the resident from the toilet to the wheelchair, the resident yelled and said they threw him/her into the sink. -Staff should report any allegation of abuse to the charge nurse; -CNA A and CNA B informed the charge nurse LPN C of what the resident said, and wrote a statement regarding the incident. During an interview on 9/20/23 at 10:55 A.M., LPN C said the following: -On 9/17/23 at about 5:00 A.M., the resident complained staff threw him/her up against the sink while in the bathroom; -CNA A and CNA B said they answered the resident's call light and took the resident to the toilet. CNA A and CNA B said they did not throw the resident up against the sink but transferred the resident quickly away from the soiled toilet seat and placed the resident in the wheelchair. -LPN C thought the resident was confused and staff did not intentionally hurt the resident; -LPN C reported the incident to the day shift charge nurse LPN D during 7:00 A.M. report; -All allegations of abuse should be reported immediately to the administrator. -He/She did not tell the Administrator or Director of Nursing about the incident. He/She did not think the incident was abusive. During an interview on 9/20/23 at 12:25 P.M., the resident said two CNAs took him/her to the bathroom in the middle of the night. He/She was incontinent of feces and staff provided incontinence care while he/she stood at the grab bar near the toilet. The staff shoved him/her against the sink area hitting his/her right hip during the transfer. He/She told the two staff members they hurt him/her, and one of the staff said he/she did not shove the resident against the sink area. No other staff asked him/her about the incident until a day or two later. He/She was not afraid of the staff but preferred someone else took him/her to the bathroom. During an interview on 9/20/23 at 12:45 P.M., LPN D said the following: -He/She was the charge nurse on day shift on 9/17/23. LPN C reported (during report at change of shift) that the resident said two CNA staff (CNA A and CNA B) shoved the resident against the sink in the bathroom and hurt his/her hip while providing toileting assistance. -On 9/17/23 around 7:00 A.M., he/she informed the administrator of the incident by telephone. During interview on 9/21/23 at 9:20 A.M., Registered Nurse (RN) E said the following: -He/She was the RN supervisor on 9/17/23; -At about 7:00 A.M., LPN D informed him/her the resident reported staff threw him/her into the bathroom sink while transferring from the toilet during the night shift; -Any allegation of abuse should be reported to the Administrator immediately and the facility abuse policy followed, including reporting the allegation to the State Agency within two hours of the allegation; -He/She did not report the allegation to the administrator or the State Agency; -He/She should have reported the incident to the State Agency. During an interview on 9/21/23 at 11:50 A.M., the administrator said on 9/17/23 at about 7:00 A.M. staff informed him/her of the resident's allegation of staff throwing him/her into the sink while toileting the resident. Any allegations of abuse should be reported to the State Agency within two hours of the allegation. Staff should have implemented the abuse policy immediately regarding the incident. He/She had not reported the allegations of abuse to the State Agency. He/She did not believe after talking with staff on 9/18/23 that the incident was abuse. He/She should have reported the incident within two hours of the allegations, and should follow the facility abuse policy.

Based on interview and record review, the facility failed to protect residents from potential abuse after one resident (Resident #2), in a review of five sampled residents, reported Certified Nurse Assistant (CNA) A and CNA B threw him/her into the sink while assisting the resident in the bathroom. The facility allowed the staff to continue to work the remainder of their shift on 9/17/23 and the following night shift. The facility census was 67. Review of the facility policy, Abuse Prevention Policy, dated 5/12/22, showed the following: -Abuse was the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain or mental anguish, or deprivation by and individual, including a caretaker of goods or services that were necessary to attain or maintain physical, mental and psychological well-being; -Physical abuse was hitting, slapping, pinching, kicking, etc. It also included controlling behavior through corporal punishment; -The facility must ensure all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source were reported immediately to the administrator. Immediately protect residents involved in identified reports of possible abuse; -The facility was committed to protecting the residents from abuse by anyone including but not limited to facility staff, other resident, consultants, volunteers, family member, friends. 1. Review of Resident #2's nurses' notes, dated 9/14/23 at 12:24 P.M,. showed the resident was admitted following hospitalization for a fractured right hip with surgical repair from a fall at home, history of stroke with left sided weakness. The resident required one staff member assist with gait belt transfers to the wheelchair. He/She was alert and oriented, answered questions appropriately with clear speech. Review of the resident's baseline care plan, dated 9/14/23, showed the following: -Diagnosis of weakness, fractured hip with surgical repair. Staff should provide a safe environment, properly use devices, monitor condition, and provide comfort and care; -The resident required assistance with toileting and hygiene. Staff should encourage participation in Activities of Daily Living (ADLs), maintain safety precautions, and toilet as needed; -The resident had problems with safety and required staff assistance with transfers, balance, ambulation and fall prevention. Staff should assist with transfers and utilize a gait belt, assist with ambulation, and monitor for falls. Staff should monitor for unsteady gait and loss of balance and provide a wheelchair or walker for mobility. Review of the resident's nurses' notes, dated 9/17/23 at 6:33 A.M., showed Licensed Practical Nurse (LPN) C documented certified nurse assistant (CNA) staff said staff took the resident to the bathroom in a wheelchair and transferred the resident to the toilet. Staff cleaned the resident, and transferred him/her back into the wheelchair. The resident said the staff members threw him/her into the sink. LPN C spoke with the resident who said CNA A picked him/her up and threw him/her into the sink. During interview on 9/20/23 at 2:00 P.M., CNA A said sometime early in the morning on 9/17/23, he/she assisted the resident to the bathroom. After providing incontinence care, he/she attempted to transfer the resident to the wheelchair. The resident started to sit on the feces soiled toilet seat, and CNA A quickly pivoted the resident to the wheelchair. The resident sat down hard in the wheelchair. The resident went down fast and hard. The resident said the staff threw him/her into the sink and became irrate. CNA A did not throw the resident into the sink or wall area. CNA A and CNA B reported the incident to LPN C. During interview on 9/20/23 at 1:45 P.M., CNA B said the following: -Early on the morning of 9/17/23, he/she and CNA A took the resident to the toilet. -While transferring the resident from the toilet to the wheelchair, the resident yelled and said they threw him/her into the sink. -Staff should report any allegation of abuse to the charge nurse; -CNA A and CNA B informed the charge nurse LPN C of the incident. During an interview on 9/20/23 at 10:55 A.M., LPN C said the following: -On 9/17/23 at about 5:00 A.M., the resident complained staff threw him/her up against the sink while in the bathroom; -CNA A and CNA B said they answered the resident's call light and took the resident to the toilet. CNA A and CNA B said they did not throw the resident up against the sink but transferred the resident quickly away from the soiled toilet seat and placed the resident in the wheelchair. -LPN C thought the resident was confused and staff did not intentionally hurt the resident; -LPN C reported the incident to the day shift charge nurse LPN D during 7:00 A.M. report; -He/She did not tell the Administrator or Director of Nursing about the incident. He/She did not think the incident was abusive. -Both CNA A and CNA B continued to work following the incident and finished the night shift. During an interview on 9/20/23 at 12:45 P.M., LPN D said the following: -He/She was the charge nurse on 9/17/23. LPN C reported (during report at change of shift) that the resident said two CNA staff (CNA A and CNA B) shoved the resident against the sink in the bathroom and hurt his/her hip while providing toileting assistance. -On 9/17/23 around 7:00 A.M., he/she informed the administrator of the incident by telephone.The administrator gave no instruction to remove CNA A and CNA B from the working schedule. During interview on 9/21/23 at 9:20 A.M., Registered Nurse (RN) E said the following: -He/She was the RN supervisor on 9/17/23. At about 7:00 A.M., LPN D informed him/her the resident reported staff threw him/her into the bathroom sink while transferring from the toilet during the night shift; -Any allegation of abuse should be reported to the Administrator immediately and the facility abuse policy followed. Staff involved should be suspended and removed from the facility pending the investigation. -CNA A and CNA B continued to work following the incidents and completed the night shift. Both returned and worked the night shift on 9/17/23. Neither CNA A nor CNA B should have completed the shift or returned the following night shift. During an interview on 9/20/23 at 1:15 P.M. and 9/21/23 at 11:50 A.M., the administrator said on 9/17/23 at about 7:00 A.M., staff informed him/her of the resident's allegation that CNA A and CNA B threw him/her into the sink while toileting the resident. Staff should have implemented the abuse policy immediately regarding the incident. CNA A and CNA B should not have continued to work the night shift, they should have been immediately removed from the facility pending the investigation. The administrator became aware the morning of 9/18/23 that CNA A and CNA B returned to work 9/17/23 at 7:00 P.M. and worked the night shift through 7:00 A.M. on 9/18/23. On 9/18/23 following completion of the night shift, both CNA A and CNA B were suspended pending the investigation.

Based on interview and record review, the facility failed to identify and communicate to staff effective interventions to prevent falls for one resident (Resident #2), who was admitted with left sided weakness from stroke, in a review of six sampled residents. The resident rolled out of bed on the left side when trying to obtain items that were out of reach. The facility staff also failed to use appropriate transfer techniques for the resident, who staff assessed as high risk for falls, when they failed to transfer the resident using a gait belt (canvas belt placed around the resident's waist to assist with ambulation, transfer, and positioning) as directed in the resident's plan of care. The facility census was 67. Review of the facility's undated policy, How to Transfer an Individual Using a Gait Belt, showed the purpose was to provide safety and protection from possible injury during transfers and ambulation. Apply the belt while the individual was in a comfortable sitting position. If the individual had a weak side, make sure his/her stronger side was facing the destination such as toward the wheelchair or toilet. When the destination was reached, gently lower and encourage the individual to use his/her arms to reach toward the destination and bear some of the weight. Review of the facility policy, Assessing Falls and Their Causes, dated October 2010, showed the purpose was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Falls might be related to underlying clinical conditions and functional decline, medication side effects, and /or environmental risk factors. Residents must be assessed in a timely manner for potential causes of falls. Within 24 hours of a fall, the nursing staff would begin to try to identify possible or likely causes of the incident. Staff should refer to resident specific evidence including medical history and known functional impairments. 1. Review of Resident #2's nurses' notes, dated 9/14/23 at 12:24 P.M., showed the resident was admitted following hospitalization for a fractured right hip with surgical repair from a fall at home and history of stroke with left-sided weakness. The resident could bear weight as tolerated on the right leg. Bruising to the right hip and thigh area were healing with no swelling. The resident required one staff member to assist with gait belt transfers to the wheelchair and was occasionally incontinent of bowel and bladder. He/She was alert and oriented, and answered questions appropriately with clear speech. Review of the resident's baseline care plan, dated 9/14/23, showed the following: -Diagnosis of weakness, fractured hip with surgical repair. Staff should provide a safe environment, properly use devices, monitor condition, and provide comfort and care; -The resident required assistance with toileting. Staff should encourage participation in Activities of Daily Living (ADLs), maintain safety precautions, assist to toilet as needed; -The resident had problems with safety and required staff assistance with transfers, balance, ambulation and fall prevention. Staff should assist with transfers and utilize a gait belt, assist and encourage bed mobility, assist with ambulation, and monitor for falls. Staff should monitor for unsteady gait and loss of balance, and provide a wheelchair or walker for mobility. (Review of the resident's baseline care plan showed no information or interventions for staff to follow regarding the resident's history of stroke with left sided weakness.) Review of the resident's fall risk assessment, dated 9/14/23, showed staff documented the resident's Fall Risk Assessment Tool (FRAT) score was 27, indicating he/she was at high risk for falls. Review of the resident's nurses' notes, dated 9/16/23, showed at 12:15 P.M., staff found the resident on the floor, lying on his/her left side with a pillow under his/her head. The resident was on the left side of the bed. The resident said he/she rolled over in bed to grab his/her phone and rolled out of bed. The bed was in the low position. Range of motion intact, a little weaker on the left side. The resident reported he/she had strokes and was weaker on the left side. Alert and oriented to person place and time. The resident asked for the call light to be placed closer to his/her right hand. Review of the resident's care plan, updated 9/16/23, showed staff documented the resident rolled over to get the telephone and fell out of bed. Staff should help make sure items were in reach. (Review of the resident's care plan showed no additional interventions identified to address the resident's left sided weakness and risk for falls. Staff did not identify the resident had requested the call light be placed closer to his/her right hand.) Review of the resident's nurses' notes, dated 9/17/23, showed the following: -At 11:26 A.M., staff reported during transfers, the resident tended to flop down even with staff assisting during transfer to the bed or wheelchair; -At 12:18 P.M., the resident asked for assistance to the toilet that morning and was incontinent of bowel. Staff took the resident to the bathroom in the wheelchair, provided incontinence care and applied a clean incontinence brief. The resident wanted to sit back down on the feces soiled toilet seat instead of the wheelchair. The resident started to fall back, staff pivoted the resident to the wheelchair instead of the soiled toilet seat. Discussed with the resident's family member tendency for resident to flop down when sitting or lying down. Review of the resident's care plan showed no information or interventions regarding the resident's tendency to flop down when sitting or lying down. During an interview on 9/20/23 at 10:55 A.M., Licensed Practical Nurse (LPN) C said on 9/17/23, CNA A said while providing the incontinence care for the resident on the toilet, the resident stood up and lost his/her balance. CNA A pivoted the resident to the toilet away from the soiled toilet seat and caught the resident's right hip on the side of the wheelchair. During an interview on 9/20/23 at 12:25 P.M., the resident said two CNAs took him/her to the bathroom in the middle of the night. He/She was incontinent of feces and staff provided incontinence care while he/she stood at the grab bar near the toilet. Staff did not use a gait belt while assisting him/her to the bathroom. During an interview on 9/20/23 at 2:00 P.M., CNA A said on 9/17/23 he/she assisted the resident to the bathroom. This was the first night CNA A worked with the resident and did not know much about the resident. The resident was incontinent of feces. After providing incontinence care, CNA A attempted to transfer the resident to the wheelchair. The resident started to sit on the feces soiled toilet seat, and CNA A quickly pivoted the resident to the wheelchair. The resident sat down hard in the wheelchair. The resident went down fast and hard. He/She did not use a gait belt during the transfers. CNA A was not aware the resident had a history of stroke with left sided weakness. During an interview on 9/21/23 at 9:20 A.M., Registered Nurse (RN) E said on 9/16/23, the resident fell out of bed on his/her left side and it was noticed then the resident flopped down hard when sitting. The resident had a history of stroke with left sided weakness. Staff should transfer the resident with a gait belt and provide support during transfers. Staff should be informed of the resident's current condition and care required. During interviews on 9/20/23 at 1:15 P.M. and 9/21/23 at 11:50 A.M., the administrator said staff provided a bad transfer for the resident and should have used a gait belt during transfers. Staff sat the resident down hard in the wheelchair. The resident's stroke and left sided weakness affected his/her transfer and mobility status on the left side and the fractured hip repair affected the right side. Staff should be aware of the resident's weakness and need for assistance. The resident's care plan should reflect the resident's current status and assistance required. Staff should update the care plan and ensure all staff were aware of incidents and changes to the care plan. MO00224574 MO00224632

Based on interview and record review, the facility failed to provide appropriate care and services to maintain the highest practical well-being for one resident (Resident #1) with a diagnosis of dementia, in a review of five sampled residents. The facility identified the resident did not like and became upset when staff of the opposite sex provided his/her care. The facility failed to ensure the direct care staff who provided care for the resident on 9/17/23 were of the same sex as the resident, and failed to follow the resident's care plan to approach the resident at another time when the resident was combative or refused care. During incontinence care on 9/17/23, the resident became upset, combative, swatting his/her arms, and resisted care. Staff continued to provide care for the resident, and the resident sustained a skin tear. The facility census was 67. Review of the facility policy, Dementia Clinical Protocol, dated March 2015, showed the following: -The facility would review the past and current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications and functional impairments using several sources including the resident if appropriate, family and information from prior records. Staff would collect and document in the resident's medical record life experiences, personal preferences, overall health and current medical conditions, cognitive status and related abilities, mood and behavior patterns, including how the resident typically expressed physical, emotional and psychosocial needs including distress and current medications; -Staff would identify a resident-centered care plan to maximize remaining function and quality of life; -Train staff in the care of resident with dementia and related behaviors; -Strive to optimize familiarity through consistent staff-resident assignments; -Direct care staff would support the resident in initiating and completing activities and tasks of daily living such as bathing, dressing, meals, activities and supervise and support throughout the day; -Identify and document the resident's condition and level of support needed during care planning and review, change needs as they arise. Resident needs would be communicated to direct care staff through care plan conferences, change of shift communications and through written documentation; Progressive or persistent worsening of symptoms and increased need for staff support should be reported to the care plan team; -Staff would monitor the individual with dementia for change in condition and decline in function; -Adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, and development of new acute medical conditions or complications, or changes in resident or family wishes. 1. Review of Resident #1's care plan, dated 5/16/23, showed the following: -Diagnosis of dementia; -The resident's cognition and abilities varied from day to day and moment to moment; -He/She required staff assistance with care and refused care at times; -Staff should ensure the resident was safe. If swatting at staff or refused care, have another staff care for the resident and/or come back at a later time and try again. The resident preferred the opposite sex not bath him/her. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 7/18/23, showed the following: -Severely impaired cognition; -Required limited assistance of one staff member with bed mobility, transfers and toileting; -Required extensive assistance of one staff member with dressing; -Always incontinent of bowel and bladder. Review of the resident's nurses' note, dated 9/17/23, showed the following: -At 7:01 A.M., Licensed Practical Nurse (LPN) C documented certified nurse aide (CNA) staff said during incontinence care, the resident was combative and scratched his/her right forearm leaving a skin tear; -At 9:58 A.M., LPN D documented the resident had a 6 centimeter skin tear on the right lower arm. During an interview on 9/20/23 at 10:55 A.M., LPN C said the following: -He/She was the night shift charge nurse on 9/17/23. At about 6:50 A.M., CNA A said the resident had a skin tear on his/her right arm. The resident was combative during incontinence care and scratched his/her arm resulting in a skin tear. -The resident had dementia, was confused, and became combative at times. -Staff should ensure the resident was safe if resisting care and not force the resident to complete the care. -CNA A and CNA B were assigned the resident's hall and were of the opposite sex of the resident; -On the following shift, he/she was informed the resident did not like staff of the opposite sex caring for him/her. During an interview on 9/20/23 at 12:45 P.M., LPN D said the if the resident refused care, staff should not make him/her do anything. Staff should stop trying to clean the resident and let the resident settle down. Staff were aware the resident did not like staff of the opposite sex caring for him/her. The night shift CNA A and CNA B were the opposite sex and were assigned to the resident's hall. During an interview on 9/20/23 at 2:00 P.M., CNA A said the following: -On 9/17/23 at about 5:00 A.M., he/she and CNA B provided incontinence care for the resident at the end of the night shift. The resident was wet and soiled and took some time to provide complete care; -The resident was calm at first and quiet. -Staff turned the resident to his/her left side while providing care, and the resident faced the wall with his/her right arm raised. The resident became combative, swatting his/her arm. The resident was upset and resisted care. -During care, a skin tear occurred on the resident's right forearm; -He/She was aware the resident was afraid of staff of the opposite sex. He/She should have found another staff member of the same sex as the resident to provide incontinence care. -Staff should have stopped cares, ensured the resident was safe and found other staff of the resident's same sex to provide cares. CNA A wanted the resident clean at the change of shift and did not want to leave the resident soiled. During an interview on 9/20/23 at 1:45 P.M., CNA B said the following: -He/She assisted CNA A provide the resident's incontinence care at the end of the night shift on 9/17/23. -The resident said no when they started care. The resident was handsy and grabbed at staff during care on 9/17/23; -Staff pushed the resident over towards the wall on his/her left side and both staff provided incontinence care. The resident grabbed at things and was moving his/her arms while they provided care. In the process, the resident got a skin tear on the arm; -CNA A and CNA B needed to change the resident as he/she was soiled and had to be done before the end of the shift. -CNA B did not know the resident was afraid and did not like staff of the opposite sex; -He/She should have found staff of the same sex as the resident to provide the resident's care. During an interview on 9/21/23 at 9:20 A.M., Registered Nurse (RN) E said the resident had dementia, confusion and agitation, fragile skin and could be combative. The resident preferred staff of the same sex and was afraid of staff of the opposite sex. CNA A and CNA B provided the resident's care on the night shift and were the opposite sex of the resident. It was a mistake to assign staff of the opposite sex to care for the resident. The working schedule was a misshap and should not have been assigned that way. During interviews on 9/20/23 at 1:15 P.M. and 9/21/23 at 11:50 A.M., the administrator said the resident did not like staff of the opposite sex. CNA A and CNA B should have calmed the resident, ensured he/she was safe and found other staff the same sex as the resident to provide his/her care. If the resident was upset, flailing arms, and refused care, staff should make sure the resident was safe and get other staff to provide the care. The resident needed at least one staff member of the same sex as the resident to provide direct care. Two staff of the opposite sex should not be assigned to the resident's hall. Staff that completed the schedule knew to assign a staff member of the same sex as the resident on the resident's hall. During an interview on 9/21/23 at 2:45 P.M., the resident's physician said the resident was combative with fragile skin. The resident was confused all the time and did not like staff of the opposite sex to provide care. Staff were aware the resident did not like staff of the opposite sex. The resident had severe dementia and staff should care for the resident accordingly. Staff should keep the resident safe first, then provide care, and not upset the resident. He expected staff to provide dementia care appropriately, and for staff to ensure residents had a safe environment to live and receive care as needed. MO00224574 MO00224632

