Every finding on record at Mahnomen Health Center

Based on interview and document review, the facility failed to accurately submit the payroll-based journal system (PBJ) staffing data to Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 31 residents residing in the facility.Findings include:The facilities PBJ data submitted to CMS for 10/1/25, through 12/31/25 (Q4 25), identified the facility was triggered for failure to submit data for the quarter.On 3/10/26 at 10:40 a.m., the chief financial officer (CFO) stated the staff member that submitted the PBJ data in 2025 no longer worked for the facility as of 2026. The staff member had access to the PBJ submission program, however there wasn't anyone else in the facility with access and the staff member had not submitted Q4 2025 data prior to leaving their position. The CFO stated by the time they realized the data hadn't been submitted, the timeframe had passed, and they were unable to submit. The CFO stated they have a plan to move forward to ensure the data will be submitted in a timely manner.A policy regarding submitting data to the Centers for Medicare and Medicaid (CMS) was requested but not received.

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee failed to ensure the medical director was present quarterly and attendance of key members was documented. In addition, the facility infection preventionist (IP) failed to provide comprehensive infection control and antibiotic infomration as required for proper QAA analysis. These findings had potential to affect all 29 residents residing within the facility. Findings include:The Quality Assurance and Performance Improvement (QAPI) meeting minutes from the last standard survey dated 6/4/25 were reviewed and identified the following:June 2025 meeting minutes failed to identify who attended the meeting. The director of nursing (DON), medical director or their designee, and at least three other staff members are required, one of which must be either the administrator, owner, board member or other individual in a leadership role along with the infection preventionist (IP)July/August 2025 meeting identified the following were in attendance: DON who is also the IP, the administrator, case manager, maintenance, therapy, dietary, and two licensed practical nurses had attended the meeting. The medical director was not identified as attending the meeting.September/October 2025 meeting minutes failed to identify who attended the meeting. November/December 2025 meeting minutes failed to identify who attended the meeting. January 2026 meeting identified the following people attended the meeting: DON/IP, case manager, maintenance, therapy, dietary, and two licensed practical nurses had attended the meeting. The medical director and the administrator did not attend were not identified as attending.February 2026 meeting identified the DON/IP, the administrator, case manager, maintenance, therapy, dietary, and two licensed practical nurses attended the meeting. The medical director was not identified as attending the meeting.The QAPI meeting minutes from the last standard survey dated 6/4/25 were reviewed for infection prevention and identified the following information was presented to the QAA committee members for review:June 2025, there was one resident had a urinary tract infection (UTI) and was treated for five days but lacked name of medication and analysis of urine cultures. Another resident was started on an antibiotic due to possible aspiration but lacked the name of the medication and noted they were not having any symptoms.July/August 2025, there were five UTIs of which all were treated with identified medications, two urine cultures did not grow any bacteria, but treatment continued, and one had symptoms but did not specify. Once resident was receiving an antibiotic for an infected toe, and one resident was being treated for pneumonia.September/October 2025, there were five UTIs and two pneumonias but lacked any identification of bacteria or treatment.November/December 2025, there were five UTIs, one prophylactic for UTI, and two wounds but lacked any other information. January 2026, notes identified a covid outbreak and stated to see outbreak for information. There were seven UTIs of which six identified culture results (three with an identified organism, two with mixed flora (contamination from the skin or genital area during collection rather than a true UTI), one with no growth), five identified the medication used. Under analysis it identified Many UTI's February 2026, there was one UTI, one resident on prophylaxis for chronic UTIs, one skin infection and one jaw infection.The QAPI meeting minutes provided by the IP was not comprehensive and lacked a comprehensive review of outcome surveillance to include trending and analysis. It also lacked a comprehensive review of antibiotic use and resistance data to ensure the QAA attendees could adequately review bench markers and when to develop an action plan for quality infection control and antibiotic stewardship problems. During an interview on 3/11/26 at 3:15 p.m., the director of nursing (DON), who was the facility IP, stated the QAPI meeting was held at least quarterly. It was supposed to be attended by the DON who is also the acting infection preventionist, the administrator, the medical director and care coordinators. Activities, dietary, maintenance and other department head also joined. Attendance was taken at each meeting and entered into the meeting minutes and stated the medical director would join the meeting if able but would have to review the meeting minutes to see when he had last attended. The DON stated QAPI meeting minutes going back to eight months did not identify attendance by the medical director and also that they were still trying to figure out what was needed with QAPI regarding infection control information and follow up needed with areas of concern. During an interview on 3/11/26 at 4:50 p.m., the medical director stated he attended the QAPI meetings sometimes but could not clearly recall the last time he had attended a meeting; however,, reviewed the meeting minutes. See also F880: Based on interview and document review the facility failed to establish and implement a surveillance plan to track, trend and analyze resident actual and potential infections. This had the potential to affect all 29 residents that resided in the facility. See also F881: Based on interview and document review, the facility failed to implement their comprehensive antibiotic stewardship program to help reduce unnecessary antibiotic use and infections; and implement a facility-wide system to monitor the use of antibiotics for 2 of 2 residents (R5, R16) in the sample who were prescribed antibiotics. The lack of a follow through on a program had the potential to affect all residents prescribed antibiotics. The facility's Quality Assurance and Improvement Plan for Long Term Care policy dated 1/22/26, identified the QAPI committee was to be attended by the medical director.

Based on interview and document review the facility failed to establish and implement an outcome surveillance program to track, trend and analyze resident actual and potential infections. This had the potential to affect all 29 residents that resided in the facility. Findings include:The last three months of infection control tracking, trending and analysis were requested and not received. On 3/9/26 at 5:11 p.m., the director of nursing (DON), who also worked as the infection preventionist, stated she did not have a system to track resident symptoms or infections. She stated she reviewed the resident's medical records and communicated with the nursing staff to help identify symptoms of illnesses or infections.On 3/10/26 at 8:20 a.m., the DON stated although she had not been formally tracking infections, she did have interdisciplinary (IDT) notes and Quality Assessment and Performance Improvement (QAPI) minutes to show what she had been doing regarding infections.The QAPI meeting minutes from the last standard survey dated 6/4/25 were reviewed and identified the following:June 2025, there was one resident had a urinary tract infection (UTI) and was treated for five days but lacked name of medication and analysis of urine cultures. Another resident was started on an antibiotic due to possible aspiration but lacked the name of the medication and noted they were not having any symptoms.July/August 2025, there were five UTIs of which all were treated with identified medications, two urine cultures did not grow any bacteria, but treatment continued, and one had symptoms but did not specify. Once resident was receiving an antibiotic for an infected toe, and one resident was being treated for pneumonia.September/October 2025, there were five UTIs and two pneumonias but lacked any identification of bacteria or treatment.November/December 2025, there were five UTIs, one prophylactic for UTI, and two wounds but lacked any other information. January 2026, notes identified a covid outbreak and stated to see outbreak for information. There were seven UTIs of which six identified culture results (three with an identified organism, two with mixed flora (contamination from the skin or genital area during collection rather than a true UTI), one with no growth), five identified the medication used. Under analysis it identified Many UTI's February 2026, there was one UTI, one resident on prophylaxis for chronic UTIs, one skin infection and one jaw infection.The minutes did not contain comprehensive data collection for tracking including but not limited to identify resident name, if facility acquired, location, signs and symptoms, testing, results, organism, if precautions were implemented and lifted and when the infection was resolved. The only infections identified were those requiring antibiotics and not any potential infections. There was no analysis of infections for trending to try and midigate infections in the facility.During interview on 3/11/26 at 11:59 a.m. the DON reviewed the QAPI minutes and had to look up each resident and identify signs and symptoms and the progression of the infection as it was not tracked, trended and analyzed.During an interview on 3/11/2026 at 1:22 p.m., the DON gave the following information about the facility UTI's. During September 2025 and October 2025, five residents had UTI's. We noticed the bathtub was not draining properly. The interdisciplinary team (IDT) and discussed the infections, the tub not draining properly, and discussed the possibility of the tub being the cause of the UTI's. Maintenance cleaned the drain, and staff were educated regarding proper cleaning after each use. The facility failed to have the drain tested for bacteria, and the microorganisms were not investigated for possible trends and did not look for a pattern of same organism. During November 2025 through December 2025, there were five residents with UTI's. The DON stated she had not documented any other possible reasons for the continued UTI's. Reviewing the infections one-by-one was an eye-opener because most of the residents' symptoms had not met Loeb's criteria for UTI. The DON stated she should have followed Loeb's criteria because it was important to treat an infection when the resident needed it and overtreating infections could lead to resistant microorganisms. The DON failed to analyze the microorganisms for patterns to ensure effective mitigation. The medical director returned a phone call after facility exit on 3/11/26 at 4:48 p.m. and stated he oversaw the review of the facility policies and procedures for resident care. The medical director stated he reviewed the infection control QAPI minutes but was unable to identify when he last attended a meeting. The facilities Infection Control Surveillance Plan dated 5/22/25, identified infection control was used to identify and reduce the risk of acquiring and transmitting disease among patient, staff and visitors. Infection control included surveillance, which included measuring outcomes, analyzing data, and providing information to members of the health care team to assist in improving outcomes.The facilities Infection Prevention policy revised 5/27/25, identified the Infection Prevention and Control Program (IPCP) to prevent infections in patients and employees. The Infection Preventionist was responsible and accountable for IPCP. The priority services included prevention strategies, managing data and information and policies and procedures to prevent infections in patients and employees, and referred to the Infection Control Surveillance Plan.

Based on interview and document review, the facility failed to implement their comprehensive antibiotic stewardship program to help reduce unnecessary antibiotic use and infections; and implement a facility-wide system to monitor the use of antibiotics for 2 of 2 residents (R5, R16) in the sample who were prescribed antibiotics. The lack of a follow through on a program had the potential to affect all residents prescribed antibiotics. Findings include:R5:R5's progress notes dated 12/25/26 through 12/26/26, identified R5 had confusion and weakness, and on 12/26/26, was sent to the emergency room (ER). Later that same day, R5 returned to the facility with a diagnosis of UTI (urinary tract infection) and new orders for outpatient intravenous (IV) Rocephin (antibiotic). R5's UA (urine analysis) results dated 12/26/25, identified there was no predominant organism, and no further identification or susceptibility would be done.R5's ED notes dated 12/26/25, identified R5 received Rocephin (antibiotic) 1gm IV x 1 dose.R5's progress note dated 1/28/26, identified R5's IV antibiotics were discontinued and R5 started sulfamethoxazole-trimethoprim (antibiotic) 800-160 mg twice daily for 3 days on 12/27/25.The facility continued to treat R5 for a UTI even though the lab results showed no predominant bacterial growth.R16:R16's progress note dated 1/25/26, identified R16 was frequently requesting to use the bathroom. UA was sent to lab.R16's UA dated 1/25/26, identified no predominant organism and UC (urine culture) was not completed.R16's orders report dated 1/18/26 through 2/13/26, identified an order for Macrobid 100 mg take 1 capsule twice daily x 5 days for UTI dated 1/26/26.R16's 72-hour antibiotic time-out dated 1/28/26, identified R16 was prescribed Macrobid 100 mg twice daily for 5 days, end date 1/31/26. The facility continued to treat R16 for a UTI even though the lab results showed no predominant bacterial growth.On 3/9/26 at 5:11 p.m., the director of nursing (DON), who also worked as the infection preventionist, stated she did not have a tracking system to quickly identify resident symptoms or infections and reviewed the residents' medical record.On 3/11/2026 at 1:22 p.m., the DON stated for the most part the providers over prescribed antibiotics and many of the residents had not met Loeb's criteria for UTI. The DON stated Loeb's criteria was important to follow because they want to be able to treat an infection when the resident needed it. The medical director returned a phone call after facility exit on 3/11/26 at 4:48 p.m. and stated he oversaw the review of the facility policies and procedures for resident care. The medical director was uncertain how the facility tracked antibiotic use and one of the nurses would know more. Further, the facility uses an algorithm and communicates to the provider and either sends the resident to the emergency room or schedule an appointment with their provider; a lot of the mid-level practitioners prescribed 3-day antibiotics, and he and the physicians usually prescribed 5-day antibiotics. The facilities Antibiotic Stewardship Program revised 3/4/25, identified the facility would promote the appropriate use of antibiotics (right dose, drug, and duration) to treat infections that result in the best outcome with the least amount of toxicity and resistance. Antibiotic Stewardship actions included assessment of residents suspected of having an infection by considering the Loeb Criteria when considering initiation of antibiotics. Key Components of the Loeb Criteria for Urinary Tract Infection (UTI) - No Catheter included acute dysuria OR fever (100.2 F or greater) plus one of the following: urgency, frequency, suprapubic pain, gross hematuria, or costovertebral tenderness. A 72-hour antibiotic time-out is performed after initiation of antibiotic or first dose in the facility. The 72-hour timeout includes resident assessment for consideration of antibiotic need, duration, selection of antibiotic/change, and de-escalation potential.

Based on interview and document review the facility failed to ensure the infection preventionist (IP) had completed specialized training in infection prevention and control and received certification. This had the potential to affect all 29 residents residing in the facility. Findings include:See F880: Based on interview and document review the facility failed to establish and implement a surveillance plan to track, trend and analyze resident actual and potential infections. This had the potential to affect all 29 residents that resided in the facility. See F881: Based on interview and document review, the facility failed to implement their comprehensive antibiotic stewardship program to help reduce unnecessary antibiotic use and infections; and implement a facility-wide system to monitor the use of antibiotics for 2 of 2 residents (R5, R16) in the sample who were prescribed antibiotics. The lack of a follow through on a program had the potential to affect all residents prescribed antibiotics. The infection preventionist infection control certification was requested and not received. During interview on 3/10/26 at 4:50 p.m., the director of nursing (DON), who also worked as the facility infection preventionist (IP), stated she had worked as the IP nurse for two years. The DON stated she had completed the on-line courses for infection control last year; however, had not taken the certification test. The DON was unable to provide any documentation or certificate of completion of an approved infection prevention course.A copy of the facilities Infection Preventionist job description was requested and not received.

Based on interview and document review, the facility failed to ensure medications were coded correctly on the Minimum Data Set (MDS) for 2 of 5 residents (R5, R20) reviewed for unnecessary medications. Findings include: The MDS 3.0 Resident Assessment Instrument (RAI) Manual dated 10/25 directs facilities to document how many days the resident received the following classes of medications: antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant, antibiotic, diuretic, opioid, antiplatelet, hypoglycemic and none of the above. R5: During the MDS observation period from 1/29/26 through 2/4/26, R5's February 2026, medication administration record (MAR), identified R5 was receiving the following medications:Aldactone (a diuretic) (commonly known as a water pill) 25 milligrams (mg) every morning for congestive heart failure.Buspirone (an anti-anxiety medication) 7.5 mg twice a day for anxiety. R5's annual Minimum Data Set (MDS) dated [DATE], identified R5 had diagnoses of congestive heart failure, high blood pressure and anxiety. R5 was taking an antipsychotic, antidepressant and hypoglycemic. R5's MDS did not identify R5 received a diuretic or an anti-anxiety medication during the observation period.R20:During the MDS observation period from 1/31/26 through 2/6/26, R20's February 2026, MAR, identified R20 had received the following medication:Plavix (an antiplatelet medication) 75 mg once a day for heart attack. R20's admission MDS dated [DATE], identified R20 had a diagnosis of left hip fracture. The MDS identified R20 was taking antipsychotic, antianxiety, antidepressant, and opioid medications. R20's MDS did not identify they received an antiplatelet medication during the observation period. During an interview on 3/11/26 at 8:29 a.m., registered nurse (RN)-A, unit coordinator/MDS nurse, stated when they were completing a MDS they reviewed the residents' chart during the observation period and completed the MDS using that data. When the MDS for R5 and R20 were completed, RN-A stated the medications were missed and did not get entered into the MDS. During an interview on 3/11/26 at 11:09 a.m., the director of nursing (DON) stated it was the expectation each portion of the MDS would be completed correctly. It is important because it can affect care plans, payment and quality measures. A facility policy related to MDS accuracy was requested but not received.

Based on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 2 residents (R11, R27) reviewed for unnecessary medications; 2 of 2 residents (R8, R17) reviewed for restraints; and 7 of 7 residents (R4, R8, R26, R6, R10, R17, R20, R26) reviewed for grab bars. Findings include: MEDICATIONS: R11 R11's annual Minimum data set (MDS) dated [DATE], identified R11 had a moderate cognitive impairment and had diagnoses that included dementia, major depressive disorder, anxiety, and chronic obstructive pulmonary disease (COPD). R11used antipsychotic, antianxiety, and antidepressant medications. The MDS further identified R11 had not had a gradual dose reduction (GDR) or R11 had documented an indication for use. R11's physician orders identified the following: - buspirone (antianxiety medication) 7.5 milligram (mg) tablet; take 1 tablet by mouth three times a day. - donepezil ((cholinesterase inhibitors) Donepezil is a medication primarily used to treat dementia associated with Alzheimer's disease. It helps improve cognitive functions such as attention, memory, and daily activities in patients with dementia. Donepezil is indicated for mild to severe dementia and may result in a small benefit in mental function.) Take 1 tablet at bedtime. - Lexapro (escitalopram oxalate) (antidepressant) 10 mg tablet; take 1 tablet by mouth daily. - mirtazapine (antidepressant) 15 mg tablet; take ½ tablet (7.5 mg) by mouth daily at bedtime. R11's physician orders failed to identify R11 used an antipsychotropic medication. R11's Pharmacy Monthly Medication Review dated 12/19/24, identified R11's medication regimen review was complete. No pharmacy recommendations at this visit. Dose of Remeron recently reduced due to daytime drowsiness and decreased appetite. R11 appeared to be tolerating dose reduction thus far and continued to be followed closely by psychiatry. R11 Psychiatry Provider Note dated 3/6/25, identified the following: R11's Psychiatric Problem History: Alzheimer's Dementia R11 presented with a history of memory impairment, moderate to severe in intensity, with additional impairments in executive functioning, learning, language, social cognition, as well as having visual perception problems, impacting the patient in all contexts of life and requiring structured living with nursing support. R11 met criteria for a DSM diagnosis of Major Neurocognitive disorder/dementia, most likely of Alzheimer's type. Major Depressive Disorder R11 presented with an endorsement of depression symptoms occurring most days, moderate in intensity, affecting R11 in a number of contexts both at home and at work or when away from home. Symptoms included low mood, sadness, feelings of hopelessness, low energy, problems with concentration, appetite and sleep disturbance, and at times R11 would have feelings of low self-worth. The periods of depression were episodic, lasting two weeks or more, meeting the DSM criteria for Major Depression, recurrent. Generalized Anxiety Disorder (GAD) R11 presented with a recent history of ongoing daily anxiety symptoms with ruminative worry, tight muscles, initial insomnia, and autonomic arousal, occurring in a number of contexts, and meeting DSM criteria for GAD. Continue Buspar (buspirone)7.5 mg three times a day for Anxiety Lexapro 10 mg daily for MOD/anxiety Remeron (mirtazapine)7.5mg daily at bedtime for MDD/GAD - decreased 12/17/2024 Aricept (donepezil) 10mg daily at HS for dementia During an interview on 6/3/25 at 3:55 p.m., the director of nursing (DON) stated R11's MDS was incorrectly coded as R11 taking an antipsychotropic medication, R11 had GDR of Remeron, and her medications were clinically indicated by the psychiatrist. The MDS is important for payment reimbursement and to ensure GDR and documentation was correct. It must have been missed. R27: R27's admission MDS dated [DATE], identified R27 had diabetes mellitus and was receiving and anticoagulant (blood thinner). R27's physician order's dated 3/6/25, did not indicate R27 was on an anticoagulant. During an interview on 6/4/25 at 12/20 p.m., the DON stated when the resident was admitted they were not taking an anticoagulant and the admission MDS was coded in error and should have been reviewed. RESTRAINTS: R8 R8's quarterly MDS dated [DATE], identified R8 had a mild cognitive impairment and had diagnoses that included history of a stroke, hallucinations, disorientation, restlessness and agitation, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness). R8 was nonambulatory and required touching/supervision assistance for eating and was dependent on staff for all other care areas. The MDS further identified no restraints were used for R8. R8's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 2/20/25, identified R9 was dependent on staff for most ADLs and R8 had left sided neglect from a stroke. The MDS failed to identify R8 used a restraint. R8's care plan revised 5/22/25, identified R8, on admit, did seem to be a low risk for falls/elopement. R8 was chair fast and could not move herself to transfer and could not walk. R8 required a full body mechanical lift for all transfers, but did move a little in bed at night. Staff were directed to place a pool noodle on the edge of R8's bed to prevent falls. During an observation on 6/3/25 at 9:52 a.m., nursing assistant (NA)-A and NA-B assisted R8 to lie down in bed. NA-A and NA-B provided incontinence care for R8 and positioned R8 on her left side to be able to take a nap. At 10:00 a.m., NA-A covered R8 with a blanket then placed a pool noodle (a long foam cylinder approximately 5 feet in length and 3 inches in diameter) behind R8 underneath R8's fitted sheet. NA-A lowered R8's bed to the floor and exited R8's room. During an interview on 6/3/25 at 10:02 a.m., NA-A stated a pool noodle was put under the fitted sheet in case R8 rolled over so R8 couldn't fall on the floor. During an observation on 6/4/25 at 9:10 a.m., NA-D and NA-E assisted R8 to lie down in bed. - At 9:19 a.m., NA-D placed the pool noodle under R8's fitted sheet and lowered R8's bed to the floor. During an interview on 6/4/25 at 9:27 a.m., NA-D stated, when R8 was first admitted , R8 would throw her legs out of bed and try to get up. Staff put the pool noodle under the fitted sheet to prevent R8 from doing that. NA-D stated R8 had never been seen trying to remove the pool noodle but R8 had left sided weakness and probably couldn't remove the pool noodle. During an interview on 6/4/25 at 10:08 a.m., registered nurse (RN)-A stated, when R8 was first admitted , R8 would throw her legs over the side of the bed to get out of bed. The pool noodle prevented R8 from doing that. RN-A stated R8 was unable to remove the pool noodle. RN-A's eyes widened then stated, that's a restraint. R17: R17's quarterly MDS dated [DATE], identified R17 had severe cognitive impairment and was dependent on staff for bed mobility and transfers. The MDS identified R17 was not using restraints. R27's Restraints and Alarms assessment dated [DATE], identified resident R27 did not use restraints or alarms, and did not identfiy the use of a pool noodle R27's care plan dated 5/14/25, did not identify the use of restraints. During observation on 6/4/25 at 8:40 a.m., trained medication assistants (TMA)-A and TMA-B assisted resident to bed following breakfast. When R27 was in bed TMA-A placed a 3 inch high pool noodle under the fitted sheet on the left side of the bed. R27 was seen to have a long, raised area under the fitted sheet on the right side of the bed. R27 had side rails up on each side of the bed. During an interview on 6/4/25 at 8:50 a.m., TMA-A stated the pool noodles were used to keep R27 in her bed, R27 cannot get out of bed when the pool noodles were in place. During an interiew on 6/4/25 at 10:19 a.m., the director of nursing (DON) stated the pool noodles were for a a fall intervention. The DON stated she nor the staff considered the pool noodle could be a possible restraint and was not coded on the MDS as a restraint. GRAB BARS/ BEDRAILS R4 R4's annual MDS dated [DATE], identified R4 had a severe cognitive impairment and had diagnoses that included dementia. R4 was nonambulatory, required substantial assistance for eating and was dependent on staff for all other care areas. The MDS did not identify R4 used grab bars. During an observation on 6/4/25 at 8:51 a.m., R4 did not use his bilateral bedrails to assist with turning nor did NA-C or NA-D encourage him to do so. R8 R8's quarterly MDS dated [DATE], identified R8 had a mild cognitive impairment and had diagnoses that included history of a stroke, hallucinations, disorientation, restlessness and agitation, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness). R8 was nonambulatory and required touching/supervision assistance for eating and was dependent on staff for all other care areas. The MDS further identified no restraints were used for R8. R8's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential CAA dated 2/20/25, identified R9 was dependent on staff for most ADLs and R8 had left sided neglect from a stroke. The MDS failed to identify R8 used grab bars. R8's care plan revised 5/22/25, identified R8, on admit, did seem to be a low risk for falls/elopement. R8 was chair fast and could not move herself to transfer and could not walk. R8 required a full body mechanical lift for all transfers, but did move a little in bed at night. The care plan failed to identify R8 used grab bars. During an observation on 6/3/25 at 9:52 a.m., NA-A and NA-B assisted R8 to lie down in bed. NA-A and NA-B provided incontinence care for R8 and positioned R8 on her left side to be able to take a nap. R8 did not use her grab bars to assist with turning and repositioning nor did NA-D or NA-E encourage her to do so. During an observation on 6/4/25 at 9:10 a.m., NA-D and NA-E assisted R8 to lie down in bed. R8 did not use her grab bars to assist with turning and repositioning nor did NA-D or NA-E encourage her to do so. During an interview on 6/4/25 at 9:27 a.m., NA-D stated R8 was unable to use her grab bars and staff completed turning for R8. R26 R26's quarterly MDS dated [DATE], identified R26 had a severe cognitive impairment and diagnoses that included epilepsy, generalized anxiety disorder, history of craniotomy (A craniotomy is a surgical procedure that involves removing part of the bone from the skull to expose the brain. The section of bone removed is called the bone flap, which is temporarily removed and then replaced after the brain surgery has been done. If the bone flap is not replaced, it is either a craniectomy (bone removed) or cranioplasty (non-osseous surgical repair). R26 required supervision/touching assistance with personal hygiene, and partial/moderate assistance with toileting. The MDS did not identify R26 used grab bars. During an observation on 6/4/25 at 7:16 a.m., R26 was lying in bed, curled up in ball, with her face sticking out of the blankets. R26 was sleeping. A grab bar was connected to R26 bed on each side. During an observation on 6/4/25 at 1:03 p.m., R26's bed had grab bars on each side. R6: R6's quarterly MDS dated [DATE], identified no cognitive impairment and identified R6 had not used bed rails/grab bars or restraints. R6's care plan dated 5/16/25, identified R6 used the grab bars on both sides of the bed to turn and reposition. During observation on 6/4/25 at 9:56 a.m., R6's bed was observed to have grab bars on both sides of the bed. R10: R10's annual MDS dated [DATE], identified moderate cognitive impairment and diagnosis of a stroke. The MDS did not identify the use of bed rails/grab bars. R10's care plan dated 6/2/25, identified R10 used grab bars to reposition in bed. During observation on 6/4/25 at 1:17 p.m., R10's bed was observed to have grab bars on both sides of the bed. R20: R20's quarterly MDS dated [DATE], identified no cognitive impairment and a diagnosis of Parkinson's disease (a progressive neurological disorder which affects movement, causing symptoms like tremors, stiffness, and slow movement). The MDS did not identify use of bed rails/grab bars. During observation on 6/4/25 at 9:56 a.m., R20's bed was observed to have grab rails on both sides of the bed. During an interview on 6/4/25 at 10:19 a.m., the DON stated the grab bars should have been coded on the MDS and were not. A facility policy related to MDS accuracy was requested but not received.

