Every finding on record at Palm Garden of Largo

Based on observations, interviews, and record review, the facility failed to ensure the safety of one resident (#2) out of three residents sampled. This failure resulted in a fall with major injury for Resident #2 when the individual care plan for transfer was not followed during a shower. Findings included: On 05/18/2026 at 12:15 p.m. Resident #2 was observed lying down in bed. She stated she was still in pain from the fall she had a week ago during a shower. She stated a Certified Nursing Assistant (CNA) transferred her with the Hoyer Lift without assistance in the shower chair. She stated during her shower she kept telling the CNA she felt like she was going to fall out of the chair. She stated the chair felt like it was falling apart and she knew she was going to fall. She stated the CNA left her in the bathroom alone and that is when she fell out of the shower chair. Resident #2 stated she has never broken anything on her body before and she was in a lot of pain.Review of an admission record, dated 05/20/ 2026, revealed Resident #2 was admitted to the facility readmitted on [DATE] with diagnoses to include: active primary progressive multiple sclerosis, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, paraplegia, narcolepsy without cataplexy, contracture, left knee. Review of a Minimum Data Set (MDS) assessment, dated 02/10/2026, showed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #2 was cognitively intact. Review of a Situation Background Assessment Recommendation (SBAR) Communication Form, dated 04/21/2026, revealed a change in condition due to a fall. According to the documentation an 11-7 CNA had hollered out in the hallway for help. Resident #2 was observed lying on the bathroom floor, with the CNA bracing her neck and head. Shower seat grip noted on floor, resident verbalized severe pain during movement when she was transferred from the bathroom floor. The resident verbalized pain in her left hip noted as 9 out of 10. Medical Doctor gave orders to send {Resident #2} out to the hospital due to high probability of resident having sustained an acute fracture. Review of Hospital Record revealed Resident #2 was admitted to the hospital on [DATE] due to a fall and left hip pain. Review of an operative report, dated 4/22/2026, revealed Resident #2 operative diagnoses was Left hip displacement. She underwent treatment of left intertrochanteric fracture with intramedullary implant placement of gamma nail. Review of a Psychiatry progress note, dated 5/4/2026, revealed Resident #2 was seen due to staff reported concerns regarding a prior incident to a recent fall in the shower. Resident # 2 had expressed concerns that her chair felt unstable and may have been malfunctioning. Resident #2 subsequently experienced a fall, resulting in injury.Review of Resident #2's care plan, date initiated 09/09/2015 with a revision dated 04/27/2026, revealed the following:Focus: Activity of Daily Living (ADL) self-care deficit related to: Multiple Sclerosis with paraplegia, spasticity, right sided hemiplegia with contractures. She returned on 4/24/2026 status post left hip fracture status post open reduction and internal fixation with intramedullary nailing.Goal: Resident #2 will maintain ADL's self-performance levels as evidence by no decline in current level of functioning through review date, revision dated 11/14/2025, target date 08/06/2026.Interventions: Hoyer Lift, and 2 persons assist with transfers, and showers. During an interview on 05/18/2026 at 3:12 p.m. with Staff A, Registered Nurse (RN), stated she was Resident #2 assigned nurse. She stated Resident #2 had a recent fall on the morning shift. Staff A stated Staff B, CNA did not follow Resident #2's plan of care, which required her to have two people assistance during bathing because the resident has poor trunk ability. Staff A stated on the day of the fall she saw Staff B standing in the hallway asking for help with Resident #2. Staff A stated she went down to the resident room, and once she entered the bathroom, she saw resident #2 on the floor, with nothing underneath her. Staff A stated she immediately assessed Resident #2. The resident said her pain level was a 10. She stated she immediately contacted the doctor because she suspected Resident #2 had broken something by the way her leg was positioned on the floor. The doctor ordered a stat x-ray, but he decided to send the resident out to the hospital. Staff A stated Resident #2 told her that she had told Staff B she was slipping out of the shower chair before she fell, but the aide kept showering her. Staff A said the aide left the bathroom to get assistance, the resident fell out of the shower chair. Staff A stated they removed the resident shower chair from the room because the Risk Manager told her the chair was faulty and not safe for use. During an interview on 5/18/26 at 4:28 p.m. with Staff B, CNA stated, I got {Resident #2} in the shower chair and took her in the shower. {Resident #2} said she felt like she was falling. Someone was supposed to come to assist me, but they never came. Staff B stated they only worked with three CNA's that night and each aide had 18-19 residents each. I transferred {Resident #2} using the Hoyer to the shower chair with no issues. After five minutes in the shower {Resident #2} said she felt like she was going to fall out of the shower chair. When I went to get her out the shower, the resident said, 'You haven't washed my hair', and she wanted her hair washed. Staff B stated while she was washing Resident #2's hair the chair started to come apart. She stated, The whole half of the silicone came off the shower chair. Staff B stated, It was the piece of the chair that holds the resident in that came off. Her butt was on the floor but her back was still in the chair. I put the call light on and waited 5-6 minutes. I propped her up and yelled for help. No one came. Staff B stated after she propped Resident #2 in a sitting position she left the resident in the bathroom to get help. She stated she had to walk halfway down the hall toward the nurses station and saw the nurse. She said, The nurse came. She went and got another aide to assist us with getting the resident off the floor. Staff B stated she had to wait another 5-6 mins to help get Resident #2 off the floor. The nurse had moved her leg and the resident said ouch. The nurse asked if she was in pain. The resident said no but it hurt when the nurse moved her leg. Staff B stated the Risk Manager said the shower chair blue piece was old and dirty and the other half was hanging on by a string and she said the chair was not pushing properly. Staff B stated part of the cushion on the shower chair was attached to the chair and the other half of the cushion came off. She stated the chair did not recline and it was not working properly. Staff B stated. They fired me because I didn't use two people to transfer Resident # 2. She stated she was not trained properly; she had 19 residents assigned to her that night and three out of the 19 residents assigned to her had to have showers. Staff B stated she did not know the resident plan of care prior to assisting her. She only had one day of orientation then assigned to the floor to work.During an interview conducted on 5/19/2026 at 10:07 a.m. with the Risk Manager (RM), she stated when she looked at the chair the silicone nonslip pad looked like it was ripped. She stated it may have happened when the resident slipped off the chair and the nonslip silicone was dislodged from the chair. She stated the part was supposed to keep a resident from slipping out of the chair. The Risk Manager stated the resident should have had two people assisting her during her shower, it would have prevented her from falling; if the aide had followed the resident's care plan.During an interview conducted on 5/19/26 at 1:55 p.m. with Resident #2's Primary Care Provider he stated he sees Resident #2 every week. He stated, I've seen her for 15 years. Resident #2 is paraplegic with multiple sclerosis. She totally depends on the assistance of others for all of her care. I was told the shower chair broke down under her while she was in it and she fell on the floor. She was assisted by one person at the time of her shower which is a total violation due to safety. Her fall caused her a fracture of the left hip, and she had to undergo surgery while in the hospital. She will have agonizing pain for a long time as a result of her injury. At this time her pain is controlled by medications. Prior to the fall she was not taking any pain medications. It is hard to tell if she is going to continue on opioids for a longer period of time or not. My main concern is to make sure she is comfortable, but she is not there at this time due to her consistent pain. This has impacted on her psychosocially as she normally goes to bingo, and likes to attend other activities at the facility, but obviously with her having to recover from the surgery she is confined to the four walls of her room. My recommendation is to make sure her pain is controlled, we are gradually coming to that point. It's going to take another 2 to 4 weeks to work on the pain where she is at a level where she could be placed in a chair to attend activities again. This sudden change has caused more difficulties for her. Review of the Certified Nursing Assistant Job Description, dated September 2019, revealed the following:Basic Function; Provide routine daily clinical care and services that support the care delivered to guests requiring long-term or rehabilitative care in accordance with the established with the established clinical care procedures and directed by your supervisor. Essential Functions; Provides care as directed by the professional nurse to guests requiring long-term rehabilitative care. Provide services that support the care delivered to the guests. Marginal Functions; All equipment is operated in a safe manner and the only equipment utilized that which previous training of use has occurred. Defective equipment is reported to the Charge/ Staff Nurse. Review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation, Revised September 2023, revealed the following:Neglect, Neglect as defined in statute 483.5 is the failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This occurs when the center was aware of or should have been aware of, goods or services that the resident (s) required but the center failed to provide them resulting in or may result in physical harm, pain, mental anguish, or emotional distress. The facility did not have any other policy related to this citation

Based on observations, interviews, and record review, the facility failed to ensure proper infection control practices were utilized related to contact precautions on two resident units (100 and 200) out of three resident units in the facility.Findings included:An observation was conducted on 5/18/26 at 9:42 a.m. of a staff member entering room [ROOM NUMBER], which had a contact precaution sign on the door. The staff did not use personal protective equipment (PPE) while in the room.An observation as conducted on 5/18/26 at 9:53 a.m. of a staff member in room [ROOM NUMBER], which had a contact precaution sign on the door. The staff member did not have any PPE on while in the room. The staff member exited the room, spoke to the nurse in the hall, reentered the room, then exited again. No hand hygiene was observed. At 9:58 a.m. Staff C, LPN entered room [ROOM NUMBER] without donning PPE.An interview was conducted on 5/18/26 at 10:03 a.m. with Staff C, Licensed Practical Nurse (LPN). Staff C confirmed a resident in room [ROOM NUMBER] was on contact precautions. She said staff only wear PPE in the room if they are doing direct care or dressing changes. She said if staff are dropping off trays, passing medications, or talking to the resident they do not wear PPE in contact precaution rooms. The following observations were conducted on 5/18/26 between 10:19 a.m. and 11:43 p.m. on the 100 resident unit: -A Certified Nursing Assistant (CNA) entered room [ROOM NUMBER], which had a contact precaution sign. The staff member did not don PPE to enter the room. The staff member was then observed exiting the room without performing hand hygiene and entered another resident room.-A CNA entered room [ROOM NUMBER], which had a contact precaution sign, with only gloves on and no gown.-An unknown staff member was in room [ROOM NUMBER], which had a contact precaution sign, with no PPE on.-Staff D, CNA was in room [ROOM NUMBER], which had a contact precaution sign, with no PPE on.An interview was conducted on 5/18/26 at 11:50 a.m. with Staff D, CNA. She said for residents on contact precautions, staff only wear PPE when doing personal care for the resident. She said they do not have to wear PPE all the time in the room for resident on contact precautions.An observation and interview was conducted on 5/18/26 at 1:50 p.m. of Staff E, Housekeeper, in room [ROOM NUMBER], which had a contact precaution sign on the door. Staff E was cleaning the room with no PPE on. Upon exiting the room, Staff E was asked about the contact precaution sign and the use of PPE. She said she had training but forgot to put PPE on.An observation and interview was conducted on 5/18/26 at 1:56 p.m. with Staff F, Van Driver. room [ROOM NUMBER] had a contact precaution sign on the door. The Unit Manager, CNA, and van driver were all observed to be in the room with no PPE on. Staff F exited the room and stated he had training on the types of precautions and PPE use. He said he is a driver for the facility but also helps with small maintenance things when he is not busy. He said he would normally ask the nurse what the precautions are for and if it is for a wound or something like that or he is just walking in to fix something he would not wear PPE.An interview was conducted on 5/18/26 at 2:21 p.m. with the Director of Nursing (DON). The DON provided a list of residents on contact precautions and said there were a few additional residents they just removed from precautions that shift. She said they had so many residents on precautions due to a gastrointestinal (GI) outbreak the week before. The DON said if the residents had no diarrhea after 48 hours, they were taking them off precautions. The DON said they had not figured out what the bacteria was.At 2:26 p.m. the facility's Infection Preventionist (IP) joined the interview.She said she is the IP as well as the staff educator in the facility. The IP stated they had 14 residents and 3 staff members with the GI symptoms in the last week. She said some had nausea, vomiting, and diarrhea while others and just one or two of those symptoms. The IP said they did hand hygiene education for the whole house and were cleaning high touch surfaces every two hours. She said they put residents with symptoms on contact precautions and a few on special contact precautions due to those being tested for clostridium defile (C-Diff). The IP said for residents on contact precautions there is a sign W for window or D for door on the sign. She said staff know if the door bed is the one on precautions they should wear PPE when encountering that resident. The IP said staff did not have to wear PPE anytime they entered the room. The DON then said for contact precautions staff should wear a gown and gloves anytime they enter the residents' room if there is a sign on the door. She said it did not matter which resident was specifically on the precautions. The DON and IP both reiterated staff should read the signs and follow what it says.Review of a facility policy titled Transmission Based Precautions, effective September 2019, showed the following:Transmission based precautions are used when route of transmission is not completely interrupted using standard precautions alone and the pathogen may have multiple routes of transmission. Transmission based precautions are divided into: contact precautions, droplet precautions, and airborne precautions. Precautions in place when symptomatic infections are not deemed colonized by the resident physician or center infection preventionist.1. Contact precautions: wear PPE (personal protective equipment) gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas of the resident environment.

Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from neglect related to: 1) providing timely care and services to prevent physical/emotional discomfort for toileting assistance for one resident (#4) out of five residents sampled, and 2) protecting residents from unsympathetic/negative attitudes from staff for three residents (#6, #7, and #5) out of three residents sampled. These failures resulted in emotional/psychological distress and a fear of retaliation among residents. Findings included: 1. During a facility tour on 6/21/25 at 9:32 a.m., an observation was made of a call light signal on in Resident #4's room. There were no staff observed in the hallway responding the call light. On 6/21/25 at 9:40 a.m., an observation was made of a staff member at the nurse's station while the call light was displaying on above the nurse's station. The staff member, Staff H, Certified Nursing Assistant (CNA), said she was looking for something and could not answer a question on staffing assignments. She said, I don't mean to ignore you; I'm looking for something. Staff H walked away. Staff H did not respond to Resident #4's call light. On 6/21/25 at 9:44 a.m., the call light was still on in Resident #4's room. An interview was conducted with Resident #4 who was in her room, sitting in her wheelchair by her bedside. She stated she was waiting to be assisted with toileting. She said, I have been waiting to go to the bathroom. I need help. The resident stated the CNA (Certified Nursing Assistant) already came a half hour earlier and stated she was passing trays and would come and assist her later. The resident said, Don't call anyone else, she already said to wait . Please do not say anything . She will be mad if you ask her. The resident stated she waits for assistance all the time. When a surveyor suggested again going to get her help, the resident stated a third time, No, do not ask them. They get mad at me. I know they are busy. The CNA said to wait. Review of Resident #4's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses to include: acute respiratory failure with hypoxia, colostomy status, Bipolar Disorder, and depression. Review of a Minimum Data Set (MDS) for Resident #4, dated 5/30/2025, showed the resident had a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Section GG: Functional abilities showed, for lower body dressing: The ability to dress and undress below the waist, including fasteners, the resident needs substantial to maximal assistance (meaning helper does more than half the effort). Helper lifts or holds trunk or limbs and provides more than half the effort). C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy include wiping the opening but not managing equipment, the resident required supervision or touching assistance (meaning helper provides verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. Review of the comprehensive care plan for Resident #4, initiated on 4/1/2025, showed a focus area of ADL (Activities of Daily Living) self-care and/or mobility deficit - at risk for developing complications associated with decreased ADL's self-performance related to disease process condition. The goal indicated the resident will have all ADLs completed by staff as needed. Interventions included toileting assistance - Total assist x1. A second focus area revealed Resident #4 was at risk for alteration in skin integrity related to fragile skin, impaired mobility, use of blood thinning medication and morbid obesity with interventions to assist with toileting and peri-care as needed. Review of Resident #4's Kardex report (a document used by staff with specific instructions to a resident's care needs) showed for bladder/bowel: - Assist with toileting and peri-care as needed. - Provide ostomy care as ordered and prn (as needed). The report showed for transfers the resident required extensive assistance x1, for toileting - Total assist x1, for dressing, UB (upper body) limited assistance and LB (lower body) extensive assistance x1. On 6/21/25 at 9:56 a.m., an observation was made of the call light still on in Resident #4's room. Staff D, Registered Nurse (RN)/Weekend Supervisor (WS), was observed going to a storage closet in the same hallway, picking up some supplies, and speaking to Staff E, CNA, asking, Who has room [number]? The resident wants to go the bathroom. I can't do it myself. Staff E, CNA, stated another CNA [Staff B] had the room. Staff D, RN/WS, was observed walking to the resident's room and leaving immediately. She did not assist the resident. The call light remained on. On 6/21/25 at 10:19 a.m. Resident #4's call light was still on. Staff B, CNA, was observed in the hallway, not providing care at the time. On 6/21/25 at 10:23 a.m., Resident #4's call light was still on. An interview was conducted with the resident. She confirmed staff had not assisted her to the bathroom yet. She stated it had been a very long time, since breakfast time. The resident became teary-eyed and said, I need to be changed. Resident #4 said, You can get me help now. I can't wait anymore. The resident stated her colostomy bag needed to be changed as well. She said, The smell is embarrassing. An interview was conducted on 6/21/25 at 10:27 a.m. with Staff E, CNA. She stated she was not assigned the room. She stated another CNA has her [Resident #4]. Staff E, CNA, said, I saw the call light. The supervisor told me. It has been on, probably an hour. I told her CNA the resident was waiting. Staff E, CNA, stated the resident's assigned CNA [Staff B] was helping another resident. Staff E said, Anyone can assist the resident. I could have. Staff E stated they were expected to help each other. She stated the residents should not wait that long to receive assistance. She said, I will go and help her now. On 6/21/25 at 10:33 a.m., an interview was conducted with Staff B, CNA. She stated she dropped off the breakfast trays around 8 a.m. She said, I saw her around 8 a.m.; she asked for ice and a shake. She did not ask to go to the bathroom at the time. When I picked up the tray, around 8:30 a.m., she asked to go to the bathroom, and I told her I would be back. Staff B stated another CNA had turned off the light and told her [the resident] I would be back. She said, I told her 'let me finish your roommate.' I finished her roommate and then went to care for other residents. Staff B stated she had asked the resident to wait maybe about an hour ago. She stated, I will help her now. Staff B stated the resident was dependent on staff for toileting. Resident #4 waited to be assisted with toileting for over 1.5 hours. An interview with Staff D, RN/WS, on 6/21/25 at 11:59 a.m. revealed she was filling in for the weekend supervisor. She said, I went there (Resident #4's room) and answered the light. I spoke to the resident; she said she wanted help to go the bathroom. It was after breakfast. I said I would be back with help. I told her I could not do it myself. Staff D, RN/WS, stated she went looking for help and notified a CNA [Staff E]. Staff D stated Staff E, CNA, reported they would assist her. Staff D, RN/WS said, I should have confirmed. I don't know when it went on or how long it was on. I should have gone to help. Staff D stated she was helping with discharges. She stated she tries to get the lights herself and encourages the CNAs to follow her example. Staff D confirmed waiting over an hour and half to be toileted is too long. She said, I should have gone to help her. I was aware. An hour and half or an hour is too long to wait. Other CNAs should have stepped in. It is not acceptable. I am sorry for the resident. She stated no resident should feel like it was a bother to ask for help. 2. During a facility tour on 6/21/25 at 9:20 a.m., an interview was conducted with Resident #5 in her room. She stated she had a problem with a staff member, a CNA. The resident was hesitant to talk about the problem. She said, I would rather not say anything and I don't want to upset her. The resident stated recently about a week ago, a CNA [Staff C] was providing her care. She stated the CNA was on the phone. She was ordering food during care. The resident stated she asked the CNA why she was ordering food during care. The resident reported the CNA got snappy with me. She stated, Since the incident she has been rude. The resident said, I saw her today. I pray to God I don't have her today. She stated she had not reported the incident to anyone. She said, I don't want any trouble with the CNA. The resident stated when the staff member comes to her room, She is rushed, she makes you feel bad about yourself. She stated, That sort of behavior cannot be right. Review of the admission record revealed Resident #5 was admitted to the facility on [DATE]. Review of a quarterly MDS, dated [DATE], showed the resident had a BIMS score of 14, meaning intact cognition. Review of a Kardex for Resident #5 showed the resident required an assist of x2 for toileting and an assist of x1 for grooming. The resident required an extensive assistance x2 for bed mobility. 3. An interview was conducted with Resident #7 on 6/21/25 at 10:15 a.m. in her room. She stated she has one CNA who is rough with her. She stated the staff member's name was [Staff C]. Resident #7 said, She has a nasty temper. She is short and abrupt during care. She stated the CNA handles her roughly. She stated roughly meant She pulls and tugs on you like you are a rag doll. The resident stated she takes an anticoagulant which makes her skin sensitive, but after the staff member takes care of her, she stated she leaves marks on her skin. The resident stated she had not filed a grievance. She stated she had said something to a nurse. She does not know her name. She stated, I should not say this to you. I don't want to upset her. She is going to take it out on me. You should not tell anyone. The resident was observed with bruising on her arms, consistent with her description. She said, Look, these are worse when she is assigned to me. Review of the admission record for Resident #7 revealed an admission date of 6/18/24. Review of an annual MDS, dated [DATE], showed the resident had a BIMS score of 13, meaning intact cognition. The CNA Kardex showed for ADLs the resident required extensive assist of x1 for bed mobility, toileting dressing and bathing. 4. On 6/21/25 at 10:09 a.m. an interview was conducted with Resident #6. The resident stated, Some of the CNAs here have an attitude problem. She stated she did not know if it was the new CNAs but they seem to lack in bedside skills. She stated, One CNA [Staff C], she is very grumpy, borderline verbal abuse. She is short with people. Resident #6 stated another resident (Resident #7) has expressed fear of the CNA, stating, She is rough, and she leaves marks on her skin after care. She stated some nurses knew about her. She stated, I know some residents are fearful of the staff. The resident said, If you complain, they delay your care. The resident stated she had not spoken to the facility administration, but some staff knew there are a few bad apples. On 6/21/25 at 12:16 p.m. an interview was conducted with the Staff Development Coordinator (SDC/LPN). She stated in-services were on-going due to a couple issues, such as call lights not answered. She stated customer service in-services done all the time, most recently three weeks ago. The SDC/LPN stated they educated about being respectful to residents. She said, The younger generation, they don't act well. The residents get upset with them. It is an on-going issue. We teach them to handle things in a better way. The SDC/LPN stated she had to in-service two CNAs (Staff J and Staff K) 1:1 related to customer service. She stated the residents complained about their behavior. The SDC/LPN said, I would not call it abusive, maybe insensitive. On 6/21/25 at 11:35 a.m. an interview was conducted with Staff C, CNA. She stated this was her first real job. She stated she was learning from the environment. Staff C stated a resident had a care issue with her, [Resident #11]. Staff C said, She does not want me to care for her related to something someone did to her when she was 14. I don't know what I had to do with it. I was advised not to go there by myself. She will claim I did not give her water, or she was stating I was neglecting her, like not changing her and stuff. They investigated, they spoke with her to get her side of the story. The end result they advised me not to go in there. Staff C stated she had not received customer service education. She said, Not that I know of. I did online training when I was hired, but not anything to do with that. Staff C stated she had received Abuse and Neglect training, most recently two weeks ago. She stated the SDC/LPN did it. She stated, She came and said, 'sign this paper about what not to do and how to care for the residents.' Staff C stated there was no reason why the residents would express concerns about her caring for them. She said, If they tell me they have a problem with me, I tell them I'm new and I'm still learning. Staff C said, No, I have not reported anything. Yes, some residents say stuff. I can't name them now. On 6/21/25 at 2:54 p.m. an interview with the Risk Manager revealed the way she investigates a grievance. She said, First, when I receive the grievance, I go to the resident and ask them if they had been abused. If they say 'no,' then I do not pursue it further. She stated she did not interview the staff members named in the complaints because the residents did not explicitly say they were abused. She said, I see what you are saying, the resident does not have to use the word abuse. She agreed if the use words like rough or mean, she should look into it. She stated she did not consider the residents might have been fearful of staff when they say they were not abused or neglected. She stated she did not consider the psychological impact on the residents. She said, I did not consider the fear of retaliation. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 6/21/25 at 2:21 p.m. The NHA stated they take abuse and neglect allegations very seriously. He stated in the last 11 days, they had 11 reportables. He stated they have a lot of grievances documented, which indicates they are following their policy. He said some are related to customer services. He stated sometimes they will go to the resident, and the residents will immediately say there were no concerns or they're happy with care. He said, There needs to be a more robust investigation. He said, We need to have accountability. We are trying to change a culture. We have started a Gem program - for staff to immediately reward a resident or get them a special treat if they like. Review of a facility policy titled, Grievance Policy and Procedure, Revised March 2024, showed: Purpose: The center recognizes the guest/resident/legal representative/family has the right to voice grievances to the center without discrimination and without fear of reprisal. The center team members are responsible for making prompt efforts to resolve a grievance and to keep the guest/resident appropriately updated on the progress being made toward resolution. Definitions: Prompt effort to resolve includes the center's acknowledgment of a grievance and to actively work toward a documented resolution of that grievance. Policy: The Grievance Official and Social Services personnel will serve as guest/resident liaisons/advocates in the concern grievance procedure. 1. The center will support the right of the guests/residents to file a grievance anonymously. 2. The center will make information available on how to file a grievance to the guest/resident/legal representative/family. This can be done by providing the information directly to the guest/resident and/or by posting the procedure in prominent locations throughout the center. 3. The name and contact information (business address and email address and business phone number) for the Grievance Official will be posted in prominent locations throughout the center. The Grievance Official is the Social Service Director/designee of the center. 4. The guest/resident has the right to file a grievance orally or in written format. 5. The center will make a prompt effort to resolve any grievance received. Grievances will be reviewed, investigated, resolved and documented in five days. 6. The center team members will immediately report all alleged violations involving neglect, abuse, injury of unknown origin, and/or misappropriation of guest/resident property following the center abuse prohibition policy. 7. The center will review with the guest/resident/legal representative/family the final resolution of the grievance. 8. The guest/resident/legal representative/family have the right to obtain a written decision regarding the grievance. 9. The center will maintain the grievance and any supportive documentation for a period of not less than 3 years. Procedure: 5. a. The Grievance Official is responsible for the following items: 1. Overseeing the grievance process to include receiving and tracking grievances through to their conclusions to include the investigation, documentation of the summary and the follow-up. 2. Leading any necessary investigations. Review of a facility policy titled, Abuse/Neglect prohibition policy and procedure, effective March 2015, showed: Policy: The center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of resident property and maltreatment, including, but not limited to, freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. This includes the center's identification of residents whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, observing for changes that would trigger abusive behavior, reassessment of the interventions on a regular basis. The center will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; have a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property or have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, misappropriation of property or mistreatment. This center reports suspicions of crimes committed against a resident of this center in accordance with section 1150B of the Social Security Act to at least one law enforcement agency and the State Survey Agency. Definitions: Psychological abuse is defined as: humiliation, harassment, malicious teasing, and threats of punishment or deprivation. Verbal abuse is defined as the use of oral, written, or gestured language. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to; threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. Neglect is the failure of the center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Mistreatment: Inappropriate treatment or exploitation of a resident. Procedure: 3. Employee Obligation: all employees have a duty to respect the rights of all residents, to treat them with dignity and to prevent others from violating the resident's rights. Any employee who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source of origin and misappropriation of resident property, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury to the immediate supervisor, or the Director of Quality Assurance, or the Executive Director of the center. 5. Identification: Reporting of suspected maltreatment is required of all team members. All incidents will be reviewed by the center's QAPI Committee for detection of patterns and/or trends. Non-action, which results in emotional, psychological, or physical injury, is viewed in the same manner as that caused by improper or excessive action. All actions in which employees engage with residents must have as their legitimate goal, the healthful, proper, and humane care and treatment of the resident.