Based on observation, interview and record review, the facility failed to routinely assess pain, administer pain medications timely after pain was identified, notify the physician of unresolved pain, administer pain medications in anticipation of activities that cause pain, and re-evaluate if medications administered were effective for one resident (Resident #1) who was distressed, and rated his/her pain a eight on a zero to ten scale with ten being the worst pain possible. The resident said he/she was hurting too bad to get out of bed for lunch. The resident had possible fractures that had been identified and had not been treated, and pressure ulcers to his/her heels and coccyx. The facility census was 67. Review of the facility's policy on Pain Assessment and Management, revised on March 2015, showed the following: -The purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. -Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain; -Recognizing pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain; 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying and screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his/her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite; h. Insomnia and i. Evidence of depression, anxiety, fear or hopelessness. -Assessing pain: a. History of pain its treatment, including pharmacological and non-pharmacological interventions; b. Characteristics of pain: 1. Intenisty of pain (as measured on a standardized pain scale); 2. Descriptors of pain; 3. Pattern of pain (e.g. constant or intermittent); 4. Location and radiation of pain; c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and f. Symptoms that accompany pain (e.g. nausea, anxiety) -Review the resident's medical record to identify condition or situations that my predispose the resident to pain including: fractures, pressure ulcers, and surgical incisions; -Review the resident's treatment record or recent nurses notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example: a. bathing, dressing or other ADL's; b. Treatments such as wound care or dressing changes; c. Ambulation with physical therapy; d. Turning or repositioning. -Pain management interventions may include non-pharmacological interventions and pharmacological interventions. -Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. -If pain has not been adequately controlled, the multidisciplinary team, including the physician shall reconsider approaches and make adjustments as indicated; -Document the resident's reported level of pain with adequate detail, with enough information to gauge the status of pain and the effectiveness of interventions for pain as necessary and in accordance with the pain management program. -Report the following information to the physician or practitioner; 1. Significant changes in the level of the resident's pain; 2. Adverse effects from pain medication; 2. Prolonged, unrelieved pain despite care plan interventions. 1. Review of Resident #1's Physician Progress Noted, dated 2/10/23, showed the following: -admitted for physical and occupation therapy following a fall causing a left introchanteric fracture (a type of hip fracture); -The resident reports his/her pain is under control; -Resident is alert and oriented; -Medications include gabapentin (a medication for seizures and can be used for nerve pain) 300 milligrams (mg) three times a day, oxycodone (opiate (narcotic) pain medication) 5 mg PRN (as needed) every six hours; -Skin is warm, pink and dry with no rashes or lesions. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated for 2/16/23, showed the following: -Entry date to the facility 2/9/23; -Cognitively intact; -Diagnosis include knee and hip replacement, displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease (lung disorder), hypertensive heart disease without heart failure, cervical spinal stenosis (narrowing of the cervical spine placing pressure on the spinal cord), -No signs or symptoms of delirium; -Minimal signs and symptoms of depression; -No behaviors or rejection of care; -Requires set up assistance with eating; -Requires extensive physical assistance of two or more staff members with bed mobility, transfers, and toilet use; -Scheduled and as needed pain medication; -Resident rates his/her pain as constantly and a 9 on a 1-10 scale, that affects his ability to sleep and do day to day activities; -Fall prior to admission with fracture; -Two unhealed stage II pressure ulcers (partial thickness lose of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow/white material in a wound bed) or bruising); -Skin tears and surgical wound; -Received opioid medication one day out of the last seven days (or since admission). Review of the resident's discharge MDS, dated [DATE], showed the following: -discharged to an acute care hospital; -Opioid medication received five of the last seven days; -The resident has two stage II pressures. Review of the resident's Plan of Care notes, dated 2/22/23, showed the following: -Resident having pain in his/her left hip due to recent hip fracture and hip replacement; -Give medications as ordered; -Offer cool packs as needed; -Assist with repositioning as needed; -Notify the physician if pain is not relieved by medication. Review of the resident's History and Physical, dated 3/7/23, showed the resident had a femur (thigh bone) fracture. Pain is controlled with scheduled gabapentin medications and oxycodone PRN. Skin warm and dry with dressing on left thigh peeling off. Culture wound left heel. Review of the resident's Nurse Progress Notes, dated 3/13/23, 7:00 A.M. showed walking down the hall and heard the resident yelling. The resident was on the floor on his/her back next to his/her roommates bed. The resident said, dang oxygen tubing and that he/she broke his/her hip. Review of the resident's Nurse Progress Notes, dated 3/13/23, at 8:17 A.M., showed the resident fell this morning; waiting on results from an x-ray. Review of the resident's Nurse Progress Notes, dated 3/13/23, at 2:54 P.M. showed x-ray results show left total hip arthroplasty (surgical procedure to restore the function of a joint) with a displaced greater trochanteric (top of the thigh bone) periprosthetic fracture (a broken bone that occurs around the implants of a total hip replacement), resident had open reduction (when the surgeon makes an incision to access the bone and realign it) and internal fixation (piecing the bone fragments together with hardware such as pins, plates, rods, screws or a combination of these) of left hip in February in at hospital. Resident transferred to the emergency room . Review of the resident's entry MDS, dated [DATE], showed the resident returned to the facility from the hospital on 3/17/23. Review of the resident's March 2023 Physician Order Sheet (POS) showed the following: -Gabapentin 300 mg three times a day; -Acetaminophen (pain medication) 650 mg four times a day as needed; -Oxycodone 5 mg every six hours as needed; -Oxycodone 10 mg every six hours as needed. Review of the resident's Nurse Progress Notes dated 3/17/23 at 3:30 P.M., showed the resident complained of pain in his/her hip when rolling to change in bed. No documentation to show the resident was offered a pain intervention at this time. Review of the resident's Medication Administration Record (MAR), dated March 2023, showed oxycodone 10 mg was administered on 3/17/23 at 4:20 P.M. (50 minutes after the resident reported pain). No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/18/23 at 6:42 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/18/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -At 11:03 A.M., staff documented the resident's pain score as an eight. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/18/23 at 11:21 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/18/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Nurse Progress Notes, dated 3/18/23, at 12:10 P.M. showed the resident declined getting out of bed for breakfast and lunch due to pain. There was no documentation to show staff provided any additional intervention at this time and did not notify the resident's physician. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/18/23 at 5:20 P.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/19/23, at 9:00 A.M., showed the resident's pain score as a six with activity, both upper legs, intermittent. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/19/23 at 9:47 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/19/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/19/23 at 9:00 P.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/19/23, at 10:33 P.M., showed the resident's pain score was a seven at rest and eight with activity, hip and leg aching. (The medical record did not make clear if this assessment was done with the 9:00 P.M. pain medication administration and charted later or if the resident continued to be in pain one hour and a half after the oxycodone was administered.) Review of the resident's medical record showed no documented evidence, on 3/19/23, of notification to the physician that the resident's pain was unrelieved. Review of the resident's Nurse Progress Notes, dated 3/20/23, showed the resident's left femur is WBAT (weight bearing as tolerated) with assistive device for six weeks, with no left hip abduction (moving left leg in outward motion from midline). Review of the resident's Flowsheet Print Request Pain Tools, dated 3/20/23, at 10:32 A.M., showed the resident's pain score as a five at rest, head (indicating location of pain). Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/20/23 at 10:44 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/20/23, at 10:00 P.M., showed the residen'ts pain score as a four. No interventions or medications documented. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, at 6:12 A.M., showed the resident's pain score as a four at rest, left hip aching, both heels and coccyx acute pain. No interventions or medications documented. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/21/23 at 9:13 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, at 9:44 A.M., showed the residents pain score as an seven at rest, left hip. The medical record did not make clear if this assessment was done with the 9:13 A.M. administration of pain medication or if the resident continued to be in pain a half hour after the oxycodone was administered. No documented evidence of notification to the physician if pain was unrelieved. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, at 11:58 P.M., showed the resident's pain score as a nine. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/22/23 one time at 1:02 A.M., one hour after the resident's pain was documented at a nine. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/22/23, at 9:52 A.M., showed the resident's pain score as a seven. No interventions for the pain were documented. Review of the resident's MAR, dated 3/22/23, showed no pain medications were administered after the 1:02 A.M. dose. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/22/23, at 8:00 P M., showed the pain assessment is blank, did not contain any documentation, indicating staff did not complete a pain assessment. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/22/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/23/23, at 10:21 A M., showed pain score a four, the resident was given 1=occasional moan, 1=sad, 1=tense, 1=distracted. No interventions for the pain were documented. Review of the resident's MAR, dated 3/23/23, showed no pain medications were administered on 3/23/23. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/23/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/24/23 at 9:23 A.M. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/24/23, at 10:35 A.M. showed pain level at a one; No documentation to show staff offered an intervention for pain at this time. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/24/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/25/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/25/23, at 2:56 P.M., showed the resident's pain a zero. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/25/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/26/23, at 9:15 A.M., showed the resident's pain a zero, 1=occasional moan. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/26/23 at 10:24 A.M., another dose of oxycodone 10 mg was administered at 5:24 P.M., and a dose of oxycodone 5 mg at 7:11 P.M. The facility staff did not document any reason for the increase in administration of pain medication. No follow up pain assessment documentation was provided by the facility after medications were administered. No documentation to show the physician was notified. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/26/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/27/23 at 9:43 A.M. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/27/23, at 10:22 A.M., showed the resident's pain a seven, generalized. No other pain assessment documented for 3/27/23. The medical record did not make clear if this assessment was done with the 9:43 A.M. administration of pain medication or if the resident continued to be in pain 39 minutes after the oxycodone was administered. No documented evidence of notification to the physician if pain was unrelieved. No other pain assessment documented after 10:22 A.M. for 3/27/23. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/27/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/28/23, at 10:01 A.M., showed the resident's pain a two at rest and four with activity. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/28/23 at 1:20 P.M. was administered. No follow up pain assessment documentation was provided by the facility after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/28/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the Resident Flowsheet Print Request Pain Tools, dated 3/30/23, at 8:36 A.M. showed the resident's pain a three at rest and a four with activity; no documentation to show pain medication was administered or an intervention given at this time. Review of the resident's MAR, dated March 2023, showed acetaminophen 650 mg was administered at 9:30 A.M, one hour and six minutes after the residents pain was documented at a four. No follow up pain assessment was documented after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/30/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. -At 1:00 P.M., staff documented the resident's pain a seven at rest; no documentation to show pain medication was administered or an intervention given at this time. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/29/23 at 2:07 P.M., one hour and seven minutes after the resident's pain was documented at a seven. No follow up pain assessment was documented after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Nurse Progress Notes, dated 3/30/23, showed during the care plan meeting the family expressed concern about the resident taking stronger pain medication and this causing him/her to be less willing to participate in ADL's and therapy. Pain assessment added to ensure resident pain is managed and what type of PRN as needed pain medication can help achieve this, care partners aware. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/30/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the Resident Flowsheet Print Request Pain Tools, dated 3/31/23, at 8:27 A.M., showed pain score three at rest, and six with activity. Review of the MAR, dated 3/31/23, showed no PRN pain medication administered. No documentation to show staff acted on the resident's report of pain at 8:27 A.M. or provided an intervention for his/her reported pain. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/31/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/1/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/2/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated 4/3/23, showed documentation staff administered the following: -Acetaminophen 650 mg was administered at 9:06 A.M.; -No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/3/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated 4/3/23, showed documentation staff administered the following: -Oxycodone 5 mg was administered at 11:32 A.M.; -No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Nurse Progress Notes, dated 4/3/23, at 1:32 P.M. showed the resident complained of pain in his/her knee, and the nurse obtained x-ray orders of the left hip and lumbar spine.No documentation to show an intervention for the complaint of pain was given at this time. Review of the resident's MAR, dated 4/3/23, showed documentation staff administered Acetaminophen 650 mg at 7:19 P.M. No follow up pain assessment was documented after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/3/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated 4/4/23, showed acetaminophen 650 mg was administered at 8:47 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/4/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/5/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Observation and interview on 4/5/23, at 10:55 A.M., showed the following: -The resident in bed on his/her back; - Registered Nurse (RN) B moved the resident's legs onto the bed and the resident grimaced and yelled out in pain; -RN B lifted the resident's leg and he/she moaned; -Licensed Practical Nurse (LPN) A cut off the resident's dressing on his/her left foot to reveal a large black eschar (dead tissue) wound on his/her heel; -The resident grimaced and yelled out in pain when LPN A cleansed the wound; -Resident said his/her pain is an eight out of ten; -The resident said it really hurts when the staff move his/her leg; -LPN A and RN B lifted the resident's leg and he/she grimaced; -The resident grabbed his/her left hip and yelled out in pain; -LPN A removed the dressing on the resident's right heel; -LPN A and RN B moved the resident to the center of the bed, the resident grimaced and yelled out in pain; staff rolled the resident on his/her right side to reveal his/her buttocks; the resident grimaced and yelled out in pain; -Staff removed the resident's dressing from his/her buttocks, the resident yelled out in; -LPN A said he/she would see if the resident could have another pain pill; -Resident said he/she did not want to get up for lunch; he/she said I would love to get up for lunch, but I just can't, the resident said I just hurt; (Discussion with the resident about his/her pain was while staff were in the room. The staff did not stop providing care after the resident grimaced, yelled out in pain, or expressed his/her pain level at an eight.) Review of the resident's MAR, dated 4/5/23, at 2:10 P.M., showed staff had not documented administering the resident any acetaminophen or oxycodone PRN pain medication. Review of the resident's Progress Nurses Notes, dated 4/5/23, at 2:10 P.M., showed no evidence of an assessment or documentation about pain. Review of the resident's Narcotic records on 4/5/23, at 2:40 P.M., showed the resident had not received his/her oxycodone on 4/5/23. The last dose was on 4/3/23 at 11:32 A.M. The resident had not received acetaminophen since 4/4/23 at 8:47 A.M. During an interview on 4/5/23, at 2:45 P.M., Certified Medication Technician (CMT) D said the following: -If he/she charted a zero for a resident's pain, its because they didn't report pain or ask for pain medicine; -No one reported to him/her that the resident was in pain today; -The resident has orders for acetaminophen or oxycodone and he/she can have both. Observation on 4/5/23, at 2:48 P.M., the resident told CMT D he/she had pain and it was a seven or eight, and said, it hurts real bad. The resident did not received pain medication for four hours after pain was identified. During an interview on 4/5/23, at 2:31 P.M. and at 5:25 P.M., the Director of Nursing said the following: -The resident had x-rays on 4/3/23 related to a bony prominence on the left knee; -It's possible there is another small fracture; hard copies of the x-ray sent to the surgeon on 4/4/23; -The new x-ray also shows something on the resident's spine and it could be an old fracture; -The resident has PRN oxycodone and acetaminophen; -If a resident is yelling out in pain with care staff are expected to stop and administered medication or provide an intervention that helps the pain and give it time to work before proceeding with care; -Pain should be assessed at least every shift, and documented; -Staff are expected to assess pain at least every shift; -Staff are expected to utilize pain medications and non-pharmacological interventions to relieve residents pain; -Staff are expected to follow up 30 minutes to an hour after administering a PRN pain medication to see if it was effective; -Staff are expected to notify the physician any time new acute pain is identified; -Physician should be notified if pain medications and interventions have been completed and does not relieve the residents pain to an acceptable level.

Based on observation, interview and record review, the facility failed to routinely assess pain, administer pain medications timely after pain was identified, notify the physician of unresolved pain, administer pain medications in anticipation of activities that cause pain, and re-evaluate if medications administered were effective for one resident (Resident #1) who was distressed, and rated his/her pain a eight on a zero to ten scale with ten being the worst pain possible. The resident said he/she was hurting too bad to get out of bed for lunch. The resident had possible fractures that had been identified and had not been treated, and pressure ulcers to his/her heels and coccyx. The facility census was 67. Review of the facility's policy on Pain Assessment and Management, revised on March 2015, showed the following: -The purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. -Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain; -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain; -Recognizing pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain; 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying and screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw, etc.; c. Changes in gait, skin color and vital signs; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Limitations in his/her level of activity due to the presence of pain; f. Guarding, rubbing or favoring a particular part of the body; g. Difficulty eating or loss of appetite; h. Insomnia and i. Evidence of depression, anxiety, fear or hopelessness. -Assessing pain: a. History of pain its treatment, including pharmacological and non-pharmacological interventions; b. Characteristics of pain: 1. Intenisty of pain (as measured on a standardized pain scale); 2. Descriptors of pain; 3. Pattern of pain (e.g. constant or intermittent); 4. Location and radiation of pain; c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and f. Symptoms that accompany pain (e.g. nausea, anxiety) -Review the resident's medical record to identify condition or situations that my predispose the resident to pain including: fractures, pressure ulcers, and surgical incisions; -Review the resident's treatment record or recent nurses notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example: a. bathing, dressing or other ADL's; b. Treatments such as wound care or dressing changes; c. Ambulation with physical therapy; d. Turning or repositioning. -Pain management interventions may include non-pharmacological interventions and pharmacological interventions. -Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. -If pain has not been adequately controlled, the multidisciplinary team, including the physician shall reconsider approaches and make adjustments as indicated; -Document the resident's reported level of pain with adequate detail, with enough information to gauge the status of pain and the effectiveness of interventions for pain as necessary and in accordance with the pain management program. -Report the following information to the physician or practitioner; 1. Significant changes in the level of the resident's pain; 2. Adverse effects from pain medication; 2. Prolonged, unrelieved pain despite care plan interventions. 1. Review of Resident #1's Physician Progress Noted, dated 2/10/23, showed the following: -admitted for physical and occupation therapy following a fall causing a left introchanteric fracture (a type of hip fracture); -The resident reports his/her pain is under control; -Resident is alert and oriented; -Medications include gabapentin (a medication for seizures and can be used for nerve pain) 300 milligrams (mg) three times a day, oxycodone (opiate (narcotic) pain medication) 5 mg PRN (as needed) every six hours; -Skin is warm, pink and dry with no rashes or lesions. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment, dated for 2/16/23, showed the following: -Entry date to the facility 2/9/23; -Cognitively intact; -Diagnosis include knee and hip replacement, displaced intertrochanteric fracture of left femur, chronic obstructive pulmonary disease (lung disorder), hypertensive heart disease without heart failure, cervical spinal stenosis (narrowing of the cervical spine placing pressure on the spinal cord), -No signs or symptoms of delirium; -Minimal signs and symptoms of depression; -No behaviors or rejection of care; -Requires set up assistance with eating; -Requires extensive physical assistance of two or more staff members with bed mobility, transfers, and toilet use; -Scheduled and as needed pain medication; -Resident rates his/her pain as constantly and a 9 on a 1-10 scale, that affects his ability to sleep and do day to day activities; -Fall prior to admission with fracture; -Two unhealed stage II pressure ulcers (partial thickness lose of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow/white material in a wound bed) or bruising); -Skin tears and surgical wound; -Received opioid medication one day out of the last seven days (or since admission). Review of the resident's discharge MDS, dated [DATE], showed the following: -discharged to an acute care hospital; -Opioid medication received five of the last seven days; -The resident has two stage II pressures. Review of the resident's Plan of Care notes, dated 2/22/23, showed the following: -Resident having pain in his/her left hip due to recent hip fracture and hip replacement; -Give medications as ordered; -Offer cool packs as needed; -Assist with repositioning as needed; -Notify the physician if pain is not relieved by medication. Review of the resident's History and Physical, dated 3/7/23, showed the resident had a femur (thigh bone) fracture. Pain is controlled with scheduled gabapentin medications and oxycodone PRN. Skin warm and dry with dressing on left thigh peeling off. Culture wound left heel. Review of the resident's Nurse Progress Notes, dated 3/13/23, 7:00 A.M. showed walking down the hall and heard the resident yelling. The resident was on the floor on his/her back next to his/her roommates bed. The resident said, dang oxygen tubing and that he/she broke his/her hip. Review of the resident's Nurse Progress Notes, dated 3/13/23, at 8:17 A.M., showed the resident fell this morning; waiting on results from an x-ray. Review of the resident's Nurse Progress Notes, dated 3/13/23, at 2:54 P.M. showed x-ray results show left total hip arthroplasty (surgical procedure to restore the function of a joint) with a displaced greater trochanteric (top of the thigh bone) periprosthetic fracture (a broken bone that occurs around the implants of a total hip replacement), resident had open reduction (when the surgeon makes an incision to access the bone and realign it) and internal fixation (piecing the bone fragments together with hardware such as pins, plates, rods, screws or a combination of these) of left hip in February in at hospital. Resident transferred to the emergency room. Review of the resident's entry MDS, dated [DATE], showed the resident returned to the facility from the hospital on 3/17/23. Review of the resident's March 2023 Physician Order Sheet (POS) showed the following: -Gabapentin 300 mg three times a day; -Acetaminophen (pain medication) 650 mg four times a day as needed; -Oxycodone 5 mg every six hours as needed; -Oxycodone 10 mg every six hours as needed. Review of the resident's Nurse Progress Notes dated 3/17/23 at 3:30 P.M., showed the resident complained of pain in his/her hip when rolling to change in bed. No documentation to show the resident was offered a pain intervention at this time. Review of the resident's Medication Administration Record (MAR), dated March 2023, showed oxycodone 10 mg was administered on 3/17/23 at 4:20 P.M. (50 minutes after the resident reported pain). No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/18/23 at 6:42 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/18/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -At 11:03 A.M., staff documented the resident's pain score as an eight. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/18/23 at 11:21 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/18/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Nurse Progress Notes, dated 3/18/23, at 12:10 P.M. showed the resident declined getting out of bed for breakfast and lunch due to pain. There was no documentation to show staff provided any additional intervention at this time and did not notify the resident's physician. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/18/23 at 5:20 P.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/19/23, at 9:00 A.M., showed the resident's pain score as a six with activity, both upper legs, intermittent. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/19/23 at 9:47 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/19/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/19/23 at 9:00 P.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/19/23, at 10:33 P.M., showed the resident's pain score was a seven at rest and eight with activity, hip and leg aching. (The medical record did not make clear if this assessment was done with the 9:00 P.M. pain medication administration and charted later or if the resident continued to be in pain one hour and a half after the oxycodone was administered.) Review of the resident's medical record showed no documented evidence, on 3/19/23, of notification to the physician that the resident's pain was unrelieved. Review of the resident's Nurse Progress Notes, dated 3/20/23, showed the resident's left femur is WBAT (weight bearing as tolerated) with assistive device for six weeks, with no left hip abduction (moving left leg in outward motion from midline). Review of the resident's Flowsheet Print Request Pain Tools, dated 3/20/23, at 10:32 A.M., showed the resident's pain score as a five at rest, head (indicating location of pain). Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/20/23 at 10:44 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/20/23, at 10:00 P.M., showed the residen'ts pain score as a four. No interventions or medications documented. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, at 6:12 A.M., showed the resident's pain score as a four at rest, left hip aching, both heels and coccyx acute pain. No interventions or medications documented. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/21/23 at 9:13 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, at 9:44 A.M., showed the residents pain score as an seven at rest, left hip. The medical record did not make clear if this assessment was done with the 9:13 A.M. administration of pain medication or if the resident continued to be in pain a half hour after the oxycodone was administered. No documented evidence of notification to the physician if pain was unrelieved. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/21/23, at 11:58 P.M., showed the resident's pain score as a nine. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/22/23 one time at 1:02 A.M., one hour after the resident's pain was documented at a nine. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/22/23, at 9:52 A.M., showed the resident's pain score as a seven. No interventions for the pain were documented. Review of the resident's MAR, dated 3/22/23, showed no pain medications were administered after the 1:02 A.M. dose. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/22/23, at 8:00 P M., showed the pain assessment is blank, did not contain any documentation, indicating staff did not complete a pain assessment. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/22/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/23/23, at 10:21 A M., showed pain score a four, the resident was given 1=occasional moan, 1=sad, 1=tense, 1=distracted. No interventions for the pain were documented. Review of the resident's MAR, dated 3/23/23, showed no pain medications were administered on 3/23/23. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/23/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/24/23 at 9:23 A.M. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/24/23, at 10:35 A.M. showed pain level at a one; No documentation to show staff offered an intervention for pain at this time. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/24/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/25/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/25/23, at 2:56 P.M., showed the resident's pain a zero. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/25/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/26/23, at 9:15 A.M., showed the resident's pain a zero, 1=occasional moan. Review of the resident's MAR, dated March 2023, showed oxycodone 10 mg was administered on 3/26/23 at 10:24 A.M., another dose of oxycodone 10 mg was administered at 5:24 P.M., and a dose of oxycodone 5 mg at 7:11 P.M. The facility staff did not document any reason for the increase in administration of pain medication. No follow up pain assessment documentation was provided by the facility after medications were administered. No documentation to show the physician was notified. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/26/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/27/23 at 9:43 A.M. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/27/23, at 10:22 A.M., showed the resident's pain a seven, generalized. No other pain assessment documented for 3/27/23. The medical record did not make clear if this assessment was done with the 9:43 A.M. administration of pain medication or if the resident continued to be in pain 39 minutes after the oxycodone was administered. No documented evidence of notification to the physician if pain was unrelieved. No other pain assessment documented after 10:22 A.M. for 3/27/23. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/27/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/28/23, at 10:01 A.M., showed the resident's pain a two at rest and four with activity. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/28/23 at 1:20 P.M. was administered. No follow up pain assessment documentation was provided by the facility after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/28/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the Resident Flowsheet Print Request Pain Tools, dated 3/30/23, at 8:36 A.M. showed the resident's pain a three at rest and a four with activity; no documentation to show pain medication was administered or an intervention given at this time. Review of the resident's MAR, dated March 2023, showed acetaminophen 650 mg was administered at 9:30 A.M, one hour and six minutes after the residents pain was documented at a four. No follow up pain assessment was documented after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/30/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. -At 1:00 P.M., staff documented the resident's pain a seven at rest; no documentation to show pain medication was administered or an intervention given at this time. Review of the resident's MAR, dated March 2023, showed oxycodone 5 mg was administered on 3/29/23 at 2:07 P.M., one hour and seven minutes after the resident's pain was documented at a seven. No follow up pain assessment was documented after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Nurse Progress Notes, dated 3/30/23, showed during the care plan meeting the family expressed concern about the resident taking stronger pain medication and this causing him/her to be less willing to participate in ADL's and therapy. Pain assessment added to ensure resident pain is managed and what type of PRN as needed pain medication can help achieve this, care partners aware. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/30/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the Resident Flowsheet Print Request Pain Tools, dated 3/31/23, at 8:27 A.M., showed pain score three at rest, and six with activity. Review of the MAR, dated 3/31/23, showed no PRN pain medication administered. No documentation to show staff acted on the resident's report of pain at 8:27 A.M. or provided an intervention for his/her reported pain. Review of the resident's Flowsheet Print Request Pain Tools, dated 3/31/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/1/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/2/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated 4/3/23, showed documentation staff administered the following: -Acetaminophen 650 mg was administered at 9:06 A.M.; -No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/3/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated 4/3/23, showed documentation staff administered the following: -Oxycodone 5 mg was administered at 11:32 A.M.; -No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Nurse Progress Notes, dated 4/3/23, at 1:32 P.M. showed the resident complained of pain in his/her knee, and the nurse obtained x-ray orders of the left hip and lumbar spine.No documentation to show an intervention for the complaint of pain was given at this time. Review of the resident's MAR, dated 4/3/23, showed documentation staff administered Acetaminophen 650 mg at 7:19 P.M. No follow up pain assessment was documented after medications were administered to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/3/23, showed staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's MAR, dated 4/4/23, showed acetaminophen 650 mg was administered at 8:47 A.M. No follow up pain assessment documentation was provided by the facility to show if the resident reported the medication administration was effective or not. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/4/23, showed the following: -Staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score; -Staff was to assess and document a pain score at 10:00 P.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Review of the resident's Flowsheet Print Request Pain Tools, dated 4/5/23, showed staff was to assess and document a pain score at 10:00 A.M.; the box was blank, indicating staff did not complete the assessment or obtain a pain score. Observation and interview on 4/5/23, at 10:55 A.M., showed the following: -The resident in bed on his/her back; - Registered Nurse (RN) B moved the resident's legs onto the bed and the resident grimaced and yelled out in pain; -RN B lifted the resident's leg and he/she moaned; -Licensed Practical Nurse (LPN) A cut off the resident's dressing on his/her left foot to reveal a large black eschar (dead tissue) wound on his/her heel; -The resident grimaced and yelled out in pain when LPN A cleansed the wound; -Resident said his/her pain is an eight out of ten; -The resident said it really hurts when the staff move his/her leg; -LPN A and RN B lifted the resident's leg and he/she grimaced; -The resident grabbed his/her left hip and yelled out in pain; -LPN A removed the dressing on the resident's right heel; -LPN A and RN B moved the resident to the center of the bed, the resident grimaced and yelled out in pain; staff rolled the resident on his/her right side to reveal his/her buttocks; the resident grimaced and yelled out in pain; -Staff removed the resident's dressing from his/her buttocks, the resident yelled out in; -LPN A said he/she would see if the resident could have another pain pill; -Resident said he/she did not want to get up for lunch; he/she said I would love to get up for lunch, but I just can't, the resident said I just hurt; (Discussion with the resident about his/her pain was while staff were in the room. The staff did not stop providing care after the resident grimaced, yelled out in pain, or expressed his/her pain level at an eight.) Review of the resident's MAR, dated 4/5/23, at 2:10 P.M., showed staff had not documented administering the resident any acetaminophen or oxycodone PRN pain medication. Review of the resident's Progress Nurses Notes, dated 4/5/23, at 2:10 P.M., showed no evidence of an assessment or documentation about pain. Review of the resident's Narcotic records on 4/5/23, at 2:40 P.M., showed the resident had not received his/her oxycodone on 4/5/23. The last dose was on 4/3/23 at 11:32 A.M. The resident had not received acetaminophen since 4/4/23 at 8:47 A.M. During an interview on 4/5/23, at 2:45 P.M., Certified Medication Technician (CMT) D said the following: -If he/she charted a zero for a resident's pain, its because they didn't report pain or ask for pain medicine; -No one reported to him/her that the resident was in pain today; -The resident has orders for acetaminophen or oxycodone and he/she can have both. Observation on 4/5/23, at 2:48 P.M., the resident told CMT D he/she had pain and it was a seven or eight, and said, it hurts real bad. The resident did not received pain medication for four hours after pain was identified. During an interview on 4/5/23, at 2:31 P.M. and at 5:25 P.M., the Director of Nursing said the following: -The resident had x-rays on 4/3/23 related to a bony prominence on the left knee; -It's possible there is another small fracture; hard copies of the x-ray sent to the surgeon on 4/4/23; -The new x-ray also shows something on the resident's spine and it could be an old fracture; -The resident has PRN oxycodone and acetaminophen; -If a resident is yelling out in pain with care staff are expected to stop and administered medication or provide an intervention that helps the pain and give it time to work before proceeding with care; -Pain should be assessed at least every shift, and documented; -Staff are expected to assess pain at least [TRUNCATED]