Based on observation, interview and document review, the facility failed to ensure residents with attached grab bars were comprehensively assessed for use on the bed for 7 of 7 residents (R4, R8, R26, R6, R10, R17, R20) whom had grab bars. Findings include: R4 R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had a severe cognitive impairment and had diagnoses that included dementia. R4 was nonambulatory, required substantial assistance for eating and was dependent on staff for all other care areas. The MDS did not identify R4 used grab bars. R4's care plan dated 7/7/22, identified R4 was contracted at bilateral knees to 90 degrees flexion (bent). R4 had pain with some stretching into extension more in left knee than in right knee but was able to complete range of motion (ROM) at ankles and hips with no difficulties. Res. also has tightness noted in left ring and pinky finger, no other tightness or difficulties noted with ROM in bilateral upper extremities. The care plan did not identify R4 used grab bars for bed mobility. R4's medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During an observation on 6/4/25 at 8:51 a.m., nursing assistant (NA)-C and NA-D assisted R4 to lie down in bed and incontinence cares. At 8:55 a.m., R4 was transferred into bed with a full body mechanical lift. R4 sat upright in the sling with his hands and arms resting across his chest and lap. NA-C and NA-D rolled R4 from left to right to pull R4's pants and performed incontinence cares. R4 did not use his bilateral grab bars to assist with turning nor did NA-C or NA-D encourage him to do so. At 8:57 a.m., R4 stated his face was up against the right-side grab bar and NA-C apologized to R4 and assisted him to roll towards the left slightly to allow room for R4's face. During an interview on 6/4/25 at 9:09 a.m., NA-C and NA-D stated R4 was unable to move on his own and staff needed to move R4 for him. R4 never used his grab bars and R4 was unable to help at all with turning; staff had to turn R4. NA-D stated R4 was too stiff and contracted to be able to use his grab bars. During an interview on 6/4/25 at 10:01 a.m., registered nurse (RN)-A was not aware why R4 had grab bars. R4 couldn't roll/turn on his own and staff had to assist him completely. RN-A stated R4's grab bars needed to be assessed to ensure he even needed them. R8 R8's quarterly MDS dated [DATE], identified R8 had a mild cognitive impairment and had diagnoses that included history of a stroke, hallucinations, disorientation, restlessness and agitation, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness). R8 was nonambulatory and required touching/supervision assistance for eating and was dependent on staff for all other care areas. The MDS did not identify R8 used grab bars. R8's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 2/20/25, identified R9 was dependent on staff for most ADLs and R8 had left sided neglect from a stroke. The CAA did not identify R8 used grab bars. R8's care plan revised 5/22/25, identified R8, on admit, did seem to be a low risk for falls/elopement. R8 was chair fast and could not move herself to transfer and could not walk. R8 required a full body mechanical lift for all transfers, but did move a little in bed at night. Staff were directed to place a pool noodle on the edge of R8's bed to prevent falls. The care plan did not identify R8 used grab bars. R8's medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During an observation on 6/3/25 at 9:52 a.m., nursing assistant (NA)-A and NA-B assisted R8 to lie down in bed. NA-A and NA-B provided incontinence care for R8 and positioned R8 on her left side to be able to take a nap. R8 did not use her grab bars to assist with turning and repositioning nor did NA-D or NA-E encourage her to do so. During an observation on 6/4/25 at 9:10 a.m., NA-D and NA-E assisted R8 to lie down in bed. R8 did not use her grab bars to assist with turning and repositioning nor did NA-D or NA-E encourage her to do so. During an interview on 6/4/25 at 9:27 a.m., NA-D stated R8 was unable to use her grab bars and staff completed turning for R8. R26 R26's quarterly MDS dated [DATE], identified R26 had a severe cognitive impairment and diagnoses that included epilepsy, generalized anxiety disorder, history of craniotomy (A craniotomy is a surgical procedure that involves removing part of the bone from the skull to expose the brain. The section of bone removed is called the bone flap, which is temporarily removed and then replaced after the brain surgery has been done. If the bone flap is not replaced, it is either a craniectomy (bone removed) or cranioplasty (non-osseous surgical repair). R26 required supervision/touching assistance with personal hygiene, and partial/moderate assistance with toileting. The MDS failed to identify R26 used grab bars. R26's care plan did not identify R26 used grab bars. R26's PT Evaluation & Plan of Treatment dated 8/1/24, did not identify R26's need for grab bars. R26's medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During an observation on 6/4/25 at 7:16 a.m., R26 was lying in bed, curled up in ball, with her face sticking out of the blankets. R26 was sleeping. A grab bar was connected to R26 bed on each side. During an observation on 6/4/25 at 1:03 p.m., R26's bed had grab bars on each side. A black canvas material cover with pockets was over each grab bar and held R26's personal items. Licensed practical nurse (LPN)-A stated R26 used the grab bars to help roll in bed and transfer herself. When a resident was admitted to the facility, staff put in a request for maintenance to put the grab bars on the bed, if the resident needed them. LPN-A believed physical therapy made that decision. During an interview on 6/4/25 at 1:08 p.m., LPN-A stated she asked and was told grab bars were addressed during an IDT meeting after the resident was admitted but ultimately nursing was responsible for the assessment. During an interview on 6/4/25 at 1:10 p.m., RN-A stated usually when a resident was admitted they just come with siderails. RN-A thought it was part of the physical therapy evaluation, but it was something staff needed to work on. RN-A stated staff didn't realize a grab bar could be a potential problem. R6: R6's quarterly MDS dated [DATE], identified no cognitive impairment and identified R6 had not used bed rails/grab bars or restraints. R6's care plan dated 5/16/25, identified R6 used the grab bars on both sides of the bed to turn and reposition. R6's medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During observation on 6/4/25 at 9:56 a.m., R6's bed was observed to have grab bars on both sides of the bed. R10: R10's annual MDS dated [DATE], identified moderate cognitive impairment and diagnosis of a stroke. The MDS did not identify the use of bed rails/grab bars. R10 medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During observation on 6/4/25 at 1:17 p.m., R10's bed was observed to have grab bars on both sides of the bed. R17: R17's quarterly MDS dated [DATE], identified R17 had severe cognitive impairment and was dependent on staff for bed mobility and transfers. The MDS identified resident was not using restraints. R17's Restraints and Alarms assessment dated [DATE], identified resident R27 did not use restraints or alarms. The assessment did not identify the grab bars. R17's medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. R17's care plan dated 5/14/25, did not identify use of bed rails/grab bars. During observation on 6/4/25 at 8:40 a.m., R17 bed was observed to have bed rails/grab bars on both sides of the bed. R20: R20's quarterly MDS dated [DATE], identified no cognitive impairment and a diagnosis of Parkinson's disease (a progressive neurological disorder which affects movement, causing symptoms like tremors, stiffness, and slow movement). The MDS did not identify use of bed rails/grab bars. R20's care plan dated 5/9/25, did not identify use of bed rails/grab bars. R6's medical record failed to identify a grab bar assessment to include entrapment risk, risk versus benefits, consent, bed dimentions in relation to the residents height and weight and what alternatives were attempted or containdicated before installation. During observation on 6/4/25 at 9:56 a.m., R20's bed was observed to have grab rails on both sides of the bed. During an interview on 6/4/25 at 1:18 p.m. director of nursing stated residents should have an assessment completed prior to installing and using grab bars. The facility's Bed Rail Mattress Guidelines revised 9/3/24, identified it was the policy of the facility to provide a safe environment for all patients and residents. It was a policy to adhere to the guidelines set forth by the FDA in regard to safe spacing of bed railings and mattresses. By following the FDA guidelines, we will have a reduced incidence of injury due to a patient/resident potentially becoming confined in a restricted area. However, the policy failed to direct staff to obtain an assessment for use prior to implementation.

Based on observation, interview and document review, the facility failed to ensure residents were free from physical restraints while in bed for 2 of 2 residents (R8, R17) reviewed for restraints. Findings include: R8: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 had a mild cognitive impairment and had diagnoses that included history of a stroke, hallucinations, disorientation, restlessness and agitation, hemiplegia (one sided paralysis) and hemiparesis (one sided weakness). R8 was nonambulatory and required touching/supervision assistance for eating and was dependent on staff for all other care areas. The MDS identified no restraints were used for R8. R8's Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 2/20/25, identified R9 was dependent on staff for most ADLs and R8 had left sided neglect from a stroke. R8's care plan revised 5/22/25, identified R8, on admit, did seem to be a low risk for falls/elopement. R8 was chair fast and could not move herself to transfer and could not walk. R8 required a full body mechanical lift for all transfers, but did move a little in bed at night. Staff were directed to place a pool noodle on the edge of R8's bed to prevent falls. R8's medical record failed to identify a restraint assessment for the use of the pool noodle. During an observation on 6/3/25 at 9:52 a.m., nursing assistant (NA)-A and NA-B assisted R8 to lie down in bed. NA-A and NA-B provided incontinence care for R8 and positioned R8 on her left side to be able to take a nap. At 10:00 a.m., NA-A covered R8 with a blanket then placed a pool noodle (a long foam cylinder approximately 5 feet in length and 3 inches in diameter) behind R8 underneath R8's fitted sheet. NA-A lowered R8's bed to the floor and exited R8's room. During an interview on 6/3/25 at 10:02 a.m., NA-A stated a pool noodle was put under the fitted sheet in case R8 rolled over so R8 couldn't fall on the floor. During an observation on 6/4/25 at 9:10 a.m., NA-D and NA-E assisted R8 to lie down in bed. - At 9:19 a.m., NA-D placed the pool noodle under R8's fitted sheet and lowered R8's bed to the floor. During an interview on 6/4/25 at 9:27 a.m., NA-D stated, when R8 was first admitted , R8 would throw her legs out of bed and try to get up. Staff put the pool noodle under the fitted sheet to prevent R8 from doing that. NA-D stated R8 had never been seen trying to remove the pool noodle but R8 had left sided weakness and probably couldn't remove the pool noodle. During an interview on 6/4/25 at 10:08 a.m., registered nurse (RN)-A stated, when R8 was first admitted , R8 would throw her legs over the side of the bed to get out of bed. The pool noodle prevented R8 from doing that. RN-A stated R8 was unable to remove the pool noodle. RN-A's eyes widened then stated, that's a restraint. R17: R17's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment. R17 was dependent with bed mobility and transfers. The MDS identified restraints were not used with R17. R17's medical record failed to identify a restraint assessment for the use of the pool noodle. During observation on 6/4/25 at 8:40 a.m., trained medication assistant/nursing assistant (TMA)-A and TMA-B put R17 to bed. Once in bed TMA-A placed a pool noodle under the fitted sheet along R17's left side. During an interview on 6/4/25 at 8:49 p.m., TMA-A stated R17 was not mobile but moved her legs around and toward the edge of the bed and was at risk to fall. R17 was a fall risk, and the pool noodle kept R17 in bed and R17 was not able to get over the pool noodle. During an interiew on 6/4/25 at 10:19 a.m., the director of nursing (DON) stated the pool noodle was a fall intervention. The DON stated she nor the staff considered the pool noodle could be a possible restraint and had not completed a restraint assessment. Residents should have been assessed to determine if there was an alternative option and/or how to use the restraint as safely as possible. A restraint policy was requested but not received.