Based on interview and record review, the facility failed to follow the comprehensive person-centered care plan for three (#2, #4, #5) of three sampled residents related to bed mobility and transfers. Findings included: 1. Resident #2 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to traumatic subarachnoid hemorrhage without loss of consciousness on 08/18/2021; orthostatic hypotension, intervertebral disc displacement, lumbar region; other specified disorders of the brain; diabetes; anemia; adult failure to thrive; unspecified dementia severe; Cognitive Communication Deficit; stage 3 chronic kidney disease; Chronic Obstructive Pulmonary Disease, tremor, low back pain, hypertensive chronic kidney disease and spondylosis. Review of the Care Plans showed: ADL (Activities of Daily Living) Self-Care and/or mobility deficit. Resident #2 was at risk of developing complications associated with decreased ADL self-performance related to: weakness, tremors, often chooses to not get out of bed as of 08/19/2021 and revised 02/03/2025. Interventions included but not limited to: Bed Mobility are total assist of 2 related to air mattress; Transfers are total assist of 2 with the mechanical lift; Bathing was total assist of 2; Toileting was total assist of 2 as of 10/05/2023. Review of the ADL Tasks dated 01/12/2025 to 01/31/2025 Bed Mobility-how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required total dependence assistance for 34 out of 44 opportunities Bed Mobility required extensive assistance for 6 out of 44 opportunities Bed Mobility required limited assistance for 2 out of 44 opportunities Bed Mobility required resident not available for 1 out of 44 opportunities Bed Mobility is not applicable for 1 out of 44 opportunities Bed Mobility- how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required two + persons physical assistance for 5 out of 43 opportunities Bed Mobility required one-person physical assistance for 37 out of 43 opportunities Bed Mobility required resident not available for 1 out of 43 opportunities During an interview on 02/10/2025 at 12:06 p.m., the Director of Nursing (DON) and Risk Manager (RM) revealed the following information. On 01/13/2025 at approximately 8:00 a.m., Staff A, Certified Nursing Assistant (CNA) was trying to turn Resident #2 on his left side. He was facing away from her. While she was changing his brief, he rolled off the mattress. The RM started the investigation on 01/13/2025 and spoke with Staff A, CNA, regarding details. The RM reviewed the resident's care plan and noted the resident was a two person assist for bed mobility. The RM gave one on one education to Staff A, CNA. The DON and the RM stated they performed an audit of all the care plans of residents on air mattresses to ensure their care plans showed two persons assist. They stated they were all in compliance. 2. Resident #4 was admitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to spinal stenosis of the cervical region, asthma, a history of traumatic brain injury, weakness, and history of falls. Review of the Care Plans showed: Resident #4 had ADL self-care and /or mobility deficit. Needed assistance with ADLs, at risk of developing complications associated with decreased ADL self-performance related to disease process/condition, weakness, asthma, migraines, morbid obesity as of 09/10/2024 and revised 01/10/2025. Interventions included but not limited to: Bed Mobility are total assistance of 2 related to air mattress; Transfers are total assist of 2 with the mechanical lift; Bathing was total assist of 2; Toileting was total assist of 2 as of 09/10/2024 and revised on 01/29/2025. Review of the ADL Tasks dated 01/12/2025 to 02/10/2025 Bed Mobility-how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required total dependence assistance for 58 out of 86 opportunities Bed Mobility required extensive assistance for 24 out of 86 opportunities Bed Mobility required limited assistance for 3 out of 86 opportunities Bed Mobility required independent assistance for 1 out of 86 opportunities Bed Mobility- how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required two + persons physical assistance for 12 out of 86 opportunities Bed Mobility required one-person physical assistance for 74 out of 86 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required total dependence for 21 of 30 opportunities Transfers required extensive assistance for 7 of 30 opportunities Transfers required limited assistance for 2 of 30 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required two + persons physical assistance for 18 out of 30 opportunities Transfers required one-person physical assistance for 12 out of 30 opportunities During an interview on 02/10/2025 at 3:07 p.m., the DON verified Resident #4 was a 2-persons assist for bed mobility and transfers. The DON verified the documentation showed the staff was performing 1-person assists for bed mobility and transfers. The DON stated she would expect to see 2-persons assist for this resident. 3. Resident #5 was admitted on [DATE] and readmitted on [DATE]. Review of the Admission Record showed diagnoses included but not limited to displaced intertrochanteric fracture of left femur, orthopedic aftercare; osteoarthritis (OA) of left hip, congestive heart failure (CHF), ischemic cardiomyopathy; dementia, history of falls, history of traumatic brain injury on 09/24/2024, delirium due to known psychological condition, hypotension. Review of the Care Plans showed: Resident #5 had ADL self-care and/or mobility deficit. Resident needed assistance with ADL's and was at risk of developing complications associated with decreased ADL self-performance related to left intertrochanteric femur fracture status post-surgery, weight bearing as tolerated left lower extremity, OA left hip, dementia, CHF, disease process/condition, weakness as of 06/01/2024 and revised on 11/21/2024. Interventions included but not limited to: Bed Mobility are limited assistance of 2; Transfers are limited assistance of 2; Toileting are limited assist of 2. Review of the ADL Tasks dated 01/12/2025 to 02/10/2025 Bed Mobility-how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required total dependence assistance for 5 out of 83 opportunities Bed Mobility required extensive assistance for 25 out of 86 opportunities Bed Mobility required limited assistance for 32 out of 83 opportunities Bed Mobility required independent assistance for 21 out of 83 opportunities Bed Mobility- how resident moves to and from a lying position, turns side to side, and positions body while in bed: Bed Mobility required two + persons physical assistance for 1 out of 83 opportunities Bed Mobility required one-person physical assistance for 61 out of 83 opportunities Bed Mobility required set up only for assistance for 2 out of 83 opportunities Bed Mobility required no set up or physical help from staff for 19 out of 83 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required total dependence for 4 of 54 opportunities Transfers required extensive assistance for 7 of 54 opportunities Transfers required limited assistance for 27 of 54 opportunities Transfers required supervision for 16 of 54 opportunities Transfers-How resident moves between surfaces including to or from bed, chair, wheelchair, standing position Transfers required two + persons physical assistance for 0 out of 54 opportunities Transfers required one-person physical assistance for 38 out of 54 opportunities Transfers required set up only for 16 out of 54 opportunities During an interview on 02/10/2025 at 3:07 p.m., the DON verified Resident #5 was care planned for a 2-person limited assist for bed mobility and transfers. The DON verified the documentation showed the resident was only being assisted by one person for bed mobility and transfers. The DON stated she would expect to see the resident receive 2-person assistance. The DON stated she would have to have therapy to re-evaluate the resident. The DON stated she needed an evaluation to update the resident's transfer status. During an interview on 02/10/2025 at 3:58 p.m., the MDS RN (Minimum Data Set, Registered Nurse) stated a therapy evaluation was completed as well as a nursing assessment from which a baseline for the resident was formed. The assessment was performed quarterly or for a significant change. She stated the aides would let us know of a decline in the resident and we would have therapy re-evaluate. The aides were to follow the Kardex / care plan and if it said 2-person assist, that was what they were supposed to do. The Interdisciplinary team met for morning meetings to discuss any changes. Review of the facility's policy, Person-Centered Comprehensive Care Plan, dated October 2022 showed it is the practice of the center to develop and implement a person-centered comprehensive care plan that include measurable objectives and time frames to meet their preferences and goals, and address the guest / resident's nursing, medical, physical, mental, and psychosocial needs. The conference care plan will be developed within 7 days after completion of the comprehensive assessment and no more than 21 days after admission. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest / resident's condition. The interdisciplinary team will work collaboratively with the guest/resident, responsible party and or family members to develop a comprehensive person-centered care plan that encompasses each guest/resident's personal preferences, goals, and objectives. The comprehensive person-centered care plan will address the following services: Services to be furnished to attain or maintain the guest/resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interviews, and record review, the facility failed to ensure three (#320, #62, #321) of four residents reviewed for falls out of a total sample of 53 residents received accurate evaluations of fall risks to ensure adequate supervision, assistance devices, and individualized interventions were implemented to prevent accidents with injuries. Findings included: 1. Review of the Admission Record revealed Resident #321 was originally admitted to the facility on [DATE] with diagnoses to include: history of falling, difficulty in walking, pain in left hip, muscle weakness, unspecified dementia, cognitive communication deficit, essential hypertension, and history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. The resident had a recent hospital stay from 2/16/2024 to 2/24/20224 when she was readmitted back to the facility. The Admission Record showed an additional diagnosis of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter dated 2/24/2024 following the recent hospitalization . During an interview with Resident #321's family member on 2/27/2024 at 10:24 AM, they revealed Resident #321 had a fall shortly after being admitted to the facility on [DATE]. She stated the staff don't come quickly enough when the call bell is pushed. The family member reported that it could take 20 minutes for the staff to come when she has visited. The family member stated the staff only came after she went to the nurses' station to request assistance because staff were not responding to the call light. On 2/26/2024 at 11:47 AM Resident #321 was observed lying in bed on a scoop mattress with floor mats on both sides of the bed. Review of Resident #321's clinical record revealed an eINTERACT SBAR (Situation, Background, Appearance, and Review) Communication Form dated 2/16/2024. The form revealed the Situation/change in condition was falls, and it was unknown if this had occurred before. The Background section revealed the resident was in the facility for post-acute care with a history of dementia. The Appearance section documented the nurse called this writer (Licensed Practical Nurse [LPN], Staff F) to patient's room. Resident noted on floor bleeding from left side of head. Urinary catheter in place and attached to bed frame. The Review section revealed the primary care clinician ordered the resident to be sent to the hospital and the family member was notified. Review of the Skilled Nursing Facility (SNF) to Hospital Transfer Form revealed the resident was transferred to an acute care hospital on 2/16/24 at 12:00 AM from the facility's Rehab Unit. The resident's usual functional status before the acute change in condition showed the resident ambulated with an assistive device, was totally dependent on staff for bathing, dressing, and toileting and needed assistance with transfers. The resident's usual mental status before the acute change was alert, disoriented, but can follow simple instructions. Risk alerts was checked for high fall risk. A review of the hospital History and Physical, dated 2/16/2024, revealed Resident #321 had an assessment of status post closed head injury; left parafalcine traumatic subdural hemorrhage with no mass effect as well as a large left frontal scalp hematoma status post unwitnessed fall. Resident was evaluated by neurosurgery in the emergency room and recommended ICU (Intensive Care Unit) admission for close monitoring. Plan included no surgical intervention, patient cleared for discharge back to rehabilitation from neurosurgical viewpoint on 2/24/2024. A review of the 02/15/2024 Admission Minimum Data Set (MDS) assessment revealed a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The resident displayed inattentive behavior that fluctuated (comes and goes, changes in severity). The resident had a history of falls, and falls in the last 2-6 months prior to admission was marked unable to determine. The resident had lower extremity impairment on both sides and required substantial/maximum assistance with mobility, lower body dressing and toileting. Review of Resident #321's Care Plan showed a focus concern (initiated 2/13/2024 and revised 2/16/2024) for Risk for further falls related to: Decreased lower extremity strength, h/o [history of] fall, dementia with Poor safety awareness, Unsteady gait/balance, bowel incontinence, balance deficit, decreased activity intolerance. The Goal for the focus concern (initiated 2/13/2024 with a target date of 2/28/2024) was Will strive to have falls and/or injuries minimized thru management of risk factors while maintaining independence and quality of life through the review date. All interventions to meet the goal were initiated on 2/13/2024 and included: Encourage appropriate foot wear Place items used in easy reach i.e. water, telephone, call lights; Physical Therapy (PT) and Occupation Therapy (OT) to screen prn (as needed); Keep adaptive equipment within reach Check for toileting needs Encourage frequent rest periods Review of Resident #321's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 2/12/2024, showed resident to be at risk for falls. Resident #321's AHCA Form 5000-3008 dated 2/18/2024, showed resident to be at risk for falls. Review of Resident #321's Medication Administration Record (MAR) for February 2024 revealed she was receiving: Amlodipine (antihypertensive), Metoprolol (antihypertensive), Pravastatin (antihypertensive), Senna Lax (cathartic), Dulcolax (cathartic), GlycoLax Powder (cathartic), Milk of Magnesia(cathartic), Tramadol (narcotic), and other medications. Review of Resident #321's Fall Risk Evaluation dated 2/12/2024 showed the resident had 1-2 falls in past 3 months, was alert (oriented x 3), was chairbound/continent; and had no predisposing diseases. The sections for systolic blood pressure, gait/balance, and medications were not completed. Because these sections were not completed the fall risk score was not calculated accurately to indicate if the resident was at high risk of falls and no focus care areas, interventions or clinical suggestions were completed to assist in the prevention of falls. On 2/28/2024 at 1:10 PM, Resident #321 was observed sitting in the room lying in the bed. The resident stated, I fell . The resident had no other recollection of a fall and was not able to verbalize what happened. During an interview on 2/28/2024 at 1:15 PM Staff F, LPN reported Resident #321's fall occurred on 2/16/2024 very early in the morning. Staff F reported she was working another hall when the Cart 1 nurse called for me in response to Certified Nursing Assistant's (CNA) call that Resident #321 was on the floor. When I arrived to the room, Resident #321 was lying on her back near the bathroom door. Her head was bleeding, and she was complaining of pain. Staff F stated Resident #321 had a foley catheter, which was still intact, even though the bag was still attached to the bed frame. During an interview on 2/28/2024 at 1:36 PM Staff J, Registered Nurse (RN) stated she reviewed Resident #321's hospital records and family information to complete the evaluations. She reported Resident #321 has a low bed. Staff J, RN reviewed the CNA Kardex and tasks and stated nothing is showing on the task/Kardex that would indicated Resident #321 is a fall risk. Staff J stated the CNAs would know Resident #321 was a fall risk by verbal report to one another. During an interview on 2/28/2024 at 2:00 PM the Nursing Home Administrator (NHA) stated she does not know about the falls and to speak with Director of Nursing (DON). During an interview on 2/28/2024 at 2:05 PM the Director of Nursing (DON) stated the Risk Manager (RM) takes responsibility for fall investigations. During an interview on 2/28/2024 at 2:10 PM the RM stated she does not have any information regarding the fall for Resident #321 and would need to follow up. Follow up interview on 2/28/2024 at 4:19 PM with the RM revealed she was just finding out about the fall of Resident #321. The RM confirmed the medical record showed Resident #321 was admitted back to the facility on [DATE] status post fall with a subdural hematoma. The RM continued to state the Fall Evaluation was not completed appropriately for the 2/12/2024 admission. The RM reported that the Fall Evaluation left off a number of factors that would have increased Resident #321's score. The RM validated that no Fall Evaluation had been completed upon Resident #321's return to the facility on [DATE]. The RM stated a Fall Evaluation should be completed for all admissions and after every fall. The RM confirmed Resident #321's care plan had not been updated after her most recent fall on 2/16/2024. 2. Review of the Admission Record revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Left hip artificial joint, after care following joint replacement, osteoarthritis, rheumatoid arthritis, spinal stenosis, lumbar region, anxiety disorder, depression, muscle weakness, and difficulty in walking. Upon readmission on 1/9/2024 the following diagnosis was added: periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, incomplete rotator cuff tear or rupture of left and right shoulder traumatic subdural hemorrhage. Review of a MDS with an assessment reference date of 1/5/2024 for Resident #62 revealed a BIMS score of 4 indicating severe cognitive impairment. The resident displayed inattentive behavior that fluctuated (comes and goes, changes in severity). The resident had lower extremity impairment on one side and required partial/moderate assistance with mobility. Review of the Progress Notes for Resident #62 revealed Resident #62 was transferred to an acute care hospital on 1/7/2024 at 3:35 PM due to a fall. Resident #62 was readmitted on [DATE]. Review of Resident #62's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 12/31/2023, showed resident to be at risk for falls. Resident #62's AHCA Form 5000-3008 dated 1/9/2024, showed resident to be at risk for falls. Resident #62's AHCA Form 5000-3008 dated 1/15/2024, showed resident to be at risk for falls. Review of Resident #62's MAR for January 2024 revealed the resident was receiving: Buspirone HCl (psychotropic), Fluoxetine HCl (psychotropic), GlycoLax Powder (cathartic), Senna Lax (cathartic), Bupropion HCl (psychotropic), Dulcolax (cathartic), Milk of Magnesia (cathartic), Tramadol (narcotic), and other medications. Review of Resident #62's Fall Risk Evaluation dated 1/2/2024 showed the resident had 1-2 falls in past 3 months, was alert (oriented x 3), and had 1-2 predisposing diseases. The sections for ambulation/elimination status, gait/balance, and medications were not completed. Because these sections were not completed the fall risk score was not calculated accurately to indicate if the resident was at high risk of falls and no focus care areas, interventions or clinical suggestions were completed to assist in the prevention of subsequent falls. Review of Resident #62's Fall Risk Evaluation dated 1/10/2024 showed the evaluation was incomplete for the section of level of consciousness/mental status. Based on the completion of the other sections of the evaluation, the resident scored a 16 (Score 10 or higher indicated high risk of fall); however, the Risk for Falls focus, goals, interventions and clinical suggestions to prevent future falls was not completed. Review of Resident #62's Care Plan showed a focus concern of risk for falls related to: Unsteady gait/balance due to recent left hip replacement, antidepressant medication, and incontinency (created 1/2/2024, initiated 1/22/2024, and revised 1/26/2024). The Goal: will strive to have falls and or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date (created 1/2/2024, initiated and revised 1/22/2024). Interventions to meet this goal created 1/2/2024 and initiated 1/22/2024 included: Place items used in easy reach i.e. water, telephone, call lights PT and OT to screen prn (as needed) Keep adaptive equipment within reach Check for toileting needs Interventions dated 1/11/2024 showed: TTWB LLE (Toe Touch Weight Bearing Left Lower Extremity). During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) reviewed Resident #62's Fall Evaluation and admission documentation and stated the Fall Evaluation was not accurate. Staff J reported the information missed would have resulted in a higher score and would have placed the resident at moderate risk for falls. Staff J, RN confirmed that the care plan was not individualized for Resident #62 and had not been updated after the fall that resulted in a fracture. 3. Review of the Admission Record revealed Resident #320 was admitted to the facility on [DATE], with diagnoses to include: Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Difficulty Walking, Anxiety Disorder, Diabetes Type 2, Anemia, and Monoplegia of upper limb following Cerebral Infarction. Review of Resident #320's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 1/5/2024, showed resident to be at risk for falls. Review of Resident #320's Physician Order Summary Report active as of 1/14/2024 revealed resident was receiving: Alprazolam (psychotropic), Diphenhydramine HCl (antihistamine), Bupropion HCl (psychotropic), Dicyclomine HCl (cathartic), Dulcolax (cathartic), GlycoLax Powder (cathartic), Guaifenesin ER (antihistamine), Labetalol HCl (antihypertensive), Lasix (diuretic), Linzess (cathartic), Milk of Magnesia(cathartic) , Oxycodone-Acetaminophen (narcotic), Sertraline HCl (psychotropic), and other medications. Review of Resident #320's Fall Risk Evaluation effective 1/6//2024 showed the sections for systolic blood pressure and predisposing disease were not completed. Because these sections were not completed the fall risk score was not calculated accurately to indicate if the resident was at high risk of falls and no focus care areas, interventions or clinical suggestions were completed to assist in the prevention of subsequent falls. Review of Resident #320's progress note dated 1/14/2024 at 10:40 AM showed CNA found resident on the floor. Nurse noted resident was lying face down on floor next to the bed. Resident had complaints of pain all over. Supervisor alerted, 911 called. Son and physician notified. Review of the Local County Emergency Medical Services Patient Care Report dated 1/14/2024 at 9:50 AM reveals Resident #320 was found by the Paramedics in bed with care staff at bedside. Patient Primary complaint of a headache. Patient is alert to person, place and event and reports she reached for nurse call button and fell out of bed. Complains of left sided head pain denies loss of consciousness. Review of Resident #320's Care Plan showed a focus concern of risk for further falls related to: daily use of Antidepressants, history of falls, Unsteady gait/balance, occasional bladder accidents (created 1/6/2024, revised 1/11/2024). The Goal for the focus concern was: will strive to have falls and/or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date (created 1/6/2024). The interventions to assist in meeting the goal were Interventions dated 1/6/2024 included: Place items used in easy reach i.e. water, telephone, call lights; PT and OT to screen prn (as needed); Keep adaptive equipment within reach Check for toileting needs Interventions dated 1/11/2024 included: Encourage appropriate foot wear and frequent rest periods. During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) reviewed Resident #320's Fall Evaluation and admission documentation and stated the Fall Evaluation was not accurate. The information missed would have resulted in a higher score. The score would have placed the resident at high risk for falls. Staff J, RN confirmed that the care plan was not individualized for Resident #320. During an interview on 2/28/2024 at 10:05 AM Staff D, Certified Nursing Assistant (CNA) stated, I just know how to care for residents, I've been doing this a long time. Staff D, CNA continued to state they don't really have a way to know if a resident is a fall risk. Most of the residents on this unit (Rehab) are oriented. An interview was conducted with Staff FF, CNA on 2/28/2024 at 1:10 PM. Staff FF, CNA stated she just knows how to care for residents. There is not any documentation we need to refer to regarding care. Staff FF, CNA stated, we don't need to treat anyone differently. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 2/28/2024 at 1:15 PM. Staff F, LPN stated when a resident is admitted the nurse reviews the hospital transfer form and any attached orders. The nurse receives a nurse to nurse report regarding the resident. This verbal report gives us a short description of the resident's diagnosis, health status, behavior, and any unusual events, falls and orientation status would be included in this report. With all of this information the nurse is able to complete the facility required documentation, including the Fall Risk Evaluation. We usually put the same interventions in place for all admits. During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) stated the nurse reviews the orders from the hospital to include the hospital transfer form. This information will give us insight on how to complete the evaluations for admission. Sometimes, the family is present and will assist with some of the history if needed. We usually put the same interventions in for all new residents. The information entered in the evaluation assists with the resident's care plan. The care plan links to the CNA Kardex. The Kardex is the document the CNAs utilize to care for the resident. The CNAs also know by verbal report from the nurse at times, if there is nothing on the Kardex. During an interview on 2/28/2024 at 5:18 PM with Staff U, LPN/Supervisor said on all admissions she double checks the evaluations to ensure nothing got missed. The baseline care plan is developed from the evaluations and given to the family. We tailor the care plan based on the evaluations and information is added as it is learned. An interview was conducted on 2/29/2024 at 9:06 AM with the Director of Nursing (DON). The DON stated the nurse admitting the resident completes the Fall Evaluation based on the information they have from the hospital and family. The nurse implements a generic care plan for falls. The supervisor for the shift will review the information for accuracy and update as needed. Therapy will see the resident the following day and assist with updating the care plan, as necessary. The Interdisciplinary Team meets with the family and reviews the baseline care plan with them within 48 hours of admission. We complete an Interdisciplinary Plan of Care Summary (IPOC). If the family is not available to meet in person we complete with them via the phone. The Care Plan Coordinators take over the updating of the care plans after this. During an interview on 2/28/2024 at 10:00 AM the Risk Manager (RM) stated the Fall Evaluation gives a score to alert the staff if the resident is at high risk of falls. This would alert them to ensure additional interventions are in place for the resident. During an interview on 2/29/2024 at 1:13 PM with the Medical Director. The Medical Director stated he is in the facility several times per week and attends the monthly Quality Assurance Meeting. During the meetings the committee discusses several quality related items, for example; response times of call lights, falls, vaccinations and infection rates to name a few. In relation to falls we discuss total numbers. The goal is to minimize injury and identify a resident at admission for fall risks as this would lead to implementation of appropriate measures to prevent a fall with injury. My expectation would be the nurses identify the resident at the time of admission for correct fall risk. The nurse should take the extra minute to review the documentation to determine the correct risk elements. Review of the facility policy titled, Nursing/Risk Management-Risk Evaluation for Falls dated July 2017. Purpose: to identify and address risk factors associated with resident falls, to determine the need for any special care, assistive device or equipment needs, assist with resident care planning needs and to confirm the continued accuracy of the evaluation Post Admission within 24 hours of admission, a risk evaluation for falls will be completed to confirm the continued accuracy of the evaluation and to assist with resident care planning Post-Fall 1. Post fall a team meeting of all available should occur. The goal is to huddle, discuss and assess the area of the fall and surroundings prior to the end of shift. This meeting initiates the investigation process. The team should become comprised of the fall ambassador or therapist on duty that shift, nursing team members and housekeeping. The post fall evaluation should be completed by the nurse 2. Therapy should screen for every post fall event 3. Interdisciplinary team (IDT) note will be utilized for documentation of repeat fall review and new fall related interventions . Review of the facility policy titled nursing/risk management-documentation of resident fall dated June 2021. Nursing documentation-resident fall when a resident fall occurs, a detailed narrative description will be documented on the SBAR. Evaluation and documentation will continue each shift for 72 hours using the 72 eval in [the electronic medical record] this narrative nursing note should include: 1. Date, time, and place of accident 2. A witnessed fall: if the fall was witnessed, describe what you saw if witnessed by another, document reported that 3. Unwitnessed fall: if unwitnessed, describe the position and location of the resident 4. Resident statement: document what the resident said regarding the fall. The statements made at the time of the fall are often most accurate 5. Condition of resident: * note the residence mental status at the time of the fall. If there is no change, document no change * obtained vital signs and compare to usual vital signs. Initiate neurological check when head injury is possible or if the fall was unwitnessed * document complaints of pain, using pain scale or no complaints of pain * document any visual signs of injury and evaluate for usual range of motion 6. Where was resident moved -injury: if possible, head, hip, or back injury, evaluate whether residents should be moved to bed. Emergency transport to hospital? How was resident moved? Number of people, lift, etc.? 7. Where was resident moved-no injury: if no injury, documented resident went to bed, sat in chair, continued inactivity 8. Document all resulting actions/interventions to care for the resident 9. Notification-physician: document full conversations to the physician concerning your evaluation(s), your intervention(s), and orders or directives received 10. Notification-legal representative: document all notifications. Indicate time and name of person information was relayed to. Document responsive person identified 11. Review and revise the care plan with new intervention(s) Review of the facility Guideline for Person-centered Comprehensive Care Plan with Effective Date: October 2022 revealed: Guideline: it is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and time frames to meet the preferences and goals, and address the guest/residents nursing, medical, physical, mental, and psychosocial needs The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition.

Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for four of four residents sampled for PASARRs (Residents #16, #20, #74 and #71). Findings included: 1. Review of the electronic medical record (EMR) revealed Resident #16 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder date 4/26/23, major depressive disorder date 7/14/23, schizoaffective disorder bipolar type date 6/20/23 and anxiety disorder date 4/26/23. Review of a level I PASARR for Resident #16 dated 04/25/23 showed the qualifying diagnoses were not checked or indicated. Further review showed a level II PASARR not submitted following qualifying diagnoses of schizoaffective disorder. 2. Review of the EMR for Resident #20 revealed the resident was admitted to the facility on [DATE] with diagnoses to include major depressive disorder. Review of a level I PASARR for Resident #20 dated 07/01/23 showed qualifying diagnoses were not checked or indicated. On 02/29/24 at 04:14 p.m., an interview was conducted with the Director of Nursing (DON). She stated she does not do PASARRs. She stated social services should be doing them. On 02/29/24 at 04:19 p.m., an interview was conducted with the facility's Social Services Directors (SSD). The SSD stated they did not do PASARRs, saying they did not have the qualifying licenses. The SSD stated they did not have access to the system. They stated they had discussed it at a recent morning meeting, and agreed the clinical staff should take the lead. On 02/29/24 at 04:28 p.m., a follow-up interview was conducted with the Nursing Home Administrator (NHA) and the Risk Manager. The NHA stated nursing/clinical staff should take the lead on completing PASARRs. She stated they did not have access to the system at the time. She stated they could print them and get them done that way. The NHA said, we are behind. I wish I could tell you otherwise. The NHA stated they did not have a PASARR policy. 37999 3. Review of Resident #71's Admission Record revealed the resident was admitted on [DATE], 11/2/22, and recently on 2/25/24. The record included diagnoses not limited to End Stage Renal Disease, mild cognitive impairment of uncertain or unknown etiology (onset 8/25/23), and adjustment disorder with depressed mood (onset 3/24/22). Review of Resident #71's Preadmission Screening and Resident Review (PASARR), dated 7/8/23, did not show the resident had any mental illness (MI), suspected mental illness (SMI). intellectual disability (ID), or suspected intellectual disability (SID). The PASARR showed the resident did not have a diagnosis or suspicion of SMI or ID and a Level II PASARR evaluation was not required. Review of Resident #71's PASRR did not show the resident's diagnosis of adjustment disorder with depressed mood was included in the screening. 4. Review of Resident #74's Admission Record revealed the resident was admitted on [DATE]. The record included diagnoses at the time of admission not limited to unspecified Alzheimer's disease, unspecified depression, and unspecified anxiety. Review of Resident #74's Preadmission Screening and Resident Review (PASARR), dated 11/20/23, showed the resident had diagnoses of anxiety and depressive disorders. Review of Resident #74's PASARR did not show the resident's diagnosis of Alzheimer's disease.