Based on observation and interview, the facility failed to ensure proper handwashing techniques during meal service. The facility census was 76. Observation on 02/06/23 during the noon meal service showed the following: -At 12:03 P.M., Dietary Aide A wore gloves and touched trays, plates, meal tickets, and ice cream cups, and without removing his/her gloves touched the potatoes on a resident's plate with his/her gloved hand; -At 12:10 P.M., Dietary Aide A touched plates and the microwave, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on a resident's plate; -At 12:17 P.M., Dietary Aide A touched plates, trays, and utensils, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on a resident's plate; -At 12:27 P.M., Dietary Aide A touched plates, the plate warmer, and trays, and without removing his/her gloves, picked up a hamburger bun with his/her gloved hand, and placed it on the resident's plate. He/She then touched utensils, menu slips, and trays, and without removing his/her gloves, held a piece of chicken with his/her gloved hand and cut it into small pieces. During interview on 02/08/23 at 2:30 P.M., the dietary manager said he expected staff to wash their hands and change gloves any time they touch non-food items, such as the microwave, trays, meal tickets, etc. and before handling any food items. During interview on 02/08/23 at 3:00 P.M., the administrator said she expected the dietary staff to change gloves and wash their hands between handling non-food items and food items. 47246

Based on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for three residents (Residents #9, #17 and #53), in a review of 19 sampled residents, when their call lights were not accessible for use. The facility census was 76. The facility did not have a policy on call light accessibility. 1. Review of Resident #9's face sheet showed the resident's diagnoses included dementia and cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as a stroke). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/22, showed the following: -Moderately impaired cognition; -Total dependence on two staff for transfers. Review of the resident's care plan, revised on 1/23/23, showed the following: -Provide him/her with dependent help of two staff for transfers with a hoyer lift (a mechanical lift used with a sling to transfer a person from one surface to another); -He/She has history of falls. Make sure his/her call light is within reach. Observation on 2/6/23, at 3:42 P.M., showed the following: -The resident self propelled his/her wheelchair into his/her room and over toward his/her bed; -There was a hoyer lift placedagainstt the resident's bed which blocked the resident from reaching his/her call light; -The resident's call light sat on the resident's bed, near the head of the bed. During an interview on 2/6/23 at 3:42 P.M., the resident said he/she sure would like to lay down but he/she could not reach his/her bed. He/She pushes the button (call light) when he/she needs something, but he/she could not reach his/her button. 2. Review of Resident #17's face sheet showed the resident's diagnoses included cerebral infarction and dementia. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of one staff for transfers, walking in room, and toileting; -Frequently incontinent of bladder and occasionally incontinent of bowel. Review of the resident's care plan, updated on 1/23/23, showed the following: -Provide the resident with extensive help of one to two staff members for transfers, toilet use, and walking with a walker; -He/She has history of falls and does not remember his/her limitations or abilities; -Make sure call light is in reach; -Come see what he/she needs if he/she is yelling. Observation on 2/6/23 at 12:16 P.M., showed the following: -The resident sat in the recliner in his/her room; -The resident's call light lay on the floor beside his/her recliner and out of his/her reach. During interview on 2/6/23, at 12:17 P.M., the resident said he/she could not reach the call light. Observation on 2/6/23 at 12:28 P.M., showed the resident sat in his/her recliner and was yelling his/her spouse's name numerous times. The resident's call light remained on the floor beside the recliner and out of the resident's reach. Observation on 2/9/23 at 10:49 A.M., showed the resident sat in his/her recliner with his/her eyes closed. The resident's call light was attached to left side assist bar on the bed, out of reach of the resident. The resident's recliner was placed to the left of the resident's bed, approximately three feet away from the bed. 42592 3. Review of Resident #53's face sheet showed the resident's diagnoses included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and anxiety disorder, and heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Cognition severely impaired; -Required extensive assistance from two staff for bed mobility and transfers; -Frequently incontinent of bowel and bladder. Review of the resident's Care Plan, dated 1/16/23, showed the following: -He/She has a history of falls; -He/She has a history of trying to transfer on their own; -Ensure his/her call light is in reach. Observation on 2/8/23 at 7:40 A.M. showed the following: -The resident lay on his/her back in bed and called out repeatedly that he/she needed a drink and that he/she was lying too flat and could not breathe; -The resident's call light was draped through and around the raised upper bed rail on the resident's right side and hung down below the mattress to the floor and out of the resident's sight or reach; -The resident was trying to swing his/her left leg off the bed; -The resident continued to call out that he/she needed a drink and that he/she was lying too flat; -Staff arrived and asked the resident why he/she did not use his/her call light, and the resident said he/she could not find it. 4. During an interview on 2/9/23 at 11:09 A.M., Certified Nursing Assistant (CNA) C said the residents' call lights should always be within the resident's reach. During an interview on 2/9/23, at 11:19 A.M., CNA K said call lights should always be in the resident's reach. During an interview on 2/9/23 at 9:39 A.M., Licensed Practical Nurse R said the call light should be in reach of the resident. During an interview on 2/9/23, at 3:10 P.M., the Director of Nursing said call lights should be in a resident's reach at all times. 47246

Based on observation, interview, and record review, the facility failed to follow physician's orders and professional standards of care for two residents (Residents #5 and #38), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy Physician/Provider Orders, revised 5/2018, showed all physician orders should be executed in a timely manner. Review of the facility policy, Administering Medications through a Metered Dose Inhaler, reviewed 10/2010, showed allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 1. Review of Resident #38's face sheet showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD; a group of lung disease that block air flow and make it difficult to breathe). Review of the resident's February 2023 physician order sheet showed the following: -Symbicort inhaler (an inhaled steroid medication used to treated COPD), inhale one puff twice a day; -Spiriva Respimat inhaler (an inhaled medication used to treat COPD), inhale one puff daily; -Bevespi Aerosphere inhaler (an inhaled medication used to treat COPD), inhale two puffs twice a day (original order dated 12/19/22). Review of the resident's February 2023 Medication Administration Record (MAR) showed the following: -An order to administer Bevespi Aerosphere, two puffs twice a day at 8:00 A.M. and 8:00 P.M.; -Bevespi Aerosphere indicated as not given on 2/6/23 at 8:00 P.M. Review of administration instructions for Symbicort inhalers on Drugs.com showed the following: -Symbicort contains a combination of budesonide and formoterol, budesonide is a corticosteroid that reduces inflammation in the body; -Rinse your mouth with water after each use of Symbicort inhaler. Observation on 2/7/23 at 7:32 A.M., showed Certified Medication Technician (CMT) Q handed the resident his/her SpirivaRespimatt inhaler and Symbicort inhaler to self-administer. The resident administered each inhaler one right after the other with approximately 30 seconds between each inhaler. CMT Q did not provide the resident with instructions related to technique or to rinse his/her mouth after administration of the Symbicort inhaler. CMT Q did not give the resident a Bevespi Areosphere inhaler to self-administer. Review of the resident's February 2023 MAR showed the following: -On 2/7/23, staff documented the Bevespi Aerosphere inhaler was not administered at 8:00 A.M. and 8:00 P.M.; -On 2/8/23, staff documented the Bevespi Aerosphere inhaler was not administered at 8:00 A.M. and 8:00 P.M.; -On 2/9/23, documented the Bevespi Aerosphere inhaler was not administered at 8:00 A.M. Review of the resident's progress notes, dated 2/6/23 through 2/9/23 showed no documentation the Bevespi Aerosphere inhaler was not administered, no documentation to show the reason the medication was not administered, and no documentation to show staff notified the resident's physician when the inhaler was not administered. During an interview on 2/9/23 at 9:31 A.M., CMT Q said the following: -The resident had not had the Bevespi Aerosphere inhaler for four or five days; -The inhaler had been ordered and he/she was not sure why the inhaler had not arrived from the pharmacy; -The inhaler was not available in the emergency medication kit; -If a resident can self-administer an inhaler, staff should instruct the resident how to administer the medication; -When giving multiple inhalers, the resident should wait at least 5 minutes between the inhalers; he/she did not wait that amount of time between the two inhalers for the resident; -He/She did not instruct the resident to wait for a period of 5-10 minutes between the Spiriva and Symbicort inhalers and should have; -When giving an inhaler that has a steroid in it, the resident should rinse their mouth; -He/She believes one of the inhalers given on 2/8/23 to the resident was a steroid; -He/She did not instruct the resident to rinse and spit; -If the resident does not rinse his/her mouth out after a steroid inhaler, the resident runs the risk of getting a fungal infection in his/her mouth. During an interview on 2/09/23, at 11:00 A.M., the resident said he/she had been out of one inhaler for a couple of days. 2. Review of Resident #5's care plan, dated 10/6/22, directed staff to monitor and document weight loss/gain. The resident has a history of chronic urinary tract infection (UTI) which can increase his/her risk for dehydration. He/She was also on fluid medication and has a poor oral intake. Monitor weight as ordered. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Diagnoses of dementia and malnutrition; -Weight loss of 5% or more in the last month or loss of 10% or more in the last six months; -Weight 115 pounds. Review of the resident's physician's orders dated 12/2/22 showed an order for weekly weights. Review of the resident's weight flowsheet, dated 12/1/22 through 2/6/23, showed the following: -Staff weighed the resident on 12/2, 12/12, 12/13, and 12/19; -No documentation facility staff obtained the resident's weight 12/20/22 through 1/9/23; -Staff weighed the resident on 1/10/23; -No documentation facility staff obtained the resident's weight 1/11/23 through 2/5/23. 3. During an interviews on 2/09/23 at 10:37 and 2/24/22 at 11:10 A.M., the Director of Nursing said the following: -If a medication was not available for numerous days, she would expect staff to check and see what the issue was and to notify the physician for further orders; -There should be a little bit of a break between administration of inhalers, but she was not sure how long; -Any time an inhaler is administered that contained a steroid, she would expect the staff to instruct the resident to rinse their mouth out and spit the liquid out; -Nursing staff was responsible for weighing residents weekly, but she was not completely sure who was responsible for weighing the residents; -The charge nurse was responsible for delegating who was to complete the weekly weights; -She would expect staff to weigh the residents weekly if they have an order for weekly weights. During interviews on 2/8/23 at 12:32 P.M. and 2/23/23 at 3:54 P.M., the administrator said the following: -Staff didn't get Resident #5's weekly weights in January. Staff just missed them; -Staff should have weighed the resident weekly; -She would expect medications to be available to administer as ordered; -She would expect staff to notify the physician for further direction if a medication is not available to administer. 42592

Based on observation, interview, and record review, the facility failed to ensure staff provided the necessary care and services to maintain good personal hygiene for eight residents (Residents #9, #17, #22, #26, #27, #37, #51, and #53), who required assistance to perform their activities of daily living (ADLs), in a review of 19 sampled residents. The facility census was 76. Review of the facility policy, Care of Fingernails/Toenails, revised 10/2010, showed the following: -The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection; -General Guidelines: 1. Nail care includes daily cleaning and regular trimming; 2. Proper nail care can aid in the prevention of skin problems around the nail bed; 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin; -Documentation: The following information should be recorded in the resident's medical record:1. Thee date and time that nail care was given;6. If the resident refused the treatment, the reason(s) why and the intervention taken. Review of the facility policy, Shaving the Resident, revised 10/2010, showed the following: -The purpose of this procedure is to promote cleanliness and to provide skin care; -Documentation: The following information should be recorded in the resident's medical record:1. Thee date and time that the procedure was performed; 3. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure; 5. If the resident refused the treatment, the reason(s) why and the intervention taken; The policy did not indicate how often residents should be shaved. 1. Review of Resident #37's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 12/27/22 showed the following: -Cognitively intact; -No rejection of care; -Required extensive assist of one staff member for personal hygiene; -Diagnoses of diabetes and dementia. Review of the resident's care plan dated 1/4/23 showed the following: -The resident was in the memory care neighborhood because of his/her confusion; -The resident needed oversight to extensive help from one to two staff with his/her every day cares; -Provide the resident with extensive help from one to two staff for toilet use and personal hygiene. He/She may refuse this often. Come back at a later time if the resident refuses or have a different staff attempt to help him/her. Observation on 2/7/23 at 8:50 A.M. showed the following: -The resident sat in his/her recliner in his/her room watching TV; -The resident's face was covered with hair stubble; -The resident's fingernails were long. Observation on 2/8/23 at 8:28 A.M. showed the following: -The resident sat in a chair at the dining room table with his/her eyes closed; -The resident's face was covered with hair stubble; -His/Her fingernails were long. Observation on 2/8/23 at 1:38 P.M. showed the following: -The resident sat at the dining room and fed himself/herself lunch; -The resident's fingernails were long; -His/Her face was covered with hair stubble. 2. Review of Resident #51's care plan dated 10/21/22 showed the following: -The resident needed oversight to extensive help from one staff with his/her every day cares; -The resident's diagnoses of dementia, poor memory, arthritis, anxiety, history of refusing cares, and medication use puts him/her at risk for increased help needed with his/her every day cares; -The resident is very hard of hearing and needs direction with him/her cares; -The resident does better with one step directions; -Provide the resident with limited help from one staff for toilet use and personal hygiene. Review of the resident's quarterly MDS dated [DATE] showed the following: -Severely impaired cognition; -No rejection of care; -Required extensive assist of one for personal hygiene. Observation on 2/7/23 at 12:26 P.M. showed the following: -The resident sat at the table in the dining room and fed himself/herself; -The resident's face was covered with hair stubble; -His/Her fingernails were long. Observation on 2/8/23 at 1:37 P.M. showed the following: -The resident sat at the dining room table; -His/Her fingernails were long and his/her face was covered with hair stubble. Observation on 2/9/23 at 9:35 A.M. showed the resident walked out of the shower room with his/her walker. The resident's fingernails continued to be long. During interview on 2/6/23 at 11:39 A.M., the resident's family member said the resident's fingernails and toenails badly needed trimming. 3. Review of Resident #9's face sheet showed the resident's diagnoses included dementia. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Total dependence on two staff for toilet use; -Required extensive assistance from two staff for personal hygiene; -Always incontinent of bowel and bladder. Review of the resident's care plan, revised on 1/23/23, showed the following: -Provide the resident with extensive help from one to two staff for personal hygiene; -Provide him/her with supplies for oral care; -He/She is always incontinent of bladder and bowels. Provide him/her with peri-care after any incontinent episode. Observation on 2/6/23 showed the following: -At 2:55 P.M., activity staff placed the resident in the day room after the resident attended an activity. The resident had a strong fecal odor; -At 3:42 P.M., the resident wheeled himself/herself down the hallway to his/her room and had a strong fecal odor; -At 3:58 P.M., Certified Nurse Aide (CNA) K wheeled the resident to the oxygen room to change the resident's oxygen tank; -At 4:05 P.M., CNA K took the resident to his/her room to provide incontinence care. The resident's incontinence brief was saturated with urine and the resident had a large bowel movement in the incontinence brief. During an interview on 2/6/23, at 4:30 P.M., the resident said he/she had been up all day and had not been changed since he/she had been up. He/She did not realize he/she had a bowel movement but felt better after being changed. Observation on 2/8/23 at 5:57 A.M., showed the following: -CNA P positioned the resident in his/her wheelchair after getting dressed; -CNA P combed the resident's hair; -The resident had dentures in his/her mouth; -CNA P did not provide oral care or wash the resident's hands or face. During an interview on 2/9/23, at 11:19 A.M., CNA K said the following: -Staff should check and change residents at least every two hours; -He/She was responsible for providing care for Resident #9 on 2/6/23; -Normally Resident #9 lays down after meals but did not lay down on 2/6/23; -On 2/6/23, he/she checked and changed the resident before lunch and then not again until after 4:00 P.M.; -The day was crazy and he/she just didn't get to Resident #9 to change him/her every two hours. 4. Review of Resident #26's quarterly care plan, dated 11/8/22 showed the following: -Severely impaired cognition; -No rejection of care; -Requires supervision with set up help only for personal hygiene. Review of the resident's care plan, revised 1/17/23, showed the following: -The resident has been needing more help with his/her cares at times; -Required extensive help for toilet use and personal hygiene. Observation on 2/6/23 at 11:57 A.M. showed the following: -The resident sat at the table in the dining room and drank coffee; -The resident's fingernails were long and his/her face was covered with hair stubble. Observation on 2/7/23 at 12:39 P.M. showed the following: -The resident sat at the table in the dining room and fed himself/herself; -The resident's face was covered with hair stubble; -His/Her fingernails were long. Observation on 2/8/23 at 7:42 A.M. showed the following: -The resident sat at the table in the dining room and fed himself/herself breakfast; -The resident's face was covered with hair stubble and his/her fingernails were long. Observation on 2/8/23 at 1:36 P.M. showed the following: -The resident sat at the dining room table; -His/Her fingernails were long; -His/Her face was covered with hair stubble. 5. Review of Resident #17's face sheet showed the resident's diagnoses included dementia. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for personal hygiene. Review of the resident's care plan, updated on 1/23/23, showed to provide him/her with extensive help of one to two staff members for personal hygiene. Observation on 2/6/23, at 12:16 P.M., showed the resident sat in his/her recliner. The resident had facial hair approximately 1/8 inch long. Observation on 2/8/23, at 6:10 A.M., showed the resident sat in his/her recliner. The resident had facial hair approximately 1/4 inch long. Observation on 2/9/23, at 10:49 A.M., showed the resident sat in his/her recliner. The resident had facial hair approximately 1/2 inch long. During an interview on 2/9/23, at 10:49 A.M., the resident said he/she was unsure when he/she was shaved last and didn't typically have facial hair. 6. Review of Resident #22's face sheet showed his/her diagnoses included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited assistance from one staff for personal hygiene; -Required extensive assistance from one staff for dressing. Review of the resident's care plan, updated on 2/7/23, showed the resident needed assistance from one to two staff for dressing and hygiene. Observation on 2/6/23, at 11:36 A.M., showed the following: -The resident was up in his/her wheelchair visiting with his/her durable power of attorney (DPOA); -The resident had spots of dried food on the front of his/her sweatshirt; -The resident had facial hair approximately 1/4 inch long on his/her face. During an interview on 2/6/23, at 11:36 A.M., the resident's DPOA said the resident has a razor in his/her room but has a hard time shaving himself/herself and needs help from staff. Observation on 2/6/23, at 2:30 P.M., showed the resident lay in bed asleep with the same soiled shirt he/she wore before lunch. Observation on 2/7/23, at 9:08 A.M., showed the resident lay in his/her bed. The resident had facial hair on his/her face approximately 1/4 inch long. The resident had a dried brown substance around his/her mouth and in his/her facial hair. Observation on 2/8/23, at 5:54 A.M., showed the resident sat in his/her wheelchair. The resident had facial hair on his/her face. During an interview on 2/8/23, at 5:55 A.M., the resident said he/she would like to be shaved. 7. Review of Resident #53's significant change in status MDS, dated [DATE], showed the following: -Cognition severely impaired; -Required extensive assistance from one staff for hygiene. Review of the resident's Care Plan, dated 1/16/23, showed the resident had a history of limited mobility and Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movement, such as shaking, stiffness and difficulty with balance and coordination). Observation on 2/6/23 at 3:02 P.M. showed the following: -The resident sat in a wheelchair in his/her room; -The resident's face was covered with hair stubble; -There was a dried orange substance on the resident's chin and fingernails. Observation on 2/7/23 at 9:05 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident's face was covered with hair stubble; -The resident had a dried brown substance on his/her chin. Observation on 2/8/23 at 8:00 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident's face (chin and cheeks) was covered with white hair stubble, approximately 1/8 inch long. Observation on 2/9/23 at 9:30 A.M. showed the following: -The resident sat in his/her wheelchair in the main living area of the facility; -The resident's face (chin and cheeks) was covered with white hair stubble, approximately 1/4 inch long. 8. Review of Resident #27's face sheet showed the resident's diagnoses included dementia. Review of the resident's care plan, updated 1/27/23, showed the following: -He/She needs oversight to extensive help of one staff with every day care; -He/She has no natural teeth and can perform his/her own oral care after set up; -Provide limited help of one for personal hygiene. Review of the resident's annual MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance from two staff for personal hygiene. Observation on 2/8/23 at 6:23 A.M., showed the following: -Certified Nursing Assistant (CNA) P positioned the resident in his/her wheelchair after getting dressed; -CNA P combed the resident's hair and washed the resident's face; -CNA P did not provide oral care or set up oral care supplies for the resident; -The resident had no natural teeth and did not wear dentures. During an interview on 2/8/23, at 6:46 A.M., CNA P said the following: -Staff should assist a resident with oral care when they get the resident up and before bed; -Staff should wash a resident's face and hands when they get the resident up for the day and anytime it is needed; -Staff should perform oral care for the resident when they get the resident up and before bed. During interview on 2/9/23 at 9:45 A.M., CNA G said the following: -Some residents should be shaved daily; -Residents' nails should be trimmed as needed. During interview on 2/9/23 at 9:36 A.M., LPN A said the following: -All residents should get two showers a week; -Some residents should get shaved on their shower day; -Nails should be trimmed when they get too long; -The aides should check residents' nails when in the bath; -The aides can't trim nails. During an interview on 2/9/23, at 9:39 A.M., Licensed Practical Nurse (LPN) R said the following: -CNAs shave the residents on bath days if the resident allows it; -Female and male residents should be shaved if they want to be. During an interview on 2/9/23, at 3:10 P.M., the Director of Nursing said the following: -Any nursing staff is responsible for providing nail care with the best time being during the resident showers; -She would expect nails to be trimmed and clean if the resident wants them trimmed; -She would expect staff to at least attempt to clean and trim all residents nails', if the resident refuses, attempt at a later time or day; -She would expect men and women to be shaved if the resident wants to be shaved, and follow family request/instructions if the resident is unable to tell staff what they want; -It was not appropriate for a resident to be left wet and soiled for an extended period of time; -She would expect each resident to be checked before and after meals and when put to bed. During an interview on 2/9/23, at 3:40 P.M., the administrator said the following: -Some residents should be shaved during showers, at least two times a week and also depends on the person's preferences if would like more often; -Cognitively impaired residents need to be shaved at a minimum during bathing; -Residents should be changed before and after meals, when gotten up from bed, and as needed. MO 212369 42592 45563 47246