Based on observation, interview and document review, the facility failed to develop and implement interventions to reduce fall risks for 1 of 3 residents (R3) reviewed for accidents. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition, socially isolated self often, and no behaviors identified. R3 had functional impairment upper extremity on one side. R3 required supervision or touching assistance with personal hygiene, sit to stand, ambulation, toilet transfers, toileting hygiene, shower/bath, upper body dressing, and putting on and taking off footwear. R3 required partial to moderate assistance with lower body dressing. R3 was frequently incontinent of bladder and occasionally incontinent of bowel. R3 had diagnoses of anemia (low red blood cell that carry oxygen to the body and can cause fatigue and shortness of breath), CHF (congestive heart failure), diabetes mellitus (DM), depression, and asthma (chronic lung disease affecting of the lungs and can cause shortness of breath). R3 received restorative therapy, 6 out of 7 days, active range of motion and walking. R3 had a chair alarm on her recliner. R3's physician orders identified: -Date 9/12/24: Chair Alarm: Alarm is in her recliner to alert staff she is up and walking or attempting to transfer. Staff are to check functioning and placement every shift. Twice A Day; 07:00 a.m. - 6:00 p.m. and 6:00 p.m. - 06:00 a.m. Date 6/13/24: Behavior monitoring: Please document any behaviors that were noted on your shift. Please ask the staff if the resident had any behaviors. Twice A Day; 6:00 a.m. - 6:00 p.m. and 6:00 p.m. - 06:00 a.m. R3's care plan dated 5/23/26, identified R3 as a fall risk, has had many falls at home prior admission. R3 lost balance and all of a sudden fell . R3's past falls included: 10/29/23, self-transferred with no injuries, 11/20/23, fell in room self-transferred skin tears to both elbows, and 4/1/24, self-transferring to bathroom/witnessed fall. R3 hit head on heater sustained skin tear and large bruise on left hand. On 6/23/23, staff were directed to keep call light within reach, room free from clutter, fall risk assessment, and instruct R3 of safety measures: use call light. On 4/23/24, added to R3's care plan revealed chair alarm box place behind her recliner, moved out of the sight and hopefully will not turn off alarm and staff will know when she was ringing. R3 did not use her call light for assistance, would not wait for assistance, and used chair alarm as a call light. On 4/1/24, green tape was placed around call light. 8/8/23, signed placed in room after fall, Call don't fall. R3's care plan also identified ADL deficit as she remained short of breath with any activities and required more assistance. Staff were instructed to help with toileting due to her fall risk, not safe to walk by herself, and required staff to stabilize her. The facility nursing assistant (NA) activities of daily living (ADL) worksheet last updated 9/26/23, identified R3 required assist of one with gait belt and walker off unit, can be independent in room, assist of one for toilet use, and did not use an alarm. R3's special requests identified R3 got SOB with any ambulation, was deconditioned, and needed to build her strength. R3 was alert and orientated, can use her call light appropriately, and liked to sleep in her recliner. R3's ADL worksheet 9/26/23 was not revised and current with care plan/assist date 5/23/24 and failed to identify and direct Nas on the level of care and assistance R3 required to stay safe and prevent falls. R3's Fall Risk assessment dated [DATE], identified impaired mobility, elimination status/continent and required assist with toileting. R3's medications included anticoagulants (blood thinner), antihypertensives (lowers blood pressure), and diuretics. R3 had one or two falls in the past three months. R3 had orthopedic joint pain: osteoarthritis. R3's fall risk score was 11 (10 or higher represents a high risk for falls) and determined a risk for falls. R3's Bowel and Bladder Retraining Potential dated 5/2/24, identified a urinary toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) been attempted on admission/reentry or since urinary incontinence was noted in this facility. R3 was frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). R2 was always continent of bowel. R3 wore incontinent pads/briefs and independent cognitive skills for daily decision making consistent/reasonable, and usually aware of mental awareness of toileting needs. R3 was identified as not a good candidate for retaining and summarization/explanation of that determination section was left blank. Plan of care for R3 was to continue current plan of care. R3's care plan lacked evidence of fall interventions related to frequent toileting and increased supervision despite R3 requiring assistance with mobility, toileting and having an order for a diuretic which had a common side effect of frequent urination. R3's physical therapy assessment dated [DATE], identified R3 had impulsive ambulation as a fall predictor. R3's physical therapy discharge summary dated 9/15/23, identified highest practical level achieved. R3 required minimum assistance with transfers, set up with restorative nursing program to facilitate functional abilities and increase safety and decrease need for assistance with carryover demonstrated 75% of therapeutic opportunities and required the need for further instruction for implementation of instructions/techniques. R3's physician visit dated 4/9/24, identified R3 was alert with mental status at baseline. R3's care conference notes dated 4/10/24, identified R3 stayed in her room most of the day and came out for bingo and exercises. R3 attended restorative nursing program six times a week for range of motion (ROM) and ambulation. Reviewed concerns of R3 not using her call light for help. She has a chair alarm because she gets up without calling for help. Educated R3 on the importance of using her call light and that she could seriously injure herself without help. R3 verbalized understanding but continued to get up without calling. On 4/1/24, R3 had a fall when she had gotten up to use the bathroom and did not use her call light. Staff was alerted from her chair alarm and once staff were able to assist, she was already on the floor. Facility Event Report dated 4/10/24, identified R3's fall in bathroom self-transferring on 4/1/24. R3 hit back of head complained of pain 3/10, bruising, and skin tears noted. R3 had taken diuretics (increases urination). Immediate interventions taken by facility were chair alarm and placed green take around call light. R3 had witnessed fall in bathroom. R3's chair alarm alarmed, when staff got to her room, R3 was already in bathroom. Staff saw her turn around, lost her footing, and went backwards. R3 hit head on heat register, sustained a small bump, skin tear and bruises on left hand and wrist. R3 stated this is why you guys always want someone with me, this one scared me, and would be calling more often for help. Evaluation: event still open. Review of R3's progress notes regarding self-transfers/behaviors shift (6 a.m. to 2:00 p.m., 2:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m.) documentation from 4/1/24, through 5/1/24, revealed: -4/1/24 at 5:22 a.m. behaviors. At 2:21 p.m. Writer heard R3 call light/ bed alarm going off, writer ran down to R3's room and found R3 already in restroom pulling up her bottoms. Grabbed R3 by the waist band to have a hold on her but fell back against the wall and had a hold of R3's arm, just slowly slid down on wall. R3 did her head and had a little bit of skin tear on top of hand. Help was called for immediately, 4/stayed with R3 until nurse arrive and assisted R3 up to his recliner. -4/2/24, 4/11/24, 4/18/24, and 4/28/24, no documentation on self-transfers or behaviors. -4/3/24, at 9:01 p.m. R3 continued to self-transfer after being continuously reminded to call for assistance to prevent falls. -4/4/24, at 11:53 a.m. no behaviors. At 4:35 p.m. R3's chair alarm going off, R3 on toilet when staff arrived. Reminded R3 of using call light and wait for assist. R3 stated I guess I don't listen well. Assisted R3 back to chair. At 9:44 p.m. no behaviors. 4/5/24 - 4/9/24, no behaviors noted. -4/12/2024At 8:45 p.m. Reminders to call for assistance. R3 has been pleasant this evening, continues to self-transfer. Chair alarm on bedroom recliner. 4/13/24 - 4/16/24, no behaviors noted. -4/17/24, at 3:10 p.m. Staff reported R3 was self-transferring independently to the bathroom in her room; chair alarm noted in place and in working order, alarming staff to assist. 4/18/24 - 4/19/24, no behaviors noted. -4/20/23, at 12:28 p.m. R3 had been self-transferring throughout the shift. R3 does not ring her call light before getting up. The only reason staff knows she was up because her chair alarms was sounding. R3 had been reminded to ring for help prior to getting up but she continued to self-transfer. 4/21/24 - 4/22/24, no behaviors noted. -4/23/24, at 1:53 p.m. R3 continued to self-transfer herself to the bathroom while in her room; chair alarm noted in place and in working order, alarming staff to assist. -4/24/24, at 8:54 p.m. R3 continued to self-transfer self in room to bathroom and will not ring for help or wait for help chair alarm is in place and working. 4/25/24, at 12:34 p.m. R3 does self-transfer to use the bathroom. Chair alarms in place and working properly. 4/26/24 - 4/28/24, no behaviors noted. 4/29/24, at 12:55 a.m. R3 continued to self- transfer after continuously being reminded to call for assistance d/t previous falls. 4/30/24, no behaviors noted. 5/1/24, at 2:44 p.m. Staff reported R3 was self-transferring independently to the bathroom in her room; chair alarm noted in place and in working order, alarming staff to assist. Writer reminds resident to request assistance for transfers. During an interview on 5/23/24, at 2:00 p.m. nursing assistant (NA)-A stated R3 required assist of one to transfer and ambulate in her room and to the bathroom. NA-A indicated R3 had self-transferred herself into the bathroom and fell about a month ago. NA-A stated R3 had an alarm on her chair that sounded but not until she stood up and that type of situation happened many times a day. NA-A stated R3 usually made it to bathroom by herself prior to staff getting there. During an interview/observation on 5/23/24, at 2:35 p.m. R3 sat in recliner in her bedroom alone with feet on the floor, shoes on, with door 1/2 way closed. R3 stated she tried to take the brakes off the wheelchair (located directly in front of her) and move it to the other side of the room. R3 had pushed herself to the edge of the recliner and started to stand up prior to start of interview, then remained in recliner. On wall behind the recliner was a sign LEAN FORWARD TO STAND UP. R3 stated she could use her call light (located next to her) when help was needed but usually took herself to the bathroom. R3 stated she could make it to the bathroom with her walker alone. R3 stated her chair had an alarm on it that beeped after she stood up, so cannot get away with anything, when staff hear it, they come and by then she is usually in the bathroom. R3 stated she had fallen in her apartment prior to her admission to the facility and that was the reason she lived there now. R3 stated she had gotten short of breath at times when up by herself and did not recall falling at the facility since she moved in. Additionally, signs were posted on R3's wall on each side of the bathroom door, stating Remember to Call Don't Fall. R3 stated she used the walker to go to bathroom and could make it on her own, adding the walker was pretty handy, and felt she could take off when she wanted to and that's what she did. R3 indicated there are times she got short of breath though but had exercises that helped keep her strong. During an interview on 5/23/24, at 2:55 p.m. registered nurse (RN)-A stated R3 required one on one assistance for getting up and going to the bathroom but was notorious for doing it alone. RN-A stated R3 has been given frequent reminders, had a chair alarm, and slept in her recliner. RN-A stated R3's chair alarm went off when she would stand up and by the time staff arrived in her room to assist her, she had already made it to the bathroom by herself. RN-A indicated R3 was short of breath at times when up ambulating and was concerned when R3 would turn alarm off herself. RN-A stated the chair alarm was placed behind her recliner and she was unable to see it. During an interview on 5/23/24, at 4:30 p.m. NA-B stated R3 required assist of at least one to transfer from sit to stand and ambulate to bathroom. NA-B stated R3 had most of her falls when she had to go to the bathroom, tried to turn to shut the bathroom door, then lost her balance and fell . NA-B stated we wait for the chair alarm to go off then head to her room to assist her. NA-B also stated R3 preferred to toilet herself and that was the reason staff did not go in on a regular basis to assist her with toileting. NA-B indicated R3 was a risk for falls. During an interview on 5/24/24, at 9:44 a.m. licensed practical nurse (LPN)-B stated R3 was assist of one for transfers and ambulation, high risk for falls, and required reminders. LPN-B stated R3 had a chair alarm that went off yesterday and when she arrived to R3's room she had already taken herself to the bathroom, off the toilet, and was pulling up her pants. LPN-B verified the ADL care sheet was inaccurate and lacked updating. LPN-B indicated R3 was not on a toileting schedule and brought herself to the toilet. LPN-B stated at least four times a shift R3's alarm goes off, call light goes on, and was also displayed at nurse's station on a screen, and R3 was already up and out of the chair prior to when staff arrived. LPN-B stated staff were expected to check on R3 at least every two hours. (R3's care plan lacked evidence of every two hour checks). During an interview on 5/24/24, at 10:07 a.m. LPN-A stated R3 was a high risk for falls and had a chair alarm that beeped when she stood up, staff were expected to get there as soon as possible due to her history of falls. LPN-A verified this morning (5/24/24) R3's alarm beeped for a while, no staff came and checked on her, when she entered R3's room she was already in the bathroom. LPN-A stated R3 was not independent in her room and the ADL sheet information was incorrect and had not been updated. LPN-A also stated R3 had gotten short of breath and required assistance especially to the bathroom to help prevent falls. LPN-A stated R3 needed more interventions such as a toileting assessment/schedule, reminders, a better approach, and offered the bathroom more frequently. During an interview on 5/24/24, at 10:28 a.m. NA-D stated checked communication book prior to starting shift for any changes and then relied solely on ADL care sheet to guide her on how to care for her assigned residents. NA-D stated R3 was not independent in her room and required assist of one to transfer and ambulate to bathroom. NA-D stated the ADL care sheet was not updated and identified incorrect information on R3. NA-D stated R3 liked to take herself to the bathroom, had an alarm on her chair, but usually on her way to or in the bathroom by the time she arrived in her room. NA-D stated had found R3 in the bathroom at least a couple of times, moved fast, and should have not transferred alone. NA-D indicated R3 usually used the walker when she transferred herself, became short of breath when ambulating, losses her balance turning to come back out of bathroom or when she closed door placed her at risk for another fall. During an interview on 5/24/24, at 11:15 a.m. NA-C stated at start of shift checks the communication book to see if any changes in residents, then solely relied on the ADL care sheet when transferring and caring for each resident. NA-C stated R3 required extensive assistance for cares and minimum assistance and a transfer belt for transfers. NA-C stated R3 was not on a toileting schedule and was not independent in her room. NA-C verified checked on R3 every two hours, had a chair alarm that sounded as soon as she stood up which also triggered the call light to go off. NA-C stated R3 had taken herself to bathroom frequently and witnessed this at least three times a shift. NA-C stated R3 was impulsive, very quick, confused quite a bit, placed her at higher risk for more falls. During a telephone interview on 5/24/24, at 12:16 p.m. licensed practical nurse (LPN)-C stated R3 was high risk for falls and required assistance of one to transfer/ambulate. LPN-C stated R3 had a chair alarm that was set off frequently when R3 stood up and usually guaranteed she had already headed to the bathroom by herself. LPN-C indicated R3 used a walker to ambulate but was unsteady on her feet and short of breath. LPN-C verified R3 had a fall in the middle of her bedroom and another one in the bathroom. LPN-C stated this type of alarm set off when the resident was already standing was not an effective way to prevent falls or keep R3 safe. LPN-C stated R3 was confused, some days were worse than others and lacked short-and long-term memory. LPN-C stated had seen R3 at least three times in an eight-hour shift where her chair alarm went off and she was found already in the bathroom alone. During an interview on 5/24/24, at 2:00 p.m. director of nursing (DON) stated R3's cognition included forgetfulness especially dates and was impulsive in her room. DON stated R3 was struggling to accept and come to terms she lived in the facility. DON stated R3 required assistance of one to be safe, her knees buckled up and became short of breath. DON indicated R3 was able to get up by herself out of the recliner and required assistance of at least one staff to be safe going to the bathroom. DON stated R3 did not have a three-day bowel and bladder assessment completed, more of a dribbler, and most likely would not benefit from that type of assessment. DON stated R3 would say no, she was fine then bolts to the bathroom by herself without assistance and was not placed on a toileting schedule. DON verified R3 was a high risk for falls. DON also verified the R3's ADL care sheet was not updated until today (5/24/24), she removed independent in room and added high risk for falls. DON indicated she expected staff to utilize the ADL sheet when unsure how to care for a resident as a guide. DON stated she checked on R3 this morning when alarm went off and R3 moved fast, was already halfway to the bathroom when arrived in her room. DON stated staff were expected to report to the nurse when R3 transferred on her own and the nurse would be expected to document in the progress notes every shift. DON stated R3 self-transferred so frequently, unsure it had been reported each shift. DON indicated R3 was so impulsive, she would eventually fall again. DON indicated green tape was placed on call light so that R3 would hopefully recognize it was there and maybe use it, but she tends not to use the call light and the chair alarm was used as the call light instead. DON also stated staff were expected to check on R3 at least every two hours, encourage her to use call light so staff arrived before she got off the recliner and moved around by herself to help prevent falls. DON indicated additional interventions would need to be added to R3's care plan such as frequent checks, one on one activities, bowel and bladder audit/assessment, and a physical therapy assessment to possibly deter her from self-transferring. Facility policy titled Bed and Chair Alarms dated 1/30/24, identified alarms would be used on residents with confusion and dementia, demonstrate a potential for falling, history of falling, and have scored moderate to high fall risk should be assessed for the need for alarm. Alarms will be utilized for residents based on their individual care plan. Facility policy titled Care Planning Policy dated 2/1/24, identified care plans provide continuity of care, quality no life, and to meet the quality of life needs for the individual resident. As changes in the resident condition occur, the care plan will be updated in a timely manner to reflect the current plan of care. The care plan will address the resident's needs and include measurable goals and interventions specific to each resident.

Based on observation, interview and document review, the facility failed to ensure soiled and potentially contaminated resident laundry was sorted in a manner to reduce the risk of cross contamination and subsequent infection spread. These findings had the potential to affect all 30 residents residing in the nursing home. Findings include: On 3/12/24, at 10:40 a.m. a laundry tour was completed with laundry aide (LA)-A present. LA-A stated the nursing assistants brought the resident's personal laundry down to the laundry room in blue bags and put the bags in large yellow bins. The process was to sort the resident's laundry into three separate bins of colored items, whites and heavy such as blankets. Any laundry that was contaminated would come down in a red bag, and that bag would be opened into the soaker sink and be soaked. LA-A put on gloves and removed one of the blue bags from the bin and tore it open into a laundry cart; however, did not put on a gown to protect LA-A clothes. LA-A always put disposable gloves on but had never been instructed to wear a disposable gown to complete the sorting process. LA-A had never observed anyone to gown while sorting the resident's soiled laundry and did not think gowns were kept in the area for that purpose. There were no gowns observed in the area for staff to use to sort the laundry. When interviewed on 3/12/24, at 1:45 p.m. the director of nursing (DON) stated laundry staff should always wear a disposable gown to sort resident laundry to protect their clothing and prevent spread of infection. The facility policy Laundry Department dated 11/2023, identified laundry staff would wear gowns/aprons when sorting soiled linens and resident clothing.

Based on interview and document review, the facility failed to provide pneumococcal conjugate vaccine 20 variant (PVC20) education as directed by the Centers for Disease Control (CDC) for 4 of 5 residents (R6, R7, R8, R11) reviewed for immunizations. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], identified R6 was [AGE] years of age with diagnoses hemiplegia following a cerebral infarction, and diabetes. The facility's Preventive Health Care Report dated 4/1/23 to 3/12/24, identified R6 received the pneumococcal polysaccharide vaccine (PPSV23) on 8/5/15, and the pneumococcal conjugate vaccine (PCV13) on 12/16/16. R6's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R6/R6's representative. R7's quarterly MDS dated [DATE], identified R7 was 78 with diagnoses atrial fibrillation, Raynaud's syndrome, and diabetes. The facility's Preventive Health Care Report dated 9/1/23 to 3/12/24, identified R7 had received the pneumococcal polysaccharide vaccine (PPSV23) on 9/5/19, and the pneumococcal conjugate vaccine (PCV13) on 9/27/11. R7's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R7/R7's representative. R8's significant change MDS dated [DATE], identified R8 was [AGE] years of age with diagnoses heart failure, and diabetes. The facility's Preventive Health Care Report dated 5/4/23 to 3/12/24, identified R8 had received the pneumococcal polysaccharide vaccine (PPSV23) on 10/18/10, and the pneumococcal conjugate vaccine (PCV13) on 4/21/17. R8's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R8/R8's representative. R11's quarterly MDS dated [DATE], identified R11 was [AGE] years of age with diagnoses centrilobular emphysema, and cerebral infarction. The facility's Preventive Health Care Report dated 6/5/20 to 3/12/24, identified R11 had received the pneumococcal polysaccharide vaccine (PPSV23) on 6/10/13. R11's medical record failed to provide evidence the PCV20 was offered and/or education was provided in conjunction with the provider to R11/11's representative. During interview on 3/12/24, at 1:45 p.m. the director of nursing (DON) who also served as the facility's infection preventionist stated they had reviewed the CDC guidance for PCV20 vaccine with the medical director and he had directed to offer the PCV20 vaccine to all residents who were eligible for it. They reviewed their residents and had offered and administered the vaccine as applicable to all eligible residents in January. When she used the CDC application for vaccination review for the new CDC guidance it indicated some residents were eligible to receive the PCV20 vaccine, but their vaccinations were considered complete. DON was not aware the residents should still be offered the PCV20 vaccine if they were eligible. The facility policy Influenza, Pneumonia and COVID Vaccines dated 1/2024, the facility would offer an annual influenza immunization to every resident and pneumococcal and COVID immunization as recommended by regulation and/or CDC.

Based on interview and document review, the facility failed to re-assess and implement interventions to keep residents free from sexual abuse following resident to resident abuse involving residents (R16 and R21) for 1 of 1 incidents of abuse reviewed. Findings include: R16's annual Minimum Data Set, dated dated dated [DATE], identified R16 had severe cognitive impairment. R16 had not displayed physical, verbal, or other behavioral symptoms directed towards other. R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment. R16's care plan updated 6/29/21, identified R16 had known physical affection toward others such as holding hands and touching arms/shoulders. Interventions directed staff to stop the behaviors, remind R16 the behaviors were not appropriate and remove R16 or other residents from the situation. R21's progress note dated 1/28/24, identified R21 was in the common area and R16 came up to R21 and placed his hand on R21's shoulder started rubbing, then moved down the arm and across R21's breast, and then R16 tried to placed his hand down R16's shirt. R21 refused and R16 gently lifted R21's chin and kissed her on her mouth. R21 seemed a little startled and asked to to her room. The was no report submitted to the SA regarding the observation of potential sexual abuse. The facilities undated investigation report identified on 1/28/24, an incident was reported that R16 approached R21 and was touching the R21 inappropriately on the chest area and then leaned in and gave R21 a kiss on the mouth. R16's behavior charting dated 2/13/24, identified a comment was documented of resident, but did not identify what the incident was or who the resident was. R16's progress notes identified the following: - On 2/6/24, R16 had behaviors of reaching out and touching other residents. Staff attempted to redirect, and resident ignored them and proceeded to touch other residents. Another staff intervened, redirected resident who then walked to his room. - On 2/8/24, R16 was rubbing another resident's arm. Staff intervened and reminded R16 he could not touch other residents. R16 walked back to his room. - On 2/13/24, R16 had behaviors of touching another resident on the shoulder and arm when talking to them. Staff intervened, resident was difficult to redirect, but eventually R16 walked to his room. - On 2/14/24, MDS charting: staff documented R16 had been respectful and cooperative with no noted behaviors. On 3/12/24 at 2:38 p.m., nursing assistant (NA)-A stated R16 was touchy/feely, and staff needed to be cautions when he was around other residents. Staff were to tell R16 the behavior was inappropriate and needed to stop. R16 would usually stop the behavior. On 3/12/24 at 3:23 p.m., licensed practical nurse (LPN)-A stated R16 likes to be touchy/feely, especially to one female resident. It happens every day and a lot of times in the evening. R16 would walk out of the dining room, pass the female residents seated in a chair in the TV room, walk by and rub his hand down her shoulder and say goodnight to her. R16 was usually easy to redirect by staff and would walk back to his room. LPN-A stated there was one time, couldn't remember the exact date, that R16 rubbed his hand down a females arm [R21] and then kissed her on the cheek. Staff intervened and R16 was redirected back to his room. LPN-A stated she documented a note in R21's chart. The facility investigated the incident, but LPN-A stated she was unaware of what new interventions were put into place. LPN-A stated staff intervene by keeping a close eye on R16 when he is out of his room and try to intervene right away if he was walking towards a female resident. Staff would also tell R16 the behaviors were inappropriate, take him for a walk, move him or the other resident away, bring R16 to his room. After the incident, there was a note in the communication book to keep a close eye on R16 and keep him away from other female residents. R16's medical record lacked reassessment of R16's sexual behaviors towards female residents and interventions to protect R21 and other female residents from sexual abuse. On 3/13/24 at 5:36 a.m., NA-B stated there was one male resident that was a bit touchy/feely but had not witnessed anything occurring on the night shift. If NA-B were to witness an incident, she would separate the residents and make sure the vulnerable adult's were safe. Would also remove the alleged perpetrator from the situation. On 3/14/24 at 11:27 a.m., the director of nursing (DON) stated she saw the note in the VA's medical record regarding an incident where R16 touched the VA's arm, breast and then kissed her on the lips. Follow up from the incident included an investigation lead by the social worker designee (SWD). The SWD was out of the office and unavailable for interview. The DON stated the SWD interviewed both R16 and the R21, and neither of the residents remembered the incident. There was a note placed in the staff communication book instructing staff to monitor, redirect and separate residents; and abuse prevention was discussed it at the last staff meeting. The DON stated the facility should have a plan in place for preventing R16 from inappropriately touching other residents other than keeping a close eye on him. The DON stated R16's care plan directs staff to stop the incident and remind R16 that the actions were inappropriate. The DON further stated staff did not re-assess R16's inappropriate behaviors or put new interventions in place after the incident. The Reporting of Maltreatment of Vulnerable Adult policy dated 3/5/24, identified the purpose of the policy included assuring policies and procedures are in place to protect residents from abuse and to assure the facility is doing all that is within their control to prevent occurrences. The policy further identified all residents had an initial assessment, care plans included measures taken to minimize risk of abuse, staff were trained to identify situations where abuse may occur and when to correctly intervene. A nursing behavior assessment/reassessment policy was requested and not received.

Based on interview and document review, the facility failed to ensure an allegation of sexual abuse was reported to the facility administrator and state agency (SA) within 2 hours for resident to resident potential sexual abuse involving (R16 and R21) for 1 of 1 incidents reviewed for abuse. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE] identified R16 had severe cognitive impairment. R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment. R21's progress note dated 1/28/24, identified R21 was in the common area and R16 came up to R21 and placed his hand on R21's shoulder started rubbing, then moved down the arm and across R21's breast, and then R16 tried to placed his hand down R16's shirt. R21 refused and R16 gently lifted R21's chin and kissed her on her mouth. R21 seemed a little startled and asked to to her room. The was no report submitted to the SA regarding the observation of potential sexual abuse. The facilities undated investigation report identified on 1/28/24, an incident was reported that R16 approached R21 and was touching the R21 inappropriately on the chest area and then leaned in and gave R21 a kiss on the mouth. On 3/12/24 at 3:23 p.m., licensed practical nurse (LPN)-A stated R16 liked to be touchy/feely to a particular female resident [R21] and on 1/28/24, after the evening meal R21 was seated in a recliner in the commons area when R16 stopped at her chair. LPN-A observed R16 rub his hand down the R21's arm, across her breast and then kissed her on the cheek. LPN-A stated she immediately intervened, separated the residents, kept all residents safe from R16 and made sure the VA was taken care of. LPN-A documented a note in the R21's chart but did not report the incident to her director of nursing (DON). LPN-A the incident should have been reported immediately and within 2 hours. On 3/14/24 at 11:27 a.m., the DON stated she was unaware of the alleged sexual abuse until 1/29/24, when she reviewed the VA's progress note. The progress note identified R16 touched the VA's breast and kissed R21 on the lips. The DON stated the incident was investigated but was not reported immediately but no later than 2 hours. The facility Reporting of Maltreatment of Vulnerable Adult policy dated 3/5/24, indicated all facility staff were mandated reporters and maltreatment including sexual contact should be reported immediately, but not later than 2 hours after the allegation was made.