Based on interviews and record review, the facility failed to ensure grievances were addressed in a timely manner for resident council members with potential to affect a census of 135. Findings included: On 02/26/24 at 2:05 p.m., an interview was conducted with Resident #17, who was the Resident Council President. She stated the primary complaints that were on-going were related to food, care, and call bells not answered. She stated the residents complain the issues have not changed and are still ongoing. She stated the Director of Activities (DOA) reports to the DON after each meeting. She stated she would let her know what was discussed at the meeting. Resident #17 said, The problem is they don't have consistency, because they use lots of agency aides. The agency aides makes care more difficult because they don't know the residents or their needs. Some of them don't care. Yes, we have presented grievances through resident council. On 2/27/24 at 1:20 p.m., a Resident Council meeting was held with 11 residents in attendance. The DOA and the Director of Nursing (DON) facilitated the meeting. Resident #35 voiced concerns to include, They take forever to answer call lights. They take a long time, sometimes up to 1 hour. There are too many temporary/agency staff. Residents who are dependent on staff receive the worst of it, especially from C- wing. They can't speak for themselves. The DON stated to Resident #35 they would educate the CNAs (Certified Nursing Assistants). The attendees were observed nodding in agreement as Resident #35 spoke. A follow -up was conducted with the Resident Council group on 02/27/24 at 1:35 p.m. The residents stated to the surveyor, they wait a long time for care, staff do not respond in a timely manner. Resident #273 said, call lights are useless. They don't answer them. They can go off for 2 hours. I had put on a call light and waited 45 minutes. The staff see the call light, they don't respond Resident #16 stated her call light did not work and if it did, it is not answered. Resident #17 stated they had brought it up at every resident council meeting. Resident #93 said, I walked around the nurse's station the other day. There were 3 CNA's [certified nursing assistants] at the nurse's station, just talking. Call lights were going off. No one was answering. The residents stated the supervisors were not watching and the aides were not doing their job. Resident #17 stated the Nursing Home Administrator (NHA) was aware of their grievances. She stated she receives the meeting minutes. The residents stated if they make suggestions or voice concerns related to staffing, the facility does not respond. On 02/27/24 at 2:10 p.m., an interview was conducted with the DOA and the DON. The DOA said, I usually have forms with me. We fill them out if we determine if the issue was a grievance or a concern and bring it to the Social Services Director (SSD). The DOA stated the grievance is forwarded to the relevant department such as housekeeping or nursing. She confirmed she did not document resident council grievances. The DON stated call lights should be answered promptly to ensure the needs of their residents were met. A review of the facility's grievance logs dated August 2023 to February 2024 showed resident council grievances were not documented. Continued review revealed: -Review of a grievance for Resident #324 dated 02/27/24 showed, Dissatisfied with call light response time. -Review of a grievance for Resident #275 dated 01/31/24 showed, Resident and family stating that resident's call light is not being answered in a timely manner. Resident stated [I know the girls are busy. If they can just set me on the toilet for a while and then come back] Resident #275's family reported this had happened multiple times. -A grievance for Resident #276 filed on 1/27/24 revealed, CNA answered call light at 1:55 p.m. on [NAME] 1/26/24. The resident asked to be changed and taken to the restroom. The CNA said she would be back. Resident waited until 3:55 p.m. to get assistance from her. -Review of a grievance for Resident #22 dated 1/10/24 showed, light was on Sunday at 20:00 no one answered. Resident got himself to the wheelchair at 21:30. Went to the nurse's station. Call lights were on. CNA's and supervisor sitting at the desk. Begged for care . -A grievance for Resident #277 dated 12/27/23 showed, Unhappy with call light response time . Review of the summary of pertinent findings/conclusions for these grievances showed staff were educated. On 02/29/24 at 10:47 a.m. an interview was conducted with the SSD. He stated he had not received any grievances from resident council. He stated he has spoken to the DOA about it. He stated his experience has been if residents bring up a consensus complaint, it should be documented as so. The SSD stated he was aware the residents complain about call lights not being answered in a timely manner. He said, We discuss it in morning meetings. After resident council, the DOA discusses it with us. I have told her she needs to write it down as a grievance. On 02/29/24 at 11:52 a.m. an interview was conducted with the Nursing Home Administrator (NHA). She stated she last attended a council meeting in November or December. She stated the residents ask her questions and she answers them. She stated the repeated concerns included call lights. The NHA said, this comes up in most resident councils. I do education and audits, try, and figure out the root cause. These concerns have been on-going, I'd say forever. Residents complain when the staff are not going to come within 2 minutes. I have educated them to have reasonable expectations. I have some residents who are a little bit more impatient. The NHA stated if residents bring up grievances in resident council, they should be documented. The resolution should be documented. She stated resident council concerns should be discussed with the relevant department and then put a plan in place to correct the grievance. The NHA stated their plan to address the on-going concerns related to call lights was to bring it up during orientation, training and conduct on -going audits. She stated if/when they have found particular aides who are not compliant, they address them. If it was an agency aide, they are asked not to return. Review of a facility policy titled, Grievance Policy and Procedure, dated July 2018, showed it was the policy of the center to recognize the resident/legal representative/family has the right to voice grievances and recommendations for changes through an orderly and timely process, free from discrimination and/or reprisal. They have a right to expect the center will make prompt efforts to resolve grievances and, upon request, have the right to obtain written decision regarding the grievance. 7. The grievance officer will oversee the grievance process, receiving and tracking grievances through their conclusions through investigating, document and follow-up on formal concerns and grievances registered by any resident/legal representative/family concerned party. 21. Group grievances generated in resident council meetings will be reviewed by the grievance official and determination will be made on a case-by-case basis whether to initiate and follow the grievance process described in the policy. (a.) All resident council group grievances will be copied and logged on the monthly grievance log. (b.) The grievance official will assist Life enrichment in resolving group grievances.

Based on observations, interviews and medical record review, the facility failed to implement care plan interventions for four of fifty-three sampled residents (#106, #39, #109, #94), as evidenced by:1.) Staff not providing Resident #106 with a call light within his reach, while in bed and during two days observed (2/26/2024, 2/27/2024); 2.) Staff not performing and/or documenting monitoring of psychotropic medication use for Resident #106; 3.) Staff not coordinating dental services as needed for Resident #39; and 4). Failure to provide rehabilitation and restorative services for residents #109, and #94. Findings included: 1. On 2/26/2024 at 1:34 p.m. and at 2:20 p.m., Resident #106 was observed in his room and lying flat in a low to the floor bed, and with covers pulled over him. He was noted resting comfortably with his eyes closed. The call light button and cord were observed lying on the floor on one side of the dresser and close to the roommate's side of the room. The call light was not within Resident #106's reach, should he need to use it to get staff assistance. On 2/27/2024 at 8:20 a.m. Resident #106 was observed in his room and lying flat in a low bed. The call light cord and button (soft bulb) was observed on the floor behind the left side of the bed and at the wall floor, unreachable by the resident. During both observed dates (2/26/2024 and 2/27/2024) various direct care staff were noted entering and exiting the resident's room without repositioning the call light to within his reach. On 2/27/2024 a phone interview was conducted with the resident's [family member]. The family member revealed the family lived out of state but visit every three weeks or so and will often find the call light on the floor and not within the resident's reach. The family member said he believed staff would put the call light out of his reach, so he does not continue to use it often. On 2/28/2024 at 7:50 a.m. an interview with Resident #106's sitter companion, who is provided by the resident's family to assist with meals, confirmed when she comes into the room at times in the morning, the call light is on the floor behind him or placed on the dresser back and behind his head. The sitter companion believed staff removed the call light from his reach so he would not continue to press the button all the time. Review of Resident #106's medical record revealed he was admitted on [DATE] and readmitted on [DATE]. Review of the advance directives revealed he had a Power of Attorney in place to make his medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Non-Traumatic Subarachnoid Hemorrhage, Hemiplegia, Dementia, Mood disturbance, Anxiety, Review of the Minimum Data Set (MDS) significant change assessment, dated 9/19/2023, and was the most current comprehensive MDS assessment revealed: Cognition/Brief Interview Mental Status score 3 of 15, which indicated Resident #106 would not have been able to express his medical and care decisions; ADL [activities of daily living] - Extensive two person assist with all ADLs. Review of the most recent Quarterly MDS assessment dated [DATE], revealed: Cognition /BIMS [brief interview for mental status] score 3 of 15, which indicated Resident #106 was cognitively impaired. Review of the current care plans with next review date 3/20/2024 revealed the following problem areas to include but not limited to: - Alteration in Mood State Verbal expressions of distress, Alterations in usual sleep cycle, Sad, Apathetic, Anxious Appearance, Lack of Motivational Interest, Other, with interventions in place to include: Consultation with psychological/psychiatric prn, Monitor effectiveness/side effects of medications as ordered, Report to physician changes in mood status - At risk for further falls and fall-related injuries related to: Left hemiplegia and aphasia due to recent ICH, daily use of antidepressant rx [therapy]. Incontinency, multiple recent falls, with interventions in place to include but not limited to: Move closer to nurse station when available (8/31/2023), Encourage to be out of room at nurse's station or activities when out of bed, Bed in lowest position, Place items used in easy reach i.e. water, telephone, CALL LIGHT, private sitter is not to leave resident alone in the room when up in wheelchair. Should inform staff when out of room, education provided. It was determined through observations that Resident #106 resided in the furthest room from the nurse station on the unit, and his call light was not placed within his reach while in bed, on a consistent basis. On 2/27/2024 at 2:25 p.m. Staff C, Certified Nursing Assistant (CNA) was interviewed with relation to Resident #106 daily care and routines. She confirmed that he uses the call light at times. Staff C confirmed the call light was placed back behind him on a dresser and out from his reach. Staff C confirmed the call light should be clipped on the resident's right side of the bed, and within his reach at all times when he is in bed. She further revealed that staff are to ensure placement of the call light within all residents reach in the building. Staff C further expressed if the call light does not work, or needs replaced, staff are to immediately put in a work order with maintenance. On 2/28/2024 at 9:20 a.m. an interview with the DON revealed she was familiar with the resident. The DON said she was not aware there had been times where the call light was not placed within Resident #106's reach, and that he does not really use it, but has used it before. She further confirmed through review of his current care plans he was supposed to be moved to a room closer to the nurse station, as per the care plan intervention date of 8/2023. The DON revealed she was not sure what happened with that intervention, and it should have been implemented. She also confirmed after review of the current care plans that the call light should be placed within Resident #106's reach at all times when he is in bed. On 2/29/2024 at 1:00 p.m. an interview with Staff A, Licensed Practical Nurse (LPN), who had Resident #106 on her assignment and who routinely has him on her daily assignment revealed, he does use his call light at times but not all the time. She revealed that regardless if a resident can use or not use the call light button, it should always be placed within his or her reach. 2. On 2/27/2024 at 11:00 a.m. a telephone interview was conducted with a family member for Resident #106. The family member revealed they pay and have a companion sitter sit with him daily for 5 days a week and that she assists with feeding assistance and watching him to make sure he doesn't fall. He said he feels the resident is on so many psychotropic medications and that he is so high on those medications that he sleeps all the time and staff don't get him up to place him in his wheelchair. He feels they are just doping him up to keep him sleeping all the time. Resident #106's family member stated he participates in care plan meetings and has mentioned this to the care staff. On 2/28/2024 at 8:50 a.m. an interview was conducted with Resident #106 companion sitter. She revealed she is at the facility mostly for breakfast meals about 5 days a week and sometimes comes in the facility for lunch to assist. She is responsible for assisting with meals, watching, and supervising him for safety, reading to him, assisting with television shows he may want to be on, talking with him, just generally being here for him. She revealed he sleeps a lot, and it is hard to get him to eat. She said he sleeps due to the use of psychotropic medications and had been made aware of this by Resident #106's family members. On 2/26/2024, 2/27/2024, 2/28/2024, and 2/29/2024 during the 7-3 shift, other than when Resident #106 was being assisted with the breakfast and lunch meal, he was noted in his room, lying in bed, and sleeping. When Resident #106 was observed during the Breakfast and Lunch meal service on 2/27/2024 and 2/28/2024, he was observed falling asleep during the meal service. A record review for Resident #106, revealed diagnoses to include but not limited to: Nontraumatic subarachnoid hemorrhage, Aphasia, Dysarthria, Epilepsy, Mood disorder, Abnormalities in gait, Lack of coordination Dementia, Major depression disorder, Anxiety, and Insomnia. Review of the current [NAME] Data Set (MDS) 12/15/2023 Quarterly assessment revealed; Cognition/Brire Interview Mental Status score 3 of 15, which indicated Resident #106 would not have been able to speak related to his medical and care services; Mood - None noted. However, indicated under social isolation - Sometimes; Behaviors - Rejection of care 1-3 days. Review of the current month (02/2024) physician's order sheet revealed psychotropic medication use to include; a. Ativan 0.5 mg (milligram) 1 by mouth four times a day for terminal restlessness, hold for lethargy. Contact MD (physician) if held for 3 consecutive doses, with an order date of 10/16/2023. b. Depakote Sprinkles oral capsule delayed release sprinkle 125 mg. Give 3 caps (capsules) by mouth two times a day related to mood disorder, with an order date of 10/23/2023. Review of the current Care Plans with a next review date of 3/20/2024 revealed problem areas to include but not limited to: - Resident has potential for adverse consequences of Antidepressant medication for depression with insomnia with a start date of 6/13/2023. Interventions included: Administer medications as ordered; Monitor for effectiveness of medication, Monitor for side effects of medication: i.e. Nausea, Gastrointestinal problems, Dizziness, Fatigue, Dry mouth, weight gain, Insomnia. - Resident takes supplement for diagnosis of Insomnia with a start date of 6/13/2023. Interventions included: Give medications as ordered, Montior for side effects of supplement: Dizziness, Irritability, Headache, Hangover effect. - Resident has potential for adverse consequences related to use of Hypnotics with a start date of 8/7/2023. Interventions included: Administer medication as ordered, Monitor for effectiveness of medication, and Monitor for side effects of hypnotic i.e.; Headache, Confusion, Weakness, Nausea, Irritability, Dry mouth and report to MD as needed. - Resident has a diagnosis of Anxiety and has potential for adverse consequences related to use of Antianxiety. 9/11/23 started on Depakote sprinkle for anxiety as well, with a start date of 9/6/2023. Interventions included: Administer medications as ordered, Monitor for effectiveness of medication, Monitor for side effects of antianxiety medication i.e.: Drowsiness, dizziness, weakness, dry mouth, diarrhea, nausea, constipation, blurred vision and report to MD as need. - Use of psychotropic drug places resident at risk for drug related side effects. Diagnosis for which drug has been prescribed agitation with a start date of 10/2/2023. Interventions included: Administer medications as ordered, Montior behavior and intervene as needed, Montior for effectiveness of medication and review for changes, Observe for signs and symptoms of drug related side effects. Review of the Medication Administration Record (MAR) for months 10/2023, 1/2024 and 2/2024 revealed ordered medications to include use of Depakote and Ativan. It was determined through review of the 10/2023, 1/2024, and 2/2024 MAR, there was no evidence of signs/symptoms being monitored for use of the psychotropic medications, on a daily or shift basis. On 2/29/2024 at 12:38 p.m., during an interview with the DON, she confirmed there was no daily monitoring for signs and symptoms related to the use of psychotropic medication and there should be daily monitoring. She said the care plan interventions related to monitoring should have been completed daily. The DON confirmed Resident #106's behaviors of sleeping all the time should have been monitored and documented on a daily basis, as that could be an indication of symptoms and side effects from use of psychotropic medication use. On 2/27/2024 at 2:25 p.m. Staff C Certified Nursing Assistant (CNA) was interviewed with relation to Resident #106 daily care and routines. Staff C confirmed Resident #106 does sleep most of the 7-3 shift but did not know about the other two shifts. On 2/29/2024 at 9:00 a.m. an interview with Staff A, Licensed Practical Nurse (LPN), who has Resident #106 on her assignment routinely, revealed he is hard to keep alert and awake during the day and he does have a sitter companion who sits with him in the mornings. Staff A confirmed he does not get out of bed much and does sleep most of the day. She confirmed there is no way of documenting signs/symptoms to include fatigue, sleeping, drowsiness related to psychotropic medication use, in the Medication Administration Record (MAR). She revealed usually there are orders to document each shift and on a daily basis of signs/symptoms and behaviors. On 2/29/2024 at 11:00 a.m. the Director of Nursing provided the facility's Pharmacy Service-Drug Regimen Free From Unnecessary Drugs policy and procedure, with revised date of 2/1/2020, for review. The policy states; The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reduction (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. The procedure section of the policy revealed; (a.) Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (c.) Without adequate monitoring of. (b.) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories; a. Anti-psychotic, b. Anti-depressant, c. Anti-anxiety, d. Hypnotic. 3. Review of Resident #39's care plans revealed a focus concern (initiated and revised 06/30/2023) for Oral/Dental Health problems related to Caries [decay], broken teeth, Missing Teeth, currently has no complaints of pain or difficulty chewing. Interventions for this focus concern (initiated on 6/30/2023) included: coordinate arrangements for dental care as needed/as ordered; observe for mouth pain as needed; observe/document/report to Medical Doctor (MD) and/or Nurse signs/symptoms of oral dental problems; provide mouth care daily and as needed. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The oral/dental section of the MDS revealed the resident had obvious or likely cavity or broken natural teeth. Observation and interview on 2/27/2024 at 9:30 a.m. with Resident #39 revealed several missing teeth. Of the remaining teeth, several were noted to be broken/chipped and dark in color. Resident #39 stated, I don't have any pain right now, but I have had pain and one of my teeth on my right side of my mouth cuts into my mouth at times. Resident #39 could not recall how long she had this problem and if she had reported this to staff. Review of the dental visits/notes revealed: a. 4/13/2022 Treatment Plan Notes: Periodic Oral Examination: Patient wants partials. b. 12/5/2023 Treatment Notes: Patient wants to replace missing teeth do not have a partial anymore. c. 1/16/2024 Progress notes for Assessments: Patient is interested in getting dentures. Incomplete x-rays due to patient having a strong gag reflex. Further review of the medical record revealed no additional documentation to show arrangements to coordinate dental services as care planned had been conducted since the 1/16/24 dental visit. On 2/29/2024 at 1:00 p.m., an interview with Resident #39's regular Licensed Practical Nurse (LPN), Staff A confirmed the resident had many missing and broken teeth. Staff A confirmed Resident #39 had complained about mouth pain in the past. Staff A was not aware of the resident's request to get dentures. On 2/29/2024 at 1:40 p.m., an interview with Certified Nursing Assistant (CNA), Staff B revealed Resident #39 sometimes complains of mouth pain, and she passes that information on to the nurse. Staff B was not sure if Resident #39 had requested dentures and confirmed the resident has many missing/broken teeth. On 2/29/2024 at 12:38 p.m., an interview with the Director of Nursing (DON) revealed she was also the C Wing Unit Manager. She confirmed Resident #39 had many missing teeth, several broken teeth, and dark discoloration of her bottom teeth. The DON was not aware of Resident #39's complaint of teeth cutting into her mouth or any pain in her mouth recently. The DON reviewed Resident #39's dental notes and reported she was not aware of the resident's request for dentures prior to reading the notes (on 2/29/24). She confirmed no appointment was made to follow up on Resident #39's request for dentures. 43453 4. Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain, not elsewhere classified, abnormal weight loss, adult failure to thrive, and age-related osteoporosis without current pathological fracture. On 02/26/24 at 09: 50 a.m., an interview was conducted with Resident 394. She stated she needed therapy for her legs to increase mobility. She said, I would like to stand/walk, eventually. I can't reach that goal if they don't exercise my legs. A review of Resident's #94's care plan 01/5/22 showed she did not have restorative goals. Review of the CNA documentation record did not show documentation of restorative performance or occurrence. On 02/28/24 at 10:24 a.m., an interview was conducted with the Director of Rehabilitation (DOR). She stated the resident was on case load in December 2023 for bed mobility. The DOR stated at the time the resident required maximum assistance. She stated at the time of discharge, the resident required minimal assistance. The DOR stated at the time of discharge the resident was unable to tolerate sitting on the bed. The DOR said, once therapy is no longer a goal, the care giver training takes effect, it is meant to encourage the resident to attend exercise class. Nursing staff are to assist as needed. I do not know if nursing staff are working on any restorative goals. I will check with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). On 02/27/24 at 11:29 a.m., an interview was conducted with Resident 109. She stated she was not getting any therapy. She stated she wanted to walk again. She stated Therapy used to walk with her. Record review showed Resident #109 was admitted to the facility on [DATE] with diagnoses to include acute chronic diastolic congestive heart failure. On 02/28/24 at 10:16 a.m., an interview was conducted with the DOR. She stated Resident #109 had been in therapy and was discharged on [DATE] because she was not progressing. She needed the same level of assistance. She stated related to restorative, she trains CNAs on the process of care the resident needed once discharged from therapy. She stated the resident could walk 75 feet with minimal assist. She stated the CNAs should try the walk to dine program with her. This meant the resident walks with assistance from their room to the dining room. A review of Resident's #109's care plan 01/17/24 showed she did not have restorative goals. Review of the CNA documentation record did not show documentation of restorative performance or occurrence. On 02/28/24 at 01:50 p.m., an interview was conducted with the NHA. She confirmed the facility did not have a restorative program. She said, when they are discharged from therapy, they should receive follow-up care from the CNAs. She stated the facility provides caregiver training, and the ADL (activities of daily living) care plan is updated. The treatment matches the new level of care. This may include the walk to dine program. She stated the program is facilitated by either a CNA or a therapy aide. She stated therapists should let the CNA know if the patient is able to walk or what therapy needs, they should work on. The care plan should be updated to reflect the restorative goals, so all CNAs know. The CNAs should document the task performance in the CNA documentation record.

