Every finding on record at Panola County Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of water bugs for one (1) common area hallway near secure unit, and for one (room [ROOM NUMBER]) of 5 rooms reviewed for pests.The facility failed to maintain an effective pest free from water bugs for Resident #36 and a dead water bug located in one common hall located near the secured These failures placed residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.Findings included:Record review of Resident #36's admission Record indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included acute respiratory infection (a sudden illness affecting the respiratory system), Chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breath), Type II Diabetes (a chronic condition that affects the way the body metabolizes sugar leading to high blood sugar levels and various health complications), and major depression disorder (a serious mood disorder characterized by persistent feelings of sadness and loss of interest in activities once enjoyed). Record review of Resident #36's quarterly MDS dated [DATE] revealed that the resident had a BIMS score of 15 indicating she was cognitively intact. The MDS also revealed, Resident #36 was dependent with transfers, and required substantial to maximal assistance with eating, toileting, bathing, dressing upper and lower body.Record review of Resident #36's Care Plan revised on 2/13/2025, revealed Resident #36 COPD with interventions to monitor for signs and symptoms of acute respiratory insufficiency and monitor, document and report any signs and symptoms of respiratory infection. During an observation and interview on 8/12/2025 at 8:21 AM, a water bug was located running under Resident #36's bed. Resident #36 said she had noticed bugs in her room. During an interview on 8/13/2025 at 12:39 PM, LVN K said she had seen water bugs on the secured unit. She said most of the time the water bugs were dead. LVN K said she had seen them pretty frequently noticing them every other day. LVN K said she has seen the pest control company come out and spray. LVN K said the building was old and she was not sure where they were coming from. LVN K said they could be getting in from outside door gaps. LVN K said maintenance was responsible for ensuring the pests were controlled.During an interview on 8/13/2025 at 1:00 PM, the Housekeeper N said she had worked at the facility for approximately 1.5 months. She said the water bugs get bad and some days she does not see as many. Housekeeper N said she noticed the water bugs more when there was rainy weather and humidity. Housekeeper N said she has seen them in the bathrooms. Housekeeper N said no one had complained to her about the water bugs and she did not know where they were coming from. During the interview, a water bug was observed dead on the floor at the surveyor's feet in the hallway leading to the secure unit.During an interview on 8/13/2025 at 1:23 PM the CNA E said she had seen water bugs. She said maintenance and a pest control company comes to spray the facility. She said she did not know where they were coming from, and no residents had complained to her about bugs. During an interview on 8/13/2025 at 2:00 PM, the Maintenance Director said he had been at the facility for about 1 year. He said a pest control company comes to the facility to treat for bugs monthly. The Maintenance Director said the pest control company had placed box stations outside to help. He said he had not noticed any water bugs in the facility recently. He said the last treatment was on 7/30/2025. He said the pest control had treated all areas of the facility such as dry storage, dining hall, common areas and cracked areas. The Maintenance Director said he felt the water bugs were coming in from outside and the building was old, and the bugs were under the foundation. He said the water bugs set up where there was moisture, and they run inside. He said the housekeepers and aides were to report to him if bugs were in resident rooms and they were good about letting him know. He said the housekeepers sweep under furniture and in the bathrooms. During an interview on 8/13/2025 at 4:13 PM, the Administrator said she expected the building to be as free as possible for pests. She said if the staff observed an increase in bugs, they should notify maintenance so the pest control company can come to the facility to spray. She said pest or bugs in the building could cause infection to residents.During an interview on 8/13/2025 at 4:36 PM, the DON said she was aware of the big water bugs. She said a pest control company has come out and the facility could get them to come out more frequently. The DON said the facility staff try to keep them out of the building. The DON said Maintenance was responsible for pest control, and it was all their responsibility. The DON said staff was expected to report to Maintenance and then Maintenance contacted the pest control company. She said it would not be good environmentally for the residents and the staff would not want water bugs to get on the resident. The DON said it should not be an infection control issue. She said it could be an infection control issue if bug crawls on floor, then on a resident. The DON said the staff had no reports of water bugs on residents. She said she expected housekeeping to keep floors clean and bugs off the floor. The DON said if the pest control company was doing their job, the water bugs found dead meant it was working. Record review of the pest control company's service report dated 7/30/2025 revealed that Monthly service was completed and no finding during service. Record review of facility policy titled Pest Control revealed that . Our facility shall maintain an effective pest control program.1. The facility maintains and on-going pest control program to ensure that the building is kept free if insects and rodents. 4. Only approved FDA (Federal and Drug Administration) and EPA (Environmental Protection Agency) insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas. 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 16 residents (Resident #6), reviewed for care plans. The facility failed to revise and update Resident #6's care plan after she was coded on the annual MDS assessment dated [DATE] for use of a diuretic and an antiplatelet. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.Findings included: Record review of Resident #6's face sheet dated 8/12/25 indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses including hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (is the death of brain tissue due to a blockage of blood flow), other cerebral infarction due to occlusion or stenosis of small artery (a blockage or narrowing of a small blood vessel, which can restrict blood flow and potentially lead to tissue damage) and hypertension (is when the force of blood pushing against your artery walls is consistently too high). Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 was usually understood and usually had the ability to understand others. Resident #6 had a BIMS score of 14 which indicated intact cognition. Resident #6 had received a diuretic (are medicines that help reduce fluid buildup in the body) and an antiplatelet (are medications that prevent platelets from sticking together and forming blood clots) during the last 7 days. Record review of Resident #6's care plan dated 8/6/24 indicated Resident #6 had hemiplegia and hemiparesis related to previous cerebral infarction. Intervention included give medications as ordered and monitor/document for side effects and effectiveness. Resident #6's care plan did not reflect use of a diuretic and an antiplatelet. Record review of Resident #6's consolidated physician orders dated 8/12/25 indicated:*Aspirin 81mg Oral tablet Delayed Release, give 1 tablet by mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction, other cerebral infarction due to occlusion or stenosis of small artery. Ordered date 3/7/25. *Spironolactone Oral Tablet 25mg, give 25mg by mouth one time a day for edema. Ordered date 2/24/25. Record review of Resident #6's MAR dated 8/1/25-8/31/25 indicated:*Aspirin 81mg Oral tablet Delayed Release, give 1 tablet by mouth one time a day related to hemiplegia and hemiparesis following cerebral infarction, other cerebral infarction due to occlusion or stenosis of small artery. Resident #6 received 12 out of 12 scheduled doses. *Spironolactone Oral Tablet 25mg, give 25mg by mouth one time a day for edema. Resident #6 received 12 out of 12 scheduled doses. During an interview on 8/13/25 at 12:45 p.m., the MDS Coordinator said the resident's care plans were revised with the MDS assessments and changes of condition. She said each department of the IDT were responsible for updating the care plan, after the MDS assessment. She said the resident's care plans were reviewed and updated quarterly. She said Resident #6's use of a diuretic and an antiplatelet should have been care planned. She said she normally only care planned the major antiplatelets on the resident's care plans. She said the resident's medications should be care planned to know which type of medications the resident was on and what to monitor for. She said when a resident's medications were not care planned, the comorbidities it was treating may not be monitored or assessed. She said the DON and Regional/Corporate MDS Coordinator were responsible for overseeing her. During an interview on 8/13/25 at 2:00 p.m., the ADON A said the MDS Coordinator with the assistance of the DON were responsible for revising and updating care plans after the MDS assessment. She said she would expect Resident #6's use of a diuretic and an antiplatelet to be on her care plan. She said it was important for Resident #6's diuretic use to be on the care plan to know what to monitor for fluid control. She said the antiplatelet needed to be care planned to assess and monitor for the side effects. She said if the resident had a fall and would not stop bleeding, the facility needed to know why. She said if the resident's medications were not care planned, it placed the resident at risk for not being assessed or monitored and affected the level of care and needs provided. She said the IDT should review the resident's care plan to ensure it was revised by the MDS Coordinator. During an interview on 8/13/25 at 2:42 p.m., LVN D said the DON, ADON and SS were responsible for updating the resident's care plan. She said it was important to care plan the resident's medications to know the history, diagnosis, and care needs. She said when medications were not care planned, the resident could not get the care they needed. She said the staff could think the resident was urinating too much and had an UTI (is when bacteria gets into your urinary tract- kidneys, bladder, or urethra) but it was from the diuretics. She said a resident on an antiplatelet needed to be monitored for excessive bleeding, bleeding gums, and blood in the stool. She said those things were normally on the resident's care plan to do. During an interview on 8/13/25 at 3:04 p.m., the DON said the MDS Coordinator was responsible for updating the care plan after the MDS assessment. She said but all the IDT was responsible for the care plans. She said she would expect Resident #6's diuretic and antiplatelet use to be care planned. She said they should be care planned to ensure the facility was providing accurate care. She said the medications needed to be monitored and assessed. She said the ADM and Regional MDS Coordinator oversaw the MDS Coordinator. During an interview on 8/13/25 at 5:02 p.m., the ADM said the MDS Coordinator was responsible for updating the resident's care plan after a MDS assessment was done. She said she would expect Resident #6's diuretic and antiplatelet use to be care planned. She said the resident's care needed to be revised after the MDS assessment, so everyone knew what was being used and what for. She said when the resident's care plan was not updated, the resident's needs could not be met. She said the DON and Regional MDS Coordinator oversaw the MDS Coordinator. She said the resident's care plan were reviewed daily during stand up meetings. Record review of a facility's Care Plans, Comprehensive Person-Centered policy revised 12/2016 indicated, .assessments of the resident are ongoing and care plans are revised as information about the residents and the residents condition change. the Interdisciplinary Team must review and update the care plan.at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to include all residents with newly evident or possible serious mental disorder for 1 of 7 residents (Resident #28) reviewed for the PASRR program. The facility failed to ensure Resident #28 was referred for a PASRR (Level II) evaluation when she admitted to the facility on [DATE] with a possible serious mental disorder. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.The findings included: Record review of the face sheet, dated 08/13/25, reflected Resident #28 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder, bipolar type (chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). Record review of the PASRR Level 1 Screening form, dated 09/30/24, reflected Resident #28 had no evidence or indicator of a mental illness. No PASRR Level II screening was completed. Record review of the admission MDS assessment, dated 10/10/24, reflected Resident #28 was not considered by the state level II PASRR process to have serious mental illness. The MDS reflected Resident #28 had clear speech, was understood by others, and was able to understand others. Resident #28 had a BIMS score of 15, which indicated no cognitive impairment. Resident #28 had no documented behaviors or refusal of care during the look-back period. The MDS reflected Resident #28 had an active diagnosis of Schizophrenia, which included schizoaffective disorder. Record review of the comprehensive care plan, initiated on 10/07/24, reflected Resident #28 had a mood problem related to a diagnosis of schizoaffective disorder, bipolar type and was taking psychotropic medication. During an interview on 08/13/25 beginning at 5:33 PM, the MDS Coordinator stated she was responsible for obtaining the PL1 from the referring entity, entering the PL1 into the system, and coordinating with the local authority when it was needed. The MDS Coordinator stated she reviewed the PL1 and any diagnoses prior to the residents admitting to the facility. The MDS Coordinator stated if the PL1 was inaccurate and needed to be changed, she normally called the hospital or referring entity and asked them to change it, or she would change it in the system, or a form 1012 could have been completed, as needed. The MDS Coordinator stated some of the diagnoses that she looked for prior to admission were schizophrenia and bipolar disorder. The MDS Coordinator stated the local authority made the determination of eligibility after a positive PL1 was submitted. The MDS Coordinator stated Resident #28's PL1 screening should have been positive for mental illness because of her diagnosis of schizoaffective disorder. The MDS Coordinator stated she was not working full time at the facility during the time period Resident #28 admitted . The MDS Coordinator stated she was going to enter a new PL1 and notify the local authority. During an interview on 08/13/25 beginning at 6:08 PM, the Administrator stated she expected the correct PASRR documentation to have been on file at the facility. The Administrator stated if the PL1 screening was incorrect, it should have been fixed so the local authority could have completed the level II PASRR evaluation. The Administrator stated the MDS coordinator was responsible for coordinating the PASRR services and performed audits on admission. The Administrator stated it was important to ensure PL1 screening was accurate to ensure residents received the correct services at the facility. Record review of the admission Criteria policy, revised March 2019, reflected all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid PASRR process. the facility conducts a Level 1 PASRR screen for all potential admission, regardless of payer source to determine if the individual meets the criteria for a MD, ID, or RD. if the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 16 residents reviewed for care plans. (Resident #8, Resident #43)1. The facility failed to ensure Resident #8's care plan had interventions to be used for the use of a self-releasing seat belt, on his motorized wheelchair. 2. The facility failed to implement the comprehensive person-centered care plan for Resident #43's low air loss mattress on the correct settings for her current weight. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services. Findings include: 1. Record review of Resident #8’s face sheet dated 8/12/25 indicated Resident #8 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 had diagnoses including cerebral palsy (is a group of conditions that affect movement and posture), paraplegia (is paralysis that affects your legs, but not your arms), abnormal posture, and contractures (is a type of scarring in your soft tissues that causes them to tighten and stiffen). Record review of Resident #8’s consolidated physician order dated 8/12/25 indicated may use motorized wheelchair for mobility when out of bed. If motorized wheelchair is unable to be used, may use Geri-chair for mobility related to contractures and poor trunk control. Ordered date 5/6/25. Record review of Resident #8’s quarterly MDS assessment dated [DATE] indicated Resident #8 was usually understood and had the ability to understand others. Resident #8 had unclear speech, adequate hearing, and impaired vision with corrective lenses. Resident #8 had a BIMS score of 99 which indicated the resident was unable to complete the interview. Resident #8 had short term memory call problem and moderately impaired cognitive skill for daily decision making. Resident #8 had functional limitation in range of motion to the upper and lower extremities, on both sides of his body. Resident #8 used a wheelchair for mobility. Resident #8 was dependent for ADLs. Resident #8 was not coded for a physical restraint. Record review of Resident #8’s care plan sated 4/24/25 indicated Resident #8 was at risk for falls related to decreased safety awareness, paraplegia, psychoactive drug use, vision/hearing problems, incontinence, cerebral palsy, chronic flexion contractures (is a long-term inability to fully extend a joint, meaning the joint is stuck in a bent position) to upper/lower extremities, muscle spasms, pain and spina bifida (is a condition that occurs when the spine and spinal cord don't form properly). Resident #8 has self-releasing seat belt because Resident stated, he “feels safer with it on.” Resident #8 was able to release upon request. Resident #8’s care plan did not reflect interventions or services that would attain or maintain the resident’s physical well-being for the use of a self-releasing seat belt. During an observation on 8/12/25 at 9:40 a.m., LVN C and CNA F placed Resident #8 in a motorized wheelchair. CNA F buckled Resident #8’s seat belt. CNA F asked Resident #8 to release the seat belt. After CNA F and LVN C asked Resident #8 two more times and CNA F showed him the release button, he successfully pushed the button. During an interview on 8/13/25 at 12:45 p.m., the MDS Coordinator said she was responsible for the initial care plans and care plans after the MDS assessments. She said the DON and ADON were responsible for acute care plans. She said the interventions were important for the monitoring and assessment of the care plan problem. She said the IDT met to discuss the resident’s care plan on admission and quarterly. She said the DON and Regional/Corporate MDS Coordinator were responsible for overseeing the MDS Coordinator. During an interview on 8/13/25 at 2:42 p.m., LVN D said the ADON and DON was responsible for the residents’ care plans. She said Resident #8’s use of the seat belt on his wheelchair should be care planned. She said the interventions were important to assess the safety of the seat belt. She said the staff should make sure Resident #8 was able to release the seat belt and the seat belt was working properly. She said if Resident #8 use of the seat belt was not assessed, it placed the resident at risk for falls. She said Resident #8 could hurt himself. During an interview on 8/13/25 at 3:03 p.m., LVN C said the DON or a RN was responsible for the residents’ care plans. She said Resident #8’s use of the seat belt on his wheelchair should be care planned with interventions. She said the staff should make sure Resident #8 was able to release the seat belt and the seat belt was functioning correctly. She said the care plan was important to let the staff know what interventions were in place, what had been tried, and what to expect from the facility. She said Resident #8’s seat belt not being care planned with intervention was a safety issue. During an interview on 8/13/25 at 3:04 p.m., the DON said the IDT was responsible for the residents’ care plans. She said Resident #8’s wheelchair seat belt needed interventions for monitoring and assessment. She said the interventions were important to know what to monitor to prevent injury. She said the facility did not consider Resident #8’s seat belt as a restraint because he could release it. She said the facility should have still developed a care plan with interventions to ensure it did not become a restraint. She said when the care plan problem did not have interventions, the residents’ needs could not be met. She said the IDT monitored each other to ensure the residents’ care plans were complete. During an interview on 8/13/25 at 5:02 p.m., the ADM said the DON was responsible for developing care plan interventions for Resident #8’s wheelchair seat belt. She said the care plan interventions were important to ensure Resident #8’s seat belt was not a restraint. She said when the resident’s care plan problem did not have interventions, the resident’s needs could not be met. She said the IDT oversaw the care planning process. She said the IDT reviewed the residents’ care plans during the daily “stand up” meetings. 2. Record review of Resident #43’s admission Record indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included contracture of right knee (a condition characterized by the inability to fully extend the knee joint), dementia (a general term for a decline in cognitive function that affects memory, thinking, and social abilities, significantly interfering with daily life), essential hypertension (a form of high blood pressure that occurs when the pressure in your blood vessels is consistently too high), severe protein-calorie malnutrition (serious health condition stemming from an insufficient intake or absorption of protein) and major depression disorder (a mood disorder that cause persistent feelings of sadness and loss of interest). Record review of Resident #43's Annual MDS dated [DATE] revealed that the resident did not have a BIMS score indicating Resident #43 was rarely or never understood. The MDS also revealed, Resident #43 was dependent with all ADL’s such as eating, toileting, bathing, dressing upper and lower body, and transfers. The MDS revealed Resident #43 weighed 104 lbs. Record review of Resident #43's Care Plan revised on 7/22/2025, revealed Resident had Deep tissue injury to Right Distal Lateral foot with interventions for a low air loss mattress for pressure relief. Record review of Resident #43’s weight and vital sign summary dated 8/13/2025 revealed on 5/22/2023 Resident weighed 104.2 lbs. During observation on 8/12/2025 at 1:57 PM, observed Resident #43 lying in bed on her left side with covers pulled up. Resident #43 was nonverbal and unable to communicate. During an observation and interview on 8/12/2025 at 2:33 PM, Resident #43 was lying in bed and wearing pressure relieving boots to bilateral lower extremities. The ADON said Resident #43 was on Hospice care. The ADON said Resident #43 was contracted on her lower extremities and wore the pressure relieving boots to her bilateral lower extremities. The ADON said Resident #43 was followed by a wound care specialist. The ADON said Resident #43 rubs her legs in her bed which she felt contributed to her DTI (deep tissue injury) (a serious condition that affect the underlying layers of skin and soft tissue, often resulting from sustained pressure or shear forces). The ADON said the DTI (deep tissue injury) was closed and she was not required to be on EBP (Enhanced Barrier Precautions) (Infectious control measures designed to reduce the transmission of multidrug-resistant organisms in healthcare settings). The ADON said Resident #43 was unable to position herself and required a Hoyer lift and a Geri-chair (geriatric chair). The ADON said Resident #43 had wounds on her bottom but had healed and the facility left Resident #43 on the low air loss mattress for prevention. The ADON looked at the settings and said it was set on 210. She said the Geri-chair must have bumped the setting and said the setting was not correct. The ADON said more pressure could cause a skin injury. The ADON said she was going to check on Resident #43’s weight and adjust the setting after checking the orders and update the orders if there was not one. During an interview on 8/13/2025 at 12:39 PM, LVN K said Resident #43 had an air loss mattress. She said Resident #43 was to be repositioned every 2 hours and had these wounds in the past stating that the wounds had healed and reopened. LVN K said Resident #43 was terminal and the wounds were unavoidable. LVN said Resident #43 did not have any current wounds to her bottom. LVN K said the staff gets her up in the Geri-chair. LVN K said normally the staff does not touch the settings on the low air loss mattress and said she did not know if the settings were supposed to be on an order. LVN K reviewed Resident #43’s order and said there was not an order. She said the low air loss mattress settings were based on the weight of the resident. She said the low air loss mattress would circulate to ensure the pressure was not in one spot. LVN K said it could cause pressure sores and skin breakdown if not on the correct settings. During an interview on 8/13/2025 at 1:39 PM, the Wound Care Physician said he started seeing Resident #43 a couple of weeks ago. He said she was currently wearing her pressure relieving boots. He said Resident #43 likes to turn on her right side and he said the deep tissue injury was unavoidable due to her contractures. He felt with her wearing the boots, she would be ok. The Wound Care Physician said sometimes people turn up the settings on the low air loss mattress while positioning a resident. He said more air could cause more pressure. He said Resident #43’s wound was scabbed over and not ready to come off yet. He said Resident #43’s wound showed no signs of infection. During an interview on 813/2025 at 4:13 PM, the Administrator said she expected the nurses to check the settings on the low air loss mattress to ensure it was on the proper settings. The Administrator said she thought there should be specific settings on the care plan and orders. The Administrator said a resident could develop pressure ulcers if the low air loss mattress was not on the proper setting. The Administrator said the ADON and DON were responsible for ensuring the orders were on the care plan and the settings were correct. During an interview on 8/13/2025 at 4:36 PM, the DON said she expected the nurses and aides to assess Resident #43 low air loss mattress and for it to be on the proper settings. The DON said she was working on order to make sure they were specific. The DON said the aides could place the settings on static while they are positioning a resident but would need to be placed back on the correct setting. The DON said there was a potential for skin breakdown or if a resident had a current skin issue, it could make a wound worse. The DON said it could be a comfort issue as well. The DON said she had started an in-service with staff and was adding a task for the aides to check as well. Record review of a facility policy revised on December of 2016 titled Care Plans, Comprehensive Person-Centered revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs is developed and implemented for each resident…the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment…describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being…”

Based on observations, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition for 1 of 5 residents (Resident #50) reviewed for ADLs. The facility did not ensure Resident #50 received set-up assistance during the lunch meal on 08/11/25. This failure could place residents at risk of decreased quality of life, weight loss, and injury related to choking.The findings included: Record review of the face sheet, dated 08/13/25, reflected Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, affecting the right dominant side (right-sided weakness/paralysis from a stroke), history of a stroke, and the need for assistance with personal care. Record review of the admission MDS assessment, dated 06/26/25, reflected Resident #50 had clear speech, was understood by others, and was able to understand others. Resident #50 had a BIMS score of 6, which reflected severely impaired cognition. Resident #50 had no behaviors or refusal of care during the look-back period. The MDS assessment reflected Resident #50 usually required partial/moderate assistance with eating, which indicated the helper did less than half the effort. Record review of the comprehensive care plan, initiated on 06/26/25, reflected Resident #50 had an ADL self-care performance deficit and required partial/moderate assistance as needed with eating. Record review of the ADL flow sheet for eating, dated from 07/31/25 to 08/12/25, reflected Resident #50 required setup or clean-up assistance with eating on 08/01/25, 08/02/25, 08/03/25, 08/06/25, 08/11/25, and 08/12/25. During an observation on 08/11/25 at 12:04 PM, Resident #50 was served her lunch meal tray. Resident #50 was asked if she wanted her plate on or off the serving tray. The tray was placed down in front of her, and the cover was removed. The plastic was taken off the drinks, her utensils were unfolded from her napkin, and then the staff left her with her tray. Resident #50's dinner roll was left in the plastic bag. During an observation on 08/11/25 at 12:07 PM, Resident #50 was eating the plastic bag that her dinner roll was in. Resident #50 would take a bite of the plastic and then spit it out. Resident #50 was unable to remove the dinner roll herself. During an observation on 08/11/25 at 12:18 PM, Resident #50 continued to take bites of the plastic bag and then spit it out on her tray. Surveyor notified CNA G in the dining room. CNA G immediately removed the plastic from her dinner roll. During an interview on 08/13/25 beginning at 3:26 PM, CNA G stated Resident #50 normally required setup help with eating but would not allow staff to assist her with eating. CNA G stated setup help included taking everything off the serving tray and sitting it on the table, taking the plastic off of the food, unwrapping and placing straws in the cups, and putting condiments on the food as needed or requested. CNA G stated Resident #50's dinner roll should have been removed from the plastic bag when she was served. CNA G was unsure why Resident #50's dinner roll was not removed from the bag, but it was usually taken out. CNA G stated she believed Resident #50 had not attempted to eat the plastic around her dinner roll before that incident. CNA G stated it was important to ensure Resident #50 received setup assistance during mealtimes to ensure she did not choke on the plastic. During an interview on 08/13/25 beginning at 3:39 PM, LVN C stated Resident #50 required setup assistance during meals because of a previous stoke that caused right-sided weakness. LVN C stated setup assistance included asking if they wanted their food on or off the serving tray, cutting up any vegetables or meat, taking the plastic wrapper off of all the food, and then asking if they wanted salt/pepper or sweetener. LVN C stated the plastic should have been removed from Resident #50's dinner roll on 08/11/25. LVN C stated she was the nurse in the dining room on 08/11/25 but was unable to remember who served Resident #50. LVN C stated she was unaware until later that Resident #50 was eating the plastic. LVN C stated it was important to ensure Resident #50 received setup assistance during mealtimes to maintain a homelike environment. LVN C stated Resident #50 was unable to remove the plastic herself because of the stroke that caused weakness. During an interview on 08/13/25 beginning at 5:44 PM, the DON stated she expected the nursing staff to ensure residents received setup assistance during mealtimes. The DON stated setup assistance included: opening milks, removing plastic from food, setting up the utensils, or adding salt/pepper. The DON stated the nurse in the dining room was responsible for monitoring to ensure residents received setup assistance in the dining room. The DON stated it was important to ensure residents received setup assistance during mealtimes to ensure adequate nutrition and maintain the resident's safety during meals. During an interview on 08/13/25 beginning at 6:08 PM, the Administrator stated she expected staff to ensure the residents received setup assistance during mealtimes. The Administrator stated all food items should have been unwrapped or taken out of the plastic. The Administrator stated the nurse in the dining room was responsible for monitoring to ensure setup assistance was provided. The Administrator stated it was important to ensure setup assistance was provided because most residents need help and would be unable to perform the task themselves. Record review of the Assistance with Meals policy, revised March 2022, reflected .facility staff will serve resident trays and will help residents who require assistance with eating. The policy did not address setup assistance.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 16 residents reviewed for activities. (Resident's #30 and #50) The facility failed to ensure Resident #30, and Resident #50 were offered to participate in activities on 08/11/25 and 08/12/25. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.The findings included: 1. Record review of the face sheet, dated 08/13/25, reflected Resident #30 was a [AGE] year-old female who initially admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (neurodegenerative disease that causes memory loss). Record review of the annual MDS assessment, dated 04/22/25, reflected Resident #30 had clear speech, was understood by others, and was usually able to understand others. Resident #30 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #30 had delusions, physical and verbal behavior, and refusal of care 1 to 3 days during the look-back period. Resident #30 stated it was very important to participate in her favorite activities and was somewhat important to do things with groups of people. Record review of the comprehensive care plan, revised 04/03/23, reflected Resident #30 was dependent on staff for activities, cognitive stimulation, and social interaction. The goal was Resident #30 will attend/participate in activities of choice 3 -5 times weekly by the next review date. The interventions included: all staff to converse with resident while providing care and invite Resident #30 to scheduled activities. Record review of the Activities - Quarterly/Annual Participation Review assessment, dated 07/08/25, reflected Resident #30 participated in activities of choice, she enjoys the daily chronicles, nail are, and watching/visiting with staff and residents in the dining room. The assessment reflected her favorite activities were the daily chronicles and a hot cup of coffee. 2. Record review of the face sheet, dated 08/13/25, reflected Resident #50 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, affecting the right dominant side (right-sided weakness/paralysis from a stroke). Record review of the admission MDS assessment, dated 06/26/25, reflected Resident #50 had clear speech, was understood by others, and was able to understand others. Resident #50 had a BIMS score of 6, which reflected severely impaired cognition. Resident #50 had no behaviors or refusal of care during the look-back period. The MDS assessment reflected Resident #50 stated it was very important to participate in her favorite activities and somewhat important to do things with groups of people. Record review of the comprehensive care plan, initiated on 07/14/25, reflected Resident #50 was dependent on staff for activities, cognitive stimulation, and social interaction. The goal was Resident #50 will attend/participate in activities of choice 3 to 5 times a week. The interventions included: notify resident daily of daily activities and times, provide assistance as needed with daily activity, and assure activities are compatible with physical and mental capabilities. Record review of the Activities - Initial Review, dated 06/20/25, reflected Resident #50 participated in activities of choice. The assessment reflected Resident #50 participated in weekly bible study. Resident #50 wished to participate in activities while in the home, group activities, and independent activities. Record review of the activity calendar, dated August 2025, reflected the following:08/11/25 - 11 AM Painting08/11/25 - 2 PM Bingo08/12/25 - 8 AM Daily Chronicles08/12/25 - 1 PM Noodle ball During an observation on 08/11/25 beginning at 11:03 AM, the AD was in the dining room. She gathered the supplies for rock painting. The AD sat a small table with 2 residents and began the activity. Resident #30 and Resident #50 were sitting at a table in the dining room. The AD did not offer or encourage Resident #30 or Resident #50 to participate in the activity. During an observation on 08/11/25 beginning at 2:12 PM, the AD was calling bingo numbers in the dining room. Resident #30 and Resident #50 were sitting at the same table in the dining room with no bingo cards in front of them. Resident #30 was sitting up with her head looking down. Resident #50 was staring at the table. Resident #50 asked the surveyor about a funeral and said she did not know what to do. During an observation on 08/11/25 beginning at 3:32 PM, Resident #50 was sitting up in her wheelchair at the same dining room table. During an observation on 08/12/25 beginning at 8:25 AM, Resident #30 was sitting at the same dining room table. There were a stack of daily chronicles sheets in a neat pile. Resident #30 was staring around the room. During an observation on 08/12/25 beginning at 1:18 PM, Resident #30 and Resident #50 were sitting at the same dining room table. Both residents were just looking around the room. There were no activities. During an interview on 08/13/25 beginning at 5:18 PM, the AD stated she was responsible for ensure residents were offered to participate in activities. The AD stated some of the nursing staff helped assist residents to the activities but most of the time it was on her. The AD stated most of the residents do not participate in the activities and prefer to stay in their rooms. The AD stated Resident #30 and Resident #50 were dependent on staff to assist them to the activities. The AD stated Resident #30 and Resident #50 usually refuse to participate in activities, so she stopped asking them. The AD stated she should have provided encouragement or offered activities even if they normally refuse. The AD stated activities were important for socialization and quality of life. The AD stated activities, especially for dementia care residents, were important to improve the mood and behaviors. During an interview on 08/13/25 beginning at 5:44 PM, the DON stated she expected residents to be offered activities. The DON stated Resident #30 and Resident #50 will refuse to attend activities at times because of their dementia (memory loss) but it should have still been offered. The DON stated the AD was responsible for ensuring residents attended activities. The DON stated activities were important to improve their quality of life. During an interview on 08/13/25 beginning at 6:08 PM, the Administrator stated she expected activities to have been offered to the residents. The Administrator stated the AD was responsible for ensuring residents attended activities or were offered to participate in activities. The Administrator stated activities were important to help the residents stay social. Record review of the Activity Programs policy, revised June 2018, reflected .activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.the activities program is ongoing, and includes facility-organized group activities, independent individual activities, and assisted individual activities.our activity programs are designed to encourage maximum individual participate and are geared to the individual resident's needed.residents are encouraged, but not required, to participate in scheduled activities.

Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #49) reviewed for accidents and hazards. The facility failed to ensure Resident #49's fall mat was utilized while he was in his bed on 08/11/25 and 08/12/25. This failure could place residents at risk of injury or harm and a decreased quality of care related to falls.The findings included: Record review of the face sheet, dated 08/12/25, reflected Resident #49 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), apraxia (inability to execute purposeful, previously learned motor tasks, despite physical ability and willingness, as a result of brain damage) following a stroke, and paranoid schizophrenia (A serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior.). Record review of the quarterly MDS assessment, dated 07/11/25, reflected Resident #49 had clear speech, was understood by others, and usually able to understand others. The MDS reflected Resident #49 had a BIMS score of 10, which indicated moderately impaired cognition. The MDS reflected Resident #49 had rejection of care 1 - 3 days during the look-back period. The MDS reflected Resident #49 had an impairment on both upper and lower extremities. Resident #49 was dependent on staff assistance with most ADLs. Resident #49 had no falls since the prior assessment. Record review of the comprehensive care plan, revised on 10/16/23, reflected Resident #49 was at risk for falls related to decreased safety awareness, confusion, psychoactive drug use, vision/hearing problems, incontinence, cardiovascular disease, impaired muscle control, and limited range of motion to lower extremities. The interventions included apply mat to bedside while Resident #49 is in bed. Record review of the fall risk assessment, dated 08/08/25, reflected Resident #49 was at high risk for falls. Record review of the order summary report, dated 08/13/25, reflected Resident #49 had an order, which started on 01/15/20, for May have fall mat every shift for fall risk. Record review of the MAR dated August 2025, reflected Resident #49's fall mat was signed off by the nurse daily. During an observation on 08/11/25 beginning at 3:33 PM, Resident #49 was laying in the bed with his eyes closed. Resident #49's bed was in the lowest position and his fall mat was laying long ways, against the wall at the head of his bed. Approximately 6 inches of the fall mat was sticking out on both sides of the bed and the legs of the bed, at the head, were indenting the fall mat. Another fall mat on the right side of his bed was folded in half and laying in the floor between Resident #49's bed and his roommate's bed. During an observation on 08/12/25 beginning at 8:26 AM, Resident #49 was laying in the bed with his eyes closed and covers pulled up to his chin. Resident #49's bed was in the lowest position and his fall mat was laying long ways, against the wall at the head of his bed. Approximately 6 inches of the fall mat was sticking out on both sides of the bed and the legs of the bed, at the head, were indenting the fall mat. Another fall mat on the right side of his bed was folded in half and laying in the floor between Resident #49's bed and his roommate's bed. During an observation on 08/12/25 beginning at 1:38 PM, Resident #49 was laying in the bed with his eyes closed. Resident #49's bed was in the lowest position and his fall mat was laying long ways, against the wall at the head of his bed. Approximately 6 inches of the fall mat was sticking out on both sides of the bed and the legs of the bed, at the head, were indenting the fall mat. Another fall mat on the right side of his bed was folded in half and laying in the floor between Resident #49's bed and his roommate's bed. During an interview on 08/13/25 beginning at 3:26 PM, CNA G stated she was the restorative CNA and has worked at the facility for a while. CNA G stated Resident #49 had not had any falls recently but was at risk for falls. CNA G stated Resident #49 had a low bed and fall mats beside his bed. CNA G stated the fall interventions should have been in place to prevent injuries from falls. CNA G was unsure why Resident #49's fall mats were not in place because she did not work the floor. During an interview on 08/13/25 beginning at 3:34 PM, CNA H stated Resident #49's fall mats were not in place this morning when she arrived at work. CNA H stated she put them down this morning. CNA H stated Resident #49 was at risk for falling and required a low bed and fall mats while in bed. CNA H stated she did not specifically check for fall mat placement when she arrived at work, but if she noticed they were not being utilized she would place them down appropriately. CNA H stated it was important to ensure fall interventions were utilized to protect the resident from injuries related to falls. During an interview on 08/13/25 beginning at 3:54 PM, LVN K stated Resident #49 had fallen in the past but had behaviors at times where he would thrash around in the bed and try to throw himself out. LVN K stated the fall mats were placed to prevent injuries from throwing himself out of the bed. LVN K stated his behaviors had been controlled recently and he has been calmer. LVN K stated the nurse was responsible for checking to ensure the fall mats were placed every shift and had to sign-off and document that on the MAR. LVN K stated she did not work on 08/11/25 or 08/12/25 and was unsure why the falls mats were not placed appropriately. LVN K stated it was important to ensure fall interventions were utilized to prevent injuries related to falls. LVN K stated LVN L was the nurse who worked on 08/11/25 and 08/12/25. During an attempted phone interview on 08/13/25 at 4:52 PM, LVN L did not answer the phone. A brief message was sent via text message with a return call requested. A return call was not received upon exit of the facility. During an interview on 08/19/25 beginning at 5:44 PM, the DON stated she expected the staff to ensure fall interventions were in place for residents who were at risk for falling. The DON stated the nurse was responsible for monitoring to ensure fall interventions were in place. The DON stated the nurses had to sign off on the MAR for fall mats. The DON stated Resident #49 had fallen in the past but had some recent behaviors where he was thrashing around in the bed and trying to throw himself out of the bed. The DON stated Resident #49's behaviors have improved in the last few months. The DON stated it was important to ensure fall interventions were utilized to prevent injuries related to falling. During an interview on 08/13/25 beginning at 6:08 PM, the Administrator stated she expected fall interventions to be utilized for residents who were at risk for falling. The Administrator stated the nurse was responsible for monitoring to ensure fall interventions were in place. The Administrator stated it was important to ensure fall interventions were utilized to prevent accidents or injuries. Record review of the Falls - Clinical Protocol policy, revised March 2018, reflected the staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.if interventions have been successful in fall prevention, the staff will continue with current approaches, and will discuss periodically with the physician whether these measures are still needed.

Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 resident (Resident #6) reviewed for trauma-informed care. The facility failed to ensure Resident #6 had a care plan to address past trauma with a PTSD diagnosis. Resident #6 completed a brief trauma assessment on [DATE] which indicated a positive trauma screen. This failure could place residents at an increased risk for psychological distress due to re-traumatization.Findings included: Record review of Resident #6's face sheet dated [DATE] indicated Resident #6 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #6 had diagnoses including post-traumatic stress disorder (is a mental health condition that can develop after experiencing or witnessing a traumatic event), generalized anxiety disorder (persistent and excessive worry about various everyday events and activities), major depressive disorder (is a serious mental health condition characterized by persistent sadness, loss of interest in activities, and difficulty functioning in daily life), and intermittent explosive disorder (is a behavioral disorder characterized by episodes of impulsive aggression that are disproportionate to the situation). Record review of Resident #6's annual MDS assessment dated [DATE] indicated Resident #6 was usually understood and usually had the ability to understand others. Resident #6 had a BIMS score of 14 which indicated intact cognition. Resident #6 did not have experience psychosis or behavioral symptoms. Resident #6 had an active diagnosis of PTSD. Record review of Resident #6's care plan dated [DATE] indicated Resident #6 had ADL self-care performance deficit related to hemiplegia following cerebral infarction affecting the right side and PTSD. Intervention included praise all efforts at self-care. Resident #6's care plan did not reflect triggers, interventions, and goals related to her PTSD diagnosis. Record review of Resident #6's Brief Trauma Questionnaire dated [DATE] indicated Resident #6 had experienced being made or pressured into some type of unwanted sexual contact and she thought her life was in danger or might be seriously injured. Resident #6 also experienced a close family member or friend who died violently. The Brief Trauma Questionnaire indicated that none of the above questions were answered with a yes. The Brief Trauma Questionnaire did not reflect the date and time an IDT meeting was scheduled regarding interventions and plan of care. Record review of Resident #6's progress note dated [DATE] by the MDS Coordinator indicated, .spoke with resident [Resident #6] about her brief trauma questionnaire and her answers on that form.Resident [#6] stated that her triggers are.1. Too many people talking to her at once.2. No male CNAs.Resident [#6] did state that all that was a long time ago and she has not had any triggers since moving into the facility. During an interview and observation on [DATE] at 10:29 a.m., Resident #6 was heading out of her room. LVN C said Resident #6 was headed out to smoke. Resident #6 looked at the surveyor and appeared anxious. Resident #6 walked to the smoking area, unable to complete interview. LVN C said Resident #6 was an anxious person. During an interview and observation on [DATE] at 11:42 a.m., Resident #6 was heading out of her room. CNA F told Resident #6 the surveyor wanted to talk to her. Resident #6 shook her head and said, no! Unable to complete interview. During an interview on [DATE] at 12:43 p.m., the SS said she had started in [DATE]. She said she did not complete Resident #6's Brief Trauma Questionnaire. She said the MDS Coordinator would be responsible for care planning Resident #6's PTSD diagnosis. During an interview on [DATE] at 12:45 p.m., the MDS Coordinator said she was responsible for the resident's initial care plans. She said the ADON and DON completed the acute care plans. She said the SS, AD, and DM completed their portion of the care plan. She said SS completed the Brief Trauma Questionnaire. She said if the resident triggered for experiencing trauma, then the SS notified the DON. She said the SS would initiate the PTSD care plan in the beginning and everyone else would add to it. She said the PTSD care plan was important to know Resident #6's triggers. She said due to Resident #6 not having a PTSD care plan, the staff would not know her triggers and may have caused some triggers. She said on admission, the IDT met to discuss each resident. She said the IDT also met quarterly to discuss the resident's care plans. She said she did not remember Resident #6 mentioning any triggers during the care plan meetings. During an interview and observation on [DATE] at 1:17 p.m., Resident #6 was lying in her bed. Resident #6 said she was sleeping. Unable to complete interview regarding the PTSD diagnosis. During an interview on [DATE] at 2:00 p.m., the ADON A said the DON was responsible care plans for acute changes of care. She said she was responsible for infection control and wound care plans. She said she would expect Resident #6's PTSD diagnosis to be care planned. She said if Resident #6 was admitted with the PTSD diagnosis, the MDS Coordinator would be responsible for the care plan. She said if Resident #6 developed the diagnosis after admission, then it would be an acute change of care. She said then the IDT would be responsible for Resident #6's PTSD care plan. She said the PTSD care plan for Resident #6 was important because it was a broad knowledge of the resident's issue. She said the staff would also know to factor in the PTSD diagnosis into Resident #6's care and treatment. She said not having Resident #6's PTSD diagnosis care planned placed her at risk for the staff accidently doing triggers and experiencing acute events. She said the IDT was responsible for overseeing the care planning process. She said the process was monitored by audit reviews and the care plan meetings. During an interview on [DATE] at 2:24 p.m., CNA E said she knew Resident #6's triggers. She said Resident #6's triggers were telling her, No, going into her room, and not having cigarettes. She said she would want to know Resident #6's triggers related to her PTSD diagnosis. She said the CNAs had access to the resident's care plan in the facility's charting system. She said the resident's care plan interventions told the staff how to take care of the resident. She said when the resident's PTSD diagnosis was not care planned, the staff could trigger the resident. She said if Resident #6 got a male CNA, she would cuss him out. She said it would also upset her. During an interview on [DATE] at 2:42 p.m., LVN D said the MDS Coordinator, DON, ADON, and SS were responsible for the trauma informed care plans. She said she would want Resident #6's PTSD diagnosis care planned. She said she would want to know Resident #6's triggers related to the PTSD diagnosis. She said the trauma care plan was important so everyone knew what was needed to care for Resident #6. She said if Resident #6 experienced her triggers, she could cry, become aggressive, or be retraumatized. During an interview on [DATE] at 3:04 p.m., the DON said all the staff were responsible for providing the resident with trauma informed care. She said Resident #6 should have been assessed for her triggers related to her PTSD diagnosis. She said one of the interventions would be to make sure Resident #6 only had female caregivers. She said it was important to care plan Resident #6's PTSD diagnosis to avoid triggers. She said she interviewed Resident #6 before admission to the facility. She said Resident #6 told her she did not want male CNAs. She said when a resident's PTSD diagnosis was not care planned, the facility staff could cause triggers. She said the resident could experience emotional distress. During an interview on [DATE] at 5:02 p.m., the ADM said she would expect a resident who experienced trauma or had a PTSD diagnosis to have a trauma informed care plan. She said the SS was responsible for completing the trauma assessment. She said the current SS was not employed at the facility when Resident #6's trauma assessment was completed. She said the previous SS should have notified the MDS Coordinator and DON of Resident #6's trauma assessment results. She said Resident #6's PTSD diagnosis should have been care planned so everybody knew her triggers and to avoid those triggers. She said if Resident #6 experienced her triggers, it could have been horrific. She said Resident #6 could have experienced emotional distress or behaviors. She said the MDS Coordinator was responsible for overseeing this process by doing audits. Record review of a facility's Trauma Informed Care policy revised on 3/2019 indicated, .to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma.As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools. Record review of a facility's Care Plans, Comprehensive Person-Centered policy revised on 12/2016 indicated, .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. incorporate identified problem areas.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 16 residents (Resident #31 and Resident #26) reviewed for pharmacy services. The facility failed to ensure Resident #31's Claritin (Loratadine) order had a dosage for administration. The facility failed to ensure RN B documented the medication order change for Resident #26's Folic Acid 400 MCG to 1000MCG on 8/12/25, which resulted in RN B documenting administration of the wrong medication dosage on the MAR. These failures could place residents at risk for inaccurate drug administration.Findings included: 1. Record review of Resident #31's face sheet dated 8/13/25 indicated Resident #31 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #31 had diagnoses including chronic obstructive pulmonary disease (is a lung condition that obstructs airflow, making it difficult to breathe) and dyspnea (shortness of breath). Record review of Resident #31's quarterly MDS assessment dated [DATE] indicated Resident #31 was understood and had the ability to understand others. Resident #31 had a BIMS score of 12 which indicated moderate cognitive impairment. Record review of Resident #31's care plan dated 6/28/25 indicated Resident #31 had oxygen therapy. Intervention included give medications as ordered by physician. Record review of Resident #31's consolidated physician order dated 8/13/25 indicated Claritin Oral Tablet (Loratadine), give 1 tablet by mouth, one time a day for allergies. Ordered date 5/27/25. Resident #31's physician order did not reflect a MG dose of Claritin to administer. Record review of Resident #31's MAR dated 8/1/25-8/31/25 indicated Claritin Oral Tablet (Loratadine; is an antihistamine that prevents and treats allergy symptoms), give 1 tablet by mouth, one time a day for allergies. Resident #31 received 12 out of 13 scheduled doses. 2. Record review of Resident #26's face sheet dated 8/13/25 indicated Resident #26 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #26 had diagnoses including nutritional anemia (is a condition where a lack of essential nutrients in the diet leads to a decrease in red blood cell production or function, causing a deficiency in oxygen delivery to the body) and vitamin deficiency (occurs when the body doesn't receive enough of a vital vitamin). Record review of Resident #26's quarterly MDS assessment dated [DATE] indicated Resident #26 was understood and had the ability to understand others. Resident #26 had a BIMS score of 15 which indicated intact cognition. Record review of Resident #26's care plan dated 8/14/23 indicated Resident #26 had a vitamin/mineral deficiency. Intervention included administer medications as ordered by MD. Record review of Resident #26's consolidated physician order dated 8/13/25 indicated Folic Acid Oral Tablet (is used for preventing and treating low blood levels of folate (folate deficiency)), give 1000 mcg by mouth one time a day for supplement. Ordered date 8/12/25. Start dated 8/13/25. Record review of Resident #26's MAR dated 8/1/25-8/31/25 indicated:*Folic Acid Tablet 400 MCG, give 1 tablet by mouth one time a day related to osteoarthritis (is a common joint disease where cartilage breaks down, leading to pain, stiffness, and swelling in affected joints). Discontinued 8/12/25 at 11:42 a.m. The MAR indicated RN B administered 400 MCG on 8/12/25 at 7:00 a.m. * Folic Acid Oral Tablet, give 1000 mcg by mouth one time a day for supplement. The MAR indicated the first dose was administered on 8/13/25 at 8:00 a.m. During an observation on 8/12/25 at 8:01 a.m., RN B showed a 1000 MCG bottle of Folic Acid and stated she had received a new order from the physician but had not changed the order yet. RN B administered 1 tablet of Folic Acid 1000 MCG to Resident #26. On 8/13/25 at 12:39 p.m., attempted to contact RN B by phone. A voicemail was left for a return call. During an interview on 8/13/25 at 2:00 p.m., the ADON A said the physician order needed the resident and medication name, route, dose, and frequency. She said a medication should not be given without a complete order. She said the wrong dose could be given. She said the resident could be under and over dosed. She said everybody who looked at Resident #31's Claritin order was responsible for getting the dose to administer. She said before administering a medication, the nurses should follow the 6 rights of medication administration. She said the DON, ADON, and Pharmacy consultant were responsible for ensuring the nurses inputted complete physician's orders. She said they monitored this process by doing chart audits. She said RN B should have administered Resident #26's current medication order until the new physician order had been placed in the charting system. She said RN B's documentation of Resident #26 MAR was inaccurate. She said RN B should have documented the dose she administered. She said the resident needed an accurate record of administration. She said when the documentation was inaccurate, the MD would not be able to accurately assess the resident's needs. She said the ADON and DON were responsible for ensuring the nurse had accurate documentation. She said they monitored this process by daily chart audits and reviewing the 24-hour report for new orders. During an interview on 8/13/25 at 3:04 p.m., the DON said she expected Resident #31's Claritin order to have a dose. She said a dose on the physician order ensured the resident received the accurate amount of medication for the issue. She said the nurse who received Resident #31's order for Claritin was responsible for ensuring it included a dose amount. She said Resident #31 would not have too many negative effects from receiving Claritin without a dose since it was an allergy medication. She said Resident #31 could have experienced negative effects from receive other type of medications without a dose amount. She said she was responsible for ensuring the nurses received and placed accurate physician orders in the resident's chart. She said she did this process by reviewing orders during morning stand up meetings. She said she expected RN B to discontinue Resident #26's 400 MCG order and place the new order for the 1000 MCG in the system. She said RN B should then have documented on the 1000 MCG Folic Acid order. She said documenting on the 400 MCG order but giving 1000 MCG was not accurate documentation and could be considered a medication error. She said an accurate medication administration record was important so everyone knew what the resident was taking. She said it was important to know which dose was taken to monitor for any adverse reactions and which dose was received for the resident's medical record. She said the ADON and DON were responsible for ensuring the nurse had accurate documentation. On 8/13/25 at 4:53 p.m., attempted to contact the CP P by phone. I was unable to leave a message because the mailbox was full. During an interview on 8/13/25 at 5:02 p.m., the ADM said she expected the nursing staff to document the medication they administered. She said it was important to have accurate documentation so if any adverse reaction occurred, they would know where to start. She said it would be detrimental to the resident if they received too much or not enough of a medication. She said the nurse who received the physician order should have ensured the MG dose was specified. She said also any nurse that noticed the medication did not have a MG dose specified, should have notified someone for clarification. She said Claritin only came in a certain MG dose, but some medications came in different MG doses. She said it was important to know the exact amount the physician wanted administered. She said the ADON and DON should ensure the nurses were documenting accurately and receiving complete orders. She said they should be monitoring this process by doing chart/order audits. During an interview on 8/15/25 at 1:10 p.m., RN B said the DON preferred to do the initial or admission physician orders. She said the floor nurse could also put in physician orders. She said the physician orders should have the MG dose to make sure the right dose was administered. She said the 5 rights of drug administration should be followed. She said Resident #31's Claritin order should have the MG dose because the facility may not be given what the physician wanted and it was important to keep the residents safe. She said she should have discontinued Resident #26's Folic Acid 400 MCG, inputted the 1000 MCG order, then administered and documented on the 1000 MCG order. She said it was important for the documentation to be correct to reflect and match the new physician order. She said when the documentation did not reflect the physician order, it could be considered a medication error. Record review of a facility's Administering Medications policy dated 4/2019 indicated, .the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication.As required or indicated for a medication, the individual administering the medication records in the resident's medical record. The date and time the medication was administered. The dosage.