Based on interview and document review, the facility failed to ensure a Level I Pre-Admission Screening and Resident Review (a requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 residents (R6) reviewed for PASARR. Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE] identified R6 had moderate cognitive impairment and a diagnoses of psychotic disorder (other than schizophrenia) and depression. R6's undated face sheet, received on 3/14/24, identified R6 was admitted to the facility on [DATE], and diagnoses included dependent personality disorder and major depressive disorder. During an interview on 3/13/24 at 11:30 a.m., the social services designee (SSD) stated R6 was a direct admit from a nursing home which was closing and called Senior Linkage Line (a help line for PASARR). The Senior Linkage Line stated R6 did not require a new PASARR if they were a direct transfer from another facility, but a copy of the PASARR also needs to be sent to receiving facility. SSD could not locate a copy of the PASARR in R6's chart and could not verify it was completed. During an interview on 3/13/24 at 12:55 p.m., the director of nursing (DON) stated the social service person was responsible for the PASARR and would expect them to complete the task. On 3/14/24, a request was made to the facility to provide a copy R6's PASARR. A PASARR was not provided. A request for the PASARR, and pre-admission screening policy was requested from the facility. The policy was not provided.

Based on observation, interview and document review, the facility failed to ensure medication error rates were 5 percent or less for 3 of 11 residents (R4, R18, R26) observed during medication administration. Findings include: R4's physician order dated 3/8/23, inlcuded calcium carbonate-vitamin D3 600 mg-200 international units (iu) tablets. Take one tablet by mouth twice a day. During observation on 5/1/23 at 7:02 p.m., registered nurse (RN)-A administered one tablet of calcium-vitamin D3 600 mg - 400 iu to R4. During an interview on 5/3/23 at 9:41 a.m., licensed practical nurse (LPN)-A stated the medication dosage on the bottle and provider prescribed dosage did not match. Because of this, the physician should have been contacted. During an interview on 5/3/23 at 9:42 a.m., LPN-B stated R4's calcium with vitamin D order was the same order since 2019. The order was recently reviewed and signed by primary care provider (PCP)-A on 3/8/23. Anytime a medication dosage and physician's order does not match, staff would need to contact the PCP. During a telephone interview on 5/3/23 at 9:44 a.m., pharmacist (P)-A stated the pharmacy records identified RN-B called in the order for calcium carbonate - vitamin D3 600 mg - 400 iu one tab by mouth twice a day on 7/20/22, . P-A stated the medication dose was not equivalent to the medication ordered. R18's physician order dated 6/30/22, identified to discontinue timolol ophthalmic eye drop (focused to treat open-angle glaucoma and other causes of high pressure inside the eye) in left eye and continue latanoprost eye drop (treat high pressure inside the eye due to glaucoma [open angle type] or other eye diseases such as ocular hypertension, ophthalmic-intraocular pressure reducing agents, prostaglandin analogs) in both eyes at bedtime. During observation on 5/2/23 at 4:04 p.m., LPN-C administered timolol 0.5% one drop to the left eye. During a telephone interview on 5/3/23 at 12:02 p.m., LPN-C stated the process for ordering medications was done electronically. The medication was received from the pharmacy in a locked bag with a packing slip for the nurse to check off medications received. If LPN-C was unsure of a correct medication, she could use her phone or drug book to verify the correct medication. Further, timolol eye drops and latanoprost eye drops were not the same. LPN-C shouldn't have given the timolol eye drop because it was discontinued. The nurse should have double checked the order and called the pharmacy for the correct medication when the medication was received. During interview on 5/3/23 at 1:34 p.m., director of nursing (DON) stated sometimes the physician discontinues a medication at the nursing home and forgets to take it off clinic chart and the pharmacy continues to refill the prescription. R26's physician order dated 4/18/23, included citrus calcium-vitamin D3 200 mg -250 iu tablets. Take one tablet by mouth twice a day. During observation on 5/1/23 at 6:11 p.m., RN-A administered calcium-vitamin D 600 mg-400 iu one tab by mouth to R26. During interview on 5/3/23 at 8:36 a.m., LPN-A stated family brought in an over-the-counter bottle of calcium with vitamin D. The bottle's manufacturer label identified each tablet contained calcium-vitamin D 600 mg -400 iu. Further, the dosage on the manufacturer label did not match the physician's order. During an interview on 5/3/23 at 9:38 a.m., LPN-B stated family brought in the over-the-counter bottle of calcium with vitamin D for R26. The medication should have been verified against the physician's order prior to use. If the medication dosage was not correct, nursing should contact the physician for guidance. During a telephone interview on 5/3/23 at 9:47 a.m., P-A stated the pharmacy had not delivered calcium-vitamin D 600 mg -400 iu for R26. The medication dose given was not equivalent to the medication ordered. During a telephone interview on 5/3/23 at 1:45 p.m., PCP-A stated staff should reach out to him with any medication discrepancies to prevent a medication error. During an interview on 5/3/23 at 2:39 p.m., DON stated staff should perform the five rights of medication administration (the right dose, the right medication, the right resident, the right route and the right time) to reduce medication errors. Staff should utilize resources such as the physician, the pharmacy and/or online drug references if there are discrepancies. The policy Medication and Treatment Administration dated 2023, identified when drugs were administered, staff should verify the correct resident, medication, time, route and dose by referring to the medication administration record (MAR).

Based on observation, interview and document review, the facility failed to ensure an over the counter (OTC) prescribed medication was labeled with the resident name for 1 of 11 residents (R26) observed during medication pass and who's medication was not labled. Findings include: R26's physician order dated 4/18/23, included an order for citrus calcium-vitamin D3 200-250 milligram (mg) tablets. Take one tablet by mouth twice a day. During an observation on 5/1/23 at 6:11 p.m., registered nurse (RN)-A administered one tablet of calcium with vitamin D to R26. The medication bottle was not labeled with R26's name or directions for use. The manufacturer label on the bottle identified calcium 600 mg along with 400 iu of vitamin D. The physician's order was citrus calcium-vitamin D3 200-250 milligram (mg) tablets. Take one tablet by mouth twice a day. During an interview on 5/3/23 at 8:36 a.m., license practical nurse (LPN)-A stated family brought in R26's bottle of calcium 600 mg along with 400 iu of vitamin D. The bottle lacked identifying markers that the calcium 600 mg along with 400 iu of vitamin D belonged to R26. The bottle should have been labeled directing who's medication it was. During an interview on 5/3/23 at 9:38 a.m., LPN-B stated R26's family brought in all of R26's over the counter medications. When the medication was received, the nurse should have written R26's name on bottle. During a telephone interview on 5/3/23 at 9:47 a.m., the pharmacist stated the pharmacy did not deliver calcium 600 mg along with 400 iu of vitamin D. The pharmacist failed to identify the process for labeling an OTC medication brought in by family. The policy Medication and Treatment Administration dated 2023, lacked labeling directions for medications brought in by family.

Based on interview and document review the facility failed to ensure the family member was notified of a change of condition in a timely manner for 1 of 1 resident (R1) who sustained fractured ribs resulting from an unwitnessed fall. Finding include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required extensive assistance of one staff for bed mobility, transfers, dressing, personal hygiene, toileting, bathing and required assistance of staff for walking. The MDS identified R1 utilized a walker, a wheelchair and was not steady with movement and required staff assistance to stabilize herself. R1's MDS indicated R1 had a fall on her prior assessment with injury. Review of R1's care plan revised on 8/25/22, indicated R1 was at risk for falls related to [CONDITION(S)], [CONDITION(S)], moderate vision impairment and severe hearing impairment. The care plan listed various interventions which included: staff were to provide toileting assistance and were not leave R1 in bathroom alone. Review of R1's Event Report dated 8/21/22, at 12:46 a.m. identified R1 had an unwitnessed fall at 8:30 p.m. on 8/20/22, and was found on the floor sitting next to the toilet. Nursing assistant (NA)-A and NA-B assisted R1 up off the floor utilizing a gait belt, positioned her back onto the toilet and proceeded to walk R1 back to her recliner with her walker. The report indicated registered nurse (RN)-A was notified of R1's fall at 9:00 p.m. and assessed R1 with no visible signs of injury. At 10:00 p.m. R1 was brought out to the commons area to sit per her request and at 12:00 a.m. R1 requested to go back to her room. While RN-A was attempting to ambulate R1 with her walker, she had complaints of lower back pain on her left side. RN-A assessed R1, gave her Tylenol, applied bio-freeze to the area and called the provider in the emergency room (ER). The ER provider instructed staff to continue to monitor and offer as needed Tylenol for pain control. The report indicated R1's FM-A was notified of the unwitnessed fall on 8/22/22 at 11:40 a.m. Review of R1 progress notes from 8/20/22, to 8/23/22, revealed the following: - on 8/21/22, at 12:58 p.m. R1 had complaints of leg pain,Tylenol was adminstered and was effective. - on 8/22/22, at 11:41 a.m. R1's family member (FM)-A was updated on R1's fall and was scheduled for an appointment at the clinic to follow up on her pain to her lower back from the fall. - on 8/23/22, at 10:49 a.m. follow up clinic appointment, x-rays identified R1 had rib fractures on her left side. The provider instructed staff to continue with Tylenol as needed for pain. The progress note indicated staff would be using the standing mechanical lift for transfers from that point forward as a gait belt may be too painful to her ribs The note identified staff were updated on the use of the standing mechanical lift. Review of R1's medical record, revealed staff had not notified R1's FM-A for 39 hours after R1 had an unwitnessed fall which resulted in lower back pain and fractured ribs. During an interview on 8/25/22, at 2:39 p.m. RN-A confirmed the above findings. RN-A stated R1 had an unwitnessed fall on 8/20/22, around 8:00 or 8:20 p.m. and NA-A reported to him R1 had fallen off the toilet when NA-A left her unattended. RN-A indicated he notified the director of nursing (DON) of R1's fall on 8/21/22, around 12:56 a.m. and indicated staff had not followed R1's care plan by leaving her unattended in the bathroom. RN-A verified R1 was having some lower back pain resulting from the fall and had not notified R1's family. During an interview on 8/26/22, at 9:19 a.m. the DON confirmed the above findings and indicated she was notified on Saturday 8/20/22, around midnight, of R1's unwitnessed fall and R1's complaints of lower back pain. The DON verified RN-A had not notified R1's family when she fell , and the family had not been notified until 8/22/22. The DON indicated her expectation of staff were to update and notify family in a timely manner and follow facility policies. During an inerview on 8/26/22, at 9:59 a.m. FM-A indicated she was R1's primary emergency contact. FM-A confirmed the facility had not contacted her about R1's 8/20/22, fall until 8/22/22, at around 11:00 a.m. On 8/26/22, a facility policy was requested for notification of family with change of condition, and one was not provided.

Based on interview and document review, the facility failed to timely report an allegation of potential neglect of care with major injury for 1 of 1 resident (R1) immediately but no later than 2 hours to the administrator and State Agency (SA). Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R1 required extensive assistance of one staff for bed mobility, transfers, dressing, personal hygiene, toileting, bathing and required assistance of staff for walking in room. The MDS identified R1 utilized a walker, a wheelchair and was not steady with movement and required staff assistance to stabilize herself. R1's MDS indicated R1 had a fall on her prior assessment with injury. Review of R1's care plan revised on 8/25/22, indicated R1 was at risk for falls related to [CONDITION(S)], [CONDITION(S)], moderate vision impairment and severe hearing impairment. The care plan listed various interventions which included: staff were to provide toileting assistance and were not leave R1 in bathroom alone. Review of R1's Event Report dated 8/21/22,at 12:46 a.m., identified R1 had an unwitnessed fall at 8:30 p.m. on 8/20/22., and was found on the floor sitting next to the toilet. Nursing assistant (NA)-A and NA-B assisted R1 up off the floor utilizing a gait belt and positioned her back onto the toilet and proceeded to walk R1 back to her recliner with her walker. The report indicated registered nurse (RN)-A was notified of R1's fall at 9:00 p.m., and assessed R1 with no visible signs of injury. At 10:00 p.m. R1 was brought out to the commons area to sit per her request and at 12:00 a.m. R1 wanted to go back to her room. While RN-A was attempting to ambulating R1 with her walker, she had complaints of lower back pain on her left side. RN-A assessed R1, gave her Tylenol and applied bio-freeze to the area and called the provider in the emergency room (ER). The ER provider indicated to continue to monitor and offer as needed Tylenol for pain control. Review of R1 progress notes from 8/20/22, to 8/23/22, revealed the following: - on 8/21/22, at 12:58 p.m. R1 had complaints of leg pain,Tylenol was adminstered and was effective. - on 8/22/22, at 11:41 a.m. R1's family member (FM)-A was updated on R1's fall and was scheduled for an appointment at the clinic to follow up on her pain to her lower back from the fall. - on 8/23/22, at 10:49 a.m. follow up clinic appointment, x-rays identified R1 had rib fractures on her left side. The provider instructed staff to continue with Tylenol as needed for pain. The progress note indicated staff would be using the standing mechanical lift for transfers from that point forward as a gait belt may be too painful to her ribs The note identified staff were updated on the use of the standing mechanical lift. Review of the Incident Report # 2, submitted to the SA on 8/23/22, at 9:15 a.m. listed an allegation of neglect with a fall in the bathroom for R1 and listed the incident had occurred on 8/21/22, with no time noted. The incident report indicated R1 had fractured ribs and interviews were started with staff as well as education provided to staff. The report identified the allegation of neglect had been reported to the SA on 8/23/21, at 9:15 a.m. The allegation of neglect was reported to the SA two and a half days later after the incident had been reported by staff on 8/20/22, to RN-A. During an interview on 8/25/22, at 2:39 p.m. RN-A confirmed the above findings and indicated R1 required staff assistance with transfers and ambulation while utilizing a gait belt and walker. RN-A indicated R1 was at risk for falls and was able to use her call light for assistance however R1 was not to be left alone in the bathroom due to having a tendency to self-transfer at times. RN-A indicated R1 had fallen on 8/20/22, around 8:00 or 8:20 p.m. and NA-A reported to him R1 had fallen off the toilet. RN-A indicated NA-A had to use the bathroom and had reported off to NA-B to check on R1 while she was using the bathroom. RN-A indicated when NA-A returned to R1's room, R1 was sitting on the floor next to the toilet. RN-A indicated NA-A called for assistance, NA-C assisted her to transfer R1 back up onto the toilet using a gait belt and walked R1 back to her recliner with the walker. RN-A indicated he notified the director of nursing of R1's fall on 8/21/22, around 12:56 a.m. During a telephone interview on 8/26/22, at 8:27 a.m. NA-A confirmed the above findings and indicated R1 required staff assistance with transfers and ambulation using a gait belt and walker. NA-A stated she had brought R1 back to her room after supper on 8/20/22, at around 7:00 p.m. to use the bathroom and was asssiting her to get ready for bed when she suddenly had to use the bathroom herself. NA-A indicated she left R1 on the toilet and reported off to NA-B to check on R1 while she used the bathroom. NA-A stated when she was done using the bathroom, she returned to R1's room, found her sitting on the floor next to the toilet and was leaning to her left. NA-A indicated she asked NA-C for assistance. NA-A stated she and NA-C boosted R1 back up onto the toilet from the floor using a gait belt and assisted R1 to walk back to her recliner using her walker. NA-A indicated R1 walked with a limp after her fall on 8/20/22, and had reported the incident to the nurse right away. NA-A indicated she was not aware R1 was not supposed to be left unattneded in the bathroom and believed NA-B would check on her. During an interivew on 8/26/22, at 9:19 a.m. the DON confirmed the above findings. The DON indicated R1 was a fall risk and should not have been left unattended on the toilet. The DON stated her expectations of staff were to follow R1's care plan as written. The DON indicated she was notified on Saturday 8/20/22, around midnight, although she did not read the message until the morning of 8/21/22. The DON verified any allegations of abuse or neglect would need to be reported to the SA immediately within two hours. The DON indicated she would expect staff to follow the facility's policy and procedures for timely reporting to the SA. Review of the facility policy titled, Reporting of Maltreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow the OHFC (Office of Health Facility Complaints) Investigation Process Policy . All employees of the facility were mandated reporters and must report all incidents of actual or suspected maltreatment. The policy defined neglect as the failure or omission of a care giver to supply the vulnerable adult with care or services, including but not limited to food, clothing, shelter, health care or supervision. The failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Further, the policy defined serious bodily harm as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization or physical rehabilitation. In addition, the policy defined immediately as No later than two hours after forming the suspicion, if events that caused the suspicion involved abuse or result in serious bodily injury, or not later than 24 hours if events that caused the suspicion did not involve abuse and did not result in serious bodily injury. The facility policy OHFC Investigation Process Policy dated 7/21, indicated the purpose of the policy was to document resident incidents, to conduct an investigation of each incident, and to identify root causes for future prevention. The scope of the policy identified all Mahnomen Health Center staff and directed under the policy procedure the incident was to be Reported to OHFC (Immediately or within 2 hours of initial report if abuse or bodily harm or no later than 24 hours if no bodily harm).

