Every finding on record at Maple Springs Senior Living

Based on interview and record review, the facility did not ensure each resident had supervision to prevent accidents. Specifically, for 2 out of 39 sampled residents, a resident was not secured in the facility van and tipped backwards sustaining a closed head injury. This example was cited at a harm level. Resident identifier: 73. Findings included: Resident 73 was admitted to the facility on [DATE] and discharged on 6/21/25 with diagnoses which included urinary tract infection, acute respiratory failure with hypoxia, chronic kidney disease, hypertension, diastolic heart failure, and anxiety. The facility reported to the State Survey Agency (SSA) on 5/29/25, that resident 73 was transported to an appointment when her wheelchair tipped backwards and she bumped her head on the ramp that was folded up behind her. The transport driver asked resident 73 if she was okay, tipped the wheelchair upright, and strapped the front of the chair in, and took her to instacare where her appointment was and ensured that the medical staff knew of the event so they could assess her. Resident 74's medical record was reviewed on 2/23/26 through 2/25/26. There was no information on the incident in resident 74's medical record. There were neurological checks completed after. A final report from an Urgent Care Clinic dated 5/29/25, revealed resident 74 presented for an evaluation of a head injury after an injury earlier today. The patient reported that she was in a facility transport vehicle when her wheelchair was not secured and it rolled back and she struck her head on the back door. She did not lose consciousness and did not have any pain or symptoms present. She came in here for evaluation based on recommendation from her primary care clinic. She denies headache, neck pain, or back pain. Resident 74 was diagnosed with a closed head injury. On 2/25/26 at 8:34 PM, an interview was conducted with the Transportation Director (TD). The TD stated when he started with transportation 5 years ago, he was not provided much training besides how to secure a resident in the van. The TD stated he had transported with another facility prior. The TD stated there were 4 staff who transported residents including Transportation Driver 1. The TD stated Transportation Driver 1 occasionally transported residents maybe one time per week and had been a driver for 5 years. The TD stated 2 to 3 years ago the facility developed an online training for drivers and the drivers completed it yearly. The TD stated resident 74 was loaded into the van and there were back straps hooked but not the front straps. The TD stated resident 74 fell backwards, hit her head, and chipped some teeth. The TD stated after the incident a training with drivers was completed on how to hook in the wheelchairs and a sign was placed in the van to make sure all straps were secured correctly. The TD stated he also completed a monthly check off. The TD provided the Securement 101: Basic Wheelchair Securement Training certificates for the drivers including Transportation Driver 1 which was completed on 4/17/24. In addition, a form titled Resident Transportation Checklist was completed on 1/13/26, with no concerns. On 2/25/26 at 8:40 AM, an interview was conducted with Transportation Driver 1. Transportation Driver 1 stated he occasionally did transport, usually less than one time per week. Transportation Driver 1 stated he had been transporting residents for about 8 years. Transportation Driver 1 stated he received online training and there were monthly checks done by the TD to make sure they were correctly placing residents in the vehicle and making sure everything was safe. Transportation Driver 1 stated there were two vans and one had built-in retention straps in the front secured to the floor and the other van had a place to secure straps. Transportation Driver 1 stated resident 74 was in the van that did not have the built in retention straps. Transportation Driver 1 stated he secured the back 2 straps but forgot the front straps and when he stopped she tipped over. Transportation Driver 1 stated she did not fall all the way to the floor but was tipped at a 45 degree angle backwards in her wheelchair. Transportation Driver 1 stated he asked if resident 74 was okay and she said yes, so he lifted her chair upright, secured the 4 straps and took her to an appointment. Transportation Driver 1 stated he informed her father of what happened so he could let the physician know. Transportation Driver 1 stated there was a sign placed in the van to remind the driver to check for all 4 straps before transporting a resident. On 2/25/26 at 12:23 PM, an interview was conducted with the Administrator. The Administrator stated the training process for transportation drivers was to submit their drivers license to the facility insurance, orientation was done, and an on-line training on how to latch the equipment. The Administrator stated the TD then passed off the driver by observing the driver securing residents in the van. The Administrator stated there were 2 different vans used, one of the vans had four built in straps to the floor of the van. The Administrator stated the one that resident 74 was in was different and the straps needed to be latched in the front to the floor hooks. The Administrator stated Transportation Driver 1 loaded resident 74 into the van and unfortunately forgot the front hooks. The Administrator stated when he was down the street from the facility resident 74 tipped backwards but did not fall. The Administrator stated Transportation Driver 1 continued on to resident 74's appointment after securing her in the van because there were no visible signs of injury at that time. The Administrator stated after the incident, there was a discussion of what to do and they determined adding a sign to the van to remind the driver to secure in 4 areas was appropriate. The Administrator stated all transportation drivers were educated to call emergency medical services if there was an accident of any kind to assess the resident. The sign was hung in the van on 5/29/25. On 2/25/26, an observation was made of the van and there was a stop sign on the glove box reminding staff to secure the straps.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated, and sanitizer buckets did not meet the required sanitation testing levels. Findings included: 1. On 2/23/26 at 8:25 AM, an initial tour of the kitchen was conducted. The following observations were made: a. The Dietary Manager (DM) was behind the preparation table and was not wearing a hairnet. b. An opened and undated bag of whipped topping was in the refrigerator. c. A pan of meatballs was undated in the refrigerator. d. A bag of frozen rolls were opened and undated in the freezer. e. The sanitation bucket at the preparation table was tested by the DM and resulted at 150 parts per million (PPM). The DM stated that the level should be at 200 PPM. The DM stated that she needed to pour out the water from the bucket and start again. The DM stated that the sani buckets were changed at least three times a day after every meal service. 2. On 2/24/26 at 9:09 AM, a follow-up tour of the kitchen sanitation was conducted. The sanitation bucket at the front end of the kitchen tested at 150 PPM. The DM stated that it should be at 200 PPM. The DM stated that the dishwasher was responsible for changing the sanitation buckets and that he changed the sanitation bucket at 8:00 AM, that morning. On 2/24/26 at 9:13 AM, an interview was conducted with the dishwasher. The dishwasher stated that he was responsible for preparing the sanitation buckets and that he changed the solution when they transitioned from breakfast to lunch. The dishwasher stated that he had not changed the sanitation buckets in the kitchen that morning because dishes had started to pile up and he needed to get them washed. 3. On 2/25/26 at 10:46 AM, a follow-up tour of the kitchen was conducted. The following observations were made: a. An opened dijon honey mustard was opened and undated in the refrigerator. b. A bag of opened and undated frozen rolls were in the freezer. On 2/25/26 at 10:55 AM, a follow-up interview was conducted with the DM. The DM stated that all items in the refrigerator and freezer should have dates on them. The DM stated that she expected all of her staff to wear a hairnet while in the kitchen, including herself. The DM stated that she had new kitchen staff and some of them were not dating foods when they were placed in the refrigerator and freezer or when they opened items. The DM stated that the sanitation buckets should be at the correct sanitation levels and if they were not then they were not sanitizing surfaces to kill germs.

Based on interview and record review, for 1 of 39 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, a resident was not provided crushed medications as ordered by the physician. Resident identifier: 64. Findings include: Resident 64 was admitted to the facility on [DATE] and discharged on 1/5/26 with diagnoses which included fractures of right pubis and left pubis, sacrum fracture, dysphagia, and age-related osteoporosis. Resident 64's medical record was reviewed 2/23/26 through 2/25/26. The facility reported to the SSA on 12/30/25, that resident 64's family reported resident 64 was receiving whole pills instead of crushed medications. The investigation revealed that resident 64 had 3 medications that were not able to be crushed. Resident 64's Discharge Summary from the hospital dated 12/20/25, revealed resident 64 was observed to have an episode of choking on toast while eating breakfast. There were reports this had been going on for about 6 months, mostly with bread. A Speech Language Pathology (SLP) evaluation and Treatment was completed on 12/19/25. The use of swallow strategies were documented to sit upright as much as possible, single small bites and sips, slow rate, turn head for solids, continue to add moisture, chase with a liquid sip, and chew well. A diet order and communication dated 12/20/25, revealed regular soft and bite sized. There were no chewing/swallowing problems checked on the order. SLP Evaluation and Treatment Plan from 12/22/25 through 1/20/26, revealed Pills/meds [medications]= [equal] severe: Clinical S/S [signs and symptoms] dysphagia: difficulty initiating oral stage coughing after swallow and watery eyes. No recommendations regarding medication texture were documented. A diet order and communication dated 12/23/25, revealed regular, thin liquids with allergies to red dye. Medication Administration: crushed in puree. A Physician's order dated 12/23/25, revealed Crush meds r/t [related to] choking risk. every shift for choking risk. There were nurses' initials in the Medication Administration Record twice daily. On 12/30/25, the Director of Nursing performed a crushed medication audit. The following medications were not able to be crushed and were administered until 12/31/25. a. Align Oral Capsule give 4 milligrams (mg) by mouth every morning for probiotic. It was noted Acidophilus. b. Cholecalciferol Oral tablet 50 micrograms give 3 tablets by mouth in the morning for supplement. It was noted will get tab [tablet] form. c. Celebrex Oral Capsule 200 mg give 1 capsule by mouth in the morning for pain management. It was noted the capsule could be opened. d. Vitamin E Oral tablet give 400 units by mouth in the morning for supplement. It was noted needs a tablet form. e. Tamsulosin hydrochloride oral capsule 0.4 mg give 1 capsule by mouth in the morning for urine retention. It was noted get different form. f. PreserVision AREDS 2 oral capsule give 2 capsule by mouth in the morning for supplement. It was noted tab next to the medication. On 12/31/25 at 4:01 PM, there was a progress note Doing crush med audit and will DC [discontinue] Align and start Acidophilus, Vitamin E, Preservation will be sent in different form Celecoxib can be opened. On 2/25/26 at 12:28 PM, an interview was conducted with the Administrator. The Administrator stated the facility had a process with the SLP after admission to have the resident evaluated for medication swallowing. The Administrator stated the facility used to have a physician's order to Crushed as needed for medications but they felt that was too much on the nurse to determine when a medication needed to be crushed. The Administrator stated the physician now gave orders on crushing medications or not. The Administration stated during the investigation regarding resident 64's medication not being crushed, they found there were medications that could not be crushed so the Director of Nursing reached out to the pharmacist to determine if medications needed to be changed in order for them to be crushed.

Based on observation and interview, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, for 1 out of 39 sampled residents, a controlled drug was stored in a manner that failed to prevent potential drug diversion and ensure safe medication administration. Resident Identifier: 21. Findings included: On 2/25/26 at 10:38 AM, during a review of the facility's medication carts, an observation was made of a blister pack containing Percocet 10-325 milligram tablets. The blister pack had 1 tablet taped into an opened blister cell. The Percocet, a Schedule II narcotic, was prescribed for resident 21. At the time of the observation an interview was conducted with Registered Nurse (RN) 2. RN 2 stated medication tablets should not be taped back into blister cells to prevent the incorrect medication from being replaced in the blister cell. Additionally, RN 2 stated if a narcotic tablet was removed from the blister cell and not administered, the tablet needed to be wasted (destroyed) with another nurse acting as witness. On 2/25/26 at 2:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a medication was not administered, it should have been wasted in the drug disposal system that was available on all medication carts. The DON elaborated that if the medication was a controlled substance it would need to be wasted with another nurse witnessing and documented in the narcotic log. The DON stated medications would not be securely stored if taped into blister cells and could unintentionally fall out. Additionally, the DON stated taping medications into blister cells increased the risk of cross contamination and medication errors, such as the incorrect medication being returned to the blister cell or the medication being returned to the incorrect blister pack.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, for 2 out of 39 sampled residents, one resident had a urinary catheter bag observed on the floor, and for a second resident receiving wound care, hand hygiene and glove changes were not performed. Resident identifiers: 2 and 9. Findings included: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction, retention of urine, and obstructive and reflexive uropathy.Resident 9's medical record was reviewed.A physician's order with a start date of 1/28/26, documented, Catheter cares: Clean foley site with soap and water, check foley for kinks and that foley bag is being kept below the bladder and off the floor in privacy bag. every morning and at bedtime for foley use Do not irrigate. Change catheter and tubing prior to obtaining a sample for UA/UC [urinalysis/urine culture].The following observations were made of resident 9:a. On 2/23/26 at 10:18 AM, resident 9 was sitting in a recliner in his room. His urinary catheter bag was observed on the floor of his room to the left side of the recliner and was not in a privacy bag.b. On 2/24/26 at 10:07 AM, resident 9 was sitting in his recliner. His urinary catheter bag was observed to be on the floor next to a yellow basin and was not in a privacy bag.On 2/24/26 at 10:08 AM, an interview was conducted with resident 9. Resident 9 stated that he had just returned from physical therapy and wanted to sit in his recliner. Resident 9 stated that staff placed his urinary catheter bag on the floor anytime he was out of his wheelchair.On 2/24/26 at 11:04 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated urinary catheter bags should not be placed on the floor because the floor was not clean. CNA 1 stated that the urinary catheter bag should be hanging up off the floor.On 2/25/26 at 10:20 AM, an interview was conducted with CNA 2. CNA 2 stated that if a resident was sitting in a recliner or in bed the urinary catheter bag should be placed in a yellow basin. CNA 2 stated that a urinary catheter bag should not be placed on the floor because it was an infection hazard. On 2/25/26 at 10:23 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that urinary catheters need to be stored in the yellow buckets that were kept in the resident's room. RN 1 stated that storing a urinary catheter bag on the floor was an infection control issue because the bags could leak and it was safer for the resident and staff. On 2/25/26 at 10:25 AM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that if she was doing therapy with a resident that had a urinary catheter she would make sure that the urinary catheter bag went into the yellow basin and never on the floor. The PTA stated there could be contamination risks if the urinary catheter bag was placed directly on the floor. On 2/25/26 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that catheter bags should be placed in a basin with a privacy bag and not on the floor. The DON stated that if urinary catheter bags were placed on the floor there was an increased risk of infection to the resident.2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, orthopedic aftercare of the left ankle.Resident 2's medical record was reviewed. On 2/18/26, resident 2's wound care orders documented Pressure Sore L [left] Heel: Cleanse w/ [with] NS [normal saline] or Wound Cleanser, (No topicals) Cover w/Non-Adherent Pad as Primary, Place Offloading Dressing as Secondary, Secure w/Keflex and Tape.On 2/25/26 at 10:43 AM, an observation was made of resident 2's wound care by Licensed Practical Nurse (LPN) 1. LPN 1 was observed to perform hand hygiene, don a disposable gown, gloves, and mask prior to initiating wound care. LPN 1 was observed to remove resident 2's old dressing from the left foot and discard them. LPN 1 did not doff the dirty gloves, perform hand hygiene and don new clean gloves prior to continuing with wound care. LPN 1 then obtained a sterile 4 x 4 gauze pad that was soaked in normal saline from the bedside table and cleaned resident 2's left foot dorsum surgical incision, left lateral foot surgical incision, and the left heel pressure ulcer. All three wound sites were cleaned with a new gauze pad. An immediate interview was conducted with the LPN 1 upon exit of resident 2's room. LPN 1 stated that she switched out gloves and performed hand hygiene when placing ointment or cream on the wound bed. LPN 1 stated that she should have doffed her dirty gloves and performed hand hygiene after removing resident 2's old dressing and prior to cleaning the wound bed. On 2/25/26 at 11:32 AM, an interview was conducted with the DON. The DON stated that staff should reduce the risk of infection with wound care by performing hand hygiene, having all equipment prepped prior to initiation, and following wound care orders.