Based on observation, interviews, and record review, the facility failed to revise and individualize a care plan to reflect a resident's condition for three residents (#320, 321, and 62) out of four sampled residents. Finding included: Review of the Admission Record revealed Resident #320 was admitted to the facility on [DATE], with diagnoses to include: Chronic Obstructive Pulmonary Disease (COPD), Heart Failure, Difficulty Walking, Anxiety Disorder, Diabetes Type 2, Anemia, Monoplegia of upper limb following Cerebral Infarction, other co-morbidities. Review of Resident #320's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 1/5/2024, showed resident to be at risk for falls. Review of Resident #320's Physician Order Summary Report active as of 1/14/2024 revealed resident was receiving: Alprazolam (psychotropic), Diphenhydramine HCl (antihistamine), Bupropion HCl (psychotropic), Dicyclomine HCl (cathartic), Dulcolax (cathartic), GlycoLax Powder (cathartic), Guaifenesin ER (antihistamine), Labetalol HCl (antihypertensive), Lasix (diuretic), Linzess (cathartic), Milk of Magnesia(cathartic) , Oxycodone-Acetaminophen (narcotic), Sertraline HCl (psychotropic), and other medications. Review of Resident #320's Fall Risk Evaluation dated 1/5/2024 shows: AS_1. History, Current Status, Predisposing Conditions: question #2. History of Falls (past 3 months) - no falls checked, #7. Predisposing Diseases: respond based on the following predisposing conditions: Hypotension, Vertigo, CVA Parkinson's Disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures, and Delirium. #8. Predisposing disease - left blank #9. Change of condition in last 14 days - no checked, AS_2. Gait/Balance: #10. N/A - not able to perform function - checked. AS_3. Medications: 1. Medications: Respond based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics. #2. Medications - Takes 3-4 these medications (or medication classes) - checked. #3. Resident has had a change in medication (or medication classes) or change in dosage in the past 5 days - left blank. #4. Score 10 or higher indicated the resident is at high risk of fall #5. Risk for Falls: - left blank; AS_4. Clinical Suggestions: left blank. Resident #320 with a fall risk score of 9.0. Indicating Moderate Risk for falls. Review of Resident #320's Care Plan showed: Focus - Resident #320 is at risk for further falls related to: daily use of Antidepressants, history of falls, Unsteady gait/balance, occasional bladder accidents Created on 1/6/2024 and revised 1/11/202. The Goal: will strive to have falls and/or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date. Created on 1/6 2024. Interventions dated 1/6/2024 revealed: * place items used in easy reach i.e. water, telephone, call lights; * PT and OT to screen prn (as needed); * keep adaptive equipment within reach * check for toileting needs Interventions dated 1/11/2024 revealed: * encourage appropriate foot wear During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) reviewed Resident #320's Fall Evaluation and admission documentation and stated the Fall Evaluation was not accurate. The information missed would have resulted in a higher score. The score would have placed the resident at high risk for falls. Staff J, RN confirmed that the care plan had been very generic for Resident #320. Review of the Admission Record revealed Resident #321 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Dementia, history of Transient Ischemic attack (TIA), and Cerebral Infarction (CVA), history of falling, difficulty in walking, and other co-morbidities. Upon readmission the following diagnosis was added: Traumatic subdural Hemorrhage. Review of Resident #321's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 2/12/2024, showed resident to be at risk for falls. Resident #321's AHCA Form 5000-3008 dated 2/18/2024, showed resident to be at risk for falls. Review of Resident #321's Medication Administration Record (MAR) for February 2024 revealed resident was receiving: Amlodipine (antihypertensive), Metoprolol (antihypertensive), Pravastatin (antihypertensive), Senna Lax (cathartic), Dulcolax (cathartic), GlycoLax Powder (cathartic), Milk of Magnesia(cathartic), Tramadol (narcotic), and other medications. Review of Resident #321's Fall Risk Evaluation dated 2/12/2024 shows: AS_1. History, Current Status, Predisposing Conditions: question #2. History of Falls (past 3 months) - 1-2 falls in past 3 months checked, #3. Level of consciousness/mental status - Alert (oriented x3) OR comatose; #4. Ambulation/elimination status - Chairbound/Continent; #5 Systolic blood pressure - left blank; #7. Predisposing Diseases: respond based on the following predisposing conditions: Hypotension, Vertigo, CVA Parkinson's Disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures, and Delirium. #8. Predisposing disease - none present checked; #9. Change of condition in last 14 days - no checked, AS_2. Gait/Balance: entire section left blank. AS_3. Medications: 1. Medications: Respond based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics. #2. Medications - left blank. #3. Resident has had a change in medication (or medication classes) or change in dosage in the past 5 days - left blank. #4. Score 10 or higher indicated the resident is at high risk of fall #5. Risk for Falls: - left blank; AS_4. Clinical Suggestions: left blank. Resident #321's with a fall risk score of 6.0. Indicating low risk of falls. Review of Resident #321's Care Plan showed: Focus - Resident #321 is at risk for further falls related to: Decreased lower extremity strength, h/o fall, dementia with poor safety awareness, Unsteady gait/balance, bowel incontinence, balance deficit, decreased activity intolerance. Created on 2/13/2024. The Goal: will strive to have falls and/or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date. Created on 2/13 2024. Interventions dated 2/13/2024 revealed: * encourage appropriate foot wear * place items used in easy reach i.e. water, telephone, call lights; * PT and OT to screen prn (as needed); * keep adaptive equipment within reach * check for toileting needs * encourage frequent rest periods During an interview on 2/28/2024 at 4:19 PM the Risk Manager (RM) stated the Fall Evaluation was not completed appropriately for the 2/12/2024 admit. The Fall Evaluation left off a number of factors that would have increased Resident #321's score. The RM validated that no Fall Evaluation was completed for the 2/24/2024 admit. The RM stated a Fall Evaluation should be completed for all admissions and after every fall. The RM confirmed Resident 321's care plan had not been updated after her fall. Review of the Admission Record revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Left hip artificial joint, after care following joint replacement, osteoarthritis, rheumatoid arthritis, spinal stenosis, lumbar region, anxiety disorder, depression, muscle weakness, difficulty in walking, and other co-morbidities. Upon readmission on 1/9/2024 the following diagnosis was added: periprosthetic fracture around internal prosthetic left hip joint, subsequent encounter, incomplete rotator cuff tear or rupture of left and right shoulder Traumatic subdural Hemorrhage. Review of the Progress Notes for Resident #62 revealed Resident #62 was transferred out on 1/7/2024 at 3:35 PM due to a fall. Resident #62 was readmitted on [DATE]. Review of Resident #62's Medical Certification for Medicaid Long-Term Care Services and Patient Treatment Transfer Form, AHCA Form 5000-3008 dated 12/31/2023, showed resident to be at risk for falls. Resident #62's AHCA Form 5000-3008 dated 1/9/2024, showed resident to be at risk for falls. Resident #62's AHCA Form 5000-3008 dated 1/15/2024, showed resident to be at risk for falls. Review of Resident #62's MAR for January 2024 revealed resident was receiving: Buspirone HCl (psychotropic), Fluoxetine HCl (psychotropic), GlycoLax Powder (cathartic),), Senna Lax (cathartic), Bupropion HCl (psychotropic), Dulcolax (cathartic), Milk of Magnesia(cathartic), Tramadol (narcotic), and other medications. Review of Resident #62's Fall Risk Evaluation dated 1/2/2024 shows: AS_1. History, Current Status, Predisposing Conditions: question #2. History of Falls (past 3 months) - 1-2 falls in past 3 months checked, #3. Level of consciousness/mental status - Alert (oriented x3) OR comatose; #4. Ambulation/elimination status - left blank; #7. Predisposing Diseases: respond based on the following predisposing conditions: Hypotension, Vertigo, CVA Parkinson's Disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures, and Delirium. #8. Predisposing disease - 1-2 present checked; #9. Change of condition in last 14 days - no checked: #10. Recent hospitalization history in last 30 days - no checked: AS_2. Gait/Balance: entire section left blank. AS_3. Medications: 1. Medications: Respond based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics. #2. Medications - left blank. #3. Resident has had a change in medication (or medication classes) or change in dosage in the past 5 days - left blank. #4. Score 10 or higher indicated the resident is at high risk of fall; #5. Risk for Falls: - left blank; AS_4. Clinical Suggestions: left blank. Resident #62's with a fall risk score of 4.0. Indicating low risk of falls. Review of Resident #62's Fall Risk Evaluation dated 1/10/2024 shows: AS_1. History, Current Status, Predisposing Conditions: question #2. History of Falls (past 3 months) - 1-2 falls in past 3 months checked, #3. Level of consciousness/mental status - left blank; #4. Ambulation/elimination status - ambulatory/Incontinent checked; #7. Predisposing Diseases: respond based on the following predisposing conditions: Hypotension, Vertigo, CVA Parkinson's Disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, Fractures, and Delirium. #8. Predisposing disease - 1-2 present checked; #9. Change of condition in last 14 days - yes checked: #10. Recent hospitalization history in last 30 days - yes checked: AS_2. Gait/Balance: balance problem while standing and balance problem while walking - checked. AS_3. Medications: 1. Medications: Respond based on the following types of medications: Anesthetics, Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics. #2. Medications - takes 1-2 of these medications checked. #3. Resident has had a change in medication (or medication classes) or change in dosage in the past 5 days - left blank. #4. Score 10 or higher indicated the resident is at high risk of fall; #5. Risk for Falls: - left blank; AS_4. Clinical Suggestions: left blank. Resident #62's with a fall risk score of 16.0. Indicating high risk of falls. Review of Resident #62's Care Plan showed: Focus - Resident #62 is at risk for falls related to: Unsteady gait/balance due to recent left hip replacement, antidepressant rx (prescription), incontinency. Created on 1/2/2024 and date initiated: 1/22/2024 and revised on 1/26/2024. The Goal: will strive to have falls and or injuries minimized through management of risk factors while maintaining independence and quality of life through the review date created on 1/2 2024 date initiated 1/22/2024 and revised on 1/22/2024. Interventions dated 1/2/2024 revealed: * Place items used in easy reach i.e. water, telephone, call lights * PT and OT to screen prn (as needed) * Keep adaptive equipment within reach * Check for toileting needs Interventions dated 1/11/2024 showed: TTWB LLE (Toe Touch Weight Bearing Left Lower Extremity). During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) reviewed Resident #62's Fall Evaluation and admission documentation and stated the Fall Evaluation was not accurate. The information missed would have resulted in a higher score. The score would have placed the resident at moderate risk for falls. Staff J, RN confirmed that the care plan had been very generic for Resident #62 and not updated after the fall that resulted in a fracture. During an interview on 2/28/2024 at 10:05 AM Staff D, Certified Nursing Assistant (CNA) stated, I just know how to care for residents, I've been doing this a long time. Staff D, CNA continued to state they don't really have a way to know if a resident is a fall risk. Most of the residents on this unit are oriented. An interview was conducted with Staff FF, CNA on 2/28/2024 at 1:10 PM. Staff FF, CNA stated she just knows how to care for residents. There is not any documentation we need to look refer to regarding care. Staff F, CNA stated, we don't need to treat anyone differently. An interview was conducted with Staff F, Licensed Practical Nurse (LPN) on 2/28/2024 at 01:15 PM. Staff F, LPN stated when a resident is admitted the nurse reviews the 3008 and any attached orders. The nurse receives a nurse to nurse report regarding the resident. This verbal report gives us a short description of the resident's diagnosis, health status, behavior, and any unusual events, falls and orientation status would be included in this report. With all of this information the nurse is able to complete the facility required documentation, including the Fall Risk Evaluation. We usually put the same interventions in place for all admits. During an interview on 2/28/2024 at 1:36 PM, Staff J, Registered Nurse (RN) stated the nurse reviews the orders from the hospital to include the 3008. This information will give us insight on how to complete the evaluations for admission. Sometimes, the family is present and will assist with some of the history if needed. We usually put the same interventions in for all new residents. The information entered in the evaluation assists with the resident's care plan. The care plan links to the CNA Kardex (CNA documentation system). The Kardex is the documents the CNAs utilize to care for the resident. The CNAs also know by verbal report from the nurse at times, if there is nothing on the Kardex. During an interview on 2/28/2024 at 5:18 PM with Staff U, LPN/Supervisor said on all admissions she double checks the evaluations to ensure nothing got missed. The baseline care plan is developed from the evaluations and given to the family. We tailor the care plan based on the evaluations and information as the information is learned. An interview was conducted on 2/29/2024 at 9:06 AM with Director of Nursing (DON). The DON stated the nurse admitting the resident completes the Fall Evaluation based on the information they have from the hospital and family. The nurse implements a generic care plan for falls. The supervisor for the shift will review the information for accuracy and update as needed. Therapy will see the resident the following day and assist with updating the care plan, as necessary. The Interdisciplinary Team meets with the family and reviews the baseline care plan with them within 48 hours of admission. We complete an Interdisciplinary Plan of Care Summary (IPOC). If the family is not available to complete in person with complete with them via the phone. The Care Plan Coordinators take over the updating of the care plans after this. During an interview on 2/28/2024 at 10:00 AM the Risk Manager (RM) stated the Fall Evaluation gives a score to alert the staff if the resident is at high risk of falls. This would alert them to possible ensure additional interventions are in place for the resident. Review of the facility Guideline for Person-centered Comprehensive Care Plan with Effective Date: October 2022 revealed: Guideline: it is the practice of the center to develop and implement a person-centered comprehensive care plan that includes measurable objectives and time frames to meet the preferences and goals, and address the guest/residents nursing, medical, physical, mental, and psychosocial needs The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments and with significant changes in the guest/resident's condition.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and five errors were identified for four (#17) out of five residents observed. These errors constituted a 16.67% medication error rate. Findings included: 1. On 2/28/24 at 7:29 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #17. The staff member dispensed the following medications: - Vitamin D3 125 microgram (mcg) tablet over-the-counter (otc) (5000 international unit (iu)) - Ferrous sulfate 325 (milligram) mg otc tablet - Gabapentin 300 mg capsule - Tizanidine 2 mg capsule - Tamsulosin 0.4mg capsule - Metformin 1000 mg tablet The staff member had dispensed 2 tablets of Vitamin B12 then moved them both to another cup and set it aside, reporting the Vitamin B12 was to be administered by injection not orally. Staff H confirmed dispensing 6 oral tablets, and these were all the medications to be given at this time. The staff member entered the resident room (leaving the 2 tablets of Vitamin B12 on the cart) and administered the medications. The staff member returned to the medication cart, entered the electronic record, and did not reveal any further medications were to be administered. Review of Resident #17's Medication Administration Record (MAR) revealed the following medications were to be administered during the morning (morning) scheduled time and not observed. - Cranberry 450 mg - Give 1 tablet by mouth two times a day for Urinary Tract Infection (UTI) prophylaxis - Cyanocobalamin solution - Inject 1000 mcg intramuscularly in the morning every 4 weeks on Wednesday (Wed) for anemia. Review of the Resident #17's Medication Administration Audit Report for 2/28/24 showed the 6 medications observed with Staff H were administered on 2/28/24 at 7:34 a.m. and the tablet of Cranberry was administered at 7:36 a.m. (this was not observed or accounted for during the administration). The audit report and the MAR showed the resident's Cyanocobalamin was injected on 2/28/24 at 12:08 p.m. (4.5 hours after the observation). Review of the Patient-Centered Med Pass Times, provided by facility on 2/26/24 revealed morning medications were scheduled to be dispensed between the 3-hour period of 8 a.m. and 11 a.m. During an interview on 2/28/24 at 5:18 p.m., the Director of Nursing (DON) stated technically the nurses have one hour before and one hour after the scheduled morning administration time of 8 a.m. to 11 a.m. to administer the morning medications, confirming the 5-hour period (7 a.m. to 12:00 p.m.) The DON confirmed Resident #17's Cyanocobalamin was injected by Staff H at 12:08 p.m. on 2/28/24. The DON confirmed the medication, Cyanocobalamin, was shown to be outside of the 5-hour period the facility allows staff to administer morning medications. 2. On 2/28/24 at 8:12 a.m., an observation of medication administration with Staff F, Licensed Practical Nurse (LPN), was conducted with Resident #221. The staff member dispensed the following medications: - Prednisone 5 milligram (mg) - 5 tablets - Hydroxyzine 25 mg tablet - Diltiazem Extended Release (ER) 60 mg capsule - Pantoprazole Delayed Release (DR) 40 mg tablet - Bisoprolol fumarate 5 mg tablet - Ferric X150 150 mg tablet - Symbicort 160/4.5 metered dose inhaler - one inhale (multiple attempted) Staff F confirmed dispensing 10 oral tablets and one inhaler. The staff member administered the oral medications, handed the resident a small cup of water which the resident drank all of it. Staff F handed the Symbicort inhaler to Resident #221 who attempted to self-administer, the staff member attempted then opened the inhaler and administered one inhalation dose to the resident as evidence of observed aerosol in the immediate area. The staff member did not offer or encourage the resident to rinse mouth. Review of the manufacturer website, mysymbicort.com, showed Symbicort may cause serious side effects, including: Fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chance of getting thrush. Review of Resident #221's Medication Administration Record (MAR) showed a physician order: Symbicort Inhalation Aerosol 160-4.5 microgram/act - 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease with (acute) exacerbation. The order did not instruct staff to have the resident rinse mouth and spit out per the manufacturer instruction. During an interview on 2/28/24 at 5:29 p.m., the Director of Nursing (DON) reported yes residents do need to rinse mouth out (after the administration of Symbicort) then stated no residents did not have to with a puffer. 3. On 2/28/24 at 8:26 a.m., an observation of medication administration with Staff G, Licensed Practical Nurse (LPN), was conducted with Resident #222. The staff member dispensed the following medications: - Calcium + Vitamin D 500 milligram (mg) over-the-counter (otc) tablet - Multi Vitamin otc tablet - Eliquis 2.5 mg tablet - Fluoxetine 10 mg tablet - Gabapentin 300 mg tablet - Memantine 10 mg tablet - Metoprolol Succinate Extended Release (ER) 50 mg tablet - Ranolazine Extended Release (ER) 500 mg tablet The observation revealed Staff G obtained a sheet of paper with multiple vital signs written on it from an unknown Certified Nursing Assistant (CNA). The staff member revealed a blood pressure had been obtained of 131/65 from Resident #222. Staff G corrected the measurement to 136/76 after being asked to check the paper again, 131/65 was a measurement written above this resident. Staff G confirmed dispensing 8 tablets. Staff G traveled from the medication cart, which was parked across from the nursing station to the resident room, located approximately 1/2 way down the hallway to Resident #222's room. The resident took (under staff supervision) medications one tablet at a time. Review of Resident #222's MAR showed in addition to the above medications the resident was to be administered AZO Cranberry Urinary Tract Capsule 250-60 mg (Cranberry-Vitamin C) - Give 1 capsule by mouth in the morning for supplement. The MAR revealed Staff G had documented AZO Cranberry had been administered, this medication was not observed or confirmed. Review of the Medication Administration Audit Report for Resident #222 showed the observed medications of Calcium - Vitamin D and Multiple Vitamin were administered at 8:27 a.m., Memantine, Gabapentin, Fluoxetine, and Apixaban were administered at 8:28 a.m., Ranolazine was administered at 8:29 a.m., and Metoprolol Succinate was administered at 8:31 a.m. Staff G documented AZO Cranberry was administered at 8:27 a.m. (along with the Calcium - Vitamin D and Multiple Vitamin) and documented as given at 8:27 a.m. on 2/28/24. 4. On 2/28/24 at 11:43 a.m., an observation of medication administration with Staff X, Licensed Practical Nurse (LPN), was conducted with Resident #222. The staff member dispensed the following medications: - Insulin Lispro Kwikpen - 6 units Prior to the administration of insulin, Staff X obtained a blood glucose level of 323 from the left index finger of Staff X. The staff member returned to the medication cart, obtained the Insulin Lispro pen, applied a needle, and took the pen into the resident room. The staff member held the pen perpendicular to the floor and dialed it to 6 units and injected the insulin into the upper left arm. An interview immediately following the administration was conducted with Staff X. The staff member confirmed not priming the Kwikpen. During an interview on 2/28/24 at 5:15 p.m., the Director of Nursing confirmed staff are to prime insulin pens prior to selecting the dosage, and staff have been inserviced (on priming the pens). Review of the manufacturer's instructions, located at https://uspl.lilly.com/humalog/humalog.html#ug1, for the administration of insulin utilizing a Humalog Kwikpen included the following: - Priming your Pen: Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. - Step 6: To prime your pen, turn the dose knob to select 2 units. - Step 7: Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. - Step 8: Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat the priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the needle, and repeat priming steps 6 to 8. - Small air bubbles are normal and will not affect your dose. Review of the facility policy - 6.0 General Dose Preparation and Medication Administration, revised 1/1/22, revealed this policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the state operations manual when administering medications. The policy included the following: 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: - 4.1 Facility staff should: - 4.1.1 verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule. 5. During medication administration, Facility staff should take all measures required by Facility policy and applicable law, including, but not limited to the following: - 5.4 Administer medications within timeframes specified by facility policy or manufacturers information - 5.7 Provide the resident with any necessary instructions (e.g., using an inhaler) - 5.8 Follow manufacture medication administration guidelines (e.g., rotating transdermal patch sites, providing medications with fluids or food, shaking medications prior to pouring, rotating injection sites) 6. After medication administration, facility staff should take all measures required by facility policy and ethical law, including, but not limited to the following: 6.1 document necessary medication administration slash treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, as needed (PRN) medications, application site) on appropriate forms. Review of the facility policy - 6.8 Medication Administered through Certain Routes of Administration, effective 1/1/22, revealed this policy describes appropriate methods of medication administration. Staff should refer to manufacturer recommendations for administration. The policy included the following: - The Subcutaneous Injections section did not include instructions on how staff were to use a pen for administration of insulin. - Orally Inhaled Medications revealed Medications administered by inhalation are dispersed by aerosol mist, spray, or fine powder. The medication is delivered via meter dose nebulizer or turbo- inhaler and is designed to deliver drug for local effect on the respiratory tract. Bronchodilators mucolytics, topical steroids, and topical anticholinergics are the most used drugs. Prime inhaler for initial use or if not used in 14 days. Shake inhaler immediately before use to well to disperse medication. 2. Do Not administer inhalers in common areas in the facility. 4.2 Ask resident to exhale fully; 4.5 while inhaling slowly and deeply through mouth, depress medication canister fully. 4.6 instruct resident (to) hold breath for 10 seconds or as long as possible or according to manufacturer's recommendations. - Wait approximately 1 minute between puffs or as ordered by physician or according to manufacturer's recommendations. - Gargling or rinsing mouth after spraying will reduce drug absorption from the oral mucosa. Rinsing the mouth is commonly recommended with long term steroid use. Review of the facility provided education, Avoiding Common Medication Errors, 2022, revealed Knowing and adhering to the right of medication administration as well as the basic guidelines for medication administration will help you prevent medication errors that can result in complications and even death. In this course you will learn about the most common medication administration errors and the steps to take to avoid these errors. The goal of this course is to educate direct care staff who can administer medication in a post-acute care setting on ways to prevent common medication errors. - Rights: The rights of medication administration is the most important guideline that you must follow when administering medications. The five original rights include the: right person, right medication, right dose, right time and frequency, and right route. Some literature refers to 8, 9, or even 10 rights of medication administration. The following five rights are sometimes added and are important to know: right documentation, right education, and information, right to refuse, right history and assessment, and right evaluation. Knowledge of and adherence to all of these rights is the foundation to ensuring that you give medications safely. Forgetting to follow one of these rights can easily result in an error. - Specific Circumstances: Improper administration of certain types of drugs is common. Inhalers, eye drops, and liquid medications require special attention to ensure you administer the medication properly. Some specific circumstances for medication administration include: Wait at least 1 minute between puffs or the same medication and 5 minutes before administering a different inhaled medication. Follow the specific steps to ensure effective inhalation of inhaled medications. - Documentation: In addition to following proper guidelines, it is important to document medication administration accurately. Documentation should occur at the time of administration to reduce the likelihood of errors and to ensure the accuracy of medication records.

Based on observations, record reviews, and interviews, the facility failed to ensure medications were stored appropriately in six resident rooms (202, 207, 223, 304, 317 and 325), medications were stored in locked cart while unattended in one (A-wing #2) out of six carts, one insulin vial for one (#37) out of two residents sampled for insulin administration was not expired, medications with a shortened life once open were labeled with an open date on two (A-Wing#1 and Rehab #2) of three sampled medication carts, one (A-wing) of three medication refrigerators were locked and inaccessible to unauthorized personnel, and one (Rehab) out of three refrigerated controlled substance boxes were locked. Findings included: 1. On [DATE] at 10:08 a.m., a tube of Preparation H, hemorrhoidal ointment, was observed sitting in a cardboard box on top of a dresser in room [ROOM NUMBER]-W. The observation also revealed one container of disinfecting wipes in the bottom drawer of a dresser belonging to Resident #52 and one on top of bedside dresser next to the bed nearest the door. Staff Z, Certified Nursing Assistant (CNA) removed the containers of disinfection wipes from the room, stating they should not be in the room. The staff member did not acknowledge the presence of the Preparation H medication. (Photographic Evidence Obtained) 2. On [DATE] at 10:29 a.m., an observation was made of two tablets, one yellow and one green/light blue, in a medication cup on the over-the-bed table of Resident #46 (room [ROOM NUMBER]-D). The resident stated the tablets were her (name brand) antacid tablets the nurse had given her last night. Resident #46 reported not taking them due to not having enough food. The resident refused to have photo taken of the tablets stating, are you going to take them away? Review of Resident #46's Medication Administration Record (MAR) showed the resident had been administered 2 tablets of Tums Chewable 500 milligram (mg) at bedtime on [DATE]. The order did not show the resident was able to self-administer medications or the medication could be left at bedside. The MAR did not reveal the resident had another order, other than the one mentioned. 3. On [DATE] at 10:39 a.m., an observation was made of a bottle of 24-hour allergy relief nasal spray sitting on top of the bedside table of Resident #87 (room [ROOM NUMBER]-W). The resident stated the bottle came from (pronoun) home country of Croatia. Review of Resident #87's Annual Minimum Data Set (MDS) assessment, dated [DATE], showed the resident had a Brief Interview of Mental Status score of 9 out of 15, indicating a moderate cognitive impairment. 4. On [DATE] at 7:15 a.m., an observation was made of an unlocked medication cart parked around the corner from the nursing station on A-wing. Staff N, Licensed Practical Nurse (LPN) left the cart and ambulated to the other side of the nursing station, with back turned away from the cart. Staff N returned to the cart, attempted to put keys into the lock, and confirmed the cart had been left unlocked. The staff member confirmed being unable to view the cart when in the nursing station. The staff member revealed the medication cart was A-wing cart #2. 5. An observation on [DATE] at 7:45 a.m. was conducted with Staff N, Licensed Practical Nurse (LPN) of medication administration for Resident #37. The observation revealed the staff member removed a vial of Insulin Glargine from the cart. The medication bottle showed the vial was opened on [DATE] and the attached pharmacy label instructed users to discard after 28 da (days). Staff N confirmed the current date was ,d+[DATE] and the vial should have been discarded. Review of the yearly calendar revealed 28 days after the vial of Insulin Glargine was opened on [DATE] was [DATE] and according to the pharmacy label should have been discarded after that date. Review of Resident #37's Medication Administration Record (MAR) revealed a physician order, Lantus Subcutaneous solution 100 unit/milliliter (mL) (Insulin Glargine) - Inject 15 unit subcutaneously in the morning for Diabetes Mellitus (DM). The MAR revealed the resident had received 10 doses of Insulin Glargine after the vial should have been discarded. 6. An observation on [DATE] at 7:33 a.m., of A-wing Cart #1 was conducted with Staff X, LPN. The observation revealed the following: - an unopened bottle of Latanoprost 0.005% eye drops. The pharmacy packaging revealed the medication was to Refrigerate until opened. The label was dated [DATE]. - an opened bottle of Brimonidine Tartrate 0.1% drop (eye). The bottle was not labeled with an opened date. The plastic bag with pharmacy label was labeled with an open date and expiration date. The label instructed users to Discard 28 days after opening. - an opened bottle of Latanoprost 0.005% ophthalmic solution was undated as to when it was opened. The plastic bag with a pharmacy label containing the medication was dated and read Discard 42 days after opening. 7. An observation on [DATE] at 7:50 a.m., of the A-wing medication room was conducted with Staff X, LPN. The observation revealed the medication refrigerator was unlocked with a padlock available. The staff member confirmed the findings. 8. An observation on [DATE] at 8:03 a.m. was conducted with Staff F, LPN of Rehab cart #2. A bottle of Latanoprost ophthalmic solution was observed opened and undated. The plastic pharmacy bag instructed Discard 42 days after opening. The date on the bag was [DATE]. 9. An observation on [DATE] at 8:04 a.m., of the Rehab unit medication room was conducted with Staff F, LPN. The observation revealed the refrigerator's controlled substance lock box was unlocked and able to be opened without a key. The staff member confirmed the findings and reported the box contained a resident's liquid Lorazepam and emergency supply of liquid Lorazepam vials. 48223 10. On [DATE] at 10:12 AM in resident room [ROOM NUMBER] (private room) an observation of the following: a bottle of DermaKlenz wound cleanser, triple strength [NAME] oil, and ciclopirox topical solution 8% were sitting out on the resident's dresser. In the bathroom on the counter was a container of A&D ointment. 11. On [DATE] at 11:32 AM in resident room [ROOM NUMBER]-D an observation of medication on the resident's nightstand was a bottle of Flonase. 12. On [DATE] at 11:05 AM in Resident #325's bathroom counter (room [ROOM NUMBER]) was a bottle of antifungal powder. An interview was conducted with Staff I, Licensed Practical Nurse (LPN) on [DATE] at 3:15 PM. Staff I, LPN reviewed the photographs of room [ROOM NUMBER], room [ROOM NUMBER] D, and Resident #325 and validated the medications were not secured properly and none of the residents on the unit had self-administration orders. Staff I, LPN continued to state the medications should not be in the resident rooms. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:22 PM. The DON stated her expectation would be medication is not left at bedside. Review of the policy - Storage and Expiration Dating of Medications, Biologicals, revised [DATE], revealed This policy 5.3 sets forth the procedures relating to the storage and expiration dates of medications, biologicals, syringes, and needles. The policy revealed the following: -2. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. -4. Facility should ensure that medications and biologicals that (1) have an expired date on the label; (2) have been retained longer than the recommended by manufacturer supplier guidelines; Or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or return to the pharmacy or supplier. -5. Once any medication or biological packages is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. -- 5.3 if a multi dose vial of an injectable medication has been opened or accessed (e.g., needle punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened file. --5.4 when an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility should record the date and the date to expire on the container. --12.4 controlled substances stored in the refrigerator must be in a separate container in double locked. -- 13.2 facility should store bedside medications or biologicals in a locked of compartment within the resident's room.

