Every finding on record at Mineral Wells Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (Resident #9) reviewed for comprehensive care plans, in that: 1. Resident #9's comprehensive care plan did not address Resident #9's urinary catheter needs and associated risk factors. The failure placed the resident at risk for not receiving the care and services needed to meet the resident's needs and a decline in health status.The findings included: Record review of Resident #9's admission Record, dated 6/24/2026, indicated a [AGE] year-old male with an original admission date on 11/14/2024 and a most recent readmission date on 4/02/2026 following a hospital stay. The resident's diagnoses included: surgical aftercare following surgery on the digestive system (bowel obstruction hernia repair); urinary tract infection (infection in the urinary system - bladder, kidneys, ureters or urethra); edema (swelling caused by too much fluid trapped in the body's tissues); type 2 diabetes mellitus (the body's resistance to insulin resulting in high blood sugar levels); benign prostatic hyperplasia (enlarged prostate that can obstruct urine flow); obstructive and reflux uropathy (occurs when urine flow is partially or completely blocked anywhere along the urinary tract, including the ureters, bladder, or urethra, that increases pressure and causes urine to back up into the kidneys). Record review of Resident #9's electronic health record census report indicated he had been hospitalized [DATE] - 11/12/2025 and 3/27/2026 - 4/02/2026. Record review of Resident #9's admission MDS Assessment, dated 4/05/2026, indicated a BIMS score of 10 out of 15 (mild cognitive impairment), indwelling [bladder] catheter, and diagnoses of benign prostatic hyperplasia and obstructive uropathy. Record review of Resident #9's Nursing Notes indicated the following:- 4/02/2026 - Nursing readmission Note, indicated the resident was readmitted from the hospital following surgery for a bowel obstruction. The note indicated: Urine Control: Catheter. Type and size of catheter: 16F/10ml.- 4/12/2026 Transfer Note. Resident transferred to a hospital on [DATE] at 2:30 PM related to bleeding after Foley placement.- 4/12/2026 Returned from the hospital emergency department. Foley catheter replaced in the emergency room; blood in catheter [drainage] bag. Encouraged to increase po fluids.- 4/13/2026 Order for Amoxicillin-Potassium Clavulanate oral tablet 875-125 mg - Give 1 tablet by mouth two times a day for 14 days for UTI. Record review of Resident #9's order summary indicated the following orders dated 4/13/2026:- Empty drainage bag every shift.- Foley Catheter: change for occlusion, leaking, closed system was compromised as needed.- Ensure Foley bag is in privacy bag while in bed or w/c every shift.- Ensure catheter strap is in place and holding every shift change as needed.The orders did not include the catheter type and size with an indication for use. Record review of Resident #9's comprehensive care plan, dated as initiated 3/13/2025 and reviewed 4/28/26, indicated it did not address the resident's urinary catheter use and the risk factors associated with the catheter. During an interview and observation on 6/23/2026 at 3:08 PM, Resident #9 stated the catheter was placed while he was hospitalized during December [2025]. He stated his bladder was not emptying. Observation revealed the catheter drainage bag was covered in a dignity bag hanging on the side of the bed frame. The catheter tubing had amber colored urine and a slight amount of sediment. Resident #9 stated he took a diuretic medication. During an interview and record review on 6/24/2026 at 3:58 PM, the DON stated Resident #9 had the catheter and had wanted it removed. She reviewed Resident #9's electronic health record and stated the resident was sent to the emergency room on 4/12/2026, the catheter was placed, and he returned to the facility. She stated on 4/13/2026 the resident received an order for Amoxicillin for a UTI. During an interview and record review on 6/24/2026 at 4:17 PM, the DON reviewed Resident #9's comprehensive care plan and stated he had a care plan for an indwelling urinary catheter, dated 11/14/2025, and it was resolved. She stated she did not know why the catheter had not been added to the resident's care plan again. The DON stated she did not set any expectations for the MDS Coordinators regarding the completion of care plans. She stated the expectations were set by the MDS Consultant - the Regional Reimbursement Specialist. During an interview and record review on 6/24/2026 at 4:24 PM, the Regional Reimbursement Specialist stated the expectation for the MDS nurses was to follow the RAI manual. She stated the care plan was developed by the IDT and the facility nurses could add a care plan as needed to address new care needs. The Regional Reimbursement Specialist stated an outcome of not revising the care plan to address the resident's current or changing needs could place the resident at risk for not having accurate care. The Regional Reimbursement Specialist reviewed Resident #9's care plan and stated the indwelling catheter was included with the care plan for enhanced barrier precautions, and none of the approaches included the care for the catheter. She stated a care plan addressing the indwelling urinary catheter and the associated risk factors should have been developed after the resident had the catheter placed. Record review of the facility's policy and procedures for Comprehensive Care Planning, undated, indicated [in part]: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following -- The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.Residents' preferences and goals my change throughout their stay, so facilities should have ongoing discussions with the resident and representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on observation, interview and record review, the facility failed to ensure that a resident who was incontinent of urine and had an indwelling urinary catheter had a clinical condition demonstrating the catheterization was necessary for 1 of 4 residents (Resident #9) reviewed for urinary catheters, in that:Resident #9's order summary did not include an order that specified the type and size of urinary catheter and the clinical indication for use of the catheter. The failure placed the resident at risk for not receiving the care and services needed to manage the resident's urinary incontinence and avoid the development of urinary tract infections.The findings included: Record review of Resident #9's admission Record, dated 6/24/2026, indicated a [AGE] year-old male with an original admission date on 11/14/2024 and a most recent readmission date on 4/02/2026 following a hospital stay. The resident's diagnoses included: surgical aftercare following surgery on the digestive system (bowel obstruction hernia repair); urinary tract infection (infection in the urinary system - bladder, kidneys, ureters or urethra); edema (swelling caused by too much fluid trapped in the body's tissues); type 2 diabetes mellitus (the body's resistance to insulin resulting in high blood sugar levels); benign prostatic hyperplasia (enlarged prostate that can obstruct urine flow); obstructive and reflux uropathy (occurs when urine flow is partially or completely blocked anywhere along the urinary tract, including the ureters, bladder, or urethra, that increases pressure and causes urine to back up into the kidneys). Record review of Resident #9's electronic health record census report indicated he had been hospitalized [DATE] - 11/12/2025 and 3/27/2026 - 4/02/2026. Record review of Resident #9's admission MDS Assessment, dated 4/05/2026, indicated a BIMS score of 10 out of 15 (mild cognitive impairment), indwelling [bladder] catheter, and diagnoses of benign prostatic hyperplasia and obstructive uropathy. Review of Resident #9's Nursing Notes indicated the following:- 4/02/2026 - Nursing readmission Note, indicated the resident was readmitted from the hospital following surgery for a bowel obstruction. The note indicated: Urine Control: Catheter. Type and size of catheter: 16F/10ml.- 4/12/2026 Transfer Note. Resident transferred to a hospital on [DATE] at 2:30 PM related to bleeding after the foley placement.- 4/12/2026 Returned from the hospital emergency department. Foley catheter was replaced in the emergency room; blood in catheter [drainage] bag. Encouraged to increase po fluids.- 4/13/2026 Order for Amoxicillin-Potassium Clavulanate oral tablet 875-125 mg - Give 1 tablet by mouth two times a day for 14 days for UTI. Record review of Resident #9's order summary indicated the following orders dated 4/13/2026:- Empty drainage bag every shift.- Foley Catheter: change for occlusion, leaking, closed system was compromised as needed.- Ensure Foley bag is in privacy bag while in bed or w/c every shift.- Ensure catheter strap is in place and holding every shift change as needed.The orders did not include the catheter type and size with an indication for use. Record review of Resident #9's comprehensive care plan, dated as initiated 3/13/2025 and reviewed 4/28/26, indicated it did not address the resident's urinary catheter use and the risk factors associated with catheter. During an interview and observation on 6/23/2026 at 3:08 PM, Resident #9 stated the catheter was placed while he was hospitalized during December [2025]. He stated his bladder was not emptying. Observation revealed the catheter drainage bag was covered in a dignity bag hanging on the side of the bed frame. The catheter tubing had amber colored urine and a slight amount of sediment. Resident #9 stated he took a diuretic medication. During an interview and record review on 6/24/2026 at 3:58 PM, the DON stated Resident #9 had the catheter and had wanted it removed. She reviewed Resident #9's electronic health record progress notes and stated the resident was sent to the emergency room on 4/12/2026, the catheter was placed, and he returned to the facility. She stated on 4/13/2026 the resident received an order for Amoxicillin for a UTI. The DON reviewed Resident #9's current order summary and stated she did not see an order for the urinary catheter with a diagnosis. In an interview on 6/24/2026 at 6:04 PM, the DON stated the admitting nurse was responsible for entering orders into the resident's electronic health record. The DON stated the expectation was for the nurse to enter orders accurately and completely. She stated an outcome of not entering orders accurately and completely could be missed care for the resident. In an interview on 6/24/2026 at 6:17 PM, the DON stated there was not a specific policy and procedure for catheters or entering catheter orders. She provided a copy of the facility's policy and procedures for Medication Orders. The DON stated both she and the ADO looked and they could not find any other policy and procedure related to entering physician orders into the electronic health record. Record review of the facility's policy and procedure for Medication Orders, dated 2003, indicated [in part]: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by licensed nurses or pharmacists.Procedure:3. Specific Procedures for the four types of medication ordersC. WRITTEN TRANSFER ORDERS (SENT WITH A RESIDENT BY A HOSPITAL OR OTHER HEALTH CARE FACILIITY). Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending physician before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure the temperature of the banana pudding was taken prior to leaving the kitchen. The facility failed to ensure that staff performed hand hygiene while preparing food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation and interview on 04/15/2025 between 11:00 AM and 12:30 PM the cook failed to take the temperature of the banana pudding, prior to resident's lunch trays being plated, placed on cart and ready to leave the kitchen. [NAME] F stated she had forgotten to take the temperature of the banana pudding. [NAME] F stated the banana pudding should have had temperature taken prior to food being plated. The AD failed to perform hand hygiene, when she entered the kitchen, before she grabbed a can of tomato juice and an empty container. The AD opened the can of tomato juice and poured into the empty container. During an interview on 04/15/2025 at 12:30 PM the DM stated the temperature of food should have been taken prior to leaving the kitchen. The DM stated the [NAME] F was responsible to take temperature of food prior to plating food. The DM stated she was responsible to monitor. The DM stated she had gotten busy and thought [NAME] F had taken the temperature of the banana pudding. The DM stated every time staff walk into the kitchen they should have performed hand hygiene. The DM stated the AD should have washed her hands prior to getting the tomato juice. The DM stated the affect on residents could have been cross contamination. The DM stated she was responsible to monitor. The DM stated she did not have an explanation to why the failure occurred. The DM stated the AD had her food handlers and had been reminded several times. During an interview on 04/17/25 at 5:06 PM the MIT stated her expectation was for food to be tempted prior to leaving the dinning room. The MIT stated the DM was responsible to ensure food temperatures were taken before served to residents. The MIT stated residents could have received food that was not prepared appropriately. The MIT stated she was not sure what led to failure of staff not taking the temperature of the banana pudding. The MIT stated her expectation was that hand hygiene be performed by any staff that entered the kitchen. The MIT stated the AD had a food handlers license and was a department head and was responsible to ensure she had performed hand hygiene went entered the kitchen. The MIT stated not performing hand hygiene could have affected residents by cross contamination. The MIT stated what led to failure was the AD's lack of following thru with AD's previous training she had received and in-services she had been provided. Record review of facility policy titled Daily Food Temperature Control dated 2012, revealed: Prior to meal service, the cook shall take the temperature of all hot and cold foods. Record review of facility policy titled Hand Washing dated 2012 revealed: Employees are to frequently perform hand washing.

Based on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 of 10 (Resident #9) residents reviewed forreasonable accommodation of needs The facility failed to provide a working communication system on 04/15/2025 that was easily at reach and that would allow Resident #9 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living. The findings included: Record review of Resident #9's face sheet dated 04/17/2025, revealed: an [AGE] year-old-female admitted on [DATE] with a recent readmission on 09/02/2024. Resident #9 had the following diagnosis Dementia, anxiety disorder, Type 2 Diabetes, and respiratory failure. Record review of Resident #9's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns: Resident #9 had a BIMS score of 5, meaning severe cognitive impairment; Section GG- Functional Abilities: Resident #9 required maximal or total assistance for transfers, toileting, dressing, and transferring. Record review of Resident #9's most recent Care Plan revealed: Focus: The resident is risk for falls joint pain and weakness Date initiated on 09/03/2024. Goal: The Resident will be free of falls through the review date. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an observation and interview on 04/15/2025 at 3:48 PM Resident # 9 was sitting up in her bed, call light was not in reach. Resident # 9's call light was laying on the floor at the head of her bed, between the headboard and the wall. Resident #9 stated if she needed assistance she would push her button, Resident #9 stated she did not know where her button was. During an interview on 04/15/25 at 4:08 PM MA E stated Resident # 9 was able to use her call light and if she could not find it she will ask her roommate if she needed assistance. MA E stated the call light should have been connected to Resident #9. MA E stated everyone was responsible to ensure resident call lights were in reach. During an interview on 04/16/25 at 10:38 AM LVN D stated she was the charge nurse for the 400, 500 and 600 hall. LVN D stated Resident #9 resided on one of her hall's. LVN D stated Resident #9 was able to use her call light on some days. LVN D stated the call light should not have been behind her bed in the floor. LVN D stated the call light should have been attached to her clothes. LVN D stated the call light not being in reach could have caused harm to resident. LVN D stated she did not know why the call light was not in reach of Resident #9. During an interview on 04/17/2025 at 5:06 PM the MIT stated her expectation was call lights should have been in reach of residents. The MIT stated everyone who entered resident rooms were responsible to ensure call lights were in reach of residents. The MIT stated staff making champion rounds, and charge nurses were responsible to monitor to ensure lights were in reach. The MIT stated if call light was not in reach, it could have caused resident to not have needs met. The MIT stated what led to failure of call light not being reach could have been due to hospice brought in new equipment. The MIT stated they did not have a policy regarding call lights.

Based on observation, interview and record review, the facility failed to ensure at the time each resident was admitted , the facility had a physician order for the resident's immediate care for 1 (Resident #47) of 32 residents reviewed for residents receiving necessary care and services upon admission. The facility failed to obtain physician's order prior to placing Resident #47's knee immobilizer to her right leg. This failure could place residents at risk of not having a physician order followed. Findings include: Record review of Resident #47's electronic face sheet dated 04/17/2025 revealed an [AGE] year-old female admitted on [DATE]. Resident #47's diagnosis included Unspecified Fracture of Right Patella (kneecap), Hypertension (high blood pressure), Type 2 Diabetes Mellitus, Unspecified Dementia, Muscle Weakness (generalized) Record review of Resident #47's physician orders revealed an admitted [DATE], and further review revealed no evidence of an order for a knee immobilizer. Record review of Resident #47's care plan dated 03/27/2025 did not address the use of a knee immobilizer. Record review of Resident #47's hospital records dated 03/12/2025 revealed final diagnosis closed nondisplaced fracture of right patella. Hospital course: Right patella fracture non operative treatment as per orthopedic. WBAT (weight bearing as tolerated) in knee immobilizer. Record review of Resident #47's physician progress note dated 03/28/2025 revealed an [AGE] year-old female admitted post right patella fracture. Wear brace on right lower extremity at all times. Review of systems; Musculoskeletal -right patella fracture; knee brace in place. written by facility's medical director. Record review of Resident #47's admission MDS dated [DATE] revealed: Section C - Cognitive Patterns: Resident #47 had a BIMS of 4 (severe cognitive impairment); Section G- Functional Abilities: Resident #47 had functional Limitation in Range of Motion to lower extremity impairment on one side. Section I-Active diagnosis Resident #47: had Fractures and other multiple traumas. During an observation on 04/15/2025 at 11:00 AM Resident #47 was lying in bed with knee immobilizer to right leg. During an observation on 04/16/2025 at 10:22 AM Resident #47 was lying in bed with knee immobilizer on right leg. During an observation on 04/17/2025 at 02:30 PM Resident #47 was sitting at a table in the dining area of the secure unit playing cards. Resident #47 was observed wearing a hinged brace (knee immobilizer) to right leg. During in an interview on 04/17/2025 at 03:50 PM LVN C stated there should have been an order for a rResident #47 who had a knee immobilizer. LVN C stated the admitting nurse would have been responsible for putting in the orders from the hospital. LVN C stated if no order on the EMR the resident could possibly not have the knee immobilizer in place as needed. LVN C stated they did not know how this failure occurred. During an interview on 04/172025 at 04:05 PM CNA B stated she knew that the knee immobilizer was to be put on rResident #47 because the charge nurse told her the resident needed it. During an interview on 04/17/2025 at 04:10 PM The RCN stated admission orders were put in the EMR by the nurse who had performed the admission assessment. The RCN stated the DON or the ADON reconciled orders the day after a resident was admitted to the facility. The RCN stated there should have been an order for the knee immobilizer. The RCN stated she did not know how this failure occurred. The RCN stated the effect on the resident would have been the resident would not have the needed support for her right knee and this could cause further injury to the resident's knee. The RCN stated the staff would not know the resident needed the knee immobilizer and would not be putting the immobilizer on the resident. The RCN stated she was responsible for monitoring the physician orders when she visits the facility. The RCN stated she visits facility at least one time a month. The RCN stated she did not know how this failure occurred. Record review of the facility's policy titled: Physician Orders without a date revealed: Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders and ADL order for each resident. Person responsible: Medical Records/Designee 1. Physician's monthly consolidated orders must be reviewed by a licensed nurse to assure they reflect all current orders. Any orders not within the monthly physician's order must be added before physician review or being sent out for physician signature. 2. 3. The physician must approve/sign/return the monthly consolidated orders within 30 days. 4. The original paper monthly orders should be retuned and placed on the chart within 30 days. Effective June 22, 2015 the white paper copy of the physician's orders is no longer necessary. If a copy is needed, one can be printed from the electronic medical record.

Based on interviews and record reviews, the facility failed to ensure nursing staffing information was posted in a prominent place readily accessible to residents and visitors that included: the census, the total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 1 of 3 days (04/15/2025) reviewed for required postings. The facility failed to ensure the daily staffing information for licensed and unlicensed nursing staff was posted in a prominent location on 04/15/2025. This failure could place residents, their families, and visitors at risk of not knowing how many nursing staff were currently working and the total hours were to be worked by nursing staff to provide care on all shifts. Findings Included: During an observation on 04/15/2025 at 10:11 a.m., the daily staffing posted in hallway was dated 03/06/2025 totaling 40 days of posting not being updated. During an interview on 04/16/2025 at 10:27 a.m., the DON stated her expectation was that the daily staffing be posted daily. The DON stated she was responsible for posting daily nursing staff. She stated she had forgotten to post the staff posting but had kept them in a binder in her office. She stated in the future, she would delegate the staff posting to her ADON. The DON stated the ADMN may monitor that staffing hours were posted but was unsure if he did. She stated staff knew how many staff were on schedule by looking in another binder, but visitors and residents would not know to look in that binder. She stated failing to post nurse staffing could interfere with visitors and residents knowing if the facility had adequate staffed. During an interview on 04/17/2025 at 10:58 a.m., the RCN stated it was the DON who monitored that daily nursing staff was posted. She stated the staffing coordinator was responsible for posting the nursing staff daily and the ADON was the back up if the staffing coordinator was not present. She stated the DON mentioned that she may have just not updated the date on the posting and that may have been the failure. She stated anyone entering the building could ask one of the staff how many people were on shift, and they would tell them about the binder listing staff members scheduled. She did not feel any negative impact occurred from daily nurse staffing not being posted for public to view. During an interview on 04/17/2025 at 11:00 a.m., the interim ADMN stated he expected nurse staffing to be posted daily. He stated he was unsure who monitored or who was responsible for posting the nurse staffing. He stated the DON had come up with a plan for who was responsible and who would monitor the staffing was posted daily. He stated he was unsure why the nursing staffing had not been posted daily. He stated no posting could interfere with visitors and resident knowing how many direct care staff were scheduled. He stated there was no policy other than the mandatory posting check off sheet on required postings. Review of facility document titled Mandatory Posting revision date on 05/16/2019 revealed: NAME OF POSTING .Daily Staffing by shift of Licensed and Unlicensed Nursing Staff .POSTED .Yes No.

Based on interview, and record review, the facility failed to ensure residents were free from misappropriation of property for one (Resident #7) of 5 residents reviewed for misappropriation of property. The facility failed to ensure Resident #7 was free from misappropriation of property when AP borrowed money for personal benefit. The non-compliance was identified as past non-compliance dated 1/24/25. The facility had corrected the noncompliance on 1/28/25 before the survey began. This failure could place residents at risk of exploitation/misappropriation of property and financial distress. Findings include: Record review of Resident#7's face sheet dated 3/5/25 revealed [AGE] year-old male, with an original admitted [DATE] and a re-admitted [DATE]. Resident #7 Diagnoses include Traumatic subarachnoid hemorrhage with loss of consciousness (brain injury), depression, anxiety, apraxia (motor disorder caused by brain), hemiplegia affecting left side (paralysis on one side). Record review of Resident #7's MDS assessment dated [DATE], revealed Resident #7 had a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Resident #7 was extensive assist with ADLs for toileting, bathing, and dressing. Record review of the PIR (Form 3613-A of Texas Health and Human Services) dated 1/30/25, revealed in part: POA of [Resident #7] reported to ADON and DON that AP began texting resident asking for money, POA and resident agreed to help AP and sent money to AP via Cashapp (transfer money by phone), using [Resident #7's] account. [Resident #7] and POA asked AP to repay when payday arrived. AP has not been in contact with POA or [Resident #7] and has failed to repay the full amount. PIR confirmed allegation. Record review on 3/5/25 of photos taken from Resident #7's phone revealed cash amounts sent to AP, and AP acknowledging and replying to Resident #7. An interview with Resident #7 on 3/5/25 at 11:30am, Resident #7 stated on 1/24/25, unsure of the time, the AP told him she had no heat at her home. Resident #7 stated the weather was cold and he felt sorry for the AP. Resident #7 stated he used his $310 out of his account to give to the AP. Resident #7 stated his POA was also in room on 1/24/25 talking to the AP and they both felt that they could loan the AP money and she would pay back when she got paid, Resident #7 stated the AP avoided coming to his room after she received the money. Resident #7 stated that the facility did not know any of this, it was just between him (the resident), the POA, and the AP. When the AP failed to repay, the resident stated his POA told the facility Assistant Administrator and Administrator. Resident #7 stated the amount was around $310. Resident #7 stated the AP did pay him $80. Resident #7 stated that the facility reimbursed him his full amount. Resident #7 stated that he had a big heart and wanted to help but had learned his lesson. An interview on 3/5/25 at 11:38am with Resident #7's POA, the POA stated she and Resident #7 felt sorry for the AP and agreed to give her money with the agreement the AP would pay back the money on payday. The POA stated money was voluntarily taken out of Resident #7's account by Resident #7 and sent by Cashapp to AP on 1/8/25 for $250 and on 1/10/25 for $20, on 1/13/25 $80, and on 1/14/25 $40. POA stated that AP did repay $80 on 1/14/25 back to Resident #7. The POA stated the AP was not seen again. The POA stated she told the Administrator what had happened on 1/24/25. An interview on 3/6/25 at 9:27am, the Administrator stated on 1/24/25 at 10:09am (POA) told her about loaning money to the AP and that AP was not paying the resident back. The POA showed transactions with the AP's name and phone number with a picture on CashApp. The Administrator stated on 1/28/25 (time unknown) she interviewed the AP. The Administrator stated the AP never admitted to taking money from the resident and the money came from the resident's POA. AP stated she paid $80 back. The Administrator stated that phone records from Resident #7's phone revealed the AP knowingly was in contact with Resident #7, and Resident #7's phone showed that money was sent to the AP and that AP acknowledged that she received money. The Administrator stated her investigation confirmed that AP took money from the resident and that AP was terminated from the facility. Resident #7 was fully reimbursed by facility. Police were notified and a report made. The Police Report number was #250000119. The Administrator stated there was a warrant out for the AP but at this time the AP's where abouts were unknown. A phone call to the AP, 3/5/25 at 11:55am, revealed a nonworking number. Record review of facility of facility's provided policy on abuse, neglect and exploitation dated 9/9/24 revealed in part The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure 5 pies were covered when being stored in the refrigerator. This failure could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 02/25/2024 between at 8:30 AM to 9:00 a.m. of the kitchen's refrigerator revealed: Two metal trays with 5 pies sitting on them uncovered surrounded by food. Above the uncovered pies were boxes and plastic containers with liquid food. Three kitchen staff were present in the kitchen that did not include the DM. During an interview on 02/25/2024 at 8:43 a.m., the DA stated she was unsure if pies stored in the refrigerator needed to be covered. She stated that the pies had been cooked and placed in the refrigerator on the night of 02/24/2024. During an interview on 02/26/2024 at 10:10 a.m., the DM stated she did not see a failure from pies being uncovered in the refrigerator. She stated the pies had been cooked on 02/25/2024 and that they were stored in the refrigerator to cool down. She stated she believed that the pies had only been in the refrigerator for several minutes. She stated the facility used the FDA Food Code 2022 for cooling methods. She denied any negative effect that pies being in refrigerator uncovered could have on residents. She stated since the foods over the pies and foods that surrounded the pies in the refrigerator were covered and there was no observable condensation then cross contamination could not occur. She stated that she was responsible for monitoring kitchen staff stored foods properly. During an interview on 02/27/2024 at 3:00 p.m., the ADMIN stated his expectation would be for kitchen staff to follow the facility's policy. He stated that the policy stated open packages of food should be stored in closed containers with covers or in sealed bags. He stated improper training and understanding of facility's policy and expectations led to the failure. The ADMN stated DM was to monitor dietary staff are storing food appropriately and that he was responsible for monitoring the DM. He stated the effect of storing food uncovered could lead to food borne illnesses in the residents. Record review of facility's policy titled, Food Storage and Supplies dated 2012 revealed: Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.