Based on observation, interview and record review the facility failed to ensure resident safety for three residents (Residents #5, #14 and #53) in a review of 19 sampled residents. Staff failed to use a gait belt while assisting two residents (Resident #5 and #14), and lifted the residents under both arms and pulled up on the back of the residents' pants during the transfer. Staff also failed to ensure two residents (Residents #14 and #53) had foot pedals on their wheelchairs prior to staff propelling the residents in the facility. The facility census was 76. Review of the facility policy How to Transfer an Individual Using a Gait Belt dated 2010 showed the following: The purpose was to provide safety and protection from possible injury during transfer and ambulation; 3. Apply the gait belt while the individual is in a comfortable sitting position. If the individual is lying in bed and has poor sitting balance, apply the gait belt while they are lying down; 4. Make sure the belt is applied tightly enough to prevent it from riding up or down on the individual's body, but loosely enough so you can grasp it firmly and comfortably; 8. Stand as close to the individual as possible. Stand in front keeping your back straight, your knees slightly bent, and your feet with a wide stance; 9. Hold the individual at the waist rather than arms or shoulders. Lean forward and grasp the gait belt on both sides; 14. When the destination has been reached, gently lower and encourage the individual to use his/her arms to reach toward the destination and bear some of the weight; Notes: -If the individual is particularly heavy or has difficulty supporting their own weight, consider using a lift transfer device. 45563 1. Review of Resident #53's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/5/23, showed the following: -Cognition severely impaired; -Required extensive assistance from two staff for bed mobility and transfers. Review of the resident's Care Plan, dated 1/16/23, showed staff was to provide the resident with limited to extensive help from one to two staff for transfers. Observation on 2/8/23 at 7:55 A.M. showed the following: -The resident lay on his/her back in bed; -Nurse Aide (NA) D hooked his/her left arm beneath the resident's left underarm; -Certified Nurse Assistant (CNA) C hooked his/her right arm beneath the resident's right underarm; -CNA C and NA D used their arms beneath the resident's arms to lift him/her up to a sitting position in bed and then assisted him/her to sit at the side of the bed; -CNA C hooked his/her right arm beneath the resident's right arm and lifted him/her up to a standing position, while NA D turned to get the resident's clothes from the closet; -CNA C used his/her left hand to pull up on the back of the resident's pants while he/she began to pivot the resident into the wheelchair at the bedside; -CNA C and NA D did not place a gait belt on the resident and did not use a gait belt to transfer the resident from the bed to the wheelchair; -CNA C pushed the resident in the wheelchair to the bathroom in his/her room; -CNA C lifted the resident up from the wheelchair and onto the toilet by holding onto the back of the resident's pants; -The resident held onto a safety bar with his/her right hand during the pivot and transfer. During interview on 2/9/23 at 1:30 P.M., CNA C said the following: -He/She usually used a gait belt for transfers; -He/She wasn't sure why he/she did not use one for Resident #53's transfer on 2/8/23; -He/She knew he/she should not use the resident's arms or pants to pull him/her up because it could cause an injury to the resident; -The purpose of the gait belt was to prevent injuries, to provide comfort and to be able to transfer the resident safely; -Sometimes he/she got in a hurry. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of one staff for transfers; -Not steady, only able to stabilize with human assistance for surface to surface transfers and moving from seated to standing. Review of the resident's care plan, revised 1/25/23, showed the following: -The resident has impaired cognition related to dementia and he/she has some memory issues; -He/She is alert to self but may get confused as to what is happening; -He/She is needing assist with his/her activities of daily living (ADLs) and this may vary from moment to moment with his/her alertness; -He/She needs extensive help of one with transfers. Encourage him/her to help with transfers. Observation on 2/6/23 at 3:35 P.M. in the resident's room showed the following: -The resident lay sideways at the end of his/her bed; -Nurse aide (NA) F and Licensed Practical Nurse (LPN) E entered the resident's room; -LPN E and NA F assisted the resident to sit on the side of the bed; -NA F and LPN E placed their arms under the resident's arms while pulling up on the waist band of the resident's pants; -NA F and LPN E pivoted the resident to his/her wheelchair; -NA F and LPN E did not place a gait belt on the resident or utilize a gait belt during the transfer; -The resident's feet slid across the floor and his/her knees were bent during the transfer; -The resident did not fully bear weight during the transfer. During interview on 2/9/23 at 10:10 A.M., NA F said the following: -The resident should be transferred with a gait belt; -The resident's ability to bear weight was dependent on his/her behaviors; -He/She usually tries to get things done quickly; -He/She usually holds onto the resident's pants during pivot transfers. 3. Review of Resident #14's quarterly MDS, dated [DATE], showed the following: -Cognition severely impaired; -Required extensive assistance with transfers. Review of the resident's Care Plan, revised 2/1/23, showed the following: -The resident requires oversight to extensive help with every day cares; -The resident uses a wheelchair for most of mobility; -The resident requires limited to extensive assistance from one staff for transfers. Observation on 2/8/23 at 7:50 AM, showed the following: -CNA H pushed the resident from the dining room to the resident's room in wheelchair; -The resident's feet were not on the foot pedals and his/her feet drug the floor as CNA H pushed the resident to his/her room; -CNA H did not put a gait belt on the resident, and placed his/her hands under the resident's arms to assist the resident to stand from the wheelchair and transfer to the toilet; -CNA H lifted the resident from under the arms to transfer the resident from the toilet back to the wheelchair without a gait belt; -CNA H pushed the resident in a wheelchair from the bathroom to the recliner in the resident's room without placing the resident's feet on foot pedals; -The resident's feet drug the floor; -CNA H lifted the resident by using the back of the resident's pants and an arm under the resident's right arm to transfer the resident from the wheelchair to the recliner without a gait belt. Observation on 2/8/23 at 11:18 AM, showed CNA H pushed the resident from resident's room to the TV room in a wheelchair. The resident wore non-slip socks and his/her feet drug the floor. During interview on 2/9/23 at 9:05 A.M., CNA H said the proper technique for transferring a resident with an assist of one should involve a gait belt. 4. During interview on 2/9/23 at 3:10 P.M., the Director of Nurses (DON) said the following: -She would expect staff to use a gait belt; -Staff should not transfer a resident under the arms and by the back of the pants; -If a resident is unable to bear weight, staff should use a gait belt and not pull up on the resident's arms or pants. During an interview on 2/9/23 at 3:40 P.M., the administrator said the following: -She would staff to use a gait belt during a pivot transfer; -If the resident is unable to bear weight, staff should use a gait belt to transfer the resident rather than pulling on the resident's arm and the back of the resident's pants; -She would expect staff to push a resident in a wheelchair with foot pedals on the wheelchair and for foot pedals to be used during transport in the wheelchair. 47246

Based on observation, interview, and record review, the facility failed to obtain informed consent and educate residents and their responsible parties on the risk of bedrail use and failed to document attempted alternatives prior to installing the bed rails for seven residents (Resident #57, #27, #25, #22, #17, #4 and #7) and failed to assess one resident (Resident #7) in a review of 19 sampled residents, for bed rails and risk of entrapment. The facility census was 76. Review of the facility policy, Siderails and Beds - Safety, updated 5/22/22, showed the following: -Beds, bed frames, siderails and mattresses shall be routinely inspected by the engineering department for possible areas of entrapment; -Resident's individualized needs for siderail use shall be determined by a multidisciplinary team, and shall include, but not limited to, an assessment of: psychiatric diagnosis, medical needs, comfort, nighttime and sleeping habits, and freedom of movement; -Siderails shall not routinely be placed in the up position; -Use of siderails shall be documented in the medical record, including, but not limited to: 1. Siderail use, effectiveness, and regular review of use and effectiveness; 2. Risk/benefit assessment with demonstrated attempts at use of alternative care interventions, and reason why said interventions were not effective; 3. If siderail use is related to a medical symptom/condition, documentation shall include, but not limited to: a care plan for the symptom/condition, plans for attempts of less restrictive care interventions, a description of less restrictive care interventions and, if applicable, their failure to meet patient needs; -Residents shall be assessed for risk of entrapment, including physical, mental, behavioral or medication impairment, the size and weight of the resident and the type of mattress shall be considered in the risk assessment; -The resident and/or his/her family shall receive education about the purpose and potential dangers of bed rails. Review of the FDA's Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the patient's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; - A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; - Reassess the need for using bed rails on a frequent, regular basis. 1. Review of Resident #4's Face Sheet showed the following diagnoses: -Syncope (fainting or passing out) and collapse; -Dizziness and giddiness; -Unspecified abnormalities of gait and mobility; -Osteoarthritis, right shoulder. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/19/23, showed the following: -Requires supervision with transfers and bed mobility; -No bed rail usage indicated. Review of the resident's Care Plan, revised 1/27/23, showed the following: -Bed positioning devices on both sides of my bed to help keep my highest level of function; -Provide me with oversight for transfers; -I have poor safety awareness; -History of falling out of bed, monitor environment for trip hazards. Review of the resident's bed safety assessment, dated 1/20/23, showed the following: -Bed positioning device location(s): bilateral upper; -Quarterly assessment; -Bed Rail assessment: the bars with the bed rails (halos) are closely spaced to prevent entrapment resulting from a resident's head passing through the opening, the mattress-to-bed rail interface prevents the resident from falling between the mattress and bed rails possibly smothering the resident, latches on the bed rails are stable and will not fall with shaken; -Interventions/Alternatives: resident requires a bed in a low position but has difficulty getting into the low bed from a standing position, consider an adjustable height bed; -Recommendations/Benefits: at this time, bed positioning devices are needed to assist with positioning of the resident and help resident maintain their highest level of function; -Comments/Discussion: no comments indicated. Review of the resident's February 2023 physician order sheets showed the resident did not have an order for bed positioning devices/side rails. Observation on 2/7/23 at 8:55 A.M. in the resident's room, showed the resident lay in his/her bed that had 1/4 bilateral (both sides) bed rails in the upright position. Observation on 2/8/23 at 5:50 A.M. in the resident's room, showed the resident lay asleep in his/her bed that had 1/4 bilateral bed rails in the upright position. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent, listing the risks for bed rail use prior to its use and no documentation to show the attempted alternatives prior to installing the bed rails. 2. Review of Resident #'7s Face Sheet showed the following diagnoses: -Unspecified convulsions; -Parkinson's disease; (central nervous system disorder) -Dementia. Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Requires limited assistance with transfers and bed mobility; -No bed rail usage indicated. Review of the resident's Care Plan, revised 1/15/23, showed the following: -Requires limited assistance with transfers; -Bed positioning devices on both sides of the bed to help maintain highest level of function; -History of falls with major injury. Review of the resident's February 2023 physician order sheets showed the resident did not have an order for bed positioning devices/side rails. Observation on 2/7/23 at 9:40 A.M. in the resident's room, showed the resident sat on the side of his/her bed; the bed had 1/4 bilateral bed rails in the upright position. Observation on 2/8/23 at 2:07 P.M. in the resident's room, showed the resident was sitting in his/her recliner; his/her bed beside the recliner had 1/4 bilateral bed rails in the upright position. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent or that a side rails assessment or entrapment risk assessment had been completed prior to side rail use. Further review of the medical record showed no documentation of the attempted alternatives prior to installing the bed rails. 3. Review of Resident #17's face sheet showed diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it, also known as a stroke) and dementia without behavioral disturbance. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assistance of one staff member for bed mobility and transfers; -No indication of bed rail usage. Review of the resident's bed safety assessment, dated 1/17/23, showed the following: -Bed positioning device location(s): bilateral upper; -Quarterly assessment; -Bed Rail assessment: the bars with the bed rails (halos) are closely spaced to prevent entrapment resulting from a resident's head passing through the opening, the mattress-to-bed rail interface prevents the resident from falling between the mattress and bed rails possibly smothering the resident, latches on the bed rails are stable and will not fall with shaken, if an air mattress or overlay is utilized it does not move or have straps that could entrap a resident or have the effect of pouring the resident into a bed rail; -Interventions/Alternatives: none indicated; -Recommendations/Benefits: at this time, bed positioning devices are needed to assist with positioning of the resident and help resident maintain their highest level of function; -Comments/Discussion: no comments indicated; -Re-evaluation assessment: no change. Review of the resident's care plan, updated on 1/23/23, showed the following: -He/She has bed positioning devices on both sides of his/her bed to keep him/her at highest level of functioning; -He/She has history of falls and does not remember his/her limitations or abilities. Review of the resident's February 2023 physician order sheets showed the resident did not have an order for bed positioning devices/side rails. Observation on 2/06/23, at 12:16 P.M. showed the resident sat up, awake in his/her recliner in his/her room, with bilateral 1/8 halo bed rails in the raised position on the resident's bed. Observation on 2/7/23, at 2:12 P.M., showed the resident sleeping in his/her recliner, in his/her room, with bilateral 1/8 halo bed rails in the raised position on the resident's bed. Observation on 2/8/23, at 6:10 A.M., showed the resident sleeping in his/her recliner, in his/her room, with bilateral 1/8 halo bed rails in the raised position on the resident's bed. Observation on 2/09/23, at 10:49 A.M., showed the resident was sleeping in his/her recliner, in his/her room, with 1/8 halo bed rails in the raised position on the resident's bed. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent, listing the risks for bed rail use prior to its use and no documentation to show the attempted alternatives prior to installing the bed rails. 4. Review of Resident #22's face sheet showed diagnosis of atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow). Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assistance of one staff member for bed mobility and transfers; -No indication of side rail use. Review of the resident's February 2023 physician order sheets showed no order for side rail usage. Review of the resident's care plan, updated on 2/7/23, showed the following: -He/She needs one to two person assist with bed mobility and transfers; -He/She has history of falls and has poor safety awareness; -No indication of side rail use. Review of the resident's bed safety assessment, dated 12/27/22, showed the following: -Bed positioning device location(s): right halo -Initial assessment; -Bed Rail assessment: the bars with the bed rails (halos) are closely spaced to prevent entrapment resulting from a resident's head passing through the opening, the mattress-to-bed rail interface prevents the resident from falling between the mattress and bed rails possibly smothering the resident, latches on the bed rails are stable and will not fall with shaken, if an air mattress or overlay is utilized it does not move or have straps that could entrap a resident or have the effect of pouring the resident into a bed rail; -Interventions/Alternatives: none indicated; -Recommendations/Benefits: at this time, bed positioning devices are needed to assist with positioning of the resident and help resident maintain their highest level of function; -Comments/Discussion: no comments indicated. Observation on 2/7/23, at 2:30 P.M., showed the resident lay sleeping in bed; the bed had bilateral upper 1/8 halo bed rails in the raised position. Observation on 2/7/23, at 9:08 A.M. and 1:30 P.M., showed the resident lay sleeping in bed; the bed had bilateral upper 1/8 halo bed rails in the raised position. Observation on 2/8/23, at 1:15 P.M., showed the resident lay sleeping in bed; the bed had bilateral upper 1/8 halo bed rails in the raised position. Observation on 2/9/23, at 1:45 P.M., showed the resident lay sleeping in bed; the bed had bilateral upper 1/8 halo bed rails in the raised position. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent, listing the risks for bed rail use prior to its use and no documentation to show the attempted alternatives prior to installing the bed rails. 5. Review of Resident #25's face sheet showed diagnoses including: atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow), and chronic obstructive pulmonary disease (a group of lung disease that block air flow and make it difficult to breathe). Review of the resident's bed safety assessment, dated 12/20/22, showed the following: -Bed positioning device location(s): left -Initial assessment; -Bed Rail assessment: the bars with the bed rails (halos) are closely spaced to prevent entrapment resulting from a resident's head passing through the opening, the mattress-to-bed rail interface prevents the resident from falling between the mattress and bed rails possibly smothering the resident, latches on the bed rails are stable and will not fall with shaken, if an air mattress or overlay is utilized it does not move or have straps that could entrap a resident or have the effect of pouring the resident into a bed rail; -Interventions/Alternatives: none indicated; -Recommendations/Benefits: at this time, bed positioning devices are needed to assist with positioning of the resident and help resident maintain their highest level of function; -Comments/Discussion: no comments indicated. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assistance of one staff for bed mobility and transfers; -No indication of bed rail use. Review of the resident's care plan, updated 1/27/23, showed the following: -He/She needs one person assist with bed mobility and transfers; -Has a history of falling; -No indication of bed rail use. Review of the resident's February 2023 physician order sheets showed no orders for bed rail use. Observation on 2/06/23, at 11:46 A.M. showed the resident sat up, awake in his/her wheelchair in his/her room, with a left side 1/8 halo bed rail in the raised position and the resident's right side of bed against the wall. Observation on 2/7/23, at 9:06 A.M., showed the resident sat up, awake in his/her wheelchair in his/her room, with a left side 1/8 halo bed rail in the raised position and the resident's right side of bed against the wall. Observation on 2/8/23, at 6:00 A.M., showed the resident sleeping in his/her bed, with a left side 1/8 halo bed rail in the raised position and the resident's right side of bed against the wall. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent, listing the risks for bed rail use prior to its use and no documentation to show the attempted alternatives prior to installing the bed rails. 6. Review of Resident #27's face sheet showed the following diagnoses: dementia without behavioral disturbances (a group of thinking and social symptoms that interferes with daily functioning without aggression), bradycardia (a slow heart rate), heart failure (a chronic condition in which the heart does not pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly cause poor blood flow), and chronic obstructive pulmonary disease (a group of lung disease that block air flow and make it difficult to breathe). Review of the resident's care plan, updated 1/27/23, showed the following: -He/She needs oversight to extensive help of one staff with every day care; -Provide limited help of one for transfers; -He/She has history of falls; -No indication of side rail use. Review of the resident's bed safety assessment, dated 1/27/23, showed the following: -Bed positioning device location(s): both upper; -Initial assessment; -Bed Rail assessment: the bars with the bed rails (halos) are closely spaced to prevent entrapment resulting from a resident's head passing through the opening, the mattress-to-bed rail interface prevents the resident from falling between the mattress and bed rails possibly smothering the resident, latches on the bed rails are stable and will not fall with shaken; -Interventions/Alternatives: adjustable height bed, therapy and/or restorative plan to increase strength and tolerance; -Recommendations/Benefits: at this time, bed positioning devices are needed to assist with positioning of the resident and help resident maintain their highest level of function; -Comments/Discussion: no comments indicated. Review of the February 2023 physician order sheets showed no order for side rail use. Observation on 2/8/23, at 6:12 A.M., showed the resident lay asleep in a bed that had bilateral 1/8 halo bed rails in the raised position. Observation on 2/08/23, at 2:30 P.M., showed the resident lay awake in his/her bed that had 1/8 halo bed rails in the raised position. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent, listing the risks for bed rail use prior to its use and no documentation to show the attempted alternatives prior to installing the bed rails. 7. Review of Resident #57's current Face Sheet showed the following diagnoses: -Alzheimer's disease; -Chronic systolic (congestive) heart failure. Review of the resident's Quarterly MDS, dated [DATE], showed the following: -Cognition severely impaired; -Requires supervision with bed mobility and transfers; -No bed rail usage indicated. Review of the Resident's Care Plan, revised 1/27/23 showed the following: -Bed positioning devices on my bed help me maintain my highest level of function; -Provide me with oversight help of one staff for transfers; -Help me with repositioning throughout the day and night according to my abilities; -Poor safety awareness and varying abilities; -At risk for falls with major injury. Review of the resident's bed safety assessment, dated 1/18/23, showed the following: -Bed positioning device location(s): left side -Quarterly assessment; -Bed Rail assessment: the bars with the bed rails (halos) are closely spaced to prevent entrapment resulting from a resident's head passing through the opening, the mattress-to-bed rail interface prevents the resident from falling between the mattress and bed rails possibly smothering the resident, the mattress to bed rail interface prevent the resident from falling between the mattress and bed rails possibly smothering the residents, make sure there is less that a 3/4 inch gap when the resident is in bed, the HOB is elevated, the HOB is flat, and when the resident is laying on their side, latches on the bed rails are stable and will not fall with shaken, if an air mattress or overlay is utilized, it does not move or have straps that could entrap a resident or have the effect of pouring the resident into a bed rail; -Interventions/Alternatives: none indicated; -Recommendations/Benefits: at this time, bed positioning devices are needed to assist with positioning of the resident and help resident maintain their highest level of function; -Comments/Discussion: no comments indicated. Review of the resident's February 2023 physician order sheets showed the resident did not have an order for bed positioning devices/side rails. Observation on 2/6/23 at 12:15 P.M. in the resident's room showed the resident sitting in his/her chair; the resident's bed was beside the chair that had 1/4 bed rails on left side in the upright position. Observation on 2/7/23 at 8:45 A.M. in the resident's room showed the resident lay asleep in his/her bed that had 1/4 bed rails on the left side in the upright position. Observation on 2/8/23 at 5:53 A.M. in the resident's room showed the resident lay asleep in his/her bed that had 1/4 bedrail on left side in upright position. Review of the resident's electronic medical record showed no documentation that staff obtained informed consent, listing the risks for bed rail use prior to its use and no documentation to show the attempted alternatives prior to installing the bed rails. During an interview on 2/9/23, at 3:10 P.M., the Director of Nursing said the following: -Side rail assessment should be done quarterly; -To her knowledge entrapment zone assessments are not completed routinely; -An informed consent and physician order has not been obtained prior to initiation of side rails. During an interview on 2/9/23, at 3:40 P.M., the administrator said the following: -No informed consent is obtained from the resident or resident family member prior to initiation of side rails; -She was not sure if routine side rails assessments are done; -All resident's have been evaluated for risk of entrapment by myself or the MDS coordinator but not on a routine basis. 45563