Based on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to provide each resident with a safe diet that met the special dietary needs of each resident. Specifically, a resident had a diet order for moist and minced texture and was given a cheese stick and pretzels for a snack which resulted in the resident choking and passing away. Resident identifier: 1It was determined the provider's noncompliance with this rule caused harm. However, based on the facility's corrective actions and a review of its current compliance, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by December 3, 2025, included the following measures. The Director of Nursing (DON) added a column on the Nurse report sheet to identify textures and diets for all current residents. The DON audited diets and textures to ensure that all residents were appropriately documented. Online training was completed by all nursing staff. The facility's corrective action plan included additional future training and weekly audits. The surveyor reviewed the facility's investigation involving an incident with Resident 1 dated November 29, 2025 which revealed the followingOn November 29, 2025, Nurse 1 had taken Resident 1's blood sugar and it was 59, so Nurse 1 proceeded to give her juice, cheese, and pretzels in order to raise her blood sugar. Nurse 1 stayed in the room while Resident 1 took a few bites of food and swallowed with no problems. Nurse 1 left the room with the door open and told Resident 1 that she would come back in 10 minutes to recheck her blood sugar. Resident 1 had started choking, and staff began the Heimlich maneuver, but after several minutes of back slaps and Heimlich, Resident 1 went unresponsive. Nurse 1 noted that Resident 1's code status was DNR, and Nurse 1 called Resident 1's Power of Attorney (POA) to confirm, and the POA confirmed DNR. The facility's investigation included a statement from Nurse 1, I was training a new nurse [Nurse 2] on my shift. Around 1600 I had asked him to go check [Resident 1]'s blood sugar prior to dinner. When he returned he told me her blood sugar was 59. I grabbed a few snacks that included: Orange Juice, a Slice of Cheese and some pretzels for some consistent carbs. In the past when [Resident 1]'s blood sugar was this low she has become tired/lethargic. She was laying in her bed. I did not want to transfer her with the [NAME]-Steady to avoid a possible fall due to weakness from her low blood sugar. I spoke with her and she replied to her name. I let her know her blood sugar was low and she needed to have a snack. She agreed. I sat the head of the bed up 90 degrees. I sat next to her on the bed and opened the piece of cheese first. I watched her chew and swallow a few bites with no problems. She was alert and oriented. I told her I would be back to reassess her blood sugar. I left her door open so we could check on her in passing. It had been maybe 5-10 minutes. CNA working the swing shift radioed me to come to her room as soon as possible. I ran to her room and saw she was choking. She was not coughing or responding to her name. She had gone unconscious. At this time I helped lay the head of her bed down. Started CPT [Manual Chest Physiotherapy] on her back. Had [staff names redacted] help me lower her to the ground where I sat her up and performed the heimlich 5 times. I tried multiple times to use the sweep method to see if the object could be dislodged. I was unsuccessful. I asked [CNA] to go check the report sheet to see what her POLST was. She radioed me and let me know she was DNR. At this time I left the room to call her advanced directive [name redacted] to clarify he did not want CPR performed. Before I left [Nurse 2] had checked to see if [Resident 1] had a pulse and she still did. She had gasped twice. [Staff] continued to perform the [NAME]. Once i got a hold of the [POA] he said not to perform CPR. When I entered back into the room she was pulseless. At this time I notified the local authorities due to the nature of the incident. Once the paramedics arrived they had pronounced her deceased . After talking with [the] DON and [the] Administrator, Resident 1 had her diet order changed on 11/5/25 to moist and minced this was not placed on the nurses report sheet or in the TAR/MAR. But in PCP orders only. I received no information in the report that morning of changes to her diet or new/increased difficulties to swallow. The facility's investigation included a Root Cause Analysis Tool which revealed that the incident had occurred because the nurse was unaware of the texture restrictions, the nurses report sheet only documented how residents took their pills, and it did not have information about the diet texture. Therefore, the texture order was not easily accessible when staff were in the residents' room or in an urgent situation. The surveyor reviewed Resident 1's medical record. Resident 1 had diagnoses that included type 2 diabetes and vascular dementia. The Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. A physician's order dated November 5, 2025 indicated, Minced and Moist texture, thin consistency for diet orders. The surveyor interviewed the Speech Language Pathologist (SLP) on December 8, 2025. The SLP stated that Resident 1 had her diet order changed due to recent swallowing complications, including coughing and vomiting up food. The SLP confirmed that Resident 1 had received string cheese and a small bag of mini pretzels, and that both food items were not appropriate for a minced and moist diet. The SLP stated that a new process for diet order changes had been put in place to ensure staff had easy access to identify a resident's diet orders and texture. The surveyor interviewed the DON on December 8, 2025. The DON stated that prior to this incident involving Resident 1, the nurse report sheets did not include information about the resident's diet order. The DON stated that the diet texture order was not readily available for nursing staff. The DON stated that a column had been added to the nurse report sheet to include a resident's diet order.

Based on interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the information provided to the receiving provided included: contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; Advanced Directive information; all special instructions or precautions for ongoing care; all other necessary information, including a copy of the resident's discharge summary; and any other documentation to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found of the information that was provided to the receiving provider. Resident identifier 32, 39 and 93. Findings included: 1. Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. On 9/10/2023 at 6:08 PM, the resident 39's progress note documented, Pt's [patient's] daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin (administration), pt did calm down but still not cooperative and refused to take any medications. During dinner while staff were passing room trays, heard door alarm and noted pt was not in her room. Unable to find her in the parking lot. Charge Nurse aware and assisting in looking for pt and notified Administrator. While checking cars, noted pt to be walking in the road at the end of the block. A Samaritan stopped their truck and pt got into their vehicle when they noticed me running towards them. Pt became very agitated. I got into the truck and they gave us both a ride back to the main entrance of the facility. Charge Nurse and Admin notified EMS [Emergency Medical Services] and Law Enforcement as well as pt's daughter [name omitted] and [name of Nurse Practitioner omitted] of incident and that pt would be transferred to [local area emergency room (ER)] for a psych [psychiatric] eval. Pt pleasant and cooperative at this time, but does become more irritable and agitated the more people show up around her. Able to assist pt into Ambulance safety and without incident. Transported to ER and informed she will not be coming back to the facility. It should be noted that no documentation could be found of a discharge summary or any information that was provided to the receiving provider. On 11/14/23 at 2:16 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the day of resident 39's elopement she was transported to the hospital. LPN 2 stated that resident 39 should have been sent to the hospital with a face sheet, medication list, Physician Orders for Life Sustaining Treatment (POLST) form, most recent weight and vital signs, and then the nurse should call and give report to the emergency room (ER). On 11/15/23 at 2:21 PM, a follow-up interview was conducted with LPN 2. LPN 2 stated that she thought the charge nurse (CN) 1 handled the transfer paperwork. LPN 2 stated that normally she would complete the discharge summary in the assessments and it would detail everything going to the receiving provider. On 11/16/23 at 9:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they send a POLST, face sheet, Medication Administration Record to the receiving provider and then call report to the ER. The DON stated that staff document the transfer in a progress note and it should include what paperwork was sent to the receiving provider. 2. Resident 93 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, atrial fibrillation, chronic kidney disease, congestive heart failure, hyperlipidemia, restless leg syndrome, hyperaldosteronism, obstructive sleep apnea, chronic pain, thrombocytopenia, and polyneuropathy. On 11/16/23, resident 93's medical records were reviewed. On 5/31/23, resident 93's Quarterly MDS Assessment documented a BIMS score of 14/15, which would indicate that the resident was cognitively intact. The assessment documented that resident 93 was an extensive 2-person assist for bed mobility and toilet use; and extensive 1-person assist for transfers, locomotion on/off unit, dressing and personal hygiene. Review of the facility initial investigation, form 358, documented, On 6/21/23 at 4:41 PM, the facility reported that on 6/21/23 at 9:30 AM the resident [93] was being transferred to a chair in her room, at the residents request, by 2 therapy staff members. The legs of the resident buckled and the resident fell causing a laceration in her lower leg that required sutures. The therapy staff alerted the nursing staff, the ADON [Assistant Director of Nursing]/wound nurse and the hospice nurse of the situation. The hospice nurse alerted the family. The NP [Nurse Practitioner] arrived at the facility to assess the resident prior to the resident being sent to the ER. No other injuries reported. No other agencies were notified. Review of resident 93's progress notes revealed no documentation of the residents transfer to theER on [DATE]. On 6/21/23 at 9:30 AM, resident 93's Initial Post Fall Clinical Review documented, sent to ER for sutures and rule out fractures. On 6/21/23, the ER note documented, Outside historians: We did get some history from EMS who was at the scene and brought her in today. They provided some of the HPI [History of Present Illness]. The ER note further documented, We reviewed recent and relevant documentation to help in the management of this patient. These included: I did review an admission hospitalist note from a month ago where she came in in respiratory distress On 11/16/23 at 12:53 PM, an interview was conducted with the DON. The DON stated that the information from the transfer to the hospital was contained in the initial post fall assessment. It should be noted that the post fall assessment did not document the paperwork that was provided to the receiving provider. 46232 3. Resident 32 was admitted to the facility on [DATE] with the following diagnoses that included but not limited to unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. On 11/14/23 at 10:36 AM, an interview was conducted with resident 32. Resident 32 stated they were sick a while ago and had to go to the hospital because of it. Resident 32 stated that was why he was still on the IV [intravenous] antibiotics. Resident 32's medical record was reviewed on 11/14/23. Resident 32's progress notes revealed the following: a. On 10/26/23 at 1:04 PM, a nurse note stated, Resident's spouse came to the desk and reported resident was shaking despite turning up the thermostat and receiving blanket coverage x 2 . b. On 10/26/23 at 3:32 PM, a nurse note stated, Received information from the CNAS [certified nursing assistants] that resident had thrown up. Upon assessment, resident was breathing 28 times/min. Resident stated he felt tight in his abd [abdomen]. [Name removed], NP [nurse practitioner], assessed. Stated resident should continue on with NC [nasal cannula] for the time being. This nurse called [name of local hospital] lab and enquired about UA [urinalysis] status. Reportedly, it had been run and results needed to be recorded in their computer system. This nurse asked for the results to be put in their computer ASAP [as soon as possible]. Receptionist verbalized understanding and stated she would hurry the results along. Spoke with resident's daughter and informed her about the situation. Forwarded the message about the labs to [name removed], NP. Will continue to monitor. c. On 10/26/23 at 4:08 PM, a nurse note stated, Resident's UA was resulted and reviewed by [name removed], NP. Resident has a substantial urinary infection. [name removed] gave the following order: Sent to [local hospital] ER [emergency room ] for Eval [evaluation] and tx [treatment]. Dx [Diagnosis]: vomiting, chilling, tachypnea, and hypoxia . On 11/3/23, a hospital history and physical documented the facility did not give the hospital any additional information other than the facility was concerned resident 32 had a deep infection. The hospitalist documented resident 32 had had multiple UTI's in the past month and had a history of Proteus grown with his urine cultures which made it hard to treat due to a drug resistance. It should be noted that no documentation could be found that indicated what information was provided to the receiving institution or provider. On 11/16/23 at 9:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident was sent to the hospital, they normally tried to call the ER to give them report. The DON stated the documents sent with the resident included the face sheet, medication list, POLST [physician form for life sustaining treatment] form and sometimes the recent vitals' signs. The DON stated they were not aware of nurses having to document a transfer assessment. The DON stated when a resident transferred to the hospital the nurses documented a progress note about it. On 11/16/23 at 11:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a resident was transferred to the hospital, the nurses sent over the resident face sheet, the MAR [medication administration record] to show what medication they had been taking, an order summary, and a POLST form. The LPN 1 stated they also included a progress note in the resident's chart which included why the resident was transferred, where they were transferred to, and the mode of transportation used to get to the facility.

Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food in the refrigerator was not dated and labeled. In addition, there were soiled areas in the kitchen. Findings included: 1. On 11/13/23 at 11:07 AM, an initial tour of the kitchen was conducted. The following observations were made: a. The floor in the bistro area under the cappuccino machine had black build up and debris in the corners. b. The doors and handles on the refrigerator in the bistro area were soiled. c. There was a container labeled Cream Cheese Frosting with no open date or expiration date in the walk in refrigerator. d. There was thawed Whipped Topping in the walk in refrigerator with no date when it was pulled from the freezer. The label revealed to use thawed Whipped Topping within 2 weeks. e. There was black substance in the corners of the kitchen, around table legs and under shelves throughout the kitchen. There was black substance under the shelving that had pans and dishware on it. f. The vents on the ceiling and the ceiling above the food preparation area had dust on and around them. There was dust on the pan hanging rack above the meal preparation area. g. Under the ice machine there was white, brown and black substance on the floor. h. There was food splatter on the ceiling. i. There was debris and dust on the back of the Alternate Dining Preparation refrigerator. j. Inside the Alternate Dining Preparation refrigerator the following observations were made: i. Macaroni salad dated 10/29. ii. A plastic bag labeled BLT (bacon, lettuce and tomato) Bacon dated 11/7. ii. Another plastic bag with bacon that had no date or label. iii. A yellow pepper cut in half with no date and had mold on it. iv. Containers with lettuce, tuna, hard boiled eggs, tomatoes, cheese, onions, turkey, ham and cheese were not labeled or dated. k. The shelf above the trayline line foods was soiled underneath. 2. On 11/16/23 at 12:36 PM, a follow-up observation of the the kitchen was conducted. The following was observed: a. Under the boxes of soda for the soda machine there was black substance on the floor. b. Vents on the ceiling above trayline and above the food preparation area had dust on them. c. Cream cheese frosting in the [NAME] refrigerator did not have an open date. d. There was black substance in the corners of the kitchen, around table legs and under shelves throughout the kitchen. There was black substance under the shelving that had pans and dishware on it. e. The vents on the ceiling and the ceiling above the food preparation area had dust on and around them. There was dust on the pan hanging rack above the meal preparation area. f. Under the ice machine there was white, brown and black substance on the floor. g. There was food splatter on the ceiling. h. There was debris and dust on the back of the Alternate Dining Preparation refrigerator. i. The shelf above the trayline line foods was soiled underneath. j. The ice machine had a filter that had dust and debris above where the ice machine was opened to get ice out. An interview was immediately conducted with the Dietary Manager (DM). The DM stated the ice machine was cleaned every 3 months but the filter should be cleaned nightly. The DM stated the kitchen staff performed a Double Scrub every 3 months after the kitchen was closed. The DM stated the last double scrub was June of 2023 and everything was cleaned including the ceiling. The DM stated the trayline was cleaned every day after each meal. The DM stated the shelf above the trayline food had not been cleaned and needed to be cleaned. The DM stated alternative dining area was also called the Sandwich/line fridge. The DM stated that all the items were for sandwiches and alternative meals. The DM stated all items should be marked with the date they were put into the container and the last date to use. The DM stated after each shift the cooks restocked and refilled the items in the refrigerator. The DM stated the dust on the ceiling above food preparation table, the pots and pans rack, and vents on the ceiling needed to be dusted. The DM stated the cream cheese frosting was from 11/15/23. [It should be noted the item was observed on 11/13/23.]

Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician; and notify when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, a resident expressed feelings of suicidal ideation and the physician was not notified. Resident identifier 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. Review of resident 39's physician orders revealed the following: a. Seroquel Oral Tablet 25 milligram (mg) (Quetiapine Fumarate), give 12.5 mg by mouth every morning and at bedtime for Anxiety/Delusions. The order was initiated and discontinued on 9/10/23. b. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth at bedtime for Anxiety/Delusions. The order was initiated on 9/7/23 and discontinued on 9/10/23. c. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth two times a day for Anxiety/Agitation. The order was initiated on 9/5/23 and was discontinued on 9/7/23. d. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for Agitation for 1 Day. The order was initiated on 9/5/23 and discontinued on 9/6/23. e. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for agitation for 1 Day. The order was initiated on 9/3/23 and discontinued on 9/4/23. f. Escitalopram Oxalate Oral Tablet 20 mg (Escitalopram Oxalate), give 20 mg by mouth one time a day for anxiety/agitation. The order was initiated on 9/2/23 and discontinued on 9/10/23. Review of resident 39's progress notes revealed the following: a. On 9/10/2023 at 12:55 PM, the nursing progress noted documented, Res [resident] became increasingly agitated/paranoid to the point of wandering around the halls and attempting exit. Staff assisted res around hallways and prevented exit. Res was seen kicking the doors and demanding staff walk in front of her to 'avoid any funny business'. Attempted to give Norco for pain, res refused. [Family member] notified, will be coming in to sit with patient. Notified [Nurse Practitioner] of behaviors - received orders to change seroquel 12.5mg back to BID [two times a day]. b. On 9/10/2023 at 6:08 PM, the progress note documented, Pt's [patient's] daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin (administration), pt did calm down but still not cooperative and refused to take any medications. It should be noted that no documentation could be found to show that the medical provider was notified of the incident with the knife. 11/14/23 at 2:36 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 39's family was really involved with her care. LPN 2 stated that resident 39's family was in the building (9/10/23) from 11:00 AM to 4:30 PM. LPN 2 stated that resident 39 was a difficult patient and had a lot of behaviors that included agitation, wandering, and paranoid thoughts. LPN 2 stated that resident 39 seemed like she had a long standing mental health issue and was very paranoid. LPN 2 stated that resident 39's daughter had informed her that resident 39 had said I wish I were dead, and then proceeded to grab a butter knife from her meal tray. The daughter reported that resident 39 then went after her husband with the knife and then resident 39 placed the knife to her neck. LPN 2 stated that this incident had occurred a day or two prior to resident 39's elopement on 9/10/23. LPN 2 stated that she made sure resident 39's bedroom door was always open; she was located next to the nurse's station; and they made sure resident 39 did not have sharp objects in her room. LPN 2 stated that she informed the charge nurse of resident 39's suicidal ideation, and she thought the charge nurse would notify the physician. LPN 2 stated that documentation of the physician notification should be in a progress note. On 11/15/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that this incident occurred while she was on leave. The DON stated any suicidal ideation or attempt should be reported immediately to the provider and the whole interdisciplinary team would be involved.

Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the the allegation was made to the administrator, State Survey Agency (SSA), and Adult Protective Services. Specifically, a resident eloped from the facility and the State Survey Agency was not notified. Resident identifier 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. On 9/10/2023 at 6:08 PM, the resident 39's progress note documented, Pt's [patient's] daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin (administration), pt did calm down but still not cooperative and refused to take any medications. During dinner while staff were passing room trays, heard door alarm and noted pt was not in her room. Unable to find her in the parking lot. Charge Nurse aware and assisting in looking for pt and notified Administrator. While checking cars, noted pt to be walking in the road at the end of the block. A Samaritan stopped their truck and pt got into their vehicle when they noticed me running towards them. Pt became very agitated. I got into the truck and they gave us both a ride back to the main entrance of the facility. Charge Nurse and Admin notified EMS [Emergency Medical Services] and Law Enforcement as well as pt's daughter [name omitted] and [name of Nurse Practitioner omitted] of incident and that pt would be transferred to [local area emergency room (ER)] for a psych [psychiatric] eval. Pt pleasant and cooperative at this time, but does become more irritable and agitated the more people show up around her. Able to assist pt into Ambulance safety and without incident. Transported to ER and informed she will not be coming back to the facility. It should be noted that no documentation could be found to show that the SSA was notified of resident 39's elopement on 9/10/23. On 11/15/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that this incident occurred while she was on leave. The DON stated that an elopement was normally something that should be reported to the SSA. The DON stated that they thought that resident 39's elopement did not need to be reported because the resident was not anticipated to return to the facility.