Based on interview and document review, the facility failed to ensure interventions were developed and implemented to prevent falls for 3 of 3 residents (R1, R2, R3) who had a history of falls. This resulted in actual harm to R1 who sustained a [CONDITION(S)] following a fall, actual harm to R2 who required 7 staples in her head following a fall, and actual harm to R3 who sustained a compression fracture following a fall. Findings include: R1 R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 was cognitively intact with a diagnosis of stroke. The MDS indicated R1 required extensive assist of two staff for bed mobility, transfers, ambulation in room, and toileting. In addition, the MDS indicated R1 had two or more falls since admission. R1's Face Sheet printed 4/12/22, indicated R1 was discharged [DATE]. R1's care plan dated 3/23/22, indicated R1 was at risk for falls due to the use of diuretics and antipsychotics, as well as poor communication skills due to [CONDITION(S)] (curved tube that is inserted into a [CONDITION(S)] stoma, the hole made in the neck and windpipe) diagnosis of paralysis of vocal cords, stroke affecting left side of the body and a broken left shoulder. R1's care plan identified R1 had a fall that occurred on 3/20/22, which resulted in a broken hip. In addition, R1's care plan identified fall interventions which included of the use of a fall mat on the floor and the bed lowered to the ground when R1 was in bed implemented 3/23/22, call light on both recliner and bed implemented 3/15/22, and increased supervision with intensity or agitation episodes implemented on 3/15/22, for R1's fall interventions. Review of R1's falls indicated: On 3/8/22, 5:07 p.m. a Post Fall Huddle Form indicated R1 had an unwitnessed fall in room related to a self-transfer from bed. R1 stated he didn't want to stay in bed any longer due to his legs hurting. At the time of the incident, R1 reported pain to the right elbow and left knee, and appeared to have a small hematoma (bruising happens when blood collects under skin) on knee. Immediate intervention implemented following the fall was another call light by chair. On 3/11/22, 6:00 p.m. Post Fall Huddle Forms indicated R1 had an unwitnessed fall in room. R1 was found on the floor at the side of the bed, and was unable to state what happened. Immediate intervention implemented following the fall was to provide frequent checks. On 3/20/22, 5:15 p.m. Post Fall Huddle Forms indicated R1 had an unwitnessed fall in his room while attempting to self-transfer from the recliner to his bed. R1 reported pain in his left shoulder, and he obtained a skin tear to the left elbow area. Immediate intervention implemented following the fall was to add a low bed. R1's progress notes dated 3/21/22, indicated R1 was noted to have increased complaints of pain in his left hip. R1 would not allow nursing staff to assess, and even lightly touching his left leg would cause R1 to yell. R1 was transferred to the emergency department (ED). On 3/21/22, R1 returned from the ED where x-rays revealed a left hip fracture. R1's electronic medical record lacked evidence of Safety Events-Fall event, which is the facility's process of completing the form as an interdisciplinary team (IDT) to determine casuative factors and review of interventions, was completed for R1's three falls that occurred on 3/8/22, 3/11/22 and 3/20/22. On 4/7/22, at 12:04 p.m. registered nurse (RN)-A stated R1 was a huge fall risk when he was displaying delusions and hallucination episodes. RN-A indicated R1 had a fall on 3/8/22, related to self-transferring from bed due to pain in legs with an intervention added for a call light by recliner. RN-A stated R1 had another fall that occurred on 3/11/22, with an intervention implemented for frequent checks; however, did not clarify how often frequent checks were and can't find much in the chart other than that. RN-A stated on 3/20/22, R1 had another fall self-transferring from recliner to bed and intervention added was a low bed. RN-A stated I have no clue why that was implemented and I am getting so frustrated. R2 R2's quarterly MDS dated [DATE], indicated R2 had a diagnosis of stroke and was cognitively intact. R2 required extensive assist of one staff for bed mobility, transfers, ambulation, and toileting. The MDS indicated R2 had two or more falls with no injury since the previous assessment. R2's Face Sheet printed 4/12/22, indicated R2 discharged on [DATE]. R2's care plan revised 3/15/22, indicated R2 was at risk for falls related to impaired mobility resulting from stroke, [CONDITION(S)] (inability to move on one side of the body) and lack of motivation. R2's care plan indicated R2 had falls on 10/30/21, 11/1/21, 11/2/21, 11/5/21, 1/10/22, 2/12/22, 2/19/22, 3/7/22, and 3/13/22. R2's fall interventions included encourage gripper socks if she is not wearing shoes implemented 3/15/22; place bell at table for use in commons area implemented on 3/7/22; chair and bed alarms to alert staff to assist with needs implemented 2/17/22; redirect R2 with snack, activity or phone call to family when ambulance arrives at the hospital implemented 12/24/21; have R2's clothes ready the night before implemented 9/10/21; staff will dress R2 at 5:00 a.m. implemented 8/30/21; remind R2 to call and wait for assistance implemented 8/2/21; gripper socks on while in bed implemented 7/18/21; call don't fall sign in room and bathroom implemented on 7/6/21; limited assist of one with front wheeled walker, be aware veers left, guide walker as needed, non-skid shoes implemented 7/1/21; be aware gets dizzy when ambulating with glasses on ensure they are removed before transferring/ambulating implemented on 7/1/21; bed alarm on bed to alert staff of attempts to get up unassisted implemented on 7/1/21; and fall assessment quarterly and as needed, assess falls and implement interventions as appropriate implemented on 7/1/21. Review of R2's falls per facility fall report log : Facilitiy's fall report log printed 4/6/22, indicated R2 had fall which occured on 10/31/21, 11/1/21, 11/2/21, 11/5/21 which lacked evidence a Post Fall Huddle Form was completed per facility Fall policy. On 12/19/21, at 2:00 p.m. Post Fall Huddle Form indicated R2 had an unwitnessed fall in the commons area while attempting to stand up from the chair. R2 transferred to the ED for further evaluation due to hitting her head. The form lacked evidence an immediate intervention was implemented. On 1/10/22, at 6:30 p.m. Post Fall Huddle Form indicated R2 had an unwitnessed fall in room while self-transferring to get ready for bed. R2 reported pain in her coccyx following the fall. R2 was provided up to date education to call for assistance. The form lacked evidence of additional interventions being implemented following the incident. On 2/12/22, at 12:00 p.m. Post Fall Huddle Form indicated R2 had an unwitnessed fall in room while self-transferring attempting to change the television channel. R2 sustained a laceration to a finger on her right hand and struck her head on the dresser. Immediate intervention implemented at the time of the fall included education to nursing assistant to not leave R2 alone in room unless R2 is in bed with bed alarm. On 2/19/22, lacked evidence a Post Fall Huddle Form was completed per facility policy. On 3/6/22, at 4:30 p.m. Post Fall Huddle Form R2 had a witnessed fall in commons area while self-transferring attempting to return to room. Nursing staff was guiding resident back to her seat in the commons area, staff was adjusting the chair alarm on the seat while holding onto R2 by the gait belt. R2 stated she was going to fall, and staff was unable to catch her. R2's head was noted to bounce off the floor, and R2 reported a headache following the incident. R2 was noted to have a bulge on the back of her head where she had staples from a previous fall. R2 was transferred to the ED for further evaluation. The form lacked evidence of immediate intervention implemented following the incident. On 3/13/22, at 3:45 p.m. Post Fall Huddle Form R2 had an unwitnessed fall in her room while attempting to self-transfer to the bathroom. At the time of the fall, R2's shoes were off and non-skid footwear was implemented at time of incident. Review of R2's Safety Events-Falls event report, which is the facility's process of completing the form as an interdisciplinary team (IDT) to determine casuative factors and review of interventions, was completed for R2's falls that occurred 10/21/21, 11/1/21, 11/2/21, and 12/19/21. -11/5/21,at 2:17 p.m.Safety Event-Fall indicated R2 was witnessed walking with her walker in hallway and fell on to the [MEDICATION(S)] edge on the end table and hit the right side of head and shoulder. Event lacked evidence of intervention implemented following incident -2/19/22, at 2:46 p.m. Safety Event- Fall indicated R2 had a fall in commons area while attempting to self-transfer and fell backwards hitting head and sustained a laceration to the back of her head. R2 was sent to the emergency room and received 7 staples in the posterior of head. Event lacked evidence of intervention implemented following the incident. R2's Nursing Home Fall Risk assessment dated [DATE], indicated R2 had total disregard for level of functioning and her comprehension and retention of information was poor to nonexistent. R2 required constant cues by staff to call for assistance to transfer or ambulate. The director of nursing (DON), registered nurse (RN)-A, RN-B, and social worker (SW)-A met to discuss R2's falls from January through March of 2022, and determined staff had attempted every intervention possible and nursing continued to come up with new interventions following R2's fall; however, R2 was impulsive, which caused difficulty for staff to try to prevent falls. Further, R2's fall risk assessment indicated nursing would continue to try to find interventions to prevent major injury falls, and family had been updated on R2's falls with no additional input on interventions for staff to attempt. On 4/7/22, at 12:04 p.m. RN-A stated R2 was at extremely high risk for falls related to impaired gait and previous stroke. RN-A stated a post fall huddle form was not completed for R2's fall on 10/11/21, and confirmed there were no additional interventions added to care plan for this time. RN-A stated R2 had a fall on 11/1/21, and intervention was added for staff to encourage R2 to sit in commons area, however the intervention was not added to R2's care plan. RN-A stated R2 had another fall on 11/2/21, while attempting to self-transfer in room and intervention added directing staff to place R2 in commons area with no additional interventions added to R2's care plan. RN-A stated R2 had a fall on 11/5/21, while self-transferring in the hallway with no additional interventions added following the fall. RN-A stated R2 had a fall on 1/10/22, while attempting to self-transfer to room and confirmed no additional interventions implemented following team review. R2 had a fall on 2/12/22, attempting to change TV channel in room and intervention included nursing education provided R2 was not to be in room alone unless in bed with no care plan updates initiated after team review. R2 had a fall on 2/19/22, and RN-A stated a post fall form was not completed following the incident, however progress notes revealed R2 had a fall which resulted in 7 staples to the back of her head. RN-A was unsure the root cause of the fall and was unsure of an intervention added following the incident. RN-A stated R2 had a fall on 3/6/22, while self-transferring and while nursing staff assisted R2 to a chair, staff was unable to catch R2 from falling. R2 was sent to the emergency room for evaluation and sustained a hematoma (bruising when blood collects under the skin) to the back of R2's head where staples from previous fall were located and RN-A stated immediate intervention was call bell placed in commons area. Further RN-A stated R2 was emotionally afraid of the alarms and she didn't like the loud noise and due to dignity concern the alarms were removed from R2 for a while before bringing them back. RN-A indicated the bed and chair alarms are not monitored and staff are not expected to chart on the alarms to identify any trends or patterns they are solely used for staff purpose to know when a resident is attempting to get up without assistance R3's quarterly MDS dated [DATE], indicated R3 had a diagnosis of dementia and had severe cognitive impairment. R3 required extensive assist of two staff for bed mobility, transfers, and toileting. The MDS indicated R2 had one fall with injury since the previous assessment. R3's Face Sheet printed 4/12/22, indicated R4 discharged on [DATE]. R3's care plan revised 2/17/22, indicated R2 was at risk for falls related to dementia diagnosis and arthritis in knees. The care plan indicated R3 had falls that occurred on 10/21/21, 11/6/21, 12/14/21, and 2/13/21. R3'a fall interventions included chair and bed alarms implemented on 2/17/22, provide toileting assistance in early morning -resident to be one of the first ones up implemented on 12/16/21, and provide proper non-slip footwear implemented on 5/31/21. Review of R3's falls: On 10/21/21, at 8:30 a.m. Post Fall Huddle Form indicated R3 had an witnessed fall in room while attempting to straighten bed linens and no injury was noted. Immediate intervention implemented was frequently checks. On 11/6/21, R3's medical record lacked evidence a Post Fall Huddle Form was completed for this incident per facility policy. On 12/14/21, at 8:10 a.m. Post Fall Huddle Form indicated R3 had an unwitnessed fall in room while attempting to self-transfer to bathroom or get dressed. No injury was noted. Immediate intervention implemented to wake R3 up by 7:00 a.m. and assist with cares. On 2/13/22, at 3:00 a.m. Post Fall Huddle Form indicated R3 had an unwitnessed fall in room while attempting to self-transfer to the bathroom. R3 was noted to report worsening back pain and had bruising on right hand. Immediate intervention implemented was encourage resident not to self-transfer. Review of R3's x-ray results dated 2/15/22, revealed slight compression of the superior end plate of T12 noted of indeterminate age. Review of R3's Safety Event-Fall reports, which is the facility's process of completing the form as an interdisciplinary team (IDT) to determine casuative factors and review of interventions, was not completed following R3's falls which occurred 10/21/21, and 11/6/21. On 4/6/22, at 3:07 p.m. licensed practical nurse (LPN)-A was interviewed and stated R1 was a huge fall risk and R1's fall interventions included low bed, fall mat, frequent checks, and re-education to use his call light for assistance. LPN-A stated R2 was a high fall risk and interventions included bed and chair alarms, and constant reminders to call for assistance. LPN-A stated R3 had a couple falls but was unsure what interventions were in place to prevent falls for R3. On 4/6/22, at 3:37 p.m. LPN-B stated R2 was at risk for falls and interventions included bed and chair alarms; however, at times the alarms would malfunction. Further, LPN-B stated the licensed nurses were expected to complete a progress note and a fall sheet after a fall incident and notify family, doctor and DON as well as implementing an immediate intervention. In addition, LPN-B stated the supervising RN will investigate the root cause of the fall and implementing a different intervention to prevent another fall if needed. On 4/7/22, at 9:25 a.m. nursing assistant (NA)-A stated R1 was at risk for falls and interventions included low bed and fall mat on floor while in bed, frequent checks making sure he was good, promptly answering call light and a chair alarm. NA-A stated R2 was also a high fall risk and interventions included bed and chair alarm, toileting program, and offering activities. Further, NA-A stated R2 disliked the bed and chair alarms and R2 would attempt to shut off the alarms and silence the box so staff would not hear R2 attempting to self transfer. NA-A stated staff were not monitoring the alarms or charting when the alarm was going off but stated it was to alert staff if R2 was attempting to self-transfer. On 4/7/22, at 12:04 p.m. RN-A stated R3 was noted to self-transfer, which put her at risk for falls. RN-A stated R3 had a fall that occurred on 10/21/21, with an intervention of check on R3 frequently however was not sure what frequently meant and confirmed no additional interventions were added to R3's care plan following the fall. RN-A stated R3 had another fall on 11/8/21, but was unsure what the root cause of the fall was or what interventions were put in place as electronic medical record lacked evidence. When asked about the facility's fall procedure, RN-A stated the nurse on duty when the fall occurs were expected to complete the top portion of the Post Fall Huddle Form and implement an immediate intervention determined on cause and the completed form would be forwarded to the RN supervisors, which included RN-A, RN-B, and DON, who review the form as a team and determine a root cause for the fall to determine an appropriate intervention and update the care plan. Further, RN-A stated she should be completing the bottom of the Post Fall Huddle forms and confirmed these things I need to work on obviously. In addition, RN-A stated with recent staffing changes clarification was needed on who was supposed to complete what following a fall. On 4/7/22, at 3:19 p.m. the DON was interviewed and stated when a resident falls, the licensed nurse on duty when the fall occurred should complete an assessment and report the fall to the DON, administrator, family and provider. The nurse is expected to complete the Post Fall Huddle form and a head-to-toe assessment and implement an immediate intervention. Further, DON stated the team meets every morning and will determine a root cause for the fall and determine an intervention for long term to keep them the safest when they fall. At this time, the resident's care plan is updated to reflect the new intervention and put a note in the communication log for staff to be educated. In addition, DON stated R2 disliked the chair and bed alarms due to the noise, so they were discontinued, however R2 continued to self-transfer so staff re-established the alarms. DON stated alarms are initiated as a last resort intervention since they don't prevent falls. When asked how staff are monitoring the alarms, DON stated staff are expected to monitor if the alarm was functioning appropriately other than that there was no additional monitoring for alarms and the alarms are used for staff purpose to respond quickly. The facility policy Bed and Chair alarms dated 2022, directed residents with confusion and dementia who may get out of bed or chair without assistance, demonstrate potential for falling, history of falling are guidelines for staff for the use of bed or chair alarms. Further, policy indicates bed and chair alarms will be used in accordance to manufacturers instructions however, policy lacks criteria for when a resident would begin the use of alarms, monitoring alarms for trends and patterns or criteria for alarms being removed. The facility policy Falls revised 01/22, directed nursing home procedure included after resident is determined safe immediately complete a post fall huddle and put an appropriate intervention into place, notify the DON immediately, notify the provider or on-call medical provider, notify family, and report fall to on-coming personnel. Further, facility's documentation procedure post fall included immediately complete the post fall huddle and investigation tool in its entirety, give the form to the RN unit coordinator or DON, the form will be reviewed at the interdisciplinary team meetings, the form will be handed to the falls prevention coordinator and discussed at the next fall prevention meeting. In addition, the RN staff will enter the event into the electronic incident reporting tool and update the care plan accordingly.

Based on observation, interview, and document review, the facility failed to ensure complaints of worsening low back pain were comprehensively assessed and treated in a timely manner to provide comfort and reduce risk of complications for 1 of 1 residents (R3) who voiced concerns about pain management. This resulted in actual harm when staff failed to follow physician ordered lumbar xrays, collaborate with other health professionals and address ongoing severe pain for several weeks which resulted in a decline in R3's activities of daily living (ADLs). Findings include: R3's significant change Minimal Data Set (MDS) dated [DATE], indicated R3 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS indicated R3 was independent with ambulation in room and required supervision while ambulating out of room and with toileting. R3 reported occasional pain during assessment period. R3's quarterly MDS dated [DATE], indicated R3 required extensive assist of two staff for ADLs such as bed mobility, transfers and toileting. Further review of MDS indicated R3 required extensive assist of one staff for ambulation in room and through out the facility. R3 reported almost constant pain during assessment period R3's care plan dated 2/15/22, indicated R3 suffers from painful knees related to arthritis. R3 recently had injections which seemed to help very little. R3 was needing increased assistance ambulating long distances and was not able to at times. R3 was needing to use wheelchair due to increased pain. R3 recently started yelling and shouting out when staff try to transfer. Further review of care plan indicated R3's goal for pain included adequate pain control and continue to walk with interventions that included encourage R3 to take small rest breaks when ambulating or increase pain occurs, scheduled pain medications, repositioning, warm/cold packs, stretching, and therapy. R3's progress notes were reviewed and R3 reported increased pain often. R3's progress notes lacked evidence a physician was updated on increased low back pain and change in condition. R3's progress notes also lacked evidence a comprehensive pain assessment was completed to determine root cause of pain. R3's progress notes include: -12/20/21 The following medication changes were made due to emergency room visit this weekend [MEDICATION(S)] was increased to 100 milligrams (mg) three times daily, Ibuprofen 400 mg every six hours as needed, [MEDICATION(S)] gel every four hours for pain. Follow up with primary physician on 12/20/21. -12/21/21 Medical doctor (MD) decreased [MEDICATION(S)] back down to 50 mg three times daily and ordered lumbar x-rays, -12/23/21 R3 complained of low back pain and used the wheelchair for locomotion and required assistance with transfers -12/24/21 R3 complained of pain upon transfer and Ibuprofen was given. -12/25/21 R3 complained of back pain with assistance of morning ADLs and Ibuprofen was given. -12/27/21 R3 complained of back pain when assisted to sit up in bed. R3 was able to walk to the bathroom with walker and assist of one and complained of low back pain. R3 required cues several times to stand up straight and to stay close to walker as she was leaning over and unsafe. -12/29/21 R3 refused rehabilitation due to back hurting. -1/1/22 R3 complained of lower back pain, Biofreeze was applied, and scheduled medications given. -1/3/22 R3 complained of lower back pain, Biofreeze and scheduled medications given which were somewhat effective. -1/4/22 R3 reported more pain today. -1/6/22 R3 complained of low back pain. -1/14/22 R3 ambulated slowly into the dining room in the morning and had complaints of pain in back. -1/17/22 R3's gait noted to be slow, shuffling and slightly stooped over while ambulating. -1/26/22 R3 complained of back pain in the am. R3 was independent to assist of one with locomotion depending on back pain -1/27/22 R3 had complaints of back pain in the morning with Biofreeze was applied and small amount of relief. R3 yelled out ouch during transfers. -1/28/22 R3 required the use of the mechanical sit to stand lift and was not able to tolerate walking or sitting up in bed without assist. R3 required total care with dressing staff must thread arms into shirt and pull arm over head and body, thread legs into pants and pull them up over body. R3 refused restorative therapy due to back pain. Later in the day on 1/28/22, R3 required the use of a full body mechanical lift and assistance of two staff to transfer due to back pain. R3 had also been noted to have been using the wheelchair. -1/29/22 R3 required assist with all ADLs. R3 required the use of mechanical sit to stand lift for transfers. R3 was noted to yell out during transfers. R3 was observed shifting her weight on and off her buttocks while trying to eat. R3 refused restorative therapy due to back pain. R3 was also noted to require total assist with dressing, transfers with lift and two staff and transports in wheelchair with the assistance of one staff. -1/30/22 R3 continued to complain of increased pain. R3 had been requiring total care due to increased back pain. R3 required assistance of two staff using the mechanical lift for transfers and was unable to ambulate and is utilizing the wheelchair currently. R3 refused restorative therapy due to back pain. -1/31/22 R3 had been transferring using full mechanical lift and assistance of two staff for transfers from bed due to back pain. R3 had been using a wheelchair with assistance of one staff. -2/1/22 R3 complained of back pain and transferred using lift due to back pain. R3 had lower back pain which she had scheduled and as needed pain medication. -2/2/22 R3 had back pain throughout the day. R3 would yelp in pain with first movement and then gets better. Certified nurse practitioner (CNP) assessed R3 and R3 winced some when CNP pressed on lower back, not her spine but her muscle. CNP indicated it was more muscle pain than spine and suggested continuing with heat and Biofreeze and may use the [MEDICATION(S)] gel. -2/3/22 R3 screamed out in pain while being transferred with assist of two staff. Pain noted in the back and worse upon getting up in the morning. R3 noted to have difficulty transferring to a standing position and would scream out in pain. R3 will continue with current goals of ambulation with rest breaks and being able to push up from sitting position in restorative therapy due to residents set back with back pain. -2/7/22 R3 yelled out in pain upon getting out of bed. R3's sister was worried and crying saying why can't she have a back brace, writer explained that she had been seen by a doctor. -2/8/22 R3 could be heard screaming from her room while transferring with staff due to lower back pain. R3 was noted to be walking with severe flexion over her walker in a very poor stance and unable to get R3 to stand up straight. R3 was provided Motrin for pain management. -2/11/22 R3 yelled out in pain while transferred. -2/12/22 R3 kept repeating my back is so bad and R3 was educated to keep walking and moving so pain doesn't get bad. -2/13/22 R3 had an unwitnessed fall in bathroom. R3 was found in bathroom on the floor sitting on her bottom with her legs out in front of her and back against the wall. R3 was noted to have pain in midback with raising arms up over head and a red area to midback was noted. On call provider ordered Motrin, ice packs and muscle rub for the back pain if pain continues and treatments are not effective send to the emergency room . -2/14/22 R3 was noted to scream out in pain in back reporting extreme pain 9/10. -2/15/22 R3 was seen by MD for increased pain. MD ordered x-rays for back. X-rays revealed compression fracture of T12 noted. MD increased R3's [MEDICATION(S)] to 100 mg three times daily. Review of progress note from nursing home visit dated 2/2/22, indicated R3 was seen by CNP for a routine nursing home follow-up. R3 reported to CNP she had a fall on 12/14/21, and has been having some residual back pain since then. R3 had been getting scheduled [MEDICATION(S)] and Tylenol three times daily and Ibuprofen as needed. CNP indicated no new orders and encouraged [MEDICATION(S)] gel and heat to low back as needed. Review of spine lumbar x-ray results dated 2/15/22, indicated R3 had a slight compression of the superior endplate of T12 noted of indeterminate age. On 4/11/22, at 3:35 p.m. MD indicated lumbar x-rays were ordered on 12/21/22, due to R3 reporting increased pain in her back which were not completed as ordered. MD indicated depending on what those x-rays would have shown would have determined R3's pain management plan. MD indicated the facility staff did not report R3 had consistent pain and appeared to be more behavioral. Further, MD indicated R3 had a fall which occurred on 2/13/22, which she became more tender on her midline and MD was then worried about a fracture. On 4/6/22, at 3:07 p.m. licensed practical nurse (LPN)-A indicated R3 had a change in condition following her fall on 12/14/21. LPN-A indicated R3 required limited to extensive assist of one staff for ADLs and after the fall due to pain and weakness required total care with ADLs. On 4/6/22, at 3:57 p.m. registered nurse (RN)-C indicated R3 had a few falls and due to increased pain in her back, R3 was no longer independent with ADLs and required more assistance from staff for ADLs depending on her pain level. On 4/7/22, at 8:54 a.m. RN-D indicated R3 had increased weakness before she passed and had sustained a fracture to her lower spine which caused increased pain and made it difficult for R3 to ambulate. Further, RN-D indicated R3's pain management consisted of scheduled [MEDICATION(S)] and Tylenol around the clock. RN-D indicated R3 had a change in condition related to increased pain in lower back and prior R3 was independent with ambulation. In addition, RN-D indicated R3 was noted to sustain a compression fracture in her back and received a back brace that helped alleviate the pain to that area. On 4/7/22, at 9:25 a.m. nursing assistant (NA)-A indicated when she first started working as a traveling assistant for the facility R3 required minimal assistance for ADLs and R3 became weaker and had increased pain which then she required assistance of two staff for ADLs. In addition, NA-A indicated change in condition and increased pain noted is reported to the nurse on shift immediately. On 4/7/22, at 12:04 p.m. RN-A indicated R3 was needing increased amount of assistance. R3 was noted to scream out in pain during transfers and MD was following her for pain management. Further, RN-A indicated R3's back pain started approximately in November of 2021 and MD ordered a lumbar x-ray for increased back pain. RN-A confirmed the x-ray was not completed as ordered on 12/21/21, and was unsure why. On 4/8/22, at 10:57 a.m. NA-B indicated R3 required minimal assistance with ADLs and then began to require extensive to total assistance with all ADLs. RN-B indicated R3 had a fall on 12/14/21, and slowly started to decline with ADL ability and requiring more staff assistance. RN-B indicated R3 had excruciating pain that began a couple of months ago and R3 would scream in pain in her lower back during cares. Further RN-B indicated nursing would apply heat or cold to her back as needed for pain management. On 4/8/22, at 12:20 p.m. director of nursing (DON) indicated R3 was confirmed to have a compression fracture in her back and family did not want to pursue further treatment just wanted to keep R3 comfortable. Further, DON indicated R3 received a back brace for the compression fracture which helped a lot. DON stated R3's pain was being treated the best we could and sometimes residents just have pain after a call doing the x-ray earlier would not have changed anything but adding a brace. On 4/12/22, at 12:14 p.m. RN-A indicated R3 was being followed by MD for pain management. RN-A indicated R3's pain management consisted of scheduled Tylenol three times a day for arthritis pain and added [MEDICATION(S)] 100 mg three times daily for lumbar pain, as well as Biofreeze, and hot/cold packs applied to back. Further, RN-A stated R3 had a decline in ADLs due to pain and there was a big change noticed following R3's fall in December. In addition, RN-A indicated a comprehensive pain assessment was expected to be completed annually, quarterly, and as needed. RN-A indicated as needed pain assessment should be completed when a resident has a significant change and confirmed a pain assessment should have been complete following R3's fall on 12/13/21, when increased back pain was noted. On 4/12/22, at 1:47 p.m. RN-A confirmed there was no evidence MD was updated from 12/21/22 through 2/2/22, related to R3's increased back pain and increased need for assistance with ADLs due to back pain. On 2/2/22, R3 was seen by CNP related to back pain. In addition, RN-A confirmed there was not a comprehensive pain assessment completed related to significant change in R3's condition. RN-A indicated licensed nurses are expected to update the MD with change in each resident's condition, however there is no evidence MD was updated. RN-A also confirmed a pain assessment was completed on 1/31/22, for R3's quarterly assessment but no other pain assessments were completed when increased pain and significant change was noted. On 4/12/22, at 2:03 p.m. administrator indicated nursing assistants are expected to notify the floor nurse if a resident reports pain and the nurse should complete a comprehensive assessment and licensed nursing staff are expected to communicate with the clinic provider or the emergency room provider to determine next steps related to the pain. Further, administrator indicated staff are expected to complete an x-ray order timely. In addition, administrator indicated completing a comprehensive pain assessment is important and it is an expectation that it is completed especially if there has been a fall to help the resident get healthy as quickly as possible. Review of facility policy titled Pain Management revised 11/7/18, indicated the purpose of the policy is to ensure that resident's will receive pain management that allows them to maintain the highest degree of functioning and wellbeing, enhance resident comfort and satisfaction, and ensure pain relief defined by a mutually determined goal by patient, family and staff is provided for each resident according to their individual needs. Further review of policy indicated an initial pain assessment tool shall be completed on every resident upon admission and with the MDS schedule and may also be used with new onset or pain or increased pain. In addition, the policy also indicated reassess after each intervention and with each new complaint of pain in a timely manner and evaluation of resident's who receive scheduled pain medications shall be ongoing with adjustments in dosage or changes in medication made as needed after consultation with the resident and primary physician.