Based on observation, interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 (Resident #4) residents reviewed for pressure ulcers. The facility failed to provide care as ordered to bilateral heel pressure ulcers. The facility failed to assess pressure ulcers weekly. The facility failed to provide interventions to prevent development or worsening of Resident #4's heel pressure ulcers. These failures could place residents at risk of infections and worsening of wounds. Findings include: Record review of Resident #4's electronic face sheet dated 02/27/2024 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included: rhabdomyolysis (muscle deterioration), insomnia, gout (inflammation in joint), muscle weakness, and protein-calorie malnutrition (low protein levels and calorie intake). Record review of Resident #4's admission MDS assessment dated [DATE] revealed resident had a BIMS score of 11 meaning moderate cognitive impairment; helper performed more than half the effort with dressing and putting on footwear; helper performed less than half the effort with bed mobility, sitting to lying, sitting to standing, and bed to chair transferring; resident had 1 unhealed pressure ulcer and received pressure ulcer care with pressure reducing device for bed. Record review of Resident #4's orders dated 02/27/2024 revealed: Order with start date of 01/26/2024 resident may have pressure relieving mattress; Order with start date of 01/26/2024 cleanse stage 1 to left buttocks with wound cleanser pat dry apply collagen and cover with bordered dressing one time a day every Mon, Wed, Fri for pressure area; Order with start date of 02/08/2024 resident may have Prevalon Boot (heel protection boot) to right and left foot for pressure area two times a day for pressure area; Order with start date of 02/08/2024 cleanse left heel ruptured blister with normal saline pat dry apply iodine skin prep and cover with dressing one time a day for blister; Order with start date of 02/08/2024 cleanse right heel ruptured blister with normal saline pat dry apply iodine skin prep and cover with dressing one time a day for blister. Record review of Resident #4's care plan dated 02/27/2024 reflected it does not address resident's non-compliance with pressure relieving interventions: Avoid positioning the resident on the location of the pressure ulcer right and left heel date initiated: 01/26/2024 revision on: 02/09/2024 . Ensure heels are floated (not touching another surface) with the use of pillows date initiated: 01/26/2024 .Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Record review of Resident #4's treatment administration record on 02/27/2024 revealed wound care was not documented for either the left or right heel on Sunday 02/11/2024 with no rationale why treatment was not performed. Record review of pressure ulcer assessments on 02/27/2024 revealed: Left heel stage 2 pressure ulcer measured 3.0cm(L) by 3.0cm(W) by 0cm(D) on 02/08/2023. Left heel stage 2 pressure ulcer measured 5.0cm(L) by 5.0cm(W) by 0cm(D) on 02/13/2024. Left heel stage 2 pressure ulcer measured 4.5cm(L) by 3.0cm(W) by 0cm(D) on 02/23/2024. Left heel stage 2 pressure ulcer measured 3.0cm(L) by 4.5cm(W) by 0cm(D) on 02/26/2024. Right heel stage 2 pressure ulcer measured 2.0cm(L) by 2.0cm(W) by 0cm(D) on 02/08/2024. Right heel stage 2 pressure ulcer measured 5.0cm(L) by 4.0cm(W) by 0cm(D) on 02/13/2024. Right heel stage 2 pressure ulcer measured 2.5cm(L) by 3.5cm(W) by 0cm(D) on 02/23/2024. Right heel stage 2 pressure ulcer measured 3.0cm(L) by 4.0cm(W) by 0cm(D) on 02/26/2024. Weekly pressure ulcer assessment was not performed on February 20th 2024. During on observation and interview on 02/26/2024 at 3:10 p.m., Resident #4 was sitting in his wheelchair in his room. Resident's bed had a standard mattress. The wheelchair had feet pedals on it and Prevalon boots (heel protection boots) were being worn. Resident #4 said that he did not like wearing Prevalon boots (heel protection boots) in the bed and he wished staff would allow him to not wear them. He stated Prevalon boots (heel protection boots) were used to help wounds on his feet heal. The resident said his heel wounds were getting better. During an interview on 02/27/2024 at 2:34 p.m., LVN C stated she performed treatments and assessments on Resident #4 when she worked. She stated that Resident #4 had a pressure ulcer to his buttocks when he admitted to the facility on [DATE]. LVN C stated that on 02/08/2024 she was called to evaluate Resident #4's heels and she observed new skin issues at that time. She received physician's orders and treated the pressure ulcers that day. LVN C stated that on 02/11/2024 she did not work since it was a Sunday. She stated charge nurses were to perform wound care on the days that she did not work, and she did not know why wound care was missed. She stated Resident #4 was non-compliant with letting staff offload his heels with pillows and would kick the pillows out from under his legs. She stated Resident #4 said the Prevalon boots (heel protection boots) the facility used for offloading the area at this time caused his claustrophobia to worsen and he would kick them off at times. She stated he refused to allow the facility to put on foot pedals to his wheelchair until recently and would plant his heels on the hard floor when sitting in the wheelchair. She stated he had started allowing staff to assist more since he had been at facility longer. LVN C stated she was out on personal leave between 02/14/2024 and 02/23/2024 and did not know why pressure ulcer assessments were not performed in her absence. She stated that charge nurses should have performed the assessments. She stated the DON monitors that assessments and treatments are performed. She stated that Resident #4 was on the list for the wound care physician to assess him on 03/01/2024 due to pressure ulcer worsening. She stated that when Resident #4 was admitted , the air mattress was not available. The facility was working on getting him one at this time and she felt that the facility would be able to rent a low air loss mattress to help relieve pressure areas while in bed. During an interview on 02/27/2024 at 2:42 p.m., the DON stated pressure ulcers were preventable. She stated her expectation was for pressure ulcer assessments to be performed weekly and weekly meant every 7 days. She stated her expectation would be for the charge nurses to perform assessments and treatments on days when the treatment nurse was not working in the facility. On 02/11/2024 she expected for the charge nurse or the weekend supervisor to perform treatment. She did not know what led to the failure. She stated that if treatment was not documented then it was not done. The DON stated she did not know the assessment was missed on 02/20/2024 and that treatment was missed on 02/11/2024 therefore did not follow up. She stated that missing treatments and assessments could cause wounds to worsen. She voiced that she was responsible for monitoring treatments and assessments were performed. Review of facility policy titled Comprehensive Care Planning that is not dated revealed In situations where a resident's choice to decline care or treatment (e.g. due to preferences, maintain autonomy, etc.) poses a risk to the resident's health or safety, the comprehensive care plan will identify the care or service being declined, the risk the declination poses to the resident, and efforts by the interdisciplinary team to educate the resident and the representative, as appropriate. The facility's attempts to find alternative means to address the identified risk/need should be documented in the care plan. Review of facility policy titled Skin assessment dated [DATE] revealed It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to ensure appropriate intervention are initiated in a timely manner .All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed by the Treatment Nurse/designee within four (4) hours of the resident's arrival at the facility. If the Treatment Nurse/designee is not available, then the charge nurse should complete the skin assessment within four (4) hours of the resident's arrival at the facility. The charge nurse will then notify the Treatment Nurse/designee of any skin concerns noted and complete the appropriate attachments/assessments. The DON (Director of Nursing) or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations. Any pressure ulcer should also be care planned. Any alterations in skin integrity will be treated according to physician orders. Notify DON and responsible family member. Documentation will then be entered into the resident's chart with the following information. All residents should have a skin assessment on a weekly basis completed in PCC (electronic medical record). If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for oxygen administration. The facility failed to place nebulizer mask and tubing in a bag and date when replaced. The facility failed to obtain physician's order prior to supplying oxygen to resident. The facility failed to monitor oxygen concentrator tubing connected appropriately. The facility failed to date humidifier on oxygen concentrator when replaced. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection. The findings include: Record review of Resident #5's electronic face sheet dated 02/27/2024 revealed a [AGE] year-old female who was admitted to the facility most recently on 11/10/2023 with diagnoses that included: dementia, gastrointestinal hemorrhage (stomach bleed), heart failure (heart disease that affects how much blood the heart can pump), muscle wasting, and COVID 19. Record review of Resident #5's significant change MDS assessment dated [DATE] revealed a BIMS score of 9 meaning moderate cognitive impairment; no oxygen treatment was coded on admission or while a resident. Record review of Resident #5's orders dated 02/27/2024 revealed order with start date of 12/13/2023 furosemide solution 10mg/ml (furosemide) 4mL (milliliter) inhale orally via nebulizer every 6 hours as needed for SOB (shortness of breath) and no order for oxygen therapy . Record review of Resident #5's care plan dated 02/27/2024 revealed no mention of oxygen therapy or nebulizer use on the care plan. During an observation and interview on 02/25/2024 at 1:25 p.m., Resident #5 stated she used oxygen as needed. She stated facility staff helped her when she needed oxygen. There was an oxygen concentrator and tubing with humidifier not connected to the concentrator. The humidifier tubing had a different electronic machine plug prong inserted into the end of it instead of being connected to the concentrator. The oxygen concentrator turned on, and no air bubbles were rising up to the top of water observed in the humidifier canister and the end of the tubing was placed in the top drawer of the nightstand. During an observation on 02/26/2024 at 11:41 a.m., Resident #5 had the oxygen concentrator sitting to the left of her bed. The oxygen tubing with humidifier was not connected to the concentrator and had a different electronic machine plug prong inserted into the end of the tubing that should have been connected to the concentrator. The oxygen concentrator was turned on with no bubbles forming in the humidifier canister and the end of the tubing was placed in the top drawer of the nightstand. During an interview on 02/27/2024 at 10:33 a.m., LVN B stated a physician's order was needed for oxygen to be administered to a resident. She stated she would change the oxygen tubing as needed when the oxygen tubing was visibly soiled and that she checked the oxygen concentrator / tubing once a shift. During an interview on 02/27/2024 at 10:47 a.m., the DON stated if oxygen was used, there was to be a physician's order obtained. The DON stated there should not be an oxygen tank or concentrator in a resident's room if they did not use oxygen. She stated she expected the charge nurses to assess the oxygen tubing and concentrator once a day to make sure they are all functioning well. She stated oxygen tubing was replaced as needed when visibly soiled per facility policy. The DON stated if a resident used humidified oxygen, the humidifier canister should be replaced weekly and dated when replaced. She stated when a resident was on hospice services, the nursing facility staff were responsible to make sure oxygen tubing was replaced when needed. She stated she did not know why the oxygen concentrator and nebulizer were not monitored by the charge nurse daily. During an observation and interview on 02/27/2024 at 10:55 a.m., Resident #5 had the oxygen concentrator in her room that was turned on. The humidifier canister was not connected to the concentrator and no bubbles were observed in the humidifier canister. The end of the humidifier canister's tube had an electric prong inserted into the end that should have been attached to the concentrator. The humidifier canister was not dated when it was last replaced. The nebulizer mask was lying on the floor without a date on it and not covered. The DON stated she expected the charge nurses to monitor oxygen equipment and replace tubing when appropriate. She stated not monitoring that oxygen equipment was set up correctly could cause the resident to sustain harm from attempting to use oxygen that was not set up properly and could cause infection when the tubing and nebulizer mask were not changed appropriately. She stated that she was responsible to monitor that charge nurses were monitoring oxygen and nebulizer equipment and tubing. Review of facility policy titled oxygen administration dated February 13, 2007, revealed: Assemble the concentrator .Fill the humidifier container to the marked level with distilled water. Turn on the flow and set the desired rate. Note that the water in the humidifier is bubbling and hold hand near the device to feel the flow .Place nasal cannula, usually used for flow rate under 6L/min, in the nares with the prongs straight or curving downward and around the ear and under the chin .Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated. Review of facility policy titled breathing therapy devices dated February 13, 2007, revealed: Attach the oxygen delivery equipment to the bubble diffusion humidifier and turn the oxygen gauge to the ordered rate. Note the bubbles in the water when the oxygen is turned on and flowing.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet dated 11/15/23, revealed a 76- year- old female admitted to the facility on [DATE] with diagnoses including senile degeneration of brain and morbid obesity. Review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 required extensive assistance with most activities of daily living (ADLs) and one-person physical assistance with transfer. Resident #1 was frequently incontinent of bladder and always of bowel. Review of Resident #1's Care Plan undated revealed she had bowel and bladder incontinence. Observation of incontinence care for Resident #1 on 11/14/23 at 2:55 p.m. revealed CNA A did not wash her hands prior to donning gloves in the hallway. CNA A removed Resident #1's brief that was soiled with urine. CNA A wiped the resident from front to back. CNA A did not change gloves but continued to clean Resident #1. CNA A's gloves were visibly soiled with urine. She did not wash her hands, change gloves, or perform hand hygiene before retrieving Resident #1's clean brief and placing it underneath the resident and fastening. CNA A again, did not wash her hands before exiting Resident #1's room. In an interview on 11/14/23 at 3:05 p.m. with CNA A, she revealed she should have washed her hands before starting care and changed her gloves during care. CNA A also revealed she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she had infection control training about one year ago. She said the resident could acquire an infection when she did not follow good infection control practices including washing hands before commencing care. During an interview with the DON on 11/15/23 at 2:22p.m., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand washing and change of gloves as needed. Review of the facility's Hand hygiene policy undated reflected, 1) You may use alcohol-based hand cleaner or soap/water for the following: a) When coming on duty . b) Before or after assisting a resident with personal care (e.g., oral care, bathing) 2) You must soap/water for the following (Alcohol-based cleaner is not recommended) a) When hands are visibly b) After personal use of the toilet (hand washing with soap and water) c) Before and after assisting a resident with toileting (hand washing with soap and water)

Based on observation, interview, and record review the facility failed to ensure that 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 for 1 (Resident #238) of 6 residents reviewed for pain management. 1. The facility failed to ensure that Resident #238's pain was controlled for 11 days by not following physicians' orders regarding administration of hydrocodone. 2. The facility failed to ensure that Resident #238's pain was controlled for 5 days by not administering hydrocodone and fentanyl patch, due to not having the medication available. These failures affected one resident and placed all residents who require pain management at risk for further decline in their mental and/or physical functioning, unnecessary pain, and discomfort. Findings included: Review of Resident #238's electronic face sheet accessed 12/18/22 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included cancer of the esophagus (tube that connects the throat to the stomach), alcohol abuse, and heart failure. Review of Resident #238's admission MDS dated [DATE] Section C Cognitive Patterns revealed no BIMS score which indicated an assessment had not been completed yet. Review of Section J Health Conditions J0100. Pain Management revealed he had received PRN pain medications and non-medication intervention for pain in the five-day lookback period prior to the assessment. Section J Health Conditions J0400 Pain Frequency. Frequently. Review of Resident's #238's electronic care plan initiated 12/12/2022 revealed no evidence of a focus, objective, or interventions related to pain or a diagnosis of cancer. Review of Resident #238's discharge and admission paperwork from the hospital sent to the facility upon admission titled, Medication Administration Record, dated 12/09/2022 revealed: Hydrocodone Bitart/Acetaminophen 15 ml solution give 15 ml via feeding tube every 4 hours as needed for pain scale 4-6. Review of Resident #238's electronic physician orders accessed 12/18/22 revealed no evidence of a hydrocodone or fentanyl patch order. Further review revealed no evidence of an order for pain evaluation. Review of electronic physicians' orders revealed an order for Tylenol with Codeine #3 Tablet 300-30 MG (Acetaminophen-Codeine) Give 2 tablet via G-Tube every 4 hours as needed for Pain dated 12/12/2022. Review of the December 2022 MAR for Resident #238 revealed the following administrations: -Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/12/22 at 11:02 p.m. with an associated pain scale of 6. Follow up pain scale for this administration was listed as effective. - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/13/22 at 5:14 p.m. with an associated pain scale of 8. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/13/22 at 10:52 p.m. with an associated pain scale of 8. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/14/22 at 3:30 a.m. with an associated pain scale of 5. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/14/22 at 2:32 p.m. with an associated pain scale of 8. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/15/22 at 7:05 a.m. with an associated pain scale of 10. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/15/22 at 8:55 p.m. with an associated pain scale of 2. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/16/22 at 8:46 a.m. with an associated pain scale of 6. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/16/22 at 2:26 p.m. with an associated pain scale of 6. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/16/22 at 10:59 p.m. with an associated pain scale of 5. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/17/22 at 6:56 p.m. with an associated pain scale of 4. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/17/22 at11:38 p.m. with an associated pain scale of 3. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/18/22 at 5:00 a.m. with an associated pain scale of 4. Follow up pain scale for this administration was listed as effective - Tylenol with Codeine #3 Tablet 300-30 MG 2 tablets given on 12/19/22 at 8:05 a.m. with an associated pain scale of 10. Follow up pain scale for this administration was listed as effective Review of skilled nurse's notes for Resident #238 revealed each note included a pain assessment. These pain assessments were documented as follows: -12/16/22 7:30 a.m. pain was 8.8 out of 10 -12/17/22 9:02 a.m. pain was 4.4 out of 10 -12/17/22 10:03 p.m. pain was 4.4 out of 10 -12/18/22 9:05 a.m. pain was 4.4 out of 10 -12/18/22 9:09 p.m. pain was 4.4 out of 10 -12/19/22 9:09 p.m. pain was 10 out of 10 Record review of Resident #238's electronic nurses notes accessed on 12/18/22 revealed a nurses' note written by LVN A, dated 12/15/22 at 6:02 PM, which read: Returned from MD appointment. Transport reported the Dr. called in orders to pharmacy and that copies will be faxed tomorrow. Further review or electronic nurses' notes revealed no evidence of documentation regarding new orders or waiting for medications to arrive. During observation and interview on 12/18/22 at 2:30 PM, Resident #238 was sitting up in bed. Resident #238 was very tense and fidgety in appearance. He stated he was in pain. He stated his pain level was at a 10 in his neck and throat area. He stated he went to his oncology doctor on Thursday (12/15/22) and got an order for hydrocodone and fentanyl patches and had not received the medication yet. He stated he was waiting for the nurse to come by to talk to her about his pain medication. He stated he felt he should not have to wait this long for pain control. During an interview on 12/19/22 at 09:32 AM, Resident #238 stated he was in a lot of pain. He stated he went to the doctor last Thursday (12/15/21) and received and order for Hydrocodone and pain patches. He stated the nurses told him that the medication had not arrived from the pharmacy yet. Resident #238 stated his pain was a level 10 out of 10 and Tylenol with Codeine did nothing for his pain. He stated the facility had not offered him anything except Tylenol with Codeine. During an interview on 12/19/22 at 10:00 AM, LVN B stated she was not aware of any new orders for pain medication for Resident #238, but she would investigate it. During an interview on 12/19/22 at 10:30 AM, LVN B stated she spoke with the DON and the medication ordered by the oncologist was still not available from the pharmacy. Record review of Resident #238's electronic nurses notes accessed on 12/19/22 revealed a nurses' note written by the DON, dated 12/19/22 at 11:47 AM, which read: .Spoke with pharmacy regarding residents' fentanyl and hydrocodone from oncologist. Pharmacist states drug order should be delivered by this afternoon around 4pm . During an interview on 12/20/22 at 10:00 AM, the DON stated the pharmacy did not have the medications in stock. She stated the pharmacy was supposed to receive a truck yesterday and deliver the medications. She stated she was about to go to the pharmacy and pick up the medications. DON stated Resident #238 told her his pain was controlled with the Tylenol with Codeine and he wanted to wait for his prescriptions. She stated he refused to take the hydrocodone from the emergency kit because he did not think it was the same as he was prescribed. She stated the facility can get all medications from their pharmacy within 24 hours of new orders and prescribed medications. She stated she did not try other alternatives to get his new medications because on 12/16/22 Resident #238 stated he was ok and wanted to wait for his medications from the pharmacy. She stated Resident #238's pain had been controlled. She stated it was not acceptable to let a resident hurt for 5 days. During an interview on 12/20/22 at 11:30 PM, Resident #238 stated when he was in the hospital, he received hydrocodone and it completely relieved his pain. He stated his acceptable pain level was a 2. He stated he had been in pain the whole time he had been in the facility. He stated the Tylenol with Codeine only brought his pain from a 10 to an 8. He stated he had never been offered any other medication. He stated was told that he had to wait until his medications came from the pharmacy. During an interview on 12/20/22 at 2:15 PM, LVN C stated when Resident #238 was admitted to the facility his admission orders had an order for hydrocodone, but the hospital did not send a triplicate for the medication. She stated the facility could not order the medication without the triplicate. She stated on 12/10/2022 Resident #238 asked for pain medication. She stated she called his primary care physician and he refused to order the hydrocodone because he was not the original physician that ordered that medication. She received an order for Tylenol with Codeine. She stated she did not call the oncologist or the hospital to get another order or a triplicate for the hydrocodone. During an interview on 12/20/22 at 3:00 PM, the DON stated the charge nurse was responsible for completing the admission assessment and orders. She stated admission orders were taken from the discharge and admission paperwork from the hospital sent to the facility upon admission titled, Medication Administration Record. She stated it was the DON's place to follow-up and ensure that this was done properly. She stated she called the hospital on Monday 12/13/22 to ask for a triplicate but was unable to get one. She stated she did not call the oncologist to get an order for the hydrocodone. She stated Resident #238's pain was being managed and the Tylenol with Codeine was effective. The DON did not provide a policy related physicians orders or medication availability. Review of facility policy titled Pain Management, Assessment Tool,' revised May 2016 revealed: pain is a subjective sensation of discomfort he received from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy: complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: 1. resident identifies pain characteristics.2. Resident articulates factors that anticipatory pain. 3. Resident expresses a feeling of comfort and relief from pain. 4. Resident States and carries out appropriate pain interventions from pain relief. 5. Cognitively impaired residents will demonstrate actions of pain relief. Procedure: 1. assess residents' physical symptoms of pain, physical complaints, and daily activities . If resident complaints of pain the nurse will assess, implement relief measures as ordered and or care planned .7. Ask resident to help establish goals and develop plan for pain control. This gives resident sense of control. 8. Instruct resident in use of relaxation techniques.9. Add the resident to right pain on a scale of 1 to 10 with one being the least pain and 10 being the worst pain experience .10. Assist the resident in maintaining a pain management and reschedule, exercise program, and medication regimen .12. Talk with the resident about pain and assess for pain relief after interventions.13. Monitor for effectiveness of pain intervention.