Based on observation, interview, and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that the resident received care, consistent with professional standards of practice, to prevent the development of pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident developed a new pressure ulcer after admission to the facility and interventions were not implemented specific to the prevention of its development. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of left humerus, syncope and collapse, chronic kidney disease, dementia, peripheral vascular disease, prediabetes, history of venous thrombosis, and long term use of anticoagulants. On 11/14/23 at 9:43 AM, an observation was made of resident 23. Resident 23 right lower extremity was positioned in a podus boot with a stocking over the top of the foot. Resident 23 stated that she could feel a sore spot on the back of her ankle and that she wore the boot all the time. On 11/15/23, resident 23's medical records were reviewed. On 7/3/23, resident 23's Admission Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 5/15, which would indicate a severe cognitive impairment. The assessment documented that resident 23 was an extensive 2-person assist for bed mobility, transfer, ambulation in room/corridor, locomotion on/off unit, dressing, toilet use, and personal hygiene. The assessment documented that resident 23 used a walker and wheelchair as a mobility device. Review of resident 23's physician orders revealed the following: a. Wound Care: Right heel: apply skin prep every day shift for wound care. The order was initiated on 8/5/23. b. Wound Care: Left heel: Apply skin prep every day shift for wound care. The order was initiated on 8/12/23. c. Wound Care: Right heel Deep Tissue Injury (DTI): Clean with Normal Saline (NS) or wound cleanser, apply Silvakollagen, cover with dry dressing every day shift for wound care. The order was initiated on 8/12/23. d. WOUND CARE: Right Heel - Remove old dressing, cleanse with NS, place plain aquacel or alginate over wound bed, place foam dressing with skin prep every other day and as needed (PRN). The order was initiated on 9/27/23. e. WOUND CARE: Right Heel - Cleanse with Puracyn, apply skin prep to peri wound, apply Endoform on wound bed, cover with a dry dressing every day shift every 3 day(s) for wound care. Only Replace Endoform if it comes off. The order was initiated on 10/18/23. f. Keep feet elevated with bootie on right heel to offload every shift for wound care. The order was initiated on 9/27/23. g. Apply heel protectors when in bed or recliner two times a day for Wound care. The order was initiated on 8/5/23. h. Remind aides to place toe spacers on during day off at night two times a day for toes. The order was initiated on 7/6/23. Review of resident 23's progress notes revealed the following: a. On 6/26/2023 at 5:03 PM, the note documented, Assessed resident skin no sign of pressure sore on coccyx, buttock, heels. No excoriation in peri area. Did note dry cracked heels, and toe nail fungus. b. On 8/3/2023 at 10:04 PM, the note documented, Pt [patient] complained of pain on R [right] heel to CNA [Certified Nurse Assistant] and called nurse in. Nurse observed what appears to be a Deep Tissue injury on R heel. Notified wound care nurse. received orders to apply skin prep and float heels until she could take a look Friday 8/4. Approximately 1x [by]1 unblanchable purple area. c. On 8/5/2023 at 6:41 PM, the Skin/Wound note documented , Right heel DTI [Deep Tissue Injury] -Measuring 2.5 x 2.5 x 0 -Place heel protectors on -Tx [treatment] per wound care orders d. On 8/5/2023 at 6:42 PM, the note documented to apply skin prep to the right heel DTI, and apply heel protectors when in bed or recliner for protection. e. On 8/10/2023 at 9:37 AM, the Skin/Wound note documented, Note Text: R heel DTI -Measuring 3.5 x 4 x 0.1 -Minimal drainage -Cleaned et [and] tx per wound care orders Stage I pressure sore -Measuring 0.7 x 0.5 x 0.1 -Tx per wound care orders f. On 8/10/2023 at 11:30 AM, the note documented, Called Residents daughter [name omitted] to notify her about DTI on right heel and interventions (heel protectors, slippers when not in therapy, skin prep, bigger shoes) in place, daughter will get bigger shoes to prevent causing pain and pressure. g. On 8/18/2023 at 3:24 PM, the Skin/Wound note documented, Note Text: R heel DTI -Measuring 2.5 x 2.5 x 0.1 -Minimal drainage -Cleaned et tx per wound care orders L [left] heel Stage 1 -Measuring 0.8 x 0.4 x 0 -Tx per wound care orders h. On 8/25/2023 at 9:13 AM, the Skin/Wound note documented, Note Text: Right heel DTI -Measuring 2 x 2.2 x 0.1 -Minimal drainage -10% pink wound bed 90% eschar -Cleaned et tx per wound care orders left heel Stage 1 pressure sore -Measuring 0.4 x 0.5 x 0 -Tx per wound care orders i. On 9/1/2023 12:10 PM, the Skin/Wound note documented, Right heel unstageable DTI -Measuring 2.5 x 2.5 x 0.1 -Minimal drainage -Pale wound bed -30% Pink 70% stationary slough -Cleaned et tx per wound care order j. On 9/8/2023 at 11:47 PM, the Skin/Wound note documented, R heel unstageable DTI -Measuring 2.5 x 2.5 x 0.1 -90% slough, 10% granulation -Minimal drainage -Cleaned et tx per wound care orders k. On 9/14/2023 at 1:01 PM, the Skin/Wound note documented, Right unstageable pressure ulcer -Measuring 1.5 x 2.5 x 0.1 -55% slough, 45% Granulation -Moderate drainage -Cleaned et tx per wound care orders l. On 9/19/2023 at 10:19 AM, the note documented, [Physician name omitted] looked at Wound culture and Ordered Ciprofloxacin 500 mg [milligrams] BID [two times a day] x [times] 10 days for Infection in Left heel pressure ulcer. He also ordered to send her to Wound clinic at [local area hospital]. m. On 9/19/2023 at 12:56 PM, the Skin/Wound Note documented, Got DTI d/t [due to] sitting in white chair where family wants her to sit to be able to see outside. They do not want her sitting in recliner d/t 'it makes her nauseas (sic)'. n. On 9/22/2023 at 11:51 AM, the Skin/Wound Note documented, R heel unstageable pressure ulcer -Measuring 2.3 x 2 x 0.1 -Moderate drainage -55% slough, 45% Granulation -Macerated peri wound -Cleaned et tx per wound care orders o. On 9/27/2023 at 11:11 AM, the Skin/Wound Note documented, Patient returned from apt [appointment] with [physician name omitted] DPM [Doctors of Podiatric Medicine] in good spirits. Progress note as follows, Patient's wound needs to be debrided and we will do a better job of keeping pressure off the back to heal so we have dispensed a Podus boot and will start with a foam dressing with alginate dressing. Patient to return to clinic in 1 week or sooner if there is any problems. p. On 9/27/2023 at 11:24 AM, the Skin/Wound Note documented, Wound care orders from [physician name omitted] DPM as follows, 'R Heel, Cleanse with Puracyn. Use plain aquacel or alginate as the primary dressing, use bordered foam as the secondary dressing. May use skin protectant PRN [as needed] to help with dressing adherence. This order is to be carried out Every other Day, more PRN for soiling/dislodgment. Offload with mulipodus boot on right foot as often as patient will tolerate, with special emphasis on when patient is in bed or sitting in a chair when her feet are resting against anything such as a footrest. Continue to protect left heel. Keep wound dry when showering and bathing. [Name of facility omitted] If patient misses/doesn't have a wound care appointment SNF [skilled nursing facility] to change 4 times that week. Continue orders until the end of certification period or until new orders are received. q. On 10/5/2023 at 11:16 AM, the Skin/Wound Note documented, R heel unstageable pressure ulcer -Measuring 2.2 x 1.5 x 0.1 -Minimal drainage -50% slough, 50% granulation tissue -Cleaned et tx per wound care orders r. On 10/18/2023 at 12:46 PM, the Skin/Wound Note documented, resident came back from wound clinic with new orders: -Right heel: Cleanse w/Puracyn, Apply Skin Prep peri wound where adhesive border of dressing touches the skin. Use Endoform as primary dressing, Leave in place during the week. Replace if it comes off. Extra sent with patient. Use Foam Border dressing as secondary dressing. May use skin protectant PRN to help with dressing adherence. This order to be carried out Q3D [every 3 days] and PRN when soiled or wet. Offload with Multipodus boot on right foot as patient tolerates. Keep wound dry when showering. s. On 10/24/2023 at 1:24 PM, the Skin/Wound Note documented, R heel stage 4 pressure ulcer -Measuring 2.5 x 2 x 0.2 -100% granulation -Moderate drainage -Macerated peri wound t. On 11/14/2023 at 3:29 PM, the Skin/Wound Note documented, R heel stage 4 pressure ulcer -Measuring 2 x 1.4 x 0.1 -Moderate drainage -90% granulation 10% slough -cleaned et tx per wound care order Resident 23's care plan documented the following: a. A focus area for The resident has increased risk for pressure ulcer or potential for pressure ulcer development related to decreased movement and has stage 4 pressure ulcer to right heel. The care plan was initiated on 6/26/2023. It should be noted that the care plan was initiated on the date of resident 23's admission, but the nursing skin assessment on 6/26/23 did not identify any skin alterations. Furthermore, the DTI was not identified on the right heel until 8/3/23. Interventions identified included: Administer Multivitamin, Vitamin C, Zinc for wound healing as ordered per physician (initiated on 8/14/23); Administer treatments as ordered and monitor for effectiveness (initiated on 6/26/23); Follow facility policies/protocols for the prevention/treatment of skin breakdown (initiated on 6/26/23); Follow wound care orders to Left heel (initiated on 8/8/23); Follow wound care orders to Right heel (initiated on 8/16/2/3); If The resident refuses treatment, confer with the resident, Interdisciplinary Team (IDT) and family to determine why and try alternative methods to gain compliance. Document alternative methods (initiated on 6/26/23); Inform the resident/family/caregivers of any new area of skin breakdown (initiated on 6/26/23); Monitor nutritional status, serve diet as ordered and monitor intake and record (initiated on 6/26/23); and Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort (initiated on 6/26/23). b. A focus area for The resident has infection of the Right heel pressure ulcer. The care plan was initiated on 9/19/23. Interventions identified on the care plan were to administer antibiotic per physician orders; maintain universal precautions when providing resident care; monitor temperature/pulse; monitor/document/report to physician as needed for signs and symptoms (s/sx.) of a urinary tract infection (UTI): frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, behavioral changes; and monitor/document/report to physician any s/sx of delirium: changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness and agitation, altered sleep cycle. On 11/15/23 at 11:23 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 23 just went to wound clinic and on those days that she goes to wound clinic they did not perform wound care. LPN 2 stated that resident 23's current order for wound care were for every three days. On 11/16/23 at 8:58 AM, an observation was made of resident 23 seated in the dining room eating breakfast. Resident 23 had the right lower extremity podus boot applied. An immediate observation was made of resident 23's room. The resident did not have an air mattress applied to the bed. The resident's preferred seat was a chair situated at the foot of the bed and was not a recliner. On 11/16/23 at 9:04 AM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 23 had a sore on her heel. CNA 1 stated that after the development of the pressure ulcer they floated resident 23's heel and the boot was supposed to keep pressure off the heel. CNA 1 stated that when resident 23 was sitting in the chair they placed a pillow below her ankles to keep it from touching the floor. CNA 1 stated that resident 23 preferred the chair and not a recliner and it was difficult to float the foot in the chair. CNA 1 stated that resident 23 was on a regular mattress. On 11/16/23 at 9:16 AM, an interview was conducted with LPN 3. LPN 3 stated that the protocol for pressure ulcer prevention was to rotate or turn the resident every 2 hours, apply barrier cream, and monitor the skin condition at least daily or every shift. LPN 3 stated that any signs or symptoms of skin breakdown were to be reported to the charge nurse or wound care nurse and they would create a care plan. On 11/16/23 at 9:55 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility protocol for prevention of skin breakdown was to identify any high risk residents and to reposition the resident frequently. The DON stated that the wound nurse evaluated all new admits and if the resident was identified as high risk they would put an air mattress or a gel cushion in the chair. The DON stated that resident 23 had a gel cushion. The DON stated that resident 23 did not have an order for an air mattress or the gel cushion. The DON stated that resident 23's heel boots were ordered after the pressure ulcer was identified. The DON stated that they identified an intervention to float resident 23's heels when the DTI was identified on 8/3/23. The DON stated that resident 23 preferred to sit in the chair and they encouraged the recliner to elevate her feet. The DON stated that they implemented wound clinic after the development of the wound infection.

Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards was was possible and that the resident received adequate supervision to prevent accidents. Specifically, a resident who was identified as exit seeking did not have adequate supervision to prevent the resident from eloping. Resident identifier: 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. Review of resident 39's physician orders revealed the following: a. Seroquel Oral Tablet 25 milligram (mg) (Quetiapine Fumarate), give 12.5 mg by mouth every morning and at bedtime for Anxiety/Delusions. The order was initiated and discontinued on 9/10/23. b. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth at bedtime for Anxiety/Delusions. The order was initiated on 9/7/23 and discontinued on 9/10/23. c. Seroquel Oral Tablet 25 mg (Quetiapine Fumarate), give 12.5 mg by mouth two times a day for Anxiety/Agitation. The order was initiated on 9/5/23 and was discontinued on 9/7/23. d. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for Agitation for 1 Day. The order was initiated on 9/5/23 and discontinued on 9/6/23. e. Ativan Oral Tablet 1 mg (Lorazepam), give 1 mg by mouth one time only for agitation for 1 Day. The order was initiated on 9/3/23 and discontinued on 9/4/23. f. Escitalopram Oxalate Oral Tablet 20 mg (Escitalopram Oxalate), give 20 mg by mouth one time a day for anxiety, agitation. The order was initiated on 9/2/23 and discontinued on 9/10/23. Review of resident 39's progress notes revealed the following: a. On 9/1/2023 at 2:49 PM, the progress note documented that resident 39 was admitted after a ground level fall, had extensive dementia, and utilized a cane for mobility. b. On 9/3/2023 at 8:57 PM, the note documented, Pt [patient] has refused to take any meds PO [by mouth] today. Nurse earlier tried to admin [administer] them whole which she refused, and then tried them crushed and pt then decided that it was poison and that all her food was poisoned and refused to eat. Unable to reason with her. Pt's daughter was in earlier today and they brought in a hamburger and tried to get her to eat. Daughter reports that pt has a long history of dementia and has advanced to a higher state of paranoia. Daughter told me that pt was convinced that the TV was spying on her, that her son was installing cameras to watch her. Daughter reports that she has been cleaning out her home and that she has found several dirty, broken and useless items that have had to be thrown away. Daughter also reported an incident of physical aggression towards her husband where she tried to choke him. Daughter reports that she has had several fractures and repairs done. Pt has began wandering in halls and looking for her daughter. Going into other patients rooms looking for her family, and then began accusing family of trying to trick her. Unable to redirect her or reason with her. Requires constant 1:1 to prevent her form going outside or confronting other patients. Notified [Administrator's name omitted] and [Nurse Practitioner's (NP) name omitted]. Received order for 1mg Ativan PO. [Administrator] talked with daughter [name omitted] and was able to get her to come in and stay with pt 1:1. Daughter was able to get pt to take medications including Ativan which was effective. Pt's left arm is visibly red, swollen, and warm. Was started on Keflex for post op infection yesterday. Unable to keep it immobilized. She has removed splint and wrap several times and will not leave the sling in place. But has been better to leave the splint and wrap on today. c. On 9/5/2023 at 4:08 PM, the note documented, [Nurse Practitioner name omitted] ordered Seroquel 12.5mg PO BID [two times daily] and One time dose of Ativan 1mg PO Now d/t [due to] resident trying to run away and Paranoid thinking people want to poison her. d. On 9/6/2023 at 2:41 PM, the note documented, CNA's [Certified Nurse Assistants] charted the resident was wondering and having repetitive movements. e. On 9/10/2023 at 12:55 PM, the note documented, Res [resident] became increasingly agitated/paranoid to the point of wandering around the halls and attempting exit. Staff assisted res around hallways and prevented exit. Res was seen kicking the doors and demanding staff walk in front of her to 'avoid any funny business'. Attempted to give Norco for pain, res refused. Daughter [name omitted] notified, will be coming in to sit with patient. Notified [name omitted] NP of behaviors - received orders to change seroquel 12.5mg back to BID. f. On 9/10/2023 at 6:08 PM, the note documented, Pt's daughter did come in this after noon (sic) and was able to get her to take the Seroquel, but pt pocketed the Reflex and Norco and later spit them out. Daughter reported that they got some silverware to feed her a pudding which included a spoon, fork and butter knife. Daughter reported that pt grabbed the knife and held it up to her throat. After Seroquel admin [administration], pt did calm down but still not cooperative and refused to take any medications. During dinner while staff were passing room trays, heard door alarm and noted pt was not in her room. Unable to find her in the parking lot. Charge Nurse aware and assisting in looking for pt and notified Administrator. While checking cars, noted pt to be walking in the road at the end of the block. A Samaritan stopped their truck and pt got into their vehicle when they noticed me running towards them. Pt became very agitated. I got into the truck and they gave us both a ride back to the main entrance of the facility. Charge Nurse and Admin notified EMS [Emergency Medical Services] and Law Enforcement as well as pt's daughter [name omitted] and [NP name omitted] of incident and that pt would be transferred to [local area hospital] ER [emergency room ] for a psych [psychological] eval [evaluation]. Pt pleasant and cooperative at this time, but does become more irritable and agitated the more people show up around her. Able to assist pt into Ambulance safety and without incident. Transported to ER and informed she will not be coming back to the facility. It should be noted that no documentation could be found of monitoring for exit seeking behaviors, nor interventions to prevent elopement. 11/14/23 at 2:36 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 39's family was really involved with her care, and if resident 39 could get out she would. LPN 2 stated that resident 39 had a fractured elbow, and the goal was to get her recovered enough to return home. LPN 2 stated that resident 39 was confused and would wander. LPN 2 stated that resident 39 needed to be a 1:1 with a staff and her family would also stay with her. LPN 2 stated on the day of the elopement resident 39's family was in the building from 11:00 AM to 4:30 PM. LPN 2 stated that when they were passing dinner trays they heard an alarm. LPN 2 stated that they went to the front door to look for resident 39 and they found her walking in the middle of the street down by the round about. LPN 2 stated that a bystander was talking to resident 39. LPN 2 stated that this incident occurred towards the end of her day shift. LPN 2 stated that in the past if resident 39 was up and wandering they would call the resident's daughter and she would come in and sit with her. LPN 2 stated that resident 39 would wander up and down the hallway. LPN 2 stated that resident 39 was a difficult patient and had a lot of behaviors that included agitation, wandering, and paranoid thoughts. LPN 2 stated that resident 39 seemed like she had a long standing mental health issue and was very paranoid. LPN 2 stated that she suspected that resident 39 had bipolar disorder. LPN 2 stated that resident 39's daughter had said that the resident thought her son was putting cameras up to watch her. LPN 2 stated that resident 39 also thought that they were poisoning her food and she would not take her medication. LPN 2 stated that resident 39's daughter had informed her that resident 39 had said I wish I were dead, and then proceeded to grab a butter knife from her meal tray. The daughter reported that resident 39 then went after her husband with the knife and then resident 39 placed the knife to her neck. LPN 2 stated that this incident had occurred a day or two prior to resident 39's elopement on 9/10/23. LPN 2 stated that they were working on transferring resident 39 to another facility, because she did not qualify for their locked unit. LPN 2 stated that she made sure resident 39's bedroom door was always open; she was located next to the nurse's station; and they made sure resident 39 did not have sharp objects in her room. LPN 2 stated that the day of the elopement they ended up calling dispatch and the resident was transferred to the hospital. On 11/15/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON) and the Wound Nurse (WN). The DON stated that this incident occurred while she was on leave. The DON stated that at the time of the elopement resident 39 was not on 1:1 with a staff member. The WN stated that they tried to keep resident 39 at the nurse's station to monitor her and they would try to keep her busy with activities. The WN stated that since they were not doing 1:1 with a staff the family tried to be present as much as possible. The WN stated that when they realized she needed more assistance they tried to place her in memory care unit. The WN stated that interventions to keep resident 39 safe were to have her room located close to the nurse's station; kept her busy with activities; and they would take her to get a soda or an ice cream. The WN stated that the interventions were passed on in report. The WN stated that they administered Lorazepam to help with resident 39's anxiety. The WN stated that resident 39 would frequently say, i want to go home, where's my family. The WN stated that they tried to have staff watch her more when the family wasn't present. The WN stated that every time resident 39 was close to walking out they would call the family and they would come sit with her. The WN stated that they did not have a care plan for wandering or at risk for elopement as the resident was still in the 14 day window to develop them.

Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's medication was not administered per the physician ordered parameters. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included acute posthemorrhagic anemia, dissection of thoracoabdominal aorta, atrial fibrillation, heart failure, depression, diabetes and fibromyalgia. Resident 26's medical record was reviewed 11/13/23 through 11/16/23. A form from a home health company dated 10/27/23 revealed an order for ergocalciferol 1.25 milligrams (mg) (500 intl (international) units) oral capsule (cap). Administration of 1 cap every week. An order note in the progress notes dated 10/27/23 revealed This order is outside of the recommended dose or frequency. Ergocalciferol Oral Capsule 1.25 MG (50000 UT) (Ergocalciferol) give 1 capsule by mouth at bedtime for supplement. The daily dose of 1 capsule exceeds the usual dose of 0.1428 to 0.1429 capsule. The frequency of daily exceeds the usual frequency of every 7 days. A physician's order dated 10/27/23 revealed Ergocalciferol Oral Capsule 1.25 MG (50000 UT) Give 1 capsule by mouth at bed time for supplement. The order was discontinued on 11/7/23. The Medication Administration Record (MAR) October 2023 and November 2023 revealed Ergocalciferol was administered daily from 10/27/23 until 11/6/23. A physician's order dated 11/10/23 revealed Ergocalciferol Oral Capsule 1.25 MG (50000 UT) . Give 1 capsule by mouth one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday], Sun [Sunday] for supplement. The MAR for November 2023 revealed Ergocalciferol was administered 11/12/23, 11/13/23 and 11/15/23. An order note in the progress notes revealed on 11/7/23, This order is outside of the recommended dose or frequency. Ergocalciferol Oral Capsule 1.25 MG (50000 UT) (Ergocalciferol) Give 1 capsule by mouth one time a day every Mon, Wed, Fri Sun for Supplement. The daily dose of 0.5714 capsule exceeds the usual dose of 0.1428 to 0.1429 capsule. The frequency of 4 times per week exceeds the usual frequency of every 7 days. Resident 25's pharmacy reviews were completed for October 2023 and November 2023. There were no irregularities documented by the pharmacist. On 11/15/23 at 3:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when a resident was admitted the medication list was faxed to the pharmacy. The DON stated the nurse entered the medication into the electronic medical record. The DON stated resident 26 was getting 50,000 units of Ergocalciferol daily and it should have been weekly. The DON stated the medication was transcribed wrong and was administered daily to resident 25.

Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed an antipsychotic medication for insomnia. Resident identifier: 31. Findings included: Resident 31 was admitted on [DATE] with diagnoses which included laceration of muscles and tendons of the right lower extremity, tear of meniscus, coronary artery disease, chondromalacia, gout, dysarthria and anarthria, polyneuropathy, tremor, polyosteoarthritis, thrombocytopenia, hypothyroidism, and presence of bypass graft. On 11/15/23, resident 31's medical records were reviewed. Resident 31's physician orders revealed an order for Seroquel Oral Tablet 50 milligrams (mg) (Quetiapine Fumarate), give 1 tablet by mouth at bedtime for agitation. The order was initiated on 7/12/23. The Nursing 2022 Drug Handbook documented Seroquel's therapeutic drug class was an antipsychotic and was indicated to treat Schizophrenia, Bipolar I Disorder, Bipolar Depression, and Major Depressive Disorder. [NAME]. Nursing 2022 Drug Handbook. Philadelphia PA: Wolter Kluwer. 2022. p.1250-1255. On 11/15/23 at 1:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that when resident 31 was admitted he had a lot of situational depression, and initially he was not participating in therapy. LPN 2 stated that resident 31 was prescribed Seroquel to help him sleep and not to treat any psychosis. LPN 2 stated that the resident did not have any diagnoses of depression, schizophrenia, or bipolar disorder. On 11/15/23 at 1:34 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Seroquel was initially ordered in the hospital for insomnia. The DON stated that they realized during the psychotropic meeting that it was not prescribed for any mental health disorder.

Based on interview and record review, it was determined, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, for 2 of 23 sampled residents, a urinalysis was not done as requested by the provider and a resident did not have ordered labs completed. Resident identifiers: 31 and 32. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. On 9/16/23 at 5:21 PM, a nurse note stated, Pt [patient] continues on PO [by mouth] ABTx [antibiotics] for UTI [urinary tract infection], however, urine remains significantly bloody. Received orders from [name removed] to do a f/u [follow up] UA [urinalysis] 72 hrs after last dose of antibiotics. Pt and family aware. Physician's orders revealed the following laboratory orders: a. A physician order dated 9/16/23 read as follows, UA with C&S [culture and sensitivity] 72 hours after PO ABTx complete. 9/20/2023. One time only for Hematuria for 1 Day. [Note: this diagnostic order was ordered to be done on 9/20/23.] There were no laboratory results provided by the facility or located in resident 32's medical record. On 11/16/23 at 9:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there was not UA results for 9/20 and stated they were unable to find the order in the resident's medication administration record/ treatment administration record. The DON stated the order was put incorrectly and because of that the nurse was not flagged to obtain a UA that day. The DON stated if an order was put under diagnostic, it went no where in the resident's chart to alert staff. On 11/16/23 at 11:37 AM, an interview was conducted with the Medical Doctor (MD). The MD stated they ordered the follow up UA on 9/20/23 to make sure there was not any evidence of an ongoing infection from his foley catheter/irritation, nephrolithiasis, or irritation from stone due to resident 32 having the bloody urine. The MD stated the expectation was to obtain the UA if they had ordered it. 38031 2. Resident 31 was admitted on [DATE] with diagnoses which included laceration of muscles and tendons of the right lower extremity, tear of meniscus, coronary artery disease, chondromalacia, gout, dysarthria and anarthria, polyneuropathy, tremor, polyosteoarthritis, thrombocytopenia, hypothyroidism, and presence of bypass graft. On 11/15/23, resident 31's medical records were reviewed. On 7/19/23, an order for a Complete Blood Count (CBC) was initiated for resident 31. No documentation could be found of the CBC laboratory results in resident 31's medical records. On 11/15/23 at 12:50 PM, an interview was conducted with the DON. The DON stated that the order for the CBC was not obtained. The DON stated that the day nurse was not able to get a sample and she thought she passed it on to the night shift to complete.

Based on interview and record review it was determined, for 1 out of 23 sample residents, that the facility did not ensure that resident's laboratory reports were filed in the clinical record. Specifically, a resident's urine culture results were not in the resident's medical record. Resident identifier 32. Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. A physician order dated 9/8/23 for a urinalysis and culture and sensitivity due to signs and symptoms of a UTI was reviewed. The laboratory results for the above listed physician's order were not located in resident 32's electronic medical record. Resident 32 progress notes were reviewed and documented the following: a. On 9/25/23 at 4:01 PM, a nurse note stated, Also, resident reports [name removed], PA [physician assistant], took a UA @ [at] [name removed] Urology, which should have results 'soon'. b. On 9/27/23 at 2:23 PM, a nurse note stated, Requested UA results from Lab - suspected gram negative bacilli identified, susceptibility still pending. Will continue to monitor for culture results. c. On 9/28/23 at 3:44 PM, a nurse note stated, .Called [clinic name removed] Urology and left this information for PA, [name removed]. Receptionist stated he is looking into UA Cx [culture] status. This nurse left the Nature desk phone number with her and asked for [name removed] to call with any f/u [follow up] orders. Will continue to monitor. d. On 9/28/23 at 4:09 PM, a nurse note stated, [name removed], [clinic name removed] Urology, called and stated he received the messages left today re: [resident 32]. He stated, since resident's catheter is currently patent and resident's has a hx [history] with ABX [antibiotic] resistant bladder infections, he would rather wait for thecx [sic] results to grow out. He agreed to call with orders when CX has grown out. It should be noted that the urine culture results collected on 9/25/23 at the urologist office were not located in resident 32's electronic medical record. On 11/16/23 at 11:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the charge nurses were the one's responsible for keeping an eye out for lab results. LPN 1 stated normally lab results were upload into the resident's chart once they get them. LPN 1 was unable to locate resident 32's urine culture report for 9/8/23 and 9/25/23. LPN 1 stated they had an issue with the local hospital sending lab results back in a timely manner in the past. On 11/16/23 at 1:40 PM, an interview was conducted with the Director of Nursing (DON). The DON stated lab results were uploaded into the residents charts once they had been noted by the medical doctor (MD). The DON stated the charge nurse printed out the lab results and then gave it to the MD to review. The DON stated once the MD had reviewed and noted the results, they were given to medical records to upload them. The DON stated they were changing the process up so results were upload into the resident charts in a more timely manner. The DON stated they wanted to have results in the resident charts within 3 days of receiving the results.

Based on interview and record review it was determined, for 1 of 23 sampled residents, that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that was complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's physician's orders did not match the medication administered. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included acute posthemorrhagic anemia, dissection of thoracoabdominal aorta, atrial fibrillation, heart failure, depression, diabetes mellitus and fibromyalgia. Resident 26's medical record was reviewed 11/13/23 through 11/16/23. Resident 26's admission physician's orders dated 10/27/23 revealed Metoprolol Succinate Extended Release (ER) 50 milligrams (mg) oral tablet daily (QD). A physician's order in resident 26's electronic medical record dated 10/27/23 revealed Metoprolol Tartrate 50 MG by mouth QD. Resident 26's October and November 2023 Medication Administration Record (MAR) revealed that Metoprolol Tartrate 50 MG was administered daily. On 11/15/23 at 1:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated she was not sure if Metoprolol Succinate and Metoprolol Tartrate were the same. LPN 2 stated she would have to ask the pharmacist. LPN 2 was observed to look at a phone and then stated after looking at the difference, the Tartrate was not extended release and needed to be administered twice daily. LPN 2 stated the Succinate was extended release and needed to be administered once daily. LPN 2 stated those were two different medications and she would need to contact the physician to obtain a clarification order for resident 26. On 11/15/23 at 2:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated admission orders were obtained from the hospital sent to the pharmacy. On 11/15/23 at 3:10 PM, a follow-up interview was conducted with the DON. The DON stated that resident 26 was receiving the Succinate and not the Tartrate. The DON stated that the Succinate was an extended release should be administered once daily. The DON stated the Tartrate was short acting and needed to be administered more often. The DON stated resident 26 was receiving the appropriate medication but it was documented incorrectly.

Based on interview and record review, it was determined, the facility did not establish an infection prevention and control program that included, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 23 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with the incorrect antibiotic that was not listed on the susceptibility laboratory report. Resident Identifier: 32 Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. Resident 32's progress notes were reviewed and documented the following: a. On 9/9/23 at 10:13 AM, a nurse note stated, [name removed] NP [nurse practitioner] seen [sic] Pt [patient] today for symptoms of a UTI [urinary tract infection]. Ordered Keflex 500mg [milligrams] PO [by mouth] TID [three times a day] x7 days . b. On 9/16/23 at 5:21 PM, a nurse note stated, Pt continues on PO ABTx [antibiotics] for UTI, however, urine remains significantly bloody. Received orders from [name removed] to do a f/u [follow up] UA [urinalysis] 72 hrs [hours] after last dose of antibiotics. Pt and family aware. On 9/11/23, a finalized urine culture result, documented resident 32 had a UTI due to having grown out an organism. It should be noted that the prescribed antibiotic [Keflex] was not included on the susceptibility list. On 11/16/23 at 9:06 AM, an interview was conducted with the Director of Nursing (DON). The DON stated nurses went off resident symptoms to determine if they had a UTI. The DON stated the symptoms included frequency, change in urine odor, change in urine status, flank pain and a change in the resident's activities of daily living or cognition. The DON stated once a resident had these symptoms, the physician was notified, and a UA was collected. The DON stated a urine culture was always ordered in conjunction with the UA. The DON stated sometime the lab did not run a urine culture if the UA looked clean. The DON stated a UA resulted within 4-6 hours and a urine culture took 2-3 days for results. The DON stated if a resident had a long history of UTIs, most times the physician waited to start them on antibiotics until the urine culture had been finalized so the resident was not started on an antibiotic, they were resistant too. The DON stated sometimes the physician started a resident on antibiotics before the urine cultures were finalized but made adjustments to the antibiotic once the urine culture results were available. On 11/16/23 at 11:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when a resident experienced UTI symptoms, they notified the doctor who then ordered a UA based on the symptoms a resident was experiencing. LPN 1 stated a urine culture was always ordered with a UA. LPN 1 stated the doctor sometimes prescribed broad spectrum antibiotics based on the UA results and would then adjust the antibiotics according to the urine culture results. On 11/16/23 at 11:37 AM, an interview was conducted with the Medical Doctor (MD). The MD stated once the urine culture results were finalized, they were printed and given to the provider to see if any adjustments needed to be made to the prescribed antibiotic. The MD stated the susceptibility report gave a representative drug in the category. The MD stated as long as the antibiotic prescribed was included in the same drug class that the organism was susceptible to, it was effective in treating the UTI. The MD stated the antibiotic prescribed to resident 32 on 9/9/23 needed to be changed. The MD stated the drug class equivalent to Keflex, indicated the organism which grew in resident 32's urine was resistant to the antibiotic prescribed.