Based on observation, interview and document review, the facility failed to test all active staff for COVID-19 prior to working, after an identified COVID-19 outbreak, as directed by the Centers for Disease Control (CDC). This practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death for 3 of 26 residents (R13, R15, R20) who resided at the facility and were not fully vaccinated against COVID-19. The IJ began on 3/24/21, when a staff member tested positive for COVID-19 and the facility failed to ensure all active staff were immediately tested for COVID-19 prior to working; along with following ongoing outbreak testing to ensure no more active cases were circulating within the facility. The director of nursing (DON), administrator and registered nurse (RN)-A were notified of the IJ on 5/24/21, at 6:34 p.m. The IJ was removed on 5/26/21, at 5:25 p.m. but noncompliance remained at the lower scope and severity level of D, isolated, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: The CDC guidance People with Certain Medical Conditions dated 5/13/21, identified older adults were more likely to get seriously ill from COVID-19. More than 80 percent of COVID-19 deaths have occurred in people over the age of 65, and more than 95 percent of COVID-19 deaths have occurred in people older than 45. Further, among adults, the risk for severe illness from COVID-19 increases with age, with older adults at highest risk. Severe illness means that the person with COVID-19 may require hospitalization , intensive care, or a ventilator to help them breathe, or they may even die. The CDC Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 4/27/21, identified COVID-19 testing was required regardless of vaccination status during an outbreak. In nursing homes with an outbreak of COVID-19, healthcare workers and residents regardless of vaccination status should have a [CONDITION(S)] test immediately and every 3-7 days until no new cases were identified for 14 days. During the entrance conference on 5/23/21, at approximately 5:45 p.m. the DON indicated there were no staff or residents with current active or suspected COVID-19 in the facility. Documentation regarding the facility's COVID-19 testing tracking was requested including the testing, testing schedules, list of staff and residents with confirmed or suspected COVID-19 and documentation of contact with state or local health department officials related to any testing issues. The facility returned testing rosters which consisted of multiple testing labels affixed to sheets of paper, grouped by weeks into folders which identified staff and residents tested by date. A roster of untested staff, with an identified accompanying testing strategy to meet testing requirements was not provided. The facility's COVID-19 testing results and corresponding staff schedules from 3/21/21 through 5/25/21, identified the following: - During the week of 3/21/21 to 3/27/21, the facility had 50 staff members scheduled to work in the facility. Routine COVID-19 testing was completed for 17 staff members which resulted in one positive test and placed the facility in outbreak status. The facility then tested 20 staff members which resulted in an additional positive COVID-19 test. However, the facility failed to require all active staff to immediately report for COVID-19 outbreak testing. The corresponding schedule identified 17 of 32 remaining scheduled staff members continued to work in the facility without subsequent outbreak COVID-19 testing. - During the week of 3/28/21 to 4/3/21, the facility had 48 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for 28 staff members which resulted in two newly identified positive COVID-19 cases, and maintained the facility's outbreak status. However, the corresponding schedule identified 25 staff members worked in the facility without timely testing (every 3-7 days) prior to the new COVID-19 cases. Additionally, the facility failed to initiate outbreak COVID-19 testing for all staff after the newly identified COVID-19 positive cases and 17 staff members worked in the facility without the additional required testing. - During the week of 4/4/21 to 4/10/21, the facility had 45 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for 28 staff members which resulted in one newly identified positive COVID-19 case, and maintained the facility's outbreak status. However, the corresponding schedule identified 41 staff members worked in the facility without timely testing prior to the newly identified COVID-19 case. Additionally, the facility failed to initiate outbreak COVID-19 testing for all staff after the newly identified COVID-19 positive case and 17 staff members worked in the facility without the required additional testing. - During the week of 4/11/21 to 4/17/21, the facility had 44 staff members scheduled to work who required outbreak COVID-19 testing. Testing was only completed for 30 staff members. No new positive cases were identified; however, the facility remained in outbreak status as all staff had not received testing and the last case was identified less that 14 days prior. The corresponding schedule identified 40 of 43 staff members did not receive outbreak testing timely and worked in the facility prior to receiving the required testing. - During the week of 4/18/21 to 4/24/21, the facility had 46 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for only 19 staff members. No new positive COVID-19 cases were identified; however, the last positive case was identified on 4/9/21, and the facility remained in outbreak status as all staff members had not received testing. The corresponding schedule identified 32 of 46 staff members did not receive outbreak testing timely and worked in the facility without the required testing. - During the week of 4/25/21 to 5/1/21, the facility had 42 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for only 30 staff members which resulted in one newly identified positive COVID-19 case and continued the facility's outbreak status. The corresponding schedule identified 28 staff members worked in the facility without timely testing prior to the newly identified COVID-19 case. The facility then tested 11 staff members; however, failed to require all active staff to immediately report for COVID-19 testing. The corresponding schedule identified 29 of the remaining 34 scheduled staff members worked in the facility without the additional required testing. - During the week of 5/2/21 to 5/8/21, the facility had 44 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for only 21 staff members. No new positive cases were identified; however, the facility remained in outbreak status as all staff had not received testing and the last case was identified less than14 days prior. The corresponding schedule identified 36 of 44 staff members did not receive outbreak testing timely and worked in the facility without the required testing. - During the week of 5/9/21 to 5/15/21, the facility had 43 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for only 10 staff. No new positive COVID-19 cases were identified, and although the last positive case was identified on 4/28/21, the facility remained in outbreak status as all staff had not received testing. The corresponding schedule identified 38 of 42 staff members did not receive outbreak testing timely and worked in the facility without the required testing. - During the week of 5/16/21 to 5/22/21, the facility had 44 staff members scheduled to work who required outbreak COVID-19 testing. On 5/17/21, testing was completed for 5 staff members which resulted in 2 newly identified positive COVID-19 cases and continued the facility's outbreak status. The corresponding schedule identified 20 staff members worked in the facility without timely testing prior to the newly identified COVID-19 cases. The facility then tested 13 staff members; however, failed to require all active staff to immediately report for COVID-19 outbreak testing. The corresponding schedule identified 35 of the remaining 37 scheduled staff members did not receive outbreak testing timely and worked in the facility without the required testing. - From 5/23/21 to 5/25/21, the facility had 40 staff members scheduled to work who required outbreak COVID-19 testing. Testing was completed for 39 staff members. No new positive cases were identified; however, the facility remained in outbreak status as all staff had not received testing and the last case was identified less than 14 days prior. The corresponding schedule identified 18 of 40 staff members did not receive outbreak testing timely and worked in the facility without the required testing. During interview on 5/24/21 at 10:16 a.m. the DON indicated the most recent COVID-19 positive result for a staff member occurred the previous week. Nursing assistant (NA)-A worked on 5/16/21, and became symptomatic after her shift that evening. On 5/17/21, NA-A's symptoms worsened, and she was tested . The facility notified staff via text message and immediately did outbreak testing on Monday, 5/17/21. On 5/18/21, NA-A's COVID-19 test returned positive along with one additional staff member. - At 10:45 a.m. the DON stated the facility encouraged but did not force active staff to be tested for COVID-19 and staff who declined testing were allowed to continue working due to the facility's internal staffing concerns. They were in contingency staffing; however, were able to utilize agency staff to fill open positions. Further, there were three residents in the facility that were unvaccinated for COVID-19. R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R13's signed COVID-19 Vaccine Consent Form dated 12/9/20, indicated R13 declined consent for the COVID-19 vaccination. R15's quarterly MDS dated [DATE], indicated R15 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Potassium is a chemical that is critical to the function of nerve and muscle cells, including those in the heart). The undated COVID-19 Vaccine Consent Form indicated R15's family provided verbal declination for the COVID-19 vaccination. R20's quarterly MDS dated [DATE], indicated R20 was greater than [AGE] years of age and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's undated Resident Face Sheet indicated R20 also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The COVID-19 Vaccine Consent Form indicated R20 declined the COVID-19 vaccination on 1/25/21. On 5/24/21, at 11:44 a.m. licensed practical nurse (LPN)-A was observed working at the facility. LPN-A stated she tested negative for COVID-19 on 5/10/21, and was unaware of the testing frequency or when she should've been tested again. LPN-A stated she worked during the week of 5/10/21, 5/17/21 and 5/24/21 even though she had not tested for COVID-19 since 5/10/21. During interview on 5/24/21, at 11:52 a.m. NA-C, who was working in the facility, stated some staff and residents were tested for COVID-19 approximately two weeks ago. NA-C was not tested at that time and did not remember the last time she was tested . NA-C was uncertain when staff were to be tested again. When interviewed on 5/24/21, at 3:11 p.m. DON stated she was aware of QSO (Quality Safety and Oversight) memo 20-38, updated 4/27/21, which identified the outbreak testing requirements; however, she allowed staff to decline testing and continue to work if they were asymptomatic. Further, not every staff member was tested as required by the QSO memo. She indicated this practice was in the facility staffing plan for contingency staffing; however, had not reached out to the State Agency (SA) regarding her staffing concerns. Additionally, she was not tracking the vaccination status of the staff but estimated approximately 45% of the staff had received the COVID-19 vaccine while 55% remained unvaccinated, which was needed to determine routine testing requirements. During interview on 5/24/21, at 4:56 p.m. NA-D, who was working in the facility, stated he was last tested for COVID-19 maybe two weeks ago but had worked in the facility since that time. On 5/24/21, at 5:02 p.m. NA-B, who was working in the facility, stated she tested negative for COVID-19 the week prior and was not tested since. She was notified via text message of a positive staff member and instructed to be tested again on 5/24/21. NA-B was not tested upon entering the facility on 5/24/21, and continued to perform her NA duties without being tested since the week prior. The Centers for Medicare and Medicaid (CMS) QSO-20-38-NH memo dated 8/26/20, directed, Facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing. The facility Response Plan to Support COVID-19 Testing updated 2/11/21, identified testing would be conducted in addition to existing infection prevention and control measure recommended by the CDC and/ or SA as appropriate. The testing plan included the following trigger: point prevalent testing when a positive result has occurred among staff who had worked within 48 hours of onset, or any positive result with a resident. While the plan identified the testing approach should follow any guidelines put out by SA or CDC it also directed testing was strongly encouraged for all residents, and staff and other essential visiting caregivers indicated in the plan; however, was not mandatory. The plan further directed, if a staff member refused to be tested the testing team would continue to monitor for symptoms. Staff would be allowed to work if they were asymptomatic. If staff were symptomatic and there was no other diagnostic reason, staff would be required to quarantine based on CDC/SA/CMS guidelines before returning to work. If a staff member missed the testing dates, the staff would be tested on their next scheduled shift. The IJ which began on 3/24/21, was removed on 5/26/21, at 5:25 p.m. when it was verified through interview and document review: 1)The facility updated their testing policy to follow QSO memo 20-38 revised 4/27/21, requiring all staff to be tested regardless of vaccination status during an outbreak and any staff who refused testing would be restricted from work until testing was completed. Further, all unvaccinated staff would be required to routinely test based on county positivity rates. 2) All staff were tested prior to working. They implemented a plan to ensure all staff were tested prior to their next scheduled shift by RN staff. Further, any staff who tested positive would be restricted from working until the recommended return to work guidance per the CDC. 3) The facility educated the RN charge nurses on testing staff prior to their next shift. All facility staff were educated on the requirements for outbreak and routine testing prior to their next scheduled shift, including casual staff.