Based on observations, interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities and to ensure the attending physician documented in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it in response to the pharmacist report for 1 of 5 residents (Resident #35) reviewed for (MRR) Medication Regimen Review. The facility failed to ensure Resident #35's Medication Regimen Review dated 4/30/25, had a specific duration for the extended duration beyond 14 days of PRN Ativan (Lorazepam). This failure could place residents at risk from maintaining their highest practicable level of physical, mental, and psychosocial well-being, and could place them at risk for adverse consequences related to medication therapy. Findings included: Record review of Resident #35's face sheet dated 8/12/25 indicated Resident #35 was an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #35 had diagnoses including dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (repeated episodes of sudden feelings of intense anxiety), and heart failure (is a condition where the heart cannot pump enough blood and oxygen to meet the body's needs). Resident #35 was on a local hospice service. Record review of Resident #35's quarterly MDS assessment dated [DATE] indicated Resident #35 usually understood and usually had the ability to understand others. Resident #35 had clear speech, moderate difficulty hearing and impaired vision. Resident #35's BIMS score was 2 which indicated severely impaired cognition. Resident #35 experienced inattention and disorganized thinking. The MDS assessment did not reflect use of an antianxiety medication during the last 7 days. Resident #35 received hospice care. Record review of Resident #35's care plan dated 6/16/25 indicated Resident #35 had a mood problem related to anxiety disorder. Resident #35 currently taking Lorazepam (is used to treat anxiety disorders). On 6/9/25, per MD regarding end date for Lorazepam: Medication was needed for end-of-life care. DO NOT STOP MED Intervention included administer medications as ordered. Monitor/document for side effects and effectiveness. Record review of Resident #35's consolidated physician order dated 8/12/25 indicated Lorazepam Oral Concentrate 2MG/ML, give 0.25 ml by mouth every 4 hours as needed for anxiety related to anxiety disorder. Per MD, Do Not Stop Medication it is needed for End-of-Life Care. Ordered date 6/6/25. Record review of Resident #35's Nurse Administration Record dated 8/1/25-8/31/25 indicated Lorazepam Oral Concentrate 2MG/ML, give 0.25 ml by mouth every 4 hours as needed for anxiety related to anxiety disorder. Per MD, Do Not Stop Medication it is needed for End-of-Life Care. The NAR did not reflect any administration. Record review of Resident #35's Treatment Administration Record dated 8/1/25-8/31/25 indicated Lorazepam antianxiety medication behavior monitoring. The TAR did not reflect Resident #35 experienced anxious/nervous related to terminal illness. Record review of Resident #35's MRR dated 4/30/25 indicated, .this resident [Resident #35] is currently receiving the following psychotropic (Non Antipsychotic) medication on a PRN basis : ATIVAN.per regulatory guidelines, the duration of treatment with such medications on a PRN basis should be limited to 14 days, however, a new order may be written to extend the duration beyond 14 days if the prescriber believes it is appropriate. please evaluate the continued need for this medication. If it is to be extended. please document the rationale for the extended time period in the medical record and indicate a specific duration.CP P.Physician/Prescriber Response.Medication is needed for end-of-life care.Do Not Stop Med.MD O.6/6/25. Record review of Resident #35's progress notes dated 6/1/25-8/12/25 did not reflect Resident #35 had experience anxious/nervous related to terminal illness. During an interview and observation on 8/11/25 at 10:30 a.m., Resident #35 was sitting up in his bed. Resident #35 was watching television and appeared comfortable. Resident #35 displayed inattention and disorganized thinking when interviewed. Resident #35 was pleasant and did not appear anxious. Resident #35 only had questioned related to an investigation about his missing money. During an observation on 8/11/25 at 3:06 p.m., Resident #35 was sitting up in his bed. Resident #35 was watching television and appeared comfortable. During an observation on 8/12/25 at 7:42 a.m. Resident #35 was sitting up in his bed. Resident #35 was eating breakfast and appeared comfortable. During an observation and interview on 8/12/25 at 3:00 p.m., Resident #35 was sitting up in his bed. Resident #35 was watching television and appeared comfortable. Resident #35 was pleasant and did not appear anxious. Resident #35 only had questioned related to an investigation about his missing money. During an interview on 8/13/25 at 2:00 p.m., the ADON A said she had been back at the facility full time for a week. She said the MRR form was sent to the physician or the information was relayed by text. She said the DON was responsible for ensuring the MD responded to the MRR appropriately. She said but whoever received the MRRs that month would be responsible for them. She said the DON and ADON should have made sure MD O addressed both parts of the request to extend Resident #35's Lorazepam prn order. She said the prn medication needed to be 14 days or rationale provided with a specific date to prevent adverse reactions and over medication. She said the DON and ADON oversaw the MRR process. She said the CP P also reviewed the MRR responses from the physicians. During an interview on 8/13/25 at 3:04 p.m., the DON said she was responsible for the resident's MRRs. She said she felt like end of life was the specified duration for Resident #35's MRR form. She said the 14 days and specified duration was to monitor for the continued need or use of the prn medication. She said the CP P reviewed the MRRs forms the next month for compliance. She said CP P did not mention MD O response not addressing the Resident #35's MRR request. On 8/13/25 at 4:53 p.m., attempted to contact the CP P by phone. The Surveyor was unable to leave a message because the mailbox was full. During an interview on 8/13/25 at 5:02 p.m., the ADM said MD O responded to Resident #35's MRR how he felt like the appropriate response was. She said what could the facility really do. She said the stop date on prn medications were important so it did not get overlooked. She said the prn medication needed to be reviewed in case it needed to be changed. She said the DON was responsible and oversaw the MRR process. Record review of a facility's Medication Regimen Reviews policy revised 5/2019 indicated, .the MRR involves a thorough review of the resident's medical record to prevent, identify, report and re- solve medication related problems, medication errors and other irregularities.an irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. it may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences.if the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #8) of 16 residents reviewed for infection control. The facility failed to ensure LVN C did not place Resident #8 feeding tubing, in his bed during g-tube medication administration on 8/12/25. This failure could place a resident at risk for an infection. Findings included:Record review of Resident #8's face sheet dated 8/12/25 indicated Resident #8 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 had diagnoses including cerebral palsy (is a group of conditions that affect movement and posture), paraplegia (is paralysis that affects your legs, but not your arms), abnormal posture, contractures (is a type of scarring in your soft tissues that causes them to tighten and stiffen), and artificial openings of gastrointestinal tract status. Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated Resident #8 was usually understood and had the ability to understand others. Resident #8 had unclear speech, adequate hearing, and impaired vision with corrective lenses. Resident #8 had a BIMS score of 99 which indicate the resident was unable to complete the interview. Resident #8 had short term memory call problem and moderately impaired cognitive skill for daily decision making. Resident #8 was dependent for ADLs. Resident #8 had a feeding tube while a resident and received 51% or more of total calories from tube feeding. Record review of Resident #8's care plan dated 5/9/24 indicated Resident #8 required an alternate method of nourishment due to nothing by mouth status and required use of feeding tube. Intervention included g-tube site (is a feeding tube inserted through the abdomen into the stomach) assessed every shift and notify MD of signs and symptoms of infection. During an observation on 8/12/25 at 9:00 a.m., LVN C disconnected Resident #8 feeding tubing from the g-tube site. LVN C placed the feeding tubing directly on the bed, towards the foot of the bed. LVN C checked Resident #8's residual and g-tube placement. LVN C reattached the feeding tubing to the g-tube. LVN C prepped her medication for administration. LVN C disconnected Resident #8's feeding tubing from the g-tube site. LVN C placed the tubing on the bed, near his chest and arm area. The tip of the feeding tubing was visualized touching the bed sheets. After medication administration, LVN C reconnected the feeding tubing to Resident #8's g-tube site and restarted the enteral feedings. During an interview on 8/12/25 at 2:06 p.m., the DON said the nursing staff should store the feeding tubing, when it was disconnected from the resident, where it could be kept clean. She said the tubing should not be placed on the bed or hanging in the wind. She said the nursing staff could use the cap that came with the feeding syringe to cover it. She said the facility's policy and procedure did not specify, not to lay it on the bed. She said it was best practice to store the tubing in a clean environment. She said if Resident #8's tubing was placed in the bed and reattached to the resident, it needed to be discarded. During an interview on 8/13/25 at 2:00 p.m., the ADON A said the resident's feeding tubing needed to be recapped when it was not in use. She said Resident #8's feeding tubing should not have been placed in his bed. She said the feeding tubing should not have been laid in the bed to prevent infection to the g-tube site. She said if the resident developed an infection, they could require antibiotics, hospitalization, and additional care. She said the ADON and DON were responsible for ensuring the nurses used infection control precautions during medication administration. She said they monitored this process by doing checkoff with the nursing staff. She said checkoffs were done upon hire, annual, and after an event where reeducation was needed. During an interview on 8/13/25 at 3:03 p.m., LVN C said she should have placed Resident #8's feeding tubing in a clean environment on 8/12/25. She said she could have placed the tip of the feeding tubing in the flush bag. She said she should not have placed it on the bed because it was an infection control issue. She said the g-tube that the feeding tube went into, was in the body. She said she did not want to put an infection in the body through the g-tube. She said if the resident developed an infection, they could experience a fever, an increase in white blood cells, and lower their immune system. She said the resident could require antibiotic, probiotics, and hospitalization. She said she had been checked off on g-tube medication administration and infection control. During an interview on 8/13/25 at 3:04 p.m., the DON said a resident's feeding tubing should be stored in a clean environment when disconnected, like previously stated. She said the nurses were responsible for ensuring infection control measures were done during medication administration. She said those measures needed to be followed to decrease the potential for causing an infection. She said if the resident developed an infection, they could require antibiotics. She said the facility ensured the nursing staff were competent in g-tube medication administration by doing check offs and in-services. She said these were done annually and after incidents with periodical follow ups. During an interview on 8/13/25 at 5:02 p.m., the ADM said she would expect the nursing staff to place a cap on the end or hanging the resident's feeding tubing when not in use. She said doing those things would prevent the potential for an infection. She said if a resident developed an infection, they could need antibiotics or some type of treatment. She said the nursing management ensured the nursing staff were competent by doing annual check offs. Record review of LVN C's Medication Pass Competency dated 2/24/25 indicated LVN C was satisfactory on infection control and enteral tube medication administration. LVN C was checked off by the DON. Record review of a facility's Administering Medication through an Enteral Tube policy revised 11/2028, indicated, .the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. remove the syringe and clamp tubing.place the end of the tubing on a clean gauze pad positioned on the abdomen or chest of the resident. Record review of the facility's Infection Prevention and Control Program Policy, dated 10/2018, indicated, .an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.

Based on observation, interview, and record review the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practices for 1 of 5 residents (Resident #31) reviewed for respiratory care. The facility failed to ensure Resident # 31's internal filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) was free of white/yellow, fuzzy particles. This failure could place residents at risk for respiratory infections.Findings included: Record review of Resident #31's face sheet dated 8/13/25 indicated Resident #31 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #31 had diagnoses including heart failure (is a condition where the heart can't pump enough blood to meet the body's needs for oxygen and nutrients), chronic obstructive pulmonary disease (is a lung condition that obstructs airflow, making it difficult to breathe) and dependency on supplemental oxygen. Record review of Resident #31's quarterly MDS assessment dated [DATE] indicated Resident #31 was understood and had the ability to understand others. Resident #31 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #31 received oxygen therapy. Record review of Resident #31's care plan dated 6/28/25 indicated Resident #31 had oxygen therapy. Intervention included oxygen settings: oxygen via nasal cannula at 2-3 liters per minute. Record review of Resident #31's consolidated physician order dated 8/13/25 indicated change respiratory tubing, mask, bottled water, and clean filter every 7 days, every night shift, every Sunday. Ordered date 12/27/24. Record review of Resident #31's nurse administration record dated 8/1/25-8/31/25 indicated:*Oxygen at 3 liters per minute via nasal cannula during daytime, with ambulation and while resting and 2.5 liters per minute via nasal cannula at hour of sleep every shift for Chronic Obstructive Pulmonary Disease. *Change respiratory tubing, mask, bottled water, and clean filter every 7 days, every night shift, every Sunday. During an observation on 8/11/25 at 11:23 a.m., Resident #31 was sitting in her recliner with a nasal cannula connected to an oxygen concentrator. Resident #31's internal filter vent had a moderate amount of white/yellow, fuzzy particles. During an observation on 8/12/25 at 7:40 a.m., Resident #31 was sitting in her recliner with a nasal cannula connected to an oxygen concentrator. Resident #31's internal filter vent had a moderate amount of white/yellow, fuzzy particles. During an interview on 8/13/25 at 2:00 p.m., the ADON A said the oxygen company was responsible for the internal filters on the oxygen concentrators. She said the DON and ADON were responsible for notifying the oxygen company. She said the nurses changed the resident's oxygen equipment and cleaned the filters on Sundays. She said having an oxygen concentrator filter with dust was not good because the resident would be breathing it in. She said it could cause respiratory issues. During an interview on 8/13/25 at 2:42 p.m., LVN D said the nurses should notify the DON if they were unable to clean the resident's oxygen concentrator filter. She said the nurses were responsible for the oxygen filter when everything was changed on Sunday nights. She said a dirty oxygen filter affected the air quality. She said a dirty filter placed the resident at risk for a respiratory infection and breathing problems. She said if a resident developed a respiratory infection or experienced breathing problems, they could need antibiotics or hospitalization. During an interview on 8/13/25 at 3:04 p.m., the DON said the nurses were responsible for notifying the maintenance worker and DON when the internal oxygen filter needed to be cleaned. She said it was important to receive clean and the right amount of oxygen. She said if the internal oxygen filter was clogged with dust particles, it placed the resident at risk for not getting the right amount of oxygen. She said this could cause decrease oxygen intake, increase work of breathing and affect the resident's respiratory status. She said maintenance was overall responsible for the oxygen concentrator internal filters. She said maintenance should ensure the cleanliness of the internal filters by rounding. During an interview on 8/13/25 at 5:02 p.m., the ADM said the oxygen company was responsible for the internal oxygen concentrator filters. She said the nurses should check the internal filters every Sunday and notify the DON when it needed to be cleaned. She said an unclean oxygen filter could lead to an infection. She said the resident could then need antibiotics or hospitalization. She said the ADON and DON should ensure the nurses were cleaning and checking the internal and external filters every Sunday by rounding. Record review of a facility's Oxygen Administration policy revised 10/2010 indicated, .the purpose of this procedure is to provide guidelines for safe oxygen administration.report other information in accordance with facility policy and professional standards of practice. Record review of a facility's Departmental (Respiratory Therapy)- Prevention of Infection policy revised 11/2011 indicated, .the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment. wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols for 6 of 6 months (January 2024 through June 2024) reviewed for Infection Control Tracking and Trending. -The facility did not implement the antibiotic orders protocol in their Antibiotic Stewardship policy. -The facility had missing information on the Tracking and Trending Logs as to the outcome of the antibiotic use (if the infections were resolved or not). -The facility did not implement the 72-hour Antibiotic Time Out protocol in their Antibiotic Stewardship program. These failures could place residents with infections at risk for unnecessary antibiotic use and increased infections that are resistant to antibiotics. Findings included: Record review of the Antibiotic Stewardship Policy revised 02/2022 indicated Goals: Prescribers will document a dose, duration, and indication for all antibiotic usage. Policy: Antibiotic Stewardship Program (ASP) Core Elements: 5. Tracking: The Facility monitors at least one process measure of antibiotic use and at least one outcome or training in antibiotic use: a. Process Measure: Medical records are reviewed when a new antibiotic is started to determine whether the clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices Antibiotic Stewardship Protocols: 4. Antibiotic Time Out: d. Infection Preventionist or other designated member of the Facility nursing staff notifies the ordering provider of the 3-day expiration and requirement for Antibiotic Time Out: 1. Provider may consult Infectious Disease provider and eliminate need for the Time Out Process. ii. Provider may complete Antibiotic Time Out telephonically with member of the Antibiotic Stewardship Team or clinical designee. iii. If provider fails to complete the Antibiotic Time Out on or prior to Day 3 of treatment, the Antibiotic Stewardship Team in collaboration with Pharmacy Consultant and Medical Director, may complete the process and determine the appropriateness and effectiveness of continuing or discontinuing the medication. Any actions require a valid and complete physician's order. Record review of the Infection Control Tracking and Trending Log for January 2024 to June 2024 indicated the following: -January 2024- 1. Log had no indication of 72-hour time out review and no indication of infection resolution. 2. A physician order for antibiotics prior to culture on 01/12/2024. -February 2024 1.Log had no indication of 72-hour time out review and no indication of infection resolution. 2. Log has no indication of cultures for infections. -March 2024- 1. There was no indication of 72-hour time out review and no indication of infection resolution. 2. Logs were missing information about antibiotic indications (signs and symptoms of infection) and cultures. -April 2024- 1. There was no indication of 72-hour time out review and no indication of infection resolution. 2. Logs were missing information about antibiotic indications and cultures. -May 2024- 1. There was no indication of 72-hour time out review and no indication of infection resolution. 2. Logs were missing information about antibiotic indications and cultures. -June 2024- 1. There was no indication of 72-hour time out review and no indication of if infections were resolved. During an interview on 06/05/2024 at 10:20 a.m., the IP stated she would bring the tracking and trending for infection control, but it was not completed, and it was behind several months. The IP stated she had been working the floor as a CNA on the secured unit at night and had not had time to keep it up. The IP stated it was the duty of IP to keep up with the tracking and trending on a weekly basis to ensure it was done. The IP stated it was important for antibiotic usage to be kept at a minimum to decrease resistance. The IP stated she would add the 72-hour antibiotic time out to the tracking log and she would continue to encourage the MD to follow the antibiotic stewardship guidelines of culturing and not prescribing broad spectrum antibiotics prior to the culture if symptoms are mild. The IP stated overuse of antibiotics can cause superbugs and resistant strands of common bacteria which are harder for the elderly population to fight off and could lead to illness and even death. During an interview on 06/05/2024 at 2:30 p.m., the ADM stated it was the nursing department's job to ensure all the antibiotic stewardship program was being conducted correctly. The ADM stated the IP had been stretched thin by having to work the floor several shifts over the last several months, but it was ultimately their responsibility to ensure it was complete and correct. The ADM stated not following the facility policy and state guidelines for antibiotic stewardship could lead to more serious infections for the residents that are already susceptible to infections. Record review of the CDC's Core Elements of Antibiotic Stewardship for Nursing Homes Appendix A: Policy and practice actions to improve antibiotic use accessed on 06/06/2024 at https://www.cdc.gov/antibiotic-use/core-elements/nursing-homes.html. Antibiotic prescribing and use policies: Documentation of dose, duration, and indication. Specify the dose (including route), duration (i.e., start date, end date, and planned days of therapy), and indication, which includes both rationale (i.e., prophylaxis vs. therapeutic) and treatment site (i.e., urinary tract, respiratory tract), for every course of antibiotics. This bundle of antibiotic prescribing elements should be documented for both nursing home-initiated antibiotic courses as well as courses continued in the nursing home which were initiated by a transferring facility or emergency department. Documenting and making this information accessible (e.g., verifying indication and planned duration is documented on transfer paperwork) helps ensure that antibiotics can be modified as needed based on additional laboratory and clinical data and/or discontinued in a timely manner Broad interventions to improve antibiotic use: Perform antibiotic time outs. Antibiotics are often started empirically in nursing home residents when the resident has a change in physical or mental status while diagnostic information is being obtained. However, providers often do not revisit the selection of the antibiotic after more clinical and laboratory data (including culture results) become available. An antibiotic time out is a formal process designed to prompt a reassessment of the ongoing need for and choice of an antibiotic once more data is available including: the clinical response, additional diagnostic information, and alternate explanations for the status change which prompted the antibiotic start. Nursing homes should have a process in place for a review of antibiotics by the clinical team two to three days after antibiotics are initiated to answer these key questions: o Does this resident have a bacterial infection that will respond to antibiotics? o If so, is the resident on the most appropriate antibiotic(s), dose, and route of administration? o Can the spectrum of the antibiotic be narrowed or the duration of therapy shortened (i.e., de-escalation)? o Would the resident benefit from additional infectious disease/ antibiotic expertise to ensure optimal treatment of the suspected or confirmed infection?