Based on observation, interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, an unvaccinated newly admitted resident on Transmission Based Precautions (TBP) did not isolate in their room for 14 days after admission and was allowed to exit the droplet isolation room to attend therapy services in the facility gym. Staff were observed not donning the appropriate Personal Protective Equipment (PPE) prior to entering rooms on droplet precautions, and did not sanitize their protective eyewear upon exit of droplet precaution rooms. Staff were observed to enter and exit a droplet precaution room without doffing the PPE prior to entering another resident room, and housekeeping equipment was taken into the droplet precaution room and then into another resident room for use. Staff were observed removing meal trays from rooms on droplet precautions and placing those trays onto the meal cart with other dishes for return to the kitchen. Additionally, staff were observed wearing PPE incorrectly, hand hygiene was not performed during medication administration, and food was transported uncovered through the hallways. Resident identifiers: 16, 143, and 191. Findings included: A. TBP and Droplet Isolation Rooms On 1/10/22 at 9:10 AM, an observation was made of a sign posted at the front entrance desk. The notice was dated January 8, 2022 and stated that the facility was in outbreak status and had COVID positive staff on two hallways in the Skilled Nursing Facility (SNF). On 1/10/22 at 9:26 AM, a interview was conducted with the facility Administrator (ADM). The ADM stated that the facility was currently in outbreak status with 7 staff members testing positive for COVID-19 throughout the building in both the Assisted Living Facility (ALF) and the SNF. The ADM stated that they they were conducting outbreak testing every 3-5 days for all facility staff and residents, and no residents were currently COVID positive. The ADM stated that the outbreak originally began with a resident who contracted it from their family member, and that resident was transferred to a COVID facility for care. On 1/10/22 at 9:55 AM, the ADM clarified and stated that the outbreak originally began on December 20, 2021 with a COVID positive Certified Nurse Aide (CNA) 3. The ADM stated that all residents were tested on [DATE] and none were COVID positive. On 12/25/21 the first resident became symptomatic with a cough and weakness, and subsequently tested positive. This resident was transferred to a COVID facility for care. The ADM stated that all COVID positive residents were transferred out of the facility. The ADM stated that they conducted testing of all residents on the affected unit Floral on 12/25/21 as the resident was isolated to that area. The ADM stated that they conducted contact tracing for any staff that worked on Floral and tested on ly staff that worked on the Floral unit and tested all resident on Floral. The ADM stated that on 1/3/22 a housekeeper (HK) 2 tested positive, but had not worked in 5 days. The ADM stated that the first round of testing ended on January 1/3/21. Then on 1/7/21 a Licensed Practical Nurse (LPN) 1 from Floral complained of a headache. LPN 1 subsequently tested positive for COVID. The ADM stated that around this time she had 3 additional staff on the ALF and 2 staff on the SNF with symptoms that tested negative with the rapid [MEDICATION(S)] test. The ADM called the local health department and arrangements were made to have all staff members polymerase chair reaction (PCR) tested . From the PCR tests CNA 10 came back positive for COVID and had worked on the Nature unit. The ADM stated that the first round of testing for all residents on the Floral and Nature unit would be conducted today. The ADM stated that all staff were notified on Friday, 1/7/22, to test for the current outbreak. The ADM stated that all residents on the Floral and Nature unit were on quarantine and isolating in their room on contact/droplet precautions. The ADM clarified that the north section of the building was considered the Floral unit and the south section of the building was the Nature unit, and that all of the SNF residents were isolating in their rooms on contact/droplet precautions. The ADM stated that staff entering the rooms should be wearing a gown, gloves, N95, and eye protections. The ADM stated that staff were universally wearing an N95 masks and eye protection. The ADM stated that the rest of the building staff were also wearing an N95 mask and eye protection, and this included the kitchen staff, maintenance staff, and housekeeping staff. The ADM stated that the facility was utilizing reusable washable gowns and they were located on a hook in the resident rooms. The ADM stated that they were changed each shift, and the same staff should be using the same gown throughout the shift. The ADM stated that there were multiple hooks in the resident room if more gowns were needed. The ADM stated that all staff were wearing N95 and eye protection and should be donning gowns and gloves when entering resident rooms. The ADM stated that they were in contingency supply with PPE and the N95 masks could be worn up to 3 times and then discarded if they were not soiled or damaged. The ADM stated that for new admissions they determine vaccination status prior to arrival and the resident had a negative COVID test. The ADM stated that if the new admission was not vaccinated against COVID-19 then they would be placed in isolation on droplet precautions for 7 days. The ADM stated that after day 7 they would test the resident again and if they had a second negative COVID test they could come off of isolation after 7 days. On 1/11/22 at 8:02 AM, the ADM stated that Physical Therapist (PT) 2, CNA 11, and LPN 2 had tested positive on 1/10/22. The ADM stated that the staff were not working yesterday. The ADM stated that all residents had tested negative for COVID. 1. Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at approximately 11:50 AM, an observation was made of resident 16's room. The door was closed and a sign was posted that stated droplet precautions. Instructions on the sign stated, 1.) A. Private room, door may remain open B. Patient must be confined to room 2.) Health Care Workers must wear mask and gloves upon entry to the patient's room 3.) Mask should be worn by all entering the room 4.) Clean hands after removing mask and gloves and before leaving room A PPE cart was located outside of resident 16's room contained gloves, surgical mask, disposable gowns, and red biohazard bags. On 1/10/22 at 12:11 PM, an interview was conducted with CNA 2. CNA 2 stated that isolation precautions were for new residents and residents who had symptoms consistent with COVID-19. CNA 2 stated that resident 16 was symptomatic but she believed the COVID test was negative. CNA 2 stated that they wear disposable gowns for the rooms on droplet precautions. On 1/10/22 at 12:23 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 16 had new onset symptoms of a fever, cough and pain. RN 1 stated that resident 16's rapid [MEDICATION(S)] test came back negative, and that she had just received the results of the PCR test that morning and it was also negative. RN 1 stated she was not sure why resident 16 was still on droplet precautions, and maybe it was just as an added precaution. RN 1 stated that she would check and let me know. RN 1 stated that resident 16 had been on isolation precautions for 2 days. On 1/10/22 resident 16's medical records were reviewed. Review of resident 16's immunization records documented that resident 16 had received the [CONDITION(S)]-CoV-2 dose 1 on 1/15/21, [CONDITION(S)]-CoV-2 dose 2 on 2/5/21, and the Pfizer Booster on 10/21/21. Review of resident 16's progress notes revealed the following: a. On 1/9/2022 at 2:45 AM, Fever of 100.3, prn (as needed) tylenol given to decrease fever and rapid Covid-19 test done due to fever and pt (patient) c/o (complaints of) of (sic) 'body pain head to toe that won't go away'. b. On 1/9/2022 at 5:53 AM, tylenol effective, temperature reduced to 98.8. Covid-19 rapid test results negative. Will follow up with DON (Director of Nursing) regarding possibility of getting a PCR due to persisting pt c/o body pain, sore throat, and higher than normal temperature. c. On 1/9/2022 at 10:15 AM, Pt is having several s/sx (signs and symptoms) of a covid-19 infection. Fever, controlled with tylenol. Dry cough, nauseated. Reported to Medical team. Orders received to perform PCR test, d. On 1/9/2022 at 11:30 AM, Obtained COVID-19 PCR Nasopharyngeal sample per orders at 1100 and transported to [local hospital] lab. e. On 1/11/2022 at 1:46 PM, Results received from state lab for PCR done. Resident no longer having symptoms and test negative. Droplet precautions removed. No documentation could be found of laboratory test results for the PCR test nor the rapid [MEDICATION(S)] test obtained on 1/9/22. On 1/11/22 at 8:50 AM, an observation was made of the Minimum Data Set (MDS) Nurse in resident 16's room. The MDS nurse was located inside resident 16's room at the side of resident 16. Resident 16 was seated in a wheelchair, and the MDS nurse was rubbing resident 16's back with bare hands. The MDS nurse did not have a gown or gloves donned. The MDS nurse was wearing an N95 mask and eye protection. Resident 16's room was observed with signs posted that stated droplet precautions and the PPE cart was located outside of the room. An immediate interview was conducted with the MDS nurse upon exit of resident 16's room. The MDS nurse did not disinfect the eye protection upon exit of resident 16's room. The MDS nurse stated that she was going room to room making rounds to make sure that all residents had their call lights next to them. The MDS nurse stated she was not sure why resident 16 had a droplet precaution sign posted. The MDS nurse stated that if they were providing cares they should be donning PPE for droplet precautions, but that they did not need any other PPE just to enter the resident room. On 1/11/22 at 3:00 PM, an observation was made of resident 16's room without the droplet precaution sign and PPE cart. On 1/11/22 at 3:02 PM, an interview was conducted with RN 2. RN 2 stated that the droplet precaution signs for resident 16 were removed because the dates had passed and they were there longer than they needed to be. RN 2 stated that the droplet precautions were for complaints of nausea and body aches. RN 2 stated that both the [MEDICATION(S)] and PCR test were negative. RN 2 stated that she could have taken the signs down this morning but she had not gotten around to it yet. RN 2 stated that she would have to ask where resident 16's test results were located. RN 2 stated that when she conducted a rapid [MEDICATION(S)] test she would write the results down on paper and turn it into the DON and they recorded the information. RN 2 stated that she did not know where that information would be located. RN 2 stated that she currently did not have any residents right now that were exhibiting any signs or symptoms (s/sx) of COVID. RN 2 stated that even resident 16 did not have anymore s/sx of COVID, and that she was no longer nauseated or febrile. RN 2 stated that the aides would report any s/sx to her. RN 2 stated that some residents were assessed daily for lung sounds if they were Medicare. If they meet that criteria then she would listen to their lung sounds. If not, then they would have a respiratory assessment completed weekly. 2. Resident 143 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at approximately 11:50 AM, an observation was made of resident 143's room. The door was closed and a sign was posted that stated droplet precautions. Instructions on the sign stated, 1.) A. Private room, door may remain open B. Patient must be confined to room 2.) Health Care Workers must wear mask and gloves upon entry to the patient's room 3.) Mask should be worn by all entering the room 4.) Clean hands after removing mask and gloves and before leaving room A PPE cart was located outside of resident 143's room contained gloves, surgical mask, disposable gowns, and red biohazard bags. On 1/10/22 at 12:11 PM, an interview was conducted with CNA 2. CNA 2 stated that isolation precautions were for new residents and residents who had symptoms consistent with COVID-19. CNA 2 stated that resident 143 was a new admission. CNA 2 stated that they wear disposable gowns for the rooms on droplet precautions. On 1/10/22 at 12:23 PM, an interview was conducted with RN 1. RN 1 stated that resident 143 was a new admit on quarantine. On 1/10/22 at 2:19 PM, an observation was made of resident 143 being wheeled back to their room by Certified Occupational Therapist Assistant (COTA). The resident was observed wearing a surgical mask. The COTA was wearing a N95 mask and eye protection. The COTA did not donn a gown or gloves prior to entering resident 143's room. The COTA assisted resident 143 back to bed. The COTA did not disinfect their eye protection after exiting resident 143's room. An immediate interview was conducted with the COTA upon exit of resident 143's room. The COTA stated that he was just coming back from the therapy gym with resident 143. The COTA stated that resident 143 went to therapy daily in the facility gym. The COTA stated that unless he was providing personal cares he did not need to wear a gown or gloves when working with resident 143. The COTA stated that examples of personal care were assisting resident 143 with toileting, and that he did not do that today. The COTA stated that he did not wear a gown or gloves in the therapy gym either. On 1/10/22 resident 143's medical records were reviewed. Review of resident 143 immunization records documented under [CONDITION(S)]-CoV-2 dose 1, Consent Refused. No date was documented. On 12/31/21 resident 143 signed a COVID-19 Vaccination Declination. The form did not document that the resident had received a COVID-19 vaccine prior, or had received passive antibody therapy. Review of resident 143's orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/22 at 11:38 AM, a follow-up interview was conducted with the ADM. The ADM stated that they were down a housekeeper and could not keep up with washing the reusable gowns. The ADM stated that they did not have enough disposable gowns, so they were going to implement universal gowning. The ADM stated that meant that staff would be wearing the same gown throughout the shift unless soiled or damaged. The ADM stated that this did not apply to the rooms on droplet precautions. The ADM stated that those rooms the staff would have to donn an additional disposable gown over the universal gown prior to entering. On 1/11/22 at 3:00 PM, an observation was made of resident 143 without the droplet precaution sign and PPE cart. Resident 143 door was open and a staff member was located at the bedside providing therapy. The staff member was wearing a N95 mask, goggles, reusable gown, and gloves. The staff member did not have a second disposable gown donned over the reusable gown. It should be noted that per the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/22 at 3:02 PM, an interview was conducted with RN 2. RN 2 stated that the droplet precaution signs for resident 143 were removed because the dates had passed and they were there longer than they needed to be. RN 2 stated that resident 143 was on droplet precautions for new admission, and was admitted on [DATE]. RN stated that resident 143 should be on isolation precautions for 2 weeks, and was taken off of isolation precautions a couple of days short. RN 2 stated she would ask why it was removed. RN 2 stated that she believed that resident 143 had been vaccinated, but had not had both doses. RN 2 stated that the facility policy for new admissions was to check the resident's vaccination status, encourage them to get vaccinated if they were not, and if they were not vaccinated they were placed on contact/droplet precautions for two weeks. RN 2 stated resident 143's PPE cart and droplet sign was removed a couple of days early. RN 2 stated that they monitored for signs and symptoms of COVID daily with temperature checks, and some residents get oxygen saturation but not all residents. RN 2 stated that now that we are on outbreak status she was not sure if they were going to change the monitoring to include more. RN 2 stated that the outbreak status meant they were wearing N95 masks, goggles, gloves, and gowns with all residents. RN 2 stated that since this morning they had received an email that stated that since the community positivity rate had gone up they should be wearing full PPE with all residents. RN 2 stated, to be honest gloves should have been worn with all patient care this morning. RN 2 stated staff should be wearing gowns, gloves, goggles, N95 with all care not just feeding, transferring, and incontinence care. RN 2 stated that there was no additional or different measures or PPE needed for residents on TBP verses other residents in the facility. RN 2 stated maybe an extra mask, because a gown and gloves were implemented for everyone now. On 1/11/22 at 3:55 PM, an interview was conducted with the DON. The DON stated that she along with the facility Infection Preventionist (IP), and MDS Coordinator conducted the [MEDICATION(S)] testing of all the residents yesterday. The DON stated that the results were documented on a paper and then they were scanned into the residents individual records. The DON stated that she was behind in scanning due to having to help out with staffing shortages from the current outbreak. On 1/12/22 at 10:19 AM, an interview was conducted with the DON and IP. The DON stated that unvaccinated new admissions were placed on quarantine for 14 days and could test out on day 10 if they were not showing and s/sx consistent with COVID and had a negative COVID test. The DON stated that the guidance was provided by the state. The DON stated that droplet precautions PPE utilized was a gown, gloves, mask, and eye protection. The DON stated that all residents were tested prior to admit. The DON stated that they could use a surgical masks to preserve their N95 mask supply if the resident was not symptomatic and on droplet precautions. The DON stated that it was in the contingency supply policy. The DON stated that all PPE was hard to get at the moment. The DON stated that they have been using the contingency PPE supply plan approximately since the county case positivity rate had been going up. The DON stated that the ADM monitored the county positivity rate, and emailed the number to her. The DON could not recall how long the county positivity rate had been above 10%, but that was how they determined how often to schedule the COVID testing for the unvaccinated staff. The DON stated that the county positivity rate was also what they based the use of the surgical mask verses the use of the N95 mask for the TBP rooms. The DON stated that if they were having difficulty obtaining supplies of N95 masks from their vender then they reached out to the health department for additional supplies. The DON stated that they were using surgical masks instead of N95 masks because they did not want to use the N95 mask on asymptomatic cases. The DON stated that the Centers for Disease Control and Prevention (CDC) guidance was to use a N95 or higher if you had the supplies for any suspected or confirmed COVID cases. The DON stated that they currently had supplies of N95 masks and were being supplied supplemental by the health department. The DON stated that for new admissions on droplet precautions they try to have them do therapy in the resident room as much as possible. The DON stated that if they need to go out of the room they maintain social distancing, the resident wore a mask, and the therapist wore a gown, gloves, mask and eye protection. The DON stated that the nursing staff should be monitoring for COVID daily and charting in the Treatment Administration Record (TAR). Monitoring for COVID included daily screening of a temperature check and symptoms of cough, shortness of breath, difficulty breathing, headache, loss of taste or smell and a temperature greater than 100.3 degrees Fahrenheit. The DON stated that the nursing staff should be aware of all of those signs and symptoms and the screening process. The DON stated that if a resident should display any signs staff should do a rapid test, place the resident in quarantine, and notify the DON. The DON stated that a follow-up PCR test may be conducted also. The DON stated that resident 143 was taken off of TBP because she tested negative and it was past day 10. The DON stated that all the licensed nurses and CNAs should know that they should be wearing a gown, gloves, mask and eye protection before entering the resident room. The DON stated that all staff had been provided education on PPE and COVID guidelines and that any updated guidance was emailed directly to the staff. The IP stated that staff should be cleaning eye protection with disinfecting wipes at the end of the shift or if they become visibly soiled, and when exiting a droplet precaution room. The DON stated that rooms on TBP the meal trays should be served on disposable plates with disposable cutlery and disposable cups. The DON stated that they should be discarded in the resident room in the bin and would not be returned to the meal cart or the kitchen for disposal. Review of the facility PPE inventory list revealed a N95 masks quantity of 1675. On 1/13/22 at 9:20 AM, an observation was made of resident 143's room. The droplet precaution sign and PPE cart was located back outside of the resident room. Housekeeper (HK) 1 was observed to perform hand hygiene and donn gloves. HK 1 was wearing a reusable cloth gown, N95 mask and goggles. HK 1 donned a surgical mask over the N95 mask. No additional disposable gown was donned over the reusable gown by HK 1. HK 1 entered resident 143's room with the housekeeping cleaning cart and vacuum. HK 1 was heard vacuuming resident 143's room. HK 1 exited resident 143's room with the cleaning cart and vacuum. HK 1 discarded the gloves and hand hygiene was performed. HK 1 did not disinfect their eye goggles upon exit of droplet precaution room. HK 1 was observed to go directly to room [ROOM NUMBER] with the cleaning cart and vacuum, where the cleaning cart was wheeled inside the resident room for use. On 1/13/22 at 9:39 AM, an interview was conducted with HK 1. HK 1 stated PPE for droplet precaution rooms were N95, goggles, and a gown. HK 1 stated that she wore the same gown into the droplet precaution room that she wore throughout the facility. HK 1 stated that she used clean rags and a clean mop rag for each room. HK 1 stated that she did not know if she had to clean her eye goggles after exiting a droplet precaution room. HK 1 stated that she just cleaned the goggles at the end of the day. On 1/13/22 at 9:47 AM, observed CNA 3 to enter resident 143's room. CNA 3 donned a surgical mask over her N95 mask, a disposable gown over the reusable cloth gown, and gloves. CNA 3 wore eye goggles. CNA 3 exited resident 143's room and placed the residents meal tray on the meal cart. The meal tray was served on regular dishes and not disposable. CNA 3 doffed the surgical mask, gloves, disposable gown and hand hygiene was performed. CNA 3 did not disinfect their eye goggles upon exit of the droplet precaution room. On 1/13/22 at 10:06 AM, an observation was made of PT 1 wheeling resident 143 to the therapy gym. Resident 143 had to be wheeled past another resident to enter the therapy gym and was within six feet of each other. Three other residents were present in the gym at the same time. An immediate interview was conducted with the ADM. The ADM stated she would go to the gym and speak to the therapist immediately. The ADM followed-up and stated that PT 1 knew immediately that resident 143 was not supposed to be out of the room. Review of the facility COVID-19 POLICY & PROCEDURES documented that if both exposure and illness were present that the individual would need to isolate in a private room with the door closed. TBP, including Contact and Droplet were to be implemented and PPE included gown, gloves, mask and eye protection. The policy further documented that N95s should be worn by care staff when caring for COVID positive residents and those who have been exposed to COVID-19. The guidance further stated that new admits would be placed on restrictive interventions for 14 days. The guidance was last updated on November 26, 2021. Review of the facility COVID-19 COHORTING POLICY AND PROCEDURES documented newly admitted residents and residents who have traveled outside the facility to locations that have not followed proper infection control practices will be subject to this 'soft quarantine' for 14 days. Resident room doors will be kept closed unless safety concerns require otherwise. Staff will wear goggles or face shields in addition to surgical masks. The guidance was last updated on November 26, 2021. Review of the CDC guidance on Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes documented under New Admissions and Residents who Leave the Facility that all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance further stated that all Healthcare Personnel (HCP) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). The guidance was last updated on September 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html 3. Resident 191 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at 12:16 PM, an observation was made of resident 191's room. The door was closed and a sign was posted that stated droplet precautions. Instructions on the sign stated, 1.) A. Private room, door may remain open B. Patient must be confined to room 2.) Health Care Workers must wear mask and gloves upon entry to the patient's room 3.) Mask should be worn by all entering the room 4.) Clean hands after removing mask and gloves and before leaving room A PPE cart was located outside of resident 191's room contained gloves, N95 masks, disposable gowns, red biohazard bags, and alcohol based hand rub (ABHR). On 1/11/22 resident 191's medical records were reviewed. Review of resident 191's immunization records documented under [CONDITION(S)]-CoV-2 dose 1, Consent Refused. No date was documented. On 1/1/22 resident 191 signed a COVID-19 Vaccination Declination. The form did not document that the resident had received a COVID-19 vaccine prior, or had received passive antibody therapy. Review of resident 191's orders revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/10/22 at 12:22 PM, an interview was conducted with CNA 5. CNA 5 stated the facility was in outbreak status and all residents were being quarantined for 5 days. CNA 5 stated the resident 11 was a new admission. CNA 5 stated she was not sure how long resident 191 would be in quarantine. On 1/10/22 at 1:04 PM, CNA 5 delivered the lunch meal tray to resident 191. CNA 5 donned a gown and gloves in addition to the N95 mask and eye protection that was worn. CNA 5 delivered the meal tray to the droplet precaution room on a regular uncovered plate, no disposable service ware was used. CNA 5 did not disinfect their eye protection upon exit of the droplet precaution room. On 1/10/22 at 2:34 PM, an observation was made of CNA 9 entering resident 191's room without donning a gown. CNA 9 was wearing a surgical mask and eye protection. CNA 9 exited resident 191's room at 2:37 PM with a meal tray. CNA 9 carried the uncovered tray down the entire hallway and around the corner where the meal cart was located. Resident 191's lunch meal tray was placed on the meal cart with all the other meal trays for return to the facility kitchen. B. PPE Usage On 1/10/22 at approximately 9:15 AM, an observation was made of a CNA 2 seated in the dining room next to a resident assisting with dining. The CNA was observed with their eye protection placed on top of their head and their surgical mask was down below their nose. On 1/10/22 at 9:55 AM, a interview was conducted with the facility ADM. The ADM stated that communal dining in the dining room had been suspended during the outbreak and all residents were eating in their rooms unless they required dining assistance. On 1/10/22 at 3:33 PM, a phone interview was conducted with resident 3's family member. Resident 3's family member stated his spouse had observed the CNA's taking off their masks while in resident 3's room multiple times. On 1/11/22 at 3:07 PM, an interview was conducted with Housekeeper (HK) 2. HK 2 was wearing a gown, gloves, eye protection and an N95 mask. HK 2 stated she cleaned resident room's daily and cleaned common areas weekly. HK 2 stated she wasn't told much about the need to wear a gown. HK 2 stated she was just handed a gown and told to put it on. HK 2 stated she had been wearing the gown the whole shift. HK 2 stated she had not been told if she needed to change her gown based on what room she went in. HK 2 stated she had to wear gloves while in resident rooms. On 1/11/22 at 3:20 PM, an interview was conducted with CNA 8. CNA 8 stated she did not know why the staff were wearing gowns. CNA 8 stated she was told to wear gloves, eye protection and a mask to go into a resident room. CNA 8 stated she was not told when to change the gown or how often. CNA 8 stated she thought it was to protect the resident's and staff. On 1/11/22 at 3:27 PM, an interview was conducted with CNA 7. CNA 7 stated she did not know why staff were wearing gowns. CNA 7 stated she thought it was for extra precautions. CNA 7 stated if a resident was positive the staff would use the gowns in the room. CNA 7 stated all residents were negative on that hallway. CNA 7 stated all residents were tested on the previous evening before she left between 6:30 and 6:45 PM. On 1/12/22 at 8:33 AM, an interview was conducted with the Housekeeping Manager (HKM). HKM stated staff were wearing gowns, goggles, and N95 masks. HKM stated staff were wearing gloves only for personal cares of the residents. HKM stated he avoided newly admitted resident rooms to avoid having to change his gown. HKM stated that facility started using gowns and N95 masks yesterday due to the high county positivity rate. C. Medication Administration On 1/12/22 at approximately 8:05 AM, an observation was made of RN 1 during medication administration. RN 1 was observed to apply gloves. RN 1 then proceeded to touch the med [TRUNCATED]