Based on observations, record reviews, and interviews, the facility failed to initiate an effective Infection Control program related to the posting of precautions required for one (room [ROOM NUMBER]) of one rooms observed with a Personal Protective Equipment (PPE) caddy hanging from doorway, ensure direct care staff (Staff B, J, BB and DD) kept fingernails at an appropriate length and within policy parameters, ensure facility staff were knowledgeable on the types of PPE required to enter two resident rooms (#104 and #327) with posted precaution signage, and PPE caddies were stocked with required PPE for one (#104) of three residents on precautions. Findings included: 1. On 2/26/24 at 9:41 a.m. an observation was made of a PPE caddy containing gowns, gloves, and face masks hanging from the shut door of room [ROOM NUMBER]. The caddy and surrounding area of the doorway did not have a sign posted indicating the type of precautions staff and visitors were to take prior to entering the resident room. (Photographic evidence was obtained) An interview was conducted on 2/26/24 at 9:41 a.m., with Staff AA, Housekeeper who was near the doorway of room [ROOM NUMBER]. The staff member stated the door caddy was up, so they (staff) knew there was an infection, the facility was not allowed to tell them the type. Staff AA reported staff had to dress in everything, gown, gloves, and mask. The staff member confirmed there was no sign posted and stated maybe it fell down, opening the door slightly. The staff member stated the doors needed to be closed if they (resident) had an infection, closing the door to the room. On 2/26/24 at 11:21 a.m., an observation showed a sign was posted showing staff were to observe Droplet precautions while caring for the resident in room [ROOM NUMBER]. During an interview on 2/29/24 at 10:00 a.m., Staff J, Infection Preventionist (IP)/Assistant Director of Nursing (ADON)/Rehab Unit Manager (UM), stated signs should be posted on precaution rooms, identifying the type of precaution. A follow-up interview was conducted on 2/29/24 at 1:15 p.m., with Staff J, IP. The staff member reported the resident in room [ROOM NUMBER] was put on precautions for an overabundance of caution from being exposed (to COVID) by the spouse. 2. On 2/26/24 at 12:08 p.m., an observation was made of Staff BB, Certified Nursing Aide (CNA), was observed during the meal service on C-wing with a nose ring and square-cut fingernails painted with hot pink tips extending approximately 1/2 inch past the fingertips. During the observation, Staff B, CNA was observed with nude-colored fingernails extending past fingertips with multiple hair braids, tied back at nape of neck, extending past buttocks. On 2/27/24 at 9:01 a.m., Staff DD, CNA, was observed with square-cut fingernails extending approximately 1/4 (inch) past fingertips, retrieving a towel from the linen rack and entering room [ROOM NUMBER]. On 2/27/24 at 9:00 a.m., Staff BB was observed with the same fingernails status as observed on 2/26/24. During an interview on 2/29/24 at 10:00 a.m., Staff J, Infection Preventionist (IP)/Assistant Director of Nursing (ADON)/Rehab Unit Manager (UM), was observed with pale pink fingernails with black painted designs extending approximately 1/3 past the fingertips. She stated direct care staff fingernails should not be longer than 1/4 but would check on that information and was unsure of the policy regarding fake fingernails. A follow-up interview was conducted on 2/29/24 at 1:15 p.m. with Staff J, IP/ADON/UM. The staff member read the facility's Dress Code policy, and stated her nails were also too long per policy. The policy - Dress Code Policy, revised January 16, 2023, revealed the purpose was to provide the very best service and care possible to our resident/patients. Our manners of dress, grooming, personal cleanliness speak for us at Palm Garden when we are in contact with residents, family members, guests, and co-workers. Team Members are expected to demonstrate good taste and judgement in wearing clothing appropriate for the workplace at any Palm Garden location even if you are on PTO/took day off. The policy detail showed Hair and nails should be clean and groomed. Nails should be no longer than the tip of the fingers for all direct-care staff to include Nursing, CNA's, Environmental services/Laundry, and Culinary team members. Nail polish must be a professional color and cannot be chipped. No nail 3D art and/or gems, rhinestones, beads, etc. permitted on fingernails. Team members with inappropriate nails will be removed from the schedule until nails meet the above state standards. Hair color and hair style should be business professional. Visible body piercing, such as nose, lip, and tongue, are prohibited. Where Team Member and/or resident safety may be an issue, the Executive Director reserves the right to expand these guidelines to include personal appearance issues not identified in this section. Review of the Center for Disease Control and Prevention (CDC) guidance for healthcare, Hand Hygiene In Healthcare Settings, last reviewed January 8, 2021, revealed Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms). Keep natural nail tips less than 1/4 inch long. 3. An observation and interview was conducted on 2/26/24 at 9:37 a.m., with Staff X, Licensed Practical Nurse (LPN) at the doorway of room [ROOM NUMBER]. The door was posted with a sign for Enhanced Barrier Precautions (EBP). The staff member reported being at the facility for 6 months and Resident 104 had been on EBP, for C. Auris for that long and gone out to the hospital a few times. A follow-up observation was made on 2/26/24 at 12:41 p.m., of room [ROOM NUMBER] with a PPE caddy hanging from the door and a sign hanging from the caddy showing the resident was under Enhance Barrier Precautions (EBP). The sign revealed All family and visitors, please report to the nurses' station or see staff BEFORE entering room and Everyone MUST: Perform hand hygiene, with alcohol-based hand rub (ABHR) or soap and water before entering and exiting. Wear gown and gloves for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs/assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy), (and) wound care. An observation and interview was conducted on 2/26/24 at 12:41 p.m., with Staff EE, CNA at the entrance to room [ROOM NUMBER]. The staff member reported dressing in a gown, gloves, and mask even when just answering the call light for the resident. Staff EE instructed writer should wear what the signs says then read gown and gloves when going into the room to speak to the resident. An observation and interview was conducted on 2/26/24 at 12:44 p.m. with Staff X, Licensed Practical Nurse (LPN), a floor nurse assigned to the 100-unit, at the entrance to room [ROOM NUMBER]. The staff member reported writer did not have to wear any PPE if wanting to speak to the resident in room [ROOM NUMBER]. The staff member stated technically a gown and gloves should be worn in room [ROOM NUMBER] to say hello (to the resident). An interview was conducted on 2/26/24 at 4:55 p.m., with Staff FF, Registered Nurse (RN). The staff member stated Resident 104, in room [ROOM NUMBER], had been on EBP for a long time at least 2 hospitalization s ago. Staff FF read the EBP sign posted to room [ROOM NUMBER]'s PPE caddy and stated if any contact with the environment, persons were to wear gown and gloves, and during high contact care (such as) the areas listed on sign, the staff member would wear a mask also. The interviews conducted with staff revealed staff were unsure of the PPE required and when PPE was required for the implementation of Enhanced Barrier Precautions. During an interview on 2/29/24 at 10:00 a.m., Staff J, Infection Preventionist (IP)/Assistant Director of Nursing (ADON)/Rehab Unit Manager (UM), stated Resident 104 had multiple hospitalization s and C. Auris was identified during one of those (hospitalization s). The IP reported in regard to educating staff for precautions and PPE use, I watch them to make sure they are putting on (PPE) the right order, and return demonstration, staff are educated at least annually, thinks quarterly, also. Staff J stated agency staff are either educated by her or the night supervisor. The IP stated, Our isolation signs will tell you, also tell you what to wear, Enteric (Cdiff) precautions will tell you to wash hands. The Center for Disease Control and Prevention (CDC), - About Candida auris (C. auris), last reviewed on October 4, 2023, included the following information: - Candida auris (C. auris) is a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities. It is often resistant to antifungal treatments, which means that the medications that are designed to kill the fungus and stop infections do not work. - A recent report shows that cases of C. auris increased dramatically from 2020-2021 in states across the U.S. - If a patient is colonized or infected, healthcare providers take special steps to prevent the spread of C. auris, including placing the patient in a room separated from those at risk, cleaning the rooms with special disinfectant products, and wearing gloves and gowns to deliver care. This information was located at: https://www.cdc.gov/fungal/candida-auris/candida-auris-qanda.html. The CDC guidance for Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated as of July 12, 2022, revealed the following key points: -Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. - Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status Infection or colonization with an MDRO. - Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. - Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. This information was located at: https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html. 48223 4. An observation was conducted on 2/26/2024 at 10:03 AM during the initial tour of the facility. Resident #327 room door had an 8 1/2 by 11 (letter size) laminated paper sign printed in color attached and showed; A laminated Florida Health sign with: Special Droplet/Contact Precautions in the upper left corner in English and in Spanish in the upper right corner. Next after this was a large red STOP sign. Next to the stop sign typed was Only essential personnel should enter this room, followed the Spanish version. Next section: Everyone MUST: *Clean hands when entering and leaving room *Wear a NIOSH-approved N95 or equivalent or higher-level respirator at all times *Wear eye protection * Gown and glove at door. Next section: Keep door closed (if safe to do so). Next section: Use patient-dedicated or disposable equipment * Clean and disinfect shared equipment. The entire sign was translated to for the Spanish language. Continued observation revealed hanging on the outside of Resident #327's room door was a storage unit with the above sign clipped to the unit. The unit had a section to hold isolation gowns, gloves, eye protection, and a door that opened where masks could be stored. No masks or eyewear were available in the unit at the time of the observation. On 2/26/2024 at 10:03 AM Resident #327's call light was observed activated. The staffing coordinator (SC) was observed approaching the room. The SC started to enter the resident's room after knocking. The SC stopped and looked at the sign on the storage unit hanging on the front of the Resident's room door. The SC took out a gown and donned. Next, donned gloves looked around the storage unit on the door and then entered the room and closed the door. The SC exited the resident room and completed hand hygiene (HH). An interview was conducted with SC on 2/26/2024 at 10:05 AM. The SC stated she was not sure why the resident was on isolation. The SC confirmed the storage unit on the door was not stocked properly with the appropriate personal protective equipment (PPE). An interview was conducted with Staff D, Certified Nursing Assistant (CNA) on 2/26/2024 at 10:05 AM. Staff D, CNA stated she was assigned to Resident #327 and was not sure why the resident was on isolation precautions. Staff D, CNA continued to state she was unsure of what PPE was supposed to be worn and when. Staff D, CNA was then observed entering the resident room with no PPE. On 2/24/2024 at 10:15 AM an observation occurred of Resident #327's room door. The room door had a new sign on the door. The sign was on yellow paper with a large STOP sign and the words Please See Nurse Before Entering no other signs were on the door. The storage unit hanging on the door had isolation gowns, gloves (2 sizes) and masks. An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 2/26/2024 at 10:15 AM. Staff G, LPN stated Resident #327 was on contact isolation. Staff G, LPN continued to state contact isolation meant to don PPE only when providing care. Any other time in the room does not require PPE. An interview was conducted with Staff F, LPN on 2/26/2024 at 11:03 AM. Staff F, LPN stated contact isolation only requires PPE when providing care. An interview was conducted with Staff J, Registered Nurse, Infection Control Preventionist (RN) on 2/26/2024 at 11:39 AM. Staff J, RN stated contact isolation PPE depends on what the person entering will be doing. If providing care, then staff should don PPE. If care is not being provided, then PPE is not necessary. On 2/27/2024 at 3:30 PM and 2/28/2024 at 11:30 AM Policy and Procedures for types of precautions utilized in the facility were requested. No documents related to precaution types were provided prior to survey exit.

Based on observations, staff interviews and medical record review, the facility failed to ensure one of fifty-three sampled residents (#76) was provided and maintained with privacy/dignity during two of four days observed (2/26/2024, and 2/27/2024). Findings included: On 2/26/2024 at 10:20 a.m. while touring the C wing halls, and prior to getting to Resident #76's room, the resident could be overheard calling out and moaning loudly. Upon reaching the resident's room, the door was open, and Resident #76 was noted lying flat in bed and with the covers off her body. She was observed not wearing any clothing and the bottom half of her body was exposed with only wearing an adult brief. Resident #76 was not interviewable. Three staff members were observed walking by the room and did not intervene to cover the resident up or assist the resident. On 2/27/2024 at 7:15 a.m. Resident #76's room was approached, and the door was open. From the hallway, the resident was observed lying in bed and with the covers off her lower body and she was noted wearing only an adult brief. Various staff, including nursing aides, were observed in the hallway, passing the resident's room while looking in, and not going in the room to cover her up, or to close the privacy curtain or room door. Review of Resident #76's medical record revealed she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the advance directives revealed the resident had a decision maker to make her medical and financial decisions. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dementia, Urogenital implants, Muscle weakness, Anxiety, Repeated falls. Review of the current Minimum Data Set (MDS) Quarterly assessment, dated 1/24/2024, revealed: -Cognition/Brief Interview Mental Status BIMS score 3 of 15, which indicated Resident #76 would not be an interview candidate and would not be able to express medical care and medical decisions; Mood - Feeling down/hopeless/depressed, checked yes 2-6 days, Behaviors - Section C Other behavioral symptoms not directed towards others e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds, checked as Behaviors not exhibited, Rejection of care 1-3 days. Review of the current care plans with next review date 5/1/2024 revealed the following areas: - ADL [activities of daily living] Self-Care and/or mobility deficit, at risk of developing complications associated with decreased ADL self-performance related to: dementia, anemia, history of TIA [trans ischemic attack], NSTEMI [non-ST elevated myocardial infarction]. Decline may be unavoidable due to terminal prognosis, with interventions in place. - Alteration in Mood State, Verbal expressions of distress, Alterations in usual sleep cycle, Sad, Apathetic, Anxious Appearance, Lack of Motivational Interest, Other, with interventions in place to include: Consult with psych, Encourage to allow to express feelings, Encourage frequent contact with family, Promote homelike environment. Review of the current care plans and progress notes dated from 11/1/2023 through to 2/28/2024 did not indicate resident disrobes or has a history of disrobing while in bed. On 2/27/2024 at 10:00 a.m. an interview with Staff B, Certified Nursing Assistant (CNA), revealed if a resident is seen from the hallway and in their room either disrobed or observed with just a brief on, staff are to go in the room and either re-cover the resident, dress the resident, or pull the privacy curtain. Staff B confirmed Resident #76 kicks off her blanket at times and staff should respond when see her that way, and then cover her or provide her with dignity/privacy. On 2/29/2024 at 9:30 a.m. during an interview Staff A, Licensed Practical Nurse (LPN), revealed Resident #76 does call out routinely as part of her daily routine behavior and will wriggle in her bed. She revealed staff, including herself, will go to the resident when they hear her call out and/or moan and will calm her. Staff A confirmed Resident #76 does at times kick off her blanket and there are times she is observed disrobed and with her adult brief on. She revealed if any staff see that, they are to re-cover her and/or close the privacy curtain so other residents and visitors do not see her in her room with only wearing a brief. On 2/29/2024 at 12:38 p.m. an interview was obtained with the Director of Nursing (DON) related to Resident #76. The DON revealed she was familiar with Resident #76 and the resident usually stays in her room and stays in bed most of the day. The DON revealed Resident #76 was not interviewable and requires total assist with her ADL care. The DON revealed Resident #76 does have calling out behaviors and does kick around while in bed. She was not sure if Resident #76 was ever observed disrobed while in bed. The DON confirmed if any staff observe a resident disrobed, and can be seen from the hallway, they are to immediately assist the resident in re-covering or pull the privacy curtain. She said non-care staff should find a direct care staff or manager and let them know a resident could be seen from the hallway and is disrobed. The DON confirmed a resident's dignity should be maintained and for those who are not able to know if they are uncovered and exposed, staff should intervene and assist them. On 2/29/2024 at 12:38 p.m. a Rights, and Dignity maintenance policy and procedure was requested from the DON. The DON was not able to provide one for review and indicated the facility did not have a specific policy with relation to Resident Dignity maintenance.

Based on observations, interviews, record review, and facility policy review, the facility failed to protect a resident's right to be free from abuse and neglect, failed to ensure a resident who required one-person assistance with ADLs (activities of daily living), was provided timely care and assistance with toileting, and neglected to ensure a comfortable environment for one out of two residents reviewed (Resident #94.) Findings included: Resident #94, an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain, not elsewhere classified, abnormal weight loss, adult failure to thrive, age-related osteoporosis without current pathological fracture, anxiety disorder, unspecified, calculus of gallbladder without cholecystitis without obstruction, constipation, unspecified, gastro-esophageal reflux disease without esophagitis, iron deficiency anemia, unspecified, other idiopathic scoliosis, lumbar region, retention of urine, unspecified, rheumatoid arthritis, and other cervical disc displacement, according to the clinical record. Review of a care plan for Resident #94 initiated on 01/05/22 showed an ADL self-care and/mobility deficit goal indicating the resident was at risk of developing complications associated with decreased ADL self-performance related to weakness, failure to thrive and dizziness. Interventions included an assist of one for toileting and to provide assistance and supervision as needed, turn, and reposition frequently as needed. A focus initiated on 01/12/22 showed incontinence of bladder related to senile degeneration of the brain and impaired mobility. Interventions included checking frequently and as needed for incontinence, provide incontinence care as needed. On 02/27/24 at 10:54 a.m., an interview was conducted with Resident #94. She stated on the night of 02/14/24, a certified nurse's assistant (CNA) was not nice. She said, I believe she was an agency staff. I do not know her. She was rough during care. I turned on the call light at about 4:30 a.m. She entered the room in a hurry, she woke me up. She turned off my call light and left. When she came back, she was not in a good mood. She treated me badly. I said, get another job. She turned off my light again and left. Five times I put on my call light and each time she came in and turned it off. The whole time she did not change me. Finally, she changed me. She then put my blanket and sheet on the chair and left me exposed. I was cold. I turned on the light again. She came in and I said, I am cold. I need my blanket. She said you should say I'm sorry first. I refused to apologize. This went on for 15-20 minutes. She still left and then I think someone spoke with her. She came back and put the covers on me and yelled have a nice day. The next day I told my [family members]. She said I had to report it. I reported it to the supervisor [Staff U, Licensed Practical Nurse (LPN)]. I explained what happened. She took notes and said we have to report. She called the police. The police came and spoke with me. I told them I did not want to press charges. I felt bad. I did not want anyone to get in trouble. Two days later someone from here came and spoke with me and said don't worry. She will not return. I have not seen her again. On 02/27/24 at 04:23 p.m., an interview was conducted with Staff U, LPN/supervisor. She stated the resident's family member was at the facility on 02/15/24 sometime after 6p.m. She stated she spoke with the family member who wanted her to speak with the resident about an incident. Staff U stated the resident said to her, I'm a little upset. She explained to me that on the night before, a third shift CNA (whom she later found out to be Staff V, an agency CNA) had come into the room around 4:45a.m. She stated they [she and her roommate] would usually get changed around 5 a.m. She stated the CNA came and opened the door, changed out water cups and left. The resident said she waited a little bit and turned the call light on. She said she told the aide that she needed to be changed. She stated the CNA had a little bit of an attitude. The resident said, she pulled my sheets and blanket and left them on the chair. She said the resident said, the aide was rough. She was not abusive, she put me on my side and changed me. and then she got me on my back she did not put a blanket or sheet on her. The resident said she would ring for the aide to give her the sheet; the aide came and turned out the light and walked out, multiple times. She did this several times. The resident said to the aide I will denounce you, which meant I will report you. The aide said to her, well, if you say please Then the resident said to the CNA if you say you are sorry. She ended up getting her blanket. Her [family member] was upset. Staff U stated she immediately reported the incident to the Risk Manager who was no longer at the facility and the Director of Nursing (DON). The CNA was removed from the assignment and told not to return to the facility. Staff U stated, I did skin checks and there was no bruising at the time. I asked the roommate, who was confused. She could not answer. Staff U stated she had contacted the 11pm-7am supervisor who worked that night, and she reported the resident did not say anything at the time. The police was notified, and they came and spoke with the resident. Staff U stated she gave the deputy the CNAs name. On 02/27/24 at 04:37 p.m. an interview was conducted with the DON. She stated she was called on 2/15/23 early on 3pm -11pm shift. She stated she interviewed the resident who stated Staff V, CNA was working with the resident and according to the resident around 0445 that morning, the aide came and changed out her cup and not her brief. The resident called the aide and requested to be changed. The aide removed sheet and blanket tossed on chair, never changed her. The resident said, she was rough with me while she changed me. The aide went out of the room. The resident reported she was left uncovered. The resident called the aide back into the room and according to the resident the aide said to the resident, tell me Please and I will cover you. Resident stated I told her I was going to denounce [report] her. The resident told a family member. The DON said in response she had to write a report. She said, I called the agency and told her supervisor she would not be scheduled at this facility moving forward. I reviewed the incident. The DON said, what I got from her statement was the resident felt like she had a bad experience regarding a blanket not placed over her, changing of water cup, and getting changed and a comment, to say please before being assisted with covers. When the DON received the call, she stated she told the supervisor, Staff U LPN to make sure the aide was not in the building. The DON stated education was provided by the CNA's agency on customer service. The DON said, we did not reach her. I did not speak to her personally. I did not personally follow - up with the agency. We did not interview other staff. I attempted to speak with her roommate. She is not interviewable. I believed [Resident #94's] statement. On 02/27/24 at 04:55 p.m., an interview was conducted with the Risk Manager (RM) and the Nursing Home Administrator (NHA). The Risk Manager stated the previous Risk Manager was originally notified of the incident, but she no longer worked at the facility. This Risk Manager stated she spoke to the resident. She did not report to anyone that night but reported to a family member the following day. She stated the CNA was rough, but the care was completed. The Risk Manager said she spoke to the resident briefly on Saturday and more extensively the following Monday, 02/19/24. She stated the Resident gave the same statement she gave to Staff U. She said she hated to report the CNA. She said, I don't want her anymore. The resident said she had put the light on, and the aide (Staff V, Agency CNA) responded, she came into the room and said I'm busy. She turned the call light on and left. The resident waited a little. She turned it on again. The aide came in. The resident said, Please change us and the aide said, I told you I would do The resident said she said it kind of hurriedly. The CNA pulled the resident's sheets and cover and placed them on a chair. The resident had a contracted arm, and she could not reach it. She tried to lean and grab the covers. She could not. She said, I was cold. The resident stated I waited a little bit longer and turned light on. The aide came and said, if you say please, I will give you the covers. the resident said to her, if you say I'm sorry first. This went back and forth a couple times. Eventually, she gave her the covers. The RM said, I don't think she is a good aide; she was not nice. The resident was not hurt. She and her roommate may have waited to be changed, no one knows how long. I spoke with the resident. I told her the aides are here to meet your needs. She had reported it to Staff U, and I went to see her. She did not deviate from her story. She kept saying she was sorry for telling the staff. I told her the aide would not be back. Later on, I found out it is an agency CNA. She had only worked here once before. I asked the Agency supervisor to have her call me back. I needed to get information. The agency and the staff member never called back. I did not reach the aide or the agency. We have not had any communication. We removed her from returning to the facility. As an IDT (inter disciplinary team) we did not feel abuse occurred, we felt it was a customer service issue. She was unharmed. We felt the CNA was not friendly and kind. The resident used the word rough. She was not harmed physically. The Risk Manager said she felt the CNA did not provide good care. The Risk Manager confirmed harm could be emotional stress when she neglected to give her covers. The Risk Manager said, There was no physical abuse. We did think of the potential of it happening again, that was why we said she could not return. She did not meet our care standards. Continuing, the NHA said, We did not consider it neglect or abuse. We saw it as an incident of customer service. When asked about delaying or withholding care and services, the NHA said, I can see where you are going with this. It was not one incident; she went in and out of the room. The Risk Manager stated, the aide neglected to provide care; the aide did not give the resident the blanket. The NHA stated they submitted a 5-day report and did not substantiate the abuse and neglect allegation. Review of the 5-day report at the time of the interview documented the resident's BIMs (brief interview for mental status) score at 15/15, indicating the resident was cognitively intact. The NHA stated their abuse and neglect education was on-going. She stated they initiate abuse and neglect training with each allegation incident. She stated they educated all staff. On 02/27/24 at 05:42 p.m., during an interview, the NHA stated they did not have the education documentation for Staff V, CNA, or evidence she signed off on the new agency staff education packet. She stated their training records would be off site because it had been a while. She stated the CNA worked at this facility once in June 2023 and then in February 2024. The NHA stated they had agency staff working for them. She stated related to agency training, there was a packet that is reviewed with them before working for the facility. She said the packet is reviewed with the agency staff by the supervisor on shift, aides who are mentors or the scheduler. She stated they try to have repeat CNAs if available for familiarity with care. On 02/29/24 at 11:03 a.m., a follow-up interview was conducted with the Risk Manager. She stated she expected staff to document anything outside the norm and to notify the Director of Quality Assurance (DQA) as soon as possible. She stated they were educating staff on completion of investigation and documentation following abuse allegations. 02/29/24 11:09 a.m., an interview was conducted with the NHA and Risk Manager. The Risk Manager re-read her own statement regarding her interview with Resident #94 submitted on 02/15/24 which read, She had summoned the CNA several times with her call lights, and she would respond by saying she will be right back she was doing care in other room. When she did not return, she put on call light again, thinking she had forgotten her request to have her brief changed. When she did provide her care, she was rough, moving fast and not friendly she said she had never had this aide before and hated to denounce[report] her, but she did not want her assigned to her care again. she then stated after her care was provided. She [aide] left without putting her blanket back on, left it on her bedside chair that she could not reach herself. she called for her again, asking her to put her covers back on to which the aide replied, when you say please and she replied, when you say you are sorry. The Risk Manager stated five days later, on 02/19/24 she audited all residents in that assignment, a total of 14 that were under the CNA's care. She asked if they had any concerns with care and services and if they knew how to report. She stated the residents did not report any concerns at the time and that she encouraged them to have any concerns addressed immediately. The Risk Manager stated if a resident alleged any form of abuse, she would expect the nurse to conduct a head-to-toe assessment. The NHA stated she thought Staff U had completed skin evaluations. She said, she should have done it. She is a good nurse. I know what is not documented did not happen. Review of Resident # 94's record revealed there were no progress notes documenting care on 2/14/23 and 2/15/23. There were no documented skin checks or evaluations. There was evidence a psych evaluation was recommended or conducted. On 02/29/24 at 11:19 a.m., continued interview with the Risk Manager and the NHA. The Risk Manager said, I don't see it [assessments/evaluations], I would expect a note. The NHA stated the resident did not have any changes in her psychosocial and that was why they did not seek psych services. The NHA stated she had reviewed the investigation. The nurse on shift was not made aware of the incident. She confirmed they did not interview her. She said, No we did not interview any other staff. We were not able to get hold of that CNA because she was agency. The NHA stated if this was a facility CNA, she would have given the CNA a coaching for customer service. The Risk manager said the fact that the CNA did not give the resident covers when she stated she was cold, meant she withheld services. The Risk Manager said, yes that would be neglect. The NHA stated according to their procedures, an investigation and education should have been initiated, whether the allegation was substantiated or not. On 02/29/24 at 1:20 p.m., an interview was conducted with the Director of Education. She stated an in-service of abuse and neglect, and misappropriation of property should be conducted whenever there was an allegation or with any reportable incident. She stated there can be multiple incidents on-going and if the abuse training was already started, they just keep it going. Review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, Revised September 2023, showed the center recognizes each resident's right to be free from abuse, neglect, and exploitation (ANE), misappropriation of property. This includes, but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Abuse is the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect is defined as the failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This occurs when the center was aware of or should have been aware of, goods or services that the resident required but the center failed to provide them resulting in or may result in physical harm, pain, mental anguish, or emotional distress.

Based on staff interviews, record review and facility policy review, the facility failed to ensure allegations of abuse and neglect were investigated for one (#94) of two residents reviewed. Findings included: On 02/27/24 at 10:54 a.m., an interview was conducted with Resident #94. She stated on the night of 02/14/24, a certified nurse's assistant (CNA) was not nice. She said, I believe she was an agency staff. I do not know her. She was rough during care. I turned on the call light at about 4:30 a.m. She entered the room in a hurry, she woke me up. She turned off my call light and left. When she came back, she was not in a good mood. She treated me badly. I said, get another job. She turned off my light again and left. Five times I put on my call light and each time she came in and turned it off. The whole time she did not change me. Finally, she changed me. She then put my blanket and sheet on the chair and left me exposed. I was cold. I turned on the light again. She came in and I said, I am cold. I need my blanket. She said you should say I'm sorry first. I refused to apologize. This went on for 15-20 minutes. She still left and then I think someone spoke with her. She came back and put the covers on me and yelled have a nice day. The next day I told my [family members]. She said I had to report it. I reported it to the supervisor [Staff U, Licensed Practical Nurse (LPN)]. I explained what happened. She took notes and said we have to report. She called the police. The police came and spoke with me. I told them I did not want to press charges. I felt bad. I did not want anyone to get in trouble. Two days later someone from here came and spoke with me and said don't worry. She will not return. I have not seen her again. On 02/27/24 at 04:37 p.m. an interview was conducted with the DON. She stated she was called on 2/15/23 early on 3pm -11pm shift. She stated she interviewed the resident who stated Staff V, CNA was working with the resident and according to the resident around 0445 that morning, the aide came and changed out her cup and not her brief. The resident called the aide and requested to be changed. The aide removed sheet and blanket tossed on chair, never changed her. The resident said, she was rough with me while she changed me. The aide went out of the room. The resident reported she was left uncovered. The resident called the aide back into the room and according to the resident the aide said to the resident, tell me Please and I will cover you. Resident stated I told her I was going to denounce [report] her. The resident told a family member. The DON said in response she had to write a report. She said, I called the agency and told her supervisor she would not be scheduled at this facility moving forward. I reviewed the incident. The DON said, what I got from her statement was the resident felt like she had a bad experience regarding a blanket not placed over her, changing of water cup, and getting changed and a comment, to say please before being assisted with covers. When the DON received the call, she stated she told the supervisor, Staff U LPN to make sure the aide was not in the building. The DON stated education was provided by the CNA's agency on customer service. The DON said, we did not reach her. I did not speak to her personally. I did not personally follow - up with the agency. We did not interview other staff. I attempted to speak with her roommate. She is not interviewable. I believed [Resident #94's] statement. On 02/27/24 at 04:55 p.m., an interview was conducted with the Risk Manager (RM) and the Nursing Home Administrator (NHA). The Risk Manager stated the previous Risk Manager was originally notified of the incident, but she no longer worked at the facility. This Risk Manager stated she spoke to the resident. She did not report to anyone that night but reported to a family member the following day. She stated the CNA was rough, but the care was completed. The Risk Manager said she spoke to the resident briefly on Saturday and more extensively the following Monday, 02/19/24. She stated the Resident gave the same statement she gave to Staff U. She said she hated to report the CNA. She said, I don't want her anymore. The resident said she had put the light on, and the aide (Staff V, Agency CNA) responded, she came into the room and said I'm busy. She turned the call light on and left. The resident waited a little. She turned it on again. The aide came in. The resident said, Please change us and the aide said, I told you I would do The resident said she said it kind of hurriedly. The CNA pulled the resident's sheets and cover and placed them on a chair. The resident had a contracted arm, and she could not reach it. She tried to lean and grab the covers. She could not. She said, I was cold. The resident stated I waited a little bit longer and turned light on. The aide came and said, if you say please, I will give you the covers. the resident said to her, if you say I'm sorry first. This went back and forth a couple times. Eventually, she gave her the covers. The RM said, I don't think she is a good aide; she was not nice. The resident was not hurt. She and her roommate may have waited to be changed, no one knows how long. I spoke with the resident. I told her the aides are here to meet your needs. She had reported it to Staff U, and I went to see her. She did not deviate from her story. She kept saying she was sorry for telling the staff. I told her the aide would not be back. Later on, I found out it is an agency CNA. She had only worked here once before. I asked the Agency supervisor to have her call me back. I needed to get information. The agency and the staff member never called back. I did not reach the aide or the agency. We have not had any communication. We removed her from returning to the facility. As an IDT (inter disciplinary team) we did not feel abuse occurred, we felt it was a customer service issue. She was unharmed. We felt the CNA was not friendly and kind. The resident used the word rough. She was not harmed physically. The Risk Manager said she felt the CNA did not provide good care. The Risk Manager confirmed harm could be emotional stress when she neglected to give her covers. The Risk Manager said, There was no physical abuse. We did think of the potential of it happening again, that was why we said she could not return. She did not meet our care standards. Continuing, the NHA said, We did not consider it neglect or abuse. We saw it as an incident of customer service. When asked about delaying or withholding care and services, the NHA said, I can see where you are going with this. It was not one incident; she went in and out of the room. The Risk Manager stated, the aide neglected to provide care; the aide did not give the resident the blanket. The NHA stated they submitted a 5-day report and did not substantiate the abuse and neglect allegation. Review of the 5-day report at the time of the interview documented the resident's BIMs (brief interview for mental status) score at 15/15, indicating the resident was cognitively intact. The NHA stated their abuse and neglect education was on-going. She stated they initiate abuse and neglect training with each allegation incident. She stated they educated all staff. On 02/29/24 at 11:03 a.m., a follow-up interview was conducted with the Risk Manager. She stated she expected staff to document anything outside the norm and to notify the Director of Quality Assurance (DQA) as soon as possible. She stated they were educating staff on completion of investigation and documentation following abuse allegations. On 02/29/24 at 11:19 a.m., continued interview with the Risk Manager and the NHA. The Risk Manager said, I don't see it [assessments/evaluations], I would expect a note. The NHA stated the resident did not have any changes in her psychosocial and that was why they did not seek psych services. The NHA stated she had reviewed the investigation. The nurse on shift was not made aware of the incident. She confirmed they did not interview her. She said, No we did not interview any other staff. We were not able to get hold of that CNA because she was agency. The NHA stated if this was a facility CNA, she would have given the CNA a coaching for customer service. The Risk manager said the fact that the CNA did not give the resident covers when she stated she was cold, meant she withheld services. The Risk Manager said, yes that would be neglect. The NHA stated according to their procedures, an investigation and education should have been initiated, whether the allegation was substantiated or not. Review of a facility policy titled, Abuse, Neglect, Exploitation and Misappropriation, Effective October 2014, showed a thorough investigation will be conducted. The abuse coordinator/designee will initiate procedures for conducting the investigation. The investigation will include: a. The type of allegation. b. What occurred when, where and to whom, by whom. Get a physical description or identify the alleged perpetrator if possible. c. Describe the injury and any treatment. d. Interview with nurses separately, interview caregivers, roommates, get statements, observe/document demeanor including names, addresses and phone numbers of actual witnesses. e. Document cognitive status of victim, resident witnesses, document if credible/believable. f. Obtain Signed statement from alleged perpetrator if possible. g. Review alleged perpetrators personal performance and reputation. h. Describe action taken to protect resident. i. Not any bias between alleged perpetrator and witness. j. If agency personnel obtain information from agency. k. If sexual abuse is alleged document regarding physical examination, obtain copy of statement from examiner. l. If neglect is alleged, identify staff length of time, an outcome to resident. m. If exploitation is alleged identify items and value. n. Review schedules and assignments. o. Review any meds that may cause residents to bruise easily or be related to nature of the injury. p. Review facility policies and procedures for unsafe technique used by staff. q. Review nurses notes and other records for information about the incident. Upon completion of the investigation the facility should prepare a summary report of the findings and conclusions including any actions taken by the facility. All investigative files will be maintained separately in a secured/locked area in the risk managers office not in the residence medical record.