Based on observations, interviews, and record reviews, the facility failed to Store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen's reviewed for food service. The facility failed to label items in refrigerators with an identifier of the food item. The facility failed to discard items in refrigerators after 7 days. The facility failed to seal items in refrigerators and dry food storage room. These failures placed all residents at risk of food borne illnesses. Findings included: During an observation and interviews on 12/18/22 at 10:06 AM Refrigerator #2 30 individual serving dishes with foil covering with a date of 12/15. There was no label on the dishes to identify the contents. Cook said they were a Chili cornbread pot pie. She said the person that prepared them should have put a label on them to identify the food item before storing them in the refrigerator. 1 clear tub of mixed salad greens with a date of 12/8. The container was open, and Cook said that it should have been a closed container and that the item should be thrown out after 7 days. 1 clear zipper sealed gallon storage bag with prepared meat sauce and noodle mix that had a label of Spaghetti with a date of 12/8/22. Cook said it was prepared on 12/8/22 and it should only be stored for 7 days, so it should have already been thrown out. Chest Refrigerator 2 clear bowls covered in plastic wrap that contained a pink substance with a marking of 12/18. Dietary Aide said they were strawberry yogurts. She said they should have had a label on them to identify the item. Obvious build up of ice along the back half of the chest refrigerator. Cook said it would need to be defrosted and said she had not paid attention to the buildup. Dry Food Storage Room 1 clear plastic zipper sealed bag containing Cream of Wheat had a date of 12/1. Cook said the date was from when it was received from the food company. It should have also included the date it was opened. She said all items in their original packaging should have the date received on the items and also a label that states opened. 1-3 compartment cereal dispenser that contained Raisin Bran and Rice Crispies that did not include a date they were placed in the container. Cook said the dispenser should have had a label placed on the back of each compartment to identify when each cereal was placed in them. 1 clear plastic jug drinking container that had a label Sanitizer 12/16 was sitting on a rolling cart next to the metal shelving unit that had a package of bread, flour container, sugar container, and other miscellaneous seasonings and cake mixes. Cook said the container should not have been stored next to the food items and it should have been in the storage closet with all other cleaners. She said she did not know why it had been left in the dry food storage room. 1 clear plastic zipper seal bag containing dinner rolls that was open. Cook said the bag should have been sealed. During an interview on 12/18/22 at 11:05 AM with DM, she said items in the refrigerators that had been prepared needed to be thrown out 7 days after preparation. She said any prepared item should have a label that identified the contents of the container and the date the item was prepared. DM said they had a cleaning supply storage closet directly beside the dry food storage room and the sanitizer should have been stored in that closet and not in the food storage room. Record review of facility policy labeled Storage Refrigerators dated 2012 revealed: All Storage Refrigerators shall be maintained clean . to ensure a proper environment and temperature for food storage .Food must be covered when stored, with a date label identifying what is in the container . Refrigeration equipment is to be routinely defrosted and compressor cleaned.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #52) of 2 residents reviewed for dialysis. The facility failed to ensure Resident #52 had orders to receive dialysis, to monitor the dialysis access site, or to monitor post-dialysis for any signs or symptoms of: infection or bleeding, edema, blood pressure, or fluid overload. This failure could place the resident who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Review of Resident #52's electronic face sheet, accessed 12/18/22, revealed the resident was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE] with diagnosis that included chronic kidney disease stage 4 (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life) dependence on renal dialysis, and Parkinson's disease. Review of Resident #52's Admission MDS, dated [DATE] revealed a BIMS score of 12 which indicated no cognition impairment. Further review revealed Section O0100. Special Treatment, procedures, and program. J: dialysis was coded-yes. Review of Resident #52's Care plan initiated 12/04/22 and revised on 12/19/22 read in part: . Focus: The resident has fluid overload or potential fluid volume overload r/t Kidney failure, depends on hemodialysis 3 times. Goal: The resident will remain free of s/sx of fluid overload through review date, as evidenced by decrease in edema, anxiety, agitation, restlessness, confusion, changes in mood or behavior, nausea/vomiting, dyspnea, congestion, orthopnea, easily fatigued, jugular vein distension. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Diet as ordered. Monitor and document intake and output as per facility policy. Monitor vital signs as ordered and record. Notify MD of significant abnormalities. Monitor/document/report to MD PRN s/sx of fluid overload: Anorexia, Anxiety, Mood/behavior changes, Confusion, Edema, Nausea/vomiting, Shortness of breath, difficulty breathing (Dyspnea), Increased respirations (Tachypnea), Difficulty breathing when lying flat (Orthopnea), Congestion, Cough, Fatigue, Jugular Venous Distention (JVD), Sudden weight gain. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide pillows; raise HOB as needed to facilitate breathing, increase comfort. The resident needs rest periods as needed/requested intervals. Focus: The resident requires Hemo-Dialysis three days a week r/t a diagnosis of End Stage Renal Failure. Goal: The resident will have no s/sx of complications from dialysis through the review date. Interventions: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis three times weekly. Monitor for dry skin and apply lotion as needed. Monitor labs and report to doctor as needed. Monitor/document for peripheral edema. Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Review of Resident #52's electronic physician order accessed 12/18/22 revealed no evidence of orders to receive dialysis, to monitor the dialysis access site, or to monitor post-dialysis for any signs or symptoms of: infection or bleeding, edema, blood pressure, or fluid overload. Review of Resident #52's nurses notes dated 11/30/22-12/18/22 revealed no evidence of monitoring the dialysis access site or monitoring post-dialysis for any signs or symptoms of: infection or bleeding, edema, blood pressure, or fluid overload. Review of Resident #52's Weights and Vitals accessed 12/18/22 revealed last blood pressure was taken on 12/03/19 during Resident #52's previous admission to the facility. During an interview on 12/18/22 at 11:30 AM, Resident #52 stated he went to dialysis on Tuesdays, Thursdays, and Saturdays. He stated no staff member had ever looked at his dialysis site. Resident #52 stated he had not had his blood pressure checked since he had been admitted . He stated he had a lot of edema and swelling to his lower extremities but no one had ever said anything about it. Resident #52 stated he could not remember ever having a nurse do an assessment on him before or after he received his dialysis treatment. During an interview on 12/20/22 at 3:30 PM, the DON stated there was no specialized monitoring for dialysis. She stated the dialysis center monitored Resident #52's access site when treatment was provided. She stated there were no required orders for monitoring. She stated the nurses monitored for edema and blood pressure daily. She stated there was no need to monitor specifically for dialysis complications. DON stated she was not aware Resident #52 had not had a blood pressure check and she thought he had an order to check for edema. The DON stated the failure ultimately occurred due to her not reviewing charts and orders as thoroughly as she should. Review of facility's policy titled; Dialysis revised November 2013 reflected in part: .Procedure: 1. Review and confirm the physicians' orders for dialysis. Follow the specifications of the medical regimen including dietary restrictions and medical management. 2. The facility will establish baseline information from the dialysis center and will monitor changes from that baseline .7. Each side will be assessed for bleeding, bruising, lack of pulsations, and aneurysm as ordered by the physician. The nurse will help palpate the access from the distal anastomosis to the proximal anastomosis. A thrill should be built along the course of the vessel. This procedure should be conducted once per shift . record the results of the examination. Report nonfunctioning accesses to the dialysis center immediately. Report any drainage, redness, or swelling around the insertion site to the dialysis center as soon as possible .14. strict intake and output will be maintained on the resident. Daily weights will be maintained unless otherwise specified by the physician. All documentation will be monitored especially by the position order. All documentation will be maintained in the residence clinical record .20. the facility will be observant of any of the following symptoms. If the resident experiences any of these symptoms, the nurse will contact the dialysis center and the attending position immediately. A. Altered mental status resident is confused or disoriented .b. Change in skin condition or color .c. distention of neck veins .d. increased edema of face or extremities .e change in color of nail beds .f. muscle twitching .

Based on observation, interview, and record review, the facility failed to ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 2 of 2 medication rooms, one located on east hall and one located on west hall, and 1 of 1 treatment cart. The facility failed to ensure that all medications and supplies stored in medication room [ROOM NUMBER], east hall and medication room [ROOM NUMBER] west hall were properly labeled and not past their expiration date. The treatment cart was left unlocked and unattended. These failures could place all residents at risk of harm, decline in health, and medications/biologicals or misappropriation of medications. The findings included: Observation of treatment cart on east hall on 10/10/2021 at 09:21 AM revealed the cart was not locked, and no licensed staff were in the vicinity to monitor the security of the cart contents. No residents were near the unlocked cart at this time; however, the cart was located across from the nurse's stations. The top drawer of the treatment cart contained one vial of [MEDICATION(S)] 70/30 prescribed to R34, one vial of [MEDICATION(S)] R prescribed to R44, one vial of [MEDICATION(S)] R prescribed to R33, one vial of insulin prescribed to R39, and eleven insulin pens. The second drawer contained multiple tubes of prescribed creams and ointments. The third drawer contained multiple boxes of prescribed inhalant solution in single dose containers. Interview with LVN A on 10/10/2021 at 09:24 AM stated she was currently assigned to the treatment cart on east hall and just stepped away for a second and I guess I forgot to lock it. She stated her normal routine was to lock the cart every time but got nervous when she heard state was in the building. LVN A acknowledged that leaving the cart unlocked puts all residents at risk for illness or harm due to the contents of the treatment cart. Interview with ADON on 10/10/2021 at 10:15 AM, the ADON stated that the medication carts and treatment cart should be locked anytime the nurse or certified medication aide (CMA) steps away from it no matter how long they think they will be gone. The ADON stated the nurses are usually real good about it. Observation of medication room [ROOM NUMBER] west hall on 10/11/2021 at 9:06 AM revealed the following: Two sealed boxes of [MEDICATION(S)] 100 units/milliliter pens with 5 pens in each box expired 03/2021. Ten 1 milliliter syringes of [MEDICATION(S)] Gel 50 mg/milliliter with discard by date of 10/06/2021. Observation of medication room [ROOM NUMBER] east hall on 10/12/2021 at 02:27 PM revealed the following: one bottle of [MEDICATION(S)] Silver Adults 50+ expired 4/2021. one opened jar of grape jelly in the refrigerator without an expiration, use by, or opened date. one 8 ounce can of Two Cal HN dietary supplement unopened expired 06/01/2021. Interview with the Director of Nurses (DON) on 10/12/21 at 02:27 PM the DON's response was the night nurses were responsible for checking the medication carts and medication rooms for expired medications on a routine basis. The DON stated there was not a policy or written guidelines specifying when this task should be completed or have a method to track nursing staff accountability for checking for expired items. The DON's reply for how this failure occurred was that the two best night nurses refuse to work with anyone else, my weak nurses, so I have my 2 best on shift at the same time. The DON explained that she expects all the nurses the check for expired medications and follow procedure for discarding expired medications. The DON described the procedure to discard expired medications was to place the medications in a locked bin with a slot in the top of the bin located in the medication rooms. If a medication was packaged and would not fit in the slot in the top of the locked bin, the nurses are to take the expired medication to her. The DON then stores the expired medication in a double locked drawer in her office until the pharmacists arrives to perform drug destruction. The DON added that she was planning in-services to present updated forms to improve medication monitoring. The DON acknowledged that dispensing expired medications could place residents at risk for illness or harm. Record review of the facility policy Storage and Maintenance of Medication, undated, stated Medication must be checked regularly for expiration dates and deterioration. Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are to be immediately removed from stock, logged in on the medications for destruction log and locked up. All medication areas such as medication room, carts, cabinets and refrigerator not stored in medication room shall be locked at all times when not in use.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 of 5 residents (Resident #33) reviewed for abuse. The facility did not thoroughly investigate an allegation of abuse for Resident #33. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated. Findings included: Review of Resident #33's electronic face sheet, revealed a 49 -year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 33's Minimum Data Set (MDS) dated [DATE] revealed: a Brief Interview for Mental Status (BIMS) of a 0 (severe impairment) and received antidepressants and antianxiety medications in the past 7 days . Record review of Facility's Incident report dated 06/22/2021 revealed an allegation of abuse of Resident #33. On 6/22/2021 CNA reported, While performing Resident #33's care, Resident #33 was having another one of her out bursts and her mother was in the room assisting., It was stated that the Resident #33's mother told her to shut her mouth and stop screaming then slapped her in the face rather hard. Record review of Resident # 33's progress notes revealed the facility failed to document the incident of abuse. Record review of Resident #33's electronic chart revealed that facility failed to complete a head to toe assessment . During interview on 10/13/21 at 01:57 PM with the ADMN , he stated that he did not make a report to the police for the incident that occurred on 06/22/2021 . He stated that he was on the fence about making a report because there was no physical proof, just an allegation . The ADMN referred to policy for self-reporting protocol, he stated that she should have made a police report. The ADMN stated he did not make a police report was that at the time he was not sure if he should because he did not see physical injury . ADMN stated that the perpetrator had cancer and was going thru chemo and was too weak to cause harm to Resident #33. ADMN stated that procedure for when incident of abuse occurs is was to ensure the resident was safe, the abuser was asked to leave immediately , and that a head to toe assessment was completed on the resident. The ADMN stated the head to toe assessment should be documented in -electronic record by the previous DON, who at that time told him she had documented everything. The ADMN looked in Resident # 33's electronic medial chart and was not able to locate any documentation of the incident or an assessment being completed. The ADMN stated the failure of incident not being documented or assessment being completed was that the DON did not follow thru with actions and that she had been terminated. Record review of Self-Reporting Protocols-Actual/Alleged Abuse revealed: DO the following: Assess residents who are unable to be interviewed for s/s of abuse, i.e bruising, skin tears, presence of fear, etc . Notify local Police if: Assault of a resident. Record review of policy titled Abuse/Neglect dated 3/29/2018 revealed: The resident has the right to be from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart Residents should not be subjected to abuse by anyone, including but not resident, family members . It is each individual's responsibility to recognize, report and promptly investigate actual abuse or alleged abuse . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse: Includes, hitting, slapping, pinching, and kicking.

Based on observation, interviews, and record review the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. Foods were not sealed and/or labeled properly in dry food storage, freezer, and refrigerators. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: In observation of kitchen on 10/10/2021 between 9:25AM and 11:00 AM with Dietary Manager(DM) the following was noted: Refrigerator #1 3 individual bowls with melon pieces in them was not labeled with date and were not sealed. Dry storage A plastic container that contained baking powder was not sealed, A plastic container that contained brown sugar was not sealed, A plastic container that contained flour was not sealed. A package of cheesecake batter in a plastic bag with a seal was not sealed. Freezer #1 A plastic bag containing frozen fish was not sealed Refrigerator #2 A disposable container containing a salad was not labeled or dated. During interview on 10/10/2021 at 9:25AM with DM , she stated that the container containing the baking powder was not sealed and that it should have been. DM stated that staff had used baking powder this morning to make rolls, so must have been in a hurry and didn't take time to close properly. During interview on 10/12/21 at 2:00 PM with DM, she stated that the failure to the items not being sealed and labeled was a lack of supervision on the weekends. DM stated that everyone was responsible for making sure items are labeled and sealed . During interview on 10/13/2021 at 1:57 PM with ADMN, he stated that the failure to the items not being sealed and labeled in kitchen was the lack of supervision on weekend shifts . Record review of the facility's policy Food Storage and Supplies dated 2012 revealed: Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled .Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.

Based on observation, interview, and record review, the facility failed to maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to Resident, consistent with the resident's comprehensive assessment; for 1 of 7 Residents (Resident #51) reviewed for weight loss. Resident #51 was care planned for total assistance during meals. The facility failed to implement interventions outlined in Resident #51 comprehensive assessment. Resident #51 had an unplanned 11.6% weight loss in six months This failure could place residents with an unplanned weight loss at risk of not maintaining their nutritional needs. The findings included: Review of Resident #51's electronic face sheet, revealed a 57 -year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 51's Minimum Data Set (MDS) dated [DATE] revealed: Revealed a Brief Interview for Mental Status (BIMS) of 0 (severe impairment). Record review of Resident #51's electronic chart revealed on 04/09/2021, Resident #51 weighed 219 lbs. and on 10/01/2021, the resident weighed 193.6 pounds which was a -11.60 % Loss. Record review Resident #51's Electronic Care Plan revised on 10/01/2021 revealed, EATING: The resident requires total assistance to eat . Record review of Resident #51's Electronic POC-Response revealed that between 9/29/21 and 10/11/21 CNA's charted they provided Supervision (oversight, encouragement or cueing) or Limited Assistance (Resident highly involved in activity; staff provide guided maneuvering of limbs or other not-weight-bearing assistance) for Resident #51 for breakfast, lunch and dinner. Observation on 10/12/21 at 7:56 AM, revealed Resident #51 alone in his room, sitting up in bed at 90 degree angle, with meal tray in reach and no staff assisting him eating. It appeared that Resident #51 had been feeding himself and had food on his shirt. During interview on 10/13/21 at 1:57 PM with the ADMN he stated he failure of care plan not being followed is a lack of communication between nurses and the CNAs. During interview on 10/13/21 at 3:15 PM with LVN 1 , she stated that residents who are supposed to be total assist with meals, should be set up in bed with a shirt protector, CNA or NA should be feeding them. LVN 1 state that a tray should not be left in room in front of resident. LVN 1 stated that CNAs documents in electronic chart. During interview on 10/13/21 at 3:22 PM with DON and Corporate Compliance nurse both stated that CNA should be feeding resident, if care planed for total assist. A CNA should not be leaving the resident with their tray on table. Record review of policy intitled Feeding, Assistive/Complete ,with revision date of February 14, 2007, revealed: Assistive or complete feeding and meals is provided to residents who have decreased appetite or unable to eat independently because of disabilities, confusion, weakness, or new neuromuscular disorders. The process of eating fulfills the basic nutritional needs and is a major factor in preventing illness and promoting Wellness. Dietary requirements and feeding needs should be incorporated into resident preferences, culture factors, illness, appetite, and functional abilities. The amount of assistance needed can vary or be temporary. The need can also be permanent As for those with paralysis or those who are sightless .Perform complete feeding; prepare the resident As for assistive feeding. Place a chair near the tray and sit facing the resident. Prepare the tray as for assistive feeding. Check the temperature of the food. Start with a small amount of food and wait before offering the next fight until the resident has chewed and swallowed the first bite . At the conclusion of the meal, allow the resident to wash their hands and face. Provide oral care. Remove the tray and note the amount of food and fluid ingested.