Based on interview and record review, the facility did not ensure that medical records were complete, accurately documented, readily accessible and systematically organized for 3 of 23 sample residents. Specifically, hospice notes and physician visit notes had not been placed in the residents ' medical records. Resident identifiers: 17, 27 and 34. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 17's medical record was reviewed on 1/10/22. Review of resident 17 ' s medical record revealed that no physician visits notes had been placed in the resident ' s record since 7/16/21. On 1/13/22, the Director of Nursing (DON) provided physician visit notes indicating that resident 17 had been seen by the facility physician on 7/29/21, 8/5/21/21, 8/13/21, 8/20/21, 8/25/21, 9/8/21, 9/17/21, 10/2/21, 10/8/21, 10/14/21, 10/22/21, 10/26/21, 11/11/21, 11/19/21, 12/7/21, 12/8/21, and 12/27/21. On 1/13/22, an interview was conducted with the DON. The DON confirmed that the above listed physician visit notes had not been placed in resident 17 ' s medical record prior to 1/13/22. The DON stated that she had identified that there was an issue with physician visits being placed in residents ' medical records in a timely manner, but had not yet been able to correct the issue. 2. Resident 34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 34 ' s medical record was reviewed on 1/10/22. Review of resident 34 ' s medical record revealed that no physician visits notes had been placed in the resident ' s record since 12/2/20. In addition, the resident was on hospice during that time, but had been discharged from hospice services on 11/26/21. No hospice notes regarding the coordination of resident 34 ' s care were located in the medical record. On 1/12/22, the DON provided physician visit notes indicating that resident 34 had been seen by the facility physician on 1/6/21, 1/27/21, 2/24/21, 3/31/21, 4/28/21, 5/26/21, 6/30/21, 8/3/21, 10/1/21, 12/1/21, 12/2/21, 12/16/21, 12/28/21, and 1/11/22. On 1/12/22 at 2:45 PM, an interview was conducted with the DON. The DON confirmed that the above listed physician visit notes had not been placed in resident 34 ' s medical record prior to 1/12/22. The DON also confirmed that no hospice notes were in resident 34 ' s medical record prior to 1/12/22, and that she had asked the hospice company to fax over their records on 1/12/22. 3. Resident 27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 27 ' s medical record was reviewed on 1/20/22. Review of resident 27 ' s medical record revealed that no physician visits had been placed in the resident ' s record since 4/23/21. In addition, the resident had been placed on hospice services as of 12/23/20. No hospice notes regarding the coordination of resident 27 ' s care were located in the medical record. On 1/12/22, the DON provided physician visit notes indicating that resident 27 had been seen by the facility physician on 2/20/21, 4/20/21, 6/20/21, 8/16/21, 10/18/21, and 12/10/21. On 1/12/22, at 2:45 PM, an interview was conducted with the DON. The DON confirmed that the above listed physician visit notes had not been placed in resident 27 ' s medical record prior to 1/12/22. The DON also confirmed that no hospice notes were in resident 27 ' s medical record prior to 1/12/22, and that she had asked the hospice company to fax over their records on 1/12/22.