Based on observation, interview, and record review, the facility failed to comprehensively assess pain, provide scheduled and PRN (as needed) pain medication, intervene when the resident exhibited crying out and facial grimacing and failed to notify the physician when the resident refused scheduled pain medication for one resident (Resident #10) in a review of 16 sampled residents. The facility census was 75. 1. Review of the facility's policy, Pain Management, revised May 2016 showed the following: Policy: -The facility recognizes a professional responsibility to accurately assess pain and to provide effective pain management using a wide range of measures including both pharmacological andnonpharmacologicalc interventions; -Resident care management and treatment strategies related to pain shall be developed and integrated into the resident's plan of care. The plan of care is selected on admission based on the admission [DIAGNOSES REDACTED]. -Initial and ongoing pain assessments occur in all inpatient and outpatient areas and are further defined through unit policy; 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, and as required or needed; 3. Continuing assessment of the pain management program will occur daily on residents unable to communicate pain and will focus on the effectiveness of the program and the comfort level of the resident and as needed on resident's unable to communicate pain; 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 two hours of administration; 5. If a resident complains of pain or if signs and symptoms of pain are noted staff will implement interventions to relieve pain. If interventions are not successful nursing staff will notify the physician; Equipment and supplies: -Pain assessment tool, use the PAINAD Scale for residents unable to communicate pain and the 1-10 scale for residents who are able to communicate pain; Steps in the Procedure:1. Askk 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; 2. Assess pain including onset and duration, location, severity, alleviating and aggravating factors, possible causes, and accompanying signs and symptoms; 3. Determine appropriate type of pain medication as ordered by the physician; 4. Medicate the resident as the physician ordered; 5. Do follow-up assessment within two hours after administration of medication; 6. Evaluate effectiveness ofnonpharmacologicalc interventions (i.e. repositioning resident, turning lights off, warm cloth, etc.); 7. If pain is not relieved, give further medication as the physician ordered. If there are no orders, notify the physician and obtain an order; Documentation: -The person performing this procedure should record the following information in the resident's medical record;1. Dailyy assessment of pain or as indicated per plan of care;2. Alll assessment data obtained during the procedure including location of pain, level of pain using the pain scale, and type of pain relief used; 3. Two hour reassessment of pain and the resident's response to the pain relief used; 4. If the resident refused the procedure, the reason(s) why and the intervention taken; Reporting:1. Notifyy the supervisor if the resident refuses the procedure;2. Reportt other information in accordance with facility policy and professional standards of practice;3. Notifyy the physician of any unrelieved pain. 2. Review of the resident's care plan edited 12/1/2015 showed the following: -Diagnosis: [REDACTED]. -PAIN: Problem: I have a history of both leg and hip pain. I can sometimes tell you that I am having pain, but due to my dementia I can't describe this well to you. I need you to monitor me for pain. I have a history of crying out but may not express my pain; -Goal: I want my pain to be controlled with my current interventions over the next 90 days; -Approach: Lay me down if I am complaining of pain. Assess me for pain throughout each shift. Administer my pain medications per my orders. Assess me 45-60 minutes after administration of pain medications to see if I got relief or if I have settled down and become more calm. Encourage me to drink all my fluids at meals and offer me fluids between meals. Offer me pain medication if I am very restless, tearful or agitated. I may be in pain but can't clearly express this to you; -COMMUNICATION: Problem: I have dementia and have difficulty expressing myself. I can sometimes communicate my needs but at times staff need to anticipate my cares; -Goal: I will continue to express myself to staff even though you may have to join me in my world throughout the next 90 days; -Approach: Observe behavior for signs of hunger or toileting. Encourage resident to communicate with staff daily. Please allow me ample time to respond when talking with me. Keep explanations simple. Ask yes or no questions. Encourage self-expression to ensure needs are met. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated 7/26/16 showed the following: -Sometimes understood; -Sometimes understands others; -Severely impaired cognition; -Required extensive assist of two staff members for bed mobility and dressing; -Totally dependent on two staff members for transfers, toilet use and bathing; -Always incontinent of urine and stool; -Received scheduled and PRN (as needed), pain medication; -No non-medication pain interventions; -No pain. Review of the resident's physician progress notes [REDACTED]. -status [REDACTED]. -More discomfort at times; -Taking pain medication PRN; -Confused, mild agitation when in pain; -Change [MEDICATION NAME] (narcotic pain medication) 5/325 to scheduled every four hours. Review of the resident's August 2016 physician's orders [REDACTED]. -[MEDICATION NAME] 5-325 milligram (mg) give one tablet by mouth every four hours as needed for pain (start date 11/6/15); -A physician's orders [REDACTED]. -Tylenol (pain medication) 325 mg take two tablets by mouth every four hours as needed for pain or elevated temperature. Not to exceed 3 grams (gm) in 24 hours (start date 11/20/14); -[MEDICATION NAME] Gel (topical pain medication) 1 gm apply twice daily for hips and lower back (start date 1/20/16). Review of the resident's September 2016 physician's orders [REDACTED]. -[MEDICATION NAME] 5-325 mg give one tablet by mouth every four hours for chronic pain; -Tylenol 325 mg take two tablets by mouth every four hours as needed for pain or elevated temperature. Not to exceed 3 gm in 24 hours; -[MEDICATION NAME] Gel, 1gm apply twice daily for hips and lower back. Review of the physician's progress notes dated 9/30/16 showed the following: -No worsening of pain, no new issues; -Pain control is good. Review of the resident's October 2016 Medication Administration Record [REDACTED] -On 10/5/16 at 12:00 A.M. and 4:00 A.M.; -On 10/7/16 at 12:00 A.M. and 4:00 A.M.; -On 10/8/16 at 8:00 P.M. Review of the resident's medical record showed no evidence staff informed the physician of the resident's refusal of the [MEDICATION NAME] on 10/5/16, 10/7/16, and 10/8/16. Review of the resident's MAR indicated [REDACTED].M., 11:48 A.M., 4:41 P.M., 9:07 P.M. and 11:35 P.M. Review of the resident's MAR indicated [REDACTED].M., 908 P.M.M.andd 11:33 P.M. Review of the resident's October 2016 MAR indicated [REDACTED].M., 12:00 P.M. and 4:00 P.M. doses. Review of the resident's nurses' notes dated 10/18/16 at 11:39 A.M. showed the following: -Late entry for 10/10/16 (no time). Called pharmacy to ask why he/she didn't have the resident's [MEDICATION NAME] since the refill button has been pressed; -The pharmacy said they were waiting on a script from the physician; -Called the physician to see if they have received the fax from pharmacy that they need a script for this resident's [MEDICATION NAME]; -The physician's office did not answer so he/she left it in a message; -Called the pharmacy back at approximately 4:00 P.M.; -The pharmacy said they still hadn't received a script yet; -Called the physician's office and got no answer and left another message; -Still awaiting a phone call. Review of the resident's October 2016 MAR indicated [REDACTED]. Staff failed to document the time they administered the medication, the reason or the effectiveness of the medication. Review of the resident's MAR indicated [REDACTED].M., 8:00 A.M., 12:00 P.M. and 4:00 P.M. doses. Review of the resident's nurses' notes dated 10/11/16 at 6:35 A.M. showed the following: -Out of [MEDICATION NAME] so not given 7:00 P.M. to 7:00 A.M. shift when scheduled; -Occasionally calls out for Fred; -Tylenol given at bedtime for comfort; -ROM within normal limits (WNL) for resident; -Continue to monitor. Review of the resident's nurses' notes dated 10/12/16 at 12:20 A.M. showed the following: -Late entry for 10/11/16; -Per report from Registered Nurse (RN) D [MEDICATION NAME] had not been given for two days; -Reported to this nurse that the medication had been ordered and staff called the pharmacy to check on delivery; -Pharmacy said they were waiting for the physician to sign the order; -Resident has been calling out frequently non-sensical words; -Attempts to reorient and distract were unsuccessful times ten attempts throughout the shift; -Staff gave PRN Tylenol by this nurse for signs/symptoms of discomfort and calling out with little relief noted; -Continue to monitor. Review of the resident's nurses' notes dated 10/18/16 at 11:43 A.M. showed staff documented the following: -Late entry 10/11/16; -He/she called the physician's office at approximately 11:00 A.M.; -The physician's office said they had the script ready for pick up; -He/she called pharmacy and made sure they knew, they said they did and the [MEDICATION NAME] should be sent out on the 1:00 P.M. shipment; -The [MEDICATION NAME] didn't come on that shipment; -He/she called the pharmacy back and asked what happened to the [MEDICATION NAME] for this resident; -The pharmacy said that the original order was different from what the physician sent on the script; -The pharmacy said they have a phone call out to clarify the order and the [MEDICATION NAME] should be sent out on the next shipment of medications from the pharmacy. Review of the resident's nurses' notes dated 10/18/16 at 11:44 A.M. noted as late entry for 10/12/16 showed the resident's [MEDICATION NAME] came in on the night shift. Review of the resident's nurses' notes dated 10/12/16 at 12:22 A.M. showed the following: -[MEDICATION NAME] given with bedtime medications; -Resident spit medication out at 8:00 P.M.; -At 12:00 A.M. took [MEDICATION NAME] without difficulty; -Confused and disoriented per usual; -Continue to monitor for signs/symptoms of discomfort. Review of the resident's October 2016 Medication Administration Record [REDACTED].M. Review of the resident's nurses' notes dated 10/17/16 at 6:12 A.M. showed the following: -Took scheduled [MEDICATION NAME] this shift times three without difficulty; -Calling out throughout the night, Oh help me, Oh Father, Oh Mary, Oh Mother at frequent intervals and appears to have discomfort by frowning, not sleeping and calling out; -Diversion, distractions, repositioning, fluids offered without success; -Continue to monitor. Review of the resident's medical record dated 10/17/16 at 8:51 P.M. showed facility staff documented a pain score of 5 on a scale of 1 to 10. During interview on 10/27/16 at 8:30 A.M. Registered Nurse (RN) D said the following: -The resident has pain and was without scheduled [MEDICATION NAME] for two days; -Staff didn't follow-up on the unavailable [MEDICATION NAME]; -The resident has severe dementia and seems like he/she is always in pain; -The resident communicates pain to staff by moaning, calling out, saying Oh mother, Help me; -The facility does not have a pain assessment; -He/she assessed the resident's pain on rounds but the assessment isn't documented anywhere; -On the night of 10/18/16 the resident had unrelieved pain while receiving his/her scheduled [MEDICATION NAME]; -He/she didn't notify the physician of the resident's pain; -He/she passed his/her concerns about the resident's pain onto the oncoming nurse and the SCU Unit Manager. Review of the resident's nurses' notes dated 10/19/16 at 6:37 A.M. showed the following: -[MEDICATION NAME] given times three this 12 hour shift with little or any relief from discomfort evidenced by calling out at regular intervals throughout the night, moaning, frowning and restlessness; -Resident called out, Help me, Oh mother, and Oh Mary; -Will pass on to oncoming shift nurse. Review of the resident's medical record dated 10/19/16 showed facility staff documented the following pain scores on a scale from 1 to 10; -At 9:23 A.M. pain score of 7; -At 11:24 A.M. pain score of 7; -At 4:45 P.M. pain score of 7. Review of the resident's October 2016 Medication Administration Record [REDACTED].M. and 4:00 A.M. Review of the resident's October 2016 Medication Administration Record [REDACTED].M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. During interview on 10/27/16 at 5:45 A.M. Licensed Practical Nurse (LPN) I said the following: -The resident suffers from chronic pain; -On 10/23/16 he/she attempted to give the resident his/her [MEDICATION NAME] but the resident refused two of three doses; -The resident communicates pain by crying or moaning; -On 10/23/16 the resident was doing a lot of moaning; -The facility does not have orders for shiftly pain assessments; -He/she used the PAINAD scale when he/she administers PRN pain medication or the resident has increased pain; -He/she notified the oncoming shift on 10/24/16 that the resident had a rough night and the oncoming shift needed to geta holdd of the physician and get different pain medication for the resident; -He/she didn't notify the physician of the resident's refusal of scheduled pain medication; -He/she tried to give the resident the scheduled [MEDICATION NAME] but the resident was not taking PO medications well. During interview on 10/27/16 at 12:55 P.M. LPN J said the following: -He/she was the charge nurse in SCU on 10/23/16; -The resident didn't receive his/her [MEDICATION NAME] on 10/23/16; -He/she didn't notify the physician that the resident didn't receive his/her scheduled [MEDICATION NAME]; -It's hard to tell when the resident is having pain; -The resident has pain but can't tell staff, he/she says Help me; -The resident screams when staff gets him/her up; -The resident is very contracted; -He/she does not do pain assessments; -He/she reassesses pain one hour after medication administration but doesn't document the assessment; -There is a drop down box in the computer to enter the pain score. Review of the resident's medical record showed no evidence facility staff notified the resident's physician that the resident refused doses of the scheduled [MEDICATION NAME] on 10/17/16, 10/21/16 and 10/23/16. Review of the resident's medical record dated 10/24/16 at 12:02 A.M. showed facility staff documented a pain score of 5 on a scale of 1 to 10. Review of the resident's October 2016 Medication Administration Record [REDACTED].M. During initial tour of the facility on 10/24/16 at 11:33 A.M. the Special Care Unit (SCU) Unit Manager said the following: -The resident has behaviors, he/she cries out; -He/she is totally dependent on staff for ADLS; -He/she has pain in his/her knees and received scheduled pain medication; -He/she has hip contractures. Review of the resident's medical record dated 10/24/16 at 11:40 A.M. showed staff documented the resident's pain as an 8 on a scale of 1 to 10. Review of the resident's nurses' notes dated 10/24/16 at 2:42 P.M. showed the following: -Resident has been resting comfortably in bed; -Staff have been rounding on him/her and making sure he/she stays dry; -He/she was yelling out Oh Mary; -He/she was incontinent of bladder and was changed with the positioning device placed between his/her legs; -He/she is now resting comfortably in bed again; -Will continue to monitor. Review of the resident's nurses' notes dated 10/24/16 at 2:47 P.M. showed the following: -Received telephone order per the physician's nurse to change resident's [MEDICATION NAME] to a [MEDICATION NAME] (narcotic pain medication in a [MEDICATION NAME]) due to the resident refusing medication at times; -Pharmacy called and notified of script ready for pick up at physician's office. During interview on 10/27/16 at 10:45 A.M. LPN G said the following: -He/she was the charge nurse in the SCU on 10/24/16; -The resident exhibited signs/symptoms of pain on 10/24/16; -The resident exhibits signs/symptoms of pain by moaning, groaning, saying, Oh please,Stop and calling out; -Being in bed seems to decrease the resident's signs/symptoms of pain; -He/she didn't notify administer PRN pain medication or notify the physician; -The resident received only scheduled pain medication on 10/24/16; -It's difficult to get the resident to take his/her medications; -The nurse last week (not sure what day) and again on 10/24/16 told him/her the resident had been refusing scheduled pain medication; -He/she called the physician on 10/24/16 to report the resident was refusing his/her scheduled [MEDICATION NAME] and to request the [MEDICATION NAME]; -He/she feels like the [MEDICATION NAME] has helped the resident's pain. -He/she applied [MEDICATION NAME] gel but doesn't know if it helped or not; -He/she should call the physician if a resident is having unrelieved pain. Continuous observation on 10/24/16 from 5:12 P.M. to 5:28 P.M. in the resident's room showed the following: -The resident lay in bed; -The resident yelled loudly, Oh, oh please please!; -The resident exhibited facial grimacing, rubbed on his/her chest and pulled at his/her gown; -The resident continued to yell, Oh please, oh please, help, help! -At 5:34P.M. thee resident lay in bed pulling at his/her gown, the resident cried out loudly, Oh please, oh please!; -At 6:26 P.M. the resident lay in bed and yelled, Oh please, oh please help me!. Observations on 10/25/16 in the resident's room showed the following: -At 5:58 A.M. the resident lay on his/her back in bed and yelled out, Oh please, oh please!; - At 6:08 A.M. the resident lay in bed, CertifiedNursee Assistant (CNA) E checked the resident for incontinence, the resident yelled out, Oh please, oh please!; -At 7:20 A.M. the resident lay in bed and drew his/her knees up to his/her chest exhibiting facial grimacing. The resident yelled out, Oh please help me, oh please oh please can you help me please! and Please, please, please can you help me oh please!; -At 7:50 A.M. the resident lay in bed and yelled loudly, Oh please, oh please darling oh please! and Please, please take it, oh please! During interview on 10/25/16 at 7:50 A.M. and 8:10 A.M. CNA A said the following: -The resident has pain in his/her right leg; -It's hard to tell what the resident wants; -The resident doesn't get up for breakfast because he/she is in so much pain; -The resident usually doesn't eat much. Observation on 10/25/16 at 8:11 A.M. in the resident's room showed the following: -The resident lay in bed; -The resident exhibited facial grimacing and cried, Oh, oh, oh please, I've got to go lady.; -The resident rubbed his/her forehead with his/her left hand; -The resident cried, I've got to go bad, oh please, oh please, oh please help me.; - At 8:53 A.M. CNA A provided incontinence care to the resident's roommate. The resident exhibited facial grimacing and yelled, Oh please! Observation on 10/25/16 at 9:12 A.M. in the resident's room showed the following: -The resident lay in bed; -The resident yelled Please, please, oh my leg!; -The resident pointed at his/her left leg; -CNA A and CNA E asked the resident if he/she wanted to take a shower; -The resident refused to get up for his/her shower; -CNA A checked the resident for incontinence; -A dark yellow ring of urine was present on the resident's bottom bed sheet; -The resident yelled, Oh, oh no! when CNA A removed the pillow from between the resident's legs; -CNA A asked the resident if he/she wanted to take a shower and the resident agreed; -CNA A removed the wet incontinence brief and placed a clean cloth pad and lift sling under the resident's hips; -The resident yelled, Please oh, please don't lady! -CNA A and CNA E transferred the resident from the bed to the shower chair with the mechanical lift; -The resident yelled, Oh please, oh please, I can't, I've had enough worries! Observation on 10/25/16 at 9:30 A.M. in the shower room showed the following: -CNA A gave the resident a shower; -The resident exhibited facial grimacing and cried, Oh please help me, oh please and prayer, oh my legs, oh my legs please! During interview on 10/25/16 at 9:38 A.M. CNA A said the following: -He/she thought the resident was hurting, probably all over; -The resident doesn't holler so much when he/she is in bed. During interview on 10/25/16 at 9:43 A.M. LPN H said the following: -The resident has a [MEDICATION NAME] for pain, it was just started last night; -The resident does have orders for PRN Tylenol; -The resident's last dose of PRN Tylenol was on 10/10/16; -The resident's physician discontinued the [MEDICATION NAME] yesterday; -The resident's last dose of [MEDICATION NAME] was on 10/24/16 at 8:00 P.M.; -The resident is having pain when he/she yells louder than usual; -He/she had not given the resident any PRN Tylenol. During interview on 10/26/16 at 3:30 P.M. the SCU Unit Manager said the following: -The resident is totally dependent on staff for all cares; -The resident will sometimes verbalize his/her needs, other days staff just check him/her; -Sometimes the resident will cry out if in pain or sometimes he/she will say yes if asked if having pain; -If the resident is awake he/she will cry out in pain; -Oh please could be a sign of pain; -Staff should let the charge nurse know if the resident is crying out in pain; -Sometimes the resident wouldn't take the [MEDICATION NAME]; -The [MEDICATION NAME] gave the resident total, [MEDICATION NAME] pain relief. During interview on 10/27/16 at 2:13 P.M. the Director of Nursing (DON) said the following: -He/she expects staff to do pain assessments on admission and if the resident appears to be in pain; -The resident has pain at times but not all the time; -The resident communicates pain by exhibiting facial grimacing, tone of voice, moaning, crying out, and drawing up of his/her legs; -He/she would expect staff to notify the physician if a resident refuses two to three doses of scheduled pain medication; -He/she would expect staff to assess the resident's pain and document the assessment in the nurses' notes; -He/she would expect staff to notify the physician if the resident's pain score was greater than four; -He/she would expect staff to administer PRN pain medication if scheduled pain medication has been administered and the resident is still exhibiting signs/symptoms of pain; -The [MEDICATION NAME] takes six to eight hours to be effective for pain relief; -He/she would expect staff to administer PRN pain medication if signs/symptoms of pain are exhibited after the [MEDICATION NAME] was started and after the scheduled [MEDICATION NAME] was discontinued. During interview on 10/27/16 at 9:00 A.M. the resident's physician said the following: -The resident has chronic pain; -Facility staff told his/her nurse on 10/24/16 that the resident was refusing pain medication; -He/she was trying a [MEDICATION NAME] for the resident's pain; -The resident can't really verbally communicate pain but communicates pain by crying out; -He/she would like to be notified by staff if the resident is having unrelieved pain or if the resident missed scheduled doses of pain medication; -The [MEDICATION NAME] may take a day or so to take effect; -The resident had not had any pain medication for several days so it would take awhile to catch up on his/her pain control; -The goal was to keep the resident comfortable.