Based on observation, interview and record review, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases for four of four residents reviewed (Resident #1, #2, #3, and #4) for infection control practices, in that: The facility failed to ensure: 1. Visitor for Resident #4 was screened upon entrance into the facility for signs and symptoms related to COVID or his temperature was taken. 2. Physical Therapist A opened the door for Surveyor and did not ensure someone was at the desk to properly screen surveyor. 3. Staff utilized appropriate PPE for two residents on quarantine. 4. Soiled PPE was not overflowing and hanging from trash receptacles, paper towels were available at the hand washing sink, and housekeeping sanitized and provided cleaning services on the COVID unit daily These deficient practices could place all residents at risk for cross contamination and/or spread of infection including COVID 19. The findings were: Resident #1 Record review of Resident #1's electronic face sheet, dated 8/13/21, revealed Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's COVID vaccination status revealed he was unvaccinated. Record review of Resident #2's electronic face sheet, dated 8/13/21, revealed Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's COVID vaccination status revealed he was fully vaccinated on 3/23/21. Record review of Resident #3's electronic face sheet, dated 8/13/21, revealed Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's COVID vaccination status revealed she was fully vaccinated on 3/23/21. Record review of Resident #4's electronic face sheet, dated 8/13/21, revealed Resident #4 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's COVID vaccination status revealed she was unvaccinated. Observation on 8/12/21 at 12:23, Responsible Party for Resident #4 walked into the building, there was not anyone at the door to screen the Responsible Party for signs and symptoms of COVID. Observation of Responsible Party walked directly passed the front desk, where visitors are required to stop, and proceeded to walk onto the secure unit in the facility. In an interview with the Responsible Party of Resident #4, he stated that he knew the code to the door at the facility to let himself in. He said that there sometimes are staff to screen him when he comes through the door for signs and symptoms of COVID and sometimes there are not any staff. Responsible Party said that half the time, that electronic thermometer doesn't work anyhow. Upon entrance into the facility on [DATE] at 10:50am, the surveyor was let into the building by Physical Therapist A, who punched the key code in and opened the door. The surveyor entered the building and there was no staff present to perform a COVID screening on the surveyor. The surveyor remained at the doorway for 10 minutes and no one came to the door or front desk to greet the surveyor. The surveyor alerted the DON, that she had entered the building and needed to be screened for COVID. Record review of the facilities Front Door Shifts sign-up sheet for Friday 8/13/21 revealed sign up times every hour starting from 8:00a.m until 5:00p.m. and there was no one signed up between the hours of 11:00am -12:00pm; 2:00-4:00pm. In an interview on 8/13/21 at 11:31am, Physical Therapist A said she thought there was someone inside the door at the front desk to screen for covid symptoms. Physical Therapist A said that she should have made sure and looked inside to ensure someone was there to screen the surveyor and she did not. Observations on 8/13/21 at 1:56pm and 2:42pm revealed staff were not present at the front desk. Observation and record review on 8/13/21 at 11:14 am, revealed PPE supplies outside of Resident #1's room and signage that read, COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel .Acceptable Alternative PPE- Use Facemask .[had a figure of a person and identified what PPE was supposed to be worn] Face shield or goggles, facemask N95 or higher respiratory are preferred, but facemasks are an acceptable alternative, One Pair of clean non-sterile gloves, isolation gown .cdc.gov/COVID19. Observation on 8/12/21 at 11:15am revealed Occupational Therapist A in Resident #1's room without a face shield on and was in direct contact with Resident #1 for approximately 10 minutes. Observation on 8/12/21 at 11:17am revealed that there were not any face shields present in the PPE bins on Hall 600. In an interview on 8/12/21 at 11:18am, the ADON said that Resident #1 was on quarantine and staff were required to don a face shield, N95 mask, gloves and a gown prior to entering the room. The ADON verified that there were no face shields in the PPE bins or on Hall 600. The ADON said that she was not sure where the PPE is kept to replenish and she was not sure who was responsible for restocking the bins and made the remark I'm sure I am. Observation on 8/12/21 at 11:20am revealed Nurse Aide A failed to don a face shield prior to entering and providing direct patient care for Resident #2. In an interview on 8/12/21 at 11:25am, Nurse Aide A said that she forgot to put a face shield on prior to entering and providing care for Resident #2. In an interview on 8/12/21 at 11:28am, Occupational Therapist A said that she had donned a gown, gloves and face mask prior to entering Resident #1's room but there were no face masks in the PPE bin and had not been told a face shield was required. The occupational Therapist A said that the reason PPE is required is due to Resident #1 being a recent admission from the hospital and is on quarantine for 14 days because he is not vaccinated for COVID. Occupational Therapist A verified that there was signage posted at the door that identified what PPE was supposed to be donned prior to entering Resident #1's room, which included a face shield. Occupational Therapist A said that she should have asked a nurse for a face shield but did not ask today because she has asked several times in the past and the nurses state that they will have to go find one. Occupational Therapist A said she was not aware of where the PPE was stored and was not sure who restocks it, but it had been an ongoing battle to keep PPE stocked appropriately. On 8/12/21 at 12:38pm and again at 12:45pm, the DON said that for contact isolation a gown, gloves, eye protection and facemask was required for residents that were quarantined on Hall 600. The DON said that the staff member over Central Supply is responsible for restocking the PPE bins on the quarantine hall, however she was sick and not at the facility. The DON said that in the event the Central Supply staff are unable to restock the PPE, she was responsible and staff knew to call her and even if it is in the evening or on a weekend, she lived close by and could come up to restock. The DON said that the facility was not short on face shields and referenced that the facility had over 500 in inventory. The DON said she was not aware of any family members having the code to the door and letting themselves in. The DON said that all staff or visitors should be screened for covid upon entrance into the facility to ensure they are not symptomatic. The DON said that the purpose is to identify if someone has signs or symptoms of illness, specifically COVID and if they had symptoms or a temperature greater than 100 Fahrenheit, they would not be allowed to enter the facility. Observation on 8/12/21 at 3:15pm revealed PPE doffing trash receptacles had soiled gowns overflowing and hanging off the edge of the container, trash receptacles in the donning area had soiled PPE overflowing and hanging over the edge of the containers, no paper hand towels were stocked at the hand washing station. Resident #3 's room had trash and laundry receptacles that were overflowing out of the receptacles, there was a sticky substance on the floor in Resident #3's room. In an interview on 8/12/21 at 3:20pm, Resident #3 stated that she had not seen housekeeping providing services in a couple of days. In an interview on 8/12/21 at 3:50pm, Housekeeper A said that she has not cleaned the covid unit in two days. Housekeeper A said that she was told by nursing staff that housekeeping was not allowed on the COVID unit. In an interview on 8/12/21 at 3:55pm, Housekeeper B said that she was told by nursing staff, [unable to provide a nurse's name] to not clean, and that the COVID unit had not been cleaned in a couple of days. Housekeeper B said that all resident rooms and hallways should be cleaned daily to disinfect and prevent infection from spreading. In an interview on 8/13/21 at 1:37pm, the DON said that the responsible party of Resident #4 is not vaccinated, nor was Resident #4. The DON said she had contacted the housekeeping supervisor to find out where the break down is regarding housekeeping on the COVID unit and I assumed housekeeping was going on the COVID unit to clean and was unaware nursing staff, uncertain who that was, told them not to go. The DON said that she had no idea the COVID unit had not been cleaned for two days, however Housekeeper A did go onto the unit late yesterday afternoon (8/12/21) and cleaned the COVID unit right before her shift ended. The DON said that the importance of cleaning daily on the COVID unit is to keep a clean, sanitary environment. If it is not cleaned, it could spread infection, specifically COVID. In an interview on 8/13/21 at 3:20pm, the Regional Nurse said that there had been dedicated staff stationed at the door until a short time ago, and that the facility owners felt that it was not necessary to have dedicated staff any longer at the door that there were enough staff to monitor and be able to watch the door for visitors and staff that enter to conduct the required screening. Record review of the facility's policy entitled, Infection Prevention and Control, Screening and Hosting Visitors During a Pandemic dated 4/20/21, revealed the following: Screening .Visitors are to be educated on the importance of: self-monitoring for signs and symptoms of covid-19, or other communicable disease at home and notify facility of positive test results within 10 days of visit. Health screening is provided at point-of-entry to the facility and must be completed prior to visit .All those who are permitted to enter the facility must complete questionnaire and pass the health screening: Anyone with symptoms of respiratory infection (fever, cough, shortness of breath, and/or sore throat) will not be permitted to enter the facility at any time. If one begins to exhibit symptoms during session, will be immediately escorted out of the facility . Record review of the facility's policy entitled, PPE Use When Positive COVID Residents are in the Facility, undated, revealed the following: Residents with unknown status (warm zone) All staff must wear N95 or KN95 face shield or eye protection, gown, change gloves, gown and perform hand hygiene before and after each resident interaction. You can continue to wear the same mask and face shield/eye protection, you must change any PPE if it becomes soiled. Record review of the facility's policy entitled, Infection Control Plan, dated 2018, revealed the following: Overview .Infection Control The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection 9. Routine and terminal cleaning .1. The room and bedside equipment of residents on standard precautions is cleaned and disinfected with an approved cleaning agent. 2. In addition to through cleaning, adequate disinfection of bedside equipment and environmental surfaces (e.g., bed rails, bedside tables, carts, commodes, doorknobs, faucets, handles) if indicated for certain pathogens, especially enterococci, that can survive as a fomite for prolonged periods of time .

Based on interview and record review the facility failed to inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of single confirmed infection of COVID-19 when 1 of 1 staff reviewed (occupational therapist) was diagnosed positive for COVID-19. Occupational Therapist was diagnosed positive for COVID-19 on 8/2/2021 and the facility did not inform residents or their representatives of the confirmed infection by 5 p.m. the next calendar day. This failure could place residents and their representatives at risk for not being aware of the presence of COVID-19 in the community and at risk for infections. The findings were: On 8/12/21 at 12:38am, the Director of Nurses (DON) stated that Occupational Therapist A had contacted the facility and reported on 8/2/21 that she was symptomatic for COVID. The DON said that she directed the Occupational Therapist A to come to the facility but remain in her car to be tested . On 8/2/21, it was confirmed that Occupational Therapist A had a confirmed positive COVID-19 rapid POC test. The DON said there were currently 3 staff members out with confirmed positive cases and 3 residents on the COVID unit with confirmed cases. In an interview on 8/13/21 at 2:44pm, LVN B said she is notified of positive COVID cases when she comes to work. In an interview on 8/13/21 at 2:45pm, RN A said she is not notified by phones, email or text regarding new confirmed positive COVID cases at the facility. RN A said the only way she is notified is if she comes to work and they tell her then. In an interview on 8/13/21 at 2:46pm, Nurse Aide B said the only way she knew there was a new confirmed case of COVID in the facility was when she comes in for her shift to work and usually is told by the person that screens her. In an interview on 8/13/21 at 2:52pm, the Responsible Party for Resident #4 stated I don't get notified when asked if the facility had contacted him regarding confirmed COVID positive case in the facility on 8/2/21. In an interview on 8/13/21 at 3:43pm, the Responsible Party for Resident #3 stated that he was notified of Resident #3's positive COVID test results, however he was not notified any other time regarding positive COVID cases in the facility. In an interview on 8/13/21 at 2:54pm, the Social Worker said that she did not remember until just recently that we [the facility] were required to notify family members and staff when there is a confirmed positive case of COVID in the building. The Social Worker said that it had been a while since their last outbreak. The Social Worker stated that she and three other employees did conduct phone calls to resident's responsible parties yesterday to notify them regarding the confirmed positive COVID case from 8/2/21. Review of the tracking log for confirmed positive cases, Occupational Therapist A had a COVID test conducted on 8/2/2021 with a positive result. The facility could not produce a facility specific document on notification to residents, their representatives, and families of those residing in facilities of by 5 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19 when requested of administrator on 10/18/2020 at 1:32pm. Review of facility COVID Response Plan document titled Emergency Preparedness Plan dated 06/09/2021 revealed: 17. Inform residents, their representatives, and families of those residing in facilities by 1700 (5:00pm) the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents and/or HCP with new onset of respiratory symptoms occurring within 72 hours of each other. A. cumulative updates will be provided weekly, Wednesday at 1700 (5:00pm) on facilities website . Communication: In an outbreak, residents' families are likely to want current information on resident status.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #2) of five residents reviewed for medications. LVN C failed to administer [MEDICATION NAME] to the correct resident, Resident #3, as ordered by physician. Instead, LVN C administered the [MEDICATION NAME] to Resident #2, resulting in a drop in the resident's blood pressure and transfer to the hospital emergency room . The failure could affect the 34 residents who resided on 400, 500 and 600 Halls where LVN C administered medications by placing them at risk for receiving medications that were not ordered for them, not receiving therapeutic dosages of their medications, decreased circulation, altered mental status. Findings included: Review of Resident #2's MDS assessment, dated 06/20/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE] for rehabilitation following a fractured femur. The resident had a [DIAGNOSES REDACTED]. Review of the facility's Provider Investigation Report submitted 06/20/17 revealed LVN C had administered Resident #3's [MEDICATION NAME] 800 mg to Resident #2 on 06/20/17, which resulted in Resident #2 being transferred to the hospital emergency room for evaluation. Review of Resident #3's face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a witness statement by LVN C revealed she had administered [MEDICATION NAME] 800 mg to Resident #2, at approximately 8:00 p.m., in error. She had told the resident the medication was an anti-depressant and when the resident's daughter arrived at 9:30 p.m., she had asked the nurse why her mother was taking an antidepressant. LVN C reviewed the MAR and realized she had administered the medication to the wrong resident. The resident's vital signs upon admission were blood pressure 122/54, heart rate 91, respirations 20, oxygen saturation level 96%. The resident was transferred to the hospital emergency room for evaluation on 06/20/17 at 10:20 p.m. Vital signs assessed at the time of transfer were blood pressure 96/50, heart rate 100, respirations 20, oxygen saturation level 96%. Review of the hospital emergency room record dated 06/20/17 revealed Resident #2 arrived in the emergency roiagnom on [DATE] at 10:23 p.m. She was alert and oriented and in no acute distress. Vital signs were assessed as normal, with a blood pressure of 100/55, heart rate 93, respirations were 20, oxygen saturation was 96%, her temperature was 97.1F. She was found to be in [MEDICAL CONDITION] with an uncontrolled rate for which a [MEDICATION NAME] drip was initiated. A chest x-ray revealed right lower lobe pneumonia for which she received [MEDICATION NAME] antibiotic. She was administered activated charcoal at 3:37 a.m. to assist in removal of the [MEDICATION NAME] from her body. The resident was admitted for observation in the intensive care unit in stable condition at 3:37 a.m. Review of Resident #2's admission orders [REDACTED]. Review of Resident #3's admission orders [REDACTED]. The Wolters Kluwer Nursing 2015 Drug Handbook, pages 1203-1206, reflected [MEDICATION NAME] (quetiapine [MEDICATION NAME]) was an antipsychotic drug used for treatment of [REDACTED]. An interview with LVN C on 07/05/15 at 1:34 p.m. revealed she worked the 6:30 p.m. to 6:30 a.m. shift on Halls 400, 500 and 600. She stated on 06/20/17, both Resident #2 and Resident #3 were admitted and placed in the same room. Both residents' MARs were on top of each other on the medication cart. She stated when she looked at the MAR that was uppermost, Resident #3's, she saw an order for [REDACTED]. She looked at what she thought was the bottom of the same MAR, and saw Resident #2's name on the MAR beneath. She stated she administered the medication from the facility's emergency kit. She stated she realized the error later that night when she checked Resident #2's MAR after the resident's daughter had asked why the resident had been administered [MEDICATION NAME]. The physician was notified and the resident was transferred to the emergency room for evaluation. LVN C stated her employment was terminated following the error. An interview with the ADON on 07/05/17 at 8:59 a.m. revealed all of the facility's LVNs received an in-service on the five rights of medication administration after the medication error on 06/20/17. Review of the facility's current Medication Administration Procedures policy and procedure, dated 2003, revealed the following: .Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered Medications prescribed for one resident are not to be administered to any other resident. Review of the facility's current Medication Recording Procedure, dated 2003, revealed the following: .Upon receiving a new punch card (blister pack) .it is critical that each punch card is carefully checked for correct medication, labeling and dosage times Always check the medication charting record against the information on the medication label. This is a professional double check of what the pharmacist has dispensed . Review of the Resident List Report dated 07/05/17 revealed the 400, 500 and 600 Hall, where LVN C worked, had a census of 34 residents.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of two (Residents #1 and Resident #2) of five residents reviewed for pharmacy services. 1. LVN C failed to administer Seroquel to the correct resident, Resident #3, as ordered by physician. Instead, LVN C administered the Seroquel to Resident #2, resulting in a drop in the resident's blood pressure and transfer to the emergency room . 2. LVN A failed to administer Coreg to Resident #1 as physician ordered. 3. LVN A failed to clarify the physician's orders [REDACTED].#1's Lidocaine patch. These failures could affect the 34 residents who resided on 400, 500 and 600 Halls where LVN A and LVN C administered medications by placing them at risk for receiving medications that were not ordered for them, not receiving therapeutic dosages of their medications, decreased circulation, altered mental status and death. Findings included: 1. Review of Resident #2's MDS assessment, dated 06/20/17, revealed she was a [AGE] year-old female admitted to the facility on [DATE] for rehabilitation following a fractured femur. The resident had a [DIAGNOSES REDACTED]. Review of the facility's Provider Investigation Report submitted 06/20/17 revealed LVN C had administered Resident #3's Seroquel 800 mg to Resident #2 on 06/20/17, which resulted in Resident #2 being transferred to the hospital emergency room for evaluation. Review of Resident #3's face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a witness statement by LVN C revealed she had administered Seroquel 800 mg to Resident #2, at approximately 8:00 p.m., in error. She had told the resident the medication was an anti-depressant and when the resident's daughter arrived at 9:30 p.m., she had asked the nurse why her mother was taking an antidepressant. LVN C reviewed the MAR and realized she had administered the medication to the wrong resident. The resident's vital signs upon admission were blood pressure 122/54, heart rate 91, respirations 20, oxygen saturation level 96%. The resident was transferred to the hospital emergency room for evaluation on 06/20/17 at 10:20 p.m. Vital signs assessed at the time of transfer were blood pressure 96/50, heart rate 100, respirations 20, oxygen saturation level 96%. Review of the hospital emergency room record dated 06/20/17 revealed Resident #2 arrived in the emergency roiagnom on [DATE] at 10:23 p.m. She was alert and oriented and in no acute distress. Vital signs were assessed as normal, with a blood pressure of 100/55, heart rate 93, respirations were 20, oxygen saturation was 96%, her temperature was 97.1F. She was found to be in [DIAGNOSES REDACTED]with an uncontrolled rate for which a Cardizem drip was initiated. A chest x-ray revealed right lower lobe pneumonia for which she received Levaquin antibiotic. She was administered activated charcoal at 3:37 a.m. to assist in removal of the Seroquel from her body. The resident was admitted for observation in the intensive care unit in stable condition at 3:37 a.m. Review of Resident #2's admission orders [REDACTED]. Review of Resident #3's admission orders [REDACTED]. The Wolters Kluwer Nursing 2015 Drug Handbook, pages 1203-1206, reflected Seroquel (quetiapine fumarate) was an antipsychotic drug used for treatment of [REDACTED]. An interview with LVN C on 07/05/15 at 1:34 p.m. revealed she worked the 6:30 p.m. to 6:30 a.m. shift on Halls 400, 500 and 600. She stated on 06/20/17, both Resident #2 and Resident #3 were admitted and placed in the same room. Both residents' MARs were on top of each other on the medication cart. She stated when she looked at the MAR that was uppermost, Resident #3's, she saw an order for [REDACTED]. She looked at what she thought was the bottom of the same MAR, and saw Resident #2's name on the MAR beneath. She stated she administered the medication from the facility's emergency kit. She stated she realized the error later that night when she checked Resident #2's MAR after the resident's daughter had asked why the resident had been administered Seroquel. The physician was notified and the resident was transferred to the emergency room for evaluation. LVN C stated her employment was terminated following the error. 2. An observation the medication pass with LVN A on 07/05/17 at 8:35 a.m. revealed she did not administer Resident #1's Coreg (heart and blood pressure medication). An interview with LVN A at the time of the medication pass revealed the Coreg was not available because they had run out it. She stated she would reorder the Coreg, and it would be delivered by the pharmacy between midnight and 2:00 a.m. During the medication pass, LVN A removed a Lidocaine 5% patch from Resident #1's foot and immediately replaced it with a new patch. Review of Resident #1's admission orders [REDACTED]. Review of Resident #1's July 2017 MAR revealed, Lidocaine Patch 5% Apply to right foot topically one time a day for pain and remove per schedule. Removal of the patch was scheduled for 8:59 a.m. and application was to be at 9:00 a.m. An observation of the Lidocaine patch medication pharmacy label revealed: Apply one patch to affected area once daily for 12 hours on, 12 hours off. An interview with LVN A on 07/05/17 at 8:40 a.m. revealed she had not realized the order on the medication label was different from the MAR order. Review of Resident #1's July 2017 MAR revealed the 9:00 a.m. scheduled dose of Coreg was not administered on 07/05/17, as of 3:00 p.m. Lidocaine Patch 5% Apply to right foot topically one time a day for pain and remove per schedule. Removal of the patch was scheduled for 8:59 a.m. and Application was to be at 09:00 a.m. An interview with the ADON on 07/05/17 at 2:02 p.m. revealed Coreg was available in the facility's emergency medication kit and LVN A should have given Resident #1's 9:00 a.m. dose from the emergency kit. She stated the LVNs were responsible for ensuring the physician's orders [REDACTED]. Information on the Lidoderm Transdermal Patch, obtained on 07/10/17 from https://medlineplus.gov/druginfo/meds/a 6.html, reflected: Your doctor will tell you how many lidocaine patches you may use at one time and the length of time you may wear the patches. Never apply more than three patches at one time, and never wear patches for more than 12 hours per day. Using too many patches or leaving patches on for too long may cause serious side effects. An interview with the ADON on 07/05/17 at 8:59 a.m. revealed all of the facility's LVNs received an in-service on the five rights of medication administration after the medication error on 06/20/17. Review of the facility's current Medication Administration Procedures policy and procedure, dated 2003, revealed the following: .Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered Medications prescribed for one resident are not to be administered to any other resident. Review of the facility's current Medication Recording Procedure, dated 2003, revealed the following: .Upon receiving a new punch card (blister pack) .it is critical that each punch card is carefully checked for correct medication, labeling and dosage times Always check the medication charting record against the information on the medication label. This is a professional double check of what the pharmacist has dispensed . Review of the Resident List Report, dated 07/05/17, revealed the 400, 500 and 600 Hall, where LVN A and LVN C worked, had a census of 34 residents.