Based on observation, interview, and document review, the facility failed to comprehensively re-assess, thoroughly investigate causal factors and implement effective interventions in order to minimize the risk of falls and injury for 1 of 3 residents (R32) who sustained harm following a fractured wrist and has had continued falls. The facility was utilizing a care planned intervention related to use of a chair alarm, however, did not follow manufacturer instructions rendering the intervention ineffective when the device was not affixed properly. This resulted in an immediate jeopardy situation for R32. Findings include: The Immediate Jeopardy (IJ) began on 9/20/16, related to the facility's failure to complete a comprehensive assessment to determine causal factors related to risk for falls and implement effective interventions for R32. The facility administrator and director of nursing (DON) were notified of the IJ on 1/5/17, at 10:15 a.m. which began on 9/20/16, when R32 had fallen and the facility failed to complete a comprehensive assessment of causal factors related to R32's continued falls, in a effort to implement interventions to minimize the risk of R32's risk for further falls. The IJ was removed on 1/6/17, at 4:00 p.m., however, non-compliance remained at a scope and severity level of G, which indicated actual harm for R32 due to a left wrist fracture sustained during a fall which required medical assessment and intervention. R32's [DIAGNOSES REDACTED]. R32's admission Minimum Data Set ((MDS) dated [DATE], indicated R32's history of falls, or fall risk could be determined. R32's MDS identified R32 had severely impaired cognition, required extensive assistance with activities of daily living (ADLs), was occasionally incontinent of urine, was not on a toileting program, received antibiotic medication and had a urinary tract infection (UTI) which increased R32's risk for falls. R32's MDS further identified R32 had hallucinations and wandered which put R32 at significant risk for injury. R32's Falls Care Area Assessment (CAA) dated 8/2/16, indicated R32 had 1 fall. R32 was found on the floor in her room in front of her recliner. She had an x-ray which was negative for a fracture, and R32 remained a high fall risk. R32's Cognitive Loss/Dementia CAA dated 8/2/16, indicated R32 had obtained a bladder infection during her first week of admission and remained very confused and delirious at times. R32's Falls Risk Acuity report dated 7/21/16, indicated R32 had poor safety awareness, required the use of assistive devices, was up ad lib and was continent. The report indicated R32 took antihypertensive and laxative medications that increased R32's risk for falls. The report further indicated R32 had cognitive impairment with a decline in cognitive function, delirium, depression and dementia. The report identified R32 was at risk for falls and was to be seen by PT and occupational therapy (OT) and a falls care plan would be initiated. R32's care plan dated 12/30/16, indicated R32 had memory and cognitive problems that seemed to worsen with UTI's. R32 had a physical decline in all of her ADLs since the UTI, and signs of delirium as she reached for things she saw in the air. R32's care plan indicated the goals were to be safe in her surroundings, needs would be met and R32 would be monitored for safety concerns. R32's care plan identified R32 had been incontinent of bowel and bladder since admission and incontinence was possibly related to her recent UTI and fall. R32 was to be toileted every 2 hours. R32's care plan indicated as of 11/21/16, staff was not to leave R32 alone in the bathroom and watch for her trying to go to the bathroom by herself. The care plan identified R32 had bed and chair alarms placed 7/27/16, due to R32 self transferring, a tab alarm placed 9/20/16, due to standing without purpose, all items were to be within reach, no clutter on the floor, call light within reach, fall mat placed, bed in low position and lipped mattress. R32's care plan further identified R32 fell on [DATE], and had no injury, another fall 9/20/16, with skin tear and left wrist fracture, and fell again on 11/21/16, with no injury. The care plan failed to identify R32's falls on 8/27/16, and 10/9/16. There were no injuries. R32's undated North Assignment sheet (tool nursing assistants use to direct care), indicated R32 required the assistance of 1-2 staff for ADLs which included transfers and toileting, and identified R32 had a bed and chair alarm. Fall events: 1. R32's Fall Safety Event report indicated R32 fell on [DATE], at 7:30 p.m. after she attempted to self transfer and was found on the floor in her room. The report indicated R32 had complaints of pain in her buttocks and right thigh, had a fever and UTI. The report identified neurological checks (neuros) and vital signs (vitals) were checked and fall interventions included analgesics (pain medication), bed alarm and rest. R32's progress note (PN) dated 7/27/16, at 7:30 p.m. indicated R32 was found on the floor in her room in a sitting position with both legs off to her right side. R32 stated her butt and right leg and thigh hurt. The note identified R32 denied hitting her head and referred to the fall safety event report. R32's pelvic and hip X-ray report dated 7/31/16, at 5:02 p.m. identified R32 had abnormal bony projections throughout her pelvis and degenerative changes without definite fracture. 2. R32's Fall Safety Event report indicated R32 fell on [DATE], at 10:21 a.m. The report indicated R32's chair alarm sounded after she attempted to self transfer from her wheelchair to the commode. R32 was observed to slip and fall on the floor on her butt and hit her head on the bathroom door knob. The report indicated R32 complained of slight pain in her lower back and her vitals signs were taken. The report failed to identify R32's mental status, possible contributing factors, if current interventions were effective, or any new interventions implemented after the fall. R32's PN dated 8/27/16, at 10:38 a.m. indicated R32 slipped and fell on her butt and bumped her head on the door knob. R32 complained about slight pain in the middle of her back. R32's vitals were taken and the new intervention was to ensure R32 had her shoes on. 3. R32's Fall Safety Event report indicated R32 fell on [DATE], at 10:30 p.m. after R32 attempted to self-transfer. She was found on the floor in her room facing her bed with a skin tear to her right forearm. The report indicated neuros and vitals were completed, there were no possible contributing factors, current interventions were effective and an additional intervention was a floor mat. The record lacked a reassessment of R32's risk for falls. R32's PN dated 9/20/16, at 10:30 p.m. indicated R32 was found seated on her floor with her back against the bed. R32 stated she scooted down. The note indicated vitals were taken and would be monitored every 4 hours per facility policy. R32 had no complaints of pain. The report identified R32 sustained a skin tear to her right forearm, neuros were at baseline and a floor mat would be requested. A PN dated 9/21/16 at 10:23 a.m. identified R32 complained of wrist pain while in therapy. Swelling was noted in the wrist and facial grimacing when touched. R32 was seen by the physician and an x-ray was ordered. R32's left wrist X-ray report dated 9/21/16, at 4:03 p.m. identified a left wrist fracture. 4. R32's Fall Safety Event Report indicated R32 fell on [DATE], at 1:53 p.m. after she self-transferred from a wheelchair to the toilet in her bathroom. R32 slid onto her butt. The report indicated R32 did not hit her head, had no complaints of pain and vitals were completed. The report failed to identify if current interventions were effective or any new interventions. R32's PN dated 10/9/16, at 1:45 p.m. identified R32 was found on the bathroom floor after she slid off the toilet onto the floor. The report indicated R32 had not hit her head, had no complaints of pain and her vital signs were taken. The note failed to identify any new interventions after R32 fell . R32's Falls Risk Acuity report dated 10/25/16, indicated R32 was disoriented with diminished safety awareness, required the use assistive devices, had impaired mobility and was continent with staff assistance. The report indicated R32 took antihypertensive, narcotic and laxative medications that increased R32's risk for falls. The report further indicated R32 had 3 or more falls in the last 3 months, loss of limb movement, decline in physical status, incontinence, hypotension (low blood pressure), cerebrovascular accident (stroke) and weakness to 1 side of her body. The report identified R32 was at risk for falls, no referrals were necessary and they were to continue current plan of care. 5. R32's Fall Safety Event Report indicated R32 fell on [DATE], at 12:33 p.m. after she self-transferred from the wheelchair to the toilet in the east bathroom. R32 slid down between the toilet and the wall. The report indicated neuros and vitals were taken and R32 complained of pain on the right top of her hand. The report failed to identify if current interventions were effective and any new interventions added after the fall. R32's PN dated 11/21/16, at 12:11 p.m. identified R32 self transferred from her wheelchair to the toilet in the bathroom before staff could get to her and she slid down between the toilet and the wall. The note indicated R32 complained her right hand was sore and she was emotionally upset. The report further indicated vitals were taken and R32's care plan would be updated. The note failed to identify any new interventions implemented after R32 fell . On 1/3/17, at 1:44 p.m. R32 was observed seated in a recliner in the common area with a TABS alarm (fall prevention monitor) adjustable cord clipped to the back of R32's shirt. The unit was not attached to the recliner but placed between arm chair cushions, which may have prevented it from sounding if R32 attempted to stand independently. When the TABS unit was not secured, the cord can stay attached to the unit. If it does not separate, the alarm will not sound alerting staff to the independent transfer. The foot rest was up on the recliner. R32 made no attempts to stand. Review of the User Instructions for the Personal Sentry Fall Monitoring System (TABS style unit) identified the monitor was to be mounted to either a chair or bed using the clip on the back of the monitor, the magnetic disc from the pull string was to be secured to the monitor magnet, and the locking clip attached to the resident's garment at the top of the shoulder or back of the neck with the appropriate cord length determined in order for the person to activate alarm. When a resident moved beyond the determined length of the cord, the disc pulled from the monitor and the alarm would sound. The user instructions directed staff to follow the installation instructions, particularly the warnings and cautions when using the fall monitoring system and failure to do so could result in injury or death. On 1/4/17, at 8:34 a.m. R32 was observed seated in a recliner in the common area with a TABS alarm cord clipped to the back of R32's shirt. The TABS unit was not attached to the recliner. It was on the right arm of the recliner chair. The footrest on the recliner was elevated. R32 made no attempt to stand. -8:45 a.m. R32 was observed seated in a recliner in the common area with a TABS alarm cord clipped to the back of R32's shirt and the unit was not attached to the recliner but on the right arm of the recliner chair. R32's right arm was in front of alarm unit. R32 made no attempts to stand. The recliner footrest remained up. -9:27 a.m. R32 was observed seated in a recliner in the common area with a TABS alarm cord clipped to the back of R32's shirt and the unit was not attached to the recliner but on the right arm of the recliner chair. The footrest remained up on the recliner. R32 made no attempts to stand. -9:35 a.m. R32 was observed seated in a recliner in the common area with a TABS alarm cord clipped to the back of her shirt and the unit was not attached to the recliner but on the right arm of the recliner chair. The footrest on the recliner remained elevated. R32 made no attempts to stand. -10:05 a.m. after asking nursing assistant (NA)-B about R32's toileting schedule NA-B stated, I was just about to do that. NA-B asked R32 if she wanted to use the bathroom. R32 said yes. R32 reached forward and grabbed the seat of her wheelchair with both hands, patted the seat, and picked at the wheelchair arms with her right hand. NA-B applied the gait belt and removed the TABS alarm unit from the recliner and R32's shirt and placed them in the storage pouch on the back of her wheelchair. NA-B cued R32 to stand up. R32 stood up slowly and held on to both arms of the wheelchair. R32 was stooped over and very unsteady. NA-B assisted R32, holding on to her with the gait belt and assisting her to turn around and sit down in her wheelchair. R32 took small steps during transfer remaining stooped over and moving slowly. -11:15 a.m. R32 was observed seated in a recliner in the common area. The footrest was up on the recliner. The TABS alarm cord was clipped to the back of R32's shirt. The unit was not attached to the recliner but was sitting on the right arm of the recliner chair. R32 made no attempts to stand. -12:27 p.m. NA-B transferred R32 from her wheelchair to the recliner using a gait belt, cueing and physical assistance. R32 leaned forward in her recliner when NA-B attempted to elevate her feet with the recliner leg rest. R32 became upset and stated loudly and harshly, I don't want that up. NA-B said ok and clipped the TABS alarm cord to the back of R32's shirt and placed the alarm unit loosely under the right recliner arm cushion. The unit was not attached to R32's chair. R32 leaned forward, lifted her bottom off the recliner seat and plopped herself back down in recliner. R32 scooted herself back in the chair. The alarm did not sound during this activity. NA-B had left the area. -12:33 p.m. R32 leaned forward in the recliner, looked around the area and leaned back in the chair. No staff were present in area. -12:36 p.m. No staff were present in area. R32 leaned forward and pulled some of the alarm unit cord forward with the unit. The alarm did not sound. There was too much slack in the cord and the unit was unattached making the alarm ineffective. R32 attempted to get up from the recliner. R32 was able to get her bottom to the edge of the recliner chair. She was then able to lift her bottom approximately 2 inches from the chair. Although the cord pulled slightly with R32 as she moved, there was too much slack for the alarm to sound. R32 then attempted to self transfer. R32 leaned forward, pushed off of the recliner chair arms with both hands and attempted to stand. No staff was present, and the alarm failed to sound, so one surveyor remained with R32 while another surveyor left to find staff to assist R32. NA-C was found running water for a bath. NA-C was alerted to R32's attempts at self transferring in the day room. NA-C called for NA-A to help her in the day area. They physically assisted R32 with cues and a gait belt from the recliner to her wheelchair. NA-C confirmed the TABS alarm was not attached to R32's chair and should have been. On 1/4/17, at 12:41 p.m. NA-B stated they usually put the TABS alarm on the side of the bed or chair. She stated there was a clip on the unit to be attached to her chair. NA-B confirmed R32's alarm should have been attached to her chair and not resting on the arms of the recliner. NA-B confirmed she had received education on how to operate and place the alarm when she was hired. On 1/5/17 , at 9:13 a.m. R32 was observed self propelling from the day room to the east bathroom using only her feet. R32 leaned forward and opened the bathroom door when the alarm sounded. R32 continued to push herself through the doorway and was scooting forward in her chair. NA-D intervened and redirected R32, wheeling R32 out of the bathroom into the hallway. NA-D and R32 had a brief conversation in the hallway and NA-D assisted her into the bathroom and closed the door. On 1/5/17, at 9:33 a.m. NA-D and NA-C were observed standing in the north hallway. R32 was seated in her wheelchair. NA-D stated they were going to assist R32 with ambulation. NA-D applied a gait belt around R32's waist and NA-D and NA-C cued R32 and physically assisted her to stand up. R32 pushed herself up with her hands on the wheelchair arms a couple times to gain momentum and NA-D and NA-C assisted her to stand. NA-D provided R32 with a walker and NA-C followed R32 and NA-D with a wheelchair. R32 was confused and grabbed the left arm handle of the walker and the front bar of her walker. NA-D cued R32 to grab the right walker handle with her right hand. R32's left foot swung in front of her right foot, R32 was leaned forward and her legs were weak. NA-D confirmed R32 had walked 100 feet and that was the farthest she ever walked. NA-D later confirmed she walked an additional 80 feet and stated R32 wanted to walk even more. On 1/4/17 at 2:16 p.m. R32's falls including fall event reports, progress notes, care plan and interventions implemented were reviewed with the DON. The DON stated the following: The DON verified the fall information and stated she were not aware staff was not placing R32's TABS alarm correctly. She stated she just assumed they affixed it to her chair or recliner. The DON stated she used a communication board and R32's care plan to ensure staff understood how to care for her. She also stated the NAs had an assignment sheet that summarized R32's care plan and stated some NA's chose not to carry it with them. She stated she expected staff to rely on their best judgement and R32's care plan to determine whether or not to apply R32's TABS alarm in a common area. The DON stated she expected the TABS alarm to be affixed if she was in her room or in her wheelchair. For the fall of 7/27/16, at 7:30 p.m. the DON verified the fall information and stated she thought R32 tried to self-transfer and get out of bed. She stated the fall was unwitnessed and after the fall R32 had complained of a sore butt and pain in her right thigh. The DON stated sometimes R32 could not make sense of things. She stated bed and chair alarms were added to R32's care plan. The DON verified the fall information dated 8/27/16, at 10:21 a.m. She stated R32 tried to self-transfer. R32 got herself up, slipped and fell when she tried to go to the bathroom. She stated the fall was witnessed and the intervention was to make sure R32's shoes were on. The DON stated the fall on 9/20/16, at 10:30 p.m. resulted from R32 self transferring, attempting to get out of bed, and stated she wasn't sure why R32 was trying to transfer. The DON verified the documentation was accurate. She stated R32 sustained a left wrist fracture after the unwitnessed fall and it was reported to the State Agency. She stated a floor matt was added after the fall. The DON verified the information documented for the fall on 10/9/16, at 1:53 p.m. She stated R32 self transferred to the toilet and slipped and fell on the bathroom floor. She stated the fall was unwitnessed, vitals were completed and R32 did not hit her head. The DON confirmed there were no new interventions added after R32's fall. The DON stated the fall information on 11/21/16, at 12:33 p.m. was accurate. R32 was in the bathroom and stood up from her wheelchair trying to get to the toilet. She said R32 fell between the toilet and the wall in the bathroom. The DON stated after one of her falls staff tried to keep her at the nurses station and give her things to do. She stated the new intervention added was not leaving R32 alone in the bathroom. The DON stated R32 had moderate to severe cognitive impairment and R32 had no concept of time, or where she was at. She confirmed R32's last fall assessment was completed on 10/25/16. There were no other fall assessments. The DON stated R32 was at high risk for falls due to the amount of assistance and cueing she required with ADLs. R32 had forgotten she wasn't as mobile as she used to be and would try to stand up. She stated she had not considered doing a bowel and bladder assessment on R32, and stated those were only done quarterly. She stated she had not considered any other fall prevention interventions for R32. The DON stated they also tried to keep R32 in their line of vision, give her something to do at the nurses desk, and did not like to leave her alone in her room for extended periods of time. The DON confirmed they do not have a, Falls, policy and would continue to use the current fall event form in Matrix (clinical documentation system) until they developed a preventative program and new plan. On 1/4/17, at 12:48 p.m. NA-A stated R32 was at risk for falls because she wandered, tried to stand up and reached forward in her chair. NA-A stated the last time she observed R32 get up from her wheelchair was a couple of days ago. She stated she thought R32 had only fallen once on the first day she was admitted . NA-A stated she thought she slid out of her bed and had to wear a cast after the fall. NA-A stated she was not aware of any other falls for R32. She stated R32's fall interventions were the TABS alarm and to keep R32 busy. She stated they tried to keep R32 by them otherwise her alarm was going off. She stated R32's tab alarm was not attached to the recliner today and should have been. On 1/4/17, at 12:53 p.m. clinical manager (CM)-A stated a fall intervention for R32 was to have a tab alarm in place secured to her recliner or chair. She stated R32 had the tab alarm because she had a history of [REDACTED]. She stated R32 was at risk for falls because she had no safety awareness. CM-A stated she expected the nurse on duty to make sure her alarm was placed correctly. On 1/4/17, at 1:06 p.m. licensed practical nurse (LPN)-A stated R32's TABS alarm should be secured. She stated she hated to see the NA's wedge the alarm unit in the arm of the recliner chair. LPN-A stated she had previously educated the NA's to secure R32's TABS alarm. On 1/5/17, at 8:56 a.m. NA-D stated R32 started a restorative program on 8/15/15. NA-D stated she was currently working with R32 on both upper and lower extremity exercises and ambulation about 3 times per week as tolerated. NA-D stated she felt R32 had moderate cognitive impairment and some day's R32 was really confused. She stated R32 was at risk for falling and required extensive assistance with ADLs. She stated she could walk 86-89 feet with staff assistance but R32's legs got tired. NA-D stated she felt R32 didn't attempt to get up that often except when her cognition was, off that day. She stated the last time she observed R32 try to stand up was 2-3 weeks ago. On 1/5/17, at 9:25 a.m. the activities director (AD) stated she felt R32 was at moderate risk for falls when she was alone in her room and when she tried to stand up from her wheelchair. The AD stated the last time she saw R32 try to get up on her own was 1/3/16 when R32 wheeled herself into the east bathroom. She stated whenever R32 tried to stand up on her own they would remind her not to and she would reply, I know. On 1/5/17, at 12:34 p.m. physical therapist (PT)-A stated he did not complete an initial physical therapy evaluation when PT started on 8/2/16. PT-A confirmed he did not complete a PT discharge summary for R32 when she was discharged from PT on 9/2/16. He stated R32's cognition dropped significantly within the first couple weeks of admission. It was difficult to get her up to walk even with cueing and assistance from staff. He stated R32 was discharged from PT because of severe cognitive and balance impairment. He further stated R32 did not make any progress during PT and continued to be at risk for falls. On 1/6/17, at 9:59 a.m. the occupational therapist (OT) confirmed R32's OT evaluation on 7/22/16. The OT stated R32 had been discharged from OT on 8/12/16. The OT confirmed she had not completed a discharge evaluation for R32 and stated she must have overlooked it. She stated when R32 began therapy she was confused and required supervision and physical assistance from staff with bed mobility and transfers and used a walker. She stated after R32 fell on [DATE], it became difficult for R32 to go from a sitting to standing position. The OT stated at that point R32 could not be left unattended because she would lose her balance. The OT confirmed R32 was at risk for falling because she required physical assistance of staff for ADLs, had weakness in her legs and had a difficult time transitioning from sitting to standing. She stated when R32 was discharged from OT on 8/12/16, she was more confused, and had increased difficultly following directions. She further stated pain was a limiting factor for OT progress after her fall on 7/27/16. The OT stated they started OT with R32 again on 11/7/16, after R32's splint had been removed and she was able to use her left wrist for ADLs. The OT stated R32 was discharged again from OT on 11/23/16, and R32's left hand was swollen, had limited flexion and some pain. She stated R32's limiting factors and reason for discharge from OT on 11/23/16, was due to poor cognition. She stated R32 required staff assistance and cues to ambulate with her walker. The OT stated R32 continued to be at risk for falls because she required assistance with ADLs and cognition. The OT additionally stated the last time she saw her, R32 was able to self propel herself in the wheelchair using only her feet. The immediate jeopardy which started on 9/20/16, was removed on 1/6/17, at 4:00 p.m. after the facility completed the following interventions as part of their removal plan: -R32 was comprehensively assessed for falls -R32's care plan was updated to reflect R32's assessment for current risks for falls and fall interventions -Staff were educated on R32's fall interventions -On 1/6/17 from 3:00 p.m. to 4:00 p.m. direct care staff, including licensed nursing staff were interviewed regarding R32's safety risks. All of the interviewed staff were aware of R32's risk for falls, and the fall interventions to ensure R32's safety.