Based on observation, interview, and record review the facility failed to identify, assess, document and provide the necessary care and treatment to prevent a pressure ulcer from developing for one resident (Resident #7), who was at risk for development of pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure combination with shear) in a review of thirteen sampled residents. Staff failed to update the plan of care, failed to keep the resident's skin clean and dry, and failed to reposition the resident. The facility census was 76. 1. Record review of the facility's Potential Alteration in Skin/Tissue Integrity Policy and Procedure, dated [DATE], showed the following: -Purpose: To outline the nursing management for all patients at risk for developing pressure ulcers; -Policy: Each patient will be assessed for altered skin integrity and provided with an individualized plan of care to prevent pressure ulcers and promote healthy skin; -Procedure: Conduct skin evaluation/risk assessment and reassessment; -Registered Nurse (RN) will complete a skin risk assessment within four hours of admission and then daily thereafter; -Physical assessment of skin will be performed within four hours of admission and with each physical assessment; -Minimize Pressure- positioning, at a minimum, nursing will turn patients in bed who are unable to redistribute their own weight, every two hours use pillows or wedges to reduce pressure on bony prominences; -Manage moisture- avoid skin wetness, protect and moisturize as needed; -Check for incontinence at least every two hours and as needed; -Cleanse skin gently after each incontinent episode avoiding excessive friction and scrubbing; -Use moisture barrier protectant on skin as needed to protect and maintain intact skin; -Collaboration- notify and collaborate with provider for any evidence of skin breakdown; -Collaborate with provider and/or Patient Care Coordinator for product selection; -Documentation: Skin risk assessment, skin assessment, including wound assessment; interventions performed, including care plan. 2. Record review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention Quick Reference Guide, dated as revised 2014, showed the following: -A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear; -Consider individuals who are bedfast and/or chair fast to be at risk of pressure ulcer development; -Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individuals condition. Reassessment should be undertaken if there is any change in the resident's condition; -Consider the impact of perfusion and oxygenation, poor nutritional status, and increased skin moisture on an individual's risk of pressure ulcer development; -Risk factors identified in a risk assessment should lead to an individualized plan of care to minimize the impact of those variables; -Document all skin assessments, noting details of any pain possibly related to pressure damage; -Whenever possible, do not turn the resident onto a body surface that is still reddened from a previous episode of pressure loading; -Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage; -Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. High pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. In order to lessen the individual's risk of pressure ulcer development, it is important to reduce the time and the amount of pressure the resident is exposed to; -The use of repositioning as a prevention strategy must take into consideration the condition of the resident and the support surface in use; -Frequency of repositioning will be influenced by variables concerning the resident and the support surface in use; -Repositioning frequency will be determined by the resident's tissue tolerance, his/her level of activity and mobility, his/her general medical condition, the overall treatment objectives, and assessments of the resident's skin condition; -Avoid subjecting the skin to pressure and shear forces; -Use transfer aids to reduce friction and shear. Lift don't drag the resident while repositioning; -Avoid positioning the resident on bony prominences with existing non-blanchable redness; -Limit the time a resident spends seated in a chair without pressure relief. When a resident is seated in a chair, the weight of the body causes the greatest exposure of pressure to occur over the ischial tuberosities (also known as the sitting bones, when sitting the weight of the body is frequently placed over these bones). As the loaded area in such cases is relatively small, the pressure will be high; therefore, without pressure relief, a pressure ulcer will occur very quickly; -Record repositioning regimens, specifying frequency and position adopted, and include an evaluation of the outcome of the positioning regimen; -Training in the correct methods of repositioning and use of equipment should be offered to all persons involved in the care of the residents at risk of pressure ulcer development; -Selection of an appropriate support surface should take into consideration factors such as the resident's level of mobility within the bed, his/her comfort, the need for microclimate control, and the place and circumstances of care provision. 3. Record review of Resident #7's admission Minimum Data set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated [DATE], showed the following: -Severe cognitive impairment; -[DIAGNOSES REDACTED]. -Required extensive assist for bed mobility and dressing; -Required total assist for transfer, dressing, toileting and personal hygiene; -Frequently incontinent of bladder and bowel; -At risk for developing a pressure ulcer. Record review of the resident's shower sheet, dated [DATE], showed the resident had no new skin issues. Record review of the resident's nurse's note, dated [DATE] at 4:10 A.M., showed the resident had excoriation (raw irritated lesion of the skin) to coccyx and barrier cream (a topical formulation to place a physical barrier between the skin and contaminates that may irritate the skin) was applied. Review of the resident's medical record showed no measurements of the excoriated area to the coccyx as noted in the nurse's not of [DATE]. Review of the resident's physician's orders [REDACTED]. Record review of the resident's care plan, dated as onset [DATE], showed the following: -Problem: I am at risk for skin breakdown because of my [MEDICAL CONDITION] use, incontinence, history of poor oral intake, history of refusing cares, and my [DIAGNOSES REDACTED]. I have no areas of concern at this time; -Goal: I want to remain free from open areas on my skin over the next 90 days; -Approaches: Assess my skin during my personal cares. Notify my nurse of any redness or open areas. Collaborate with therapies if you see a decreased ability to reposition myself. Provide me with a pressure reducing mattress on my bed. Help me with getting clean and dry after any incontinent episode. When I refuse, come back in a few minutes and try again. Notify my nurse of any changes in my skin. The care plan did not address the excoriation to the resident's coccyx identified on [DATE]. Record review of the resident's nurse's note, dated [DATE] at 6:32 A.M., showed a superficial open areas on coccyx (tailbone) and upper left gluteal (buttocks). The oncoming nurse will be notified. Record review of the the resident's hospice skilled nursing visit note, dated [DATE], untimed showed hospice was unable to assess the resident's bottom as the resident was resting in the recliner. Record review of the resident's updated care plan, dated [DATE], showed an open area. Approaches were to apply treatment as ordered. The care plan did not identify where the open area was located. Record review of the resident's Skin Integrity Report, dated [DATE], showed the following: -First observed: [DATE] (abrasion, left leg); -Present on Admission: False; -Status Description: Dry skin removed around the edges and inner wound has a scabbed over area on part of the area; -Length: 2.5 cm; -Width: 1.5 cm; -Tissue type: Non applicable. Review of the physician orders, dated [DATE], showed to cleanse leg wound with wound cleanser and skin prep daily until resolved. Review showed the resident's care plan was not updated to reflect the new area on the resident's leg or treatment. Record review of the nurse's note, dated [DATE] at 2:25 A.M., showed the resident had excoriation on his/her coccyx and upper gluteus and barrier paste was applied. During observation, on [DATE] at 5:55 A.M., Nurse Assistant (NA) F and Licensed Practical Nurse (LPN) B checked and changed the resident. The resident's right buttock was bright red; the skin was not intact; there was sanguineous exudate (fresh bleeding) present. The resident's left lower buttock area showed the skin was not intact and sanguineous exudate was present. There was a Stage II (partial thickness loss of skin, with exposed dermis) pressure ulcer on the resident's coccyx. Staff placed a pillow placed under the resident's left side of his/her back and buttocks. Observation of the resident on [DATE] showed the following: -Continuous observation from 6:00 A.M. until 8:24 A.M., showed the resident lay in bed on his/her back with a pillow at his/her left side; -At 8:30 A.M., the resident lay in bed on his/her back and had a large dark brown urine ring on his/her incontinent pad and the bottom of his/her gown had dried brown urine stains; - RN/wound care nurse C washed fresh blood from the resident's buttocks; -RN/wound care nurse C measured the resident's wound and excoriated areas, the right buttock was bright red; the skin was not intact; there was sanguineous exudate (fresh bleeding) present and measured 3.3 cm x 5.7 cm, the left lower buttock area showed the skin was not intact and sanguineous exudate was present and measured 3 cm x 1.9 cm. There was a Stage II pressure ulcer on the resident's coccyx that measured 1.5 cm x 1 cm. Staff did not reposition or check the resident for incontinence for two hours and twenty four minutes. During an interview on [DATE] at 5:55 A.M., NA (nurse aide) F said the resident's buttocks were bright red and the resident had an open area. The resident was turned/repositioned and checked/changed every two hours and protective ointment was applied. He/she had placed a pillow under the resident's left side but the resident was able to get off the pillow and ended up on his/her back. During an interview on [DATE] at 4:30 A.M., LPN D said LPN E reported the resident had two new open areas on [DATE]. He/she had not assessed the wound. During an interview on [DATE] at 5:00 A.M., LPN B said the resident had pressure areas on the resident's coccyx and upper gluteus. He/she had not measured the resident's pressure ulcer because the wound nurse assessed the wounds. He/she had informed the wound nurse of the resident's pressure ulcer and abrasions. He/she did not notify the physician of the resident's pressure ulcer. He/she was not sure how long the resident had the pressure ulcer. The resident was repositioned and checked for incontinence every two hours. During an interview on [DATE] at 8:20 A.M., LPN A said the resident's buttocks were reddened, opened and excoriated. The resident had a small open area on [DATE]. He/she had not assessed the area or notified the resident's physician. During an interview on [DATE] at 8:24 A.M., Registered Nurse (RN)/wound care nurse C said he/she assessed the resident's reddened buttocks a few weeks ago, the resident did not have any open or excoriated areas on his/her buttocks at that time. He/She had not received any reports the resident had developed any open or excoriated areas on his/her buttocks. During an interview on [DATE] at 1:15 P.M., RN/wound care nurse C said the following: -Staff was to give him/her a wound report sheet when open areas were found and were supposed to document in the nurse's notes; -He/she looked at the resident's buttocks a few weeks ago. The buttocks were reddened but had no open areas; -The charge nurse does weekly assessments and fills out skin sheets; -The charge nurse or whoever finds the wound notifies the next of kin and physician; -If the wound deteriorates staff is to notify the wound care nurse; -Staff is to notify the physician and get treatments for wound care. Record review of the resident's Skin Integrity Report, dated [DATE], showed the following: -First observed: [DATE] (other/buttocks and sacral areas); -Present on Admission: False; -Status Description: Late entry for [DATE] resident had expired and had the areas when passed; -No measurements were documented; -The area was not staged; -Color: Areas remained the same when the resident expired. During an interview on [DATE] at 6:05 P.M., LPN E said the resident developed a pressure ulcer on [DATE]. He/she didn't notify the resident's physician because staff was not to call the physician during the night and he/she passed the information on to the day nurse. He/she didn't notify the wound care nurse. When a resident has skin issues the wound care nurse was supposed to be notified. The charge nurse should measure the pressure ulcer but he/she just eyeballed the resident's skin issues because it was difficult to hold the resident over. He/she cleaned the resident's pressure ulcer with wound cleanser and applied wound barrier ointment. He/she said the resident was left sitting in his/her recliner all day in urine because there was not enough staff to care for him/her. During an interview on [DATE] at 1:30 P.M., the Director of Nurses (DON) said the following: - He/she thought staff were doing weekly skin assessments but it had been dropped from the physician order [REDACTED]. -Skin assessments were done during showers; -The wound care nurse assessed and documented on existing wounds and newly identified wounds; -They expect staff to reposition the residents and check for incontinence at least every two hours; -Pressure ulcers should be care planned. During an interview on [DATE] at 5:06 P.M., the administrator and DON said the following: -On [DATE], hospice got an order for [REDACTED].>-On [DATE] it looked like the resident skin was opened and it wasn't passed on in report and no one was notified; -The charge nurse can measure and assess pressure ulcers; they may not do a skin assessment but they had been getting the wound care nurse who measures the areas right away; -Skin assessments were done by Certified Nurse Assistants during the residents' showers; -The licensed nurses get the shower sheets and notify wound care nurse when there was a reddened area; -The weekly skin assessments were to be done by a charge nurse but they were accidentally dropped off from the physician order [REDACTED]. MO# 7

Based on interview and record review, the facility failed to immediately perform cardiopulmonary resuscitation (CPR), a combination of rescue breathing and chest compressions delivered to victims thought to be in [MEDICAL CONDITION], for one resident (Resident #1) of 22 residents identified as a full code status (the provision of CPR and other life saving measures in an attempt to preserve life), when the staff found the resident unresponsive, without pulse or respirations. Staff delayed initiation of CPR and waited until staff had first contacted the Director of Nurses and the House Supervisor, transferred the resident off the floor with a Hoyer lift, and began moving the resident on a gurney to the hospital side. Staff initiated CPR while the resident was on the gurney during the transfer to the local emergency department. The resident was then transferred on to a regional hospital where he/she was diagnosed with [REDACTED]. The facility census was 77. 1. Review of Resident #1's medical record showed he/she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He/she had full code status. Review of the resident's most recent Minimum Data Set (MDS), a federally mandated assessment to be completed by staff, dated [DATE] showed the resident required minimal assistance of one staff and the resident had no memory problems. Review of the resident's Nurses Notes dated [DATE] showed no documentation regarding the resident's condition or the code that occurred that morning. During interview on [DATE] at 11:10 A.M. Certified Medication Technician (CMT) A said on [DATE], he/she was passing medications and had just given the resident his/her medications. He/she said he/she was at the medication cart when he/she heard a thump and went back to the resident's room. He/she said the resident was face down on the floor. He/she said he/she told the Registered Nurse (RN) A the resident was on the floor he/she needed to roll him/her over. He/she said he/she went to get help to get the resident off the floor. He/she said he/she told the other aides working on the floor that the resident had fallen and he/she needed help to get him/her up and then returned to the resident's room. He/she said when he/she entered the room RN A was on the floor shaking the resident but the resident did not respond. He/she said RN A did not roll the resident over so he/she moved the bed and got the resident turned. He/she asked RN A if the resident was a full code and RN A said he/she didn't know. He /she said he/she ran to the nurse's station and looked in the chart and yelled down the hall that the resident was a full code. He/she said RN A said they were not allowed to start CPR until the CCC (clinical care coordinator/house supervisor) arrived. He/she said someone got the gurney and the Hoyer lift and they lifted the resident onto the gurney. He/she said he/she got on top of the resident and started CPR. He/she said he/she did not know the exact time but he/she had started the medication pass when he/she heard the resident fall so it was approximately 5:05 A.M., but possibly a couple minutes later. He/she said he/she told RN A to start CPR and RN A responded he/she didn't know what to do. He/she said he/she told RN A to go call somebody and CMT A began CPR. He/she said he/she was CPR certified and knew what should be done but followed the RN's direction because RN A was the charge nurse. During interview on [DATE] at 12:30 P.M. CMT B said on [DATE], he/she was on the special care unit when he/she was called to come help because the resident was not responding. When he/she arrived the resident was face down on the floor. He/she said he/she and CMT A got the resident turned over and the resident still did not respond. He/she said staff got the resident onto the gurney. He/she said RN A did not do vitals so he/she checked for a pulse and did not feel one. He/she said he/she asked RN A if the resident was a full code and RN A did not know. He/she said CMT A ran to the desk to find the code status and the resident was a full code. He/she said when he/she arrived at the room RN A had not done anything and just stood there and didn't even say anything, like he/she froze. He/she said RN A called the DON to ask if they should start CPR and was told no. He/she said when RN A said they could not start compressions they knew he/she was wrong, (however, they did not immediately start compressions). During interview on [DATE] at 11:05 A.M. RN A said on [DATE], the resident coded while CMT A was in the resident's room. The resident was a full code, the resident fell face down. The CMT told RN A he/she had to call the DON first and the DON said he/she was not to do CPR until the resident was on the hospital side. As soon as the hospital gave permission the CMT began CPR. This happened on [DATE]. Review of a written statement dated [DATE] RN A said on the morning of [DATE] between 5:30 and 6:15 A.M. while in another resident's room he/she heard what sounded like something hitting the floor hard. He/she saw CMT A standing outside the resident's room. He/she said he/she rushed down to the room and found the resident face down next to the bed. He/she said CMT A was trying to shake the resident to see if the resident would respond and he/she started doing the same. He/she said while CMT A was bent over the resident he/she was trying to figure out how to get the resident turned over. He/she's thought was the resident was unconscious from the impact of the fall as his/her forehead and upper portion of the face were resting on the table legs. He/she said it was determined right away that assistance was needed in turning the resident and instructed CMT A to get CMT B and the vital sign machine. He/she said at this point they realized the resident was not breathing and had no pulse. He/she said CMT A said to call the DON. RN A said at that point he/she became frustrated and felt it shouldn't be necessary to call the DON regarding an emergency that required immediate attention but called the DON because other's had gotten in trouble for not calling before acting. He/she said the DON instructed that "We don't do CPR in the facility, call the CCC and CPR will be started on the hospital side". RN A said he/she questioned that and was told by the DON "We do not run codes in the facility". RN A said he/she immediately hung up the phone and tried to get a hold of the CCC, then had to call the operator who also tried to get her. When the operator was told of what was going on the operator asked if RN A wanted a code called overhead to the facility. RN A said he/she said no, he/she did not want to get in trouble. The operator did get the CCC. He/she said during this time the other staff were getting the resident ready to transport to the hospital. He/she said while getting the resident from the floor to the gurney the resident did not show any reaction to the maneuvering or sternal rubbing applied during this time. No respirations were observed, no palpable pulse was felt, and no heart sounds heard upon auscultation. He/she said the CCC showed up and they grabbed the resident's chart because no paperwork had been done. He/she said the CCC asked why CPR had not been started and it was explained what the DON had said. RN A said the CCC stated he/she was not aware it was like that, he/she told the CCC he/she was just doing what the DON said. RN A said as they neared the dining room with the gurney the CCC said for someone to get on top of the resident and start CPR. During interview on [DATE] at 12:00 P.M. the Director of Nursing (DON) said when a full code resident codes staff should initiate CPR, call the operator and report a code in progress, the operator would contact the CCC and the code team. She said staff should transport the resident and the team heads toward them, (hospital and facility are connected by a hallway). She said RN A called her at home at approximately 5:10 AM to report the resident was not responsive and asked what he/she should do. She said she directed RN A to initiate CPR, call the operator, and transport the resident. She said she explained the operator would get the code team. She said she could hear that RN A was upset and told him/her she was on her way to the facility. She said when she arrived RN A appeared overwhelmed and distraught. The DON said she did not know how many residents were a full code. The DON relayed the resident's family communicated the resident was hospitalized at a regional hospital and on a ventilator. Review of the resident's Emergency Physician Record, Code Blue, dated [DATE] showed the resident arrived at 5:35 A.M. in full arrest (to the emergency department), unresponsive, no respirations, and no pulse. Down time before ACLS (Advanced Cardiac Life Support) less than ten minutes. Review of the resident's Emergency Nursing Record, Cardiopulmonary Resuscitation Record, dated [DATE] showed time of arrest was approximately 5:10 A.M. with CPR (cardiopulmonary resuscitation) begun at approximately 5:20 A.M., (ten minutes after the arrest). During interview on [DATE] at 2:15 P.M. the Administrator said staff are to initiate basic life support (BLS) and transport the resident to the emergency room . During interview on [DATE] at 2:25 P.M. the CCC said the procedure for a code was for the nursing home staff to call the CCC and say they have initiated CPR, the CCC calls the code and goes to the nursing home. The resident is transported and ALS (advanced life support), is started in the emergency room . She said the facility does not have a crash cart, to have a crash cart staff would need to be ALS certified. Observation and phone interview with hospital maintenance on [DATE] showed the Emergency Department located 150 yards from the facility. During interview on [DATE] at 9:00 A.M. the resident's physician said if one of his residents coded he expected staff to call a code blue and immediately start CPR. He said he would not expect staff to wait on a specific staff to arrive, the first available certified staff should be providing CPR. He said he was not aware that the resident had coded until he arrived at the facility two days later to see the resident and he/she was not there. Review of hospital records dated [DATE] showed the resident was admitted with a [DIAGNOSES REDACTED]. Problem list included the following: -acute hypoxic (diminished availability of oxygen to body tissues) [MEDICAL CONDITION] requiring mechanical ventilation; -status [REDACTED]. -known history of [MEDICAL CONDITION] with last cardioversion in [DATE]; -new onset [MEDICAL CONDITION] (abnormally rapid heart rate) by outside report; -hypertension; -recent colon resection; -Parkinsonism (any disorder manifesting symptoms of [MEDICAL CONDITION]). History of present illness, the patient had a fall from a bed, it appeared he/she went into cardiac arrhythmia. CPR was started and the patient received [MEDICATION NAME], and was shocked as least three times. He/she was intubated, started on [MEDICATION NAME] (vasopressor) for [MEDICAL CONDITION], and transferred for further care. Upon arrival to the unit the patient was unresponsive, intubated, had significant [MEDICAL CONDITION] of his/her lower extremities, and a right conjunctival (membrane covering the eyeball) bleed. The patient did not withdraw from painful stimuli. Cardiac catheterization will be indicated if the patient survives this significant event. Prognosis is extremely poor due to the patient's significant [MEDICAL CONDITION]. Review of the resident's discharge summary dated [DATE] showed he/she had a bedside percutaneous [MEDICAL CONDITION] (creation of an opening into the trachea through the neck to breath) done and a PEG (feeding) tube done. He/she was diagnosed to have severe [MEDICAL CONDITION] with no hope of any meaningful recovery. He/she was transferred to an outside hospital for long-term acute care, prognosis was poor. Review of the hospital (facility) Organization Wide Statement on Resuscitation/Code Blue (Policy and Procedure), showed BLS should be initiated by facility BLS certified staff and call 222. The Registration clerk calls Respiratory Care and the CCC to respond to the facility. Respiratory Care and the CCC bring the resident to the Emergency Department and the code team is called to the Emergency Department. Review of the American Heart Association Symptoms and Emergency treatment of [REDACTED]. -Sudden loss of responsiveness, no response to tapping on shoulders; -No normal breathing, the victim does not take a normal breath when you tilt the head up and check for at least five seconds. If the signs of [MEDICAL CONDITION] are present: -Call 911 for emergency medical services; -Get an automated external defibrillator if available; -Begin CPR immediately and continue until professional emergency medical services arrive; -If two people are available one should begin CPR while the other calls 911. [MEDICAL CONDITION] is reversible in most victims if it is treated within a few minutes. [MEDICAL CONDITION] can be reversed outside a hospital by properly staffed emergency teams trained to give CPR and defibrillate. Immediate treatment is essential to survival of [MEDICAL CONDITION]. The American Heart Association supports implementing a "chain of survival" to rescue people who suffer [MEDICAL CONDITION]. The chain consists of the following: -Early recognition of the emergency and activation of the emergency medical team; -Early defibrillation when indicated; -Early bystander CPR; -Early advanced life support followed by post resuscitation care delivered by healthcare providers. Complaint #MO At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility began immediate inservicing of staff prior to staff working their shift regarding expectation of action to take when a resident is found unresponsive, assessing and initiating basic life support and the Code Blue procedure and location of the rescue cart on each unit. The facility began staffing of each shift with a BLS certified staff. The facility still needed to complete inservicing of all staff regarding the facility's current policy and expectations regarding the corrective measure placed to address the immediacy of the violation and system for DNR identification. The nurse management team had not completed staff education with Mock Code Blue training. At the time of exit, the severity of the deficiency was lowered to the "D" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).