Based on observation, interview and record review, it was determined the facility failed to train six (CNA C, CNA D, CNA F, CNA I, LVN H, and LVN G) of 59 nursing staff in emergency procedures, related to the specific evacuation needs of one (Resident #1) of one resident, and periodically review the procedures with those staff. The facility failed to train staff on the East Wing of the facility how to evacuate Resident #1. An Immediate Jeopardy (IJ) was identified on 05/21/15. While the IJ was removed on 05/22/15, the facility remained out of compliance at the severity level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern", due to the facility still monitoring the effectiveness of the Plan of Removal. The failure to train all staff on facility procedures for evacuating Resident #1, who was the only resident in a bariatric bed, in an emergency could result in Resident #1 suffering a severe injury and/or death. Findings included: Resident #1's MDS assessment, dated 02/16/15, reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE] with a readmission on 03/20/15 with [DIAGNOSES REDACTED]. Resident #1 had moderately impaired cognitive skills with verbal behavioral symptoms that were directed towards others. The resident required extensive assistance with bed mobility and extensive assistance with transfers and locomotion. The resident had functional limitations in range of motion to both his upper and lower extremity on one side, and he required the use of a wheelchair for mobility. The resident's height was 72 inches (six feet), and he weighed 332 pounds. An interview on 05/21/15 at 10:15 a.m. with CNA B revealed all of the residents were moved out of their rooms and into the hallway, during a tornado warning that was issued prior to the warning on 05/19/15. She stated the staff were unable to move Resident #1 out in the hall so they pushed his bed as far away from the window as possible and propped mattresses against the window in his room. CNA B was asked what would happen with Resident #1 if there was a fire, and she stated, "I don't know." An observation on 05/21/15 at 10:20 a.m. of Resident #1 revealed the resident lying in a bariatric bed. The resident was alert, awake, and in no distress. Resident #1 was asked what happened during the tornado warning on 05/19/15, and he stated staff pushed his bed to the wall on the opposite side of the window in his room. The National Weather Service Weather Forecast Office released the following information, which was retrieved on 05/28/15 at http://www.srh.noaa.gov/fwd/?n=tornadoes 5: There were two tornadoes in Mineral Wells on 05/19/15. The first tornado started at 7:23 p.m. with up to 65 mile per hour winds, and the second tornado started at 7:29 p.m. with 110 mile per hour winds. The facility's current Emergency Procedure Binder reflected the following undated evacuation plan developed for Resident #1: "Plan B... ...An extension cord will be located at: North wall outside his room ...In case of the evacuation and the resident is in the bed, staff will perform the following actions: Alter the bed by: Moving extender rails in. Will allow bed to be moved out the door." " Plan C... The resident's bed will not fit through the room door, therefore, this resident will be safely evacuated by the following process: - Staff will use a lift and transfer the resident to a wheel chair or geri chair - The resident will then be wheeled in the chair to the closest available exit or safe area." The facility's current undated Tornado Policy and Procedure reflected: " Tornado Warning Procedures: 1. Move residents into the hallways, closets and away from windows. Close all resident room doors...." An interview on 05/21/15 at 10:39 a.m. with CNA C revealed Resident #1's bed would be lowered in the event of an emergency. Then, the staff would pull the mattress and resident through the door into the hallway. CNA C stated it had been several months since evacuation procedures had been discussed at the facility. CNA C stated if there was no time to use the Hoyer lift, Resident #1's bed could be pushed to the wall farthest from his window. An interview on 05/21/15 at 10:29 a.m. with CNA D revealed Resident #1 previously resided on the West Wing. She stated the staff, who worked the West Wing, had been in-serviced on evacuation procedures for Resident #1. However, Resident #1 was moved to the 100 Hall on the East Wing, and the staff on the East Wing had not received an in-service on evacuation procedures for the resident. CNA D stated Resident #1 refused to be transferred via Hoyer lift and evacuate from his room during a tornado alert two weeks earlier. She stated the resident's bed was pushed to the wall opposite his window and mattresses placed against the window. An interview on 05/21/15 at 10:54 a.m. with the Maintenance Supervisor, who was responsible for emergency evacuation training, revealed Resident #1's bed could be modified by collapsing the extenders and removing the footboard and side rail. The Maintenance Supervisor explained this would allow the bed to be pushed through the door. If this was not possible, he stated the resident could be Hoyer lifted and moved to the hall, or he could be lowered to the floor and pulled out of the room on a sheet. When asked if staff had been in-serviced on these options, the Maintenance Supervisor stated all staff had been in-serviced last summer in 2014. The Maintenance Supervisor revealed the protocol during tornados was to move residents to the center of the building and out of rooms. He stated he did not know what happened to Resident #1 on 05/19/15 because he was not at the facility during the event. The Maintenance Supervisor provided documentation of an in-service dated July 2014 entitled, "To Collapse Bed power bed Harness". An interview on 05/21/15 at 11:04 a.m. with LVN E revealed she knew Resident #1's bed collapsed and the foot board could be removed. LVN E stated a second option was to transfer him via Hoyer lift from the room or a final option was to lower Resident #1 to the floor on a sheet and pull him from the room. LVN E stated two weeks ago Resident #1 refused to be moved out into the hall during a tornado warning. She stated the resident's bed was moved across the room from the window, and a mattress was pushed against the window. An interview on 05/21/15 at 11:21 a.m. with LVN H revealed she was present during the tornado on 05/19/15. She stated she went to Resident #1's room to ensure his blinds were shut, and he was as close to his door as possible. LVN H stated Resident #1's bed would not break down. She stated staff could have taken the resident out of bed, but he was complaining. LVN H then clarified she was unsure if the resident's bed could be broken down or if the staff present did not try to break down the bed. LVN H stated the staff had been in-serviced on how to break down Resident #1's bed, and staff would most likely not have time to Hoyer lift Resident #1 in the event of a fire. LVN H stated staff would have to "fireman lift" (sheet sling method) Resident #1, although they did not use this method during the tornado warning. LVN H stated Resident #1 would probably scream if staff tried to move him, but the staff should have removed Resident #1 from the room. LVN H also stated the facility had the weather radio on during the storm. She stated they were aware the tornado was approaching, and the path it was taking towards the facility. An interview on 05/21/15 at 11:39 AM with LVN G revealed she worked on the East Wing of the building which consisted of Halls 100, 200 and 300. LVN G stated Resident #1 required a Hoyer lift to transfer, and the resident was adamant about not getting into the Hoyer lift because it hurt. She explained that there was a compromise with Resident #1, during the tornado warning, that the curtain would be pulled as a barrier, and his bed would be pushed as close to the door as possible. LVN G stated she performed frequent checks on Resident #1 during the warning. LVN G stated she did not believe Resident #1's bed would fit through the door because it was too wide. She stated the staff did not attempt to collapse the bed during the tornado warning on 05/19/15. LVN G stated she had never been in-serviced on how to collapse the bed or specific emergency procedures regarding Resident #1. She stated she had been employed by the facility for two years. LVN G stated, in the event of a fire, Resident #1 would be Hoyer lifted or pulled out using a sheet. An interview on 05/21/15 at 11:52 a.m. with CNA I revealed she was not working on the evening of the tornado. In the event of an emergency, she stated she would utilize the Hoyer lift to evacuate Resident #1 from his room as fast as possible. CNA I stated another option for evacuating Resident #1 would be to pull him out using a sheet and at least two to three strong staff. CNA I stated she was not sure if Resident #1's bed would fit through the door, but she assumed it would as it was able to get into the room. CNA I stated she had never been trained on collapsing Resident #1's bed. CNA I stated, if Resident #1's bed fit through the door, the staff could move him into the hall if there was a tornado, but she had not dealt with that situation. An interview on 05/21/15 at 12:38 p.m. with CNA F revealed she was working on the 100 hall where Resident #1 resided on 05/19/15. Most residents were in the hallways during the tornado warning. She stated Resident #1's bed was pushed to the door (opposite the window). CNA F was asked what she would do in regards to Resident #1 in the event of a fire. She stated she would break the resident's the bed down or use the Hoyer lift to get him out of the room. She stated she was shown how to modify the resident's bed on 05/21/15. CNA F said, "I was never in-serviced on emergency evacuation for Resident #1. I was part-time until I went full time in October 2014." An IJ was identified on 05/21/15. The Administrator and DON were informed of the IJ on 05/21/15 at 12:45 p.m. A Plan of Removal was requested at that time. The facility's Plan of Removal, accepted on 05/21/15 at 7:37 p.m., reflected the following: a. All staff would be in-serviced on the proper procedure of breaking the bariatric bed down to a size that could be moved through the door of Resident #1's room in the event of an evacuation. b. Return demonstration of the bed breakdown. c. In-service on the location of the extension cord placement in the room for emergency power. d. Binder placement in the room with instructions on how to break down the bed and in-service on the binder placement on 05/21/15. e. Administrator and DON would be in-serviced by the Corporate Nurse on 05/21/15 regarding conducting a meeting the day after an evacuation procedure had been initiated by staff, identifying additional educational needs for staff, and evaluating safety procedures to validate their accuracy. f. All facility beds were checked by the Administrator and Maintenance Director to ensure all other facility beds would fit through the room doors without adjustment. g. Staff not in-serviced by 05/21/15 would not assume their duties until in-serviced by the DON, ADON, or Administrator. An interview on 05/21/15 at 4:12 p.m. with the DON revealed demonstrations were being completed with Resident #1's bed after requesting his permission. The DON stated there were two residents in the facility that preferred to stay in bed, but were not bedfast. The DON said there were no permanently bedfast residents in the facility. The DON also indicated there were no other bariatric residents in the facility. An interview on 05/22/15 at 12:03 p.m. with the Administrator revealed before the tornado, he did not believe there was an issue with the emergency preparedness system that was in place. The Administrator said in-servicing would be taking place monthly and new employees would be trained regarding emergency preparedness to prevent the issue from reoccurring. The Administrator said bariatric patients would be a focus during the emergency preparedness training. The Administrator also said all staff would be updated on Hoyer lift transfers in an upcoming in-service. He stated that he and the DON would be performing spot checks on all staff to ensure compliance with expectations regarding the emergency preparedness training. The Administrator said the Quality Assurance committee would be monitoring with a check-off questionnaire for staff and making sure the facility was within its 100 percent compliance on all training. An interview on 05/22/15 at 12:13 p.m. with the DON revealed she felt the evacuation procedures within the facility were good prior to the identification of the immediate jeopardy. The DON said the changes after the IJ identification were about re-education. The DON said she and the Administrator were in-servicing and conducting spot checks, and would then be performing Quality Assurance to determine if the spot checks were working. The DON said all new employees would also be receiving training on emergency procedures and bariatric residents. The DON stated an in-service on lift and transfers would be conducted to also include bariatric residents. The DON said she would also be ensuring all staff was aware two people would be needed to do a Hoyer transfer, regardless if the situation was an emergency. The DON said Resident #1's behaviors were well documented and Care Planned as his history included being in five different facilities and on the verge of a 30-day notice at the current facility because of those behaviors. An observation on 05/22/15 at 7:35 a.m. of Resident #1 revealed CNA AA, CNA I, and CNA BB transferred the resident from his bed to his wheelchair via Hoyer lift. Resident #1 was alert, oriented and in no distress. The transfer was performed using correct technique. After Resident #1 was taken to [MEDICAL TREATMENT], CNA Z, CNA I, and CNA AA were asked to demonstrate how the bariatric bed could be modified to fit through the door. Bed extenders were pushed in, the footboard was removed, the side rail was removed and the bed was successfully pushed through the door into the hallway. Review of two in-service training reports, dated 05/21/15, reflected the titles: Evacuation of Bariatric Residents and Location of Bed Manual, Sling and Plan for Emergency Evacuation. In-services were taught by the Maintenance Director and the Corporate Nurse. Sign in sheets reflected 47 participants for Evacuation of Bariatric Residents in-service and 44 participants for the Location of Bed Manual, Sling, and Plan for Emergency in-service. Review of return demonstration forms, dated 05/21/15, showed participation of 48 staff in a return demonstration of bariatric bed removal. This demonstration required staff to modify the bariatric bed and move it through the door of the resident's room. An interview on 05/22/15 at 11:15 a.m. with the DON revealed no staff would be allowed to return to work without demonstrating knowledge of the evacuation procedures for bariatric residents. New employees would be trained in evacuation of bariatric residents in orientation. Beginning on 05/22/15 at 9:18 a.m. through 05/22/15 through 1:59 p.m., interviews were conducted and demonstrations of modifying a bariatric bed were conducted with 21 staff members: LVN G, Maintenance Supervisor, MA J, LVN H, CNA K, CNA L, LVN M, CNA N, LVN Q, ADON, CNA P, LVN Q, Restorative Aide R, LVN S, LVN T, CNA U, LVN V, the DON, LVN W, Dietary Manager, and CNA Z. They revealed they had attended and participated in the in-service training on 05/21/15. They knew the options available to evacuate a bariatric resident. They were able to properly demonstrate the modification of the bariatric bed within four to five minutes. All were familiar with Hoyer transfer techniques. Review of a newly developed Care Plan for Resident #1, dated 05/21/15, listed interventions: Staff will follow facility's evacuation plan (A then B) as follows: A. Resident will be Hoyer lifted to his wheelchair and taken to the appropriate area. B. Resident's bariatric bed will pushed in at the sides and the entire bed with the resident in it will be wheeled in the appropriate areas. Review of a Kardex Report for Resident #1 was also provided, listing a category for safety. It lists the two options for evacuation, Hoyer lift and bed modification. An interview on 05/22/15 at 1:00 p.m. with the Medical Director revealed he was notified of the IJ on 05/21/15. He was aware of the policy and procedure for evacuation of bariatric residents and stated it would be discussed in Quality Assurance Meetings in the future. The Medical Director stated he felt the resident resisted moving, but residents must be evacuated for their own safety. The Medical Director also stated if the resident was unable to cooperate with facility policies, the facility may not be able to meet his needs. An interview on 05/22/15 at 2:36 p.m. with the family of Resident #1 revealed the resident had a history of [REDACTED]. Training and demonstration of the modification of Resident #1's bariatric bed was continued through 05/22/15. An interview on 05/22/15 at 3:17 p.m. with the DON revealed 66 staff had completed in-services and demonstrations. The remaining third shift and PRN staff would be in-serviced during the weekend until all staff had completed the training. The IJ was removed on 05/22/15. On 05/22/15 at 4:14 p.m., the Administrator and DON were notified the IJ was removed. While the IJ was removed, the facility remained out of compliance at a severity level of "potential for harm", and a scope of "pattern" because the facility was still in-servicing staff an monitoring the effectiveness of the Plan of Removal. The facility's current, undated employee roster, provided to the survey team on 05/20/15, reflected the facility had 59 direct care nursing staff to include CNAs, LVNs, RNs, and MAs.

Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers, and a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing for three (Residents #5, #7 and #8) of four residents reviewed for pressure ulcers. The facility failed to: 1) Prevent the development of new pressure ulcers for Residents #5, #7, and #8; 2) Promptly identify new pressure ulcer development for Resident #7; 3) Procure pressure relieving devices/equipment for Residents #7 and #5; and 4) Secure prompt medical treatment for [REDACTED].#7 and #8. Resident #7 did not have a pressure relieving mattress. Resident #7 also did not have a pressure relieving cushion which stopped the resident from leaning in her wheelchair. Resident #7 developed a Stage II gluteal fold pressure ulcer on 04/25/2012 which worsened to a Stage III tunneling pressure ulcer on 06/06/12. The Stage III tunneling pressure ulcer was identified after surveyor inquiry on 06/06/12. Resident #7 also developed a Stage II pressure ulcer on the mid right buttocks on 04/25/12. Resident #8 developed a pressure ulcer with suspected deep tissue injury on her right heel. The facility was not off-loading the pressure from the heel and the resident was wearing a shoe that placed pressure on the heel This resident had a [DIAGNOSES REDACTED]. Resident #5 did not have a pressure relieving mattress or a pressure relieving cushion his wheelchair. Resident #5 developed a Stage II pressure ulcer on his coccyx, a pressure ulcer with suspected deep tissue injury to the end of his left great toe, and an unstageable pressure ulcer of the end of his left third toe with suspected deep tissue injury. These failures resulted likely caused the development or worsening of pressure ulcers to Residents #5, #7, and #8 and could affect the 32 resident who were in their chairs all or most of the time and the six resident with current pressure ulcers. Findings included: 1) Review of Resident #7's MDS assessment dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During initial tour rounds on 06/04/12 at 10:59 AM with LVN A, Resident #7 was observed sitting in her electric wheelchair in her room. LVN A described Resident #7 as alert and oriented to person, place and time, able to transfer herself from the bed to the wheelchair and back with the assistance of one person. LVN A stated Resident #7 also needed the assistance of one for bathing/toileting and the resident was able to feed herself. LVN A reported the resident had developed a Stage III pressure ulcer on the right gluteal fold, and a Stage II on the right mid buttocks while at the facility. The resident was observed not to have a pressure relieving mattress on her bed or a pressure relieving cushion for her electric wheelchair. The surveyor observed the chair-part of the electric wheelchair leaned to the left. During an interview at 4:30 PM on 06/04/12, Resident #7 was sitting in her electric wheelchair leaning to the right, placing pressure on the right side of her buttocks. When queried about the wheelchair, she stated her chair had been broken and leaning to the left side for two years. The resident stated no one had been to repair her wheelchair. When asked if she could use a regular wheelchair until her electric wheelchair was repaired, she replied, "No, not with my [MEDICAL CONDITION]." On 06/04/12 at 3:15 PM, LVN A was observed providing wound care to Resident #7. A dressing dated 06/02/12 was removed from the right upper buttocks and revealed a Stage II pressure ulcer approximately 0.5 X 0.5 cm in diameter. LVN A cleaned the pressure ulcer and applied a [MEDICATION NAME] dressing. During the dressing change, a Stage I pressure ulcer approximately 6 X 8 cm was newly identified on Resident #7's right hip, approximately 5 cm from the previous Stage II pressure ulcer. Within the center of the Stage I pressure ulcer was a dime sized white, non-blanching area. LVN A removed her soiled gloves, washed and hands, and donned a fresh pair of glove. She then removed a soiled dressing, dated 06/04/12, from a Stage III pressure ulcer on the resident's right gluteal fold (lower buttock's crease). LVN A revealed the Stage III pressure ulcer had tunneling approximately 0.5 cm deep. LVN A cleaned the wound and then while wearing her contaminated gloves, LVN A brushed her hair back with her gloved hand. Without washing her hands and/or changing her gloves, LVN A cleaned the Stage III pressure ulcer. LVN A noted another reddened area measuring approximately four cm in diameter over the resident's bony prominence of the right hip. LVN A removed her gloves and left the room to retrieve more supplies without washing her hands. Upon returning to the room, LVN A put on a clean pair of gloves without first performing hand hygiene. LVN A preceded to to pack the Stage III pressure ulcer with a Calcium Alginate dressing. She covered the pressure ulcer with a gauze dressing, removed her gloves and washed her hands. LVN A re-gloved and preceded to perform wound care to Resident #7's pressure ulcer on her left ankle. The old dressing, dated 06/04/12, was removed and the area cleaned, TAO applied, and a fresh gauze dressing applied. While the resident was turned to the right side, a reddened area, Stage I, was observed on the resident's left hip measuring approximately 5 X 6 cm. LVN A revealed Resident #7 did not have a history of pressure ulcers. In response, Resident #7 stated, "I came in with that one on my ankle." During the wound care, LVN A was observed to brush her hair back with her gloved hands, three times. Review of Resident #7's Skin Assessment Flow Sheet - Pressure Ulcer revealed on 04/25/12, the resident had a Stage II pressure ulcer on her right gluteal fold measuring 1.5 x 1.5 X <0.2 cm. On 05/09/12, the pressure ulcer had increased in size to 2.0 X 2.5 X 0.1 cm. On 05/09/12, the nurse documented, "pink granulation but bigger." (Note: Current the pressure ulcer is a Stage III with tunneling) Observation of Resident #7's Stage III pressure ulcer located on her right gluteal fold was measured by LVN A on 06/05/12 in the presence of the surveyor. The measurements were 1.7 X 1.4 cm and the tunneling was measured to be 1.6 cm deep. The Skin Assessment Flow Sheet - Pressure Ulcer revealed on 04/25/12 the resident had an unstageable pressure ulcer on her right buttock, measuring 1 X 1 cm. On 05/09/12, the pressure ulcer was identified as a Stage II, measuring 1 X 0.7 cm. On 06/05/12 at approximately 10:00 AM, LVN A was observed preparing for Resident #7's pressure ulcer dressing change. LVN A gathered all the materials needed for the dressing change, opened the packages of dressings and placed the sterile dressings on a clean butcher paper surface on top of the treatment chart in the hallway. LVN A was then paged to the East Nursing Station Desk for a telephone call. She left the opened dressings uncovered on top of the treatment cart in the hallway. Three residents were observed to pass by touching the cart. Flies were observed flying around the open dressing and the surveyors fanned the flies away from the dressings until the nurse returned seven minutes later. LVN A returned and took those dressing materials in Resident #7's room and was observed to use them during the dressing change. Review of Resident #7's Comprehensive Plan of Care dated 03/27/12 revealed the resident had a Stage II pressure ulcer on her right gluteal fold identified at that time which was believed to be cause from the pressure of her brief. The "Approach" included providing pressure relieving devices for both the bed and chair, assist with position change in chair at least hourly and prn, use padding between pressure area and positioning devices for proper body alignment, and for the RD to review and make recommendations. During an interview on 06/07/12 at 3:50 PM, the DON and ADON were queried regarding Resident #7's pressure ulcer on her gluteal fold. The ADON revealed the pressure ulcer was a Stage III with a depth of 1.6 cm. She added that the pressure ulcer did have tunneling. Interview with the Corporate Nurse Consultant on 06/07/12 at 4:00 PM revealed she identified Resident #7's gluteal fold pressure ulcer was a Stage III tunneling pressure ulcer. On 06/07/12 at 5:17 PM, Resident #7 was queried regarding pressure relieving devices. She revealed the facility had placed an air mattress on her bed and stated, "I like it." She also revealed the facility had fixed her wheelchair by placing a new cushion in the chair. She stated the new cushion positioned her much taller, but she would get used to it. 2) Review of Resident #8's MDS assessment dated [DATE] revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a nurse's note dated 06/01/12 at 1:15 PM revealed, "Looked at resident's right heel- she had a sock and black shoe on asked resident if she had another type of shoe, 'yes, tennis shoe.' " Resident #8's Skin Assessment Flow Sheet - Pressure Ulcer reflected on 05/19/12, the resident had two, overlapping SDTI pressure ulcers on her right heel. One was 3 X 1.5 cm and the other was 4 X 0.7 cm. On 05/25/12, both pressure ulcers had increased to 2.3 X 2.0 cm and 2.0 X 4.7 cm. On 06/01/12, the pressure ulcer were joined as one and measured 5 X 4 cm. Resident #8's Comprehensive Plan of Care dated 05/19/12 reflected the resident had a SDTI on her right heel. The "Approach" included off-loading heel. A hand written update written on 05/25/12 reflected, "Educate on not wearing shoe D/T pressure on site" and "encourage not to wear shoe." During initial tour rounds on 06/04/12 at 11:10 AM with LVN A, Resident #8 was observed sitting in her wheelchair watching TV in her room. She was observed to have a left, [MEDICAL CONDITION]. LVN A stated Resident #8 was alert and oriented to person, place and time, able to propel herself in her wheelchair, needed the assistance of one person for bathing/toileting, and went to the dining room for meals where she fed herself. LVN A also stated Resident #8 had a pressure ulcer on her right heel which developed at the facility. Resident #8 was observed wearing a shoe on her right foot. No pressure relief was offered the foot. On 06/04/12 at 2:09 PM, Resident #8 was observed wearing a black shoe on her right foot. An interview with the DON and the Administrator on 06/04/12 at approximately 2:40 PM revealed Resident #8's pressure ulcer on her right heel was a result of an "Ill fitting shoe." The DON revealed Resident #8 received gait training through the facility's Physical Therapy Department during the time the pressure ulcer developed. 3) Resident #5's MDS assessments dated 05/30/12 reflected the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's History and Physical dated 05/08/12 revealed additional [DIAGNOSES REDACTED]. Review of Resident #5's Admission Skin Assessment and Weekly Skin Assessments revealed "No pressure areas" on 05/16/12, 05/21/12, 05/23/12, 05/28/12, and 06/04/12. Review of Resident #5's Skin Assessment - Non Pressure Sore Conditions dated 06/04/12 reflected "Tip of left great toe reddened" was identified on 05/28/12. The physician was notified on 05/29/12. The area for documentation of treatment was blank. Resident #5's Admission Care Plan dated 05/16/12 reflected Section #16 (Pressure Sores/Skin Care) was left blank. Nutritional Progress Notes dated 05/25/12 revealed Resident #5 had no skin issues. During initial tour rounds on 06/04/12 at 12:00 PM with LVN B, Resident #5 was observed lying in bed on his back. He was observed to be thin, frail, and lethargic. Two blankets were observed covering the resident and lying directly on top of the resident's feet and toes. No off-loading device was observed in the room. There was no pressure relieving mattress on the bed and no pressure relieving cushion in the resident's wheelchair. LVN B stated at that time the resident was oriented to person and place, was able to use a wheelchair, had a Foley catheter, could feed himself with set-up assistance, ate his meals in the dining room, and had recently had a weight loss problem. LVN B stated he did not have any skin issues. Resident #5 was transferred to the emergency roiagnom on [DATE] at 6:00 PM per the Nurses Notes due to a decline in his level of conscientious, fever of 102.3 degrees Fahrenheit, [MEDICAL CONDITION](rapid heart rate), and course sounds in his right middle lobe of his lung. Review of hospital computer file on 06/04/12 at 9:37 PM revealed Resident #5 entered the hospital with the above described Stage II pressure ulcer on his coccyx, left great toe pressure ulcer and left third toe pressure ulcer. Resident #5 was observed on 06/06/12 at 9:00 AM while he resided in the hospital with a [DIAGNOSES REDACTED]. A skin evaluation was preformed in the presence of the hospital RN. Resident #5 was observed to have a 2.5 cm round red area with a small "blood red" dot which measured 0.01 cm at the edge of the pressure ulcer on his left great toe. The dot was at 2 to 3 o' clock if looking at his foot from the bottom side. The end of the left third toe had a thick scab 1.0 cm X 0.5 cm depth unknown. Both areas with expected deep tissue injury per the assessment of the hospital RN. There was a moist Stage II pressure ulcer on Resident #5's coccyx. This pressure ulcer measured 1.5 cm round. Resident #5 was interviewed during this hospital visit. He was determined to be very alert and oriented. Resident #5 stated when talking about the coccyx pressure ulcer, "It hurts me all the time. It's from me sitting on it all the time in bed." When asked if the facility staff get him up, he replied, "I don't get up much. If you say you don't care whether you get up or not, they just leave you in bed." When asked on a pain scale of 1 to 10 (10 being the worst pain he has had, to describe the pain level he has with his coccyx area, Resident #5 stated, "9 to 10." The resident stated he had the pressure ulcer for a long time but was unable to establish a date. Resident #5 did identify the pressure ulcer did occur while in the facility and was not being treated. Interview with the hospital RN and 3rd Floor Charge Nurse on 06/06/12 at 10:00 AM determined Resident #5 was admitted to the 3rd floor with the above pressure ulcers. In an interview with the facility DON on 06/06/12 at 1:15 PM she stated the resident used multiple blankets which caused the weight on his toes. Therefore the facility staff used a cardboard box over his feet to keep the sheets and blankets from touching his toes. The DON stated a foot cradle had been ordered on [DATE] but had not been received to date. The DON provided a copy of an undated invoice for a "Cradle." The invoice had no provider information other than the facility's corporate office. The following two interviews were conducted in the presence of the Corporate Nurse and Corporate Administrator: Interview with one of the CNAs who cared for Resident #5, CNA C, on 06/07/12 at 3:45 PM revealed she had no knowledge of a cardboard box ever being used on Resident #5 to keep the blankets off his feet. The Charge Nurse (LVN D) for the hall Resident #5 resided on was interviewed on 06/07/12 at 3:50 PM. LVN D stated she did take care of Resident #5 and was not aware of the use of a cardboard box to keep the blankets off the resident's feet. 4) The facility's CMS Form 672 (Resident Census and Conditions of Residents) dated 06/04/12 and signed by the DON identified six residents with pressure ulcers, which excluded Stage I pressure ulcers and 32 resident who were in chairs all or most of the time.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being according to comprehensive assessments and plan of care for one (Resident #5) of 16 residents reviewed. Resident #5 had a change of condition identified by the surveyor on 06/04/12 at 12:00 PM. The facility failed to assess and provide prompt intervention until 06/04/12 at 6:00 PM and after surveyor's insistent inquiry. Resident #5 was admitted to the hospital with [REDACTED]. These failures resulted in delay in treatment for [REDACTED]. Findings included: 1) During initial tour rounds on 06/04/12 at 12:00 PM with LVN B, Resident #5 was observed lying in bed on his back. He was observed to be thin, frail, lethargic, his skin color was gray, and he was using dry oxygen (without a humidifier connected to the concentrator and oxygen tubing). Resident #5 had two blankets covering him; however, the room was warm. There was no pressure relieving mattress on the bed and no pressure relieving cushion in the wheelchair. LVN B stated at that time the resident was oriented to person and place, was able to use a wheelchair, had a Foley catheter, could feed himself with set-up assistance, ate his meals in the dining room, and had recently had a weight loss problem. LVN B stated he did not have any skin issues. LVN B said Resident #5 did not eat breakfast that morning because he did not feel well. LVN B was then queried regarding Resident #5's current condition. When it was pointed out to LVN B that Resident #5 was lethargic, his color was pasty gray and he was not verbally responsive, LVN B responded again by saying the resident did not feel well and did not eat breakfast. LVN B stated she would assess the resident's vital signs. Review of Resident #5's clinical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #5's records revealed he was transferred to the hospital on [DATE] and returned to the facility on [DATE] per the MDS assessment dated [DATE]. The MDS assessment also had additional [DIAGNOSES REDACTED]. Resident #5's Skin Assessment Flowsheets - Non Pressure Sore Conditions dated 05/18/12 reflected the resident had a Chest Tube site that was 1 X 0.5 cm and a surgical "lung mass removal" site that was 0.1 X 0.2 cm. Both sites were to be left open to air. At 2:00 PM on 06/04/12, Resident #5 was observed in bed; he had not moved from his earlier position. He was still lethargic and non-verbal. At that time, LVN B was queried regarding her assessment of Resident #5. LVN B stated she really did not know the resident and his vital signs were "okay. His temp was 99 degrees." At that time the DON walked up and inquired as to what was being discussed. The DON stated she would go and assess Resident #5. The DON stated, "Oh, he does that." She walked to Resident #5's room but never notified the surveyor of her assessment. At 5:30 PM on 06/04/12, Resident #5 remained in his bed lying on his back with two blankets covering him. He was still lethargic and had a pasty gray skin color while receiving oxygen 2 liters by nasal cannula continuously. His urine output by Foley catheter was approximately 100 ml (milliliters) which was dark amber in color. Resident #5 did not respond verbally when spoken to and did not try to follow commands. The Administrator was immediately notified. At 5:45 PM on 06/04/12, the Administrator (also an LVN) assessed Resident #5 and at that time the Resident 5's blood pressure was 110/70, pulse rate was 123 per minute, respirations 18 per minute, and temperature was 102.3 degrees F. Resident #5 was transferred to the emergency roiagnom on [DATE] at 6:00 PM per the Nurses Notes due to a decline in his level of conscientious, fever of 102.3 degrees Fahrenheit, [MEDICAL CONDITION](rapid heart rate), and course sounds in his right middle lobe of his lung. Resident #5 was observed on 06/06/12 at 9:00 AM while he resided in the hospital with a [DIAGNOSES REDACTED]. He was alert, oriented, smiling, and sitting in bed watching TV. His skin color was dark tan and he was able to move all his extremities on command. However, he was very weak and still required oxygen. He had an IV site in his right arm where he was receiving IV fluids and IV antibiotics. He was able to converse without becoming short of breath. 2) The CMS form-672, Resident Census and Conditions of Residents, dated 06/04/12 and signed by the DON, reflected a census of 55 residents.