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 14 residents (#35, #36, #3 and #6) reviewed for infection control practices. 1.The Facility failed to ensure Resident #35 and #36 had wash basins stored properly with names and in bags. 2. The facility failed to ensure wipes with feces were properly discarded and were left on Resident #3 and #6's bedroom floor. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #35's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis included: unspecified dementia (dementia without a specific diagnosis), restlessness and agitation (agitation is a normal emotion) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #35 rarely understood and rarely understands others. The MDS indicated the BIMS assessment was not completed for Resident #35, due to cognitive function. The MDS indicated Resident #35 was dependent with ADL's. Record review of undated care plan indicated Resident #35 had impaired cognitive function dementia or impaired thought processes related to diagnoses of dementia severe and Alzheimer's disease. Record review of Resident #36's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis included: unspecified dementia (dementia without a specific diagnosis), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and Parkinson's disease (a disorder of the central nervous system that effects movement). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #36 was usually understood and usually understands others. Resident #36 was not able to complete the MDS assessment. The MDS indicated Resident #35 was dependent with ADL's. Record review of undated care plan indicated Resident #36 was monitored for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis and somnolence. Make sure call light was within reach and encourage the resident to use for assistance as needed. During observations on 06/04/24 at 3:01 PM in Resident #35 and Resident #36's bathroom was three wash basins in the bathtub without names and not in bags. Record review of Resident #3's face sheet indicated she was a [AGE] year-old male initially admitted to the facility on [DATE] with a diagnosis included: moderate protein-calorie malnutrition (protein-energy undernutrition), muscle weakness (a lack of strength in the muscles) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #3 was sometimes understood and sometimes understands others. The MDS assessment was not completed for Resident #3. The MDS indicated Resident #3 was dependent with ADL's. Record review of undated care plan indicated Resident #3 prefers to crawl on the floor in his room for mobility (per sister-this is what he did at home when he wanted to be in the floor recently, staff will monitor for signs and symptoms that he wants down on the floor). Ensure fall mat is in place on the floor for resident to crawl on to prevent injuries. Staff to assist resident as needed. Record review of Resident #6's face sheet indicated she was a [AGE] year-old male initially admitted to the facility on [DATE] with a diagnosis included: vascular dementia (brain damage caused by multiple strokes), paraplegia (paralysis of the legs and lower body) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #6 sometimes make self-understood and usually understands others. The MDS revealed Resident #6 had BIMS score of 11, which indicated moderate cognitive impairment. The MDS indicated Resident #6 was dependent with ADL's. Record review of undated care plan indicated Resident #6 revealed: Toileting: provide incontinent care with each episode and as needed. Toileting use: Resident is dependent on staff with toileting. Toileting: May use perineal wipes. Toileting: Resident is totally incontinent of his bowels and needs to be checked every 2 hours and as needed. Toileting: Resident requires assistance from 1 staff to toilet. He is bed bound and all care is anticipated and provided per staff. During observations on 06/05/24 at 9:17 AM in Resident #3 and Resident #6 room there were dirty wipes on the floor with brown feces on them. The odor from the wipes was foul with Resident #3 and Resident #6 in their room lying in bed. During an interview on 6/05/2024 at 11:20 AM with CNA I said she had witnessed a lot of the residents did not have their names on their wash basins in their bathrooms and the basins were not in bags. She said most of the time she tried to put the wash basins in bags and put their names on them. She said she really could not say what it can cause, because she did not use them. She said she only gave showers. She said using the same wash pan on a different residents could be an infection control issue. During observations and interview on 6/05/2024 at 11:55 AM the Maintenance man observed wipes with feces on Resident #3 and Resident #6's floor in bedroom. Resident # 6 was sitting up in bed eating lunch. The wipes with feces had a foul odor in the room. Maintenance man said that was unacceptable. He said expected for housekeeping to disinfect the front lobby, the dining area, then they should be cleaning the resident's room. He said housekeeping should ask permission to enter the resident's room and notify the resident what they were in the room for. He said had three housekeepers; 2 on a shift; one does the North end and the other does the South end of the facility. During an interview on 6/05/2024 at 2:58 PM with DON she said the CNA's know they are supposed to be labeling the resident's wash basins with their names and placing them in bags. She said using the same wash basins with residents was cross contamination and could cause a major infection control issue. She said she expect when the CNA's performed incontinent care on residents the trash should be properly disposed of and wipes with feces should not be left on resident's floor. The DON said that the wipes were left on the floor was unacceptable. During an interview on 6/05/2024 at 3:18 PM with the Administrator she said except the CNA's to do their jobs and dispose of trash in the correct manner. She said she expected the housekeepers to keep this facility clean like it was the President's house. She said everyone had a job to do and not keeping facility cleaned thoroughly was not acceptable. Record review of the facility Infection Prevention and Control Program Policy, date October 2018, revealed .an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary. Record review of the facility Homelike Environment Policy, dated February 2021 revealed .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Record review of the facility Resident Rights Under Federal Law Policy undated, revealed . the resident has the right to reasonable accommodation of individual needs and preferences except where the health and safety of the resident or other residents would be endangered.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 17 residents reviewed for environment. (Residents #9, #35, #36, #16, and #7) The facility failed to ensure Resident #35 and Resident #36 had a clean room free from dust and dead roaches. The facility failed to repair Resident #9 ceiling tiles in room with water spots, due to water damage. The facility failed to ensure Resident #16's room was free of roaches. The facility failed to ensure Resident #7's room was free of water bugs. The facility failed to repair the ceiling in hall by the dining area. The facility had a trash can catching rainwater. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings included: Record review of Resident #35's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnosis included: unspecified dementia (dementia without a specific diagnosis), restlessness and agitation (agitation is a normal emotion) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #35 rarely understood others and was rarely understood by others. The MDS BIMS assessment was not completed for Resident #35. The MDS indicated Resident #35 was dependent with ADL's. Record review of an undated care plan indicated Resident #35 had impaired cognitive function dementia or impaired thought processes related to diagnoses of dementia severe and Alzheimer's disease. Record review of Resident #36's face sheet indicated she was a [AGE] year-old female initially admitted to the facility on [DATE] with a diagnoses included: unspecified dementia (dementia without a specific diagnosis), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and Parkinson's disease (a disorder of the central nervous system that effects movement). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #36 was usually understood and usually understood others. Resident #36 was not able to complete the BIMS assessment. The MDS indicated Resident #35 was dependent with ADL's. Record review of undated care plan indicated Resident #36 was monitored for signs and symptoms of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath at rest, cyanosis (is a condition that causes the skin, lips or nails to turn blue or purple due to low oxygen levels in the blood)and somnolence (drowsiness). Make sure call light was within reach and encourage the resident to use for assistance as needed. During observations on 06/04/24 at 8:47 AM in Resident #35's room, the resident was lying in bed looking around. Two dead roaches were next to Resident #35's fall mat that was beside the bed. When exiting the resident's room observed Resident #36's bed faced toward the opened closet. On the closet floor were two dead roaches on their backs surrounded by hair and dust. Record review of Resident #9's face sheet indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] with a diagnoses included: multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) and unspecified disorder of nose and nasal sinuses (diseases of the respiratory system). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #9 was understood by others and understood others. The MDS assessment indicated Resident #9 had a BIMS score of 15 which indicated her cognition was intact. The MDS indicated Resident #9 was independent with ADL's. Record review of undated care plan indicated Resident #9 found these measures to be calming and to relieve risk of re-trauma: speak in a calm, non-threatening manner while working with resident. Establish and maintain a trusting relationship by listening to the client. She likes to be in her room alone at times where it is quiet. She voices that she does not have any lingering trauma from previous traumas. During observation and interview on 06/03/24 at 10:53 AM revealed in Resident #9 room there were dark and light brown water spots on the resident's ceiling tiles. The spots were noted in Resident #9's room and in bathroom. Resident #9 said the spots had been there for a while and when she complained about them the facility would paint over them with some white paint, but when it rained the spots showed up in different areas. Resident #9 said she did not like the spots on the ceiling and with tiles getting wet by rain that could cause mold and respiratory issues. During an interview on 6/05/2024 at 11:20 AM CNA I said the water spots on the facility's ceiling was a concern, because with the ceiling getting wet could cause the pieces to fall and hit someone. During observation and interview on 6/05/2024 at 11:48 AM with Resident #9 she said she told management of the facility that fungus grew in wet areas and it could cause health issues, due to the ceiling tiles getting wet when it rained. During an interview on 6/05/2024 at 11:55 AM with the Maintenance man he said pest control came and sprayed last 5/30/24. He said the chemical pest control spray brought the bugs out, that was why the roaches were observed dead on the floors. He said pest control came once a month to spray the facility. He said he expected for housekeeping to disinfect the front lobby, the dining area, then they should clean the resident's room. He said housekeeping should ask permission to enter a resident's room and notify the resident what they were in the room for. He said he did feel like the roof leak was a hazardous issue. He said the facility was in the process of getting a new roof. He said the facility had already gotten the roof approved. He said when it rained the roof leaked and got the tile pieces in the ceiling wet. He said since the ceiling pieces got wet they could get heavy, and fall and hit someone. Review of an invoice from the local pest control company dated 5/30/2024 revealed services were rendered. During an interview on 6/05/2024 at 11:30 AM Resident #16 said he saw roaches all the time in his room and all over the bathroom. Resident #16 said the roaches would be on the walls and carried germs. Resident #16 said those roaches can bite and they are very nasty. Resident #16 said the raining in the facility was dangerous, because the sheet rock crumbling and falling was dangerous. He said the tile pieces in the ceiling could fall and hurt someone also. During an interview on 6/05/2024 at 12:22 PM with Resident #7 he said he had water bugs in his room all the time. He said the water bugs came out at night. He said water bugs were all in the hallways. He said he thought the water bugs were very nasty. He said he did not like seeing the bugs and he tried to kill them. During an interview on 6/05/2024 at 12:24 PM with Resident #27, she said she saw roaches running around the facility all the time. She said she tried to kill them. She said roaches were not very sanitary. She said she did not like the roaches running around the facility. Resident #27 said she had a lot of water spots in her room and they moved her into another room while they fixed the roof. She said a piece of the ceiling fell and hit her while she was lying in bed. She said she did not get hurt and it just felt like a wet sponge hit her. She said it happened a while back. During an interview on 6/05/2024 at 1:33 PM with Housekeeper K, she said yes, she had seen a lot of cockroaches when cleaning that hall . She said she did not hear the residents complain about the roaches. She said she would not want the roaches running around in her house. She said she did not think it was sanitary for the roaches to be running around the facility. She said the tiles in the top of the ceiling have fallen down when it rained. She said she felt like wet tiles in the ceiling were a hazard, because anyone could get hit on the head from the pieces if they fell . She said a resident had been hit by wet tiles from the ceiling before. During an interview on 6/05/2024 at 1:50 PM with LVN G, she said she seen a lot of water bugs in the resident's room. She said she had seen the exterminator at the facility, but she did not think the chemical they used worked well. She said it would not make her feel good if she had lived in the facility with bugs and it needed to be taken care of. She said the ceiling leaked all the time. She said a roof guy came a couple months ago and did some repairs to the roof. She said the roof leaks could cause all kind of health conditions; such as respiratory issues and someone can get hurt with the roof leaks. During an interview on 6/05/2024 at 2:58 PM with the DON, she said she had witnessed the roaches, but thought they came out when it rained. She said pest control came and sprayed monthly, but if staff or residents saw an increase in bugs they would notify Maintenance and he would notify pest control and had them come out and spray. She said the facility had had roof leaks and they came and did roof repairs throughout the building. She said the roof leaking was hazardous because the tiles could potentially fall and injure someone. During an interview on 6/05/2024 at 3:18 PM with the ADM, she said the exterminators just came last 5/30/2024 or 5/31/2024 and sprayed the facility. The bugs have come out. She said she was sure that it made the residents uncomfortable to see the roaches, but the facility was doing what they could to eliminate the bugs. She said she expected the housekeepers to keep this facility clean like it was the President's house. She said not cleaning thoroughly was not acceptable. She said the facility was working on the leaks and would get the rest of the ceiling tiles changed out that has water damage. She said the roof leaks could be a potential hazard due to mold and the tiles in the ceilings could fall and hit a resident. Record review of the facility Homelike Environment Policy, dated February 2021 revealed . Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Record review of the facility Resident Rights Under Federal Law Policy undated, revealed . the resident has the right to reasonable accommodation of individual needs and preferences except where the health and safety of the resident or other residents would be endangered.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 3 of 17 residents reviewed for care plans. (Resident #28, Resident #47, Resident #50) 1. The facility failed to provide Resident #28 with scheduled smoke breaks. Resident #28's care plan indicated he wished to smoke. 2. The facility failed to develop a care plan for Resident #47's ADL dependence, dietary needs, vision impairment, bowel/bladder status, and diagnoses of anemia (is when you have low levels of healthy red blood cells to carry oxygen throughout your body), constipation, insomnia, and gastroesophageal reflux disease (is a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus). 3. The facility failed to ensure Resident #50's contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) were care planned. 4. The facility failed to ensure Resident #50's care plan fall intervention of fall mats (are made of high-density foam and covered with a non-slip material to keep them in place; is used to cushion falls and minimize the risk of injury) were in place when she was placed in bed by CNA A and had a fall on [DATE]. 5. The facility failed to ensure the DON placed Resident #50's fall mat on the floor when she exited the room during incontinent care on [DATE]. Resident #50 had a fall with injury. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of a face sheet printed [DATE] indicated Resident #28 was a [AGE] year-old male and was admitted [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (is one-sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side, dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and restlessness and agitation. Record review of a significant change in status MDS assessment dated [DATE] indicated Resident #28 was sometimes understood and sometimes understood others with unclear speech. The MDS indicated Resident #28 had a BIMS score of 99 which indicated he was unable to complete the interview to measure his cognition. The MDS indicated Resident #28 had short-and-long term memory recall problem but was able to recall location of his room. The MDS indicated Resident #28 had moderately impaired cognitive skills for daily decision making. The MDS indicated Resident #28 did not wander. The MDS indicated Resident #28 required substantial assistance for eating, oral, toilet, and personal hygiene and dependent for shower/bathe self. The MDS indicated Resident #28 used tobacco. Record review of a care plan dated [DATE], revised [DATE], indicated Resident #28 wished to smoke. Interventions included smoking assessment every month and as needed and monitor for any decline in ability for smoking. Record review of Resident #28's safe smoking assessment dated [DATE] indicated .Does the resident know the location(s) of the designated areas for smoking? .Yes .this resident requires direct supervision while smoking . Record review of an undated facility's Residents Who Smoke indicated .[Resident #28] . Record review of an undated facility's Smoking Schedule indicated .8:30 am .10:30 am .1:30 pm .3:00 pm .4:30 pm .6:30 pm .8:00 pm .Unit Smoking area: the end of the secure unit facing the hospital . During an observation on [DATE] at 3:01 p.m., revealed Resident #28 was not outside in the designated smoking area on the secured unit. No staff or other residents were outside either. During an observation on [DATE] at 3:15 p.m., revealed Resident #28 was in his wheelchair sitting at the exit door near the designated smoking area on the secured unit. Resident #28 was looking at the nursing station. During an interview on [DATE] at 9:15 a.m., attempted to interview Resident #28 but his speech was unclear with vocal noises. During an observation and interview on [DATE] at 9:35 a.m., revealed Resident #28 was not outside in the designated smoking area on the secured unit. CNA A said Resident #28 was the only smoker on the secured unit. During an observation on [DATE] at 1:30 p.m., revealed Resident #28 was not outside in the designated smoking area on the secured unit. No staff or other residents were outside either. During an observation on [DATE] at 1:12 p.m., revealed Resident #28 was in his wheelchair sitting at the exit door near the designated smoking area on the secured unit. Resident #28 was looking at the nursing station. 2. Record review of face sheet printed [DATE] indicated Resident #47 was [AGE] year-old, male and was admitted on [DATE] with diagnoses including iron (a condition in which blood lacks adequate healthy red blood cells), vitamin B12 (is a condition in which your body does not have enough healthy red blood cells, due to a lack (deficiency) of vitamin B12), and folate (is the lack of folic acid in the blood) deficiency anemia, dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and gastro-esophageal reflux disease. Record review of Resident #47's consolidated physician order, active as of [DATE] indicated regular diet, mechanical soft texture, regular consistency related to dementia, ordered on [DATE] with no end date. Record review of an admission MDS assessment dated [DATE] indicated Resident #47 was sometimes understood and sometimes understood others. The MDS indicated Resident #47 had unclear speech, adequate hearing, and impaired vision without corrective lenses. The MDS indicated Resident #47 had a BIMS score of 99 which indicated he was unable to complete the interview to measure his cognition. The MDS indicated Resident #47 had short-and-long term memory recall problem but was able to recall staff names and faces. The MDS indicated Resident #28 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #28 required supervision for eating, oral hygiene, toileting hygiene, partial assistance for shower/bathe self and personal hygiene, substantial assistance for dressing and putting on/taking off footwear. The MDS indicated Resident #47 was frequently incontinent of urine and bowel. The MDS indicated Resident #47 had diagnoses including anemia, constipation, insomnia, and gastro-esophageal reflux disease. The MDS indicated Resident had a mechanically altered diet. Record review of a care plan dated [DATE] indicated Resident #47 had the potential for adjustment issues related to admission, hearing/processing deficit, elopement risk/wanderer as evidence by impaired safety awareness, required psychotropic medication, full code CPR, impaired cognitive/dementia or impaired thought process related to diagnosis of severe dementia. The care plan did not reveal a care plan for ADL dependence, dietary needs, vision impairment, bowel/bladder status, and diagnoses of anemia, constipation, insomnia, and gastroesophageal reflux disease. During an observation on [DATE] at 10:02 a.m., Resident #47 was lying in his bed. Resident #47 did not respond when greeted or to questions asked. During an observation on [DATE] at 1:08 p.m., Resident #47 was sitting at the dining room table eating lunch. During an observation on [DATE] at 1:34 p.m., Resident #47 was the last one at the dining room table. He finished eating his lunch meal. 3. Record review of a face sheet printed [DATE] indicated Resident #50 was [AGE] year-old, male and was admitted [DATE] with diagnoses including contracture of muscle (is the stiffening of muscles due to disease or lack of use), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), limitation of activities due disability, and history of falling. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #50 was rarely/never understood and rarely/never understood others. The MDS indicated unclear speech, adequate hearing, and vision. The MDS indicated Resident #50 had short-and-long term memory recall problem. The MDS indicated Resident #50 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #50 had limitation in range of motion on both sides of her body and upper and lower extremities. The MDS indicated Resident #50 was dependent for eating, oral, toileting, and personal hygiene, shower/bathe self, dressing, and putting on/taking off footwear. The MDS indicated Resident #50 required dependent (helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) assistance to roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer. The MDS indicated Resident #50 had falls since admission/entry, reentry, or the prior assessment which was one with no injury. The MDS indicated Resident #50 had skin tears with application of nonsurgical dressings. Record review of a care plan dated [DATE], revised [DATE], indicated Resident #50 was at risk for falling due to co-morbid conditions, history of falling, lack of coordination, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility and impaired mobility. Intervention included beveled fall mats to bedside related to fall risk and resident's preference to scoot on floor. The care plan did not reveal Resident #50 muscle contracture or limited range of motion to upper and lower extremities on both sided of the body. Record review of an incident report completed by LVN D, dated [DATE], indicated . [Resident #50] was found on the floor bedside her bed .floor mat was not in place at bedside .this was an unwitnessed fall .no injures noted . Record review of Resident #50's incident report completed by the DON, dated [DATE], indicated .resident's room .witnessed fall .Resident #50 was transferred to bed by staff .RN [DON] observed resident's brief was wet and she needed to be changed .bed was in low position and RN [DON] exited room to get a brief for resident [Resident #50] .when RN [DON] was entering resident's room, resident was actively rolling out of low bed with scoop mattress with knees in the air .[Resident #50] was assessed for injury with laceration to right eyebrow measuring 2.5cm in length and 0.2 cm width and was bleeding .Res [Resident #50] also had a purple area approximately 1.5x1.5 cm forming on her cheek .neuro checks initiated .[Resident #50] assisted to bed and changed .mental status: impulsiveness, lack of safety awareness, forgetful .witnesses: DON .staff to ensure fall mat in place anytime resident is in bed . During an observation on [DATE] at 9:32 a.m., Resident #50 was in the dining room, in a reclining wheelchair. Resident #50's elbows and knees were contracted. Resident #50 was not interviewable. In Resident #50's room, 2 fall mats were folded and placed beside a recliner. During an interview on [DATE] at 11:05 a.m., the MDS Coordinator said she was responsible for care plans. She said she did care plan daily with order changes, when MDSs were due, and at care plan meetings. She said she normally care planned a resident's diagnoses, medications, and personal preference. She said Resident #47's care plan was incomplete and care areas were missing. She said she updated Resident #47's care plan today. She said Resident #50's contractures should also be care planned. She said care plans were important to understand the resident's needs. She said if the care plan was not developed the staff may not know the resident's care, assistance and needs of the resident. On [DATE] at 12:00 p.m., called CNA A for a phone interview regarding fall on [DATE]. A voice message was left regarding reason for call and call back phone number. No call back received before or after exit. During an interview on [DATE] at 12:10 p.m., LVN D said Resident #28 smoked. She said she tried to take Resident #28 to smoke if time and staffing allowed. She said there was no designated staff to take Resident #28 to smoke. She said she did not know about a smoke schedule for the secured unit. She said Resident #28 could not verbally express when he wanted to take a smoke break but if he sat by the designated smoke area door, he wanted to smoke. She said it probably made Resident #28 upset no one took him to smoke when he wanted to. LVN D said CNA A forgot to place Resident #50's fall mats down after she put her back to bed. LVN D said she was off the secured unit and came back and CNA A was at the nursing station near Resident #50's room. She said she heard noises and walked towards Resident #50's room. She said she noticed Resident #50 on the floor with no floor mats underneath her. She said the incident made her upset. She said CNA A was aware Resident #50's fall mats belonged on the floor when she was in the bed. She said fall mats were one of Resident #50's fall interventions. She said if the care planned fall interventions were not followed falls happened. During an interview on [DATE] at 1:30 p.m., CNA H said Resident #28 was a smoker. She said she had not offered or taken Resident #28 to smoke today. She said Resident #28 was supposed to be taken at the smoke schedule times. She said the nurse, aides, and sometimes housekeeping staff took Resident #28 to smoke. She said Resident #28 would sometimes gesture smoking a cigarette with his hands when he wanted to smoke. She said Resident #28 should be taken to smoke at the smoke schedule times, but sometimes it was not possible with what was going on the unit. She said it probably would upset Resident #28 if he wanted to smoke and no one took him. CNA H said care plan interventions should be followed. She said fall mats should be placed at the resident's bedside to prevent injury if the resident falls. She said Resident #50 was supposed to have two fall mats at her bedside. She said Resident #50 had a lot of falls. She said not following fall interventions could result in falls, injury, and skin tears. She said Resident #50 was one person assist for incontinent care. She said she did not leave Resident #50 unsupervised during changing because she rolled out of the bed. She said she made sure to bring all her supplies in the room for incontinent care. She said leaving a resident unsupervised during changing could cause falls or injuries. During an interview on [DATE] at 1:54 p.m., the DON said she expected staff to follow the resident's care plan. She said all staff had access to a resident's care plan. She said the MDS Coordinator was responsible for care plans with the help of the nursing staff. She said care plans were important to ensure proper care and know the needs of the resident. She said if care plans were not followed or developed, the resident had the potential to not receive proper care. The DON said CNAs, LVNs and housekeeping were responsible for taking residents to smoke. She said residents should be taken to smoke at the scheduled smoke times and as needed. She said Resident #28 went to back door when he wanted to smoke. She said not taking Resident #28 could cause him to have behaviors. The DON said on [DATE], she was working as a CNA on the secured unit. She said she transferred Resident #50 to bed and noticed her brief was wet. She said Resident #50's bed was in a low position, but the floor mats were not down yet after transferring her. She said she left Resident #50's room to go get a brief to change her. She said as she was entering the room, Resident #50 was lifting her knees in the air and rolled out of the bed. She said she should not have left the room without putting the floor mats down. During an interview on [DATE] at 2:45 p.m., the ADM said nurses, aides, and department were responsible for taking resident to smoke. She said resident on the secured unit should be taken on the same schedule as the non-secure unit residents. She said residents needed to be taken to smoke by staff for their safety and it was the resident's right. She said she could not speak in great depths about care plans, but she expected nursing staff to follow the resident's care plan. Record review of a facility's Care Plans, Comprehensive Person- Centered policy revised ,d+[DATE] indicated .a comprehensive, person centered care plan .meet the resident's physical, psychosocial and functional needs is developed and implemented .the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive .care plan for each resident .the comprehensive, person-centered care plan will .describe the services that are to be furnished .incorporate identified problem areas .aid in preventing or reducing decline in the resident's functional status .reflect currently recognized standards of practice for problems areas and conditions .

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit reviewed for activities. The facility failed to provide meaningful activities for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) residents on the memory care unit. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. Findings included: During an observation on 06/03/24 at 9:32 a.m., the AD had a large television playing music in the dining area of the memory care unit. Approximately 8 residents were in the dining area. During an observation on 06/03/24 at 10:21 a.m.-12:00 p.m., the dining and sitting area nor hallways had any memory care/dementia focused activities. Television on in dining area but residents did not show interest. During an observation on 06/03/24 at 3:01 p.m.-3:30 p.m., 5-8 residents in sitting area and dining area no meaningful activities offered to residents. During an observation on 06/04/24 at 9:09 a.m.-10:15 a.m., 5-8 residents in sitting area and dining area no meaningful activities offered to residents. During an observation on 06/04/24 at 1:08 p.m.- 2:00 p.m., 5-8 residents in sitting area and dining area no meaningful activities offered to residents. Record review of the June 2024 Activity schedule indicated: *06/03/24: 8am- Daily Chronicles, 10am- Music Monday, 11am- Karaoke, 1pm- Sit and Get Fit, 2pm- Bingo, 4pm- One on Ones *06/04/24: no scheduled activities due to senior games. *06/05/24: 8am- Daily Chronicles, 10am- Coffee and Chat, 11am- Craft, 1pm- Helping Hands, 2om- Bingo, 4pm- One on Ones *10am and 1pm- Memory Care, 11am and 2pm- Main Dining During an interview on 06/05/2024 at 9:00 a.m., the AD stated she tried to do one structured activity on the secured unit each day. She stated it was up to the staff on the unit to provide the other activities because she was responsible for the activities on the outside of the unit. She stated she had 2-3 residents on the unit that she did one on one activities with because they did not always come out of their rooms, and she did those 3 days per week. She stated it would be helpful to have an assistant that could provide more structured activities to the residents on the unit, so they did not just sit around all day. During an interview on 06/05/24 at 11:45 a.m., CNA H said she had received dementia care training through a company the facility used. She said activities were done with the resident at 10 a.m. and 2 p.m. She said the unit had baby dolls and stuffed animals, but a resident was hoarding them all in her room. She said there was not enough staff to do sensory stuff with the residents. She said a lot of the behaviors the residents had were from boredom. During an interview on 06/05/24 at 1:35 p.m., LVN G said she felt the facility provided dementia centered care to the secured unit residents. She said the facility could provide more dementia centered activities. She said providing the resident with dementia centered activities was a team effort. She said the secured unit had good family support and they could help the activities be more individualized. She said several of the women on the secured unit were homemakers so activities geared towards homemaking would be good for them. She said more individualized, structured activities helped with memory recall and behaviors. She said the residents would not be so bored if there were more individualized, structured activities. She said the facility had activities like a lap blanket (is a unique weighted lap pad/weighted blanket designed specifically to engage people with dementia including Alzheimer's), but they were not being used. During an interview on 06/05/24 at 1:54 p.m., the DON said staff received annual training on dementia centered care. She said all staff should providing person centered care to the memory care resident. She said the facility interviewed the resident's family to get input on activities that interested their family member before admission. She said the facility did have some activities available for the residents, but she understood there needed to be more structured activities. She said trying to find activities that all the residents would be interested in, it be safe, and not be an infection control risk could be challenging. She said not providing residents individualized, structured activities had the potential for increased behaviors and falls. During an interview on 06/05/24 at 2:45 p.m., the ADM said it was the IDT responsibility to provide the residents on secured unit dementia centered care. She said the facility should be using the resident's care plan to find activities to meet their needs. She said the activities should be at their level and staff assisting with activities. She said the secured unit needed a timeline or structured activities, things to keep them busy. She said when residents were not provided activities throughout the day, they could become agitated, altercations, and falls happened. Record review of a facility's Dementia policy dated 11/2018 indicated .direct care staff will support the resident in initiating and completing activities .therapeutic and recreational activities will be supervised and supported throughout the day as needed .

Based on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 3 of 16 residents (Resident #30, Resident #31, Resident #50) and 3 of 5 staff (CNA A, CNA H, DON) reviewed for transfer and supervision. The facility failed to ensure CNA A did not leave the secure unit unsupervised on 06/04/24 which resulted in Resident #30 ambulating without her wheelchair and with no supervision. The facility failed to ensure CNA H performed a safe 1 person transfer which resulted in Resident #31 obtaining a skin tear to his forearm on 05/28/24. The facility failed to ensure CNA H did not transfer Resident #50 without another staff assistance on 04/07/24. During one person transfer, Resident #50 obtained a skin tear during transfer. The facility failed to ensure the DON did not provide incontinent care without another staff assistance on 05/08/24. The DON left Resident #50 unsupervised during incontinent care which resulted in a fall with no fall mats on the floor. The facility failed to ensure Resident #50's care plan fall intervention of fall mats (are made of high-density foam and covered with a non-slip material to keep them in place; is used to cushion falls and minimize the risk of injury) were in place when she was placed in bed by CNA A and had a fall on 04/13/24. These failures could place residents at risk of injury from accident and supervision. Findings included: 1. Record review of a face sheet printed on 06/05/24 indicated Resident #30 was a [AGE] year-old, female and was admitted on [DATE] with diagnoses including Alzheimer's disease (is a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and cerebral infarction (stroke). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #30 was understood and usually understood others. The MDS indicated Resident #30 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #30 wandered. The MDS indicated Resident #30 normally used a wheelchair in last 7 days of the assessment period for a mobility device. The MDS indicated Resident #30 required setup for oral hygiene and eating, substantial assistance for lower body dressing and putting on/taking off footwear, partial assistance for upper body dressing, and dependent for toileting and personal hygiene, and shower/bathe self. The MDS indicated Resident #30 required partial/moderate assistance for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of a care plan dated 08/12/22 indicated Resident #30 had an ADL self-care performance deficit related to intertrochanter fracture of right femur (is a type of hip fracture or broken hip), muscle wasting to right and left shoulder, pain, dementia, and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Intervention included ambulation: required partial to moderate assist of one staff member at times with ambulation of short distance, and substantial to maximal assist with ambulation of longer distance. And locomotion: required supervision or touching assist with locomotion at times. Record review of a care plan dated 05/03/23, revised 02/08/24 indicated: *Resident #30 was at risk for falls related to Alzheimer's disease and no safety awareness. Intervention included Resident #30 needed prompt response to all request for assistance. *Resident #30 was at risk for falls related to Alzheimer's disease and no safety awareness. Fall with injury on 02/07/24. Intervention included follow facility fall protocol. Record review of Resident #30's fall risk assessment completed by the DON, dated 05/04/24, indicated intermittent confusion, 1-2 falls in past 3 months, ambulatory/incontinent, adequate vision, balance problem while standing and walking, decreased muscular coordination, takes 1-2 of listed high risk medications, and 1-2 present predisposing conditions. Score 17= High risk. Record review of the facility's nursing schedule dated 06/04/24, indicated .Nurse aide .CNA A .6A-6P .North Unit .CNA M .6A-6P .South Unit .LVN D .6A-6P .South Unit . During an observation on 06/04/24 at 9:09 a.m., revealed CNA A walked towards the secure unit and opened the door. CNA A and I both entered at the same time. Resident #30 was walking around the corner of the dining room towards the entrance of the secured unit. CNA A hurried to the dining room and grabbed Resident #30's wheelchair. CNA A helped Resident #30 back into her wheelchair. There was no other staff visualized on the unit. During an interview on 06/04/24 at 2:00 p.m., LVN D said she had just returned to the facility. She said she had left earlier this morning for a family emergency. On 06/05/24 at 12:00 p.m., called CNA A for a phone interview. A voice message was left regarding reason for call and call back phone number. No call back received before or after exit. 2. Record review of a face sheet printed 06/03/24 indicated Resident #31 was an [AGE] year-old, male and was admitted on [DATE] with diagnoses including metabolic encephalopathy (as an alteration in consciousness caused due to brain dysfunction (due to impaired cerebral metabolism)) and Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #31 was understood and understood others. The MDS indicated Resident #31 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #31 rejected care which included ADL assistance. The MDS indicated Resident #31 used a wheelchair for a mobility device. The MDS indicated Resident #31 was dependent for eating, oral, toilet, and personal hygiene, shower/bathe self, and dressing. The MDS indicated Resident #31 was dependent for sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of a care plan dated 01/30/23, revised 01/31/24 indicated Resident #31 had an ADL self-care performance deficit related to previous stroke, Parkinson's disease, history of cancer, muscle wasting and atrophy (shortening), abnormalities of gait and mobility, and muscle weakness. Intervention included transfer: required partial to moderate assist with sit to stand, chair/bed-to-chair, tub/shower transfers and substantial to maximal assist with toilet transfers. Record review of a care plan dated 05/28/24, revised 05/30/24, indicated Resident #31 had a skin tear/potential for skin tear of the left forearm. Intervention included use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Record review of an incident report by LVN G, dated 05/28/24, indicated, .[Resident #31] had a skin tear in resident's room .CNA was assisting resident to stand patient pulled arm away and patient obtained a 3 cm skin tear at this time cleansed with wound cleaner, pat dry applied steri strips without further incident .Resident description: I [Resident #31] was trying to pull away.skin tear .left forearm .mental status: impulsiveness, lack of safety awareness, oriented to person, forgetful .predisposing situation factors: during transfer . During an observation and interview on 06/03/24 at 9:40 a.m., revealed Resident #31 was sitting in the hallway near the resident's room with a soft helmet on his head. Resident #31 was in a wheelchair slowly propelling himself into the room. Resident #31's left forearm had several scattered bruises and steri-strips noted. Resident #31 knew his name but then started complaining about being cold. Unable to perform interview due to inattentiveness. 3. Record review of a face sheet printed 06/03/24 indicated Resident #50 was [AGE] year-old, male and was admitted [DATE] with diagnoses including contracture of muscle (is the stiffening of muscles due to disease or lack of use), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), limitation of activities due disability, and history of falling. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #50 was rarely/never understood and rarely/never understood others. The MDS indicated unclear speech, adequate hearing, and vision. The MDS indicated Resident #50 had short-and-long term memory recall problem. The MDS indicated Resident #50 had severely impaired cognitive skills for daily decision making. The MDS indicated Resident #50 had limitation in range of motion on both sides of her body and upper and lower extremities. The MDS indicated Resident #50 was dependent for eating, oral, toileting, and personal hygiene, shower/bathe self, dressing, and putting on/taking off footwear. The MDS indicated Resident #50 required dependent (helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity) assistance to roll left and right, sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer, and tub/shower transfer. The MDS indicated Resident #50 had falls since admission/entry, reentry, or the prior assessment which was one with no injury. The MDS indicated Resident #50 had skin tears with application of nonsurgical dressings. Record review of a care plan dated 11/15/23 indicated Resident #50 was prone to skin tears and bruising of unknown origin related to thin/fragile skin, impaired nutritional status, and osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Intervention reflected to identify potential causative factors and eliminate/resolve when possible. Record review of a care plan dated 11/15/23, revised 06/03/24, indicated Resident #50 was at risk for falling due to co-morbid conditions, history of falling, lack of coordination, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility and impaired mobility. Falls: 11/20/23 (no injuries), 02/06/24 (with injury), 02/19/24 (no injury), 04/13/24 (no injury), 05/08/24 (with injury), 05/27/24 (with injury). Intervention included beveled fall mats to bedside related to fall risk and resident's preference to scoot on floor. Record review of a care plan dated 11/17/23 indicated Resident #50 had an ADL self-care performance deficit related to dementia, comorbid conditions, history of falling, lack of coordination, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, muscle wasting and atrophy (shortening) of multiples sites, and impaired mobility. Intervention included transfer: required substantial to maximal assist with transfers. Record review of Resident #50's incident report completed by LVN G, dated 04/07/24, indicated .skin tear .resident's room .patient obtained skin tear to right forearm during transfer .predisposing situation factors: during transfer .other: thin/fragile skin .witness: [CNA H] .Statement: [Resident #50] was transferred from bed to chair .when resident was in her chair .I [CNA H] saw a skin tear to right forearm .chair was checked for sharp areas with none noted .[Resident #50] has thin/fragile skin and frequently moves arms all about . Record review of an incident report completed by LVN D, dated 04/13/24, indicated . [Resident #50] was found on the floor bedside her bed .floor mat was not in place at bedside .this was an unwitnessed fall .no injures noted . Record review of Resident #50's incident report completed by the DON, dated 05/08/24, indicated .resident's room .witnessed fall .Resident #50 was transferred to bed by staff .RN [DON] observed resident's brief was wet and she needed to be changed .bed was in low position and RN [DON] exited room to get a brief for resident [Resident #50] .when RN [DON] was entering resident's room, resident was actively rolling out of low bed with scoop mattress with knees in the air .[Resident #50] was assessed for injury with laceration to right eyebrow measuring 2.5cm in length and 0.2 cm width and was bleeding .Res [Resident #50] also had a purple area approximately 1.5x1.5 cm forming on her cheek .neuro checks initiated .[Resident #50] assisted to bed and changed .mental status: impulsiveness, lack of safety awareness, forgetful .witnesses: DON .staff to ensure fall mat in place anytime resident is in bed . Record review of Resident #50's ADL Transferring: Self Performance dated June 2024 indicated: *06/01/24: 1:27 p.m.-Total dependence (full staff performance), 9:14 p.m.- Total dependence *06/02/24: 1:56 p.m.- Total dependence *06/03/24: 1:29 p.m.- Total dependence, 8:24 p.m.- Total dependence *06/04/24: 1:58 p.m.- Total dependence Record review of Resident #50's ADL Transferring: Support Provided dated June 2024 indicated: *06/01/24: 1:27 p.m.- One-person physical assist, 9:14 p.m.- One-person physical assist *06/02/24: 1:56 p.m.- One-person physical assist *06/03/24: 1:29 p.m.- One-person physical assist, 8:24 p.m.- Two plus person physical assist *06/04/24: 1:58 p.m.- One-person physical assist During an observation on 06/03/24 at 9:32 a.m., revealed Resident #50 was in the secured unit dining room. Resident #50 was in a Broda chair (is a chair or wheelchair that provides comfort, support, and mobility throughout the day) with a bruise and steri-strips to right cheek and eye. Resident #50 made random noise and had restless legs. On 06/05/24 at 12:00 p.m., called CNA A for a phone interview regarding fall on 04/13/24. A voice message was left regarding reason for call and call back phone number. No call back received before or after exit. During an interview on 06/05/24 at 12:10 p.m., LVN D said CNA A forgot to place Resident #50's fall mats down after she put her back to bed. LVN D said she was off the secured unit and came back and CNA A was at the nursing station near Resident #50's room. She said she heard noises and walked towards Resident #50's room. She said she noticed Resident #50 on the floor with no floor mats underneath her. She said the incident made her upset. She said CNA A was aware Resident #50's fall mats belonged on the floor when she was in the bed. She said fall mats were one of Resident #50's fall interventions. She said if the care planned fall interventions were not followed falls happened. During an interview on 06/05/24 at 1:30 p.m., CNA H said on 04/07/24, she transferred Resident #50 from the wheelchair to the bed. She said she used a gait belt for the transfer. She said at the time, Resident #50 was a one person transfer but should have been a two-person transfer. She said she had been telling the nurses and DON that Resident #50 needed two-person assist for transfers. She said Resident #50 did not follow commands and was not weight bearing. She said Resident #50 did not assist with transfers. She said she could change Resident #50 by herself. She said Resident #50 was one person assist for incontinent care. She said she did not leave Resident #50 unsupervised during changing because she rolled out of the bed. She said she made sure to bring all her supplies in the room for incontinent care. She said leaving a resident unsupervised during changing could cause falls or injuries. She said she did not recall causing Resident #31's skin tear during a transfer. She said Resident #31 was a one person transfer but they used two-person assistance today (06/05/24). She said Resident #31 had days he needed a lot of assistance but occasionally like on Monday (06/03/24), he self-propelled himself and stood up without assistance. She said gait belts were supposed to be used for one person transfers. She said not using the correct amount of assistance could cause skin tears and falls. She said someone was supposed to be always on the secured unit. She said residents on the secured unit needed supervision. She said all types of things could happen if resident were left alone on the secured unit. She said falls and fights could happen when resident were left alone. She said Resident #30 did stand unassisted, but her knees gave out sometimes. She said Resident #30 should use her wheelchair to get around the unit. She said Resident #30 should not be ambulating on the unit without supervision. She said if Resident #30 ambulated without supervision or her wheelchair, she could fall and hurt herself. CNA H said care plan interventions should be followed. She said fall mats should be placed at the resident's bedside to prevent injury if the resident falls. She said Resident #50 was supposed to have two fall mats at her bedside. She said Resident #50 had a lot of falls. She said not following fall interventions could result in falls, injury, and skin tears. During an interview on 06/05/24 at 1:35 p.m., LVN G said she worked the day Resident #31 got a skin tear during transfer. She said CNA H was the CNA who transferred the resident. She said Resident #31 had a decline in ADL's especially after his recent surgery. She said Resident #31's physical and mental condition was labile. She said Resident #31 was a one-person assist transfer. She said gait belts were supposed to use for transfers. She said she did not think CNA H used a gait belt during Resident #31's transfer on 04/07/24. She said CNA H's hands would have been on the gait belt, not Resident #31's arms, for him to pull away. She said use of gait belts on the secured unit was challenging sometimes because the residents were impatient and did not follow directions. She said improper transferring could cause skin tears and falls. She said the secured unit should always have supervision. She said a CNA or LVN should be on the unit. She said the residents on the secured unit were unpredictable and so many things could happen if they are left unsupervised. She said Resident #30 should not be ambulating without supervision. She said residents unsupervised potentially could have falls, resident to resident altercation, and other injuries. During an interview on 06/05/24 at 1:54 p.m., the DON said on 05/08/24, she was working as a CNA on the secured unit. She said she transferred Resident #50 to bed and noticed her brief was wet. She said Resident #50's bed was in a low position, but the floor mats were not down yet after transferring her. She said she left Resident #50's room to go get a brief to change her. She said as she was entering the room, Resident #50 was lifting her knees in the air and rolled out of the bed. She said she should not have left the room without putting the floor mats down. She said Resident #50 had been a one-person transfer but should have been a two-person person. She said she was going to change her to a mechanical lift also. She said Resident #50 had lost trunk control in March 2024 and did not follow commands. She said gait belts were supposed to be used for one and two-persons transfer assists. She said Resident #31 was a one-person transfer assist. She said staff hands should be on the gait belt during the transfer not the resident's arms. She said transferring without a gait belt or improperly potential could cause falls and injuries. She said the secured unit should always have supervision. She said CNA A and LVN D, who were assigned to the unit, had not returned her phone call to question them about the secured unit residents being unsupervised. She said altercations and falls could happen if secured resident were unsupervised. She said Resident #30 could stand up and walk short distances. She said Resident #30's knees did give out on her without warning. She said Resident #30 should be using her wheelchair primarily for getting around. She said Resident #30 should not be standing or walking with no supervision. During an interview on 06/05/24 at 2:45 p.m., the ADM said she expected staff to use the appropriate amount of assistance for transfers and gait belts. She said she expected staff to stay on the secured and the residents to be supervised. She said it was important for the resident safety to prevent falls and elopements. Record review of CNA H's CNA Proficiency dated 04/30/24 indicated .transfers .1 person assist .satisfactory .2 person assist .satisfactory .uses gait belt with transfers .satisfactory . Record review of a Care Plans, Comprehensive Person-Centered policy revised 12/2016, indicated .assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .the Interdisciplinary Team must review and update the care plan . Record review of a Safe Lifting and Movement of Residents policy revised 07/2017 indicated .in order to protect the safety and wellbeing of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .resident safety .medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents .nursing staff .shall assess individual residents' needs for transfer assistance on an going basis .manual lifting of residents shall be eliminated when feasible .staff responsible for direct resident care will be trained in the use of manual (gait/transfer) . Record review of a Fall policy revised 03/2018 indicated .based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .

Based on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 3 (Resident #50,#32, and #31) of 16 residents residing on the secured unit. The facility failed to have sufficient staff available to provide resident care and supervision to prevent falls with injury on the secured unit for 3 of 3 months reviewed for staffing (March 2024-May2024). This failure could put residents at risk of not receiving necessary care and supervision to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: 1. Record review of an undated face sheet revealed Resident #50 was a [AGE] year-old female admitted [DATE] with the diagnoses of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety (uncontrolled feeling of anxiousness), and depression (group of conditions associated with the elevation or lowering of a person's mood). Record review of a quarterly MDS assessment dated [DATE], revealed Resident #50 had a BIMS of 00, which indicated severe cognitive impairment. The MDS revealed Resident #50 was dependent assistance for transfer, bathing, and toileting. The MDS revealed Resident #50 had falls in the past 90 days. Record review of a comprehensive care plan dated 11/23/2023 indicated an intervention for frequent visual checks related to fall risk. Record review of a progress noted dated 05/08/2024 written by the DON indicated the DON left Resident #50 unattended during incontinent care and Resident #50 fell while unsupervised and obtained a laceration to her right eyebrow and a hematoma to her cheek. Record review of a progress note dated 05/27/2024 written by LVN F indicated, Resident #50 was found on the floor by CNA B. She had laceration to the right side of the chin and her cheek. During an interview on 06/04/2024 at 10:30 a.m., the DON stated she was working the night shift (05/08/2024) as a CNA when Resident #50 fell from her bed, and she was working the secured unit alone. She stated she left the resident unattended to get a brief to change her and when she returned, she had fallen from the bed that was in the low position. The DON stated she felt having another aide on the unit would help with the supervision of the residents and was needed because of their acuity level. The DON stated that corporate directed the staffing ratio at the facility and they were not permitted to have two CNAs on the unit per shift. During an interview on 06/04/2024 at 11:45 a.m., CNA B stated she recalled when (05/27/2024) Resident #50 was found on the floor and that she had a laceration to her chin and there was blood everywhere. CNA B stated she was just one person assist and she did her best to keep an eye on everyone. CNA B stated she honestly did not know when Resident #50 fell . She stated she was doing her rounds changing people and walked into her on the floor. CNA B stated she had to call the nurse from her cell phone to come down and look at Resident #50 because she was out giving medications on south hall. CNA B stated on bad days when the residents were acting really wild it was impossible to get all the documentation and care done like you were supposed to, but if you had a routine, you could get most of the care for the resident's done. 2. Record review of an undated face sheet revealed Resident #32 was an [AGE] year-old male admitted [DATE] with the diagnoses of dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension ( high blood pressure), and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Record review of a care plan dated 11/24/2023 revealed Resident #32 had an intervention for falls of answering the call light promptly and frequent visual checks. Record review of a quarterly MDS assessment dated [DATE], revealed Resident #32 had a BIMS of 00, which indicated severe cognitive impairment. The MDS revealed Resident #32 was extensive to dependent assistance for transfer, bathing, and toileting. The MDS revealed Resident #32 had multiple falls with injuries in the past 90 days. The MDS revealed Resident #32 had physical and verbal behaviors towards others 4-6 days per week. Record review of a progress noted dated 03/05/2024 written by LVN H indicated Resident #32 was found on the floor after an unwitnessed fall and he sustained skin tears to his left hand from the fall. Record review of a progress note dated 03/11/2024 written by LVN F indicated Resident #32 has found on the floor during rounds and was noted to have redness and bruising to his left outer knee and left hip. 3. Record review of an undated face sheet revealed Resident #31 was an [AGE] year-old male, admitted on [DATE] with the diagnoses of anemia (lack of blood), hypertension (high blood pressure), and renal failure (a condition in which the kidneys lose the ability to remove waste and balance fluid). Record review of the quarterly MDS dated [DATE] revealed Resident # 31 had a BIMS of 07, which indicated a moderate cognitive deficit. The MDS indicated Resident #31 was dependent with ADLs and had no falls since the most recent admit. Record review of the care plan dated 05/25/2024 revealed Resident #31 had 9 falls since 01/19/2024. Interventions for the falls were listed as staff reorientation, ensuring proper footwear, answering call lights promptly, and reminding Resident #31 to use his wheelchair. The falls were listed as follows: 01/19/2024-witnessed; 01/25/2024-unwitnessed; 01/27/2024-unwitnessed; 02/04/2024-witnessed; 02/07/2024-witnessed; 02/06/2024-unwitnessed; 03/26/2024-witnessted; 05/09/2024-unwitnessed 05/11/2024-unwitnessed- with injury. Record review of progress notes dated 03/01/2024 to 06/01/2024 reveal no progress note documentation related to falls. Record review of the PBJ staffing Data Report dated 01/01/2024 to 03/31/2024 indicated the facility triggered for one star staff rating. Record review of the daily staff sign in sheets from 03/01/2024 to 06/04/2024 indicate one CNA assigned to the secured unit with an average census of 16-20 residents. During a general observation of the secured unit on 06/03/2024 at 9:35 a.m., there was (1) CNA providing ADL care and supervision for 16 resident's residing on the secured unit. No other staff was on the secured unit from 9:35 a.m. to 10:00 a.m. During the 10 minutes CNA A was providing incontinent care to a dependent resident the other residents were moving around throughout the unit, into other resident's rooms, attempting to stand up and walking unassisted with no supervision. The nurse assigned to the secured unit was outside of the unit passing medication to residents on another hall. During an observation and interview of the secured unit on 06/04/2024 at 9:08 a.m., CNA A was outside of the secured unit for approximately 10 minutes and the assigned nurse (LVN D) had to leave for a family emergency. There was no staff on the unit when the surveyor and CNA A arrived at the locked door outside of the secured unit together and CNA A let the surveyor into the unit. CNA stated she was taking a 10-minute break and that LVN D left the facility and the ADON was supposed to take over as the nurse. CNA A stated the ADON told her to call her if she needed any help and she would come back to the unit. No falls were noted during the absence of staff. CNA A stated she could do all the tasks assigned to her if she really hustled. She stated she was responsible for meals, bathing, toileting, dressing, and grooming all 16 residents. She stated the nurse had to pass meds in the unit and out on the south hall. She stated the nurse was probably assisting on the unit about 2-3 hours a day because of all the other things she had to do. She said during that time she could go and take her lunch break and that left the nurse on the unit by herself. CNA A stated there was not time to do things with the residents other than the basics needs because she spent a lot of time redirecting them. CNA A stated sometimes they turned on music back there, but they did not do much else because there was no time with one person back there. CNA A stated other people would come back to help on occasion but only if something serious was going on like state being in the building or someone passing away. During an interview on 06/04/2024 at 8:50 a.m., LVN D stated it was a lot of work to pass pills to the residents on the unit and south hall, but she got it done. LVN D stated she spent about half the shift out of the unit passing medications and seeing about the residents on south hall because they all had unique issues that needed to be dealt with each day. LVN D stated it would be very helpful to have another staff member on the secured unit to assist in monitoring the residents back there because they were all fall risks and most of them had behavior problems that needed to be monitored continuously. LVN D stated it would probably cut down on the falls and other behavioral issues if they had more staff to spend more one-on-one time with the residents back there. During an interview on 06/05/2024 at 2:30 p.m., the DON stated the staffing pattern for the building was one CNA on the secured unit and one CNA on south hall each, and one nurse that worked both the secured unit and south hall each shift. The DON stated when the census was up more, they were able to run two CNAs or one CNA and a medication aide. But they are unable to do that when their census was so low. The DON stated she was aware there had been a large number of unwitnessed falls with injury on the secured unit. The DON stated in a perfect world there would be two CNAs on the secured unit so that no one was ever left unattended in a common area. The DON stated not having two staff members on the secured unit at all times was a risk to the residents that reside on the unit because they are unsupervised for periods of time throughout the day and night when care was being given to others. During an interview on 06/05/2024 at 3:00 p.m., the ADM stated she understood it was not ideal to have only one staff member on the secured unit and it left the residents unattended while care was being done. She stated it would make it easier for the staff if they had two staff members back there at all times. The ADM stated corporate comes up with the PPD and that was how the facility staffs the building. During an interview with the Administrator on 06/05/2024 at 4:20PM, she stated the facility did not have any written policies or procedures related to staffing levels or staffing of the secured units.

Based on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 2 of 17 residents reviewed for dignity. (Resident #31, Resident #49) The facility to ensure CNA H did not push Resident #31 backwards in his wheelchair from his room to the dining room. The facility failed to ensure LVN D did not stand up while assisting Resident #49 with his lunch meal. These failures placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of a face sheet printed 06/03/24 indicated Resident #31 was an [AGE] year-old male and was admitted on [DATE] with diagnoses including metabolic encephalopathy (as an alteration in consciousness caused due to brain dysfunction (due to impaired cerebral metabolism)) and Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #31 was understood and understood others. The MDS indicated Resident #31 had a BIMS score of 07 which indicated severe cognitive impairment. The MDS indicated Resident #31 was dependent for eating, oral, toilet, and personal hygiene, shower/bathe self, and dressing. Record review of a care plan dated 01/30/23, revised 01/31/24 indicated Resident #31 had an ADL self-care performance deficit related to previous stroke, Parkinson's disease, history of cancer, muscle wasting and atrophy (shortening), abnormalities of gait and mobility, and muscle weakness. Intervention included encourage resident to participant to the fullest extent possible with each interaction. During an observation on 06/03/24 at 10:04 a.m., revealed CNA H pushed Resident #31, in his wheelchair, out of his bathroom then out into the hall. CNA H was in front of Resident #31 pushing his wheelchair backwards towards the dining area on the secured unit. 2. Record review of a face sheet printed 06/05/24 indicated Resident #49 was a [AGE] year-old, male and was admitted on [DATE] with diagnoses including dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), severe, with agitation and dysphagia (is when you can't swallow correctly, leading to problems eating and drinking). Record review of an annual assessment dated [DATE] indicated Resident #49 was sometimes understood and sometimes understood others with unclear speech. The MDS indicated Resident #49 had a BIMS of 99 which indicated he was unable to complete the interview process to measure his cognition. The MDS indicated Resident #49 had short-and-long term memory recall problems. The MDS indicated Resident #49 required setup assistance for eating. Record review of a care plan dated 05/17/23, revised on 11/24/23 indicated Resident #49 had an ADL self-care performance deficit related to dementia, impaired balance, unsteadiness on feet, muscle weakness generalized, abnormalities of gait and mobility. Intervention included Resident #49 required partial to moderate assist of staff participation to eat. During an observation on 06/03/24 at 12:29 p.m., revealed Resident #49 was sitting on the sofa with a bedside table in front of him. LVN D stood in front of him feeding Resident #49 his lunch meal. During an interview on 06/05/24 at 11:45 a.m., CNA H said pushing a resident backwards in a wheelchair was not allowed. She said she knew she was not supposed to do it. She said she did recall pushing Resident #31 backwards in the wheelchair on Monday, 06/03/24. She said pushing a resident backwards in a wheelchair could make the resident feel degraded. She said staff were supposed to feed a resident sitting down. She said staff should be eye level with the resident when feeding them. She said feeding the resident standing up could make them feel like a baby. During an interview on 06/05/24 at 12:10 p.m., LVN D said she did feed Resident #49 standing up on Monday, 06/03/24. She said she knew residents were supposed to be fed at their level. She said it was hard to feed Resident #49 at his level because he liked to grab at the food. She said she knew it was better to still sit. She said it was a dignity issues to stand over a resident while feeding them. During an interview on 06/05/24 at 1:54 p.m., the DON said she expected the nursing staff to sit at the resident's level when feeding them. She said sitting at the resident's level made sure the staff were feeding the resident correctly and for the resident's dignity. She said it was inappropriate to push a resident backwards in a wheelchair. She said it was a dignity issue and could upset the resident. She said staff were aware to sit down when feeding residents and not to push residents backwards. During an interview on 06/05/24 at 2:45 p.m., the ADM said she expected staff to feed a resident at eye level. She said it could make the resident feel useless or like a special needs person. She said the resident should feel as an equal to the staff. Record review of a facility's Resident Rights policy revised 02/2021 indicated .employees shall treat all residents with kindness, respect, and dignity .resident's right to .a dignified existence .be treated with respect, kindness, and dignity .

Based on observation, interview, and record review, the facility failed to ensure interventions were provided based on the comprehensive assessment to prevent the development and worsening of a pressure injury for 3 of 4 residents reviewed for pressure injuries. (Resident #s 20, 24, and 38 ) The facility did not assess a new facility acquired open area found on Resident #24's coccyx area on 3/4/18, did not provide treatment for [REDACTED]. Two day later, 3/6/18, the open area worsened with slough and the depth of the wound was unable to be determined, unstageable. The facility did not implement interventions of pressure relieving devices to prevent the development of pressure injuries on Resident #38's feet. The resident was identified as being a high risk for developing pressure injuries. The facility did not implement interventions of pressure relieving devices to prevent the development of pressure injuries on Resident #20's heels. The resident was identified as being at risk for developing pressure injuries. This failure could place 26 residents receiving preventive skin care at risk for developing new pressure injuries and 3 residents with existing pressure injuries at risk for a decline in existing pressure injuries. Finding included: 1. Physician orders [REDACTED].#24, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The resident did not have an order for [REDACTED].>The most recent MDS dated [DATE] indicated Resident #24 required extensive assistance with bed mobility and total assistance with toilet use. Resident #24 was incontinent with bowel and bladder. The resident had moderately impairment in the area of mental status and no behavioral problems. The resident was at risk for pressure injuries. Resident #24 had 2 Stage 3 pressure injuries at the time of the assessment and the dimensions of 2cm x 4cm x 0.3 cm. for the largest on. The resident was not admitted with this pressure injury. A care plan revised 2/2/18 indicated Resident #24 had a focus of potential risk for skin breakdown. A goal was for Resident #24's skin to remain intact and not to develop a pressure injury. A care plan revised 2/26/18 indicated Resident #24 had a focus of potential for pressure injury development. Interventions included notify nurse immediately of any new areas of skin breakdown to include redness. A Braden scale assessment dated [DATE] and 3/6/18 indicated Resident #24 was at high risk for skin breakdown. A weekly skin assessment dated [DATE] indicated Resident #24 had redness on the coccyx area. There was no description of the area. A Weekly Ulcer assessment dated [DATE] completed by the treatment nurse indicated Resident #24 did not have a pressure injury on his coccyx area. The resident was noted to have a pressure injury on his left great toe. During an observation and interview on 3/6/18 at 11:00 a.m., MA J and CNA G completed incontinent care for Resident #24. The resident had an open area on his tailbone. The open area was about the size of quarter, the edges were red, and the wound bed had slough (dead tissue over a wound bed). CNA G indicated the resident has had the area to his tailbone before, she stated it comes and goes. MA J reported the wound to the DON upon completion of incontinent care. During an interview on 3/6/18 at 11:25 a.m., CNA G indicated she did not work with Resident #24 on 3/5/18 so she did not know if the area was on his bottom prior to today. During an interview on 3/6/18 at 3:15 p.m., the treatment nurse indicated she helped CNA K perform incontinence care for Resident #24 on 3/5/18 and indicated Resident #24's skin was intact on his coccyx. She said his bottom was just red. During an observation on 3/6/18 at 11:20 a.m., the DON measured the wound to Resident #24's coccyx area to be 1.5 cm x 1.0 cm and she could not determine the depth because she could not see what was underneath. The DON said the surrounding skin was blanchable, the wound was a stage 2, was dry and did not have any drainage. The DON said the wound was 75% covered with slough and indicated it was a stage 3 instead of a stage 2. She indicated she would notify the hospice physician. A Weekly Ulcer Assessment completed by the treatment nurse dated 3/6/18 indicated Resident #24 had an unstageable pressure injury on his coccyx. The wound measured 1.5 cm x 1.0 cm and the depth was unable to be determined. A Nursing Progress Note completed by the treatment nurse dated 3/6/18 at 11:58 a.m. indicated the physician was notified Resident #24 had a Stage 3 on his coccyx area. A new order was received to clean with cleaner, apply Medi-honey, apply alginate dressing, and cover with an adhesive dressing every day. During an interview on 3/6/18 at 11:32 a.m., CNA K said she was the CNA for Resident #24 yesterday (3/5/18). She said the resident did have the open area to his tailbone (coccyx area). She said the area had been there since Sunday (3/4/18) and she reported the area to RN L. CNA K said RN L looked at the wound and instructed her to put [MEDICATION NAME] (barrier cream) on the area. CNA K indicated she had also reported the open area to LVN H yesterday (3/5/18). During a telephone interview on 3/6/18 at 1:40 p.m., RN L said CNA K told her Sunday (3/4/18) Resident #24's back side was red. RN L said she assessed the resident's coccyx area and found the resident had a small open rectangular area on his backside. She said she did not measure the area. RN L said she applied [MEDICATION NAME] to the area. RN L said she did not document on the area and did not notify the physician. RN L said she left a note for the wound care nurse for Monday (3/5/18). RN L said she did not perform any nursing intervention because the DON told her she was not a wound care nurse and was not to perform wound care to residents. During an interview on 3/6/18 at 11:36 a.m., LVN H indicated no one reported Resident #24 had any skin issues to her yesterday (3/5/18). During an interview on 3/6/18 at 1:55 p.m., the treatment nurse (LVN) indicated Resident #24 had a stage 2 pressure injury. She said the wound bed was pale and not white, she said that isn't slough. The DON said when she measured the wound on 3/6/18 she could not tell what was underneath or the depth of the wound, so it would be unstageable. The treatment nurse said she did not receive a note from RN L on Monday 3/4/18 regarding Resident #24's open area to his coccyx. During an interview on 3/6/18 at 1:50 pm., the DON indicated Resident #24 had an unavoidable wound on his coccyx area. The DON provided documentation of an assessment that was faxed to the hospice physician for signature on 3/6/18. The corporate nurse indicated there was no prior documentation indicating Resident #24 had an unavoidable wound on his coccyx and indicated the resident was not currently on hospice. During an interview on 3/6/18 at 11:50 a.m., the DON said she expected all nurses to document and notify the physician, family, and the DON when a pressure injury was found on a resident. The DON said she expected all nurses to follow the facility policy for pressure injuries and she did not tell RN A she was not to perform wound care services to the resident. The DON indicated she would never tell a nurse not to assess a wound because it was against nursing practice. An undated Pressure ulcer policy indicated 1. If a resident has a pressure injury you must complete an ulcer assessment on this resident weekly on same day each week. 2. Along with every ulcer assessment you must complete a Braden scale. 3. If it is a new pressure injury you must contact the family, MD and notify DON or ADON. You must ask MD for supplements he/she is wanting to implement for wound healing. Along with any lab work i.e. [MEDICATION NAME] or pre [MEDICATION NAME] level. The family must be notified of all new areas, and new orders and followed up on. You must report all this to DON/ADON daily . 2. Physician orders [REDACTED].#56 was an [AGE] year old admitted [DATE] with [DIAGNOSES REDACTED]. The orders noted the resident's right elbow pressure ulcer was to be cleaned every other day with normal saline or wound cleanser, pat dry, apply Medi-honey to the wound bed and then cover with calcium alginate, and tuck in the undermining area, cover with gauze and secure with Kerlix and secure with tape and apply [MEDICATION NAME] (moisture barrier cream) to edges only every 48 hours Change dressing every other day and as needed due to excessive drainage with an order date of 3/2/18. The most recent MDS dated [DATE] noted Resident #56's cognition was severely impaired, with no speech, rarely/never understood and sometimes understands. Resident #56 was totally dependent on two persons for bed mobility, transfers, toilet use and dressing. Resident #56 had 1 stage 4 at the time of the assessment with dimensions of 2.8 cm x 2.8 cm x 0.6 cm. Interventions used were pressure relieving device for chair and bed, nutrition and hydration interventions, pressure ulcer (injury) care, application of nonsurgical dressings, and applications of ointments/medications other than to feet. A care plan updated on 03/04/18 indicated Resident #56's wound treatment to her right elbow was cleanse the area every other day with normal saline or wound cleanser, pat dry, apply [MEDICATION NAME] to wound bed and then cover with calcium alginate, tuck in the undermining area, cover with gauze, secure with Kerlix and secure with tape. Apply [MEDICATION NAME] to edges only. A Weekly Ulcer assessment dated [DATE] indicated Resident #56 had a pressure injury on her right elbow area. The area had measurements of 1.8 cm x 1.7 cm x 0.4 depth. The wound bed margins were rolled under with a red wound bed. The drainage was described as light amount with a pink color with an opaque or purulent character. During an observation and interview on 03/07/18 at 11:24 a.m., Resident #56 received wound care to the right elbow wound which was on a pillow. The elbow was covered with a dressing dated 3/5/18. The dressing was saturated with drainage and peeling off the wound. The treatment nurse (LVN) removed the dressing, cleansed the site with wound cleanser, changed the gloves and did not wash or sanitize hands before donning additional gloves. She measured the pressure injury to be 2.0 cm x 2.8 cm x 0.7 cm. The treatment nurse said the size of wound varied week to week depending upon the resident's positioning. The treatment nurse applied Medi-honey and calcium alginate to the wound bed, applied calmaseptine to perimeter of wound with gloved finger, applied a bordered foam dressing to the right elbow and dated the dressing 3/7/18. She did not wrap the resident's elbow with the Kerlix gauze dressing. The treatment nurse said this was the normal procedure for changing and applying the dressing to Resident #56's wound. During an interview on 03/06/18 at 1:47 p.m., the DON said her expectation was physician orders [REDACTED]. During an interview on 03/08/18 at 10:27 a.m., the treatment nurse said, no she had not followed the physician's orders [REDACTED].#56's right elbow pressure injury. The treatment nurse said the order indicated gauze and Kerlix and she used a foam bandage. She indicated she got the order changed on 03/08/18 from the gauze and Kerlix to semi permeable dressing. 3. Physician orders [REDACTED].#38 was an [AGE] year old admitted [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The most recent MDS dated [DATE] noted Resident #38 cognition was moderately impaired, with clear speech, was understood and could understand. It was noted Resident #38 was at high risk for pressure ulcers. The care plan revised 7/27/17 indicated Resident #38 had a focus of potential for pressure injury development. An intervention initiated 1/29/18 indicated the resident was to have a foot cradle to the bed. During an observation on 03/05/18 at 9:45 a.m., Resident #38 did not have a foot cradle to her bed and her blanket was resting on her toes. During an observation on 03/05/18 at 1:02 p.m., Resident #38 was on her back fussing about the lunch she had received. The resident was covered with a blanket and there was no foot cradle present on the bed. The blanket was resting on the resident's toes. During an observation on 03/06/18 at 10:20 a.m. Resident #38 was asleep in her room. There was no foot cradle present and the blanket was resting on the resident's toes (not per physician order). During an observation on 03/06/18 at 11:48 a.m., Resident #38 did not have a foot cradle present on the bed. During an observation and interview on 03/06/18 at 4:18 p.m. the DON said a foot cradle was placed on Resident #38's bed. The DON said the foot cradle was placed on the bed after the surveyor asked for a copy of Resident #38's physician order [REDACTED]. During an interview on 03/06/18 at 4:23 p.m., CNA M reported last seeing the foot cradle on Resident #38's bed about 2 to 3 weeks ago. During an interview on 03/06/18 at 4:25 p.m., CNA N reported having worked with CNA M on 03/03/18 and said that was the last time the foot cradle was on Resident #38's bed. During an interview on 03/06/08 at 4:30 p.m., the DON said to her knowledge the last time she remembered seeing the foot cradle on Resident #38's bed was around Christmas time. During an interview on 03/06/18 at 4:38 p.m., LVN C said she last saw the foot cradle on Resident #38's bed the morning of 03/06/18 around 6:30 to 6:45 a.m. The LVN continued to talk and then indicated she thought it had been up and that no one had told me it was down. During an interview on 03/06/18 at 4:42 p.m., LVN/MDS Coordinator O said she and CNA N had placed the foot cradle on Resident #38's bed between 1:00 to 2:00 p.m. on 03/06/18. She reported the foot cradle was in the resident's chair dismantled. During an interview on 03/07/18 at 9:19 a.m., CNA F said the foot cradle had not been on Resident #38's bed for a couple of months. The CNA said she last saw the foot cradle on the bed in (MONTH) of (YEAR) 3. Physician orders [REDACTED].#38 was an [AGE] year old admitted [DATE] with [DIAGNOSES REDACTED]. The physician order [REDACTED]. The most recent MDS dated [DATE] noted Resident #38 cognition was moderately impaired, with clear speech, was understood and could understand. It was noted Resident #38 was at high risk for pressure ulcers. The care plan revised 7/27/17 indicated Resident #38 had a focus of potential for pressure injury development. An intervention initiated 1/29/18 indicated the resident was to have a foot cradle to the bed. During an observation on 03/05/18 at 9:45 a.m., Resident #38 did not have a foot cradle to her bed and her blanket was resting on her toes. During an observation on 03/05/18 at 1:02 p.m., Resident #38 was on her back fussing about the lunch she had received. The resident was covered with a blanket and there was no foot cradle present on the bed. The blanket was resting on the resident's toes. During an observation on 03/06/18 at 10:20 a.m. Resident #38 was asleep in her room. There was no foot cradle present and the blanket was resting on the resident's toes (not per physician order). During an observation on 03/06/18 at 11:48 a.m., Resident #38 did not have a foot cradle present on the bed. During an observation and interview on 03/06/18 at 4:18 p.m. the DON said a foot cradle was placed on Resident #38's bed. The DON said the foot cradle was placed on the bed after the surveyor asked for a copy of Resident #38's physician order [REDACTED]. During an interview on 03/06/18 at 4:23 p.m., CNA M reported last seeing the foot cradle on Resident #38's bed about 2 to 3 weeks ago. During an interview on 03/06/18 at 4:25 p.m., CNA N reported having worked with CNA M on 03/03/18 and said that was the last time the foot cradle was on Resident #38's bed. During an interview on 03/06/08 at 4:30 p.m., the DON said to her knowledge the last time she remembered seeing the foot cradle on Resident #38's bed was around Christmas time. During an interview on 03/06/18 at 4:38 p.m., LVN C said she last saw the foot cradle on Resident #38's bed the morning of 03/06/18 around 6:30 to 6:45 a.m. The LVN continued to talk and then indicated she thought it had been up and that no one had told me it was down. During an interview on 03/06/18 at 4:42 p.m., LVN/MDS Coordinator O said she and CNA N had placed the foot cradle on Resident #38's bed between 1:00 to 2:00 p.m. on 03/06/18. She reported the foot cradle was in the resident's chair dismantled. During an interview on 03/07/18 at 9:19 a.m., CNA F said the foot cradle had not been on Resident #38's bed for a couple of months. The CNA said she last saw the foot cradle on the bed in (MONTH) of (YEAR). The CMS 672 dated 3/5/18 indicated 26 residents received preventive skin care and 3 residents with existing pressure injuries.