Based on interview and record review the facility failed to obtain anti [MEDICAL CONDITION] medication for two residents (Resident #1 and #2 ) of five sampled residents . The facility failed to administer ([MEDICATION NAME]) for (Resident #1 ), a resident with [DIAGNOSES REDACTED]. The medication was ordered by the physician on [DATE] at 8:00 P.M. and not obtained by the facility until after 9:30 A.M. on [DATE] when the Director of Nurses ascertained the medication had not been ordered, received ,or administered to the resident. The facility also failed to administer the ordered [MEDICATION NAME] or to provide the medication in the dose ordered on multiple occasions when the resident presented with [MEDICAL CONDITION]. The resident continued to have [MEDICAL CONDITION] during the time the medication was not provided as ordered. Licensed staff reported not knowing how to obtain medications ordered after normal pharmacy hours. The facility failed to administer [MEDICATION NAME] to resident (Resident #2) who presented with [MEDICAL CONDITION] (on [DATE] at 2:00 A.M. and at 2:20 P.M.) , on [DATE] at approximately 8:00 A.M. the Director of Nurses ascertained the resident's physician had not been notified of Resident #2's (2 A.M.) [MEDICAL CONDITION], she notified the physician and received orders to administered an anti [MEDICAL CONDITION] medication ([MEDICATION NAME]), the medication was not administered until ([DATE] at 8:00 A.M.) . The resident continued to have [MEDICAL CONDITION] during the time the medication was not provided as ordered. The census was 81. 1. Review of the Resident #1's physician's orders [REDACTED]. Review of the resident's care plan dated [DATE] directed staff to complete the following: -Collaborate and consult with hospice(resident not on hospice) for care, medication and treatment per physician; - Collaborate with hospice (resident not on hospice) on palliative care measures as needed. Review of the resident's History and Physical dated [DATE] showed the resident with [DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] from 1330 (1:30 P.M.) to 7:15 P.M. showed the following: -At 1330 (1:30 P.M.), Resident's family at bedside. Resident turned, noted resident would jerk "every now and then"; -At 7:15 P.M. palliative care nurse visit after telephone call from visitor who reported the resident had a [MEDICAL CONDITION]. Facility nurse confirmed the above information and reported the [MEDICAL CONDITION] was grand mal, (epileptic [MEDICAL CONDITION] characterized by a generalized involuntary muscular contraction and cessation of respiration followed by tonic and clonic spasms of the muscles), and lasted approximately three minutes. When the palliative nurse arrived resident drowsy and lethargic in a daze, eyes blood shot, visitor reports this happened just since the [MEDICAL CONDITION]. Physician contacted and orders obtained, Registered Nurse (RN) B informed of new orders. Review of the resident's physician's telephone orders dated [DATE] at 8:00 P.M. showed the physician ordered staff to start [MEDICATION NAME], (anti [MEDICAL CONDITION] medication), 300 milligrams (mg.) by mouth every day and [MEDICATION NAME], (a central nervous system depressant), 1 mg. every two hours as needed for [MEDICAL CONDITION]. Review of the resident's nurse's notes dated [DATE] from 2205 (10:05 P.M.) until 2230 (10:30 P.M.) showed the following: -At 2205 (10:05 P.M.) resident had a witnessed [MEDICAL CONDITION] with jerking, eyes rolled up and snoring respirations [MEDICATION NAME] approximately three minutes, (no [MEDICATION NAME] or [MEDICATION NAME] documented as given) , no documentation staff notified the physician; -At 2230 (10:30 P.M.), resident was turned and had a [MEDICAL CONDITION] approximately 60 seconds, (no [MEDICATION NAME] or [MEDICATION NAME] documented as given), no documentation staff notified the physician. Review of the Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On [DATE] at 8:00 P.M. [MEDICATION NAME] 0.5 mg. given for anxiety, (nurses notes showed the resident had a [MEDICAL CONDITION], and the order for [MEDICATION NAME] was 1 mg .for [MEDICAL CONDITION], not 0.5 mg.), with no documentation staff gave the resident's [MEDICATION NAME]; - At 10:05 P.M. no [MEDICATION NAME] or [MEDICATION NAME] documented as administered ( nurse's notes showed a witnessed [MEDICAL CONDITION]); - At 10:30 P.M. no [MEDICATION NAME] or [MEDICATION NAME] documented administered (nurse's notes showed a witnessed [MEDICAL CONDITION]). Review of the resident's faxed pharmacy order sheet dated [DATE] at 8:55 P.M. signed by RN B showed an order for [REDACTED]. Review of the pharmacy's delivery record for the resident's [MEDICATION NAME] showed the medication was delivered to the facility on [DATE] at 9:30 A.M., the day after the physician ordered the medication. Review of the resident's care plan dated [DATE] directed staff to monitor [MEDICAL CONDITION], notify Hospice (resident not on Hospice) and physician. Review of the resident's nurse's notes dated [DATE] showed the following: -At 0045 (12:45 A.M.) called to resident's room. Resident having [MEDICAL CONDITION] activity [MEDICATION NAME] approximately 60 seconds. Resident's eyes were rolled back in head, snoring like respirations, resident bit inside of right cheek, and small amount of blood noted from mouth, family at bedside, [MEDICATION NAME] 1 mg. given per orders with no documentation staff notified the physician; -10:45 A.M. palliative care visit. Visitor called office just after 9:00 A.M. saying the resident had another [MEDICAL CONDITION]. Director of Nurses (DON) here at the time of the [MEDICAL CONDITION] and called for [MEDICATION NAME] to be delivered immediately. Discussed brain metastasis probably causing [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. -At 1530 (3:30 P.M.) had [MEDICAL CONDITION] this am [MEDICATION NAME] about 90 seconds, [MEDICATION NAME] was given when it arrived, [MEDICATION NAME] given, no documentation the physician was notified the medication had not been given prior or of the resident's continued [MEDICAL CONDITION] activity; During interview on [DATE] at 1:35 P.M. Palliative Care Nurse A said he/she was notified at about 6:40 P.M. about the resident's [MEDICAL CONDITION] and went to the facility. He/She notified the physician as staff wanted him/her to do this, and received orders for [MEDICATION NAME] and [MEDICATION NAME]. He/She told staff they needed to start the medications right away. RN B said she wasn't sure if the [MEDICATION NAME] was in the emergency kit. Palliative Care Nurse A said he/she was not aware the [MEDICATION NAME] was not given. He/She had no other calls that evening about the resident having [MEDICAL CONDITION]; he/she would have expected staff to call if the resident had continued [MEDICAL CONDITION]. The next day ([DATE]) another palliative care/hospice nurse went to the facility to see the resident and informed him/her the facility had not started the [MEDICATION NAME] until [DATE]. Palliative Care Nurse A said he/she was concerned he/she was not notified. During interview on [DATE] at 3:20 P.M. RN B said on [DATE] the resident's visitor called staff to the room, the resident was having a [MEDICAL CONDITION], (this was the resident's first [MEDICAL CONDITION]). RN B called the Palliative Care Nurse (A). The nurse came out and called the physician who ordered [MEDICATION NAME]. RN B said he/she did not give [MEDICATION NAME] as it was not in the emergency kit, it was ordered from the pharmacy by fax. RN B said he/she was not aware of any way to obtain emergency medications. The resident had more [MEDICAL CONDITION] that evening. RN B said he/she did not know how to get medications if they were not in the emergency kit and the resident did not receive [MEDICATION NAME] that night. He/she was not aware of any facility policy for obtaining medications after hours. During interview on [DATE] at 1:10 P.M. LPN D said if a resident needed a medication and it was after pharmacy hours he/she would call the hospital and try to get it there and if not then call the DON. LPN D said he/she was not aware of any policy on obtaining medications after hours. Review of the resident's nurse's notes dated [DATE] showed no documentation of any [MEDICAL CONDITION] or contact with physician regarding [MEDICAL CONDITION]/medication administration delay. Review of the resident's nurse's notes dated [DATE] showed the following: -At 1:00 A.M. resident having [MEDICAL CONDITION] activity. [MEDICATION NAME] 1 mg. given; -At 4:00 A.M. resident having [MEDICAL CONDITION] activity again, had two [MEDICAL CONDITION] , [MEDICATION NAME] 1 mg. given; -At 5:00 A.M. resident having a [MEDICAL CONDITION] again, (no documentation of any [MEDICATION NAME] administered); -At noon, resident had one [MEDICAL CONDITION] since 10:15 A.M., [MEDICATION NAME] given at 11:00 A.M.; - At 2:05 resident had three [MEDICAL CONDITION] this A.M., [MEDICAL CONDITION] between 30 seconds and one minute, transferred to the hospital. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On [DATE] at 1:00 A.M. [MEDICATION NAME] 1 mg. given for [MEDICAL CONDITION] (2:00 A.M. noted effective); - At 4:00 A.M. [MEDICATION NAME] 1 mg. given for [MEDICAL CONDITION] (4:30 A.M. effective); - No [MEDICATION NAME] documented as given at 5:00 A.M.; - At 11:10 A.M. [MEDICATION NAME] 1 mg. given. During interview on [DATE] at 9 A.M. LPN D said he/she was the charge nurse who worked the hall where the resident resided on [DATE]. LPN D said the resident had three [MEDICAL CONDITION] between 7:00 A.M. and noon, (review showed one dose of [MEDICATION NAME] given for the three [MEDICAL CONDITION] LPN D documented the resident had between 7:00 A.M. until noon). LPN D said he/she was not sure if he/she administered [MEDICATION NAME] when the resident had his/her [MEDICAL CONDITION]. LPN D said he/she did not notify the physician because Hospice (resident not on hospice) was supposed to take care of that. Review of the resident's physician's orders [REDACTED]. Review of the resident's palliative care note dated [DATE] showed: -At 10:00 A.M. phone call to office stating the resident was having [MEDICAL CONDITION] again. On arrival at the facility family said the resident has had seven [MEDICAL CONDITION] since 1:00 A.M. (nurses notes show documentation of three [MEDICAL CONDITION] , one [MEDICAL CONDITION] at 1:00 A.M., and two [MEDICAL CONDITION] at 4 :00 A.M.). Staff gave the resident [MEDICATION NAME] 0 .5 mg. at 1:00 A.M., (the physician's orders [REDACTED]. every two hours if seizing). Staff gave the resident a dose of [MEDICATION NAME] 1 mg. at 4:00 A.M., nothing since then. Instructed staff to give resident [MEDICATION NAME] 1 mg. sublingual STAT. The resident was moaning with each breath, pupils non reactive to light. Discussed need to get [MEDICAL CONDITION] controlled as soon as possible, resident transferred to the hospital. - At 1:35 P.M. the resident was moved from the long term care facility to the hospital for recurring [MEDICAL CONDITION] activity. The resident has had eight [MEDICAL CONDITION] 30 seconds to one minute and 30 seconds since 1:00 A.M.. Hoping to access resident's port and start [MEDICATION NAME] intravenous as soon as possible to control [MEDICAL CONDITION] activity. The resident quit breathing at 2:00 P.M. (at the hospital). Review of the resident's hospital expiration summary dated [DATE] showed the resident was admitted to the hospital due to [MEDICAL CONDITION] that started on [DATE], the long term care facility was not able to control the resident's [MEDICAL CONDITION]. The resident was started on intravenous [MEDICATION NAME] secondary to [MEDICAL CONDITION] activity at the long term care facility. The resident expired prior to the completion of the physical exam. Review of written statement dated [DATE] showed the DON said the facility received an order for [REDACTED].) on [DATE]. The medication was ordered by fax from the pharmacy for delivery. Normal delivery was 1300 (1:00 P.M.) daily. The pharmacy was notified on [DATE] at 0945 (9:45 A.M.) and asked to deliver the [MEDICATION NAME] stat and it was delivered. The expectation is to order medication and start medication as ordered even if that required notifying the pharmacy on call. Pharmacy will deliver stat medications after hours. During interview on [DATE] at 9:20 A.M. the pharmacy manager said the facility's DON had called her last week requesting information on the resident's [MEDICATION NAME]. The manager said that she reminded the DON of the emergency phone number to get medications after hours. The manager said the DON said he/she knew about the emergency phone number. The manager said the fax from the facility requesting the [MEDICATION NAME] was received at the pharmacy on [DATE] around 8 P.M., the pharmacy closed at 5:30 P.M. The manager said the fax would have been found on [DATE] about ,[DATE]:30 A.M. and the delivery time to the facility is 1:00 P.M. The manager said the facility called the pharmacy on [DATE] around 9:30 A.M. requesting the [MEDICATION NAME] to be delivered STAT. Review of the pharmacy on-call procedure memo that was supplied to all long term care accounts, during the Fall of 2008 showed: -Normal business hours were Monday through Friday 8:30 A.M. to 5:30 A.M. and Saturday 8:30 A.M. to 1:00 P.M.; -After hours calls should be directed as follows: Call [PHONE NUMBER] to provide relief on Mon-Fri 5:31 P.M. to 8:00 P.M., Saturday 1:01 P.M. to 6:00 P.M. and Sunday noon to 5:00 P.M.; - Emergency coverage for hours outside the ranges listed above and all holidays are covered at the following number [PHONE NUMBER]. During interview on [DATE] at 2:10 P.M. the on-call physician said the orders for the resident's [MEDICATION NAME] and [MEDICATION NAME] meant to give the medication STAT, not to wait until the next day. The physician said the resident needed to be loaded with the [MEDICATION NAME] and [MEDICATION NAME] immediately. The on-call physician did not recall being called about the resident continuing to have [MEDICAL CONDITION]. During interview on [DATE] at 11:35 A.M. the resident's physician said he/she would have expected the facility to have started the [MEDICATION NAME] the evening ([DATE]) it was ordered by the on-call physician as the resident was having [MEDICAL CONDITION]. The physician said the order for the [MEDICATION NAME] would have also helped with the [MEDICAL CONDITION]. The resident [MEDICAL CONDITION] metastasis. 2. Review of Resident #2's medical record showed his/her [DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] showed: - On [DATE] at 2:00 A.M. the resident was up in a wheel chair and started having [MEDICAL CONDITION] activity. The [MEDICAL CONDITION] lasted approximately two and a half to three minutes. The resident was incontinent of urine during [MEDICAL CONDITION] and very lethargic after [MEDICAL CONDITION]. The DON was notified and instructed staff to watch resident closely and if any more [MEDICAL CONDITION] send to the emergency room . -The note showed no documentation the physician was notified of [MEDICAL CONDITION]; - On [DATE] at 2:20 P.M. new orders received ([MEDICATION NAME] for [MEDICAL CONDITION]), the resident had a ,[DATE] second [MEDICAL CONDITION] reported, the resident was shaking and non-responsive. The resident came to and was oriented times three. The resident's physician and family aware. Review of the resident's physician's orders [REDACTED].M. showed an order for [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility documented the resident received his/her [MEDICATION NAME] 300 mg at 8:00 A.M. on [DATE]. During interview on [DATE] at 9:20 A.M. the DON said the resident had a history of [REDACTED]. (Review of the resident's nurse's notes dated August - [DATE] showed no documentation of any [MEDICAL CONDITION]). During interview on [DATE] at 2:25 P.M. Licensed Practical Nurse (LPN) E said he/she did not call the resident's physician on [DATE] after the resident had a [MEDICAL CONDITION] around 1:30 P.M. because the physician was aware of the [MEDICAL CONDITION] the resident had at 2:00 A.M. and had ordered [MEDICATION NAME]. LPN E said the DON had called the resident's physician about 8:30 A.M. and reported the 2:00 A.M. [MEDICAL CONDITION]. LPN E said he/she ordered the [MEDICATION NAME] but did not know when the resident received it. LPN E said he/she should have notified the physician about the second [MEDICAL CONDITION]. During interview on [DATE] at 2:35 P.M. LPN F said he/she worked the ,[DATE] shift on ,[DATE]-,[DATE]. LPN F said he/she had worked at the facility for three years and was not aware of the resident ever having a [MEDICAL CONDITION]. LPN F said he/she did not call the resident's physician when the resident had a [MEDICAL CONDITION] at 2:00 A.M., he/she did call the DON. LPN F said the DON instructed him/her to monitor the resident and if any more [MEDICAL CONDITION] to send to the emergency room . LPN F said he/she took the resident's vital signs twice after the [MEDICAL CONDITION] but did not know why only one set of vitals were in the nurse's notes. LPN F said staff looked in on the resident about every 15 minutes after the [MEDICAL CONDITION]. (No documentation in the resident's nurse's notes between 2:00 A.M. and 6:45 A.M. showing assessment of the resident or vital signs). During interview on [DATE] at 10:40 A.M. the Director of Nurses said he/she would have expected the facility to call the resident's physician when the resident had a [MEDICAL CONDITION]. The DON said he/she notified the resident's physician about 8:15 A.M. on [DATE] about the resident's [MEDICAL CONDITION] and received new orders about 1:30 P.M. for anti [MEDICAL CONDITION] medication ([MEDICATION NAME]). The DON said the medication would have been delivered to the facility about 5:00 P.M. on [DATE]. The DON said the medication was not given because staff saw it was ordered for once daily and the once daily medications are given at 8:00 A.M. The DON said he/she would have expected the staff to give the medication immediately when it arrived at the facility not wait until the next day. During interview on [DATE] at 8:20 A.M. the resident's physician said he/she would have expected the facility to administered the resident's [MEDICATION NAME] as soon as they received the medication. The physician said he/she did not want the facility to wait until the next day since the resident was having [MEDICAL CONDITION]. Review of the administrator's written statement dated [DATE] showed the administrator said the facility had a policy and procedure for assessing for changes in condition and proper notification of those required to be notified. The facility had procedures for ordering medications after hours, week-ends and holidays and staff have been educated to this procedure. The facility has an RN on call 24 hours a day and the charge nurse staff have been educated to the expectations for notifying such. The DON orients all charge nurse staff on the expectations related to change in condition, ordering medications and expectations of notifying DON/RN on call. The nurses involved in the incident on ,[DATE] had been provided this education. The RN was informed by the Palliative care nurse to follow the policy and procedure of the facility if the medication was not in the emergency kit. The administrator said he/she was not sure why the RN chose not to follow the policy and procedures of the facility. Expectations are that all charge nurse staff follow the education, direction,and policy of the facility, their supervisor and their licensure. Review of the facility's policy for change in a resident's condition or status revised ,[DATE] showed the facility shall promptly notify the resident's physician of changes in the resident's medical condition such as a significant change in a resident's condition or a need to alter the resident's medical treatment significantly. *Higher classification merited due to the effect on the resident. Complaint #: MO Note: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level "J". Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. During the onsite visit, the facility initiated inservicing to address ordering and obtaining medications after hours, expectations regarding start times for all orders, notification with a change of residents' condition, and communication with palliative care staff. Prior to each scheduled shift the facility completed the required inservicing before allowing the employee to work. The facility still had yet to complete inservicing of all staff, including palliative care staff, develop a policy and procedure for palliative care services, or educate staff regarding the new policy and procedure. The facility had yet to obtain consultation for assessment of the facility's Quality Improvement meeting. At the time of exit, the severity of the deficiency was lowered to the "G" level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violations.

Based on interview and record review the facility failed to notify two resident's (Resident #1's and #2's) physicians, of five sampled residents, of [MEDICAL CONDITION] activity, when ordered anti [MEDICAL CONDITION] medication had not been initiated in a timely manner or that the residents presented with continued [MEDICAL CONDITION] activity. The census was 81. 1. Review of the Resident #1's physician's orders [REDACTED]. Review of the resident's care plan dated [DATE] directed staff to complete the following: -Collaborate and consult with hospice (resident not on hospice) for care, medication and treatment per physician; - Collaborate with hospice (resident not on hospice) on palliative care measures as needed. Review of the resident's History and Physical dated [DATE] showed the resident with [DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] from 1330 (1:30 P.M.) to 7:15 P.M. showed the following: -At 1330 (1:30 P.M.), Resident's family at bedside. Resident turned, noted resident would jerk "every now and then"; -At 7:15 P.M. palliative care nurse visit after telephone call from visitor who reported the resident had a [MEDICAL CONDITION]. Facility nurse confirmed the above information and reported the [MEDICAL CONDITION] was grand mal, (epileptic [MEDICAL CONDITION] characterized by a generalized involuntary muscular contraction and cessation of respiration followed by tonic and clonic spasms of the muscles), and lasted approximately three minutes. When the palliative nurse arrived resident drowsy and lethargic in a daze, eyes blood shot, visitor reports this happened just since the [MEDICAL CONDITION]. Physician contacted and orders obtained, Registered Nurse (RN) B informed of new orders. Review of the resident's physician's telephone orders dated [DATE] at 8:00 P.M. showed the physician ordered staff to start [MEDICATION NAME], (anti [MEDICAL CONDITION] medication), 300 milligrams (mg) by mouth every day and [MEDICATION NAME], (a central nervous system depressant), 1 mg every two hours as needed for [MEDICAL CONDITION]. Review of the resident's nurse's notes dated [DATE] from 2205 (10:05 P.M.) until 2230 (10:30 P.M.) showed the following: -At 2205 (10:05 P.M.) resident had a witnessed [MEDICAL CONDITION] with jerking, eyes rolled up and snoring respirations [MEDICATION NAME] approximately three minutes, (no [MEDICATION NAME] or [MEDICATION NAME] documented as given) , no documentation staff notified the physician; -At 2230 (10:30 P.M.), resident turned and had a [MEDICAL CONDITION] approximately 60 seconds, (no [MEDICATION NAME] or [MEDICATION NAME] documented as given), no documentation staff notified the physician. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On [DATE] at 8:00 P.M. [MEDICATION NAME] 0.5 mg given for anxiety, (nurses notes showed the resident had a [MEDICAL CONDITION], and the order for [MEDICATION NAME] was 1 mg. for [MEDICAL CONDITION], not 0.5 mg.), with no documentation staff gave the resident's [MEDICATION NAME]; - At 10:05 P.M. no [MEDICATION NAME] or [MEDICATION NAME] documented as administered ( nurse's notes showed a witnessed [MEDICAL CONDITION]); - At 10:30 P.M. no [MEDICATION NAME] or [MEDICATION NAME] documented administered (nurse's notes showed a witnessed [MEDICAL CONDITION]). Review of the resident's faxed pharmacy order sheet dated [DATE] at 8:55 P.M. signed by RN B showed an order for [REDACTED]. Review of the pharmacy's delivery record for the resident's [MEDICATION NAME] showed the medication was delivered on [DATE] at 9:30 A.M., the day after the physician ordered the medication. Review of the resident's care plan dated [DATE] directed staff to monitor [MEDICAL CONDITION], notify Hospice (resident not on Hospice) and physician. Review of the resident's nurse's notes dated [DATE] showed the following: -At 0045 (12:45 A.M.) called to resident's room. Resident having [MEDICAL CONDITION] activity [MEDICATION NAME] approximately 60 seconds. Resident's eyes were rolled back in head, snoring like respirations, resident bit inside of right cheek, and small amount of blood noted from mouth, family at bedside, [MEDICATION NAME] 1 mg. given per orders with no documentation staff notified the physician. -10:45 A.M. palliative care visit. Visitor called office just after 9:00 A.M. saying the resident had another [MEDICAL CONDITION]. Director of Nurses (DON) here at the time of the [MEDICAL CONDITION] and called for [MEDICATION NAME] to be delivered immediately. Discussed brain metastasis probably causing [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. -At 1530 (3:30 P.M.) had [MEDICAL CONDITION] this am (morning), [MEDICATION NAME] about 90 seconds, [MEDICATION NAME] was given when it arrived, [MEDICATION NAME] given, no documentation the physician was notified the medication had not been given prior or of the resident's continued [MEDICAL CONDITION] activity. During interview on [DATE] at 1:35 P.M. Palliative Care Nurse A said he/she was notified on [DATE] at about 6:40 P.M. about the resident's [MEDICAL CONDITION] and went to the facility. He/She notified the physician as staff wanted him/her to do this, and received orders for [MEDICATION NAME] and [MEDICATION NAME]. He/She told staff they needed to start the medications right away. RN B said she wasn't sure if the [MEDICATION NAME] was in the emergency kit. Palliative Care Nurse A said he/she was not aware the [MEDICATION NAME] was not given. He/She had no other calls that evening about the resident having [MEDICAL CONDITION]; he/she would have expected staff to call if the resident had continued [MEDICAL CONDITION]. The next day ([DATE]) another palliative care nurse went to the facility to see the resident and informed him/her the facility had not started the [MEDICATION NAME] until [DATE]. Palliative Care Nurse A said he/she was concerned he/she was not notified. During interview on [DATE] at 3:20 P.M. RN B said on [DATE] the resident's visitor called staff to the room, the resident was having a [MEDICAL CONDITION], (this was the resident's first [MEDICAL CONDITION]). RN B called Palliative Care Nurse (A). The nurse came out and called the physician who ordered [MEDICATION NAME]. RN B said he/she did not give [MEDICATION NAME] as it was not in the emergency kit, it was ordered from the pharmacy by fax. RN B said he/she was not aware of any way to obtain emergency medications. The resident had more [MEDICAL CONDITION] that evening. Review of the resident's nurse's notes dated [DATE] at 11:30 A.M. and 3:45 P.M. showed no documentation of [MEDICAL CONDITION]. Review of the resident's nurse's notes dated [DATE] showed the following: -At 1:00 A.M. resident having [MEDICAL CONDITION] activity. [MEDICATION NAME] 1 mg. given; -At 4:00 A.M. resident having [MEDICAL CONDITION] activity again, had two [MEDICAL CONDITION] , [MEDICATION NAME] 1 mg. given; -At 5:00 A.M. resident having a [MEDICAL CONDITION] again, (no documentation of any [MEDICATION NAME] administered); -At noon, resident had one [MEDICAL CONDITION] since 10:15 A.M., [MEDICATION NAME] given at 11:00 A.M.; - At 2:05 resident had three [MEDICAL CONDITION] this A.M., [MEDICAL CONDITION] between 30 seconds and one minute, transferred to the hospital. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On [DATE] at 1:00 A.M. [MEDICATION NAME] 1 mg. given for [MEDICAL CONDITION] (2:00 A.M. noted effective); - At 4:00 A.M. [MEDICATION NAME] 1 mg. given for [MEDICAL CONDITION] (4:30 A.M. effective); - No [MEDICATION NAME] documented as given at 5:00 A.M.; - At 11:10 A.M. [MEDICATION NAME] 1 mg. given. During interview on [DATE] at 9 A.M. LPN D said he/she was the charge nurse who worked on the resident's hall on [DATE]. LPN D said the resident had three [MEDICAL CONDITION] between 7:00 A.M. and noon, (review showed one dose of [MEDICATION NAME] given for the three [MEDICAL CONDITION] LPN D documented the resident had between 7:00 A.M. until noon). LPN D said he/she was not sure if he/she administered [MEDICATION NAME] when the resident had his/her [MEDICAL CONDITION]. LPN D said he/she did not notify the physician because Hospice (resident not on hospice) was supposed to take care of that. Review of the resident's physician's orders [REDACTED]. Review of the resident's palliative care note dated [DATE] showed: -At 10:00 A.M. phone call to office stating the resident was having [MEDICAL CONDITION] again. On arrival at the facility family said the resident has had seven [MEDICAL CONDITION] since 1:00 A.M. (nurses notes show documentation of three [MEDICAL CONDITION] , one [MEDICAL CONDITION] at 1:00 A.M., and two [MEDICAL CONDITION] at 4 :00 A.M.). Staff gave the resident [MEDICATION NAME] 0 .5 mg. at 1:00 A.M., (the physician's orders [REDACTED]. every two hours if seizing). Staff gave the resident a dose of [MEDICATION NAME] 1 mg. at 4:00 A.M., nothing since then. Instructed staff to give resident [MEDICATION NAME] 1 mg. sublingual STAT. The resident was moaning with each breath, pupils non reactive to light. Discussed need to get [MEDICAL CONDITION] controlled as soon as possible, resident transferred to the hospital. - At 1:35 P.M. the resident was moved from the long term care facility to the hospital for recurring [MEDICAL CONDITION] activity. The resident has had eight [MEDICAL CONDITION] 30 seconds to one minute and 30 seconds since 1:00 A.M.. Hoping to access resident's port and start [MEDICATION NAME] intravenous as soon as possible to control [MEDICAL CONDITION] activity. The resident quit breathing at 2:00 P.M. (at the hospital). Review of the resident's hospital expiration summary dated [DATE] showed the resident was admitted to the hospital due to [MEDICAL CONDITION] that started on [DATE], (they did not note [MEDICAL CONDITION] activity started on [DATE]), the long term care facility was not able to control the resident's [MEDICAL CONDITION]. The resident was started on intravenous [MEDICATION NAME] secondary to [MEDICAL CONDITION] activity at the long term care facility. The resident expired prior to the completion of the physical exam. During interview on [DATE] at 2:10 P.M. the on-call physician said the orders for the resident's [MEDICATION NAME] and [MEDICATION NAME] meant to give the medication STAT, not to wait until the next day. The physician said the resident needed to be loaded with the [MEDICATION NAME] and [MEDICATION NAME] immediately. The on-call physician did not recall being called about the resident continuing to have [MEDICAL CONDITION] and was not notified the facility staff did not administer the [MEDICATION NAME] the evening it was ordered. During interview on [DATE] at 11:35 A.M. the resident's physician said he/she would have expected the facility to have started the [MEDICATION NAME] the evening ([DATE]) it was ordered by the on-call physician as the resident was having [MEDICAL CONDITION]. The physician said the order for the [MEDICATION NAME] would have also helped with the [MEDICAL CONDITION]. The resident [MEDICAL CONDITION] metastasis. The resident's physician said he/she was not notified about the resident's [MEDICAL CONDITION] until [DATE]. 2. Review of Resident #2's medical record showed his/her [DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] showed: - On [DATE] at 2:00 A.M. the resident was up in a wheel chair and started having [MEDICAL CONDITION] activity. The [MEDICAL CONDITION] lasted approximately two and a half to three minutes. The resident was incontinent of urine during [MEDICAL CONDITION] and very lethargic after [MEDICAL CONDITION]. The DON was notified and instructed staff to watch resident closely and if any more [MEDICAL CONDITION] send to the emergency room . -The note showed no documentation the physician was notified of [MEDICAL CONDITION]; - On [DATE] at 2:20 P.M. new orders received ([MEDICATION NAME] for [MEDICAL CONDITION]), the resident had a ,[DATE] second [MEDICAL CONDITION] reported, the resident was shaking and non-responsive. The resident came to and was oriented times three. The resident's physician and family aware. Review of the resident's physician's orders [REDACTED].M. showed an order for [REDACTED]. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility documented the resident received his/her [MEDICATION NAME] 300 mg at 8:00 A.M. on [DATE]. During interview on [DATE] at 9:20 A.M. the DON said the resident had a history of [REDACTED]. (Review of the resident's nurse's notes dated August - [DATE] showed no documentation of any [MEDICAL CONDITION]). During interview on [DATE] at 2:25 P.M. Licensed Practical Nurse (LPN) E said he/she did not call the resident's physician on [DATE] after the resident had a [MEDICAL CONDITION] around 1:30 P.M. because the physician was aware of the [MEDICAL CONDITION] the resident had at 2:00 A.M. and had ordered [MEDICATION NAME]. LPN E said the DON had called the resident's physician about 8:30 A.M. and reported the 2:00 A.M. [MEDICAL CONDITION]. LPN E said he/she ordered the [MEDICATION NAME] but did not know when the resident received it. LPN E said he/she should have notified the physician about the second [MEDICAL CONDITION]. During interview on [DATE] at 2:35 P.M. LPN F said he/she worked the ,[DATE] shift on ,[DATE]-,[DATE]. LPN F said he/she had worked at the facility for three years and was not aware of the resident ever having a [MEDICAL CONDITION]. LPN F said he/she did not call the resident's physician when the resident had a [MEDICAL CONDITION] at 2:00 A.M., he/she did call the DON. LPN F said the DON instructed him/her to monitor the resident and if any more [MEDICAL CONDITION] to send to the emergency room . LPN F said he/she took the resident's vital signs twice after the [MEDICAL CONDITION] but did not know why only one set of vitals were in the nurse's notes. LPN F said staff looked in on the resident about every 15 minutes after the [MEDICAL CONDITION]. (No documentation in the resident's nurse's notes between 2:00 A.M. and 6:45 A.M. showing assessment of the resident or vital signs). During interview on [DATE] at 10:40 A.M. the Director of Nurses said he/she would have expected the facility to call the resident's physician when the resident had a [MEDICAL CONDITION]. The DON said he/she notified the resident's physician about 8:15 A.M. on [DATE] about the resident's [MEDICAL CONDITION] and received new orders about 1:30 P.M. for anti [MEDICAL CONDITION] medication ([MEDICATION NAME]). The DON said the medication would have been delivered to the facility about 5:00 P.M. on [DATE]. The DON said the medication was not given because staff saw it was ordered for once daily and the once daily medications are given at 8:00 A.M. The DON said he/she would have expected the staff to give the medication immediately when it arrived at the facility not wait until the next day. During interview on [DATE] at 8:20 A.M. the resident's physician said he/she would have expected the facility to administered the resident's [MEDICATION NAME] as soon as they received the medication. The physician said he/she did not want the facility to wait until the next day since the resident was having [MEDICAL CONDITION]. Review of the administrator's written statement dated [DATE] showed the administrator said the facility had a policy and procedure for assessing for changes in condition and proper notification of those required to be notified. The facility had procedures for ordering medications after hours, week-ends and holidays and staff have been educated to this procedure. The facility has an RN on call 24 hours a day and the charge nurse staff have been educated to the expectations for notifying such. The DON orients all charge nurse staff on the expectations related to change in condition, ordering medications and expectations of notifying DON/RN on call. The nurses involved in the incident on ,[DATE] had been provided this education. The RN was informed by the Palliative care nurse to follow the policy and procedure of the facility if the medication was not in the emergency kit. The administrator said he/she was not sure why the RN chose not to follow the policy and procedures of the facility. Expectations are that all charge nurse staff follow the education, direction,and policy of the facility, their supervisor and their licensure. Review of the facility's policy for change in a resident's condition or status revised ,[DATE] showed the facility shall promptly notify the resident's physician of changes in the resident's medical condition such as a significant change in a resident's condition or a need to alter the resident's medical treatment significantly. Complaint #: MO