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of 8 residents reviewed for prn medication use was free from unnecessary medications. Facility failures include: On 01/25/12, Resident #1 received prn [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10 mg at 6:15 a.m. and then her scheduled [MEDICATION NAME] 10 mg at 9:00 a.m., two hours and 45 minutes later. There was no pain assessment conducted before and after the administration of the medication. LVN C gave Resident #1 a scheduled dose of [MEDICATION NAME] 10 mg and a prn dose of [MEDICATION NAME] 20 mg together at 8:00 p.m. (for a total of 30 milligrams of [MEDICATION NAME]). The LVN did not conduct/document a pain assessment and could not remember why she doubled up the [MEDICATION NAME] for Resident #1. Resident #1 became non-responsive on 01/29/12 and was transferred to the hospital on [DATE] due to family insistence. The resident was diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) was identified on 03/08/12 at 10:48 a.m. While the IJ was lowered on 03/09/12, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" because all staff had not been in-serviced on pain management and the facility was still monitoring implementation of the Plan of Removal. These failures could affect the facility's 20 residents who were receiving narcotic [MEDICATION NAME] and placed them at risk for overmedication, which could lead to increased sedation, respiratory distress, altered mental status and death. Findings included: Following administrative review, the investigation was reopened on 03/07/12 for further investigation. 1) A review of the undated face sheet for Resident #1, an [AGE] year-old female, revealed she was admitted on [DATE] from an acute care facility with [DIAGNOSES REDACTED]. Resident #1 had a Comprehensive Pain Assessment Form completed on 01/11/12. Resident #1 was documented as having pain all over, specifically the abdomen, lower legs and right hip. The plan for addressing pain reflected the facility was going to give medications as prescribed and initiate the Pain Management Flow Sheet. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #1 had clear speech, usually made herself understood, she usually understood others, she was moderately impaired in her cognitive skills for daily decision making, and she had moderate pain occasionally in the past five days, but the pain had not made it hard for her to sleep and she had not limited her day-to-day activities because of pain. The hospital's physician History and Physical dated 01/30/12 reflected Resident #1 was transferred to the hospital on [DATE] where "she was found to be heavily sedated. She was given [MEDICATION NAME] which brought her back to being alert in her consciousness." The documentation then reflected, "It is more likely that the patient became semi-comatose from the [MEDICATION NAME] she was receiving." The resident was then monitored in the Intensive Care Unit. The Impression/Plan reflected the resident had Altered Mental Status secondary to [MEDICATION NAME]. Lippincott, Williams & Wilkins Nursing 2011 Drug Handbook, pages 760-763, reflected: [MEDICATION NAME] is an opioid [MEDICATION NAME] used to treat severe and moderate to severe pain. Adverse reactions include: sedation, somnolence, [MEDICAL CONDITIONS], shock, hypertension, hypertension, [MEDICAL CONDITION] apnea, respiratory arrest, and respiratory depression. Contraindications: Use with caution in elderly or debilitated patients Nursing considerations: Reassess patient ' s level of pain at 30 minutes after giving orally. Monitor circulatory, respiratory, bladder and bowel functions carefully. Drug may cause respiratory depression, [MEDICAL CONDITION] or altered level of consciousness regardless of the route. Luckmann and Sorensen ' s Medical-Surgical Nursing, Fourth Edition, by Black and Matassarin-Jacobs, pages 355-356, reflected: Modification of Plan of Care for the Elderly: Narcotics are appropriate to treat severe pain in the elderly as long as the changes in sensitivity are accounted for. The elderly may have more problems bio transforming and excreting these medications, so lower doses and longer intervals between doses are safer. The clearance of [MEDICATION NAME] from the plasma is also decreased. This means that [MEDICATION NAME] remains in the body longer at higher concentrations. Giving lower doses at longer intervals will compensate for this problem. Luckmann and Sorensen ' s Medical-Surgical Nursing, Fourth Edition, by Black and Matassarin-Jacobs, page 1164, reflected: [MEDICAL CONDITION]: Heart failure can be defined as a physiologic state in which the heart is unable to pump enough blood to meet the metabolic needs of the body. Lippincott, Williams & Wilkins' Nursing 2011 Drug Handbook, pages 1378-379, reflected the following: [MEDICATION NAME] is given for known or suspected opioid-induced respiratory depression with the respiratory rate increasing within one to two minutes. Resident #1's hospital Emergency Nursing Record dated 01/30/12 reflected the chief complaint was the resident being unresponsive for 36 hours. The Emergency Physician Record dated 01/30/12 reflected Resident #1 was assessed as having abnormal neurological function and was in respiratory distress. Resident #1's consolidated lab report dated 01/30/12 from the hospital reflected on 01/30/12 at 8:53 a.m. the resident tested positive for opiates and benzodiazepines. Review of Resident #1's hospital Discharge Summary dated 02/01/12 listed her admitting [DIAGNOSES REDACTED]." Review of Resident #1's January 2012 Consolidated physician's orders [REDACTED]. Review of Resident #1's Physician Telephone Orders reflected an order dated 01/21/12 for [MEDICATION NAME] 20 mg/ml gel to apply 0.5 ml (10 mg) topically three times daily and as needed. Review of Resident #1's clinical record revealed a Medication count sheet, which was also used to document administration of Resident #1's [MEDICATION NAME]. For Resident #1's [MEDICATION NAME] 20 mg/ml PLO Syringe, the directions were as follows: "Apply 0.5 ml (10 mg) topically and rub in well three times daily and as need." The medication was documented as given on the following dates and times: 01/23/12 at 9:30 a.m. one dose given 01/23/12 at 8:00 p.m. one dose given 01/24/12 at 6:15 a.m. one dose given 01/24/12 at 9:00 a.m. one dose given 01/24/12 at 8:00 p.m. one dose given 01/25/12 at 9:00 a.m. one dose given 01/25/12 at 2:00 p.m. one dose given 01/25/12 at 8:00 p.m. one dose given 01/26/12 at 2:00 p.m. one dose given 01/26/12 at 9:00 p.m. one dose given Review of Resident #1's clinical record reflected a Medication count sheet for Resident #1 for [MEDICATION NAME] Concentrate 20 mg/ml with directions as follows: "Take 0.25 - 1 ml by mouth, sublingual, or nebulized every hour as needed." The medication was documented as given on the following dates and times: 01/21/12 at 8:00 p.m. 1 ml given 01/25/12 at 6:10 a.m. 0.5 ml given 01/25/12 at 8:00 p.m. 1 ml given 01/26/12 at 2:00 a.m. 0.5 ml given 01/28/12 at 8:00 p.m. 0.5 ml given Resident #1 received multiple doses of [MEDICATION NAME] both scheduled and "as needed." On 01/25/12 Resident #1 received prn [MEDICATION NAME] 10 mg at 6:10 a.m. and at 9:00 a.m. received a scheduled dose of [MEDICATION NAME] 10 mg. There was no evidence in the Progress Notes for 01/25/12 at 6:00 a.m. of the resident complaining of significant pain requiring the administration of [MEDICATION NAME]. At 8:00 p.m., the same day, Resident #1 received both the scheduled [MEDICATION NAME] 10 mg and prn [MEDICATION NAME] 20 mg at 8:00 p.m. There was no documentation in the Progress Notes to indicate the resident complained of significant pain on 01/25/12 at 8:00 p.m. or prior. Review of Resident #1's Medication Count Sheet for the [MEDICATION NAME] Concentrate revealed LVN C signed out the medication on 01/25/12 at 8:00 p.m. The resident's Medication Count Sheet for the [MEDICATION NAME] to be administered topically reflected LVN C signed out the medication on 01/25/12 at 8:00 p.m. In an interview on 03/07/12 at 11:50 a.m., LVN C stated, "They kept changing up her medications. I don't remember the 25th (01/25/12) specifically, but I almost never gave her pain medicine without her family's permission. Generally I assess their pain, administer the lowest dose ordered, then re-assess 30 minutes later to see if they need more. If it is a routine order, we just document on the MAR. If it is a PRN order, we should document their pain, then our follow up. I took care of her at night and she was always awake. She was confused but she could talk." When queried about administering Resident #1 prn [MEDICATION NAME] and her scheduled [MEDICATION NAME] at the same time on 01/25/12 at 8:00 p.m., she answered, "I don't remember why I gave her both doses of [MEDICATION NAME] or if I did." In an interview on 03/07/12 at 4:00 p.m., the DON stated, "I couldn't tell you why ____(LVN C) gave a prn and a scheduled dose (at the same time). I would be making up a reason if I tried to tell you something." In an interview on 03/07/12 at 12:10 p.m., LVN B stated, "I took care of her (Resident #1) on the 28th and 29th (of January 2012). She was so restless on the 28th so when she slept on the 29th, I thought it was a good thing. We turned her very consistently through the night and she did open her eyes but she never talked to me. It didn't occur to me that she was over sedated though, because she hadn't had any [MEDICATION NAME] in the past 24 hours. If somebody complains of pain, I assess them and start with the lowest dose available. I try to always go back and reassess. We are supposed to document on the MAR and then use the PRN sheet for all PRN medications." In an interview on 02/29/12 at 1:11 p.m., CNA G stated, "____ (Resident #1) was sick. She had been in and out of the hospital for a couple of months. On Saturday (01/28/12), she was very anxious and restless. On Sunday morning (01/29/12), she was awake but she slept from lunch on the rest of the day. The nurses were in her room a lot, but I don't know if they called the doctor. She did take naps but on Sunday, she slept a lot more than usual." Review of Resident #1's clinical record revealed Clinical Notes from the Hospice RN dated 01/29/12. The Hospice RN wrote, "Pt is minimally responsive, no response to name being called ...Pt spending most of day in bed. Family members feel pt is over sedated, not functioning due to medication that pt is receiving. Family members feel pt med is not correct." Review of Resident #1's clinical record reflected Progress Notes dated 01/29/12 at 3:30 p.m. read, "Called to room of resident by CNA, nurse in room taking V/S, (BP) 168/88, P84, (respirations) 20, (temperature) 97.4 (degrees F), repeat B/P of 118/78 with manual cuff. First with wrist cuff. Non responsive to name being called. Oxygen per N/C at 2 (liters per minute). Speaking in (R) (right) ear would get a moan response. Repositioned to drain foley cath (urinary catheter) of straw color clear urine." On 02/29/12 at 12:52 p.m., LVN A stated, "I took care of ____ (Resident #1) on Sunday (01/29/12). She had periods of being awake and of sleeping. When I went to lunch, the weekend supervisor checked on her and wanted to give her [MEDICATION NAME]. The weekend supervisor (RN F) basically took over her care the rest of the day. I checked on her a couple of times, and she was sleeping. I didn't think anything of it." LVN A stated she did not contact the doctor at any time on Sunday, 01/29/12. Progress Notes dated 01/29/12 at 4:20 p.m. reflected a family member of Resident #1 "arrived and felt that ___ (Resident #1) needed to be treated by staff." Progress Notes dated 01/29/12 at 9:00 p.m. reflected Resident #1 was "resting with OU (both) eyes closed. V/S 120/82 (pulse) 79 (respirations) 20 (temperature) 98.3 (degrees F), evening meds and insulin withheld per ___ (family member) states resident is resting don't wake her for meds. (no) S/S of distress. Will continue to monitor throughout the night." Progress Notes dated 01/30/12 at 07:30 a.m. reflected the following, " ___ (Resident #1's family members) here early this am to visit resident. Family concerned that resident is too sedated. (No) distress noted. V/S (BP) 125/45 (pulse) 68, (respirations) 18, (temperature) 97.7 (degrees F) O2 in place via NC set at 2 LPM (liters per minute). SpO2 (oxygen saturation) @ 96%. FSBS @ 253 (no) insulin given at this time. Res. able to open OU (both eyes) on command. (No) verbal response noted. F/C in place draining yellow urine to collection bag. Family requesting res. be sent out to (hospital) ER for evaluation. POA notified of transfer. Report given to ER, call to ___ (ambulance company) for transfer at this time." On 03/06/12 at 10:15 a.m. in a telephone interview RN F stated, "_____ (Resident #1)'s blood pressure was up and down (on 01/29/12). I checked her blood pressure with the arm cuff. She was less responsive than normal but she was moaning a lot. We had to position her to get her catheter to drain. I saw her three times that day and she was out of it. We talked about sending her to the hospital but there was some confusion with the family and the power of attorney wouldn't make the decision without the other (family member) there. Hospice was involved also and trying to get everybody on the same page was confusing." On 02/29/12 at 4:37 p.m. a voicemail was received from a family member of Resident #1. The family member stated, "They took my mama to the hospital on that Monday Morning (01/30/12) after she had been in a coma all day Sunday and my (sibling) requested that she be sent to the hospital. The nursing home didn't make that decision, my (sibling) told the nurse that she needed to go to the hospital in an ambulance and the nurse said why? My (sibling) said, 'because she has been in a coma for two days.'" A telephone interview on 03/09/12 at 1:11 p.m. with a family member of Resident #1 revealed the resident now resided at another facility. The family member stated Resident #1 was no longer on hospice and no longer received [MEDICATION NAME]. The family member stated Resident #1 now received only [MEDICATION NAME] for pain relief and Resident #1 was awake and alert and was able to go to church the previous day with her family. The family member stated RN F never offered to contact the doctor or transfer the resident to the hospital on Sunday, 01/29/12 when she was over-sedated. The family member stated again it was only on the insistence of the family she went to theER on Monday, 01/30/12. He/She stated RN F told him, "(Resident #1) was at the end of her journey and just needed to be made comfortable with [MEDICATION NAME] so she could go." In an interview on 03/07/12 at 2:30 p.m., the facility's only ADON was interviewed regarding the documentation staff was to do in regard to administration of pain medication. The ADON stated, "They (nursing staff) should be documenting a pain assessment on all PRN pain meds given. That is what we train them to do." In an interview on 03/08/12 at 11:30 a.m., LVN E was queried about documentation of pain medication. LVN E stated, "We are supposed to document an assessment when we give the (pain) meds and then go back and assess if they work." On 02/29/12 at 11:00 a.m., the Facility's Medical Director and Resident #1's primary physician was interviewed. He stated, "___ (Resident #1) only received [MEDICATION NAME] a few times in January (2012). In looking at her hospital records I believe she had an exacerbation of her [MEDICAL CONDITION]. Her lungs and her kidneys did not metabolize her [MEDICATION NAME] and it built up in her system quickly over the course of a couple of days. If there was a failure on the part of the nurses here, it was that they didn't send her to the hospital on the 29th. I think there may have been a failure in their assessment of her." On 02/29/12 at 10:10 a.m. in interview, the Administrator stated, "I believe our biggest failure was in having ___ (Resident #1) on hospice. The family didn't understand the true nature of hospice was to provide comfort care. They just thought it would be another set of hands to help care for her (Resident #1). I don't think we gave her too much [MEDICATION NAME] for a woman her size. I don't remember exactly how much she had but it was less than ten doses in a month. I think it was the disease process-and she had multiple diagnoses-that caused her body not to metabolize what she did get. I think our nurses have a mindset that if they (the residents) are on hospice they are going to sleep a lot and they didn't take into account that she (Resident #1) was normally alert. I am doing a lot of training with staff to ensure they know hospice patients are still our responsibility." 5) During an interview on 03/07/12 at 3:50 p.m., LVN D was queried about documentation of pain medication. The LVN stated, "I am supposed to document on the pain assessment sheet if we give PRN meds for pain. I have not been doing that I guess." On 03/08/12 at 4:07 p.m., the DON stated, "...I did a med pass with ___ (LVN D) today and I don't think we will have this problem again." 6) On 02/29/12 at 2:05 p.m. the DON provided the facility's policy on pain management, comprehensive assessments and change of condition and identified them as current. The DON stated, "We did an in-service in January (2012) because honestly, we have dropped the ball on documenting our information." The facility's Pain Management Policy and Procedure dated August 2009 reflected: "POLICY It is the policy of this home that the Pain Management Flow Sheet will be completed on residents experiencing pain and receiving prn pain medication. PROCEDURE 1. A pain Assessment must be completed for a Resident upon admission, including re-admission, the onset or an increase in pain, quarterly, and any change in the Resident's condition. 2. An intensity score based on a scale of 0 - 10 should be completed prior to and immediately following any invasive procedure, therapy, including dressing changes. Also prior to and one hour following the administration of pain medication. The intensity score should be documented on the Pain Management Flow Sheet. Physician will notified if the medication is ineffective. ...5. A care plan must be completed for any Resident with pain and updated with any change to intervention. 6. Routine and PRN medication regimens are to be determined by the physician and are to be tailored to the special needs of the Resident...." The facility's current Medication Administration Policy and Procedure dated 06/25/08 reflected: "When PRN medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration (if other than oral) and if applicable the injection site and results achieved from giving the dose if any were noted...." 7) On 03/08/12 at 10:48 a.m., the Administrator and the DON were informed an IJ was identified in Quality of Care. A Plan of Removal for the IJ was requested from the Administrator. 8) A Plan of Removal was accepted on 03/08/12 at 6:30 p.m. It reflected the following: All LVNs and RNs were inserviced on the following topics related to pain: a) Routine vs. PRN over dispensing of pain medication b) Signs/Symptoms of over medication and sedation c) Change of Condition (notification to MD and family related to potential over medication) d) Pain assessments pre and post medication The inservice was initiated by the DON and the ADON. Validation of understanding is accomplished via post-test. In-services will continue each shift to ensure all staff have training and validation testing. Employees not passing the post-test will be given one-on-one training from the DON and allowed to retest. Completion date of 03/09/12 at 3:00 p.m. The DON has been inserviced by the Regional Nurse Consultant on pain medication dispensing, signs/symptoms of being over medicated, change of condition and pain assessments and demonstrated validation of training via post-test. Administrative staff reviewed 19 residents' MARS/TARS for accurate pain medication orders, checking for pain assessments, the nursing notes were being checked for documentation of prn medication, and notification to the physician and family for change of condition. The DON conducted an audit and count of narcotics with the charge nurses' assistance. All residents currently receiving scheduled and prn pain medications were assessed for effectiveness of medication and signs/symptoms of over medication/sedation. This was to be completed by 03/09/12 at 3:00 p.m. The DON/ADON/RN Weekend Supervisor will conduct chart audits using the 24 hour report communication tool and verify medication orders, notification of physician and family had been completed as needed. They will follow-up on proper documentation of pain, pain med administration, effectiveness and/or signs/symptoms of over medication. This was initiated on 03/08/12 and will be ongoing. Employees unable to come to the facility for inservices will be provided the inservices via telephone by the DON/ADON. The oral inservice will be documented and the employee will be required to take the post-test prior to beginning work. All newly hired licensed staff will receive these inservices prior to beginning work. Failure of the post-test will result in the licensed staff and/or newly hired licensed staff not working and having to be inserviced one-on-one by the DON. This will be initiated on 03/08/12 and will be ongoing. A QA Meeting was conducted via telephone and the QA Committee, which included the Medical Director, will monitor the effectiveness of the system for 90 days. The 24 hour reports, prn documentation, and morning start up meetings and post-tests for new hires will be reviewed. This was initiated on 03/08/12 and will be on going for 90 days. 9) Review of the facility's Inservice Training Reports provided by the facility reflected the following: PRN Medication Administration was conducted on 03/07/12 and nine staff attended. Dispensing of Medication (PRNs) was conducted on 03/08/12 and eight staff attended. Change of Condition was conducted on 03/08/12 and was attended by eight staff. Assessment and Documentation was conducted on 03/08/12 and was attended by eight staff. Pain Management Policy/Procedure was conducted on 03/08/12 at 12:30 p.m. and was attended by eight staff. LVN H was given verbal inservices on all of the above on 03/08/12 by the ADON. Seven post-tests were provided for review. The licensed nurses had all passed the tests. A telephone interview with RN I on 03/09/12 at 6:51 a.m. revealed she had worked the night shift and was inserviced before she started to work. She was able to provide the information she had received from the inservices in regard to pain assessment and pain management, administration of scheduled and prn pain medications, vital signs with assessments and following up after administration of the medication to ensure it was effective. Interviews were conducted with licensed staff in regard to the inservices conducted and their knowledge of change of condition, assessment and documentation, pain management and the facility's pain management policy/procedure and dispensing of prn medication. The following staff were interviewed and answered knowledgeably about the information they had received inservices on: LVN D on 03/08/12 at 4:02 p.m. LVN E on 03/08/12 at 4:17 p.m. LVN A on 03/09/12 at 9:51 a.m. ADON on 03/09/12 at 10:00 a.m. In an interview with the Regional Nurse Consultant on 03/08/12 at 4:15 p.m., she stated she was in the facility to assist with the completion of the inservices and she would be staying at the facility over night to monitor the staff. In an interview with the ADON on 03/09/12 at 10:00 a.m., the ADON stated she was observing staff when they were giving a PRN as part of the facility's monitoring. She stated she was going to observe the assessments conducted by staff and review the documentation entered based on the assessment and medications administered. Review of the facility Employee Roster dated 03/08/12 reflected a total of 16 licensed staff, which included the DON, ADON and the MDS Coordinator. 10) On 03/08/12 at 4:07 p.m., the DON was interviewed in regard to how she thought the IJ had occurred. The DON stated their morning routine was for ___ (LVN J) and ___ (the ADON) to make rounds. The DON said, "For some reason this had dropped through the cracks." The DON then added, "The nurses are checked off on their competency. We do all the background checks and train them. We train new nurses for three shifts. If they need extra shifts or extra time training, we will (give it to them) depending on the experience of the nurses. I don't know how this happened, but I think we have very good nurses that just didn't take the time to document their care...." 11) In an interview on 03/08/12 at 4:13 p.m., the ADM stated, "I think the failure was as a result of our lack of auditing. I think our nurses are assessing but they aren't documenting what they are doing. We are going to do a better job of monitoring now." 12) While the IJ was lowered on 03/09/12, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern" because all staff had not been in-serviced on pain management and notification of the physician, and the facility was still monitoring implementation of the Plan of Removal. 13) A list provided by the DON on 03/09/12 at 10:30 a.m. identified 20 residents with orders for narcotic pain medication.