Based on observations, record reviews, and interviews, the facility failed to ensure skin conditions were identified and treated for three (#57, #274, and #21) out of nine residents reviewed for skin conditions and failed to identify and respond to one (#325) out of one residents sampled for change in condition in a timely manner that resulted in a hospitalization . Findings included: On 2/29/24 at 4:13 p.m., Resident #57 was observed lying in bed, wearing bilateral offloading boots. The observation was conducted with Staff S, Registered Nurse (RN). The staff member explained the observation to the resident, who assisted with raising right foot from the boot. The observation revealed a topical patch had been applied to the front ankle area of the resident, which the staff member reported as a Lidocaine patch, a gangrenous area was noted to the resident's right great toe and a slightly reddened approximate quarter-sized area was observed on the resident's right heel. The area was confirmed by the staff member. Review of Resident #57's clinical record with Staff S, immediately following the observation of the resident's right foot revealed no progress note, further assessment, or a treatment order regarding the resident's right heel. The staff member confirmed the findings and stated there should have been follow-up on the area. Staff S confirmed she was unaware of the area. Review of Resident #57's clinical record on 2/26/24 at 4:35 p.m., revealed a weekly skin check, dated 2/14/24 at 11:22 p.m., documenting a pressure injury to Resident #57's right heel. The purpose of the weekly skin check was To document skin condition following weekly examination and to identify new areas of concern or breakdown. The evaluation did not reveal any further information regarding the documented pressure injury. The review did not show a weekly skin check had been completed since 2/14/24. Review of the Wound Physician's wound evaluation and management summary, dated 2/13/24 (the day before the discovery of the resident's pressure injury), showed an arterial wound on Resident #57's right first toe (3.5 x 3 centimeter (cm)), left heel (1 x 1 cm), distal medial right foot (2.6 x 1.8 cm), left distal lateral foot (0.6 x 0.5 cm), and left lateral 5th toe (1.5 x 1.0 cm). The treatment plan for the 5 areas was skin prep once daily. The pressure injury to the resident's right heel was not noted on this evaluation. The summary did show the resident had peripheral artery disease (PAD), had recently been hospitalized for new arterial wounds, an angiogram had been done with any further recommended interventions as the blood flow was unable to be improved, and the resident had dry gangrene. Review of a Registered Nurse/Licensed Practical Nurse (RN/LPN) Skin Grid, effective 2/14/24 at 3:05 p.m., revealed Resident #57 had 5 arterial wounds involving the left heel, right toe(s), left lateral foot, left 5th toe, and right lateral foot. The skin grid did not reveal the right heel had any skin condition and was completed 8 hours prior to the above mentioned pressure injury. The measurements shown were the same as the Wound Physician had documented during the visit conducted on 2/13/24 (day before this grid was completed). Review of a RN/LPN Skin Grid, dated 2/20/24 at 5:30 p.m., revealed the measurements of the 1st right toe, left heel, right medial foot, left lateral foot, and left 5th toe. The grid did not include the resident's right heel and corresponded with the Weekly Wound physician visit on 2/20/24. The documentation was not locked until 2/28/24 at 5:46 p.m., 8 days after the evaluation was created. Review of progress notes, dated 2/14/24 through 2/15/24, showed Resident #57's responsible party was updated in regards to the resident's arterial wounds and notified of the treatment orders on 2/14/24 at 3:22 p.m., approximately 8 hours prior to the discovery of the resident's right heel pressure injury. The record did not show any further notes were made after the notification. Review of Resident #57's February Treatment Administration Record (TAR) showed treatments for the resident's left heel, right great toe, and right distal medial foot/lateral foot. The TAR did not include a treatment was ordered for the right heel. Review of the care plan for Resident #57 showed the resident was a potential risk for alteration in skin integrity related to: fragile skin, decreased mobility, dry skin, incontinency, Diabetes mellitus (DM), nasal cannula for oxygen, history cellulitis, history (of) prednisone use, PAD to bilateral lower extremity (BLE), critical limb ischemia with 100% occlusion of superficial femoral artery (SFA), and dry gangrene to right toe. The interventions show staff are to perform skin checks per facility protocol and to observe for signs and symptoms of alteration in skin and report. 43453 On 02/26/24 at 10:10 a.m., Resident #21 was observed in her room sitting in her wheelchair. The resident was noted with undated dressing on her right leg. A dark discoloration was noted in the middle of the dressing. She stated she must have scrapped herself during a transfer. On 02/27/24 at 10:30a.m. Resident #21 was observed in her room. She was observed with the same undated dressing on her right leg. An interview was conducted with Resident #21 and a family member at the time of the observation. The family member stated the resident had an incident in the shower the previous Saturday. She stated the aides were transferring her. She stated the resident did not fall, but she may have scrapped her leg on her chair. The family member stated the floor was slippery and the resident did not have shower shoes on. She stated a Physical Therapy (PT) saw her earlier that morning and new shower shoes have been purchased. On 02/28/24 at 09:46 a.m., Resident #21 was observed in her room sitting in her wheelchair, noted with the same undated dressing for 3 out 3 days. On 02/28/24 at 09:48 a.m. an observation was made of Staff R, PT escorting the resident to the therapy. She stated Resident #21 had an incident in the shower during a transfer. She stated PT had not assessed the incident. She stated nursing should have assessed and addressed the injury. She said, I don't know if they have. Review of Resident #21's physician orders and Treatment orders did not show documentation regarding the skin condition on the Resident's Right leg. A review of Resident #21's weekly skin assessments for the month of February 2024 showed two assessments 2/3/24 and 2/20/24 indicating the resident's skin was intact. A care plan for Resident #21 initiated 01/15/24 showed a focus Resident is at risk for alteration in skin integrity related to impaired mobility with interventions to include observe for signs and symptoms of alteration in skin and report. A follow up interview was conducted with Staff N, Licensed Practical Nurse (LPN) assigned to the resident on 02/28/24 at 09:50 a.m. Staff N saw the undated dressing and stated she did not know where it was from. She said, I was assigned to the resident the last 3 days. I did not notice it. No one said anything about an incident. I will check. On 02/28/24 at 09:51a.m. an interview was conducted with Resident #21's Certified Nursing Assistant (CNA). She stated she had worked with the resident for the previous 3 days. She said, Yes, she has a scab on her shin from the shower. I saw it. I think it happened over the weekend. On 02/26/24 at 01:59 PM Resident #274 was observed outside the nurse's unit. She was not interviewable. The resident was noted with edema. Her socks were observed tight on her legs. On 02/27/24 at 08:55 a.m. Resident #274 was observed in her room with Staff N, LPN assessing her legs. Staff N stated she did not know the resident had any concerns with her skin. The resident was observed with an open skin tear on her lower right leg which was red in color. Staff N said, I was not aware. I will call the doctor, initiate treatment, and document. Review of weekly skin assessments for Resident #274 dated 02/20/24 and 02/13/24 showed the resident's skin was intact, with no impairments. On 02/27/24 at 09:07 a.m. an interview was conducted with Staff O, CNA. She stated she had noticed the open skin area on the resident when she was putting on her socks. She stated she had applied lotion, a skin protector. She said, I should have told the nurse. I should not have covered it. A follow-up was conducted on 02/27/24 at 09:22 a.m. with Staff P, LPN, Unit Manager. She stated the CNA should have notified the nurse who should have documented a skin condition. She stated their expectation was for the CNA to alert the nurse of any open skin areas right away. On 02/28/24 at 09:59 a.m., an interview was conducted with Staff Q and Staff W wound care nurses. They stated all open skin conditions should be reported to the nurse. The nurse is expected to assess the site, administer first aid, and obtain orders to treat. Staff Q stated the nurse should notify the family, document a Change in Condition (CIC), and complete an incident report. On 02/28/24 at12:40 p.m. an interview was conducted with the Risk Manager regarding the skin tear. She said, it was discovered today Resident #21 had 3 small skin tears to her Right lower leg. That was why it was not on the incident log. I will have to find out what happened. I had a note that the nurse assisted the CNA with her shower. The resident was shaking, nervous and needed redirection. There was nothing documented regarding the incident. I have to investigate why the incident was not communicated. The Risk Manager stated she would have expected the nurses to document the skin tear, investigate what caused it, document the incident, and notify the doctor. She stated as the Risk Manager she would have liked to have been notified so they could document an incident report, notify the doctor, notify family, and treat accordingly. A review of a facility policy titled, Nursing- Accidents and Incidents/Investigating and Recording, dated October 2014 showed all accidents or incidents occurring on our premises must be investigated and reported to the administrator. An incident is defined as an unexpected or unintended event involving a client, visitor or employee that may or may not result in bodily injury and may or may not necessitate the transfer to another level of care. Procedure: regardless of how minor an accident or incident may be including injuries of an unknown source it must be reported to the department supervisor and an incident report form must be completed on the shift that the accident or incident occurred. Medical attention: the charge nurse shell examine all accidents/incident victims, notify the medical director or the victims personnel attending physician of the accident or incident, if necessary, arrange or transfer the injured person to the hospital or Medical Center. Investigative action: the church nurse and or the department director or supervisor must conduct an immediate investigation of the accident or incident. A review of a facility policy titled, skin care and wound management, dated July 2017 showed, the weekly skin sweep will be used by the licensed nurse to conduct a skin inspection at the time of admission, upon hospital return and no less than every seven days. A skin inspection will also be completed before and after a leave of absence from the center and if time permits before a hospital transfer. In addition, the CNA will document results of daily skin inspection per center protocol and report any changes or areas of concern to the nurse and/or physician. Current standards of practice will be used for skin and wound management. Appropriate treatment protocols will be based upon facilities skin and wound care guidelines and lower extremity wound care guidelines in addition to physician treatment orders. Physician treatment orders obtained and documented on the TAR (Treatment Administration Record) Resident/resident representative/ family will be notified of the skin impairment and treatment plan. The resident plan of care will be reviewed and revised as needed. New interventions will be communicated to the caregiving team. 48223 On 2/26/2024 at 10:34 AM and 11:30 AM, Resident #325 was observed sitting in a wheelchair across from the nurse's station. Resident #325's chin was to chest and appeared to be sleeping. On 2/26/2024 at 12:05 PM, Resident #325 was observed being wheeled into the Dining Room of the unit. Resident #325 was sleeping. Staff GG, Certified Nursing Assistant (CNA) was observed calling Resident #325's name. Resident #325 did not respond. Staff GG, CNA was observed giving the resident orange juice, then the meal tray. Resident #325 responded. On 2/26/2024 at 1:35 PM, Resident #325 was observed sitting in a wheelchair across from the nurse's station. Resident #325's chin was to chest and appeared to be sleeping. Staff L, Occupational Therapy Assistant (OTA) and Staff M, Physical Therapy assistant (PTA) were observed stopping and asking Resident #325, if he was in pain, then continued down the hall. Resident #325 was not heard to respond. Review of Resident #325's Minimum Data Set, dated dated dated [DATE], Section I (Active Diagnosis) showed: Type I Diabetes Mellitus, with Diabetic nephropathy, Spinal Stenosis, Chronic Kidney Disease (stage 2), Non-ST Elevation (NSTEMI) Myocardial Infarction, and other co-morbidities. Review of Resident #325's Progress Notes dated 2/26/2024 at 7:37 AM revealed, CNA notified this writer at 5am that resident was not responding to his name being called. This writer entered resident's room and tried to get resident to respond. Resident's blood sugar was taken and the results was 38. Resident was given a shot of Glucagon to bring up his blood sugar. Blood sugar was rechecked in 15 minutes and the result was 79. Resident's blood sugar rechecked at 0625 with result of 82. Next entry in the progress notes was 2/26/2024 at 8:04 PM, a change of condition was completed for Resident #325 due to an altered level of consciousness, unable to reach doctor, sending to hospital per manager. An interview was conducted with Staff H, Licensed Practical Nurse (LPN) on 2/29/24 at 10:02 AM. Staff H, LPN stated if she were to give a Resident Glucagon, I would definitely contact the physician. If a resident needs Glucogon, the resident had a change of condition and notification would be standard. An interview was conducted with the Director of Nursing (DON) on 2/29/2024 at 9:06 AM. The DON reviewed Resident #325's progress notes and stated her expectation based on the documentation would have been the nurse contact the physician when the Glucagon was administered. The DON confirmed the physician was not contacted until the resident had another change of condition and was transferred to the hospital. During an interview on 2/29/2024 at 1:13 PM the Medical Director stated his expectation is for the nursing staff to notify him if Glucagon needed to be administered. Review of the facility policy and procedure titled Nursing - Change in a Residents Condition or Status, dated October 2014 showed: Policy: The facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). In the event of a medical emergency, the facility will notify the attending physician and/or call 911 according to the resident's advance directives Procedure: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: *An accident or incident involving the resident; . * A significant change in the resident's physical/emotional/mental condition which includes discovery of the loss of vital bodily functions (loss of responsiveness to stimuli and loss of blood pressure, pulse, and respirations). * A need to alter the resident's medical treatment . *A need to transfer the resident to a hospital/treatment center . 2. Should the Attending Physician be unavailable and the change in condition is of an urgent nature, the facility will contact the Medical Director for guidance.

Based on observations, record reviews and interviews, the facility failed to respond to the consultant pharmacist's recommendations in a timely and accurate manner and for one (#3) out of 5 residents sampled for the administration of unnecessary medications. Findings included: On 2/26/24 at 11:41a.m., Resident #3 was observed and interviewed in the resident's room. The resident was alert and oriented and able to respond appropriately to initial interview questions. Review of Resident #3's Admission Record showed the resident was admitted on [DATE] with diagnoses not limited to unspecified site unspecified osteoarthritis, age-related osteoporosis without current pathological fracture, and generalized muscle weakness. Review of the Admission Medication Regimen Review Report, issued on 1/2/24, revealed the consultant Pharmacist asked for the facility to add pain intensity for use on as needed (prn) Norco (Hydrocodone/Acetaminophen (ApAp) order. The recommendation revealed Moderate pain handwritten across the recommendation and signed with initials. Review of Resident #3's January Medication Administration Record (MAR) revealed the resident had variable levels of pain ranging from 0 to 7 throughout during the day and evening shifts, zero during the night shift. The MAR showed the resident had an order for Norco oral tablet 5-325 milligram (mg) (Hydrocodone-Acetaminophen) - Give 1 tablet by mouth every 4 hours as needed for pain, started on 12/23/23 and discontinued on 1/2/23. The order written on 1/2/23 for Norco changed to every 8 hours as needed for pain. The MAR showed the resident received Norco 16 times for a pain level of 0, one time for a level of 2, 8 times for a level of 3, 8 times for a pain level of 4, 7 times for a level of 5, 2 times for a level of 6, and 3 times for a level of 7. This order did not include the recommendation response to add the pain intensity of moderate pain. Review of the consultant Pharmacist consultation report, dated 2/7/24, revealed a recommendation to Please add pain intensity for use on as needed (Prn) Ibuprofen and (&) Prn Norco (Hydrocodone/Acetaminophen (ApAp) order. The report showed a handwritten note Done. Review of Resident #3's February Medication Administration Record (MAR) revealed an order, dated 1/15/24, for Ibuprofen Oral Tablet 200 mg - Give 3 tablet(s) by mouth every 6 hours as needed for pain. The order for Ibuprofen did not show that the recommendation of adding a pain intensity was done. The MAR showed the resident received Ibuprofen one time for a pain level of 0, one time for a level of 2, 5 times for a level of 3, and one time for a pain level of 7. The MAR showed the resident order for Norco 5-325 mg - one tablet every 8 hours as needed for pain, started on 1/2/24 and was discontinued on 2/27/24. The order revealed the resident received Norco one time for a pain level of 0. one time for a level of 1, one time for a level of 2, 14 times for a level of 3, 4 times for a level of 4, 5 times for a level of 5, 8 times for a level of 6, and 6 times for a pain level of 7. The order showed the consultant recommendation on 1/2/24 was not completed until 2/27/24, 55 days after the first recommendation. A further review of the resident's MAR showed another order for Norco, dated 2/27/24 at 4:06 p.m., for one tablet to be administered every 8 hours as needed for moderate pain. The order did not reveal what level of pain was considered moderate. An interview was conducted with the Director of Nursing (DON) on 2/28/24 at 4:38 p.m. The DON reviewed the consultant Medication Regimen Report (MRR) for December 2023 and stated the resident was reviewed in January and February, she then began looking through additional pharmacy reports, was unable to produce an additional review completed in December. The DON stated the facility was in midst of a change and the consultant comes in twice monthly, does partial census and new admissions at each visit. She reported the consultant emails the recommendations to her, she prints them out, and then gives them to the Unit Managers. The DON stated she likes to have the signed recommendations back in a week (as they come in frequently) and if urgent (the staff was) to call the physician immediately. The DON stated, in regards to the January recommendation to add a pain intensity to the resident's Norco order, there was no reason for the delay, she reviewed the recommendation and confirmed the recommendation was sent to her on 1/2/24. The DON reviewed the February recommendation to add a pain intensity to both the resident's order of Ibuprofen and Norco, she confirmed the Ibuprofen portion of the recommendation had not been done, stating I missed it. Review of the policy - Medication Regimen Review, revised on 8/17/23, showed the Consultant Pharmacist would conduct MRR's if required under a Pharmacy Consultant agreement and would make recommendations based on the information available in the resident's health record. The facility should encourage Physician/Prescriber or other responsible parties receiving the MRR and the DON to act upon the recommendations contained in the MRR. The facility should encourage (the) Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. If an irregularity does not require urgent action but should be addressed before the consultant pharmacist's next monthly MRR, the facility staff and the consultant pharmacist will confer on the timeliness of attending physician responses to identified irregularities based on the specific resident's clinical condition. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation.

Based on observations, interviews, and medical record review, the facility failed to ensure one of six sampled residents (#106) for use of psychotropic medication use, was monitored and documented for signs/symptoms/side effects. Findings included: A record review for Resident #106, revealed diagnoses to include but not limited to: Nontraumatic subarachnoid hemorrhage, Aphasia, Dysarthria, Epilepsy, Mood disorder, Abnormalities in gait, Lack of coordination Dementia, Major depression disorder, Anxiety, and Insomnia. Review of the current [NAME] Data Set (MDS) 12/15/2023 Quarterly assessment revealed; Cognition/Brire Interview Mental Status score 3 of 15, which indicated Resident #106 would not have been able to speak related to his medical and care services; Mood - None noted. However, indicated under social isolation - Sometimes; Behaviors - Rejection of care 1-3 days. Review of the current month (02/2024) physician's order sheet revealed psychotropic medication use to include; a. Ativan 0.5 mg (milligram) 1 by mouth four times a day for terminal restlessness, hold for lethargy. Contact MD (physician) if held for 3 consecutive doses, with an order date of 10/16/2023. b. Depakote Sprinkles oral capsule delayed release sprinkle 125 mg. Give 3 caps (capsules) by mouth two times a day related to mood disorder, with an order date of 10/23/2023. Review of the current Care Plans with a next review date of 3/20/2024 revealed problem areas to include but not limited to: - Resident has potential for adverse consequences of Antidepressant medication for depression with insomnia with a start date of 6/13/2023. Interventions included: Administer medications as ordered; Monitor for effectiveness of medication, Monitor for side effects of medication: i.e. Nausea, Gastrointestinal problems, Dizziness, Fatigue, Dry mouth, weight gain, Insomnia. - Resident takes supplement for diagnosis of Insomnia with a start date of 6/13/2023. Interventions included: Give medications as ordered, Montior for side effects of supplement: Dizziness, Irritability, Headache, Hangover effect. - Resident has potential for adverse consequences related to use of Hypnotics with a start date of 8/7/2023. Interventions included: Administer medication as ordered, Monitor for effectiveness of medication, and Monitor for side effects of hypnotic i.e.; Headache, Confusion, Weakness, Nausea, Irritability, Dry mouth and report to MD as needed. - Resident has a diagnosis of Anxiety and has potential for adverse consequences related to use of Antianxiety. 9/11/23 started on Depakote sprinkle for anxiety as well, with a start date of 9/6/2023. Interventions included: Administer medications as ordered, Monitor for effectiveness of medication, Monitor for side effects of antianxiety medication i.e.: Drowsiness, dizziness, weakness, dry mouth, diarrhea, nausea, constipation, blurred vision and report to MD as need. - Use of psychotropic drug places resident at risk for drug related side effects. Diagnosis for which drug has been prescribed agitation with a start date of 10/2/2023. Interventions included: Administer medications as ordered, Montior behavior and intervene as needed, Montior for effectiveness of medication and review for changes, Observe for signs and symptoms of drug related side effects. Review of the Medication Administration Record (MAR) for months 10/2023, 1/2024 and 2/2024 revealed ordered medications to include use of Depakote and Ativan. It was determined through review of the 10/2023, 1/2024, and 2/2024 MAR, there was no evidence of signs/symptoms being monitored for use of the psychotropic medications, on a daily or shift basis. On 2/27/2024 at 11:00 a.m. a telephone interview was conducted with a family member for Resident #106. The family member revealed they pay and have a companion sitter sit with him daily for 5 days a week and that she assists with feeding assistance and watching him to make sure he doesn't fall. He said he feels the resident is on so many psychotropic medications and that he is so high on those medications that he sleeps all the time and staff don't get him up to place him in his wheelchair. He feels they are just doping him up to keep him sleeping all the time. Resident #106's family member stated he participates in care plan meetings and has mentioned this to the care staff. On 2/28/2024 at 8:50 a.m. an interview was conducted with Resident #106 companion sitter. She revealed she is at the facility mostly for breakfast meals about 5 days a week and sometimes comes to the facility for lunch to assist. She is responsible for assisting with meals, watching, and supervising him for safety, reading to him, assisting with television shows he may want to be on, talking with him, just generally being here for him. She revealed he sleeps a lot, and it is hard to get him to eat. She said he sleeps due to the use of psychotropic medications and had been made aware of this by Resident #106's family members. On 2/26/2024, 2/27/2024, 2/28/2024, and 2/29/2024 during the 7-3 shift, other than when Resident #106 was being assisted with the breakfast and lunch meal, he was noted in his room, lying in bed, and sleeping. When Resident #106 was observed during the Breakfast and Lunch meal service on 2/27/2024 and 2/28/2024, he was observed falling asleep during the meal service. On 2/29/2024 at 12:38 p.m., during an interview with the DON, she confirmed there was no daily monitoring for signs and symptoms related to the use of psychotropic medication and there should be daily monitoring. She said the care plan interventions related to monitoring should have been completed daily. The DON confirmed Resident #106's behaviors of sleeping all the time should have been monitored and documented on a daily basis, as that could be an indication of symptoms and side effects from use of psychotropic medication use. On 2/27/2024 at 2:25 p.m. Staff C Certified Nursing Assistant (CNA) was interviewed with relation to Resident #106 daily care and routines. Staff C confirmed Resident #106 does sleep most of the 7-3 shift but did not know about the other two shifts. On 2/29/2024 at 9:00 a.m. an interview with Staff A, Licensed Practical Nurse (LPN), who has Resident #106 on her assignment routinely, revealed he is hard to keep alert and awake during the day and he does have a sitter companion who sits with him in the mornings. Staff A confirmed he does not get out of bed much and does sleep most of the day. She confirmed there is no way of documenting signs/symptoms to include fatigue, sleeping, drowsiness related to psychotropic medication use, in the Medication Administration Record (MAR). She revealed usually there are orders to document each shift and on a daily basis of signs/symptoms and behaviors. A telephone interview was attempted on 2/29/2024 with Resident #106's physician and the facility's Pharmacist consultant. Interviews with both individuals could not be obtained. On 2/29/2024 at 11:00 a.m. the Director of Nursing provided the facility's Pharmacy Service-Drug Regimen Free From Unnecessary Drugs policy and procedure, with revised date of 2/1/2020, for review. The policy states; The intent of this policy is each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reduction (GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. The procedure section of the policy revealed; (a.) Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (c.) Without adequate monitoring of. (b.) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories; a. Anti-psychotic, b. Anti-depressant, c. Anti-anxiety, d. Hypnotic.