Based on observation, interview, and record review, the facility failed to ensure adequate supervison and assistive devices were provided to prevent accidents for 4 of 7 residents reviewed with bedrails or bed canes. (Resident #s 1, 7, 8, and 9) 1. The facility did not provide a safe assistance device for Resident #1. Resident #1 had a bed cane (transfer/mobility bar) attached to her bed frame. She required extensive assistance with bed mobility, was totally dependent on staff for transfers, and had a history of [REDACTED]. The resident was found unresponsive with her head between the mattress and bed cane. The resident was pronounced dead. 2. Resident #s 7, 8, and 9 required assistance from staff with bed mobility and transfers. The residents had bed canes/enablers with 3 to 4 inch gaps between the bed mattress and the bed cane/enabler. The facility did not provide a safe assistive device for the residents. An Immediate Jeopardy situation was identified on [DATE] at 9:26 a.m. The Immediate Jeopardy was removed on [DATE] at 4:10 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 23 residents who used bed enablers at risk for serious bodily injury or death. The findings included: 1. A face sheet dated [DATE] indicated Resident #1 was admitted [DATE] and re-admitted [DATE]. An Order Summary Report (physician orders) dated [DATE] indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated Resident #1's head of bed was to be elevated to 30 degrees or more at all times. The orders did not document an order for [REDACTED]. The latest MDS dated [DATE] indicated Resident #1 usually understood others and was understood by others. The resident was moderately impaired cognitively and she had psychomotor retardation that fluctuated in severity. The MDS indicated Resident #1 required the extensive assistance of 2 or more staff with bed mobility and required total dependence of 2 or more staff with transfers. A Fall-Risk assessment dated [DATE] indicated Resident #1 was at high risk for falls. The care plan with an initial date of [DATE] and revised date of [DATE] indicated Resident #1 had bed canes on each side of her bed to assist her with turning and repositioning. Interventions included: may use side rails as ordered by the physician, monitor the resident ' s position, monitor for the safety and security of bed canes, and complete a side rail assessment upon admit, readmit, quarterly, and comprehensive assessment. The care plan documented the resident was at risk for falls due to decreased safety awareness. The plan documented the resident had ADL self-care deficit and an intervention was she required the assistance of 2 staff to reposition and turn in bed. The care plan indicated she had cognitive loss with impaired decision making. A fall with Injury report dated [DATE] indicated LVN D found Resident #1 to the right side of her bed with her head between the mattress and bed cane and she was unresponsive. The report indicated CNAs B and F assisted LVN D with releasing the resident's head from the mattress and bed cane. During an interview on [DATE] at 5:06 p.m., the ADON said Resident #1 was found sitting on the floor unresponsive with her head against the bed cane on [DATE]. She said CNA A called for help and the other staff went in the room. The administrator (who was in the room) said the CNAs raised the resident off the floor with the Hoyer lift and placed her on the bed. She said the DON pronounced her dead at 12:45 p.m. During an interview on [DATE] at 5:57 p.m., LVN D said when she entered Resident #1's room on [DATE] the resident's neck was stuck, the rail was behind her jaw bone and her left ear. She said the head of the bed was up because the resident was on tube feedings and she had kyphosis (curving of the spine). LVN D said the last time she saw Resident #1 was at lunchtime and Resident #1 was on her back with her knees toward the window (resident ' s right side of bed). She said Resident #1 was her resident that day. LVN D said she had no idea how Resident #1 could get in the position she was found. She said she saw a mark on the left side of Resident #1's neck; it was behind her ear and extended to under her jawbone. She said she did not know how Resident #1 died . During an interview on [DATE] at 7:00 p.m., LVN C said on [DATE] she saw CNA A, and CNA B in Resident #1's room. She said she heard CNA B yell I need a nurse now! She said when she went in the room, Resident #1's neck was hyperextended, with the bed cane under her jawbone. She said her head was not hung. She said Resident #1 had kyphosis and her back was humped. LVN C said it appeared she was trying to get up and her body twisted, but her head did not. She said the bed cane was underneath her jawbone and her face was pointing to the ceiling. She said she moved the mattress and guided the resident ' s head to the floor with CNA B and LVN D. She said it was hard to say if her head was stuck. She said once the mattress was moved it would be hard to tell. LVN C said Resident #1 tried to get up before and fell about a month ago. During an interview on [DATE] at 4:26 p.m., the Chief of Police of the local police department said Resident #1 had a line/mark beginning on her right ear and extending ,[DATE] inches under her chin. The Chief of Police said the DON pronounced Resident #1 dead at 12:45 p.m. The Chief of Police said he thought Resident #1 hung herself. He said Resident #1 had a bulge on the right side of her neck. He said there was an ongoing investigation into the incident. During an interview on [DATE] at 4:51 p.m., the administrator said CNA A found Resident #1 unresponsive on [DATE]. The administrator said CNA B, LVN C, and LVN D went into the resident room after she was found unresponsive. During an interview on [DATE] at 5:12 p.m., the DON said Resident #1 had a red mark on the right side of her neck. The DON said Resident #1 had a bed cane on both sides of her bed. She said the resident used them to assist with positioning and maybe she had a heart attack and fell out of bed. The DON said Resident #1's last fall was in [DATE]. She said she was able to move her legs and feet, but was not able to walk. The DON said they were re-evaluating all residents with bed canes. During an observation with the DON on [DATE] at 5:45 p.m., Resident #1's bed had a homemade bed cane on both sides of the bed. During an interview on [DATE] at 5:16 p.m., the administrator said Resident #1's bed cane was homemade by the maintenance supervisor. The administrator said bed canes were easy to make. During an interview on [DATE] at 7:50 a.m., the administrator said she okayed the maintenance man making the bed cane for Resident #1. During an interview on [DATE] at 5:19 p.m. the surveyor asked the administrator; What prevents the other residents with canes/bars from ending up like Resident #1? The administrator said Nothing prevents the other residents from ending up like Resident #1. During an interview on [DATE] at 5:26 p.m. the regional director of operations said if the bed cane was the cause of Resident #1's death, it was an accident. 2. An Order Summary Report dated [DATE] indicated Resident #7 was [AGE] years old and admitted [DATE] with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. An MDS dated [DATE] indicated Resident #7 was cognitively intact and required the extensive assistance of 2 or more staff with bed mobility and transfers. A care plan with a revision date of [DATE] indicated Resident #7 had an ADL deficit due to a stroke and being forgetful at times. Interventions included: provided an assist bar times 2 to assist with turning and repositioning while in bed and the resident required 1 to 2 staff with bed mobility and transfers. During an observation and interview on [DATE] at 8:49 a.m., Resident #7 had bed canes on both sides of his bed. There was a 3.1 inch gap between the mattress and the bed cane LVN G said I'll get someone to fix that right now. The RN corporate nurse said there should not be a gap. During an interview [DATE] at 9:45 a.m., LVN H said Resident #7 could move his right side, but was not able to move his left. She said if he got hung in his bed cane, he could not get out of it. During an interview [DATE] at 9:53 a.m., CNA J said she did not think Resident #7 could get himself untangled from his bed canes. During an observation [DATE] at 10:11 a.m., Resident #7's bed cane was approximately 2 inches from his mattress. It is unknown if the resident could get stuck in this opening. 3. A care plan dated [DATE] indicated Resident #8 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The care plan indicated a focus of the resident desired the use of 2 quarter rails while in bed. Interventions included: assess for safety of 2 quarter rails and the resident may utilize the 2 quarter rails as an enabler with turning and repositioning. The MDS dated [DATE] indicated Resident #8 was cognitively intact, understood others, and was understood by others. The MDS indicated Resident #8 required the assistance of 2 staff for bed mobility. A Bed Rail/Assist Bar Evaluation dated [DATE] indicated Resident #8 was cognitively intact. The resident had quarter bed rails. The evaluation factor was the resident expressed a desire to have bed rails/assist bar while in bed for her own safety and comfort. An intervention was frequent monitoring. Summary of findings indicated the resident used a bed cane for support with turning and positioning in bed. During an observation with LVN G on [DATE] at 8:42 a.m., Resident #8's bed had a bedrail on one side and a bed cane on the other side. There was an approximately 2 to 3 inch gap between the mattress and the bed cane on one side and the mattress and the bedrail on the other. 4. A care plan dated [DATE] indicated Resident #9 was admitted [DATE]. The plan indicated the resident had an ADL deficit due to and old motor vehicle accident with hemiparesis. The plan indicated the resident was able to grab hold of the side rail and trapeze bar to assist with bed mobility. The plan indicated the resident required assistance from one person, but would occasionally require the assistance of two persons. A Bed Rail/Assist Bar Evaluation dated [DATE] indicated Resident #9 was severely cognitively impaired and used 2 quarter side rails as enabler with turning and repositioning. During an observation on [DATE] at 8:59 a.m., Resident #9 had ¼ bedrails. There was an approximately 2 to 3 each gap between the mattress and the bedrails. The administrator, RN corporate nurse, and the regional director of operations were notified on [DATE] at 9:26 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The Plan of Removal was accepted on [DATE] at 12:00 p.m. and included: 1. An updated bed rail/assist bar assessment was completed on each resident with any type of bed railing or cane completed [DATE]. 2. IDT that consists of the Administrator, Regional Director, DON, Regional Nurse, and other administrative nurses were aware of results. Each respective MD will be notified as needed. 3.All staff will be in-serviced on accidents and incidents prevention that includes instruction on making sure no gaps exist between an assistive device and the bed its mounted to. This will be completed [DATE] and documented on the TAR Q shift. 4.All staff were in-serviced on [DATE] Enablers Turn, Repositioning or Transfers regarding at any point that a Resident does not use the Bed cane or a Side rail for assistance in turning or repositioning to alert nursing administration. 5.The IDT which consist of the Administrator, Director of Nursing, Assistant Director of Nursing, MDS/Care Plan Coordinator, and the care plan nurse will be in-serviced on interventions to be put in place and the plan of care for. -----A resident identified with current assistive devices and continued need -----A resident who may trigger to need an assistive device -----This will be conducted by the DON and completed [DATE] 6.After the incident was brought to the attention of the corporate staff on [DATE], the Administrator was instructed to self-report to DADS and OIG, the corporate team removed all facility made assistive bed devices. This was completed on [DATE]. The 7 remaining bed canes will be removed [DATE] and replaced with appropriate interventions. 7.All bed canes will be removed and placed with ¼ rails according to protocol. 8.All residents with an assistive bed device or side rails will have a visual assessment completed [DATE] by the administrative nursing team to ensure they have the upper physical ability to move away from the assistive device and utilize it per protocol. 9.All resident with bed canes will be placed on 1:1 until this is process is complete. 10.All assessments and care plans will be updated accordingly [DATE]. The surveyors confirmed the facility had implemented sufficiently to remove the Immediate Jeopardy on [DATE] by: *Information was reviewed on assessment for bed mobility assistive devices. Three LVNs, 1 medication aide, 4 CNAs and 1 housekeeping aide were interviewed and they demonstrated they were in-serviced on the information regarding accidents and incidents prevention regarding space between the rails and bed mattress and the usage of enablers for turning, repositioning and transfers. They were knowledgeable about changes in procedures. *In-service documentation was reviewed and indicated all staff were in-serviced as indicated on accidents and incidents prevention regarding space between the rails and bed mattress and the usage of enablers for turning, repositioning and transfers. *Interviews with the administrator, DON and ADON indicated they were in-serviced on the information and were knowledgeable about changes in procedures. On [DATE] at 4:10 p.m., the administrator and DON were notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on [DATE] at 5:16 p.m., the ADON said 20 residents used side rails and 3 residents used bed canes for assistance with bed mobility.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and care plan for 1 of 6 residents reviewed for pain. (Resident #1) The facility did not implement the plan of care when Resident #1 experienced unrelieved right leg pain and a low oxygen level. This failure could place 45 residents on pain management and 12 residents receiving respiratory treatments at risk for unrelieved pain and exacerbation of respiratory conditions. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, re-admitted [DATE] with [DIAGNOSES REDACTED]. The orders included [MEDICATION NAME] (Tylenol) 325 mg (milligrams) two tablets every 4 hours as needed for fever (start date 12/14/13) and Tylenol #4 (4 grains of [MEDICATION NAME]) 1 every 6 hours as needed for pain (start date 03/31/15). The orders also included, "O2 (oxygen) per N/C (nasal cannula) or mask prn (as needed) SOB (shortness of breath)" and "O2 @ (at) 2 L (liters) per mask while asleep and PRN SOB." The most recent MDS dated [DATE] indicated Resident #1 was alert and oriented, dependent for all activities of daily living, received oxygen, and had constant pain rated 9 on a pain scale of 0 - 10. A care plan for Resident #1 updated 04/13/15 indicated potential for pain with goals including "resident will state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions." Approaches included: to monitor for worsening of pain; to report changes in pain, such as location/type/frequency/intensity to physician; to administer and monitor the effectiveness of pain medication; and to continue APAP ([MEDICATION NAME]) as ordered. An update to the care plan dated 04/14/14 indicated to administer Tylenol #3 (3 grains of [MEDICATION NAME]) as ordered and to discontinue Tylenol #4. A care plan for Resident #1 updated 04/13/15 for "difficulty breathing related to chronic condition: [MEDICAL CONDITION] and [MEDICAL CONDITION]" indicated to "monitor for changes in/ development of signs and symptoms of breathing difficulty... changes in cognition. Report changes in respiratory status to physician. Administer/monitor effectiveness of treatments... oxygen." A care plan for Resident #1 for "requires the use of oxygen therapy as needed" indicated "resident will improve ventilation and adequate oxygenation" with interventions including "oximetry results within normal limits... assess residents (SIC) neurologic response... nurse to notify physician of oxygen sats (saturation) below 90%..." 1. Pain A witness statement from the transportation aide untimed and dated 03/30/15 indicated she helped put Resident #1 in her wheelchair for a physician appointment in a nearby city. Resident #1 told the transportation aide her leg was hurting. The transportation aide indicated Resident #1 said her leg was hurting prior to and upon returning from the physician appointment. A witness statement dated 03/31/15 from CNA A indicated Resident #1 returned from a physician appointment on 03/30/15. CNA A noted she assisted in putting Resident #1 back to bed at 1:45 p.m. and the resident refused to allow the CNAs to remove her Hoyer lift pad or clothing until she received something for pain. CNA A said the resident was "crying, nauseated, and in a lot of pain." CNA A reported Resident #1's pain to the charge nurse, LVN B. During an interview on 04/27/15 at 9:17 a.m., LVN B said no one told her Resident #1 was in pain prior to her transport to the physician on 03/30/15. She said CNA A told her the resident had some leg pain after she returned from the physician. She said CNA A did not tell her the resident was crying, nauseated, and refusing to be moved due to the pain. LVN B said she assessed Resident #1 and she said she thought her leg was hurting from being up so long. LVN B said the resident later complained of increased right knee pain and she called and left a voice mail for the physician. He called back two hours later and ordered a mobile x-ray. Nursing notes for Resident #1 by LVN B dated 03/30/15 indicated the following: 2:00 p.m., back at the facility. There was no documentation of pain. 3:00 p.m., complained of right knee pain. The physician was notified. 5:00 p.m., the physician ordered a mobile x-ray of the right knee. Nursing notes for Resident #1 by LVN D dated 03/30/15 - 3/31/15 indicated the following: 5:50 p.m., The resident was complaining of right lower extremity pain. LVN D noted the resident's knee was swollen, warm to touch, and there was purple bruising to her right lower extremity measuring 12 cm (centimeters) x 3 cm. The resident was in tears and unable to turn. LVN D administered Tylenol 650 mg at 6:00 p.m. and it was ineffective. LVN D noted the resident's body was in an awkward position, pelvis was flat, and the right leg was shorter than the left with the right knee rotated outwards. Her vital signs were stable, except for a temperature of 99.9 degrees Fahrenheit. The resident complained of nausea and LVN D placed a cool towel on her forehead. LVN D left a voice mail for the resident's physician, "response pending." 10:00 p.m., The resident continued to complain of right lower extremity pain and now right hip pain, stating, "The pain is radiating from my hip to my knee." LVN D gave another dose of Tylenol 650 mg. When the mobile x-ray of her right knee was done at 9:00 p.m., the resident screamed with pain. The right hip, knee, and pelvis were unchanged. LVN D left a voice mail for the resident's physician. 10:45 p.m., The mobile x-ray results showed no fracture or dislocation of the right knee. The resident refused care due to pain. The bruising and appearance of the right leg was unchanged. 2:00 a.m., The resident's pain continued and LVN D administered another dose of Tylenol 650 mg which was ineffective. She also continued to have nausea. LVN D left a voice mail for the resident's physician. 4:50 a.m., LVN D noted she would report the resident's condition and attempts to notify the physician to the on-coming nurse. The resident still refused incontinent care due to pain. 5:45 a.m., LVN D noted the resident continued to have pain and nausea. Nursing notes by LVN C dated 03/31/15 at 6:30 a.m. indicated Resident #1 was sent to the local emergency room at the family's request. An untimed emergency room physician note dated 03/31/15 indicated Resident #1 apparently fell yesterday and had a knee scrape. There was bruising noted to right lower extremity. The resident's pain was noted as mild with no complaints of right hip pain. The x-rays resulted in no acute fractures or abnormalities. The clinical impression was contusion (bruise with swelling and some bleeding under the skin) of hip. The notes did not indicate any medications were administered. The hospital x-rays dated 03/31/15 at 8:32 a.m. indicated Resident #1 had a possible fractured right knee. Nursing notes for Resident #1 by LVN C dated 03/31/15 indicated the following: 9:15 a.m., Resident #1 returned via ambulance and stretcher occupied by 2 personnel. Moaning and groaning when transferred into bed. The resident's physician was notified she returned still in pain. The physician ordered Tylenol #4 one by mouth every 6 hours as needed for pain. The nurse requested the pharmacy send it as soon as possible since it was not in the ER box. Her son was notified of the x-ray results and of the new order for Tylenol #4. 2:00 p.m., ID (initial dose) Tylenol #4 pain 8 out of 10. "States, 'I can't sleep for pain.'" Nursing notes for Resident #1 by LVN D dated 04/03/15 at 3:50 a.m., indicated, the resident hadincreased confusion in related to taking Tylenol #4. "Tylenol #4 effectively manages pain..." Nursing notes for Resident #1 by LVN B dated 04/13/15, untimed, indicated the following: When the resident was placed in a wheelchair to go for a physician appointment, she was unable to bend or abduct her right leg to put it on the foot rest. The resident said it increased the pain and she could not sit in a wheelchair long enough to go to the appointment. The physician was notfied and ordered a computed tomography scan and venous doppler of her right leg. A CT of the right leg for Resident #1 dated 04/14/15 at 9:06 a.m. indicated the following: "Impression: Comminuted tibial plateau fracture appears to be recent to subacute. There is no substantial joint effusion." An undated "Pain Management" policy and procedure indicated the following: "The patient's self-report of pain is the most reliable indicator of the existence of pain. When a patient feels severe pain, he seeks medical help because he believes the pain signals a serious problem. To assess and manage pain properly, the nurse must depend on both the patient's subjective description and objective tools. Ask the patient to rank his pain on a scale of 0 to 10, with 0 denoting lack of pain and 10 denoting the worst pain level...begin with a nonopioid [MEDICATION NAME], such as actaminophen or aspirin, every 4 to 6 hours as ordered...assess pain 60 minutes after oral medication administration. If the patient is still in pain, reassess him and alter your care plan as appropriate." 2. Oxygenation Nursing notes for Resident #1 by LVN B dated 04/03/15 indicated the following: 9:00 a.m., increased confusion noted. Vital sign (VS) were within normal limits. except O2 saturation level was very low at 79% (normal range 95%-100%). She was placed on O2 at 2 liters (L) per nasal cannula (N/C). Slight shortness of breath was noted. 9:15 a.m., Confusion still noted. VS were within normal limits, except O2 saturation level at 87%. Continue to monitor. 9:30 a.m., were within normal limits, except O2 saturation level at 91%. Cont. O2 at 2 L per N/C. Confusion still noted. Resident #1 was able to state her name and where she was. She answered some questions inappropriately, but did not know month, date, or time. 10:00 a.m., The resident's physician was notified and the nurse was awaiting a response. 10:30 a.m., O2 sat was at 93% and the VS were 120/69 - 85 - 20. The nurse documented increased confusion was still noted and she would continue to monitor. 11:00 a.m., "Left message for (son -- responsible party). VSS (vital signs stable). O2 sat 90%. Will cont. to monitor." 11:15 a.m., The resident's physician was called with no response. 11:30 a.m., "Son returned call. Req. (requested) that we send res to ER" for evaluation and treatment. The resident was transferred to the ER and admitted . During an interview on 04/27/15 at 9:17 a.m., LVN B said on 04/13/15 at 9:00 a.m., Resident #1 had increased confusion and her O2 sat was 79%. LVN B put oxygen on at 2 L per nasal cannula. She did not call the physician until 10:00 a.m. when the O2 sat was 87%. The physician did not answer and she left a voice mail. She left a message for Resident #1's son at 11:00 a.m. and left another voice mail for the physician at 11:15 a.m. At 11:30 a.m., the son called back and asked for Resident #1 to be sent to the emergency room . LVN B said they would sometimes send a resident to the ER if they were in distress, such as chest pain. She said Resident #1's O2 sat was improving. LVN B said when she documented the physician was "notified" in the nursing notes it meant a message was left on his mobile phone. During an interview and observation on 04/27/15 at 8:07 a.m., Resident #1 was in another local facility. She was lying in bed with oxygen on at 2 liters via nasal cannula. Resident #1 said she did not remember a fall or any other injury to her right leg. She remembered returning to the facility from her physician's appointment and that her leg hurt. She remembered that her leg hurt all night. She had no memory of her oxygen levels being low, but remembered being in the hospital and having a urinary tract infection. She said her leg continued to hurt while she was hospitalized . During an interview on 04/27/15 at 11:15 a.m., LVN D said 03/30/15 - 03/31/15, Resident #1 was in pain and had nausea. LVN D said she documented "MD (medical doctor) notified" it meant she left a voice mail on his mobile phone. LVN D said she called the hospital and Resident #1's physician was the on-call doctor. LVN D said she did not think to call the DON or on-call nurse. LVN D said she did not send Resident #1 to the ER because the resident's physician "was funny about you transferring his patients to the hospital" without discussing it with him. LVN D stated, "I didn't want to get in trouble." During an interview on 04/27/15 at 11:40 a.m., the DON said during both incidents with Resident #1, the nurses were unable to get a response from the resident's physician who was also the facility's medical director. The DON said the nurses should have notified the DON and the nurse on call. The DON said the nurses should use nursing judgement and transfer the resident to the emergency room . The DON stated the nurses should "do what's best for the resident." A "Making an Emergency Transfer or Discharge" policy and procedures dated 2001 noted, "Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident...1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, or facility will implement the following procedures: a. Notify the resident's attending physician..." The CMS 672 dated 04/24/15 indicated 45 residents were on pain management and 12 residents received respiratory treatments.