Based on observation, interview and record review, it was determined the facility failed to ensure services provided or arranged by the facility met professional standards of quality for four (Residents #1, #2, #3, and #4) of eight sampled residents, by two LVNs (LVN C and LVN D) currently employed in the facility. Facility failures included: 1) On 01/25/12, Resident #1 received prn [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10 mg at 6:15 a.m. and then her scheduled [MEDICATION NAME] 10 mg at 9:00 a.m., two hours and 45 minutes later. There was no pain assessment conducted before or after either of the two doses of [MEDICATION NAME]. LVN C gave Resident #1 a scheduled dose of [MEDICATION NAME] 10 mg and a prn dose of [MEDICATION NAME] 20 mg together at 8:00 p.m. The LVN did not conduct/document a pain assessment and could not remember why she doubled up the [MEDICATION NAME] for Resident #1. Resident #1 became non-responsive on 01/29/12 and was transferred to the hospital on [DATE] due to family insistence. The resident was diagnosed with [REDACTED]. 2) Resident #2 was given 12 doses of prn [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10/325 mg and one dose of prn [MEDICATION NAME] Concentrate in February 2012 with only one pain assessment conducted. 3) Resident #3 was given seven doses of [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10/325 mg in March 2012 and 27 doses of [MEDICATION NAME] 10 mg/325 mg in February 2012 with only one pain assessment conducted. 4) Resident #4 was given 30 doses of [MEDICATION NAME] 10/325 mg in February 2012 with only six documented assessments. Resident #4 was given six doses of [MEDICATION NAME] 10/325 mg from 03/01/12 - 03/07/12 with no pain assessment. These failures could affect the facility's 20 residents receiving narcotic pain medication, including Residents #2, #3, and #4, and placed them at risk for overmedication, which could lead to increased sedation, respiratory distress, altered mental status and death. Findings included: Following administrative review, the investigation was reopened on 03/07/12 for further investigation. 1) The Texas Board of Nursing documented in RULES AND REGULATIONS relating to NURSE EDUCATION, LICENSURE AND PRACTICE" in the Texas Administrative Code Title 22 Examining Boards, Part 11, Texas Board of Nursing, Chapter 217, Licensure, Peer Assistance and Practice, RULE ?217.11 Standards of Nursing Practice, effective July 2009, the following: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and 2) A review of the undated face sheet for Resident #1, an [AGE] year-old female, revealed she was admitted on [DATE] from an acute care facility with [DIAGNOSES REDACTED]. Resident #1 had a Comprehensive Pain Assessment Form completed on 01/11/12. Resident #1 was documented as having pain all over, specifically the abdomen, lower legs and right hip. The plan for addressing pain reflected the facility was going to give medications as prescribed and initiate the Pain Management Flow Sheet. A review of the current comprehensive MDS assessment dated [DATE] revealed Resident #1 had clear speech, usually made herself understood, she usually understood others, she was moderately impaired in her cognitive skills for daily decision making, and she had moderate pain occasionally in the past five days, but the pain had not made it hard for her to sleep and she had not limited her day-to-day activities because of pain. The hospital's physician History and Physical dated 01/30/12 reflected Resident #1 was transferred to the hospital on [DATE] where "she was found to be heavily sedated. She was given [MEDICATION NAME] which brought her back to being alert in her consciousness." The documentation then reflected, "It is more likely that the patient became semi-comatose from the [MEDICATION NAME] she was receiving." The resident was then monitored in the Intensive Care Unit. The Impression/Plan reflected the resident had Altered Mental Status secondary to [MEDICATION NAME]. Lippincott, Williams & Wilkins Nursing 2011 Drug Handbook, pages 760-763, reflected: [MEDICATION NAME] is an opioid [MEDICATION NAME] used to treat severe and moderate to severe pain. Adverse reactions include: sedation, somnolence, [MEDICAL CONDITIONS], shock, hypertension, hypertension, [MEDICAL CONDITION] apnea, respiratory arrest, and respiratory depression. Contraindications: Use with caution in elderly or debilitated patients Nursing considerations: Reassess patient ' s level of pain at 30 minutes after giving orally. Monitor circulatory, respiratory, bladder and bowel functions carefully. Drug may cause respiratory depression, [MEDICAL CONDITION] or altered level of consciousness regardless of the route. Luckmann and Sorensen's Medical-Surgical Nursing, Fourth Edition, by Black and Matassarin-Jacobs, pages 355-356, reflected: Modification of Plan of Care for the Elderly: Narcotics are appropriate to treat severe pain in the elderly as long as the changes in sensitivity are accounted for. The elderly may have more problems bio transforming and excreting these medications, so lower doses and longer intervals between doses are safer. The clearance of [MEDICATION NAME] from the plasma is also decreased. This means that [MEDICATION NAME] remains in the body longer at higher concentrations. Giving lower doses at longer intervals will compensate for this problem. Luckmann and Sorensen's Medical-Surgical Nursing, Fourth Edition, by Black and Matassarin-Jacobs, page 1164, reflected: [MEDICAL CONDITION]: Heart failure can be defined as a physiologic state in which the heart is unable to pump enough blood to meet the metabolic needs of the body. Lippincott, Williams & Wilkins' Nursing 2011 Drug Handbook, pages 1378-379, reflected the following: [MEDICATION NAME] is given for known or suspected opioid-induced respiratory depression with the respiratory rate increasing within one to two minutes. Resident #1's hospital Emergency Nursing Record dated 01/30/12 reflected the chief complaint was the resident being unresponsive for 36 hours. The Emergency Physician Record dated 01/30/12 reflected Resident #1 was assessed as having abnormal neurological function and was in respiratory distress. Resident #1's consolidated lab report dated 01/30/12 from the hospital reflected on 01/30/12 at 8:53 a.m. the resident tested positive for opiates and benzodiazepines. Review of Resident #1's hospital Discharge Summary dated 02/01/12 listed her admitting [DIAGNOSES REDACTED]." Review of Resident #1's January 2012 Consolidated physician's orders [REDACTED]. Review of Resident #1's Physician Telephone Orders reflected an order dated 01/21/12 for [MEDICATION NAME] 20 mg/ml gel to apply 0.5 ml (10 mg) topically three times daily and as needed. Review of Resident #1's clinical record revealed a Medication count sheet, which was also used to document administration of Resident #1's [MEDICATION NAME]. For Resident #1's [MEDICATION NAME] 20 mg/ml PLO Syringe, the directions were as follows: "Apply 0.5 ml (10 mg) topically and rub in well three times daily and as need." The medication was documented as given on the following dates and times: 01/23/12 at 9:30 a.m. one dose given 01/23/12 at 8:00 p.m. one dose given 01/24/12 at 6:15 a.m. one dose given 01/24/12 at 9:00 a.m. one dose given 01/24/12 at 8:00 p.m. one dose given 01/25/12 at 9:00 a.m. one dose given 01/25/12 at 2:00 p.m. one dose given 01/25/12 at 8:00 p.m. one dose given 01/26/12 at 2:00 p.m. one dose given 01/26/12 at 9:00 p.m. one dose given Review of Resident #1's clinical record reflected a Medication count sheet for Resident #1 for [MEDICATION NAME] Concentrate 20 mg/ml with directions as follows: "Take 0.25 - 1 ml by mouth, sublingual, or nebulized every hour as needed." The medication was documented as given on the following dates and times: 01/21/12 at 8:00 p.m. 1 ml given 01/25/12 at 6:10 a.m. 0.5 ml given 01/25/12 at 8:00 p.m. 1 ml given 01/26/12 at 2:00 a.m. 0.5 ml given 01/28/12 at 8:00 p.m. 0.5 ml given Resident #1 received multiple doses of [MEDICATION NAME] both scheduled and "as needed." On 01/25/12 Resident #1 received prn [MEDICATION NAME] 10 mg. at 6:10 a.m. and at 9:00 a.m. received a scheduled dose of [MEDICATION NAME] 10 mg. There was no evidence in the Progress Notes for 01/25/12 at 6:00 a.m. of the resident complaining of significant pain requiring the administration of [MEDICATION NAME]. At 8:00 p.m., the same day, Resident #1 received both the scheduled [MEDICATION NAME] 10 mg and prn [MEDICATION NAME] 20 mg. at 8:00 p.m. (for a total of 30 mg.). There was no documentation in the Progress Notes to indicate the resident complained of significant pain on 01/25/12 at 8:00 p.m. or prior. Review of Resident #1's Medication Count Sheet for the [MEDICATION NAME] Concentrate revealed LVN C signed out the medication on 01/25/12 at 8:00 p.m. The resident's Medication Count Sheet for the [MEDICATION NAME] to be administered topically reflected LVN C also signed out the medication on 01/25/12 at 8:00 p.m. The hospital's physician History and Physical dated 01/30/12 reflected Resident #1 was transferred to the hospital on [DATE] where "she was found to be heavily sedated. She was given [MEDICATION NAME] which brought her back to being alert in her consciousness." The documentation then reflected, "It is more likely that the patient became semi-comatose from the [MEDICATION NAME] she was receiving." The resident was then monitored in the Intensive Care Unit. The Impression/Plan reflected the resident had Altered Mental Status secondary to [MEDICATION NAME]. Lippincott, Williams & Wilkins' Nursing 2011 Drug Handbook, pages 1378-379, reflected the following: [MEDICATION NAME] is given for known or suspected opioid-induced respiratory depression with the respiratory rate increasing within one to two minutes. Resident #1's hospital Emergency Nursing Record dated 01/30/12 reflected the chief complaint was the resident being unresponsive for 36 hours. The Emergency Physician Record dated 01/30/12 reflected Resident #1 was assessed as having abnormal neurological function and was in respiratory distress. Resident #1's consolidated lab report dated 01/30/12 from the hospital reflected on 01/30/12 at 8:53 a.m. the resident tested positive for opiates and benzodiazepines. Review of Resident #1's hospital Discharge Summary dated 02/01/12 listed her admitting [DIAGNOSES REDACTED]." In an interview on 03/07/12 at 11:50 a.m., LVN C stated, "They kept changing up her medications. I don't remember the 25th (01/25/12) specifically, but I almost never gave her pain medicine without her family's permission. Generally I assess their pain, administer the lowest dose ordered, then re-assess 30 minutes later to see if they need more. If it is a routine order, we just document on the MAR. If it is a PRN order, we should document their pain, then our follow up. I took care of her at night and she was always awake. She was confused but she could talk." When queried about administering Resident #1 prn [MEDICATION NAME] and her scheduled [MEDICATION NAME] at the same time on 01/25/12 at 8:00 p.m., she answered, "I don't remember why I gave her both doses of [MEDICATION NAME] or if I did." In an interview on 03/07/12 at 4:00 p.m., the DON stated, "I couldn't tell you why ____(LVN C) gave a prn and a scheduled dose (at the same time). I would be making up a reason if I tried to tell you something." In an interview on 03/07/12 at 12:10 p.m., LVN B stated, "I took care of her (Resident #1) on the 28th and 29th (of January 2012). She was so restless on the 28th so when she slept on the 29th, I thought it was a good thing. We turned her very consistently through the night and she did open her eyes but she never talked to me. It didn't occur to me that she was over sedated though, because she hadn't had any [MEDICATION NAME] in the past 24 hours. If somebody complains of pain, I assess them and start with the lowest dose available. I try to always go back and reassess. We are supposed to document on the MAR and then use the PRN sheet for all PRN medications." In an interview on 02/29/12 at 1:11 p.m., CNA G stated, "____ (Resident #1) was sick. She had been in and out of the hospital for a couple of months. On Saturday (01/28/12), she was very anxious and restless. On Sunday morning (01/29/12), she was awake but she slept from lunch on the rest of the day. The nurses were in her room a lot, but I don't know if they called the doctor. She did take naps but on Sunday, she slept a lot more than usual." Review of Resident #1's clinical record revealed Clinical Notes from the Hospice RN dated 01/29/12. The Hospice RN wrote, "Pt is minimally responsive, no response to name being called ...Pt spending most of day in bed. Family members feel pt is over sedated, not functioning due to medication that pt is receiving. Family members feel pt med is not correct." Review of Resident #1's clinical record reflected Progress Notes dated 01/29/12 at 3:30 p.m. read, "Called to room of resident by CNA, nurse in room taking V/S, (BP) 168/88, P84, (respirations) 20, (temperature) 97.4 (degrees F), repeat B/P of 118/78 with manual cuff. First with wrist cuff. Non responsive to name being called. Oxygen per N/C at 2 (liters per minute). Speaking in (R) (right) ear would get a moan response. Repositioned to drain foley cath (urinary catheter) of straw color clear urine." On 02/29/12 at 12:52 p.m., in interview LVN A stated, "I took care of ____ (Resident #1) on Sunday (01/29/12). She had periods of being awake and of sleeping. When I went to lunch, the weekend supervisor checked on her and wanted to give her [MEDICATION NAME]. The weekend supervisor (RN F) basically took over her care the rest of the day. I checked on her a couple of times, and she was sleeping. I didn't think anything of it." LVN A stated she did not contact the doctor at any time on Sunday, 01/29/12. Progress Notes dated 01/29/12 at 4:20 p.m. reflected a family member of Resident #1 "arrived and felt that ___ (Resident #1) needed to be treated by staff." Progress Notes dated 01/29/12 at 9:00 p.m. reflected Resident #1 was "resting with OU (both) eyes closed. V/S 120/82 (pulse) 79 (respirations) 20 (temperature) 98.3 (degrees F), evening meds and insulin withheld per ___ (family member) states resident is resting don't wake her for meds. (no) S/S of distress. Will continue to monitor throughout the night." Progress Notes dated 01/30/12 at 07:30 a.m. reflected the following, " ___ (Resident #1's family members) here early this am to visit resident. Family concerned that resident is too sedated. (No) distress noted. V/S (BP) 125/45 (pulse) 68, (respirations) 18, (temperature) 97.7 (degrees F) O2 in place via NC set at 2 LPM (liters per minute). SpO2 (oxygen saturation) @ 96%. FSBS @ 253 (no) insulin given at this time. Res. able to open OU (both eyes) on command. (No) verbal response noted. F/C in place draining yellow urine to collection bag. Family requesting res. be sent out to (hospital) ER for evaluation. POA notified of transfer. Report given to ER, call to ___ (ambulance company) for transfer at this time." On 03/06/12 at 10:15 a.m. in a telephone interview RN F stated, "_____ (Resident #1)'s blood pressure was up and down (on 01/29/12). I checked her blood pressure with the arm cuff. She was less responsive than normal but she was moaning a lot. We had to position her to get her catheter to drain. I saw her three times that day and she was out of it. We talked about sending her to the hospital but there was some confusion with the family and the power of attorney wouldn't make the decision without the other (family member) there. Hospice was involved also and trying to get everybody on the same page was confusing." On 02/29/12 at 4:37 p.m. a voicemail was received from a family member of Resident #1. The family member stated, "They took my mama to the hospital on that Monday Morning (01/30/12) after she had been in a coma all day Sunday and my (sibling) requested that she be sent to the hospital. The nursing home didn't make that decision, my (sibling) told the nurse that she needed to go to the hospital in an ambulance and the nurse said why? My (sibling) said, 'because she has been in a coma for two days.'" A telephone interview on 03/09/12 at 1:11 p.m. with a family member of Resident #1 revealed the resident now resided at another facility. The family member stated Resident #1 was no longer on hospice and no longer received [MEDICATION NAME]. The family member stated Resident #1 now received only [MEDICATION NAME] for pain relief and Resident #1 was awake and alert and was able to go to church the previous day with her family. The family member stated RN F never offered to contact the doctor or transfer the resident to the hospital on Sunday, 01/29/12 when she was over-sedated. The family member stated again it was only on the insistence of the family she went to theER on Monday, 01/30/12. He/She stated RN F told him, "(Resident #1) was at the end of her journey and just needed to be made comfortable with [MEDICATION NAME] so she could go." In an interview on 03/07/12 at 2:30 p.m., the facility's only ADON was interviewed regarding the documentation staff was to do in regard to administration of pain medication. The ADON stated, "They (nursing staff) should be documenting a pain assessment on all PRN pain meds given. That is what we train them to do." In an interview on 03/08/12 at 11:30 a.m., LVN E was queried about documentation of pain medication. LVN E stated, "We are supposed to document an assessment when we give the (pain) meds and then go back and assess if they work." On 02/29/12 at 11:00 a.m., the Facility's Medical Director and Resident #1's primary physician was interviewed. He stated, "___ (Resident #1) only received [MEDICATION NAME] a few times in January (2012). In looking at her hospital records I believe she had an exacerbation of her [MEDICAL CONDITION]. Her lungs and her kidneys did not metabolize her [MEDICATION NAME] and it built up in her system quickly over the course of a couple of days. If there was a failure on the part of the nurses here, it was that they didn't send her to the hospital on the 29th. I think there may have been a failure in their assessment of her. They did not call me on the 29th (of January) to tell me she was lethargic." On 02/29/12 at 10:10 a.m. in interview, the Administrator stated, "I believe our biggest failure was in having ___ (Resident #1) on hospice. The family didn't understand the true nature of hospice was to provide comfort care. They just thought it would be another set of hands to help care for her (Resident #1). I don't think we gave her too much [MEDICATION NAME] for a woman her size. I don't remember exactly how much she had but it was less than ten doses in a month. I think it was the disease process-and she had multiple diagnoses-that caused her body not to metabolize what she did get. I think our nurses have a mindset that if they (the residents) are on hospice they are going to sleep a lot and they didn't take into account that she (Resident #1) was normally alert. I am doing a lot of training with staff to ensure they know hospice patients are still our responsibility." 2) A review of the face sheet dated 02/08/12 for Resident #2 revealed she was originally admitted to the facility 12/28/10 and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #2 had clear speech, was sometimes able to make herself understood, she sometimes understood others, she was moderately impaired in her cognitive skills for daily decision making, and had non-verbal and vocal complaints of pain observed 1 to 2 of the last five days. Resident #2 had a Comprehensive Pain Assessment Form completed after re-admission on 01/27/12. Resident #2 was documented as having chronic back pain and pain to a wound on her left heel. The plan for addressing pain stated the facility was going to give medications as prescribed and initiate the pain management flow sheet. Resident #2's Physicians Orders for February 2012 reflected an order for [REDACTED]. Resident #2's Physician's Telephone Orders dated 02/23/12 reflected and order to D/C [MEDICATION NAME] (narcotic [MEDICATION NAME]) 10 mg/325 one by mouth every eight hours (prn) and to change to [MEDICATION NAME] 10 mg/325 one by mouth every four to six hours prn. Resident #2's February 2012 Medication Sheet reflected she was administered [MEDICATION NAME] 10 mg/325 mg twelve times: 02/01/12, 02/03/12, 02/11/12, 02/16/12, 02/17/12, 02/18/12, twice on 02/23/12, 02/24/12, twice on 02/28/10 and 02/29/12. LVN D was identified as the nurse administering the [MEDICATION NAME] six times. Resident #2's February 2012 Medication Sheet reflected she was administered [MEDICATION NAME] Concentrate 20 mg/ml once by LVN D. The Pain Management Flow Sheet for Resident #2 reflected documentation on 02/03/12 for the resident's use of [MEDICATION NAME] 10 mg/325 mg. It was the only documentation on the Flow Sheet. The [MEDICATION NAME] Concentrate had not been documented on the Flow Sheet either. 3) A review of the face sheet dated 02/17/12 for Resident #3, a [AGE] year-old male, revealed he was admitted to the facility 02/11/12 with [DIAGNOSES REDACTED]. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #3 had clear speech, was always able to make himself understand and be understood by others, had no long term or short term memory deficits, was not cognitively impaired and he had pain frequently in the past five days but the pain had not made it hard for him to sleep. He had limited his day to day activities over the past five days due to pain. " Resident #3 had a Comprehensive Pain Assessment Form completed on admission on 02/11/12 and then again on 03/08/12 following surveyor intervention. Resident #3 was documented as having a recent right knee replacement, a history of back surgeries, and carpal tunnel in both hands. The plan for addressing pain included a rehab referral and giving medications as prescribed. Resident #3's Start Up Orders for February 2012, which were dated as being initiated 02/11/12 reflected the resident had orders for [MEDICATION NAME] 10 mg/325 mg two tabs by mouth every four hours for pain prn. The Start Up Orders medication administration sheet for February 2012 reflected Resident #3 was administered the two tabs of [MEDICATION NAME] 10 mg/325 mg 27 times. LVN D administered the [MEDICATION NAME] twelve times. Resident #3's physician's orders [REDACTED]. He could be given either one or two tabs. Resident #3's Medication Sheet for March 2012 reflected he received two tabs of [MEDICATION NAME] 10 mg/325 mg seven times from 03/01/12 - 03/06/12. LVN D administered the medication six times. Resident #3's Pain Management Flow Sheet was blank. 4) A review of February 2012 Physicians Orders Resident #4, a [AGE] year-old male, revealed he was admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #4 had clear speech, was usually able to understand and be understood by others, and had no long term or short term memory deficits. He had pain frequently in the past five days but the pain had not made it hard for him to sleep and had not limited his day-to-day activities. Resident #4 did not have a Comprehensive Pain Assessment form completed until 03/08/12 following surveyor intervention. Resident #4's February and March 2012 Physicians Orders reflected the resident had orders for [MEDICATION NAME] 10 mg/325 mg by mouth every four hours prn pain. He could be given either one or two tabs. Resident #4's February 2012 Medication Sheet reflected the resident was administered two tabs of [MEDICATION NAME] 10 mg/325 mg 30 times. LVN D administered [MEDICATION NAME] 12 times. Resident #4's March 2012 Medication Sheet reflected the resident was administered two tabs of [MEDICATION NAME] 10 mg/325 mg six times from 03/01/12 - 03/07/12. LVN D administered the [MEDICATION NAME] four times. Resident #4's NURSE'S PRN NOTES/MEDICATION NOTES were blank. The Pain Management Flow Sheet for Resident #4 was also blank. 5) During an interview on 03/07/12 at 3:50 p.m., LVN D was queried about documentation of pain medication. The LVN stated, "I am supposed to document on the pain assessment sheet if we give PRN meds for pain. I have not been doing that I guess." On 03/08/12 at 4:07 p.m., the DON stated, "...I did a med pass with ___ (LVN D) today and I don't think we will have this problem again." 