Based on observation, interview, and record review, the facility failed to ensure one (#39) of two residents sampled for dental care received dental services to meet her needs as requested. Findings included: Observation and interview on 2/27/2024 at 9:30 a.m. with Resident #39 revealed several missing teeth. Of the remaining teeth, several were noted to be broken/chipped and dark in color. Resident #39 stated she brushed her teeth on her own every day and denied assistance with oral care by staff. Resident #39 stated, I don't have any pain right now, but I have had pain and one of my teeth on my right side of my mouth cuts into my mouth at times. Resident #39 could not recall how long she has had this problem and if she had reported this to staff. Resident #39 did remember dental services seeing her in the facility. Review of Resident #39's admission record revealed an original admitted in 2015 with the most recent readmitted in November of 2023. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The oral/dental section of the MDS revealed no checkmark was made for broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) and mouth or facial pain, discomfort or difficulty with chewing. Obvious or likely cavity or broken natural teeth was checked to indicate yes. Review of the following dental visits/notes revealed: a. 4/13/2022 Treatment Plan Notes: Periodic Oral Examination: Patient wants partials. b. 12/5/2023 Treatment Notes: Patient wants to replace missing teeth do not have a partial anymore. c. 1/16/2024 Progress notes for Assessments: Patient is interested in getting dentures. Incomplete x-rays due to patient having a strong gag reflex. Review of Resident #39's care plans revealed a focus concern (initiated and revised 06/30/2023) for Oral/Dental Health problems related to Caries [decay], broken teeth, Missing Teeth, currently has no complaints of pain or difficulty chewing. Interventions for this focus concern (initiated on 6/30/2023) included: coordinate arrangements for dental care as needed/as ordered; observe for mouth pain as needed; observe/document/report to Medical Doctor (MD) and/or Nurse signs/symptoms of oral dental problems; provide mouth care daily and as needed. Further review of the medical record revealed no additional documentation to show arrangements to coordinate dental care as requested by the resident and as care planned had been conducted. On 2/29/2024 at 1:00 p.m., an interview with Resident #39's regular Licensed Practical Nurse (LPN), Staff A revealed she did not remember if Resident #39 had any recent dental visits but did confirm the resident has many missing and broken teeth. Staff A confirmed Resident #39 had complained about mouth pain in the past, but not recently. Staff A was not aware of the resident's request to get dentures and reported she would follow up with that request. On 2/29/2024 at 1:40 p.m., an interview with Certified Nursing Assistant (CNA), Staff B revealed Resident #39 sometimes complains of mouth pain, and she passes that information on to the nurse. Staff B was not sure if Resident #39 had requested dentures and confirmed the resident has many missing/broken teeth. On 2/29/2024 at 12:38 p.m., an interview with the Director Of Nursing (DON) revealed she was also the C Wing Unit Manager. She confirmed Resident #39 had many missing teeth, several broken teeth, and dark discoloration of her bottom teeth. The DON was not aware of Resident #39's complaint of teeth cutting into her mouth or any pain in her mouth recently. The DON reviewed the medical record and confirmed facility staff were to coordinate dental visits as needed. She also reviewed the dental visit notes dated 4/13/22, 12/5/2023, and 1/16/2024. Prior to review of the notes, the DON was not aware the resident had requested dentures. She revealed the Nurse, the Practitioner, Social Services, and the Appointment [NAME] were all responsible for scheduling and follow up with outside service appointments. The DON confirmed no appointment was made to honor Resident #39's request to get dentures. The DON revealed the resident's Nurse Practitioner had not identified any dental issues and the previous dental service visits were not brought to her attention. Review of the facility's policy and procedure titled Dental Services last revised 7/2018 revealed: Policy: The center must assist residents in obtaining routine and 24 hour emergency dental care to meet the needs of each resident. Routine Dental Services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs), minor dental plate adjustments, smoothing of broken teeth, and limited prosthodontic procedures, such as taking impressions for dentures and fitting dentures. Emergency Dental Services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken or otherwise damaged teeth, or any other problems of the oral cavity by a dentist that requires immediate attention. Prompt Referral means, within reason, as soon as the dentures are lost or damaged. Referral does not mean that the resident must see the dentist at that time but does mean an appointment (referral) is made, or the center is aggressively working at replacing the dentures. For Medicaid residents, the center must provide the resident, without charge, all emergency services, as well as those routine dental services that are covered under the State plan. a. The center must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Based on observations, record review, and interviews, the facility failed to collaborate care with an external provider for one (#74) out of one resident sampled for Hospice services, as evidenced by not ensuring staff collaborated care with the provider, the medical record contained provider assessments, and staff had knowledge of the services provided by the Hospice staff. Findings included: An observation was made on 2/26/24 at 11:17 a.m. of Resident #74. The resident was observed lying in bed, dressed and clean, the television was playing without sound, and the resident was talking to self. The resident was confused and speaking repetitively. An observation was made on 2/27/24 at 8:30 a.m. of Resident #74 sitting in a wheelchair, feet dangling with a meal tray on the over-bed table to the side of the resident. The resident was talking to self, regarding a church. Review of Resident #74's clinical record showed the resident was admitted on [DATE] and included diagnoses not limited to unspecified chronic obstructive pulmonary disease (COPD) and unspecified Alzheimer's disease. Review of Resident #74's clinical record on 2/28/24 at 3:07 p.m., showed the record contained a Hospice care note dated 12/9/23 and uploaded on 12/15/24, an Interdisciplinary and Plan of Care update, dated 12/9/23 and uploaded on 12/28/23. The record did not reveal any Hospice nursing notes from 12/9/23 to 2/28/24. Review of Resident #74's Election of Hospice benefits, provided by the facility was signed by the resident's representative on 12/9/23 at 11:30 a.m. The Informed Consent for Hospice Care document was signed on 12/9/23 by the resident's Durable Power of Attorney for Healthcare. The contract between the facility and the chosen Hospice provider revealed Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice Patient. Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day. Facility will provide Hospice with access to electronic clinical records when applicable. Facility shall immediately inform Hospice of any change in the condition of a Hospice Patient. Review of Resident #74's clinical record showed a note, dated 12/22/23 at 00:43 a.m., revealed the resident had been found sitting on the floor in front of recliner in room. The resident reported at the time of not being able to get comfortable in bed. The assessment showed the resident had a small 1.5 x 0.5 centimeter skin tear to back of left hand, the physician and family had been notified. The note did not show Hospice had been notified of the resident's fall or injury. The Hospice Plan of Care (POC), dated 12/9/23, showed the resident's primary Hospice diagnosis was unspecified Alzheimer's disease with complete bedrest. The POC revealed the resident was oriented to person and lethargic. The POC revealed Hospice nurses had allotted 3 'as needed' visits starting 12/9/23 for the purpose of post-admission visit/condition status. The Interdisciplinary Group (IDG) Review and POC update, dated 12/14/23, revealed the resident's admission (12/9/23) had been discussed with a 2-week POC and imminent status. The functional limitation of the resident was imminence, a Palliative Performance score of <30%, with the inability of swallow with no desired intervention. The summary of problems were generalized pain, dyspnea at rest and with exertion, continuous oxygen at 2 liters/per minute, fall risk, skin breakdown, and patient very little responsiveness with Alzheimer's. The Hospice staff visits were for social worker to visit 2 times a week for 2 weeks, starting 12/12/23, aide to visit 2 x a week for 9 weeks starting 12/12/23, and nursing to visit 5 times a week for 2 weeks starting 12/12 and ending 12/23/23. According to Spirituality In-service Quality Palliative Care in Long Term Care Version 1, (www.palliativealliance.ca), The Palliative Performance Scale (PPS) is a useful tool for measuring the progressive decline of a palliative resident. The PPS showed with a 30% PPS Resident #74 was totally bed bound, unable to do any activity/extensive disease, total care, normal or reduced intake, and conscious level of full or drowsy, +/- confusion. Review of the clinical record of Resident #74 did not include any further documentation of Hospice staff notes or visits. Review of Resident #74's care plan revealed the resident was receiving Hospice care related to terminal condition of Alzheimer's dementia, at risk for unavoidable weight changes, functional decline, pain, alteration in skin integrity, and grieving. The interventions included but was not limited to Collaborate with Hospice regarding care. An interview was conducted on 2/28/24 at 2:04 p.m., with Staff X, Licensed Practical Nurse (LPN). The staff member reported being a staff member for 6 months and had seen Hospice staff twice. The staff member stated one time last week someone came in and asked for a face sheet, orders, and asked if Resident #74 had any changes. Staff X reported they would notify Hospice if any changes in condition with the resident. An interview was conducted on 2/28/24 at 2:14 p.m., with Staff P, LPN/Unit Manager (UM) while the resident was sitting with staff members behind the nursing station. The staff member reported the (Hospice) nurse and aide comes in once a week and if they need to make any changes. Staff P reported thinking Hospice documentation was in the computer, believed Hospice just talk to staff, and the aide comes out once a week and just sits with the resident, hasn't seen her provide any care. Staff P reviewed the electronic record and stated Hospice does not have access to the computer so they can't chart in the (facility) computer and confirmed not finding any Hospice visit notes downloaded into the facility computer. The staff member contacted Hospice, on 2/28/24 at 2:35 p.m., and obtained the nurse's name, reporting not meeting the nurse never seen her. Staff P stated the expectation was the Hospice staff to speak with her or the nurse and the facility nurse to write a note regarding the conversation. The staff member stated the expectation for Hospice was to obtain medications and to give support to the family and patient. Staff P said Hospice come in, look at the patient, they don't give any medications, and they really don't do anything. The staff member stated Hospice staff come in early during the day shift. A telephone interview was conducted on 2/28/24 at 2:35 p.m., with the assigned Hospice Registered Nurse (HRN). The HRN reported coming to the facility on ce a week and the aide comes in twice a week. She reported during the visits Resident #74 was assessed for change in condition, pain, mid-arm circumference was measured, assess sleeping pattern, bowel/bladder pattern, eating status, provide therapeutic presence, and contact family if they have any needs and update. The HRN reported speaking with the aide and whatever nurse was found and reviewed meds, the aide provides bed bath or shower and does hygienic care. The HRN stated the Hospice aide will notify her of any skin or pain changes. The visit notes are faxed to the facility every other week and the Hospice aide does not provide any documentation. The HRN reported not being invited to a care plan meeting but would come if the family requested. An interview was conducted on 2/28/24 at 4:52 p.m. with the Director of Nursing (DON). The DON stated the expectation was for Hospice to be an adjunct to add to the services we have here, to provide extra services to the resident, and (to) provide expertise in the dying process and facilitate comfort measures. She reported most of the time the pain management piece goes to the Hospice. The expectation was for collaboration in the planning and execution of the care plan. She stated, usually they talk to the nurse manager on the unit or herself when they are exiting. The DON stated the Hospice provider used to send their documentation directly to medical records. She stated Hospice was to send (documentation) in the electronic record or brought in printed. The DON reported she did not think the Hospice aides came in and see the residents. The DON stated it would be nice if staff would document they had spoken with Hospice but didn't think it was a regulation.

Based on interviews and record review the facility failed to provide the necessary pain medication to assure the maximum comfort level for one of three elderly post-operative residents reviewed (resident #1). Due to the facility staff failure to provide a systematic approach to obtain and maintain a therapeutic dose of pain medication after the resident's admission to the facility from the hospital resulted in, her persistent suffering with uncontrolled pain up to a level of 10 of 10, which one hour after medication remained 8 of 10. Findings include: 1. Resident #1 was admitted to the facility on [DATE]. Per the facility face sheet, she had been hospitalized for [REDACTED]. She was [AGE] years old with additional [DIAGNOSES REDACTED]. The hospital history and physical, dated 05/26/12 and found in the facility medical record, stated that x-rays and CT scans of the left shoulder showed a "100% displaced proximal humerus fracture with comminution (broken to pieces) and a head splitting component " of the head of the humerus bone. The report of the operation stated that the humerus head was found in multiple pieces. A prosthesis was used to replace it. The surgery date was 05/26/12, three days before admission to the facility. 2. Review of the hospital history and physical, dated 05/25/12, revealed she took [MEDICATION NAME] 5/325 mg every four hours as needed for chronic pain, prior to the fractured shoulder. 3. Review of the nurse admission assessment on 05/29/12 at 2:40 p.m. revealed that she was alert and oriented and able to voice her needs. She had steri- strips over a left arm surgical incision and wore a left arm sling. She required one to two person , hands on, assistance with grooming, hygiene, and toileting. She had chronic low back pain. She was unable to grasp with her left hand. 4. Review of the admission physician's orders, dated 05/29/12 (no time specified) revealed: [MEDICATION NAME] 500 mg three times daily for a UTI (urinary tract infection). Iron 325 mg twice daily for [MEDICAL CONDITION] eye drops for [MEDICAL CONDITION] No weight bearing to left upper extremity. No shoulder motion. Left shoulder dressing changes every other day and as needed. Clean incision with saline. Left arm sling. [MEDICATION NAME] 5/325, one half tablet three times daily was written and crossed out. D/C was written in the box. Page 4 of 5 revealed [MEDICATION NAME] 5/325 mg. one tablet every four hour,s as needed for pain. 5. Review of the Pain Medication Administration Record (MAR)revealed: 05/29/12: The resident received one [MEDICATION NAME] at 5:30 p.m. on 05/29/12 for a pain level of 8 of 10 of the left shoulder. One hour after intervention it remained at 3 of 10. The resident received one [MEDICATION NAME] at 9:30 p.m. on 05/29/12 for pain intensity of 8 of 10 of the left shoulder. At one hour she was sleeping. 05/30/12: The resident received one [MEDICATION NAME] tablet at 01:30 a.m. for pain of 8 of 10 of the left shoulder. At one hour it remained 3. At 06:30 a.m. the resident received one [MEDICATION NAME] for pain of 8 of 10 of the left shoulder. At one hour it remained a 2. At 10:30 a.m. the resident received one [MEDICATION NAME] for pain of 8 of 10 of the left shoulder. At one hour it remained at 8 of 10. There was no documentation that the physician was called. At 2:30 p.m. the resident received one [MEDICATION NAME] for pain of 8 of 10 of the left shoulder. At one hour it remained at 2. At 19:30 (7:30 p.m.) the resident received one [MEDICATION NAME] for left shoulder pain of 9 of 10. At one hour it remained at 5. The nurse called the physician. On 05/30/12 at 21:30 (9:30 p.m.)a nurse/Physician Communication form was completed. It stated that the resident was described as alert and oriented. The reason for the communication was listed as "unresolved pain". The primary [DIAGNOSES REDACTED]. The outcome was a change of orders to: [MEDICATION NAME] 5/325 one to two tablets every four hours as needed. May give one tablet STAT. On 05/30/12 at 21:45 one [MEDICATION NAME] 5/325 was given per the stat order. The pain intensity at 30 minutes after the administration remained at 7 of 10. At one hour the resident was sleeping. 05/31/12: At 1:30 a.m. the resident received one [MEDICATION NAME] for shoulder pain of 8 of 10. At one hour it remained 3, "discomforting pain" per the scale. At 06:30 a.m. the resident received one [MEDICATION NAME] tablet for shoulder pain of 8 of 10. At one hour it remained 2 of 10, mild pain. There was no nurse's note reflecting whether the resident requested one or two tablets, however a later complaint to a family member revealed she continued in pain with no relief. At 9:00 a.m. the resident received two [MEDICATION NAME] tablets for shoulder pain of 7 of 10. At one hour it remained at 3 of 10, discomforting pain. At 3:00 p.m. the resident received two [MEDICATION NAME] tablets for shoulder pain of 7 of 10. At one hour it was reduced to 1. At 9:00 p.m. the resident received two [MEDICATION NAME] tablets for shoulder pain of 8 of 10. At one hour it was reduced to 1. 06/01/12: At 02:50 a.m. the nurse recorded on the Pain Medication MAR that the resident received two [MEDICATION NAME] 5/325 tablets for left shoulder pain of 5 of 10. At one hour the pain was recorded as 1. Review of Controlled Drug inventory record revealed that on 06/01/12 at 2:50 a.m. one [MEDICATION NAME] tablet was removed from the blister package. It was the only remaining tablet. 6. On 07/02/12 at 4:00 p.m. review of the EDK (Emergency Drug Kit) revealed no [MEDICATION NAME] 5/325 tablets were removed from the kit for administration on 06/01/12 at 2:50 a.m. There was no evidence from the controlled drug inventory or the EDK, that the resident received more than one [MEDICATION NAME] 5/325 tablets. 7. On 07/02/12 at about 11:00 a.m. review of the grievance log with the social worker revealed that the family of resident #1 filed a grievance on 06/01/12 at 7:45 a.m. The resident had called her daughter in the early morning hours of 06/01/12 to report that she, the resident, had " been in pain " and could " not get pain medication ". The written findings of the investigation revealed that when the day shift nurse came on 06/01/12, exact time unknown, she called the pharmacy asking permission to take [MEDICATION NAME] from the EDK and was denied permission. The pharmacist stated that she, the nurse, needed to call the physician for a prescription. The nurse called the physician and the physician requested she call pharmacy back and have them call him directly. A second pharmacist approved the removal of the medication from the EDK. The nurse stated this process delayed the medication by about 45 minutes. 8. The Pain medication MAR revealed two [MEDICATION NAME] tablets of 5/325 were administered on 06/01/12 at 8:30 a.m. for left shoulder pain of 8 of 10. At one hour the pain remained 7 of 10. There was no corresponding nurse's note and no evidence of other interventions. 9. Review of the pharmacy log, provided on 07/02/12 by fax from the pharmacy, revealed an order dated 06/01/12 at 8:20 a.m. that stated " [MEDICATION NAME] 5-325, two tablets every six hours as needed". 10. On 06/01/12 at 1:00 p.m. the Pain MAR revealed that resident #1 received two [MEDICATION NAME] tablets for left shoulder pain of 10 of 10, unbearable pain per the Pain MAR guide. At one hour it remained 8 of 10, severe pain. At 3:30 p.m. the nurse ' s note stated she was medicated for pain 8-10 " with little relief " . 11. On 06/01/12 at 1:45 p.m. the physician gave a telephone order for a [MEDICATION NAME] Patch to the left shoulder daily. This order did not appear transcribed on the MAR until 06/02/12. On 06/06/12 at 9:00 a.m.,4 days later (5 days after the order was written), the resident received the first administration. Review of the pharmacy log revealed that the prescription was filled on 06/01/12. 12. On 06/01/12 at 6:00 p.m. the resident received one [MEDICATION NAME] 5/325 tablet for pain of 7 of 10. At one hour it remained 3. The nurse wrote a telephone physician ' s order on 06/01/12 at 6:00 p.m. that stated " Clarification-[MEDICATION NAME] 5/325 mg. PO, 2 tabs every 6 hours " It did not state as needed. This order was not transcribed on the MAR as written on 06/01/12. The MAR revealed an order was transcribed on 06/01/12 as " [MEDICATION NAME] 5/325 mg two tablets orally every 6 hours as needed for pain " . 13. On 06/02/12 an unknown nurse transcribed an order to the MAR that stated " [MEDICATION NAME] 5/325 two tablets orally, every six hours around the clock (ATC) " . The hours listed were midnight, 6:00 a.m., noon and 6:00 p.m. There were no recorded administrations of this medication routine until 06/04/12 at noon. There were no telephone clarifications of this order, the order written on 06/01/12 at 6:00 p.m. that stated [MEDICATION NAME] 2 tablets every six hours, and did not specify as needed or routine administration. The pharmacist stated on 07/02/12 that he had no knowledge of this order to give [MEDICATION NAME] routinely. 14. Review of the Pain medication MAR revealed that the resident continued to received two [MEDICATION NAME] pills, when requested, from 06/01 to 06/ 06/12. There were 6 administrations of two pills of [MEDICATION NAME] during this time frame and 7 administrations of one [MEDICATION NAME] pill. The frequency of administration ranged from 4 to 6 hour intervals from the prior administration, for left shoulder pain of 10 of 10 unbearable pain to 7 of 10, severe pain. The one hour post administration intensity ranged from asleep (five times) to 4 of 10, discomforting pain , three times. The administration frequency of [MEDICATION NAME] did not provide a systematic approach to pain control with resolution of pain for resident #1. 15. Review of the nurses notes on 06/03/12 at 6:50 p.m. revealed that the nurse wrote that the resident continued to complain about pain and was medicated as needed and ordered with " some relief " . 16. On 06/05/12 at 10:30 a.m. a Nurse/Physician communication from stated that the resident complained that 2 tablets of [MEDICATION NAME] every six hours "was not working" and were too large to swallow and are "const"(unknown abbreviation). No physician's order to discontinue the order for [MEDICATION NAME] one or two tablets every 4 hours was found. There was no written outcome on this communication form. At 2:00 p.m. the nurse wrote "still awaiting MD to return call". The next nurse's note dated 06/05/12 at 10:00 p.m. failed to document any follow up with the physician. There was no pain assessment recorded on the Pain MAR or the nurses notes for the evening shift of 06/05/12. No assessments for pain or administrations of [MEDICATION NAME] were recorded for the entire date of 06/05/12 on the Pain MAR. 17. Review of the Controlled Drug Use record revealed that on 06/05/12, at midnight,( recorded as MN) 2 [MEDICATION NAME] tablets were taken from the supply for the resident. There was no record of administration on the Pain MAR and no pain assessment before and after administration. There was no nurse's note during this shift. These were the last 2 pills on this blister package inventory. 18. Review of the Pain MAR and nurse's notes revealed no documentation that the resident received any additional [MEDICATION NAME] on 06/05/12 after the midnight dose, the last available pills in the resident's supply. Review of the pharmacy invoice revealed that [MEDICATION NAME] was not refilled during this time. A copy of a prescription dated 06/05/12 stated that the resident was to receive [MEDICATION NAME] 5/325 mg , two tablets every six hours as needed for pain, dispense 100 tablets. (On 06/01/12 61 tablets were dispensed). 19. There was no documentation of any pain assessments or medication given from 06/04/12 at 6:30 a.m. to 06/06/12 at 6:00 p.m. on the Pain MAR. The resident's pain condition was not documented in the nurse's notes during these two days. The administration of the [MEDICATION NAME] Patch, ordered on [DATE], was recorded on the MAR as administered for 06/06/12 at 9:00 a.m. There was no documentation of the pain relief obtained. 20. On 06/06/12 at 3:45 p.m. a physician telephone order stated to give [MEDICATION NAME] 10 mg. every four hours as needed for pain. There was no order to discontinue the [MEDICATION NAME]. 21. Review of the Pain Control MAR revealed that the resident received [MEDICATION NAME] 10 mg for pain every 4 hours, as needed, until 06/29/12 when the nurse ' s notes stated at 10:30 a.m. she developed an elevated temperature of 100.4, with vomiting. She was transferred to the hospital at 1:50 p.m. The level of pain ranged from 9 of 10 on 06/08/12 at 11:30 a.m. remaining at 8 of 10 at the one hour assessment; to 5 of 10 on 6/24/12 at 7:30 p.m. with 1 of 10 at the one hour assessment. On 06/29/12 at 9:10 a.m. the resident complained of pain of 6 of 10, received [MEDICATION NAME] 10 mg and at one hour the pain remained at 2 of 10. 22. On 07/02/12 at 12:55 p.m. an interview was conducted with the facility pharmacist. He stated the pharmacy received the original prescription ,from a hospital physician, for [MEDICATION NAME] 5/325 mg, one pill every 4 hours, as needed for pain. It stated to dispense 30 tablets. The pharmacist sent 15 tablets on the first run on 05/29/12, the day of admission. He stated this was routine to determine the need because controlled drugs cannot be returned for credit. On 06/01/12, during the early morning hours, the additional 15 pills, minus the 2 used by the day nurse on 06/01/12 at 8:30 a.m. from the EDK, were sent to the facility to " finish the script " . That refill was en-route when the day nurse called. There was no record of the night nurse asking to use [MEDICATION NAME] from the EDK for this resident during the night shift of 06/01/12. He stated that on 06/01/12 at 8:20 a.m. the pharmacy received an " emergency script " from the attending physician for [MEDICATION NAME] 5/325 mg, two tablets, as needed, every six hours for pain. He stated there were no further changes to the dose or frequency of [MEDICATION NAME] for resident #1. He had no knowledge of an order for [REDACTED]. The pharmacist faxed three documents to the surveyor: 1. The original hospital prescription dated 05/29/12 for [MEDICATION NAME] 5/325 mg 1 every 4 hours as needed for pain, dispense 30. 2. A pharmacy document dated 06/01/12 at 8:20 a.m. dispensing 15 tablets of [MEDICATION NAME] 5/325 mg , directions: give two every 6 hours, as needed for pain. 3. 06/06/12 [MEDICATION NAME] 10 mg, 1 every 4 hours as needed. Dispensed 20 tablets. 23. Review of the three Pain Medication MARs for the resident revealed that the resident did not receive complete pain relief from the [MEDICATION NAME] administrations, leading to the resident asking for family intervention for pain management on 06/01/12 , during her post operative recovery period. The documentation on three sheets of Pain MAR reviewed from 05/29/12 to 06/29/12, the day of discharge to the hospital, the resident received 73 doses of pain medication. At the one hour post treatment evaluation the resident was sleeping nine times. There was only one documentation that the pain was fully relieved, 06/12/12 at at 1:30 a.m. after receiving one [MEDICATION NAME] 10 mg tablet. 24. On 07/03/12 at 10:48 a.m. this surveyor spoke with a family member of resident #1. She stated there was confusion over the administration times and doses of [MEDICATION NAME] for the resident. She stated that neither she nor the resident understood that she, the resident, was to ask for the medication. It had been given routinely in the hospital. The resident voiced concerns to her that "even the nurses seemed unsure if the medication was ordered for two tablets every four hours or one tablet every six hours". She stated that after the grievance of 06/01/12 the facility administration sat down with her to try to clarify the situation and after that they were very attentive. The resident remained hospitalized . 25. On 07/02/12 multiple interviews with the Director of Nurses (DON) were conducted throughout the day. At around 5:00 p.m. the DON and this surveyor reviewed the findings regarding the administration of [MEDICATION NAME] 5/325 mg for pain management for resident #1. The DON confirmed that a nurse documented that on 06/01/12 at 2:40 a.m. she, the night nurse, administered two [MEDICATION NAME] tablets, however there was only one pill available at the time, per the inventory control sheet for the blister package. The DON and Unit Manager (UM) of the Rehab unit stated that they had confirmed with the pharmacist that there was no record of a nurse calling for a request to use the EDK on the night shift. The UM stated that the pharmacist stated today (7/02/12) that at 4:00 a.m. on 06/01/12 there was a request for refill of [MEDICATION NAME] 5/325 mg, which was en-route when the morning shift nurse initially called and requested permission to use a dose from the EDK. That explained why she was initially told that there was no valid script. The DON also confirmed that the telephone order of 06/01/12 at 6:00 p.m. for [MEDICATION NAME] 5/325, two tablets, with no notation of frequency, and as written, was to be given routinely, every six hours, around the clock. She agreed that this was not transcribed on the MAR until 06/02/12 and not begun until 06/04/12. The pharmacy had no knowledge of this order. None of the controlled medication inventory logs revealed this order. The DON stated she needed time to evaluate several occurrences by staff , including why staff did not communicate to the physician that the resident did not obtain complete pain relief, that contributed to the ineffective pain management for this resident. 26. On 07/03/12 a review of the Cleveland Clinic on-line resource for Pain Management after surgery, revealed that pain control was necessary to reduce the risk of complications and lead to a faster recovery. The Cleveland Clinic advised the reader to not wait until the pain was severe for intervention. Per the pain scale of 0 to 10, severe was defined as 7 or above. Resident #1 defined her pain as above 7 on 24 of 27 assessments prior to medication with [MEDICATION NAME] from 05/29/12 to 06/06/12, when the order was changed to [MEDICATION NAME] 10 mg every 4 hours as needed for pain. The effects of the persistent pain are unknown for this resident. She remained hospitalized during the time of this investigation. The cause was unknown.