Based on interview and record review, the facility failed to consult with the physician and notify the responsible party for 1 of 12 residents reviewed for notification. (Resident #1) The facility did not immediately consult with the physician and notify the responsible party when Resident #1 experienced unrelieved right leg pain and a low oxygen level. This failure could place 45 residents on pain management and 12 residents receiving respiratory treatments at risk for unrelieved pain and exacerbation of respiratory conditions. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, re-admitted [DATE] with [DIAGNOSES REDACTED]. The orders included [MEDICATION NAME] (Tylenol) 325 mg (milligrams) two tablets every 4 hours as needed for fever (start date 12/14/13) and Tylenol #4 (4 grains of [MEDICATION NAME]) 1 every 6 hours as needed for pain (start date 03/31/15). The orders also included, "O2 (oxygen) per N/C (nasal cannula) or mask prn (as needed) SOB (shortness of breath)" and "O2 @ (at) 2 L (liters) per mask while asleep and PRN SOB." The most recent MDS dated [DATE] indicated Resident #1 was alert and oriented, dependent for all activities of daily living, received oxygen, and had constant pain rated 9 on a pain scale of 0 - 10. A care plan for Resident #1 updated 04/13/15 indicated potential for pain with goals including "resident will state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions." Approaches included to monitor for worsening of pain; to report changes in pain, such as location/type/frequency/intensity to the physician; to administer and monitor the effectiveness of pain medication; and to continue APAP ([MEDICATION NAME]) as ordered. An update to the care plan dated 04/14/14 indicated to administer Tylenol #3 (3 grains of [MEDICATION NAME]) as ordered and discontinue Tylenol #4. A care plan for Resident #1 updated 04/13/15 for difficulty breathing related to chronic conditions of [MEDICAL CONDITION] and [MEDICAL CONDITION] indicated to "monitor for changes in/ development of signs and symptoms of breathing difficulty... changes in cognition. Report changes in respiratory status to physician. Administer/monitor effectiveness of treatments... oxygen." A care plan for Resident #1 for the use of oxygen therapy as needed indicated "resident will improve ventilation and adequate oxygenation" with interventions including "oximetry results within normal limits... assess residents (SIC) neurologic response... nurse to notify physician of oxygen sats (saturation) below 90%..." 1. Pain A witness statement from the transportation aide untimed and dated 03/30/15 indicated she helped put Resident #1 in her wheelchair for a physician appointment in a nearby city. Resident #1 told the transportation aide her leg was hurting. The transportation aide indicated Resident #1 said her leg was hurting prior to and upon returning from the physician appointment. A witness statement dated 03/31/15 from CNA A indicated Resident #1 returned from a physician appointment on 03/30/15. CNA A noted she assisted in putting Resident #1 back to bed at 1:45 p.m. and the resident refused to allow the CNAs to remove her Hoyer lift pad or clothing until she received something for pain. CNA A said the resident was "crying, nauseated, and in a lot of pain." CNA A reported Resident #1's pain to the charge nurse, LVN B. During an interview on 04/27/15 at 9:17 a.m., LVN B said no one told her Resident #1 was in pain prior to her transport to the physician on 03/30/15. She said CNA A told her the resident had some leg pain after she returned from the physician. She said CNA A did not tell her the resident was crying, nauseated, and refusing to be moved due to the pain. LVN B said she assessed Resident #1 and she said she thought her leg was hurting from being up so long. LVN B said the resident later complained of increased right knee pain and she called and left a voice mail for the physician. He called back two hours later and ordered a mobile x-ray. Nursing notes for Resident #1 by LVN B dated 03/30/15 indicated the following: 2:00 p.m., back at the facility. There was no documentation of pain. 3:00 p.m., complained of right knee pain. The physician was notified. 5:00 p.m., the physician ordered a mobile x-ray of the right knee. Nursing notes for Resident #1 by LVN D dated 03/30/15 - 03/31/15 indicated the following: 5:50 p.m., The resident was complaining of right lower extremity pain. LVN D noted the resident's knee was swollen, warm to touch, and there was purple bruising to her right lower extremity measuring 12 cm (centimeters) x 3 cm. The resident was in tears and unable to turn. LVN D administered Tylenol 650 mg at 6:00 p.m. and it was ineffective. LVN D noted the resident's body was in an awkward position, pelvis was flat, and the right leg was shorter than the left with the right knee rotated outwards. Her vital signs were stable, except for a temperature of 99.9 degrees Fahrenheit. The resident complained of nausea and LVN D placed a cool towel on her forehead. LVN D left a voice mail for the resident's physician, "response pending." 10:00 p.m., The resident continued to complain of right lower extremity pain and now right hip pain, stating, "The pain is radiating from my hip to my knee." LVN D gave another dose of Tylenol 650 mg. When the mobile x-ray of her right knee was done at 9:00 p.m., the resident screamed with pain. The right hip, knee, and pelvis were unchanged. LVN D left a voice mail for the resident's physician. 10:45 p.m., The mobile x-ray results showed no fracture or dislocation of the right knee. The resident refused care due to pain. The bruising and appearance of the right leg was unchanged. 2:00 a.m., The resident's pain continued and LVN D administered another dose of Tylenol 650 mg which was ineffective. She also continued to have nausea. LVN D left a voice mail for the resident's physician. 4:50 a.m., LVN D noted she would report the resident's condition and attempts to notify the physician to the on-coming nurse. The resident still refused incontinent care due to pain. 5:45 a.m., LVN D noted the resident continued to have pain and nausea. Nursing notes by LVN C dated 03/31/15 at 6:30 a.m. indicated Resident #1 was sent to the local emergency room at the family's request. An untimed emergency room physician notes dated 03/31/15 indicated, Resident #1, apparently fell yesterday and had knee scrape. There was bruising noted to right lower extremity. The resident's pain was noted as mild with no complaints of right hip pain. The x-rays resulted in no acute fractures or abnormalities. The clinical impression was contusion (bruise with swelling and some bleeding under the skin) of hip. The notes did not indicate any medications were administered. The hospital x-rays dated 03/31/15 at 8:32 a.m., indicated Resident #1 had a possible fractured right knee. Nursing notes for Resident #1 by LVN C dated 03/31/15 indicated the following: 9:15 a.m., Resident #1 returned via ambulance and stretcher occupied by 2 personnel. Moaning and groaning when transferred into bed. The resident's physician was notified she returned still in pain. The physician ordered Tylenol #4 one by mouth every 6 hours as needed for pain. The nurse requested the pharmacy send it as soon as possible since it was not in the ER box. Her son was notified of the x-ray results and of the new order for Tylenol #4. 2:00 p.m., ID (initial dose) Tylenol #4 pain 8 out of 10. "States, 'I can't sleep for pain.'" Nursing notes for Resident #1 by LVN D dated 04/03/15 at 3:50 a.m., indicated, the resident had increased confusion related to taking Tylenol #4. "Tylenol #4 effectively manages pain..." Nursing notes for Resident #1 by LVN B dated 04/13/15, untimed, indicated the following: When the resident was placed in a wheelchair to go for a physician appointment, she was unable to bend or abduct her right leg to put it on the foot rest. The resident said it increased the pain and she could not sit in a wheelchair long enough to go to the appointment. The physician was notified and ordered a computed tomography scan and venous doppler of her right leg. A CT of the right leg for Resident #1 dated 04/14/15 at 9:06 a.m. indicated the following: "Impression: Comminuted tibial plateau fracture appears to be recent to subacute. There is no substantial joint effusion." An undated "Pain Management" policy and procedure indicated the following: "The patient's self-report of pain is the most reliable indicator of the existence of pain. When a patient feels severe pain, he seeks medical help because he believes the pain signals a serious problem. To assess and manage pain properly, the nurse must depend on both the patient's subjective description and objective tools. Ask the patient to rank his pain on a scale of 0 to 10, with 0 denoting lack of pain and 10 denoting the worst pain level...begin with a nonopioid [MEDICATION NAME], such as actaminophen or aspirin, every 4 to 6 hours as ordered...assess pain 60 minutes after oral medication administration. If the patient is still in pain, reassess him and alter your care plan as appropriate." 2. Oxygenation Nursing notes for Resident #1 by LVN B dated 04/03/15 indicated the following: 9:00 a.m., increased confusion noted. Vital sign (VS) were within normal limits. except O2 saturation level was very low at 79% (normal range 95%-100%). She was placed on O2 at 2 liters (L) per nasal cannula (N/C). Slight shortness of breath was noted. 9:15 a.m., Confusion still noted. VS were within normal limits, except O2 saturation level at 87%. Continue to monitor. 9:30 a.m., VS were within normal limits, except O2 saturation level at 91%. Cont. O2 at 2 L per N/C. Confusion still noted. Resident #1 was able to state her name and where she was. She answered some questions inappropriately, but did not know month, date, or time. 10:00 a.m., The resident's physician was notified and the nurse documented she was awaiting a response. 10:30 a.m., O2 sat was 93% with VS 120/69 - 85 - 20. Increased confusion was still noted. The nurse documented she would continue to monitor. 11:00 a.m., "Left message for (son -- responsible party). VSS (vital signs stable). O2 sat 90%. Will cont. to monitor." 11:15 a.m., The resident's physician was called with no response. 11:30 a.m., "Son returned call. Req. (requested) that we send res to ER" for evaluation and treatment. The resident was transferred to the ER and admitted . During an interview on 04/27/15 at 9:17 a.m., LVN B said on 04/13/15 at 9:00 a.m., Resident #1 had increased confusion and her O2 sat was 79%. LVN B put oxygen on at 2 L per nasal cannula. She did not call the physician until 10:00 a.m. when the O2 sat was 87%. The physician did not answer and she left a voice mail. She left a message for Resident #1's son at 11:00 a.m. and left another voice mail for the physician at 11:15 a.m. At 11:30 a.m., the son called back and asked for Resident #1 to be sent to the emergency room . LVN B said they would sometimes send a resident to the ER if they were in distress, such as chest pain. She said Resident #1's O2 sat was improving. LVN B said when she documented the physician was "notified" in the nursing notes it meant a message was left on his mobile phone. During an interview and observation on 04/27/15 at 8:07 a.m., Resident #1 was in another local facility. She was lying in bed with oxygen on at 2 liters via nasal cannula. Resident #1 said she did not remember a fall or any other injury to her right leg. She remembered returning to the facility from her physician's appointment and that her leg hurt. She remembered that her leg hurt all night. She had no memory of her oxygen levels being low, but remembered being in the hospital and having a urinary tract infection. She said her leg continued to hurt while she was hospitalized . During an interview on 04/27/15 at 11:15 a.m., LVN D said 03/30/15 - 03/31/15, Resident #1 was in pain and had nausea. LVN D said she documented "MD (medical doctor) notified" it meant she left a voice mail on his mobile phone. LVN D said she called the hospital and Resident #1's physician was the on-call doctor. LVN D said she did not think to call the DON or on-call nurse. LVN D said she did not send Resident #1 to the ER because the resident's physician "was funny about you transferring his patients to the hospital" without discussing it with him. LVN D stated, "I didn't want to get in trouble." During an interview on 04/27/15 at 11:40 a.m., the DON said during both incidents with Resident #1, the nurses were unable to get a response from the resident's physician who was also the facility's medical director. The DON said the nurses should have notified the DON and the nurse on call. The DON said the nurses should use nursing judgement and transfer the resident to the emergency room . The DON stated the nurses should "do what's best for the resident." A "Change in a Resident's Condition or Status" policy and procedure revised April 2006 noted, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) or changes in the resident's medical/mental condition and/or status...1. The nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...g. A need to transfer the resident to a hospital/treatment center..." A "Making an Emergency Transfer or Discharge" policy and procedures dated 2001 noted, "Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident...1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, or facility will implement the following procedures: a. Notify the resident's attending physician..." The CMS 672 dated 04/24/15 indicated 45 residents were on pain management and 12 residents received respiratory treatments.

Based on interview and record review, the facility medical director failed to respond for 1 of 12 residents reviewed for physician notification and consultation. (Resident #1) The facility medical director, who was also Resident #1's physician, did not respond when Resident #1 experienced unrelieved right leg pain and a low oxygen level. This failure could place 45 residents on pain management and 12 residents receiving respiratory treatments at risk for unrelieved pain and exacerbation respiratory conditions. Findings included: Physician orders [REDACTED].#1 was [AGE] years old, re-admitted [DATE] with [DIAGNOSES REDACTED]. The orders included [MEDICATION NAME] (Tylenol) 325 mg (milligrams) two tablets every 4 hours as needed for fever (start date 12/14/13) and Tylenol #4 (4 grains of [MEDICATION NAME]) 1 every 6 hours as needed for pain (start date 03/31/15). The orders also included, "O2 (oxygen) per N/C (nasal cannula) or mask prn (as needed) SOB (shortness of breath)" and "O2 @ (at) 2 L (liters) per mask while asleep and PRN SOB." The most recent MDS dated [DATE] indicated Resident #1 was alert and oriented, dependent for all activities of daily living, received oxygen, and had constant pain rated 9 on a pain scale of 0 - 10. A care plan for Resident #1 updated 04/13/15 indicated potential for pain with goals including "resident will state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions." Approaches included: to monitor for worsening of pain; to report changes in pain, such as location/type/frequency/intensity to physician; to administer and monitor the effectiveness of pain medication; and to continue APAP ([MEDICATION NAME]) as ordered. An update to the care plan dated 04/14/14 indicated to administer Tylenol #3 (3 grains of [MEDICATION NAME]) as ordered and to discontinue Tylenol #4. A care plan for Resident #1 updated 04/13/15 for "difficulty breathing related to chronic condition: [MEDICAL CONDITION] and [MEDICAL CONDITION]" indicated to "monitor for changes in/ development of signs and symptoms of breathing difficulty... changes in cognition. Report changes in respiratory status to physician. Administer/monitor effectiveness of treatments... oxygen." A care plan for Resident #1 for "requires the use of oxygen therapy as needed" indicated "resident will improve ventilation and adequate oxygenation" with interventions including "oximetry results within normal limits... assess residents (SIC) neurologic response... nurse to notify physician of oxygen sats (saturation) below 90%..." 1. Pain A witness statement from the transportation aide untimed and dated 03/30/15 indicated she helped put Resident #1 in her wheelchair for a physician appointment in a nearby city. Resident #1 told the transportation aide her leg was hurting. The transportation aide indicated Resident #1 said her leg was hurting prior to and upon returning from the physician appointment. A witness statement dated 03/31/15 from CNA A indicated Resident #1 returned from a physician appointment on 03/30/15. CNA A noted she assisted to put Resident #1 back to bed at 1:45 p.m. and the resident refused to allow the CNAs to remove her Hoyer lift pad or clothing until she received something for pain. CNA A said the resident was "crying, nauseated, and in a lot of pain." CNA A reported Resident #1's pain to the charge nurse, LVN B. During an interview on 04/27/15 at 9:17 a.m., LVN B said no one told her Resident #1 was in pain prior to her transport to the physician on 03/30/15. She said CNA A told her the resident had some leg pain after she returned from the physician. She said CNA A did not tell her the resident was crying, nauseated, and refusing to be moved due to the pain. LVN B said she assessed Resident #1 and she said she thought her leg was hurting from being up so long. LVN B said the resident later complained of increased right knee pain and she called and left a voice mail for the physician. He called back two hours later and ordered a mobile x-ray. Nursing notes for Resident #1 by LVN B dated 03/30/15 indicated the following: 2:00 p.m., back at the facility. There was no documentation of pain. 3:00 p.m., complained of right knee pain. The physician was notified. 5:00 p.m., the physician ordered a mobile x-ray of the right knee. Nursing notes for Resident #1 by LVN D dated 03/30/15 - 3/31/15 indicated the following: 5:50 p.m., The resident was complaining of right lower extremity pain. LVN D noted the resident's knee was swollen, warm to touch, and there was purple bruising to her right lower extremity measuring 12 cm (centimeters) x 3 cm. The resident was in tears and unable to turn. LVN D administered Tylenol 650 mg at 6:00 p.m. and it was ineffective. LVN D noted the resident's body was in an awkward position, pelvis was flat, and the right leg was shorter than the left with the right knee rotated outwards. Her vital signs were stable, except for a temperature of 99.9 degrees Fahrenheit. The resident complained of nausea and LVN D placed a cool towel on her forehead. LVN D left a voice mail for the resident's physician, "response pending." 10:00 p.m., The resident continued to complain of right lower extremity pain and now right hip pain, stating, "The pain is radiating from my hip to my knee." LVN D gave another dose of Tylenol 650 mg. When the mobile x-ray of her right knee was done at 9:00 p.m., the resident screamed with pain. The right hip, knee, and pelvis were unchanged. LVN D left a voice mail for the resident's physician. 10:45 p.m., The mobile x-ray results showed no fracture or dislocation of the right knee. The resident refused care due to pain. The bruising and appearance of the right leg was unchanged. 2:00 a.m., The resident's pain continued and LVN D administered another dose of Tylenol 650 mg which was ineffective. She also continued to have nausea. LVN D left a voice mail for the resident's physician. 4:50 a.m., LVN D noted she would report the resident's condition and attempts to notify the physician to the on-coming nurse. The resident still refused incontinent care due to pain. 5:45 a.m., LVN D noted the resident continued to have pain and nausea. Nursing notes by LVN C dated 03/30/15 at 6:30 a.m. indicated Resident #1 was sent to the local emergency room at the family's request. An untimed emergency room physician notes dated 03/31/15 indicated, Resident #1, apparently fell yesterday and had knee scrape. There was bruising noted to right lower extremity. The resident's pain was noted as mild with no complaints of right hip pain. The x-rays resulted in no acute fractures or abnormalities. The clinical impression was contusion (bruise with swelling and some bleeding under the skin) of hip. The notes did not indicate any medications were administered. The hospital x-rays dated 03/31/15 at 8:32 a.m. indicated Resident #1 had a possible fractured right knee. Nursing notes for Resident #1 by LVN C dated 03/31/15 indicated the following: 9:15 a.m., Resident #1 returned via ambulance and stretcher occupied by 2 personnel. Moaning and groaning when transferred into bed. The resident's physician was notified she returned still in pain. The physician ordered Tylenol #4 one by mouth every 6 hours as needed for pain. The nurse requested the pharmacy send it as soon as possible since it was not in the ER box. Her son was notified of the x-ray results and of the new order for Tylenol #4. 2:00 p.m., ID (initial dose) Tylenol #4 pain 8 out of 10. "States, 'I can't sleep for pain.'" Nursing notes for Resident #1 by LVN D dated 04/03/15 at 3:50 a.m., indicated, the resident hadincreased confusion in r/t (related to) taking Tylenol #4. Tylenol #4 effectively manages pain..." Nursing notes for Resident #1 by LVN B dated 04/13/15, untimed, indicated the following: When the resident was placed in a wheelchair to go for a physician appointment, she was unable to bend or abduct her right leg to put it on the foot rest. The resident said it increased the pain and she could not sit in a wheelchair long enough to go to the appointment. The physician was notfied and ordered a computed tomography scan and venous doppler of her right leg. A CT of the right leg for Resident #1 dated 04/14/15 at 9:06 a.m. indicated the following: "Impression: Comminuted tibial plateau fracture appears to be recent to subacute. There is no substantial joint effusion." An undated "Pain Management" policy and procedure indicated the following: "The patient's self-report of pain is the most reliable indicator of the existence of pain. When a patient feels severe pain, he seeks medical help because he believes the pain signals a serious problem. To assess and manage pain properly, the nurse must depend on both the patient's subjective description and objective tools. Ask the patient to rank his pain on a scale of 0 to 10, with 0 denoting lack of pain and 10 denoting the worst pain level...begin with a nonopioid [MEDICATION NAME], such as actaminophen or aspirin, every 4 to 6 hours as ordered...assess pain 60 minutes after oral medication administration. If the patient is still in pain, reassess him and alter your care plan as appropriate." 2. Oxygenation Nursing notes for Resident #1 by LVN B dated 04/03/15 indicated the following: 9:00 a.m., increased confusion noted. Vital sign (VS) were within normal limits. except O2 saturation level was very low at 79% (normal range 95%-100%). She was placed on O2 at 2 liters (L) per nasal cannula (N/C). Slight shortness ob breath was noted. 9:15 a.m., Confusion still noted. VS were within normal limits, except O2 saturation level at 87%. Continue to monitor. 9:30 a.m., were within normal limits, except O2 saturation level at 91%. Cont. O2 at 2 L per N/C. Confusion still noted. Resident #1 was able to state her name and where she was. She answered some questions inappropriately, but did not know month, date, or time. 10:00 a.m., The resident's physician was notified and the nurse was awaiting a response. 10:30 a.m., O2 sat 93% with VS 120/69 - 85 - 20. Increased confusion was still noted. The nurse would continue to monitor. 11:00 a.m., "Left message for (son -- responsible party). VSS (vital signs stable). O2 sat 90%. Will cont. to monitor." 11:15 a.m., The resident's physician was called with no response. 11:30 a.m., "Son returned call. Req. (requested) that we send res to ER" for evaluation and treatment. The resident was transferred to the ER and admitted . During an interview on 04/27/15 at 9:17 a.m., LVN B said on 04/13/15 at 9:00 a.m., Resident #1 had increased confusion and her O2 sat was 79%. LVN B put oxygen on at 2 L per nasal cannula. She did not call the physician until 10:00 a.m. when the O2 sat was 87%. The physician did not answer and she left a voice mail. She left a message for Resident #1's son at 11:00 a.m. and left another voice mail for the physician at 11:15 a.m. At 11:30 a.m., the son called back and asked for Resident #1 to be sent to the emergency room . LVN B said they would sometimes send a resident to the ER if they were in distress, such as chest pain. She said Resident #1's O2 sat was improving. LVN B said when she documented the physician was "notified" in the nursing notes it meant a message was left on his mobile phone. During an interview and observation on 04/27/15 at 8:07 a.m., Resident #1 was in another local facility. She was lying in bed with oxygen on at 2 liters via nasal cannula. Resident #1 said she did not remember a fall or any other injury to her right leg. She remembered returning to the facility from her physician's appointment and that her leg hurt. She remembered that her leg hurt all night. She had no memory of her oxygen levels being low, but remembered being in the hospital and having a urinary tract infection. She said her leg continued to hurt while she was hospitalized . During an interview on 04/27/15 at 11:15 a.m., LVN D said 03/30/15 - 03/31/15, Resident #1 was in pain and had nausea. LVN D said she documented "MD (medical doctor) notified" it meant she left a voice mail on his mobile phone. LVN D said she called the hospital and Resident #1's physician was the on-call doctor. LVN D said she did not think to call the DON or on-call nurse. LVN D said she did not send Resident #1 to the ER because the resident's physician "was funny about you transferring his patients to the hospital" without discussing it with him. LVN D stated, "I didn't want to get in trouble." During an interview on 04/27/15 at 11:40 a.m., the DON said during both incidents with Resident #1, the nurses were unable to get a response from the resident's physician who was also the facility's medical director. The DON said the nurses should have notified the DON and the nurse on call. The DON said the nurses should use nursing judgement and transfer the resident to the emergency room . The DON stated the nurses should "do what's best for the resident." During an interview on 04/27/15 at 4:00 p.m., the administrator said there had been an on-going problem with the medical director answering his mobile phone messages. He said they had discussed the problem with the medical director and it was better for a while, but lately had been getting worse again. The administrator said the medical director was a hospitalist who did not have an office practice and his mobile phone number was the only means to reach him. A Medical Director policy and procedure revised June indicated the following: "Physician services shall be under the supervision of the medical director...2. The medical director is a licensed physician in this state and is responsible for: a. Ensuring adequate and appropriate physician services...e. Participating in efforts to improve quality of care and services...3. Medical director functions also include, but are not limited to...c. Helping assure that residents receive adequate services appropriate to meet their needs..." A "Change in a Resident's Condition or Status" policy and procedure revised April 2006 noted, "Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) or changes in the resident's medical/mental condition and/or status...1. The nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...g. A need to transfer the resident to a hospital/treatment center..." A "Making an Emergency Transfer or Discharge" policy and procedures dated 2001 noted, "Our facility shall make an emergency transfer or discharge when it is in the best interest of the resident...1. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, or facility will implement the following procedures: a. Notify the resident's attending physician..." The CMS 672 dated 04/24/15 indicated 45 residents were on pain management and 12 residents received respiratory treatments.