6) On 02/29/12 at 2:05 p.m. the DON provided the facility's policy on pain management, comprehensive assessments and change of condition and identified them as current. The DON stated, "We did an in-service in January (2012) because honestly, we have dropped the ball on documenting our information." The facility's Pain Management Policy and Procedure dated August 2009 reflected: "POLICY It is the policy of this home that the Pain Management Flow Sheet will be completed on residents experiencing pain and receiving prn pain medication. PROCEDURE 1. A pain Assessment must be completed for a Resident upon admission, including re-admission, the onset or an increase in pain, quarterly, and any change in the Resident's condition. 2. An intensity score based on a scale of 0 - 10 should be completed prior to and immediately following any invasive procedure, therapy, including dressing changes. Also prior to and one hour following the administration of pain medication. The intensity score should be documented on the Pain Management Flow Sheet. Physician will notified if the medication is ineffective. ...5. A care plan must be completed for any Resident with pain and updated with any change to intervention. 6. Routine and PRN medication regimens are to be determined by the physician and are to be tailored to the special needs of the Resident...." The facility's current Medication Administration Policy and Procedure dated 06/25/08 reflected: "When PRN medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration (if other than oral) and if applicable the injection site and results achieved from giving the dose if any were noted...." 7) Review of the facility's Inservice Training Reports provided by the facility reflected the following: PRN Medication Administration was conducted on 03/07/12 and nine staff attended. Dispensing of Medication (PRNs) was conducted on 03/08/12 and eight staff attended. Change of Condition was conducted on 03/08/12 and was attended by eight staff. Assessment and Documentation was conducted on 03/08/12 and was attended by eight staff. Pain Management Policy/Procedure was conducted on 03/08/12 at 12:30 p.m. and was attended by eight staff. LVN H was given verbal inservices on all of the above on 03/08/12 by the ADON. Seven post-tests were provided for review. The licensed nurses had all passed the tests. A telephone interview with RN I on 03/09/12 at 6:51 a.m. revealed she had worked the night shift and was inserviced before she started to work. She was able to provide the information she had received from the inservices in regard to pain assessment and pain management, administration of scheduled and prn pain medications, vital signs with assessments and following up after administration of the medication to ensure it was effective. Interviews were conducted with licensed staff in regard to the inservices conducted and their knowledge of change of condition, assessment and documentation, pain management and the facility's pain management policy/procedure and dispensing of prn medication. The following staff were interviewed and answered knowledgeably about the information they had received inservices on: LVN D on 03/08/12 at 4:02 p.m. LVN E on 03/08/12 at 4:17 p.m. LVN A on 03/09/12 at 9:51 a.m. ADON on 03/09/12 at 10:00 a.m. In an interview with the Regional Nurse Consultant on 03/08/12 at 4:15 p.m., she stated she was in the facility to assist with the completion of the inservices and she would be staying at the facility over night to monitor the staff. In an interview with the ADON on 03/09/12 at 10:00 a.m., the ADON stated she was observing staff when they were giving a PRN pain medication as part of the facility's monitoring. She stated she was going to observe the assessments conducted by staff and review the documentation entered based on the assessment and medications administered. Review of the facility Employee Roster dated 03/08/12 reflected a total of 16 licensed staff, which included the DON, ADON and the MDS Coordinator. 9) In an interview on 03/08/12 at 4:13 p.m., the ADM stated, "I think the failure was as a result of our lack of auditing. I think our nurses are assessing but they aren't documenting what they are doing. We are going to do a better job of monitoring now." 10) A list provided by the DON on 03/09/12 at 10:30 a.m. identified 20 residents with orders for narcotic pain medication.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical health for one (Resident #1) of eight residents reviewed for a change of condition. Resident #1 became lethargic and sedated on 01/29/12 and was non-responsive/semi-comatose on 01/30/12. LVN A, RN F and LVN B, who supervised/provided care for Resident #1 on those dates did not notify the resident's physician. The resident was sent to the hospital on [DATE] at the insistence of family members, where she was diagnosed with [REDACTED]. These failures could affect the 23 residents, who resided on the 400, 500, and 600 halls where RN F and LVNs A and B worked, and placed them at risk for the potential of not having their physician notified when there was a change of condition and resulted in the potential for a delay in treatment and/or transfer to the hospital. Findings included: 1) Following administrative review, the investigation was reopened on 03/07/12 for further investigation. A review of the undated face sheet for Resident #1, an [AGE] year-old female, revealed she was admitted on [DATE] from an acute care facility with [DIAGNOSES REDACTED]. Resident #1 had a Comprehensive Pain Assessment Form completed on 01/11/12. Resident #1 was documented as having pain all over, specifically the abdomen, lower legs and right hip. The plan for addressing pain reflected the facility was going to give medications as prescribed and initiate the Pain Management Flow Sheet. A review of the comprehensive MDS assessment dated [DATE] revealed Resident #1 had clear speech, usually made herself understood, she usually understood others, she was moderately impaired in her cognitive skills for daily decision making, and she had moderate pain occasionally in the past five days, but the pain had not made it hard for her to sleep and she had not limited her day-to-day activities because of pain. The hospital's physician History and Physical dated 01/30/12 reflected Resident #1 was transferred to the hospital on [DATE] where "she was found to be heavily sedated. She was given [MEDICATION NAME] which brought her back to being alert in her consciousness." The documentation then reflected, "It is more likely that the patient became semi-comatose from the [MEDICATION NAME] she was receiving." The resident was then monitored in the Intensive Care Unit. The Impression/Plan reflected the resident had Altered Mental Status secondary to [MEDICATION NAME]. Lippincott, Williams & Wilkins Nursing 2011 Drug Handbook, pages 760-763, reflected: [MEDICATION NAME] is an opioid [MEDICATION NAME] used to treat severe and moderate to severe pain. Adverse reactions include: sedation, somnolence, [MEDICAL CONDITIONS], shock, hypertension, hypertension, [MEDICAL CONDITION] apnea, respiratory arrest, and respiratory depression. Contraindications: Use with caution in elderly or debilitated patients Nursing considerations: Reassess patient ' s level of pain at 30 minutes after giving orally. Monitor circulatory, respiratory, bladder and bowel functions carefully. Drug may cause respiratory depression, [MEDICAL CONDITION] or altered level of consciousness regardless of the route. Luckmann and Sorensen ' s Medical-Surgical Nursing, Fourth Edition, by Black and Matassarin-Jacobs, pages 355-356, reflected: Modification of Plan of Care for the Elderly: Narcotics are appropriate to treat severe pain in the elderly as long as the changes in sensitivity are accounted for. The elderly may have more problems bio transforming and excreting these medications, so lower doses and longer intervals between doses are safer. The clearance of [MEDICATION NAME] from the plasma is also decreased. This means that [MEDICATION NAME] remains in the body longer at higher concentrations. Giving lower doses at longer intervals will compensate for this problem. Luckmann and Sorensen ' s Medical-Surgical Nursing, Fourth Edition, by Black and Matassarin-Jacobs, page 1164, reflected: [MEDICAL CONDITION]: Heart failure can be defined as a physiologic state in which the heart is unable to pump enough blood to meet the metabolic needs of the body. Lippincott, Williams & Wilkins' Nursing 2011 Drug Handbook, pages 1378-379, reflected the following: [MEDICATION NAME] is given for known or suspected opioid-induced respiratory depression with the respiratory rate increasing within one to two minutes. Resident #1's hospital Emergency Nursing Record dated 01/30/12 reflected the chief complaint was the resident being unresponsive for 36 hours. The Emergency Physician Record dated 01/30/12 reflected Resident #1 was assessed as having abnormal neurological function and was in respiratory distress. Resident #1's consolidated lab report dated 01/30/12 from the hospital reflected on 01/30/12 at 8:53 a.m. the resident tested positive for opiates and benzodiazepines. Review of Resident #1's hospital Discharge Summary dated 02/01/12 listed her admitting [DIAGNOSES REDACTED]." Review of Resident #1's January 2012 Consolidated physician's orders [REDACTED]. Review of Resident #1's Physician Telephone Orders reflected an order dated 01/21/12 for [MEDICATION NAME] 20 mg/ml gel to apply 0.5 ml (10 mg) topically three times daily and as needed. Review of Resident #1's clinical record revealed a Medication count sheet, which was also used to document administration of Resident #1's [MEDICATION NAME]. For Resident #1's [MEDICATION NAME] 20 mg/ml PLO Syringe, the directions were as follows: "Apply 0.5 ml (10 mg) topically and rub in well three times daily and as need." The medication was documented as given on the following dates and times: 01/23/12 at 9:30 a.m. one dose given 01/23/12 at 8:00 p.m. one dose given 01/24/12 at 6:15 a.m. one dose given 01/24/12 at 9:00 a.m. one dose given 01/24/12 at 8:00 p.m. one dose given 01/25/12 at 9:00 a.m. one dose given 01/25/12 at 2:00 p.m. one dose given 01/25/12 at 8:00 p.m. one dose given 01/26/12 at 2:00 p.m. one dose given 01/26/12 at 9:00 p.m. one dose given Review of Resident #1's clinical record reflected a Medication count sheet for Resident #1 for [MEDICATION NAME] Concentrate 20 mg/ml with directions as follows: "Take 0.25 - 1 ml by mouth, sublingual, or nebulized every hour as needed." The medication was documented as given on the following dates and times: 01/21/12 at 8:00 p.m. 1 ml given 01/25/12 at 6:10 a.m. 0.5 ml given 01/25/12 at 8:00 p.m. 1 ml given 01/26/12 at 2:00 a.m. 0.5 ml given 01/28/12 at 8:00 p.m. 0.5 ml given Resident #1 received multiple doses of [MEDICATION NAME] both scheduled and "as needed." On 01/25/12 Resident #1 received prn [MEDICATION NAME] 10 mg at 6:10 a.m. and at 9:00 a.m. received a scheduled dose of [MEDICATION NAME] 10 mg. There was no evidence in the Progress Notes for 01/25/12 at 6:00 a.m. of the resident complaining of significant pain requiring the administration of [MEDICATION NAME]. At 8:00 p.m., the same day, Resident #1 received both the scheduled [MEDICATION NAME] 10 mg and prn [MEDICATION NAME] 20 mg at 8:00 p.m. (for a total of 30 mg.) There was no documentation in the Progress Notes to indicate the resident complained of significant pain on 01/25/12 at 8:00 p.m. or prior. Review of Resident #1's Medication Count Sheet for the [MEDICATION NAME] Concentrate revealed LVN C signed out the medication on 01/25/12 at 8:00 p.m. The resident's Medication Count Sheet for the [MEDICATION NAME] to be administered topically reflected LVN C signed out the medication on 01/25/12 at 8:00 p.m. The hospital's physician History and Physical dated 01/30/12 reflected Resident #1 was transferred to the hospital on [DATE] where "she was found to be heavily sedated. She was given [MEDICATION NAME] which brought her back to being alert in her consciousness." The documentation then reflected, "It is more likely that the patient became semi-comatose from the [MEDICATION NAME] she was receiving." The resident was then monitored in the Intensive Care Unit. The Impression/Plan reflected the resident had Altered Mental Status secondary to [MEDICATION NAME]. Lippincott, Williams & Wilkins' Nursing 2011 Drug Handbook, pages 1378-379, reflected the following: [MEDICATION NAME] is given for known or suspected opioid-induced respiratory depression with the respiratory rate increasing within one to two minutes. Resident #1's hospital Emergency Nursing Record dated 01/30/12 reflected the chief complaint was the resident being unresponsive for 36 hours. The Emergency Physician Record dated 01/30/12 reflected Resident #1 was assessed as having abnormal neurological function and was in respiratory distress. Resident #1's consolidated lab report dated 01/30/12 from the hospital reflected on 01/30/12 at 8:53 a.m. the resident tested positive for opiates and benzodiazepines. Review of Resident #1's hospital Discharge Summary dated 02/01/12 listed her admitting [DIAGNOSES REDACTED]." In an interview on 03/07/12 at 11:50 a.m., LVN C stated, "They kept changing up her medications. I don't remember the 25th (01/25/12) specifically, but I almost never gave her pain medicine without her family's permission. Generally I assess their pain, administer the lowest dose ordered, then re-assess 30 minutes later to see if they need more. If it is a routine order, we just document on the MAR. If it is a PRN order, we should document their pain, then our follow up. I took care of her at night and she was always awake. She was confused but she could talk." When queried about administering Resident #1 prn [MEDICATION NAME] and her scheduled [MEDICATION NAME] at the same time on 01/25/12 at 8:00 p.m., she answered, "I don't remember why I gave her both doses of [MEDICATION NAME] or if I did." In an interview on 03/07/12 at 4:00 p.m., the DON stated, "I couldn't tell you why ____(LVN C) gave a prn and a scheduled dose (at the same time). I would be making up a reason if I tried to tell you something." In an interview on 03/07/12 at 12:10 p.m., LVN B stated, "I took care of her (Resident #1) on the 28th and 29th (of January 2012). She was so restless on the 28th so when she slept on the 29th, I thought it was a good thing. We turned her very consistently through the night and she did open her eyes but she never talked to me. It didn't occur to me that she was over sedated though, because she hadn't had any [MEDICATION NAME] in the past 24 hours. If somebody complains of pain, I assess them and start with the lowest dose available. I try to always go back and reassess. We are supposed to document on the MAR and then use the PRN sheet for all PRN medications." In an interview on 02/29/12 at 1:11 p.m., CNA G stated, "____ (Resident #1) was sick. She had been in and out of the hospital for a couple of months. On Saturday (01/28/12), she was very anxious and restless. On Sunday morning (01/29/12), she was awake but she slept from lunch on the rest of the day. The nurses were in her room a lot, but I don't know if they called the doctor. She did take naps but on Sunday, she slept a lot more than usual." Review of Resident #1's clinical record revealed Clinical Notes from the Hospice RN dated 01/29/12. The Hospice RN wrote, "Pt is minimally responsive, no response to name being called ...Pt spending most of day in bed. Family members feel pt is over sedated, not functioning due to medication that pt is receiving. Family members feel pt med is not correct." Review of Resident #1's clinical record reflected Progress Notes dated 01/29/12 at 3:30 p.m. read, "Called to room of resident by CNA, nurse in room taking V/S, (BP) 168/88, P84, (respirations) 20, (temperature) 97.4 (degrees F), repeat B/P of 118/78 with manual cuff. First with wrist cuff. Non responsive to name being called. Oxygen per N/C at 2 (liters per minute). Speaking in (R) (right) ear would get a moan response. Repositioned to drain foley cath (urinary catheter) of straw color clear urine." On 02/29/12 at 12:52 p.m., LVN A stated, "I took care of ____ (Resident #1) on Sunday (01/29/12). She had periods of being awake and of sleeping. When I went to lunch, the weekend supervisor checked on her and wanted to give her [MEDICATION NAME]. The weekend supervisor (RN F) basically took over her care the rest of the day. I checked on her a couple of times, and she was sleeping. I didn't think anything of it." LVN A stated she did not contact the doctor at any time on Sunday, 01/29/12. Progress Notes dated 01/29/12 at 4:20 p.m. reflected a family member of Resident #1 "arrived and felt that ___ (Resident #1) needed to be treated by staff." Progress Notes dated 01/29/12 at 9:00 p.m. reflected Resident #1 was "resting with OU (both) eyes closed. V/S 120/82 (pulse) 79 (respirations) 20 (temperature) 98.3 (degrees F), evening meds and insulin withheld per ___ (family member) states resident is resting don't wake her for meds. (no) S/S of distress. Will continue to monitor throughout the night." Progress Notes dated 01/30/12 at 07:30 a.m. reflected the following, " ___ (Resident #1's family members) here early this am to visit resident. Family concerned that resident is too sedated. (No) distress noted. V/S (BP) 125/45 (pulse) 68, (respirations) 18, (temperature) 97.7 (degrees F) O2 in place via NC set at 2 LPM (liters per minute). SpO2 (oxygen saturation) @ 96%. FSBS @ 253 (no) insulin given at this time. Res. able to open OU (both eyes) on command. (No) verbal response noted. F/C in place draining yellow urine to collection bag. Family requesting res. be sent out to (hospital) ER for evaluation. POA notified of transfer. Report given to ER, call to ___ (ambulance company) for transfer at this time." On 02/29/12 at 11:00 a.m., the Facility's Medical Director and Resident #1's primary physician was interviewed. He stated, "___ (Resident #1) only received [MEDICATION NAME] a few times in January (2012). In looking at her hospital records I believe she had an exacerbation of her [MEDICAL CONDITION]. Her lungs and her kidneys did not metabolize her [MEDICATION NAME] and it built up in her system quickly over the course of a couple of days. If there was a failure on the part of the nurses here, it was that they didn't send her to the hospital on the 29th. I think there may have been a failure in their assessment of her. They did not call me on the 29th (of January) to tell me she was lethargic." On 02/29/12 at 10:10 a.m. in interview, the Administrator stated, "I believe our biggest failure was in having ___ (Resident #1) on hospice. The family didn't understand the true nature of hospice was to provide comfort care. They just thought it would be another set of hands to help care for her (Resident #1). I don't think we gave her too much [MEDICATION NAME] for a woman her size. I don't remember exactly how much she had but it was less than ten doses in a month. I think it was the disease process-and she had multiple diagnoses-that caused her body not to metabolize what she did get. I think our nurses have a mindset that if they (the residents) are on hospice they are going to sleep a lot and they didn't take into account that she (Resident #1) was normally alert. I am doing a lot of training with staff to ensure they know hospice patients are still our responsibility." On 03/06/12 at 10:15 a.m. in a telephone interview RN F stated, "_____ (Resident #1)'s blood pressure was up and down (on 01/29/12). I checked her blood pressure with the arm cuff. She was less responsive than normal but she was moaning a lot. We had to position her to get her catheter to drain. I saw her three times that day and she was out of it. We talked about sending her to the hospital but there was some confusion with the family and the power of attorney wouldn't make the decision without the other (family member) there. Hospice was involved also and trying to get everybody on the same page was confusing." On 02/29/12 at 4:37 p.m. a voicemail was received from a family member of Resident #1. The family member stated, "They took my mama to the hospital on that Monday Morning (01/30/12) after she had been in a coma all day Sunday and my (sibling) requested that she be sent to the hospital. The nursing home didn't make that decision, my (sibling) told the nurse that she needed to go to the hospital in an ambulance and the nurse said why? My (sibling) said, 'because she has been in a coma for two days.'" A telephone interview on 03/09/12 at 1:11 p.m. with a family member of Resident #1 revealed the resident now resided at another facility. The family member stated Resident #1 was no longer on hospice and no longer received [MEDICATION NAME]. The family member stated Resident #1 now received only [MEDICATION NAME] for pain relief and Resident #1 was awake and alert and was able to go to church the previous day with her family. The family member stated RN F never offered to contact the doctor or transfer the resident to the hospital on Sunday, 01/29/12 when she was over-sedated. The family member stated again it was only on the insistence of the family she went to theER on Monday, 01/30/12. He/She stated RN F told him, "(Resident #1) was at the end of her journey and just needed to be made comfortable with [MEDICATION NAME] so she could go." On 02/29/12 at 2:05 p.m. the DON provided the facility's policy on pain management, comprehensive assessments and change of condition and identified them as current. The DON stated, "We did an in-service in January (2012) because honestly, we have dropped the ball on documenting our information." 2) Review of the facility's Inservice Training Reports provided by the facility reflected the following: PRN Medication Administration was conducted on 03/07/12 and nine staff attended. Dispensing of Medication (PRNs) was conducted on 03/08/12 and eight staff attended. Change of Condition was conducted on 03/08/12 and was attended by eight staff. Assessment and Documentation was conducted on 03/08/12 and was attended by eight staff. Pain Management Policy/Procedure was conducted on 03/08/12 at 12:30 p.m. and was attended by eight staff. LVN H was given verbal inservices on all of the above on 03/08/12 by the ADON. Seven post-tests were provided for review. The licensed nurses had all passed the tests. A telephone interview with RN I on 03/09/12 at 6:51 a.m. revealed she had worked the night shift and was inserviced before she started to work. She was able to provide the information she had received from the inservices in regard to pain assessment and pain management, administration of scheduled and prn pain medications, vital signs with assessments and following up after administration of the medication to ensure it was effective. Interviews were conducted with licensed staff in regard to the inservices conducted and their knowledge of change of condition, assessment and documentation, pain management and the facility's pain management policy/procedure and dispensing of prn medication. The following staff were interviewed and answered knowledgeably about the information they had received inservices on: LVN D on 03/08/12 at 4:02 p.m. LVN E on 03/08/12 at 4:17 p.m. LVN A on 03/09/12 at 9:51 a.m. ADON on 03/09/12 at 10:00 a.m. In an interview with the Regional Nurse Consultant on 03/08/12 at 4:15 p.m., she stated she was in the facility to assist with the completion of the inservices and she would be staying at the facility over night to monitor the staff. In an interview with the ADON on 03/09/12 at 10:00 a.m., the ADON stated she was observing staff when they were giving a PRN pain medication as part of the facility's monitoring. She stated she was going to observe the assessments conducted by staff and review the documentation entered based on the assessment and medications administered. 3) Review of the facility Employee Roster dated 03/08/12 reflected a total of 16 licensed staff, which included the DON, ADON and the MDS Coordinator. 4) Review of the facility's census revealed there were 23 residents, who resided on the 400, 500, and 600 halls where RN F and LVNs A and B worked.