Based on interviews and record review the facility staff failed to clarify physical orders and administer medications for pain control, as prescribed by the physician, for one of three residents reviewed, resident #1. This resulted in uncontrolled pain at a level of 10 of 10 and resulted in the resident contacting a family member to assist in pain control. Findings include: 1. Resident #1, a [AGE] year old, was admitted to the facility on [DATE], three days after a surgical repair of a [MEDICAL CONDITION] upper arm/shoulder. Per the admission nursing evaluation, on 05/29/12 at 2:40 p.m. she was alert and oriented with a history of [MEDICAL CONDITION], chronic low back pain, and respiratory disease. She required the assistance of 1-2 staff members for care, transfers, and mobility. She was unable to grasp with her left hand due to the surgery. A Foley catheter had just been removed. She described her pain as a 4 on a scale of 5, severe pain. Presence of UTI was checked. The narrative stated she had left shoulder steri-strips in place and the left should was bruised with red patches the circumference of the arm. She used the bed pan for toileting. The nurse wrote that she was medicated twice during her shift for pain , with effectiveness. 2. Review of the physician orders [REDACTED]. 5/29/12: [MEDICATION NAME] 5/325 mg, one tablet every 4 hours as needed for pain. [MEDICATION NAME] 500 mg three times a day for a UTI Iron 325 mg, twice daily for [MEDICAL CONDITION]. [MEDICATION NAME] 40 mg, one daily for GERD [MEDICATION NAME] 0.5% eye drops twice daily to both eyes. [MEDICATION NAME] 600 mg, two tablets 3 times daily for [MEDICAL CONDITION] [MEDICATION NAME] 100 mg daily [MEDICATION NAME] eye drops, one drop to each eye at bedtime for [MEDICAL CONDITION]. Sling to the left arm No weight bearing to left upper extremity No shoulder motion. Left shoulder dressing change every other day and and needed. Clean with saline. [MEDICATION NAME] 30 ml every 8 hours as needed [MEDICATION NAME] nebulizer 4 times daily, as needed. 3. On 05/30/12 at 9:30 p.m. the nurse contacted the doctor. She wrote on the nurse physician communication form that the resident had "unresolved pain". The physician ordered: [MEDICATION NAME] 5/325 mg, 1-2 tablets every 4 hours as needed. The resident received a stat dose of one pill at 9:45 p.m. She had received one tablet at 7:30 for pain described as 9 of 10 and at one hour was 5 of 10. After the second pill she was sleeping. 4. On 06/01/12 at 2:40 a.m. the nurse administered [MEDICATION NAME] for shoulder pain described as 5 of 10. The nurse removed the last single pill from the resident's supply. She recorded on the the pain MAR that she administered two pills. Review of the EDK removal record revealed that no [MEDICATION NAME] was removed form that supply during that shift. 5. On 06/01/12 at 7:45 a.m. the facility was advised that the resident had complained to a family member during the early morning hours, that she had been in pain and could not get her pain medication. The facility social worker provided the investigation documents on 07/02/12. The day shift nurse wrote that there was no supply of [MEDICATION NAME] when she came on duty (around 7:00 a.m.) and she called the pharmacy to attempt to get some. She was initially told that she could not use the EDK supply, she called the doctor, and then was given permission by the pharmacy to use the EDK for administering 2 [MEDICATION NAME] tablets. She wrote that this resulted in a 45 minute delay in giving the medication. This dose was recorded as given at 8:30 a.m. The pain was described as 8 of 10 and at one hour remained 7 of 10. 6. On 06/01/12 at 1:45 p.m. a nurse wrote a telephone order for "[MEDICATION NAME] to left shoulder daily. Review of the pharmacy invoice log revealed this medication was filled on 06/01/12 and sent to the facility. Review of the routine medication administration record (MAR) revealed the order was dated 06/05/12 and begun on 06/06/12 at 9:00 a.m. 7. On 06/01/12 at 6:00 p.m. a nurse wrote a physician telephone order stating "clarification-[MEDICATION NAME] 5/325 mg, PO , 2 tabs every 6 hours". This order appears on the routine MAR, dated 06/02/12 and stated ATC, around the clock. It was not recorded on the MAR as administered until 06/04/12 at 12:00 p.m. , three days after the clarification order. Other administrations of [MEDICATION NAME] 5/325 mg were recorded as given as needed on the pain administration MAR, a different document. Review of the Controlled Drug use record revealed a supply of [MEDICATION NAME] , labeled as filled on 06/01/12, stated [MEDICATION NAME] 5/325 mg, give 2 tabs by mouth every six hours as needed for pain. Review of all the control drug records for the resident failed to revealed that pharmacy received or filled an order for [REDACTED]. 8. On 06/05/12 at 10:30 a.m. the nurse contacted the physician and stated that the resident complained that the routine dose of [MEDICATION NAME] 5/325 mg, two tablets every 6 hours was not working and were too large to swallow . 9. On 06/06/12 at 3:45 [MEDICATION NAME] 10 mg orally every 4 hours as needed, was ordered. The MAR stated that [MEDICATION NAME] 5/325 mg every 6 hours around the clock was discontinued. This discontinuation did not appear on the telephone order. 10. On 07/02/12 at about 4:00 p.m. the pain medication administration was reviewed with the DON. She was aware of the family filing a grievance related to pain control and the administration of medications. She was unable to explain if one or two tablets were administered on 06/01/12 at 2:40 a.m. She also stated she did know why there was a delay in administration of the [MEDICATION NAME] Patch and the confusion over the frequency of administration of [MEDICATION NAME] two tablets every six hours around the clock or as needed. She agreed the resident's pain needs were not met. She stated she needed more time to investigate the circumstances. 11. Review of the Pain medication MAR revealed that the resident continued to received two [MEDICATION NAME] pills, when requested, from 06/01 to 06/ 06/12. There were 6 administrations of two pills of [MEDICATION NAME] during this time frame and 7 administrations of one [MEDICATION NAME] tablet. The frequency of administration ranged from 4 to 6 hour intervals from the prior administration, for left shoulder pain of 10 of 10 to 7 of 10. The one hour post administration intensity ranged from asleep (five times) to 4 of 10 , three times. The administration frequency of [MEDICATION NAME] did not align with either of the physician orders [REDACTED].

Based on interviews, review of controlled drug records, and review of clinical records, the facility failed to obtain the necessary supply of analgesics, Percocet 5/325 mg, for pain control for one of three post operative residents (resident #1). The failure of facility staff to obtain an adequate supply of Percocet leading to the residents uncontrolled pain at level of 10 of 10, resulted in resident #1 calling a family member during the early morning hours of 06/01/12 for assistance with pain management. Findings include: 1. Resident #1 was admitted to the facility on [DATE] for rehabilitation after a fall that resulted in a severe fracture of the left shoulder. Per the facility admission orders [REDACTED]. The medication list prior to the surgery reveaeld that she took the same medication and dose for chronic pain. 2. Review of the hospital records, found in the facility medical record, revealed she had a severe fracture of the left upper arm/shoulder resulting in a complete seperation and shattering of the bone. A surgical repair was done on 05/26/12. She was transferred to the facility three days later, 05/29/12. 3. Review of the Controlled Drug use record revealed that 15 tablets of Percocet 5/325 mg were dispensed on 05/29/12 4. Review of the Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] two doses of Percocet 5/325 mg, one tablet on 05/29/12 at 5:30 p.m. and 9:30 p.m. The pain was described as 8 of 10 and 7 of 10 respectively. 5. On 05/30/12 she recieved six doses of Percocet 5/325 mg, one tablet. Two were on the night shift at 01:30 a.m.; 06:30 a.m. The levels of pain were described by the resident as 8 of 10 both times. The medication did n0t offer full relief. The pain was reduced to 3 of 10 and 2 of 10 at the one hour check after intervention. Two doses were given on the day shift of 05/30/12. At 10:30 a.m. the resident described 8 of 10 pain intensity. At one hour post medication it remained 8 of 10. There was no documentaiton that the physician was notified. At 2:30 p.m. on 05/30/12 the resident was given one Percocet 5/325 tablet. The pain persisted at 8 of 10. At one hour it was reduced to 2 of 10. 6. At 7:30 p.m. on 05/30/12 the nurse administered one Percocet 5/325 tablet for pain described as 9 of 10. At one hour it remained 5 of 10. The nurse called the doctor and obtained a change of dose of Percocet to one or two tables every 4 hours, as needed for pain. She administered a stat dose at 9:45 p.m. The inventory of pills at the time of this dose change was 9 tablets. 7. On 05/31/12 the resident recived four doses of two pills each at 03:15 a.m.; 09:00 a.m. 3:00 p.m. and 9:00 p.m. Review of the Pain MAR for 05/31/12 revealed that the resident reported pain from 7-8 of 10 prior to the administration of two pills of Percocet and obtained relief to ranging from 3 to 1 of 10, an improvement. 8. On 05/31/12 at 9:00 p.m., after the dose of Percocet 5/325 mg, two tablets, the Controlled Drug Use Record revealed only one pill remained. The medication was not reordered at this time. There was an inadequate supply for the night shift of 06/01/12 to use. The potential needs of the resident for every four hour admisintration included a potential 1:00 a.m. dose of two pills and a potential 5:00 a.m. dose of two pills. These were not available in the resident's supply. 9. On 06/01/12 the resident requested pain relief. She described the pain as 5 of 10. The nurse recored on the Pain Management MAR indicated [REDACTED]. The 1 hour intensity was written as 1 of 10. There was no documentation in the nurses notes regarding this intervention. The Controlled Drug Use Record revealed that on 06/01/12 at 2:50 a.m. the one remaining Percocet 5/325 mg was signed out and the blister package was empty. 10. On 07/02/12 at 1:00 p.m. the facility pharmacist was interviewed. He stated to the surveyor that Percocet was reordered on [DATE] at 4:00 a.m. and sent for delivery on the first run to the facility. He stated the there was no request from any night shift nurse to use a Percocet tablet from the EDK. He confirmed that the drug was available in the EDK. 11. On 06/01/12 during the early morning hours, resident #1 called a family member and complained stating "I 've been on pain and can not get pain medication". The facility was informed and the Unit Manager began an investigation at 7:45 a.m. Review of the investigation details, provided by the social worker on 07/02/12 at around noon, revealed a statement from the day shift nurse on 06/01/12. She wrote that when she came on duty, no time specified, she was informed of the resident's pain and she called the pharmacy to request permission to use Percocet from the EDK. The pharmacist initially denied permission stating the refill was sent out and there was no further prescription. The physician was called and the pharmacy called again. The nurse removed two Percocets from the EDK and administered them at 8:30 a.m. She wrote that there was a delay of about 45 minutes for administration. The resident described the pain as 8 of 10. At the one hour post intervention it remained at 7 of 10. At 1:00 p.m. the next administrationof Percocet 5/325 mg , two tablets, the resident described the pain as 10 of 10. At one hour it was reduced to only 8 of 10. 12. On 07/02/12 several interviews over the course of the day with the DON and Unit Manager revealed that it remained unknown if the 06/01/12 dose of Percocet tablets was one or two pills. The UM stated she had not investigated that but did confirm today with the pharmacist that the nurse did not ask to use the EDK kit. The DON reveiwed the Controll Drug use record and agreed that the supply for the night shift was inadequate for the resident's needs. She stated it should have been reordered when the order changed to two pills every four hours. She stated she would continue the investigation.

Based on record review and interview, the facility failed to implement fall care plans related to adequate supervision for 2 of 3 (#2, #3)sampled residents, who were assessed and found to be at risk for falls. Failure to implement residents care plan related to supervision for falls resulted in resident #2 having a fall, which resulted in physical injuries and additional falls for resident #3. Findings include: 1. Review of resident #2's clinical record revealed a face sheet which indicated that a [AGE] year old female resident was admitted to the facility on [DATE] to the rehabilitation unit. The face sheet documented the following medical Diagnosis: [REDACTED]. Review of the nursing evaluation dated 12/8/11 revealed that resident #2 was alert with mild confusion. For locomotion the resident required the assist of 1 with weight bearing support, for transfers required the assist of 1 with weight bearing support, for toileting required the assist of 1 with weight bearing support. The mode of locomotion was wheelchair. The fall risk section of this document indicated the following: intermittent confusion, has had 1-2 falls in the past 3 months, ambulatory/incontinent, balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns, requires use of assistive devices, takes 3-4 of mind altering medication, has 1-2 predisposing diseases and has a total score of 22 ("if total score is > 10, patient/resident is at HIGH RISK"). A review the MDS dated [DATE] revealed that resident #2 is confused, has a history of falls, had a fall in the last 2-6 months, and had fallen since admission to the facility. Review of the circle of care outcome plan dated 12/9/11 revealed that resident #2 had a history of [REDACTED]. The form also indicated that the resident had poor safety awareness. A review of resident #2's record revealed 3, 72 hour post fall evaluation, dated 12/11/11 indicating fall with no injuries noted, dated 12/12/11 indicating fall with bump to the left side of the head, and dated 12/22/11 indicating a fall with bruises and swelling to right hip and knee. A review of resident #2's physical therapy notes revealed a progress report dated 12/14/11 remaining functional deficits indicates impaired cognition, safety awareness continue to compromise safety with all ADL's/and mobility skills. Resident is a high fall risk, dated 12/21/11 that indicated that "due to safety awareness, pt requires 24hr supervision and care", a discharge summary dated 12/22/11 indicating that for the impact on burden of care/daily life resident #2 due to safety reasons, the resident requires verbal , tactile, and visual cues and 24 hour supervision to prevent falls. Review of resident #2's record revealed the following nurses notes:12/10/11 6:10 p.m. "pt's been restless and unaware of safety. Attempted to get out of be unassisted, re-oriented/redirected by staff", 12/11/11 "Resident was sitting in wheelchair at rehab nurses station. She attempted to get out of her wheelchair without assistance and fell to the floor. She landed on her buttocks and laid back into supine position", 12/13/11 7:30 p.m. "Intermittent occurrences of getting out of wheelchair on own, very poor balance and unsteady gait" "must give frequent reminders related to safety/fall risk concerns, 12/15/11 6:10 p.m. "Resident unaware of safety, attempted to get up unassisted. Redirected/reoriented by staff, 12/16/11 1:30 p.m. " Resident is unaware of safety, attempted to get up unassisted redirected by staff. Encouraged to call for assistance", 12/20/11 7:15 p.m. "Is unaware of own safety, has to be reminded to sit back down", 12/21/11 2:00 p.m. "Resident continuously unaware of safety-tries to get out of bed and wheelchair without assistance, forgets to ask for help and unaware of surroundings, 12/22/11 10:35 a.m. "fall with bruise and swelling on her right forehead, right hip and right knee. Ice pack to area for 10 minutes on and 30 minutes off. Pt denies pain call given to Primary Care Physician (PCP) and telephone order to do x-ray to area. X-ray to right hip positive PCP and family notified. New telephone order to send resident out to the hospital". A review of resident #2's care plans revealed a fall risk evaluation and plan of care with an original date of 12/7/11 revealed most recent interventions dated 12/12/11 which indicated that a resident be given verbal cues for safety awareness, reminded to be call for assistance with all transfers and ambulation, frequent rounds, try to keep in public area when up in wheelchair. The form also indicated that the resident had 3 falls, one dated 12/11/11 0830, where the resident attempted to get out of her wheelchair and fell to buttocks and laid back to supine position, with injuries noted. A second fall dated 12/12/11 0220 where the resident was found on the floor in the room lying on left side, hematoma noted left posterior head. A third fall dated 12/22/11 0530 where the resident was observed standing next to geri chair, and fell to floor. Bruises and swelling noted right eye and right hip bruise/swelling and bilateral calf. Additional present in the record was a plan of care comments sheet dated 12/22/11, which indicated that the care plan was scheduled for this a.m.- resident had fall last night went out to the hospital for fracture prior to care plan meeting. A review of the radiology report dated 12/22/11 revealed that resident #2 has an acute femoral neck fracture. A review of the employee #8's statement dated 12/26/11 who was assigned to resident #2 on the 11p-7a shift on 12/22/11 revealed that this staff person "was refilling another residents water cup and when he came out of the nourishment room he saw her take 2-3 steps, and the resident hit the floor". A review of the employee #5's statement dated 12/26/11 revealed that on the 11p-7a shift on 12/22/11 resident #2 was in a geri chair by the nurses station before 11p-7a shift began, the CNA's and nurse had to put the residents legs back in the geri chair quite often during the night as she kept trying to get out of the chair". A review of the employee #3's statement dated 12/25/11 revealed that on the 11p-7a shift resident #2 was in a geri chair at the nurses station, restless and trying to climb out of the chair, at 0500 the resident was restless the LPN was able to calm the resident down with snack which the resident consumed, and closed eyes the LPN continued with medication administration, at 0530 the LPN exited a resident room, looked up the hall, observed resident on the floor with the CNA, and another nurse at the residents side. Interview with the Risk Manager on 1/9/11 at approximately 11:45 a.m. revealed that resident #2 was admitted to the facility on [DATE], had a fall on 12/11/11, and 12/12/12, on 12/12/11 the following interventions were implemented: The resident be given verbal cues for safety awareness, reminded to call for assistance with all transfers and ambulation, frequent rounds, try to keep in public area when up in wheelchair. The Risk Manager reported that these interventions seemed to be working until the 12/22/11 incident where the resident fell while at the nurses station, and sustained a fracture. The Risk manager reported that based on investigation the resident was at the nurses station in a geri chair for observations, and the CNA assigned to the resident left the area to obtain water for another resident, during this time there were no staff present at the nurses station, and when the CNA returned to the area the resident was standing up out of the geri chair, and before the CNA could reach resident #2 the resident fell to the ground. Interview with the Risk Manager on 1/9/11 at approximately 2:43 p.m. revealed that the facility has realized that there is a problem with falls, and that on 12/12/11 started a falls performance improvement team, where the team will be looking at other means of preventing falls, and looking closer at resident who have had multiple falls, all of which were reviewed as part of quality assurance. Telephone interview with employee #5 on 1/10/11 at approximately 9:32 a.m. revealed that on 12/22/11 she was not assigned to resident #2, however she was aware that the resident had been restless all night and placed in a geri chair at the nurses station for observations, and at the time of the residents fall all staff were busy assisting to other tasks, and could not confirm that any staff person was present at the rehab nurses station. Telephone interview with employee #3 on 1/10/11 at approximately 9:46 a.m. revealed that on 12/22/11 resident #2 spent the entire morning hours in a geri chair by the nurse station of the rehab unit. the resident had been agitated the entire night, and kept trying to get up out of bed without assistance, the resident was placed in the geri chair, at the nurses desk for observations, one CNA was assigned to the resident, however all staff observed the resident during the shift. At the time of the fall all staff were busy, and not at the nurse station. The CNA assigned to the resident went into the the nutrition room to obtain water for a different resident, upon exiting the nutrition room observed resident #2 up out of the geri chair and standing at the nurses station, before the CNA could reach resident #2 the resident fell to the ground. 2. A review of resident #3's clinical record revealed a face sheet which indicated that a [AGE] year old female resident was admitted to the facility on [DATE] to the rehabilitation unit. The face sheet documented the following medical Diagnosis: [REDACTED]. A review of the facility occurrences from 10/1/11 to 1/9/12 revealed multiple falls without apparent injury: 11/8//11 at 0425; 11/27/11 at 1800; 112/9/11 at 0515 and on 12/19/11 at 6:00 p.m. resident #3 was found on the floor with no injuries. Also on 1/6/12 at 0230 resident fell from the geri chair while under observations at nurses station. A review of resident #3's fall care plan, with an original date of 11/3/11, and revision dates of 11/9/11 to give verbal cues for safety, remind resident to call for assistance with all transfers, and ambulation, frequent rounds, 12/19/11 offer toileting early a.m. continue frequent checks and rounds, resident forgetful, 12/20/11 try to keep in public area when up in wheelchair, 1/6/12 continue frequent rounds especially 11p-7a, offer toileting frequently. Telephone interview with employee #1 on 1/10/11 at approximately 3:11 p.m. revealed that on 1/6/12 resident #3 due to agitation was placed at the nurses station, the resident was observed to stand from the geri chair that she was sitting in, and by the time staff could get to her resident #3 fell to the ground. The RN reported that although staff were present at the nurses station, the resident was very quick, and was able to stand and then fall to the ground before staff could get to her. Telephone interview with employee #5 on 1/10/11 at approximately 9:32 a.m. revealed that resident #3 was sitting in a geri chair at the nurses station on 1/6/12 for observations due to agitation, and that the resident stood up from the chair and fell to the floor before staff could get to her. Interview with the Risk Manger, DON, and MDS Coordinator on 1/9/12 at approximately 4:21 p.m. revealed that residents who are agitated, and who routinely attempt to ambulate without assistance and are considered a fall risk are observed at the nurses station when they are out of bed. This intervention is done to prevent falls. The Risk manager reported that resident #2 was left at the nurses station for a short time when she fell , and that resident #3 had continuous observation, but her movements were that quick that it did not allow for staff to physically intervene, and prevent the residents fall.

Based on record review and interview, the facility failed to provide adequate supervision for 2 of 3 (#2, #3)sampled residents. The facility failed to provide supervision necessary to prevent physical harm to 1 of 3 (#2) sampled residents who was assessed to be at high risk for falls. Failure to provide adequate supervision to resident #2 led to resident #2 having a fall, which resulted in physical injuries and additional falls for resident #3. Findings include: 1. Review of resident #2's clinical record revealed a face sheet which indicated that a [AGE] year old female resident was admitted to the facility on [DATE] to the rehabilitation unit. The face sheet documented the medical [DIAGNOSES REDACTED]. Review of the admission physician order [REDACTED]. Toviaz 4 mg by mouth daily for overactive bladder at 9:00 a.m. (side effects possible: insomnia). Keppra 250 mg 2 tablets by mouth 2 times a day for seizures at 9:00 a.m. and 9:00 p.m. (possible side effects: drowsiness and weakness) Levothyroxine 125 mg by mouth daily for hypothyroid at 6:30 a.m. (possible side effect insomnia) Lopressor 25 mg by mouth 2 times a day for hypertension at 9:00 a.m. and 9:00 p.m. (possible side effects: drowsiness and restlessness) Review of the nursing evaluation dated 12/8/11 revealed that resident #2 was alert with mild confusion. For locomotion the resident required the assist of 1 with weight bearing support, for transfers required the assist of 1 with weight bearing support, for toileting required the assist of 1 with weight bearing support. The mode of locomotion was wheelchair. The fall risk section of this document indicated the following: intermittent confusion, had 1-2 falls in the past 3 months, ambulatory/incontinent, balance problem while standing, balance problem while walking, decreased muscular coordination, change in gait pattern when walking through doorway, jerking or unstable when making turns, requires use of assistive devices, takes 3-4 of mind altering medication, has 1-2 predisposing diseases and has a total score of 22 ("if total score is > 10, patient/resident is at HIGH RISK"). Review of the circle of care outcome plan dated 12/9/11 revealed that resident #2 had a history of [REDACTED]. The form also indicated that the resident had poor safety awareness. A review of resident #2's care plans revealed a fall risk evaluation and plan of care with an original date of 12/7/11 revealed most recent interventions dated 12/12/11 which indicated that a resident be given verbal cues for safety awareness, reminded to be call for assistance with all transfers and ambulation, frequent rounds, try to keep in public area when up in wheelchair. The form also indicated that the resident had 3 falls, one dated 12/11/11 at 0830, where the resident attempted to get out of her wheelchair and fell to buttocks and laid back to supine position, with injuries noted. A second fall dated 12/12/11 at 0220 where the resident was found on the floor in the room lying on left side, hematoma noted left posterior head. A third fall dated 12/22/11 at 0530 where the resident was observed standing next to geri chair, and fell to floor. Bruises and swelling noted right eye and right hip bruise/swelling and bilateral calf. Additionally present in the record was a plan of care comments sheet dated 12/22/11, which indicated that the care plan was scheduled for this a.m.- resident had fall last night went out to the hospital for fracture prior to care plan meeting. A review of resident #2's record revealed 3, 72 hour post fall evaluations, dated 12/11/11 indicating fall with no injuries noted, dated 12/12/11 indicating fall with bump to the left side of the head, and dated 12/22/11 indicating a fall with bruises and swelling to right hip and knee. A review of resident #2's physical therapy notes revealed a progress report dated 12/14/11 remaining functional deficits indicates impaired cognition, safety awareness continue to compromise safety with all ADL's/and mobility skills. Resident is a high fall risk, dated 12/21/11 that indicated that "due to safety awareness, pt requires 24hr supervision and care", a discharge summary dated 12/22/11 indicating that for the impact on burden of care/daily life resident #2 due to safety reasons, the resident requires verbal , tactile, and visual cues and 24 hour supervision to prevent falls. Review of resident #2's record revealed the following nurses notes:12/10/11 6:10 p.m. "pt's been restless and unaware of safety. Attempted to get out of bed unassisted, re-oriented/redirected by staff", 12/11/11 "Resident was sitting in wheelchair at rehab nurses station. She attempted to get out of her wheelchair without assistance and fell to the floor. She landed on her buttocks and laid back into supine position", 12/13/11 7:30 p.m. "Intermittent occurrences of getting out of wheelchair on own, very poor balance and unsteady gait" "must give frequent reminders related to safety/fall risk concerns, 12/15/11 6:10 p.m. "Resident unaware of safety, attempted to get up unassisted. Redirected/reoriented by staff, 12/16/11 1:30 p.m. " Resident is unaware of safety, attempted to get up unassisted redirected by staff. Encouraged to call for assistance", 12/20/11 7:15 p.m. "Is unaware of own safety, has to be reminded to sit back down", 12/21/11 2:00 p.m. "Resident continuously unaware of safety-tries to get out of bed and wheelchair without assistance, forgets to ask for help and unaware of surroundings, 12/22/11 10:35 a.m. "fall with bruise and swelling on her right forehead, right hip and right knee. Ice pack to area for 10 minutes on and 30 minutes off. Pt denies pain call given to Primary Care Physician (PCP) and telephone order to do x-ray to area. X-ray to right hip positive PCP and family notified. New telephone order to send resident out to the hospital". A review of the radiology report dated 12/22/11 revealed that resident #2 has an acute femoral neck fracture. A review the MDS dated [DATE] revealed that resident #2 is confused, has a history of falls, had a fall in the last 2-6 months, and had fallen since admission to the facility. A review of the employee #8's statement dated 12/26/11 who was assigned to resident #2 on the 11p-7a shift on 12/22/11 revealed that this staff person "was refilling another residents water cup and when he came out of the nourishment room he saw her take 2-3 steps, and the resident hit the floor". A review of the employee #5's statement dated 12/26/11 revealed that on the 11p-7a shift on 12/22/11 resident #2 was in a geri chair by the nurses station before 11p-7a shift began, the CNA's and nurse had to put the residents legs back in the geri chair quite often during the night as she kept trying to get out of the chair". A review of the employee #3's statement dated 12/25/11 revealed that on the 11p-7a shift resident #2 was in a geri chair at the nurses station, restless and trying to climb out of the chair, at 0500 the resident was restless the LPN was able to calm the resident down with snack which the resident consumed, and closed eyes the LPN continued with medication administration, at 0530 the LPN exited a resident room, looked up the hall, observed resident on the floor with the CNA, and another nurse at the residents side. Interview with the Risk Manager on 1/9/11 at approximately 11:45 a.m. revealed that resident #2 was admitted to the facility on [DATE], had a fall on 12/11/11, and 12/12/12, on 12/12/11 the following interventions were implemented: The resident be given verbal cues for safety awareness, reminded to call for assistance with all transfers and ambulation, frequent rounds, try to keep in public area when up in wheelchair. The Risk Manager reported that these interventions seemed to be working until the 12/22/11 incident where the resident fell while at the nurses station, and sustained a fracture. The Risk manager reported that based on investigation the resident was at the nurses station in a geri chair for observations, and the CNA assigned to the resident left the area to obtain water for another resident, during this time there were no staff present at the nurses station, and when the CNA returned to the area the resident was standing up out of the geri chair, and before the CNA could reach resident #2 the resident fell to the ground. Interview with the Risk Manager on 1/9/11 at approximately 2:43 p.m. revealed that the facility has realized that there is a problem with falls, and that on 12/12/11 started a falls performance improvement team, where the team will be looking at other means of preventing falls, and looking closer at resident who have had multiple falls, all of which were reviewed as part of quality assurance. Telephone interview with employee #5 on 1/10/11 at approximately 9:32 a.m. revealed that on 12/22/11 she was not assigned to resident #2, however she was aware that the resident had been restless all night and placed in a geri chair at the nurses station for observations, and at the time of the residents fall all staff were busy assisting to other tasks, and could not confirm that any staff person was present at the rehab nurses station. Telephone interview with employee #3 on 1/10/11 at approximately 9:46 a.m. revealed that on 12/22/11 resident #2 spent the entire morning hours in a geri chair by the nurse station of the rehab unit. the resident had been agitated the entire night, and kept trying to get up out of bed without assistance, the resident was placed in the geri chair, at the nurses desk for observations, one CNA was assigned to the resident, however all staff observed the resident during the shift. At the time of the fall all staff were busy, and not at the nurse station. The CNA assigned to the resident went into the the nutrition room to obtain water for a different resident, upon exiting the nutrition room observed resident #2 up out of the geri chair and standing at the nurses station, before the CNA could reach resident #2 the resident fell to the ground. 2. A review of resident #3's clinical record revealed a face sheet which indicated that a [AGE] year old female resident was admitted to the facility on [DATE] to the rehabilitation unit. The face sheet documentation included medical Diagnosis: [REDACTED]. A review of the facility occurrences from 10/1/11 to 1/9/12 revealed multiple falls without apparent injury: 11/8/11 at 0425: 11/27/11 at 1800; 12/9/11 at 0515 and that on 12/19/11 resident #3 was found on the floor with no injuries, on 1/6/12 resident fell from the geri chair while under observations at nurses station. A review of resident #3's fall care plan, with an original date of 11/3/11, and revision dates of 11/9/11 to give verbal cues for safety, remind resident to call for assistance with all transfers, and ambulation, frequent rounds, 12/19/11 offer toileting early a.m. continue frequent checks and rounds, resident forgetful, 12/20/11 try to keep in public area when up in wheelchair, 1/6/12 continue frequent rounds especially 11:00 p.m.-7:00 a.m., offer toileting frequently. Telephone interview with employee #1 on 1/10/11 at approximately 3:11 p.m. revealed that on 1/6/12 resident #3 due to agitation was placed at the nurses station, the resident was observed to stand from the geri chair that she was sitting in, and by the time staff could get to her resident #3 fell to the ground. The RN reported that although staff were present at the nurses station, the resident was very quick, and was able to stand and then fall to the ground before staff could get to her. Telephone interview with employee #5 on 1/10/11 at approximately 9:32 a.m. revealed that resident #3 was sitting in a geri chair at the nurses station on 1/6/12 for observations due to agitation, and that the resident stood up from the chair and fell to the floor before staff could get to her. Interview with the Risk Manger, DON, and MDS Coordinator on 1/9/12 at approximately 4:21 p.m. revealed that residents who are agitated, and who routinely attempt to ambulate without assistance and are considered a fall risk are observed at the nurses station when they are out of bed. This intervention is done to prevent falls. The Risk manager reported that resident #2 was left at the nurses station for a short time when she fell , and that resident #3 had continuous observation, but her movements were that quick that it did not allow for staff to physically intervene, and prevent the residents fall.