Based on interview and record review the facility failed to ensure two residents (Resident #1 and #2) of five sampled residents, were free from significant medication error when the facility failed to obtain and administer anti [MEDICAL CONDITION] medication, ([MEDICATION NAME]), to one resident, Resident #1, a resident with [DIAGNOSES REDACTED]. The medication was ordered by the physician on [DATE] at 8:00 P.M. and not obtained by the facility until after 9:30 A.M. on [DATE] when the Director of Nurses ascertained the medication had not been ordered, received ,or administered to the resident. The facility also failed to administer the ordered [MEDICATION NAME] or to provide the medication in the dose ordered on multiple occasions when the resident presented with [MEDICAL CONDITION]. The resident continued to have [MEDICAL CONDITION] during the time the medication was not provided as ordered. The facility failed to administer [MEDICATION NAME] to resident (Resident #2) who presented with [MEDICAL CONDITION] on [DATE] at 2:00 A.M. and at 2:20 P.M. On [DATE] at approximately 8:00 A.M. the Director of Nurses ascertained the resident's physician had not been notified of Resident #2's (2:00 A.M.) [MEDICAL CONDITION], she then notified the physician and received orders to administered an [MEDICAL CONDITION] medication ([MEDICATION NAME]). The medication was received but not administered until [DATE] at 8:00 A.M. The resident continued to have [MEDICAL CONDITION] during the time the medication was not provided as ordered. The census was 81. 1. Review of the Resident #1's physician's orders [REDACTED]. Review of the resident's History and Physical dated [DATE] showed the resident with [DIAGNOSES REDACTED]. Review of the resident's nurse's notes dated [DATE] from 1330 (1:30 P.M.) to 7:15 P.M. showed the following: -At 1330 (1:30 P.M.), Resident's family at bedside. Resident turned, noted resident would jerk "every now and then"; -At 7:15 P.M. palliative care nurse visit after telephone call from visitor who reported the resident had a [MEDICAL CONDITION]. Facility nurse confirmed the above information and reported the [MEDICAL CONDITION] was grand mal, (epileptic [MEDICAL CONDITION] characterized by a generalized involuntary muscular contraction and cessation of respiration followed by tonic and clonic spasms of the muscles), and lasted approximately three minutes. When the palliative nurse arrived resident drowsy and lethargic in a daze, eyes blood shot, visitor reports this happened just since the [MEDICAL CONDITION]. Physician contacted and orders obtained, Registered Nurse (RN) B informed of new orders. Review of the resident's physician's telephone orders dated [DATE] at 8:00 P.M. showed the physician ordered staff to start [MEDICATION NAME], (anti [MEDICAL CONDITION] medication), 300 milligrams (mg.) by mouth every day and [MEDICATION NAME], (a central nervous system depressant), 1 mg. every two hours as needed for [MEDICAL CONDITION]. Review of the resident's nurse's notes dated [DATE] from 2205 (10:05 P.M.) until 2230 (10:30 P.M.) showed the following: -At 2205 (10:05 P.M.) resident had a witnessed [MEDICAL CONDITION] with jerking, eyes rolled up and snoring respirations [MEDICATION NAME] approximately three minutes, (no [MEDICATION NAME] or [MEDICATION NAME] documented as given) , no documentation staff notified the physician; -At 2230 (10:30 P.M.), resident was turned and had a [MEDICAL CONDITION] approximately 60 seconds, (no [MEDICATION NAME] or [MEDICATION NAME] documented as given), no documentation staff notified the physician. Review of the Resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On [DATE] at 8:00 P.M. [MEDICATION NAME] 0.5 mg. given for anxiety, (nurses notes showed the resident had a [MEDICAL CONDITION], and the order for [MEDICATION NAME] was 1 mg .for [MEDICAL CONDITION], not 0.5 mg.), with no documentation staff gave the resident's [MEDICATION NAME]; - At 10:05 P.M. no [MEDICATION NAME] or [MEDICATION NAME] documented as administered ( nurse's notes showed a witnessed [MEDICAL CONDITION]); - At 10:30 P.M. no [MEDICATION NAME] or [MEDICATION NAME] documented administered (nurse's notes showed a witnessed [MEDICAL CONDITION]). Review of the resident's faxed pharmacy order sheet dated [DATE] at 8:55 P.M. signed by RN B showed an order for [REDACTED]. Review of the pharmacy's delivery record for the resident's [MEDICATION NAME] showed the medication was delivered to the facility on [DATE] at 9:30 A.M., the day after the physician ordered the medication. Review of the resident's nurse's notes dated [DATE] showed the following: -At 0045 (12:45 A.M.) called to resident's room. Resident having [MEDICAL CONDITION] activity [MEDICATION NAME] approximately 60 seconds. Resident's eyes were rolled back in head, snoring like respirations, resident bit inside of right cheek, and small amount of blood noted from mouth, family at bedside, [MEDICATION NAME] 1 mg. given per orders with no documentation staff notified the physician; -10:45 A.M. palliative care visit. Visitor called office just after 9:00 A.M. saying the resident had another [MEDICAL CONDITION]. Director of Nurses (DON) here at the time of the [MEDICAL CONDITION] and called for [MEDICATION NAME] to be delivered immediately. Discussed brain metastasis probably causing [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. -At 1530 (3:30 P.M.) had [MEDICAL CONDITION] this am [MEDICATION NAME] about 90 seconds, [MEDICATION NAME] was given when it arrived, [MEDICATION NAME] given, no documentation the physician was notified the medication had not been given prior or of the resident's continued [MEDICAL CONDITION] activity; During interview on [DATE] at 1:35 P.M. Palliative Care Nurse A said he/she was notified at about 6:40 P.M. about the resident's [MEDICAL CONDITION] and went to the facility. He/She notified the physician as staff wanted him/her to do this, and received orders for [MEDICATION NAME] and [MEDICATION NAME]. He/She told staff they needed to start the medications right away. RN B said she wasn't sure if the [MEDICATION NAME] was in the emergency kit. Palliative Care Nurse A said he/she was not aware the [MEDICATION NAME] was not given. He/She had no other calls that evening about the resident having [MEDICAL CONDITION]; he/she would have expected staff to call if the resident had continued [MEDICAL CONDITION]. The next day ([DATE]) another palliative care/hospice nurse went to the facility to see the resident and informed him/her the facility had not started the [MEDICATION NAME] until [DATE]. Palliative Care Nurse A said he/she was concerned he/she was not notified. During interview on [DATE] at 3:20 P.M. RN B said on [DATE] the resident's visitor called staff to the room, the resident was having a [MEDICAL CONDITION], (this was the resident's first [MEDICAL CONDITION]). RN B called the Palliative Care Nurse (A). The nurse came out and called the physician who ordered [MEDICATION NAME]. RN B said he/she did not give [MEDICATION NAME] as it was not in the emergency kit, it was ordered from the pharmacy by fax. RN B said he/she was not aware of any way to obtain emergency medications. The resident had more [MEDICAL CONDITION] that evening. RN B said he/she did not know how to get medications if they were not in the emergency kit and the resident did not receive [MEDICATION NAME] that night. He/she was not aware of any facility policy for obtaining medications after hours. During interview on [DATE] at 1:10 P.M. LPN D said if a resident needed a medication and it was after pharmacy hours he/she would call the hospital and try to get it there and if not then call the DON. LPN D said he/she was not aware of any policy on obtaining medications after hours. Review of the resident's nurse's notes dated [DATE] showed no documentation of any [MEDICAL CONDITION]. Or contact with physician regarding [MEDICAL CONDITION]/medication administration delay. Review of the resident's nurse's notes dated [DATE] showed the following: -At 1:00 A.M. resident having [MEDICAL CONDITION] activity. [MEDICATION NAME] 1 mg. given; -At 4:00 A.M. resident having [MEDICAL CONDITION] activity again, had two [MEDICAL CONDITION] , [MEDICATION NAME] 1 mg. given; -At 5:00 A.M. resident having a [MEDICAL CONDITION] again, (no documentation of any [MEDICATION NAME] administered); -At noon, resident had one [MEDICAL CONDITION] since 10:15 A.M., [MEDICATION NAME] given at 11:00 A.M.; - At 2:05 resident had three [MEDICAL CONDITION] this A.M., [MEDICAL CONDITION] between 30 seconds and one minute, transferred to the hospital. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] - On [DATE] at 1:00 A.M. [MEDICATION NAME] 1 mg. given for [MEDICAL CONDITION] (2:00 A.M. noted effective); - At 4:00 A.M. [MEDICATION NAME] 1 mg. given for [MEDICAL CONDITION] (4:30 A.M. effective); - No [MEDICATION NAME] documented as given at 5:00 A.M.; - At 11:10 A.M. [MEDICATION NAME] 1 mg. given. During interview on [DATE] at 9 A.M. LPN D said he/she was the charge nurse who worked the hall where the resident resided on [DATE]. LPN D said the resident had three [MEDICAL CONDITION] between 7:00 A.M. and noon, (review showed one dose of [MEDICATION NAME] given for the three [MEDICAL CONDITION] LPN D documented the resident had between 7:00 A.M. until noon). LPN D said he/she was not sure if he/she administered [MEDICATION NAME] when the resident had his/her [MEDICAL CONDITION]. LPN D said he/she did not notify the physician because Hospice (resident not on hospice) was supposed to take care of that. Review of the resident's physician's orders [REDACTED]. Review of the resident's palliative care note dated [DATE] showed: -At 10:00 A.M. phone call to office stating the resident was having [MEDICAL CONDITION] again. On arrival at the facility family said the resident has had seven [MEDICAL CONDITION] since 1:00 A.M. (nurses notes show documentation of three [MEDICAL CONDITION] , one [MEDICAL CONDITION] at 1:00 A.M., and two [MEDICAL CONDITION] at 4 :00 A.M.). Staff gave the resident [MEDICATION NAME] 0 .5 mg. at 1:00 A.M., (the physician's orders [REDACTED]. every two hours if seizing). Staff gave the resident a dose of [MEDICATION NAME] 1 mg. at 4:00 A.M., nothing since then. Instructed staff to give resident [MEDICATION NAME] 1 mg. sublingual STAT. The resident was moaning with each breath, pupils non reactive to light. Discussed need to get [MEDICAL CONDITION] controlled as soon as possible, resident transferred to the hospital. - At 1:35 P.M. the resident was moved from the long term care facility to the hospital for recurring [MEDICAL CONDITION] activity. The resident has had eight [MEDICAL CONDITION] 30 seconds to one minute and 30 seconds since 1:00 A.M.. Hoping to access resident's port and start [MEDICATION NAME] intravenous as soon as possible to control [MEDICAL CONDITION] activity. The resident quit breathing at 2:00 P.M. (at the hospital). Review of the resident's hospital expiration summary dated [DATE] showed the resident was admitted to the hospital due to [MEDICAL CONDITION] that started on [DATE], the long term care facility was not able to control the resident's [MEDICAL CONDITION]. The resident was started on intravenous [MEDICATION NAME] secondary to [MEDICAL CONDITION] activity at the long term care facility. The resident expired prior to the completion of the physical exam. Review of written statement dated [DATE] showed the DON said the facility received an order for [REDACTED].) on [DATE]. The medication was ordered by fax from the pharmacy for delivery. Normal delivery was 1300 (1:00 P.M.) daily. The pharmacy was notified on [DATE] at 0945 (9:45 A.M.) and asked to deliver the [MEDICATION NAME] stat and it was delivered. The expectation is to order medication and start medication as ordered even if that required notifying the pharmacy on call. Pharmacy will deliver stat medications after hours. During interview on [DATE] at 9:20 A.M. the pharmacy manager said the facility's DON had called her last week requesting information on the resident's [MEDICATION NAME]. The manager said that she reminded the DON of the emergency phone number to get medications after hours. The manager said the DON said he/she knew about the emergency phone number. The manager said the fax from the facility requesting the [MEDICATION NAME] was received at the pharmacy on [DATE] around 8 P.M., the pharmacy closed at 5:30 P.M. The manager said the fax would have been found on [DATE] about ,[DATE]:30 A.M. and the delivery time to the facility is 1:00 P.M. The manager said the facility called the pharmacy on [DATE] around 9:30 A.M. requesting the [MEDICATION NAME] to be delivered STAT. Review of the pharmacy on-call procedure memo that was supplied to all long term care accounts, during the Fall of 2008 showed: - Normal business hours are Mon-Fri 8:30 A.M. to 5:30 A.M. and Saturday 8:30 A.M. to 1:00 P.M.; -After hours calls should be directed as follows: Call [PHONE NUMBER] to provide relief on Mon-Fri 5:31 P.M. to 8:00 P.M., Saturday 1:01 P.M. to 6:00 P.M. and Sunday noon to 5:00 P.M.; - Emergency coverage for hours outside the ranges listed above and all holidays are covered at the following number [PHONE NUMBER]. During interview on [DATE] at 2:10 P.M. the on-call physician said the orders for the resident's [MEDICATION NAME] and [MEDICATION NAME] meant to give the medication STAT, not to wait until the next day. The physician said the resident needed to be loaded with the [MEDICATION NAME] and [MEDICATION NAME] immediately. The on-call physician did not recall being called about the resident continuing to have [MEDICAL CONDITION]. During interview on [DATE] at 11:35 A.M. the resident's physician said he/she would have expected the facility to have started the [MEDICATION NAME] the evening ([DATE]) it was ordered by the on-call physician as the resident was having [MEDICAL CONDITION]. The physician said the order for the [MEDICATION NAME] would have also helped with the [MEDICAL CONDITION]. The resident [MEDICAL CONDITION] metastasis. 2. Review of Resident #2's medical record showed his/her [DIAGNOSES REDACTED]. Review of the resident's nurse's notes showed: - On [DATE] at 2:00 A.M. the resident was up in a wheel chair and started having [MEDICAL CONDITION] activity. The [MEDICAL CONDITION] lasted approximately 2 ,[DATE] to 3 minutes. The resident was incontinent of urine during [MEDICAL CONDITION]. The resident very lethargic after [MEDICAL CONDITION]. The DON was notified and instructed staff to watch resident closely and if any more [MEDICAL CONDITION] send to the emergency room . No documentation that the physician was notified of [MEDICAL CONDITION]; - On [DATE] at 2:20 P.M. resident had new orders ([MEDICATION NAME] for [MEDICAL CONDITION]). The resident had ,[DATE] second [MEDICAL CONDITION] reported, the resident was shaking and non-responsive. The resident came to and was oriented times three. The resident's physician and family aware. Review of the resident's physician's orders [REDACTED].M. order for [MEDICATION NAME] 300 mg daily for [MEDICAL CONDITION] and a CAT scan of the resident's head. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility documented the resident received his/her [MEDICATION NAME] 300 mg at 8:00 A.M. on [DATE]. During interview on [DATE] at 9:20 A.M. the DON said the resident had a history of [REDACTED]. (Review of the resident's nurse's notes dated August - [DATE] showed no documentation of any [MEDICAL CONDITION]). During interview on [DATE] at 10:40 A.M. the Director of Nurses said he/she would have expected the facility to call the resident's physician when the resident had a [MEDICAL CONDITION]. The DON said he/she notified the resident's physician about 8:15 A.M. on [DATE] about the resident's [MEDICAL CONDITION] and received new orders about 1:30 P.M. for anti [MEDICAL CONDITION] medication ([MEDICATION NAME]). The DON said the medication would have been delivered to the facility about 5:00 P.M. on [DATE]. The DON said the medication was not given because staff saw it was ordered for once daily and the once daily medications are given at 8:00 A.M. The DON said he/she would have expected the staff to give the medication immediately when it arrived at the facility and not wait until the next day. During interview on [DATE] at 8:20 A.M. the resident's physician said he/she would have expected the facility to administered the resident's [MEDICATION NAME] as soon as they received the medication. The physician said he/she did not want the facility to wait until the next day since the resident was having [MEDICAL CONDITION]. Review of the administrator's written statement dated [DATE] showed the administrator said the facility had procedures for ordering medications after hours, week-ends and holidays and staff have been educated to this procedure. The facility has an RN on call 24 hours a day and the charge nurse staff have been educated to the expectations for notifying such. The DON orients all charge nurse staff on the expectations related to change in condition, ordering medications and expectations of notifying DON/RN on call. The nurses involved in the incident on ,[DATE] had been provided this education. The RN was informed by the Palliative care nurse to follow the policy and procedure of the facility if the medication was not in the emergency kit. The administrator said he/she was not sure why the RN chose not to follow the policy and procedures of the facility. Expectations are that all charge nurse staff follow the education, direction,and policy of the facility, their supervisor and their licensure. *Higher classification merited due to the effect on the resident. Complaint #: MO