Based on observation, interview, and record review it was determined, for 3 of 4 sampled residents, that the facility did not ensure that the resident's environment remains as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident had a care plan to have an alarm but there was no alarm used and the resident sustained [REDACTED]. Two other residents were observed to be without their alarms which were care planned as interventions to prevent falls. Resident identifiers: 2, 3, and 4. Findings include: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 6/26/19. A care plan dated 12/19/18, documented . The resident is high risk for falls r/t (related to) weakness, decreased mobility, medication use. The goal was . The resident will be free of minor injury through the review date. Some of the interventions developed were: a. Date initiated 12/19/18, Anticipate and meet The resident's needs. Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Follow facility fall protocol. And PT (physical therapy)/OT (occupational therapy) to eval (evaluate) and treat. b. Date initiated 1/9/19, Encourage resident to eat meals in recliner instead of on side of the bed. c. Date initiated 1/10/19, Keep walker and room free of clutter. d. Date initiated 1/15/19, Pressure alarm for fall prevention. A Care Plan dated 12/19/18, documented . The resident has an ADL (activities of daily living) self-care performance deficit and has urinary incontinence. The goal was . The resident will maintain current level of function in (SPECIFY) through the review date. Another goal was . The resident will maintain current level of ADL function through the review date. Some of the interventions developed and initiated on 12/19/18 were, resident required limited assistance by one staff member with bathing, bed mobility, dressing, personal hygiene, and transfers. Resident required limited assistance by two staff members with toilet use. A review of resident 2's Morse Fall Scale (a rapid and simple method of assessing a patient's likelihood of falling) documented the following entries: (Note: Fall risk was based upon fall risk factors. Morse Fall Scoring of 45 and higher was considered a High Risk for falling.) a. On 12/17/18, Description: Admission, Category: High Risk for Falling, Score 80. b. On 1/8/19, Description: Post Fall, Category: High Risk for Falling, Score 90. c. On 1/9/19, Description: Post Fall, Category: High Risk for Falling, Score 90. A review of resident 2's Progress Notes and Incident Reports related to falls documented the following entries: a. On 1/7/19 at 11:31 PM, Nurse's Note Resident continues on iv (intravenous) abx (antibiotics) for uti (urinary tract infection)/pneumonia, picc (peripherally inserted central catheter) line site intact, . b. On 1/8/19 at 8:35 AM, CNA (Certified Nursing Assistant) answered residents call light and found resident sitting on floor next to his bed. CNA notified nurse and she assisted in getting resident back up into bed. Upon assessment no injuries noted, resident denies having any pain and denies hitting his head. Resident reports that he was sitting on the edge of his bed eating breakfast when he slid off the edge onto the ground. Immediate Action Taken Assisted resident back to bed and performed assessment. Call light and personal items within reach. Resident encouraged to eat in recliner instead of on side of the bed. c. On 1/9/19 at 3:03 PM, Pt (patient) was sitting on the floor next to his recliner. 'I was trying to change my pants.' Immediate Action Taken We took a full set of vitals (vital signs). We assessed the pt for injuries and none were found upon inspection. PT helped to sitting position on his recliner. Resident room was cleared of clutter and he had clothes on his walker which were hung in the closet to help him steer walker more safely and was encouraged to call for assistance with cares. d. On 1/9/19 at 8:11 PM, Orders - Administration Note Unisom Sleepgels 50 MG (milligrams). Give 50 mg by mouth as needed for night time sleeplessness. Administered by request for sleep. e. On 1/9/19 at 8:50 PM, Resident was found on the floor in his bathroom in front of toilet. He was trying to take himself to the bathroom. There was no bleeding or bruising visible. No injury noted. Pt stated he was trying to get up to the bathroom by himself et (and) fell in the bathroom. He denied having pain or any injury. Immediate Action Taken VS (vital signs) were taken et they were WNL (within normal limits) he was alert et oriented. 2 caretakers helped him stand et get back into his chair. He was shown where his call light was et asked to use it. We will call Dr. (doctor) tomorrow about getting a blood draw et ordering a pressure alarm. f. On 1/11/19 at 5:38 PM, Nurse's Note PCP (Primary care provider) contacted about increase in temp (temperature) et changes of LOC (level of consciousness) et recent falls, VO (verbal order) received to send pt to ER (emergency room ) for further eval, ., order received for pressure alarm d/t (due to) recent falls, . g. On 1/14/19 at 10:43 PM, Plan of Care Note Resident falls reviewed had 3 falls in short time- interventions placed along with visit to ER due to increased confusion and fever and was given fluid bolus in the ER. Resident also encouraged on safety interventions including to eat in recliner for meals and also to keep walker and room free of clutter. h. On 1/19/19 at 10:19 PM, Patient found sitting in bathroom. Nurse took a set a (sic) vitals and all findings were normal. No signs of injury at this time. Patient states he was standing at his bathroom sink and got dizzy. He stated a (sic) collapsed and did not hit his head at all. Patient stated he feels fine. Immediate Action Taken Nurse recorded a full set of vitals. Nurse checked for injuries (none found). Resident encourage to call for staff assistance when up and frequent checks done throughout the night. (Note: No new interventions were implemented.) i. On 1/20/19 at 10:32 PM, Pt was in his room with the door cracked. Pt in next room had daughter visiting and upon exiting a different pt's room the daughter alerted us of a noise she heard from his room. I entered the room to see pt on floor in center of room with walker. Pt has a hard time communicating but with facial grimacing we were able to determine there was pain in L (left) hip. Vitals were taken . Pt was asked what happened and he stated he was trying to use the restroom. Pt was in center of room with walker laying next to him. Pt had difficulty communicating so facial grimacing was used to evaluate where pain was originating. Pt winced when L leg was touched. Immediate Action Taken Vitals were obtained and EMS (Emergency Medical Services) services were called. Pt was transported to (Name of local hospital) with a suspected L hip injury. Daughter was notified. On-call physician notified. A review of the hospital history and physical dated 1/21/19, documented that resident 2 had sustained a fracture intertrochanteric of the left femur that required intraoperative repair. A physician's orders [REDACTED]. A review of resident 2's Medication Administration Record, [REDACTED]. A facility Grievance/Complaint Investigation Report dated 1/23/19, was filed by resident 2's family member. The family member documented . There had been a pressure alarm in place but it wasn't when resident fell . Describe your finding of the incident: . Pressure alarm was ordered, staff thought it was discontinued but was active until 1/21/19. On 6/26/19 at 12:09 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that if a resident had a bed motion alarm or a body alarm she would call the Medical Doctor for an order. RN 2 stated that the alarm would be tracked on the resident TAR and there would be a picture of a bell placed on the resident's door. RN 2 stated that the alarm might be in place all the time or when the resident was in bed only. On 6/26/19 at 12:15 PM, an interview was conducted with CNA 2. CNA 2 stated that if a resident had an alarm there would be a picture of a bell placed on the resident's door. CNA 2 stated that if a resident had increased falls the resident would require increased room checks. CNA 2 stated that the CNAs were required to check on the residents every two hours but the increased checks would require the resident be checked every hour. CNA 2 stated that the checks were not documented. CNA 2 stated that resident 2 had a couple of falls and the nursing staff ordered resident 2 a tab alarm. CNA 2 stated that the tab alarm attached to resident 2's shirt and was held together with a magnet. CNA 2 stated that resident 2 was independent with cares when he was a new admission to the facility and the staff would encourage resident 2 to use his call light. CNA 2 stated that resident 2 was having increased confusion and was becoming weaker with cares. CNA 2 stated that she worked the morning afternoon shift on 1/20/19 and had no concerns with resident 2. CNA 2 stated that when she reported to work the next morning she was told that resident 2 had a fall in the restroom and was told by staff that resident 2 did not have his tab alarm on. CNA 2 stated that resident 2 was sent to the hospital for a broken hip. On 6/26/19 at 12:43 PM, an interview was conducted with CNA 3. CNA 3 stated that if a resident was a fall risk and had a alarm the staff were to answer the alarm as quickly as possible and assist the resident. CNA 3 stated that if a resident had an alarm the resident would have a picture of a bell outside of their door. CNA 3 stated that resident 2 required extensive assistance with walking and help to the bathroom. CNA 3 stated she thought she worked the night resident 2 fell and broke his hip. CNA 3 stated that she thought she heard resident 2 yelling the night of the fall when resident 2 broke his hip but she could not remember. CNA 3 stated that she could not recall if resident 2 had the tab alarm on or not. On 6/26/19 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a performance plan was initiated in January because of the incident with resident 2. (Note: Upon review of the performance plan there was no date of compliance identified by the facility.) The DON stated that before an alarm was to be initiated for a resident there would need to be a physician's orders [REDACTED]. The DON stated that those things were not completed for resident 2 because the system was broken. The DON stated that she will track when a resident had an alarm and was to be notified when the resident alarm was initiated or discontinued. The DON stated that since resident 2 had the fall that resulted in a fracture the staff were to track the alarms on the resident TAR. The DON stated that staff were to check to ensure that the alarm was on the resident and the alarm was functioning. The DON stated that staff reported to her that resident 2 got up to brush his teeth and fell . The DON stated that resident 2 was found on the floor in his room and the body alarm was not on resident 2. The DON stated that staff removed resident 2's alarm because resident 2 knew how to disengage the alarm. The DON stated that she did not know when resident 2's alarm was removed and there was no documentation. On 6/26/19 at 4:27 PM, a confidential interview was conducted with resident 2's family member. The family member stated that resident 2 did not have a bed alarm or tab alarm implemented and she was very angry. The family member stated that resident 2 had early onset dementia and meningitis. The family member stated that she understood that resident 2 was stubborn but the facility staff would leave resident 2 pee soaked and he would have to get himself to the restroom to get changed. The family member stated that she would come visit resident 2 and the bed alarm would be folded up on resident 2's recliner. The family member stated that she was informed by the staff that resident 2 did not want the alarms. On 6/28/19 at 10:39 PM, an interview was conducted with CNA 4. CNA 4 stated that he had worked with resident 2 the evening of the fall. CNA 4 stated that the fall was at the end of his shift on 1/20/19. CNA 4 stated that resident 2's bed was low to the floor. CNA 4 stated that resident 2 required a one person assistance with ADLs when he was first admitted to the facility. CNA 4 stated that resident 2 became weaker and required a two person assistance with ADLs. CNA 4 stated that he could not remember if resident 2 had any alarms in place the evening of the fall. 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 6/26/19. A care plan dated 2/4/18, documented The resident is high risk for falls r/t Alzheimer's with poor safety awareness, [MEDICAL CONDITION], decreased mobility. The goal was The resident will be free of minor injury through the review date. Some of the interventions developed were: a. Date initiated 2/6/18, Anticipate and meet The resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Make sure all supplies are on hand prior to assistance. Continue Vitamin D and [MEDICATION NAME] as ordered. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. And Ensure that The resident is wearing appropriate footwear when ambulating or mobilizing in w/c (wheel chair). Keep room free of clutter and provide adequate lighting. b. Date initiated 3/28/18, Keep call light flagged for better visualization. c. Date initiated 4/17/18, Keep mat beside bed to prevent injuries with low bed at HS (hours of sleep). And Do not leave in room in wheelchair unattended. d. Date initiated 6/4/18, may use raised side mattress. e. Date initiated 6/11/18, Notify hospice of any changes or needs. f. Date initiated 7/5/18, Pull tab alarm in chair and motion sensor alarm in bed for safety. And Resident not to be left unattended in restroom. g. Date initiated 7/11/18, Encourage use of glasses and hearing aides daily. h. Date initiated 2/11/19, Elevate head of bed for comfort to ease breathing. i. Date initiated 4/24/19, Toileting every 2 hours due to new diuretic therapy. A Care Plan dated 2/4/18, documented The resident has an ADL self-care performance deficit r/t weakness. The goal was The resident will maintain current level of ADL function through the review date. Some of the interventions developed and initiated on 2/4/18, resident 4 requires extensive assistance by one staff member with bathing, dressing, and personal hygiene. Resident 4 was totally dependent on one to two staff members for bed mobility and extensive assistance by one to two staff members for toilet use and transfers. A review of resident 2's incident reports related to falls revealed the following entries: a. On 9/16/18 at 8:42 PM, CNAs heard a thud coming from resident's room and ran in to find him laying on the floor on his L side after falling out of his recliner. Immediate Action Taken . It appeared that resident slid out of recliner. Tab alarm was in place at the time of the incident, but did not go off. Battery was found to be dead. Replaced alarm with a functioning unit. (Note: No new interventions were implemented.) b. On 10/2/18 at 5:49 PM, Pt was resting in recliner after lunch. Call light was within reach and chair alarm in place. Alarm sounded, pt was found on the floor in front of the recliner. Immediate Action Taken . Recliner was noted to be up on wood blocks, put in place by family. Blocks removed to provide for safety. (Note: No new interventions were implemented.) c. On 10/14/18 at 6:45 AM, Pull-tab alarm went off, resident was seen in his room sitting on floor mat et leaning against mattress to the L of bed. Bed in low position. Immediate Action Taken . Hospice nurse to ask family about increasing [MEDICATION NAME] dose to help resident sleep longer into the morning as many of his falls have been in the early morning hours. (Note: No new interventions were implemented.) d. On 11/19/18 at 3:26 PM, Came upon patient and he was lying on the floor by his wheelchair, on his L side. was found in his doorway head first on the floor trying to pick up a Cheetos (sic) that had fallen on the floor. suffered rug burn scrape on forehead and on tops of hands. Immediate Action Taken . (Resident 4) was noted to be sleepy the past few days. DON to talk to hospice nurse about changing medications. (Note: No new interventions were implemented.) e. On 12/31/18 at 9:30 PM, Resident pull-tab alarm was going off, he was found laying on L side on floor mat. Immediate Action Taken Reattached pull-tab alarm, initiated neuro (neurological) checks, replaced fall mat after repositioning resident in bed, . (Note: No new interventions were implemented.) f. On 2/9/19 at 6:00 AM, Resident was found sitting on the mat next to his bed with his back against his mattress. Immediate Action Taken . Resident had had increased [MEDICAL CONDITIONS] symptoms including fluid retention and [MEDICAL CONDITION]. HOB (head of bed) to be elevated when in bed to help ease breathing and decrease anxiety. g. On 4/24/19 at 2:20 PM, heard alarm going off, went into pts room, pt found on floor at foot of recliner. Apparently had slid down et recliner tipped forward. pt was sitting on bottom sitting on R side. Immediate Action Taken . staff educated to toile q2h (every 2 hours) d/t new diuretic therapy. h. On 6/18/19 at 5:55 PM, Pt's chair tipped forward due to him attempting to get out by himself. Immediate Action Taken . Pulled chair more in view from the doorway so we can see him attempting to get up more quickly. Resident has been more agitated lately and medications have been adjsuted (sic) by hospice. (Note: No new interventions were implemented.) On 6/26/19 at 2:08 PM, an observation was conducted of resident 4 sitting in his wheelchair in the door way of his room. Resident 4 was observed with no tab alarm attached to his wheelchair or himself. Resident 4 was observed to have a picture of a bell on the door frame to his room. Resident 4's tab alarm was observed to be in the recliner in resident 4's room. RN 2 confirmed that resident 4 did not have a tab alarm attached as ordered by the physician. RN 2 also confirmed that resident 4 did not have a motion sensor alarm in his bed as ordered by the physician. An additional observation of resident 4's room was conducted. Resident 4's recliner was observed to be positioned that it was not visible from the hallway. On 6/26/19 at 3:04 PM, an observation was made of resident 4. Two CNAs were observed to assist resident 4 to his wheelchair after resident 4 was in the bathroom. The CNAs were observed to attach the tab alarm to the wheelchair and resident 4 at that time. On 6/26/19 at 3:15 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 4's motion sensor alarm for his bed was discontinued. CNA 1 stated that the nursing staff decided not to use the alarm any longer because resident 4 rolls around in bed. CNA 1 stated that she was instructed by the nursing staff to only use the tab alarm when resident 4 was in his chair. CNA 1 was unsure as to when the order was changed. On 6/26/19 at 3:16 PM, an interview was conducted with RN 2. RN 2 stated that resident 4 was to have the motion sensor alarm when in bed and the tab alarm when resident 4 was up in his chair. RN 2 stated that some of the interventions implemented to keep resident 2 safe were the alarms, keep oxygen levels above 90 percent, monitor behaviors of agitation, and resident 4 was to wear geri sleeves to prevent skin tears. RN 2 stated that interventions were to be tracked on the resident TAR . RN 2 stated that interventions would need to be discontinued with a physician's orders [REDACTED]. On 6/26/19 at 3:40 PM, an interview was conducted with the DON. The DON stated if a physician ordered a resident to have a tab alarm or a motion sensor alarm for the bed they would be tracked on the resident TAR. The DON stated that the staff were to check that the alarm was on and mark the resident TAR that the task was completed. The DON stated that the staff meet daily and will discuss the resident falls that occurred in the past 24 hours. The DON stated that fall interventions would be discussed and if they were appropriate for the resident. The DON stated that she will review trends and complete a root cause analysis on the resident incident report. The DON stated that a follow up was to be charted for 72 hours after a resident fall. The DON stated that resident 4's last couple of falls were out of the recliner. The DON stated that the staff moved resident 4's recliner so he was visible from the nurses station. The DON confirmed that she had made an observation of resident 4's recliner and it was not visible from the hall or the nurses station. 3. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/26/19 at 9:00 AM, an observation was made of resident 3 in her room. Resident 3 was observed to have a sign with a bell on the door frame outside of her room. Resident 3 was observed to be sitting in her reclining chair. Resident 3 was observed to have a pressure alarm on her bed. Resident 3 was observed to not have an alarm device under her or clipped to her. Resident 3's medical record was reviewed on 6/26/19. A care plan dated 2/5/19, revealed The resident is high risk for falls r/t history of falls, weakness, confusion, medication use and pain. The goal developed was The resident will be free of minor injury through the review date. Some of the interventions developed were, be sure the resident's call light is within reach., follow facility fall protocol, keep door open at all times.pressure alarm in bed and recliner, pt evaluate and treat as ordered or prn (as needed). A physician's orders [REDACTED]. A fall risk assessment dated [DATE], revealed that resident 3 was a high risk for falls and had fallen before. Resident 3's progress notes, incident reports, and care plans revealed the following: a. A progress note dated 2/11/19 at 9:39 PM, revealed Fall review done from fall on the 8th where resident attempted to get out of chair was caught and lowered to floor by staff. Resident had been attempting to toilet and shown increased signs of pain due to fractures. Family requesting to only use bed pan at this time for toileting until fractures heal more. (Note: There were no progress notes or assessments located in resident 3's medical record when she fell on [DATE].) There was no new interventions on the care plan after resident fell on [DATE]. The incident report revealed the fall was on 2/8/19 at 6:35 PM, and the incident report was revised on 2/11/19 at 11:38 PM. The intervention developed on the incident report was to use a bed pan. There were no follow up progress notes in resident 3's medical record regarding 72 hour monitoring after resident 3 fell . b. A progress note dated 2/22/19 at 11:50 PM, revealed Was at med (medication) cart, and heard a noise, I opened residents door and she was laying on the floor on her right side, resident blanket was under her, resident stated she tried to get up to go to bed, and could not find her call light, resident was c/o (complaining of) pain in rt. (right) arm, but when staff got her in bed, she stated that it hurt because she was laying on the arm. Staff put resident in bed, she states she is ok. Resident stated she did not hit her head. There was no new intervention documented on resident 3's care plan. The incident report revealed that resident fell on [DATE] at 11:52 PM, and the incident report was revised on 3/9/19 at 7:48 PM. An intervention documented on the incident report revealed to have resident in bed by 10:00 PM and door to be left open for safety. There were no follow up progress notes regarding 72 hour monitoring after resident 3 fell . There were no fall review notes. c. A progress note dated 3/15/19 at 6:30 AM, revealed Aide (CNA) entered room; discovered resident on floor by the side of the bed. Called this nurse for assistance and assessment of patient. Pt denied hitting head. Assessed for injuries; none detected at this time. Pt denies pain; no non-verbal signs of pain noted at this time. Pt call light was within reach; pt forgets to use it to call for assistance when ambulating. Reminded pt of importance of calling for assistance to avoid putting weight on injured leg and to prevent falls. Pt verbalized understanding and demonstrates appropriate use of call light. WCTM (Will continue to monitor) frequently throughout shift. The incident report revealed that resident 3 fell on [DATE] at 6:15 AM, and the incident report was revised on 3/16/19 at 5:08 PM. There was no intervention documented on the incident report. The care plan revealed an intervention developed to mark call light and provide night light for better visibility at night to encourage us of call light. There were no follow up progress notes for 72 hours after resident 3 fell . There were no fall review notes. d. A progress note dated 3/25/19 at 11:55 AM, revealed This nurse entered room to administer scheduled Tylenol; discovered resident sitting on the floor. Resident states 'I was on the way back from the bathroom and just sat down.' Assessed resident; denies pain at this time. Skin tears noted on L index finger and L hallux; cleansed with NS (normal saline) applied [MEDICATION NAME] and dressing. No additional injuries notes at his time.Pt verbalized understanding and demonstrated correct use of call light. The incident report revealed resident 3 fell on [DATE] at 11:55 AM, and the incident report was revised on 4/1/19 at 11:08 PM. The incident report revealed that staff were instructed to keep door open to room at all times for closer observation. The care plan revealed an intervention developed on 3/26/19, Keep door open at all times for closer observation. (Note: This intervention was used after resident 3 fell on [DATE].) There was a follow up note dated 3/27/19 regarding monitoring of resident after a fall. (Note: The progress note was 2 days after resident 3 fell .) There were no fall review notes. e. A progress note dated 3/27/19 at 5:00 PM, revealed Was called to patient's room to check on her. Pt was seen sliding down the wall of her bathroom by the restroom and sitting on the ground. No injuries noted. The incident reported revealed resident fell on [DATE] at 4:54 PM, and was revised on 4/1/19 at 11:12 PM. The intervention developed was to check for a urinary tract infection. There was no intervention documented on the care plan. There were no fall review notes. f. A progress note dated 4/3/19 at 3:14 AM, revealed Pt has unwitnessed fall trying to get self to bathroom. Pt has no injuries and denies pain. (Physician's name) and DON notified. Teaching done on using call light when needing to go to the bathroom. Will continue to monitor. The incident report revealed that resident fell on [DATE] at 12:01 AM, and the incident report was revised on 4/8/19 at 10:22 PM. The intervention documented on the incident report was to apply a pressure alarm for safety. The care plan revealed an intervention developed on 4/3/19, Pressure alarm in bed and recliner for safety due to poor safety awareness. There was no fall review notes. g. A progress note dated 4/9/19 at 4:46 PM, revealed Aide stated that the resident was seen sliding form (sic) the edge of the bed to the floor. She landed gently. No injuries to note at this time. We assisted her up and back into her bed. Pt stated that she was trying to get up to use the restroom. Educated patient on importance of using the call light for assistance. (Note: There was no information that resident 3's pressure alarm was alarming.) The incident report revealed resident 3 fell on [DATE] at 4:23 PM, and the incident report was revised on 4/15/19 at 9:59 PM. The incident report revealed a new intervention for staff to see if orthopedic physician would allow for resident to be weight bearing for therapy to do more safety training. There were no interventions on resident 3's care plan. A fall review note dated 4/9/19 at 6:34 PM revealed, .Pressure alarm added to bed and chair for safety due to resident continued attempts to transfer without assistance after frequent reminders and cueing. h. A plan of care note dated 5/30/19 at 3:02 PM, revealed Fall review done with IDT (interdisciplinary team) team for fall in room while managing personal items. More chairs placed in room to allow resident to sit while in room with personal items. (Note: There was no progress note regarding a fall.) The incident report revealed resident 3 fell on [DATE] at 4:45 PM, and was revised on 6/3/19 at 7:52 PM. The incident report revealed, Aide walked in to find patient sitting on the ground and called nurse for assistance. Vital signs obtained and patient assessed for injury. No visible injuries. Patient assisted by aide and nurse to stand. Patient denied dizziness or weakness while standing. Patient also denied pain or injury as a result of fall. The intervention documented on the incident report was, Resident given more chairs by table to increase areas to sit in room when situating belongings. (Note: There was no information that resident 3's alarm was alarming.) The care plan was updated on 5/19/19 to provide more chairs for resident to sit when she was arranging personal items. Post fall assessment revealed that staff were monitoring after resident 3's fall from 5/30/19 through 6/2/19. (Note: Resident 3 fell on [DATE] and post fall assessments were started 2 days after the fall.) On 6/26/19 at 3:05 PM, an interview was conducted with RN 1. RN 1 stated that after a resident sustained [REDACTED]. RN 1 stated that the nurse was to evaluate why the resident fell . RN 1 stated that nurses documented what happened in a nurses note and charted for 3 days after the fall. RN 1 stated that nursing staff documented vital signs and full body assessments for 3 days after the fall. RN 1 stated that if an alarm was ordered staff checked to make sure the alarm was on. On 6/26/19 at 3:10 PM, an interview was conducted with RN 2. RN 2 stated that nursing staff were to check alarms every shift. RN 2 stat