Based on observation, interview and document review, the facility failed to implement interventions, monitor for efficacy and reassess the pain management program to relieve frequent moderate to severe pain following a [MEDICAL CONDITION] clavicle for 1 of 3 residents (R18) reviewed for pain. This deficient practice caused actual harm to R18. Findings Include: R18's admission Minimum Data Set ((MDS) dated [DATE], identified R18 had moderate cognitive impairment and had [DIAGNOSES REDACTED]. The MDS identified R18 had frequent pain of a moderate level and had received as needed (PRN) pain medications. The MDS identified R18 did not receive scheduled pain medications or non-medicinal interventions for pain within the seven day look back period. On 1/6/17, at 8:20 a.m. registered nurse manager (NM) stated R18's cognition had improved since his admission assessment and no longer had moderate cognitive impairment. At the time of the survey R18 had improved in cognition. NM stated R18 had minimal cognitive impairment and was able to verbalize his needs and wishes without difficulty. NM stated R18 would be a reliable source of information regarding his pain level. Review of R18's Pain Care Area Assessment (CAA) dated 11/2/16, identified R18 had many complaints about shoulder, neck and back pain. The CAA identified R18 had a history of [REDACTED]. Although R18 reported consistent, significant pain, there were no re-assessments of pain after this CAA. The facility failed to re-assess the pain and pain management program in order to determine efficacy of interventions and the need to modify any existing or implement new interventions. Review of R18's pain assessment dated [DATE], revealed R18 had stated upon staff interview he had frequent pain of the right shoulder and clavicle (collar bone) with onset of movement. The assessment revealed R18 had described the pain as an ache and was of a moderate intensity. The assessment revealed interventions were in place of Tylenol 650 milligrams (mg) by mouth (po) every four hours as needed (PRN) and a referral for physical therapy (PT) and occupational therapy (OT). Review of R18's care plan dated 11/15/16, revealed R18 had complaints of chronic pain related to a history of [MEDICAL CONDITION] and falls with recent collar bone fracture. R18's care plan revealed R18 had complained of pain with therapy, he had been educated to continue therapy despite the pain as he had not been using his arm due to pain. R18's care plan directed staff to provide R18 with pain medications, BioFreeze (an over the counter topical pain relieving medication) and non-pharmacological pain interventions of warm/cold packs. R18's care plan revealed PT had been ordered for shoulder pain and R18's MD had declined further pain medications or diagnostic testing of an MRI as of 11/8/16. The care plan further revealed R18 had enjoyed activities of trivia, reminiscing, and western movies shortly after he was admitted and R18's shoulder pain prevented him from attending activities. The care plan also revealed R18 preferred to lay in bed for comfort and had declined further activities due to pain. An identified care plan goal was for R18 to develop coping strategies to help adapt to pain. On 1/4/17, at 12:40 p.m. R18 was lying on his left side in bed, facing the TV with his eyes open. R18 had his right arm guarded to his chest and a furrowed brow, clenched jaw and squinted eyes, with facial grimacing. On 1/4/17, at 2:37 p.m. R18 was seated on the edge of his bed, his feet on the floor. His right arm was tightly guarded to his chest. As he coughed, R18 grimaced with a furrowed brow. R18 stated he had been experiencing pain following a fall prior to admission to the facility in late October 2016. R18 continued to guard his right arm, and grimace. R18 stated he had sharp pain which started at his collar bone and radiated down to his hand. R18 stated at times the pain was severe, being at least an 8 on a pain scale of 0 to 10 with 10 being the worst imaginable pain. R18 stated he was right handed, so being independent with his cares and eating had been hard as he experienced pain whenever he moved his right arm. R18 stated at times it was hard for him to sleep at night and coughing significantly increased his pain level. R18 stated he told the nurses he had pain everyday. R18 stated the nurses offered him [MEDICATION NAME] and Tylenol for the pain which was frequently ineffective. R18 stated he had been told by the nurses to work with therapy for the pain and stated he could not work with therapy due to it causing too much pain. R18 stated his physician had recently started him on the medication, [MEDICATION NAME] (a medication used to treat nerve pain from [MEDICAL CONDITION]). R18 stated he had been taking the [MEDICATION NAME] since December and had not had relief from the pain. R18 stated he felt he had a high pain tolerance as he was no stranger to pain, and the nurses and doctor should listen to him when he said the medications were not relieving his pain. R18 stated the staff had offered ice packs right after he was admitted and that was also ineffective. R18 continued to exhibit a furrowed brow, squinted eyes, and grimacing. R18 stated he felt the pain had affected his well being, he felt depressed and all he did was smoke and try to sleep the pain away but couldn't do it. R18 stated he felt his continued pain kept him isolated and he did not feel like himself. Review of R18's current physician orders [REDACTED]. A hand written order dated 12/16/16, revealed an order for [REDACTED]. Review of R18's Medication Administration Record [REDACTED] -October 2016, revealed R18 had reported moderate to severe pain and had received PRN Tylenol 650 mg 10 times and one out of 10 times R18 had received relief from the Tylenol. R18 had reported somewhat effective relief the other nine times. -November 2016, revealed R18 reported moderate to severe pain and had received PRN Tylenol 650 mg 44 times. The MAR indicated [REDACTED]. R18 had reported effective results the other 15 times. -December 2016, revealed R18 had reported moderate to severe pain and had received PRN Tylenol 650 mg 32 times and out of the 32 times, 18 times R18 had reported the medication was somewhat effective and 3 times ineffective and 11 times was effective. The MAR indicated [REDACTED]. -January 2017, revealed R18 had reported moderate to severe pain and had received Tylenol 650 mg 3 times and out of the three times R18 had somewhat effective pain relief. The MAR indicated [REDACTED]. Review of an x-ray report dated 10/14/16, identified R18 had a displaced [MEDICAL CONDITION] third of the clavicle which appeared to be a healing subacute fracture. Review of R18's physician progress notes [REDACTED]. The note revealed R18 had attended therapy at the time of the note for right upper extremity and staff could apply moist heat 15 minutes per hour as able for the pain. The note revealed R18 had suffered a fracture of his right collarbone on 10/14/16 and had suffered constant, sharp pain which radiated from his collarbone down his right arm and occurred with any type of activity. The note revealed R18 had significant deformity of his collarbone with tenderness over the joint. The note further revealed R18 was to be seen again in four weeks. Review of R18's physician note dated 12/7/16, revealed R18 was seen by an orthopedic physician regarding his right shoulder. The note revealed R18 had been having significant pain and had been unable to comply with therapy in the facility due to right arm pain. The note identified R18 had a healing right distal clavicle fracture with possible cuff dysfunction with his pain. The note further revealed R18 had weakness with external rotation, that may have been due to pain. Review of R18's physician progress notes [REDACTED]. The note revealed R18 complained of ongoing pain in the right shoulder. The note revealed R18 had significant right shoulder girdle atrophy with a marked deformity of the distal clavicle. The note further revealed R18's internal and external rotation were limited. The note also revealed R18 had tenderness to touch over the right shoulder. The note revealed R18 was to continue to receive heat application therapy and use Tylenol and [MEDICATION NAME] for pain management. The note further revealed R18 was to continue with passive and active range of motion (ROM) exercises and the physician would consider adding additional pain medication if no improvement in R18's pain. Review of Therapy Assessment, OT evaluation form dated 10/28/16, revealed R18 had been evaluated for therapy and had impaired upper ROM both active and passive of his right upper extremity. The assessment revealed R18 was referred to the facility functional maintenance program (FMP) three times a week for ROM. Review of a Therapy Assessment, PT evaluation form dated 11/9/16, revealed R18 had shoulder pain from a fracture and had decreased ROM and pain. The assessment identified R18 has constant pain which would shoot down his arm. The assessment revealed R18 had reported Tylenol was not effective in relieving his pain which he had rated an 8 out of 10. The assessment revealed R18 understood the need to move his arm around, though did not want to due to pain. The assessment revealed PT had attempted seven visits with R18 from 11/11/16 to 12/1/16 and R18 had participated in therapy on three of the seven visits and had refused the rest. The assessment further revealed R18 continued to have pain in his shoulders. Review of facility progress notes from 10/27/16, to 1/4/17, revealed the following: -A note on 10/27/16, revealed R18 was alert and oriented, had complained of shoulder pain rated a 7 out of 10, received Tylenol 650 mg. The note revealed R18 reported a tolerable level of pain was a 3 out of 10. - A note on 10/30/16, revealed R18 complained of pain rated 6 out of 10 and received Tylenol 650 mg. -A note on 11/04/16, revealed R18 complained of right shoulder pain rated a 7 out of 10 and had received Tylenol 650 mg. -A note on 11/5/16, revealed R18 complained of right shoulder pain, rated 8 out of 10 and received Tylenol 650 mg. The note revealed R18 had reported pain of 4 out of 10 after receiving the Tylenol. - A note on 11/6/16, revealed R18 complained of right shoulder pain, rated 6 out of 10 and received Tylenol 650 mg. The note revealed R18 had reported pain of 2 out of 10 after he received the Tylenol. - A note on 11/7/16, revealed R18 refused therapy due to right arm pain. - A note on 11/8/16, revealed R18 was not seen for restorative therapy for the week of November 2 - 8, due to right shoulder pain. Another note revealed R18 had been seen in the facility by his primary physician. The note revealed R18 complained of right shoulder pain and requested an MRI. The note further revealed R18's MD ordered PT for shoulder pain and ROM. -A note dated 12/2/16, as a late entry for 11/11/16, revealed R18 was seen by PT for right shoulder pain and completed ultrasound and therapeutic exercises which included passive ROM. -A note dated 12/2/16, as a late entry for 11/15/16, revealed R18 had been seen for 25 minutes by PT, received ROM exercises and reported continued pain of the right shoulder. -Review of notes dated 12/2/16, as late entries for 11/16/16, 11/18/16, revealed R18 refused therapy. -A note dated 11/19/16, revealed R18 complained of shoulder pain rated 6 out of 10 and received Tylenol 650 mg. - A note dated 12/2/16, as a late entry for 11/22/16, revealed R18 refused therapy. -A note dated 12/2/16, as a late entry for 11/23/16, revealed R18 refused therapy. -A note dated 11/28/16, revealed R18 complained of shoulder pain rated 7 out of 10 and received Tylenol 650 mg. The note revealed R18 had rated his pain 4 out of 10 after he received the Tylenol. - A note dated 11/30/16, revealed R18 complained of shoulder pain rated a 7 out of 10 and received Tylenol. The note revealed R18 had rated his pain 3 out of 10 after he received the Tylenol. - A note dated 12/2/16, late entry for 12/1/16, revealed R18 was seen by PT, reported improved pain and completed 25 minutes of ROM exercises. - A care conference note dated 12/1/16, revealed R18 complained of right shoulder pain from a fall prior to admission. The note revealed R18 had not addressed his shoulder properly and the result was chronic pain. The note further revealed R18 resisted therapy despite the benefit. The note revealed R18 had been provided education on the benefits of therapy. - A note dated 12/1/16, revealed R18 complained of shoulder pain rated 6 out of 10, and received Tylenol 650 mg. - A note dated 12/3/16, revealed R18 complained of shoulder pain rated 8 out of 10, and received Tylenol 650 mg. - A note dated 12/4/16, revealed R18 complained of shoulder pain rated 7 out of 10, and received Tylenol 650 mg. -A note dated 12/5/16, revealed R18 spoken with the NM twice and stated something needed to be done about his shoulder. The note revealed PT had planned to discontinue services. The note revealed the NM would speak with R18's MD. A further note revealed R18 complained of pain rated 7 out of 10 and received Tylenol 650 mg. The note revealed R18's pain level was 4 out of 10 after he received the Tylenol. - A note dated 12/8/16, a late entry for 12/6/16, revealed R18 received 2 out of 3 restorative sessions for the week of 11/30/16 through 12/6/16 and completed upper extremity (U/E) exercises. - A note dated 12/7/16, revealed R18 was seen by an orthopedic MD and received no new orders or interventions for pain relief. The note revealed NM encouraged R18 to take Tylenol. A further note revealed R18's MD had ordered [MEDICATION NAME] 400 mg TID as needed for right arm pain. The note further revealed R18 was to keep using ice and heat to address pain with gentle ROM. - A note dated 12/8/16, revealed R18 complained of right shoulder pain and [MEDICATION NAME] was given. A further note revealed R18's functional maintenance program (FMP) was updated to include gentle ROM to his right upper extremity and lower extremities. A further note revealed R18 complained of pain rated a 7 out of 10 and received [MEDICATION NAME] 400 mg. The note revealed R18's pain level was 3 out of 10 after he received the [MEDICATION NAME]. - A note dated 12/9/16, revealed R18 complained of pain rated 7 out of 10, and received [MEDICATION NAME] 400 mg. The note revealed R18's pain level was rated 4 out of 10 after he received the [MEDICATION NAME]. - A note dated 12/11/16, revealed R18 complained of pain rated at 8 out of 10 and received [MEDICATION NAME] 400 mg. The note revealed R18's pain level was rated 3 out of 10 after he received the [MEDICATION NAME]. -A note dated 12/13/16, revealed R18 had been seen by his primary MD on a routine visit. The note revealed R18 complained of continued shoulder pain. The note further revealed R18 was to use heat to his shoulder for pain 15 minute intervals. -A note dated 12/15/16, revealed R18 complained of shoulder pain rated 8 out of 10 and had received Tylenol 650 mg. The note revealed R18 rated the pain level 4 out of 10 after he received the Tylenol. - A note dated 12/16/16, revealed R18 approached NM and requested to be seen in the emergency room (ER) for continued shoulder pain. The note revealed NM encouraged R18 to be seen at the clinic in the afternoon. The note revealed NM had informed R18's MD of his continued complaints of pain. The note revealed R18's MD had sent an order for [REDACTED]. -A note on 12/20/16, revealed R18 complained of pain in his arm and requested Tylenol. The note revealed R18 had become impatient when he had to wait for the pain medication. - A note on 12/21/16, revealed R18 was observed to wear a pained look upon his face and was gently holding his his arm. The note further revealed R18 refused group activities and only wanted to smoke, eat and lay down. - A note on 12/22/16, revealed R18 had trouble completing exercises due to pain and too much pressure on his right shoulder. R18's medical record lacked any documentation of non-pharmacological interventions for pain having been offered or attempted for pain management. On 1/5/17, at 7:08 a.m. R18 was seated in a stationary chair in the dining room, held a coffee cup in his left hand and his right arm was bent at the elbow resting on the armrest of the chair. R18 received scrambled eggs, two sausage links, toast and hot cereal. R18 lifted his right arm and reached for his fork. R18's eyes immediately shut, brow furrowed and R18 quickly put his right arm back down on the armrest. R18 used his left hand, grabbed the fork and proceeded to eat 4 fork bites of scrambled eggs. R18 then moved his fork to his right hand, pierced a sausage link guarded his right arm to his chest, bent his elbow and moved his head down to the fork to eat the sausage links. R18 did not raise his right arm/hand to eat the sausage. R18 picked up a spoon with his left hand and ate three bites of his hot cereal, and placed the spoon back on the table. R18 picked up a piece a toast with his left hand, ate two bites, and placed it back on his plate. R18 held the coffee cup in his left hand and drank all of his coffee. At 7:19 a.m. the director of nursing (DON) approached R18 and asked if he had enough to eat. R18 replied he was not feeling well and stated he was going to go back to bed. At 7:22 a.m. R18 independently walked out of the dining room with his right arm guarded to his right side, walked to the nurses station and obtained a cigarette and lighter. R18 walked toward the smoking room, pushed the button with his left hand to open the door, walked in the room and sat on a chair. R18 lit his cigarette with his left hand and proceeded to smoke with his left hand, while his right arm remained at his side. R18 then walked independently back to his room and sat on his bed, while his right arm remained guarded to his side, brow was furrowed, jaw tight and face taut. On 1/5/17, at 7:26 a.m. R18 stated he was not doing very well due to arm pain. R18 stated he could not sleep the previous night due to arm pain. R18 stated the nurse had given him Tylenol and it had not worked, and he continued to have severe pain. R18 said he was so tired of the pain. R18 further admitted he felt frustrated and hopeless. R18 stated he would tell the nurse when he had pain and would tell the nurses when the Tylenol or [MEDICATION NAME] was ineffective in relieving pain. R18 said he told his physician he was in pain and the Tylenol and [MEDICATION NAME] were ineffective in easing the pain. R18 stated he had pain everyday and staff knew he was in pain. On 1/5/17, at 12:14 p.m. R18 walked independently in the hallway toward his room, his right arm guarded tightly to his right side. R18's brow was furrowed, cheeks and jaw were taut, and lips were pursed. On 1/5/17, at 2:15 p.m. R18 walked independently down the hall toward the nurses station, his right arm guarded toward his side, cheeks taut, brow furrowed, lips and jaw tight. R18 obtained a cigarette, smoked with his left hand in the facility smoking room and walked back to his room. R18's facial expression remained unchanged. On 1/6/17, at 9:16 a.m. R18 walked down the hall independently toward his room, lips and jaw tight, forehead creased, brow furrowed. At that time R18 stated he was in a lot of pain, had received some Tylenol that morning, and it had not been effective in reducing his pain. On 1/5/17, at 12:27 p.m. the dietary manager (DM) stated she was aware R18 had not been using his right arm consistently during meals. The DM stated she felt R18's use of his arm would improve with therapy. She stated R18 did not want to use his right arm like he used to and would not participate in therapy because of that. On 1/5/17, at 12:43 p.m. the PT stated R18 had refused to participate in therapy due to pain in his right shoulder. The PT stated he felt R18 was a reliable source of information regarding his pain and was unsure of the last time PT was completed. On 1/5/17, at 1:55 p.m. licensed practical nurse (LPN)-A stated she felt R18 was cognitively intact and able to voice his needs and wishes. LPN-A stated R18 complained of right shoulder pain frequently. LPN-A stated she would provide R18 with ordered PRN Tylenol and [MEDICATION NAME] when he reported pain. LPN-A stated R18 often reported to her both the Tylenol and [MEDICATION NAME] were ineffective in relieving pain. LPN-A stated she reported R18's continued pain to the NM as recently as a couple of weeks ago. LPN-A stated she had not offered R18 any other interventions for pain. On 1/5/17, at 2:39 p.m. nursing assistant (NA)-A stated she had seen R18 walk up to the nurses station and complain of pain on a routine basis. NA-A stated R18 had also frequently reported to her he had pain, most recently that week. NA-A stated R18 had complained of right shoulder pain since admission a few months ago. NA-A stated she felt there were days R18 would stay in his room due to being in so much pain. NA-A stated R18 had also reported to her he often laid down due to pain and did not sleep well. NA-A stated she would inform the nurse when R18 would report pain to her. NA-A stated she routinely observed R18 grimacing when he moved his right arm on a routine basis. On 1/5/17, at 3:18 p.m. NA- F stated R18 had reported to her he had been in pain though was unable to recall the most recent time. NA-F stated she felt R18 often held his right arm to his body due to being in pain. NA-F stated she had seen R18 walk up to the nurses station and complain of pain frequently. NA-F stated she had also reported to the nurses R18 had pain, though was unable to recall the most recent time. On 1/6/17, at 1:59 p.m. the activity director (AD) stated she felt R18 was cognitively intact and able to voice his needs and wishes. The AD stated R18 had participated in activities briefly after he arrived at the facility. The AD stated R18 routinely complained of right shoulder/arm pain since admission and had stopped attending activities. The AD stated she completed 1:1 visits with R18 in his room per his preference. The AD stated R18 had stopped attending group activities due to his pain. On 1/6/17, at 8:23 a.m. NA-D stated she completed resident restorative therapy daily and R18 was supposed to have upper and lower extremity exercises. NA-D stated she was to complete range of motion (ROM) exercises with R18's right arm three times a week which started in November. NA-D stated R18 complained of pain with movement of his right arm. NA-D stated R18 had a fractured collar bone on the right side which she felt affected his range of motion. NA-D stated she had been unable to work with R18 the week of survey due to R18's complaints of pain and not feeling well. NA-D stated R18 had pain when he would bear weight with his right arm and when he attempted to lift his right arm, moving his shoulder away from his body. NA-D stated she had not seen an improvement in R18's pain management or ROM since he was admitted . On 1/6/17, at 8:30 a.m. NA-C stated R18 frequently complained of pain in his right shoulder. NA-C stated she frequently observed R18 guarding his right arm by holding it against his body. NA-C stated when R18 reported pain in his shoulder she would immediately tell the nurse. On 1/6/17, at 8:46 a.m. a phone call was placed to R18's primary physician, who was also the facility's medical director. R18's primary MD was not in the office and would not return until 1/9/17, a message was left with MD's nurse line for MD to call back. MD did not return phone call prior to survey exit. A phone call was received by MD on 1/10/17, at 4:20 p.m. During the phone interview MD stated he was aware R18 had ongoing pain, especially in his right shoulder. MD stated he was not aware of the overall ineffectiveness of R18's current pain regimen. MD stated he had thought R18's Tylenol and [MEDICATION NAME] were already given to him on a scheduled basis. MD stated the usual practice was to schedule PRN pain medication if they routinely received it. MD stated he had referred R18 to an orthopaedic MD and he had felt an MRI was not necessary. MD stated he had considered adding [MEDICATION NAME] (non-opiate prescription pain medication) to R18's medication regimen but had not at that time. MD stated he was very reluctant to order opioid and/or narcotic pain medications due to the monitoring involved in prescribing those medications. MD stated he would only order opioid and/or narcotic pain medications in cases of acute injury or pain, which he felt R18 did not meet that criteria. MD stated he had also ordered [MEDICATION NAME] for R18's pain in December some time and had hoped that would improve. MD stated R18 could have had heat and cold therapy, but was not sure if the staff had tried them or their effectiveness. On 1/6/17, at 1:56 p.m. LPN-B stated R18 had an old fracture to his right collar bone which she felt continued to cause R18 frequent pain. LPN-B stated R18 received Tylenol and [MEDICATION NAME] for pain, which were overall not effective. LPN-B stated she had reported to the NM, R18 was not receiving relief from pain with the current prn medications, most recently as the previous week. On 1/6/17, at 2:23 p.m. during a follow up interview the NM stated she was aware R18 was not receiving routine relief with the current PRN medications of Tylenol and [MEDICATION NAME]. The NM stated she had been unable to complete another cognition assessment as requested by the surveyor due to R18 not feeling well with a cough. The NM stated she felt R18 was overall cognitively intact and may have minimal memory loss. The NM stated she felt R18 was a reliable source of information regarding his pain. The NM stated she had reported to R18's primary MD the current pain medication overall was not effective. The NM stated she would routinely struggle with R18's MD regarding R18's pain management due to an unwillingness to try other pain medications. The NM stated R18's MD has started him on [MEDICATION NAME] and only saw minimal improvement. The NM stated she felt R18 continued to experience pain and that his pain was not managed at that time. A facility policy titled, Pain, reviewed 5/2016, revealed it was the facility's policy to ensure patients were free of pain or would receive pain management that would allow them to maintain the highest degree of functioning and well being, enhance comfort. The policy directed facility licensed staff to complete an initial and ongoing pain assessment of prn medications. The policy directed licensed staff to monitor the effectiveness of medications and to evaluate if a need to schedule prn pain medications.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) was free from a significant medication error when R1 received a dose of [MEDICATION NAME] (narcotic) that was 10 times over the physician prescribed dose. R1 died 1 hour and 45 minutes after receiving the medication. Findings include: R1's medical record and Medication Administration Record [REDACTED]. R1's cognitive assessment dated [DATE], indicated severe cognitive impairment. R1 was placed on hospice services on [DATE], diagnosed with [REDACTED]. The nursing progress notes were reviewed and indicated the following: -[DATE], at 2:34 a.m. R1 had 30 plus seconds of apnea (temporary cessation of breathing). - [DATE], at 2:30 a.m. R1 was not alert enough to eat or drink due to unresponsiveness. - [DATE], at 2:36 p.m. the hospice nurse had visited in the morning and the physician had discontinued all oral medications. The physician's orders [REDACTED]. The label on the MS bottle read, 100 mg/5 ml; 20 mg/ml, give 2.5 mg (0.125 ml) [MEDICATION NAME] every hour as needed for pain/shortness of breath. The PRN order transcribed on the MAR indicated [REDACTED]. (This was written as an incorrect amount). R1 received one dose of the PRN [MEDICATION NAME] on [DATE], at 1:00 p.m. On [DATE], the physician added an order for [REDACTED]. R1 received the first scheduled dose of the every 4 hour MS on [DATE], at 4:00 p.m. at the incorrect dosage. The dose of scheduled MS was taken from the PRN MS bottle. On [DATE], at 8:08 a.m. hospice registered nurse (RN)-F was interviewed. RN-F stated she had visited R1 on [DATE], from 9:45 a.m. until noon. R1 had (2) 15 second periods of apnea in a minute. RN-F stated she obtained the physician's orders [REDACTED]. During an interview on [DATE], at 10:23 a.m. RN-B stated that on [DATE], she had incorrectly transcribed R1's MS order onto the Medication Administration Record [REDACTED]. RN-B stated it was the facility's practice to check any new order with another nurse even though there was not a written policy. RN-B stated on [DATE], in the afternoon she was in her office when she transcribed R1's MS order into the computer. RN-B stated she did not review R1's new order with the day nurse licensed practical nurse (LPN)-D per facility practice. While transcribing the MS order RN-B stated she asked LPN-D to check the concentration of the MS bottle in the medication cart. RN-B stated LPN-D told her that it was 20 mg/5 cubic centimeters (cc). (This was incorrect information). RN-B stated she should have gotten up and looked at the MS bottle. RN-B stated she did not put the dosage on the MAR indicated [REDACTED]. RN-B stated since she was working the next day she did not place the order into the hard chart per protocol. RN-B stated the first scheduled dose of the MS was to be given at 4:00 p.m RN-B left the facility at 3:30 p.m. On [DATE], at 12:28 p.m. LPN-C was interviewed. LPN-C stated on [DATE], he received the nursing report from LPN-D around 3:30 p.m. LPN-D reported R1 was on hospice and not doing well. In addition, R1 had a scheduled dose of MS every 4 hours. LPN-C stated LPN-D showed him the MS medication order on the MAR. LPN-C stated he questioned LPN-D about the MS order as he thought 2.5 cc seemed like too much medication. LPN-C stated LPN-D told him it was correct. LPN-C stated LPN-D left the facility about 3:55 p.m. LPN-C then checked on R1, obtained his vital signs and noted R1 was moaning and grunting. LPN-C than contacted the director of nursing (DON) and asked her about the MS dosage as LPN-C felt it was too much medication. LPN-C stated the DON looked at the MAR indicated [REDACTED]. LPN-C then told the DON he was going to administer the MS and the DON made no comment. LPN-C added, he looked for the original MS order prior to speaking with the DON and could not find the order. LPN-C stated about 15 minutes after he had administered the 2.5 cc of MS, the DON stated they should double check the order. LPN-C stated the DON then called RN-B and explained they had given 2.5 cc of the MS, and RN-B stated they had not given the correct dose. On [DATE], at 2:19 p.m. LPN-D was interviewed. LPN-D stated on [DATE], she let LPN-C know that R1 had a new order for MS every 4 hours. LPN-D stated she did not remember telling LPN-C the MS dosage was correct on the MAR. On [DATE], at 1:33 p.m. the DON was interviewed. The DON stated on [DATE], she verified the MS 2.5 cc in the syringe with LPN-C and he went to administer the dose about 4:00 p.m. The DON stated LPN-C just thought something did not seem right with the MS order. The DON stated after she had talked with LPN-C and looked at the MAR indicated [REDACTED]. The DON stated she was unable to find the original MS order as it was not in the hard chart. The DON then called RN-B who stated they had administered the wrong dose. The DON was informed by RN-B that 0.25 cc of MS should have been administered instead of 2.5 cc to equal 5 mg. The DON stated after the medication error was noted, she called physician assistant (PA)-K at the hospital and hospice. PA-K instructed staff to monitor R1 every 30 minutes and if his respirations dropped below 10 or his oxygen level dropped then they would administer [MEDICATION NAME] ( a medication to block the effects of the MS). The DON stated R1's family arrived when she was on the phone and the family wanted the [MEDICATION NAME] administered. The DON stated the hospital RN-L came to the facility to administer the [MEDICATION NAME]. The DON stated R1's breathing had decreased to 2 breaths a minute. The family had requested another dose of [MEDICATION NAME] be given. The DON stated she went to the hospital and returned with the [MEDICATION NAME] along with PA-K and hospital RN-L. The DON stated when she returned R1 had already expired. On [DATE], at 9:50 a.m. the DON stated the facility policy was for the RN to verify orders placed on the MAR. The Medication Order policy revised ,[DATE], indicated the RN was responsible to check for new orders to be transcribed in the electronic medical record (EMR). Once transcribed into the EMR, the order would be initialed by the RN. In addition, the policy indicated when transcribing a medication order, it must include the dosage strength, frequency, route and diagnosis.