Based on interview and record review it was determined for 1 of 22 sample residents that the facility did not ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident reported pain, cried and did not attend therapy when she did not have pain medication for 22 hours. In addition, the resident physician decreased her pain medication and resident was experiencing uncontrolled pain. Resident identifier: 88. Findings include: Resident 88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/16/18 at 8:18 AM, an interview was conducted with resident 88. Resident 88 stated that she had pain all the time and her physician decreased her pain medication since admission to the facility. Resident 88 stated that her back had problems and it was just the way it was to always be in pain. Resident 88 stated that facility nurses tried to call the physician and get increased pain medications but the physician refused. Resident 88's medical record was reviewed on 7/18/18. An admission Minimum Data Set ((MDS) dated [DATE] revealed that resident 88 received pain medication as needed and a pain assessment should have been completed. The MDS further revealed that resident 88 was not receiving non-pharmalogical interventions. The MDS revealed that resident 88 reported that she was hurting and was having pain occasionally over the last 5 days. The MDS revealed that resident 88's worst pain was rated at a 7. A care plan revealed dated 6/24/18 revealed a Focus of The resident has pain r/t (related to) chronic back pain and restless leg syndrome. One of the goals developed was, The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions developed revealed, Administer [MEDICATION NAME] as per orders. Give 1/2 hour before treatments or care when needed. Another documented intervention was, Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Notify physician if intervention are unsuccessful or if current complaint is a significant change from residents past experience of pain. A review of resident 88's admission physician's orders [REDACTED]. 1 tabs (tablet) oral every 6 hr (hours) for 3 days PRN (as needed) as needed for pain. Dispense/Supply: 12 tabs. Refill: 0 Resident 88's physicians order dated 6/27/18 revealed, [MEDICATION NAME] 5mg-325mg 1 tab oral q 8 hours while awake prn pain #90. (No) refills. A review of resident 88's (MONTH) (YEAR) Medication Administrator Record (MAR) revealed that [MEDICATION NAME] tablet 7.5-325 mg was administered by mouth every 6 hours as needed for pain from 6/22/18 through 6/30/18. The MAR revealed the following times and pain scores: (Note: Pain scores were from 0 to 10 with 0 being no pain and 10 being excruciating pain.) a. 6/22/18 at 10:33 PM, pain was a 6. b. 6/23/18 at 5:23 AM, pain was a 6. At 2:15 PM, pain was a 7. At 11:01 PM, pain was a 7. c. 6/24/18 at 10:50 AM, pain was a 4. d. 6/25/18 at 5:10 AM, pain was a 4. At 11:01 AM, pain was a 4. At 5:13 PM, pain was a 4 and at 11:12 PM was a 6. (Note: There were 12 doses of pain medication filled but there were 9 doses documented from 6/22/18 until 6/25/18.) Resident 88's Narcotic Record revealed that [MEDICATION NAME] was administered on 6/24/18 at 5:00 AM, 10:50 AM, 5:00 PM and 11:00 PM with no documented pain scores. e. 6/26/18 at 9:10 PM, pain was an 8. (Note: A physicians order was obtained by nursing staff on 6/27/18 for 5-325 mg [MEDICATION NAME] every 8 hours as needed. Resident 88 was administered the 5-325 mg every 6 hours according to the MAR but it was documented on the MAR that resident was to receive 7.5 mg every 6 hours.) f. 6/27/18 at 5:30 AM, pain was an 8. At 12:42 PM, pain was a 7. At 8:32 PM, pain was an 8. g. 6/28/18 at 3:42 AM, pain was an 8. At 11:22 AM, pain was a 7, At 5:07 PM pain was a 6, and at 10:59 PM pain was a 4. h. 6/29/18 at 4:53 AM, pain was a 4. At 11:20 AM pain was a 4. At 5:18 PM, pain was at a 4 and at 11:50 PM pain was a 2. i. 6/30/18 at 5:45 AM, pain was a 2. At 11:40 PM pain was a 6. The (MONTH) (YEAR) MAR further revealed that resident 88 was administered [MEDICATION NAME] 5-325 mg at 11:00 PM on 6/30/18. Resident 88's (MONTH) (YEAR) MAR revealed [MEDICATION NAME] 5-326 mg every 8 hours as needed was administered and the following pain levels were documented: a. 7/1/18 at 6:26 AM, pain was an 8. At 1:09 PM, pain was a 4. At 10:48 PM, pain was a 5. In addition, nursing staff documented at 10:48 PM that resident 88's follow up pain was unknown. b. 7/2/18 at 7:02 AM, pain was a 10 and the follow up pain was documented as unknown. At 4:14 PM, pain was an 8 and the follow up pain was ineffective. At 11:58 PM, pain was a 4. c. 7/3/18 at 8:00 AM, pain was an 8. At 4:31 PM, pain was an 8. d. 7/4/18 at 12:29 AM, pain was a 3 and it was documented that the follow up pain was unknown. At 8:50 AM, pain was a 5. At 5:16 PM, pain was a 5. e. 7/5/18 at 1:39 AM, pain was a 3 and it was documented that the follow up pain was unknown. At 9:54 AM, pain was an 8. At 5:42 PM, pain was a 9. f. 7/6/18 at 1:42 AM, pain was an 8. At 11:54 AM, pain was an 8. At 9:30 PM, pain was a 7. g. 7/7/18 at 5:59 AM, pain was an 8. At 7:33 PM, pain was a 5. Resident 88's nursing progress notes revealed the following entries: a. 6/22/18 at 6:25 PM, .pt is admitted for generalized weakness.Will f/u (follow up) with PCP (primary care physician) on Monday.low back pain. b. 6/23/18 at 3:47 AM, .Pt C/O (complaints of) pain on (sic) her lower back et (and) PRN medication given with effective results. c. 6/25/18 10:32 PM, . Pt denies pain at this time however she is taking [MEDICATION NAME] to keep pain managed. d. 6/26/18 at 9:26 PM, Pt alert and oriented X 4. She has had a rough day because her pain meds ran out and we couldn't get another order. Pt was crying and expressing that she might just have someone bring in her meds from home. It was explained to her that it was out of our control and we were trying to get meds here tonight. Pharmacy did show with meds and pt (patient) was very happy. Meds did relieve pain and she is resting quietly. e. 6/29/18 at 6:12 PM, .Pt states 'pain in her back and knee is worse when standing.' . f. 6/30/18 at 2:56 PM, .Still hurting some. g. 7/1/18 at 1:09 PM, .Pain is bad reports she is used to taking the 7.5 [MEDICATION NAME] and the 5mg [MEDICATION NAME] are not cutting the pain and the 8 hours is to long for her to wait. h. 7/2/18 at 7:02 AM, .Pain is at 100 she report she (sic) her whole body aches reports the [MEDICATION NAME] 5mg every 8 hours is not working she is used to taking 7.5mg [MEDICATION NAME] every 6 hours. i. 7/2/18 at 4:14 PM, .Pain L (left) knee et back an '8 or a 9' out of 10 when up to use the bathroom. j. 7/2/18 at 4:57 PM, .PRN Administration was: Ineffective Knee pain unchanged. Follow-up pain scale was: 8. k. 7/3/18 at 8:00 AM, .Back pain when she moves is worse today. l. 7/3/18 at 9:43 AM, .Follow-up pain scale was: 8 PRN Administration was Effective. Reports her pain isn't down to a 6/10 in her back when she moved. m. 7/5/18 at 9:54 AM, .Pain Leg et back 8/10 pain. n. 7/5/18 at 5:24 PM, .Follow-up pain scale was: 6. o. 7/5/18 at 5:42 PM, .Pain in knee et back 9/10. p. 7/6/18 at 11:54 AM, .Pain back c (with) therapy 7/10 et knee 8/10. q. 7/6/18 at 3:14 PM, new order received from Tylenol 650 mg q 6h for pain. Can be given in addition to [MEDICATION NAME]. This dose will not exceed 4g (grams) in a 24 hour period. r. 7/7/18 at 7:47 PM, Order received to schedule [MEDICATION NAME] for 0500, 1100, 1700 each day for pain. [MEDICATION NAME] Tablet 5-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) *Controlled Drug* Give 1 tablet by mouth three times a day for [MEDICATION NAME]. Start Date: 7/8/2018 A Family Practice Office Clinic Note dated 7/6/18 revealed, Chronic pain. Recently decreased patient's chronic pain medications from 2 tabs of [MEDICATION NAME] 5/325 every 4 hours to 1 table of [MEDICATION NAME] 5/325 every 8 hours. See message log on 7/2/18. Patient reports that she is actually been on [MEDICATION NAME] 7.5-350 one tab every 4 hours for over [AGE] years. The assessment/plan revealed, .2. Chronic pain. Plan: After review of chart it appears patient has been on significant amount of pain medication for greater than 4-5 years, the first prescription come from (name of physician). As part of improve her pain and decreasing dependence on narcotics we decided to use 1 tab of [MEDICATION NAME] 5/325 scheduled at 5AM, 11AM, 5PM then we would like to use 11PM Tylenol 1000 Mg. If this regimen does not work we could consider [MEDICATION NAME] 5/325 4 times a day (which would be a decrease from her previous dose of [MEDICATION NAME] 7.5/325). Patient does need a multiple specialty approach to this including, weight loss, physical therapy, perhaps even psychiatric help for the pain and dependence on [MEDICATION NAME]. On 7/16/18 at 3:15 PM, a follow up interview was conducted with resident 88. Resident 88 stated that she was receiving [MEDICATION NAME] 7.5mg four times a day prior to admission to the facility. Resident 88 stated that after admission to the facility her Primary Care Physician (PCP) ordered 5 mg of [MEDICATION NAME] three times a day as she needed it. Resident 88 stated that her PCP refused to provide her more pain medication. Resident 88 stated that Tylenol ER (extended release) provided relief from pain as long as she was not active and did not participate in therapy. Resident 88 stated that she experienced to much pain if she did physical therapy without having a [MEDICATION NAME] prior to the therapy. Resident 88 stated that she remembered (MONTH) 26th, when she did not have pain medication for a full day. Resident 88 stated that she cried all day and her back, knee and both shoulders hurt. Resident 88 stated that at 5:00 AM she requested her [MEDICATION NAME] but the nurse told her she was out of the [MEDICATION NAME]. Resident 88 stated that her nurse stated she was going to contact her PCP when his office opened around 8:00 AM. Resident 88 stated that her PCP was concerned she had a lot of prescriptions for [MEDICATION NAME] over the last year and he refused to give resident 88 additional pain medications. Resident 88 stated that the doctor finally agreed to get her some [MEDICATION NAME] that evening. Resident 88 stated that she went to a physicians visit 7/6/18 and received a new order for [MEDICATION NAME] 5mg three times a day and Tylenol ER four times a day. Resident 88 stated that she was in pain all the time. Resident 88 stated that I hurt all the time and it's just the way it is. Resident 88 stated that she was comfortable if her pain score was less than a 4. Resident 88 stated that when she was moving her pain was at least a 6 even with pain medication three times a day. On 7/16/18 at 3:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she did not work the day that resident 88 did not have pain medication but that resident 88's physician told staff that he wanted her to do physical therapy to relieve pain. LPN 1 stated that physical therapy had been painful and it was hard to do therapy without the pain medication. LPN1 stated that she rated each resident's pain when they were resting and when they were moving. LPN 1 stated that she documented the highest number on the MAR and the other number in a nursing progress note. On 7/17/18 at 8:45 AM, a follow up interview was conducted with LPN 1. LPN 1 stated that on 6/30/18 she worked with resident 88. LPN 1 stated that resident 88 requested pain medication around 11:00 AM that day. LPN 1 stated that she noticed the MAR had 7.5 mg of [MEDICATION NAME] every 6 hours but the dosage on the [MEDICATION NAME] was 5 mg. LPN 1 stated that she notified Registered Nurse (RN) 1 of the different documentation verses the dosage on the medication. LPN 1 stated that resident 88's primary care physician did not have office hours on the weekends and she was unable to contact him until Monday morning 7/1/18 to clarify the order. LPN 1 stated that she contacted the physician on 7/1/18 regarding resident 88's pain not being controlled and to clarify the order. LPN 1 stated that the physicians Medical Assistant (MA) returned her call and informed LPN 1 that the physician would not increase resident 88's pain medication. LPN 1 stated that she had the resident call her physician. On 7/17/18 at 7:48 AM, an interview was conducted with Therapy Director (TD). The TD stated that resident 88 sometimes complained of pain when doing therapy. The TD stated that resident 88 complained of pain when he applied [MEDICAL CONDITION] wraps on her legs. The TD stated that resident 88 had not had to stop therapy from pain but that he was aware of how much therapy she was able to perform before complaining of pain. On 7/17/18 at 9:24 AM, an interview was conducted with RN 1. RN 1 stated that LPN 1 informed her that resident 88 was complaining of pain. RN 1 stated that LPN 1 reported on 6/30/18 that resident had 5 mg tablets of [MEDICATION NAME] but it was documented on MAR that resident 88 was to receive 7.5 mg of [MEDICATION NAME] four times a day. RN 1 stated that the facility Medical Director (MD) was out of the country and another physician was filling in. RN 1 stated that the physician filling in for the MD did not like to write prescriptions for narcotics if the resident had another primary care physician. RN 1 stated that she contacted resident 88's primary care physician on 7/2/18 regarding resident 88's complains of pain. On 7/17/18 at 1:12 PM, an interview was conducted with LPN 2. LPN 2 stated that resident 88 requested her pain medication [MEDICATION NAME] the morning on 6/26/18. LPN 2 stated that resident 88 stated to her that her pain score was an 8 or 9. LPN 2 stated that she did not think resident 88 participated in therapy because resident 88 did not move much since she did not have pain medication all day. LPN 2 stated that she tried to contact the physician on 6/26/18 but did not receive a response back. stated that if she did not receive a call back within a few hours then she would have called the house physician. LPN 2 stated that some of the physicians did not want the MD to write prescriptions for their residents. LPN 2 stated that she would have contacted the physician that was covering for the MD. LPN 2 stated she did not know if she documented that she called the physician covering for the MD. LPN 2 stated that she could not remember if non-pharmalogical interventions were used to relieve pain. LPN 2 stated that resident 88 asked for Tylenol and she did not have a prescription for her. LPN 2 stated she wanted to get the resident something for pain but was unable to get a hold of a physicians. On 7/17/18 at 12:50 PM, an interview was conducted with the facility MD. The MD stated that he returned 3 days ago from a 6 week vacation. The MD stated that nursing staff contacted him anytime for concerns with residents. The MD stated that another physician was covering for him while he was out of town. The MD stated that some physicians did not like for him to write orders for pain medication and would get very upset with him. The MD stated that a resident should not have gone without pain medication for 22 hours. The MD stated that We need to stay on top of pain or it gets out of control. The MD stated that he would have provided orders for pain medication if the primary care physician did not respond. On 7/17/18 at 1:41 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that a mock survey had been completed in the facility and there was a concern regarding pain assessments. The DON stated that the mock survey team felt that pain was not assessed as much as it needed to be. The DON stated that a quality assurance meeting was completed on 7/6/18 regarding assessing pain. The DON stated that there will be a staff meeting to train nursing staff on evaluating pain twice a day. The DON confirmed resident 88 did not have pain medication on 6/26/18. The DON stated that she was out of town and RN 1 had filled in for her. The DON stated that if staff were unable to get a hold of resident 88's PCP then they were to contact the MD or the physician covering for the MD. The DON stated she did not have additional information. On 7/17/18 at 2:26 PM, an interview was conducted with resident 88's PCP. Resident 88's PCP stated that he was contacted 6/25/18 regarding resident 88's pain. Resident 88's PCP stated that he responded to the facility nursing staff on the 6/26/18. Resident 88's PCP stated that resident 88 was medically stable to go without pain medication for 22 hours. Resident 88's PCP stated that refused to answer additional questions.