Based on interview and record review, the facility failed to consult the physician regarding an incident for 1 of 10 residents reviewed for physician notification. (Resident #72) The facility did not notify the physician on 01/08/14 when Resident #72 threatened to kill himself with a razor blade. This failure could place 18 residents residing on the secure unit at risk of injury or delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED].#72 was a [AGE] year old male admitted [DATE] with [DIAGNOSES REDACTED]. A complete psychiatric evaluation from the behavioral hospital dated 11/15/13 indicated Resident #72: *had at least one depressive episode, *had a history of [REDACTED]. *had a history of [REDACTED]. *"according to family has had 3 suicide attempts. Two overdoses and one where he stabbed self." A nursing note from the behavioral hospital dated 11/18/13 indicated Resident #72 had a [DIAGNOSES REDACTED]. Resident #72's care plans indicated: *11/22/13, "Potential for psychosocial maladjustment related to recent admit to facility with [DIAGNOSES REDACTED]. Approaches included: monitor need for psych consult and report changes in behavior." *11/22/13, Resident had impaired cognitive skills as evidenced by short term memory loss, decision making, and inattention. "Has long term (diagnoses) of mental illness." Approaches included: "Monitor need for psych consult as warranted." *11/29/13, Resident has a history of depression. Approaches included: "Provide psych consult per order." A social service assessment dated [DATE] indicated Resident #72's mental history included: "paranoia, suicidal ideation, suicide attempts, and depression." Resident #72's admission MDS dated [DATE] indicated: *he was independent in cognition; *was depressed; *had trouble concentrating; *had [MEDICAL CONDITION]; *was verbally abusive; *wandered; and *and walked with a cane. Resident #72's nursing notes dated 01/08/14 indicated "Pt. (patient) threatening to kill himself (with) razor blade. Pt. having delusional episodes. Pt. spoke to...(administrator with no) active doings. Will continue to monitor pt. (every) 2 (hours)." During interviews on 01/16/14 at 9:10 a.m. and 1:15 p.m., the administrator said on 01/08/14, LVN K informed him of the incident with Resident #72. He said the medication aide told him she did not see a razor. He said when he went on the secure unit, he asked Resident #72 if he had a razor. Resident #72 took the administrator to his room and showed him a black, flimsy object from his drawer. The administrator said it was not a razor Resident #72 showed him. He said Resident #72 was a poor historian. The administrator said he was a psychotherapist and was qualified to diagnose. He said he assessed Resident #72 and he was not suicidal. The administrator said he was not sure if he documented anything. He said he would have to look in the chart. No documentation of his assessment was ever provided. During interviews on 01/16/14 at 9:19 a.m. and 1:07 p.m., the social worker said she was not aware Resident #72 threatened to harm himself on o1/08/14. She said he attempted suicide before he was admitted to the facility, but there had not been any attempts since. She said she had not contacted psychological services for Resident #72. She said had she known about Resident #72's threat to kill himself with a razor blade, she would have made a referral to psychological services. During an interview on 01/16/14 at 9:57 a.m., LVN K (the charge nurse) said on 01/08/14, MA L said Resident #72 was going to cut his throat with a razor. LVN K said she notified the administrator who spoke with Resident #72. She said after the administrator said Resident #72 was not suicidal, they did not do anything further. She said MA L said it looked like he had a razor blade, but when LVN K saw it, it was like a sharp, plastic object. During an interview on 01/16/14 at 10:15 a.m., MA L said she was at her medication cart by the side door next to the social worker's office on 01/08/14 when Resident #72 came up to her and said he made past attempts to harm himself prior to his admission to the facility. She said he made statements previously about harming himself. She said Resident #72 referred to cutting himself before and demonstrated a gesture of cutting his chest as if that was how he cut himself before. She said Resident #72 told her the next time he tried to harm himself, he was going to use a razor blade and made a gesture of cutting his throat. She said Resident #72 was calm when he said it. She said Resident #72 had a razor blade in his hand. She said it looked like he broke a disposable razor and had the blade from it in his hand. She said she did not ask him where he got the razor blade. She said it scared her. She said she did not know if he would harm her, so she told the aides to close all the doors, keep everyone in their room, and called the nurse. She said the administrator arrived with the nurse. She said when the administrator came in, he asked Resident #72 if he had a razor and Resident #72 told him he had a razor because it was his. She said she saw Resident #72 walk off and the administrator followed him. She said she then left the secure unit to calm down. During an interview on 01/16/14 at 11:41 a.m., CNA M said on 01/08/14, she was at the nursing station when MA L was passing medications. CNA M said she saw Resident #72 talking to MA L and he told MA L he was going to harm himself. She said she called the nurse and the nurse and administrator arrived. She said the administrator spoke with Resident #72 and his attitude changed. She said prior, Resident #72 was paranoid and a little agitated. She said after the administrator spoke to him, he was friendly and talkative. She said she checked on Resident #72 every fifteen minutes, but did not document it. She said she was not instructed to do so. She said she just wanted to make sure Resident #72 was safe. She said normally, the nurse received an order from the doctor and the nurse would give them a sheet to document their monitoring on the resident every fifteen minutes. During an interview on 01/16/14 at 11:35 a.m., the DON said if the administrator was not a psychotherapist, they would have called the community healthcare agency for a psychiatric referral and placed Resident #72 on one-on-one monitoring following the incident on 01/08/14. She said since the administrator was a licensed psychotherapist; he looked at Resident #72 and did not see the suicidal tendencies. She said the physician was not called and reiterated she was not aware of the incident. She said Resident #72 was not receiving psychological counseling services (other than the administrator's intervention). A suicide threats policy and procedure dated April 2006 indicated, "Resident suicide threats must be taken seriously and immediately reported to the Nurse Supervisor/Charge Nurse." "2. The Nurse Supervisor/Charge Nurse shall immediately notify the resident's Attending Physician, Director of Nursing services, and sponsor a record of such threats." A list provided by the BOM dated 01/16/14 indicated 18 residents resided on the secure unit.

Based on observation, interview, and record review, the facility failed to ensure the environment was free from hazards and adequate supervision was provided to prevent accidents for 4 of 10 residents reviewed for accidents and hazards. (Resident #s 72, 59, 82, and 74) IMMEDIATE JEOPARDY A 1. Prior to admission, Resident #72 had a history of [REDACTED]. On 01/08/14, Resident #72 threatened to kill himself with a razor blade. The facility did not notify the physician, implement interventions to ensure his safety, or search the secure unit for razors or other hazardous items. An Immediate Jeopardy situation was identified on 01/16/14. IMMEDIATE JEOPARDY B 2. On 12/26/13, Resident #59's head became entrapped in the side rail with her legs off the bed on the floor. The resident did not sustain injuries, however, the facility did not implement interventions to prevent further occurrences following the incident. An Immediate Jeopardy situation was identified on 01/17/14. The Immediate Jeopardy was removed on 01/17/14. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. NON-IMMEDIATE JEOPARDY 3. Resident #82, who resided on the secure unit, had a heating pad plugged in and turned on "low" on his night stand. Resident #74 also resided in the room. These failures could place 18 residents who resided on the secure unit and 48 residents with side rails at risk for injury or death. Findings included: 1. Physician orders [REDACTED].#72 was a [AGE] year old male admitted [DATE] with [DIAGNOSES REDACTED]. There was no order for a psychiatric consultation. A complete psychiatric evaluation from the behavioral hospital dated 11/15/13 indicated Resident #72: * had at least one depressive episode, * had a history of [REDACTED]. * had a history of [REDACTED]. * "according to family, has had 3 suicide attempts. Two overdoses and one where he stabbed self." A nursing note from the behavioral hospital dated 11/18/13 indicated Resident #72 had a [DIAGNOSES REDACTED]. Resident #72's care plans indicated: *11/22/13, "Potential for psychosocial maladjustment related to recent admit to facility with [DIAGNOSES REDACTED]." Approaches included: monitor need for psych consult and report changes in behavior. *11/22/13, "Resident had impaired cognitive skills as evidence by short term memory loss, decision making, and inattention. "Has long term (diagnoses) of mental illness." Approaches included: "monitor need for psych consult as warranted". *11/29/13, "Resident has a history of depression. Approaches included: provide psych consult per order." There was no care plan addressing his history of suicide attempts. A social service assessment dated [DATE] indicated Resident #72's mental history included: "paranoia, suicidal ideation, suicide attempts, and depression." An admission MDS dated [DATE] indicated Resident #72: * was independent in cognition; * was depressed * had trouble concentrating * had delusions; * was verbally abusive; * wandered; and * walked with a cane. Nursing notes for Resident #72 indicated: *12/19/13, "...Paranoid ...Still hears voices and answers them." *12/21/13, "Agitated toward staff, feels that he's being talked about and wants it stopped." *12/27/13, at 0100 (1:00 a.m.) "Paranoid about female resident following him."At 1300, "Resident continues to refuse all meds, won't say why other than doesn't want them. Agitated (at) times". *01/03/14, "Pt. (patient) (with) delusional episodes. Pt. loud (and) rude (with) staff (at) times." *01/04/14, "Pt. (with) delusional episode. Pt. gets upset when staff is talking at times. Pt. thinks staff is talking about him." *01/08/14, "Pt. threatening to kill himself (with) razor blade. Pt. having delusional episodes. Pt. spoke to ... (administrator with no) active doings (sic). Will continue to monitor pt. (every) 2 (hours)". *01/09/14, "Resident having delusional episodes. Threatened to hit this nurse in head (with) his cane". *01/11/14, "Res. (resident) alert/confused (with) aggressiveness noted ...Res. dashed water onto weekend RN clothes from over the nurse's desk. Res. was very agitated, wanting to leave unit, kicking the doors threatening to burst windows out of the doors (with) cane." *01/12/14, "Pt. (with) delusional episodes." *01/13/14, "Pt. continue (with) delusional episodes." At 4:45 p.m., "Res. was attempting to hit staff members with his cane and he cursed them out." *01/14/14, "Pt. (with) aggressive behavior (at) times. Pt. (with) some delusional episodes." Incident/accident reports dated January 2014 indicated there was no report for Resident #72's incident on 01/08/14 when he threatened to kill himself with a razor blade. During an observation of the secure unit on 01/13/14 at 6:19 p.m., a disposable razor was in room 159 on the shelf above the bathroom sink. The room belonged to Resident #s 72 and 73, but neither was in their room at that time. During an interview on 01/16/14 at 10:15 a.m., MA L said she was at her medication cart by the side door next to the social worker's office on 01/08/14 when Resident #72 came up to her and said he made past attempts to harm himself prior to his admission to the facility. She said he made statements previously about harming himself. She said Resident #72 referred to cutting himself before and demonstrated a gesture of cutting his chest as if that was how he cut himself before. She said Resident #72 told her the next time he tried to harm himself, he was going to use a razor blade and made a gesture of cutting his throat. She said Resident #72 was calm when he said it. She said Resident #72 had a razor blade in his hand. She said it looked like he broke a disposable razor and had the blade from it in his hand. She said she did not ask him where he got the razor blade. She said it scared her. She said she did not know if he would harm her, so she told the aides to close all the doors, keep everyone in their room, and called the nurse. She said the administrator arrived with the nurse. She said when the administrator came in, he asked Resident #72 if he had a razor and Resident #72 told him he had a razor because it was his. She said she saw Resident #72 walk off and the administrator followed him. She said she then left the secure unit to calm down. During an interview on 01/16/14 at 9:57 a.m., LVN K (the charge nurse) said on 01/08/14, MA L told her Resident #72 was going to cut his throat with a razor. LVN K said she notified the administrator who spoke with Resident #72. She said after the administrator said Resident #72 was not suicidal, they did not do anything further. She said MA L said it looked like he had a razor blade, but when LVN K saw it, it looked like a sharp, plastic object. She said none of the staff searched his room or any other rooms to ensure no razors or other hazardous items were present after the incident. She said staff had to give residents razors because they were locked up. She said once the resident finished using the disposable razor, it should be disposed of in the sharps container. She said they normally would conduct a search of the rooms to make sure disposable razors were not present, but they did not following this incident. She said they did not conduct any special monitoring on Resident #72 after the incident. She said she checked on him approximately every 2.5 hours and the nurse aides checked on him approximately every 2 hours. She said Resident #72 said delusional things all the time, but he was alert and oriented to person, place, and time. She said she was not aware of his history of suicide attempts. During interviews on 01/16/14 at 9:10 a.m. and 1:15 p.m., the administrator said on 01/08/14, LVN K informed him of the incident with Resident #72. He said MA L told him she did not see a razor. He said when he went on the secure unit, he asked Resident #72 if he had a razor and Resident #72 took him to his room and showed him a black flimsy object from his drawer. He said it was not a razor. He said Resident #72 was a poor historian. The administrator said he was a psychotherapist and was qualified to diagnose. He said he assessed Resident #72 and he was not suicidal. The administrator said he was not sure if he documented anything. He said he would have to look in the chart. No documentation of his assessment was ever provided. During an interview on 01/16/14 at 11:41 a.m., CNA M said she was at the nursing station on 01/08/14 when MA L was passing medications. CNA M said she saw Resident #72 talking to MA L and he told MA L he was going to harm himself. CNA M said she called the nurse and the nurse and administrator arrived. She said the administrator spoke with Resident #72 and his attitude changed. She said prior, Resident #72 was paranoid and a little agitated. She said after the administrator spoke to him, he was friendly and talkative. She said she checked on resident every fifteen minutes, but did not document it. She said she was not instructed to do so. She said she just wanted to make sure Resident #72 was safe. She said normally, the nurse received an order from the doctor and the nurse would give them a sheet to document monitoring the resident every fifteen minutes. She said they did not conduct a search of the secure unit or Resident #72's room to remove razors or any other hazardous items. She said when she began her shift, she normally searched for hazardous items. She said when a resident requests a razor, they tell the nurse, take the resident a razor, and either staff will shave the resident or they will watch while the resident shaves themselves. She said afterwards, they place it in the sharps container. During an interview on 01/13/14 at 6:58 p.m., LVN B said no resident threatened to harm themself. She said residents on the secure unit could have a disposable razor if staff supervised them. She said disposable razors should be put in the sharps container and not left in the rooms. She said residents on the secure unit were not safe to use disposable razors unsupervised. During an interview on 01/14/14 at 8:40 a.m., the DON said there had not been any incidents with razors and no residents had threatened to harm themselves on the secure unit. During an interview on 01/14/14 at 4:43 p.m., the DON said she did not consider anyone on the secure unit interviewable. She said they were all confused. She said disposable razors were not allowed on the secure unit. During an interview on 01/16/14 at 8:56 a.m., the DON said she was not aware Resident #72 threatened to kill himself with a razor blade. She said razors should not be on the secure unit. During interviews on 01/16/14 at 9:19 a.m. and 1:07 p.m., the social worker said she was not aware Resident #72 threatened to harm himself. She said he attempted suicide before he was admitted to the facility, but there had not been any attempts since. She said she had not contacted psychological services for Resident #72. She said had she known about Resident #72's threat to kill himself with a razor blade, she would have made a referral to psychological services. During an interview on 01/16/14 at 11:18 a.m., CNA C said when a resident wants to shave with a disposable razor, they tell the charge nurse. She said Resident #72 was the only resident who asked for disposable razors and they watch him shave. She said residents were not supposed to use the razors in their room. They used razors in the shower room and kept them locked in the cabinet. She said if a resident threatened to harm themselves, they were supposed to tell the nurse and the resident would be placed on one-on-one monitoring. She said they do not have a set time for monitoring for hazardous items on the secure unit. She said they just check for hazardous items when they can. During an interview on 01/16/14 at 11:35 a.m., the DON said if the administrator was not a psychotherapist, they would have called the community healthcare agency for a psychiatric referral and placed Resident #72 on one-on-one monitoring. She said since the administrator was a licensed psychotherapist, he assessed Resident #72 and did not see suicidal tendencies. She said the physician was not called and reiterated she was not aware of the incident. She said they normally would have searched the secure unit for hazardous items. She said she had not ever known the administrator to document when he visited with a resident. She said Resident #72 was not receiving psychological counseling services (other than the administrator's intervention). During an interview on 01/16/14 at 12:03 p.m., LVN B said Resident #72 had behavior issues. She said he had a lot of paranoia. She said she was not aware of his history of prior suicide attempts. She said she monitored for hazardous items when she was on shift. She said on 01/13/14 after the surveyor identified the disposable razors in the rooms, no one was able to identify who left the razors. She said some family brought razors. She said she was not sure if anyone informed the family not to bring them and said she had not contacted them about it. During an interview on 01/16/14 at 12:31 p.m., the ADON said Resident #72 had some recurring behavioral problems. He said he was not aware of Resident #72's history of suicide attempts. He said if a resident threatened to harm themself, they would notify the administrator or community healthcare for a referral. He said they should conduct a search of the secure unit to ensure no hazardous items were present and place the resident on every fifteen minute checks. The every 15 minute checks should be documented on a form. He said if the resident was safe to shave themself, they would issue a razor to them and dispose of it in the sharps container. A suicide threats policy and procedure dated April 2006 indicated, "Resident suicide threats must be taken seriously and immediately reported to the Nurse Supervisor/Charge Nurse". "2. The Nurse Supervisor/Charge Nurse shall immediately notify the resident's Attending Physician, Director of Nursing services, and sponsor a record of such threats." "7. An assessment of the resident's behavior will be made by the Interdisciplinary Care Plan Team within 24-48 hours of such incident to determine interventions that may be necessary to prevent the recurrence of such threats. Revised care plans will be developed to reflect such interventions." An undated secure unit policy and procedure indicated, "Residents eligible for admission to the secure unit will have a [DIAGNOSES REDACTED]." "Security and safety measures are provided to prevent the residents from harming themselves or others..." A preventing resident accident and incident policy and procedure dated June 2005 indicated, "Our facility will work to prevent any accident and/or incident. The facility will also work to change (the) plan of care in the event of an accident and/or incident." "1. The facility's goal is to achieve and maintain an environment free of accidents and/or incidents." "2. Our accident/incident prevention/intervention program includes, but is not necessarily limited to, the following:" "j. assessing, care planning, and monitoring residents with changes in condition and/or recent accidents/incidents". A sharps disposal policy and procedure dated 09/2005 indicated: "This facility shall discard contaminated sharps into designated containers." "1. Whoever uses contaminated sharps will discard them immediately or as soon as feasible into designated containers." The administrator, DON, Regional Director of Operations, and Regional Clinical Nurse were notified on 01/16/14 at 1:15 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 01/16/14 at 3:35 p.m. and included: "Resident #72 was placed on one on one. This will continue until an assessment and IDT (interdisciplinary team) can decide on plan of care. That plan of care will be provided to the facility staff and carried out accordingly. The (physician) will be notified of this assessment. The appropriate referrals will be made. All (18) residents on the secured unit have the potential to be affected by the alleged deficient practice. All of these residents will be assessed related to suicidal thoughts or statements and assessed to determine if they are a threat to themselves or others. These assessments will be completed by the facility Social Worker ... led by regional staff ...to determine their needs are being met and their (plan of care) is up to date. These assessments will be completed by 01/16/14. Any resident whose Plan of Care is not accurate will have it adapted and the appropriate referrals will be made. The responsible party and primary physician will be notified of any changes. A 100% audit of all unsecured areas on the secured unit will be conducted by the facility administration, led by Regional Nurse.... This audit will be completed and documented by 1/16/14. Any hazardous items with a focus on razors or other sharps found will be removed. The Responsible Party will be notified to pick up any items from the building of a personal nature. The Medical Director ... was initially made aware of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the QA (quality assurance) process. Facility staff will be in-serviced on hazards and accident prevention by regional clinical staff...All staff will also be in-serviced on follow up to accident and incidents especially when hazards are involved. All in-servicing began 01/16/14 and will be completed by end of the day 01/17/14 (to ensure all staff are in-serviced, regardless of their work schedule). Staff will not be permitted to return to work after 01/17/14 until in-servicing is completed. The following system will be put in place to ensure compliance: 1. A sweep of the secured unit for hazardous items will be made daily by the day time charge nurse. Any hazardous items found will be removed and the information will be forwarded to the Administrator for follow up. 2. The daily sweep will be documented with the 24 hour report. The IDT will document all follow up and relay it the nursing staff accordingly. 3. All negative findings noted on the 24 hour report will be reviewed daily by Administration with proof of notification and appropriate follow up reviewed. 4. All appropriate staff will be in-serviced on the actions above. 5. All staff will be in-serviced to look for hazards such as razors consistently during their daily routine. 6. A note will be posted at the entrance to the secured unit for all visitors to check in at the nurses' station. 7. All staff will be in-serviced on what a hazard is and what they should say to visitors when they check in. 8. All responsible parties of residents on the secured unit will be notified of the need to check in at the nurse station. Following is a list of all in-servicing (we will be) completing pertaining to the alleged deficient practice: 1. All staff will be in-serviced on hazards policy and procedure. 2. All appropriate staff will be in-serviced on notification for (the physician) and facility administration related to accident/incidents. 3. All nursing staff will be in-serviced on assessments and appropriate follow up to include care planning and interventions. 4. All Administrative Staff will be in-serviced on review of 24 hour report daily and Accident/Incident follow up. 5. All staff will be in-serviced on what constitutes a hazard and a hazard list will be kept at the nurses' station. To monitor for compliance the Administrator and/or designee will make daily rounds on the secured unit to monitor for hazards such as razors. The DON and/or designee will review all accident/ incidents daily to ensure proper follow up especially if hazards are involved. The DON and/or designee will ensure that all care plans are up to date related to safety and hazards. Any negative findings will be forwarded to the Administrator and the QA committee. The next QA meeting is scheduled for 01/24/14. This plan was initially implemented 01/16/14 and will be monitored, through personal observation, through completion by Regional Director of Operations,...Regional Directors of Reimbursement (same as Regional Clinical Nurse),...and President... All Staff will be in-serviced before returning to work." The surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: Four LVNs, 4 CNAs, 1 housekeeper, the social worker, ADON, DON, and the administrator were interviewed and said they had been in-serviced (or in-serviced) on hazards, hazard list location, to look for hazards every time they enter a resident's room, incident/accident prevention and intervention, visitor check-in at the nurse's station and assuring visitors were not bringing hazards to the residents. Nurses were further knowledgeable on documenting incident/accidents on the 24 hour report, notifications to the physician, responsible party, and administration, assessing residents, and the location of resident care plans. The social worker conducted a suicide risk assessment of Resident #72 on 01/16/14. Documentation of one-on-one monitoring for Resident #72 was provided. Resident #72 was referred to psychological services and evaluated. A care plan for history of suicidal thoughts and/or actions was developed on 01/16/14 for Resident #72. The psychological services psychologist evaluated Resident #72 on 01/16/14 and and recommended inpatient psychiatric placement for Resident #72. An order was received from Resident #72's physician and he was transported to a psychiatric hospital on [DATE] at 9:00 p.m. One other resident was reviewed for proper assessment, care planning, and referrals. Documentation of three other residents was reviewed to assure family members were informed of a new policy to check in at nursing station on the secure unit and not bring hazardous items. A posting for visitors to check-in at the nursing station was posted on the secure unit door and the sign-in sheet was posted at the nursing station. A list of hazards was posted at the nursing station on the secure unit. Documentation was provided of the secure unit audit conducted for hazardous items. The following in-services were reviewed: Accident/Incident Investigation, Reporting, follow-up, secured unit daily rounds, hazards, suicide threats, and 24 hour report documentation. On 01/17/14 at 11:40 a.m., the Regional Nurse Consultant was informed the immediacy of this situation was removed; however, the facility continued with an Immediate Jeopardy in place due to the situation below. 2. Physician orders [REDACTED]. The orders did not provide for the use of side rails. The most recent MDS dated [DATE] indicated Resident #59 was cognitively impaired with periods of disorganized thinking. She required extensive assistance of two people to physically assist with bed mobility and transfers. Resident #59 could not ambulate and was totally dependent for locomotion off and on the unit. The assessment indicated Resident #59 did not have bed rails, a trunk restraint, or a limb restraint while in bed. Care plans dated 10/29/13 through 01/03/14 indicated there were no updates following the incident on 12/26/13. Resident #59's clinical record dated 09/26/13 through 01/16/14 did not have a side rail assessment. Treatment Administration Records for Resident #59 dated November 2013, December 2013, and January 2014 did not indicate use of side rails. An Incident/Accident Report dated 12/26/13 for Resident #59 noted, "...Resident was in bed @ last check, @ 0730 (7:30 a.m.) resident found out of bed on floor, c (with) head stuck @ bed rail..." Three witness statements were attached to the incident report. The statements indicated, "...Her neck was stucked (sic) in the right bed rail...She was on the floor her neck under the rail on the right side. She was on her knees...her head caught in the rail..." An untimed telephone order dated 12/26/13 following the incident where Resident #59 was caught in the side rails indicated use of a bed alarm due to increased risk of falls. During the following observations, Resident #59 had half side rails up with no pillows or bolsters to prevent the resident from becoming trapped between the rails and mattress: *01/14/14 at 8:35 a.m.; *01/14/14 at 9:06 a.m.; *01/14/14 at 12:36 p.m.; *01/14/14 at 2:15 p.m.; *01/15/14 at 8:33 a.m.; *01/16/14 at 8:18 p.m.; and *01/16/14 at 3:20 p.m. During an interview on 01/16/14 at 6:42 p.m., CNA C said on 12/26/13 between 6:30 a.m. and 7:00 a.m., she entered Resident #59's room to check on her roommate. CNA C stated, "When I walked in, her head was stuck in the rail. I thought she was choking." CNA C said Resident #59's knees were on the floor and they were able to remove the resident from the side rail. CNA C stated, "I was scared. I started crying because I thought she was hurt. I have walked into a resident's room and found them hung in the side rail dead." During an interview on 01/16/14 at 6:51 p.m., CNA D said on 12/26/13, CNA C called for help. CNA D said Resident #59's head was on the bed and her neck was caught under the side rail with her knees on the floor. During an interview on 01/16/14 at 7:10 p.m., CNA E said on 12/26/13, CNA C was hollering for help. CNA E said Resident #59 had one knee on the floor, her back against the mattress with her face and head caught in the side rail. During an interview on 01/20/14 at 10:12 a.m., LVN F (the charge nurse) said she completed the incident report for Resident #59 on 12/26/13. She denied Resident #59's head or neck was caught in the side rail. She said the left side of Resident #59's neck was on the rail and she had both knees on the floor. LVN F said Resident #59 had a bruise to her right knee, but no other injuries. During an interview on 01/17/14 at 8:01 a.m., the DON said Resident #59 used the side rails as an enabler. She said following the incident, pillows were put between the side rails and aides were to monitor Resident #59. The staff were instructed to note if the resident's head was getting caught in the side rail. The DON also said staff were in-serviced about side rails on 12/26/13, but was unable to provide documentation of the in-service. She said upon admission, the nurse should conduct an assessment of the resident and their consolidated physician orders [REDACTED]." The DON acknowledged neither had been done. The DON said their system was to monitor Resident #59 and ensure her side rails were up. The "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment " website <http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm 9.pdf> accessed 01/20/14 indicated, "...FDA received approximately 691 entrapment reports over a period of [AGE] years from January 1, 1985 to January 1, 2006...These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly...residents, especially those who are frail, confused, restless, or who have uncontrolled body movement...Long-term care facilities reported the majority of the entrapments." A Preventing Resident Accident and Incident policy revised June 2005 noted, "...Our facility will work to prevent any accident and/or incident. The facility will also work to change and plan of care in the event of an accident and/or incident...The facility's goal is to achieve and maintain an environment free of accidents and/or incidents...j. Assessing, care planning, and monitoring residents with changes in condition and/or recent accidents/incidents..." The administrator and DON were notified on 01/17/14 at 9:10 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 01/17/14 at 2:06 p.m. and included: "...Resident #59 had a side rail assessment completed on 01/17/14 by (name deleted) ADON. The MD was notified and orders were obtained according to the results of this assessment. The residents likes to use them for positioning. The order will reflect this. The plan care was updated accordingly (sic) through the care plan process. The residents Treatment Administration Record (TAR) was updated accordingly with the resident's RP notified. For the resident's safety pillows will be used at this time as bosters (sic). They will be checked every 30 minutes until the ordered bosters (sic) are in and applied. All (79) residents in the facility had a side rail assessment completed by nursing administration, supervised by Regional Clinical Nurse (name deleted) This is being done to see how many of the current (48) residents with side rails can be removed. (These assessments will be updated and/or completed upon admission, quarterly, after any readmission, or with any significant change.) The results of these assessments were reviewed and any notification needed was made to the appropriate Responsible Party and MD. After considering medical necessity and resident safety any orders obtained were carried out according to the facility policy and procedure. Items such bosters (sic), floor mats, keeping the bed in the lowest position, etc. are some of the actions that will (be) taken for resident safety. The results were care planned for each resident through the care plan process, supervised by the Director of Nurses. The Direct Care staff will be notified through in-servicing and the ADL flow sheets. The nurse aides will monitor residents whose has orders for side rails to ensure that they are up and monitor those residents who have NO orders for side rails to ensure that they are down or off of the bed. This will be done to ensure resident safety. The Medical Director, (name deleted), was initially made aware of the immediate jeopardy, and has been involved in the development of the plan to remove. These conversations are considered a part of the QA process. Facility staff will be in-serviced on hazards and accident prevention by regional clinical staff, (name deleted), RN. All staff will also be in-serviced on follow up to accident and incidents especially when side rails are involved. All in servicing began 01/17/14 and will be completed by end of the day 01/17/14 (to ensure all staff are in serviced, regardless of their work schedule). Staff will not be permitted to return to work after 01/17/14 until in-servicing is completed. The following system will be put in place to ensure compliance: 1. Any resident who has an order for [REDACTED]. 2. This information will also be relayed and checked by the nurse aides every shift via the residents ADL flow sheets. 3. Any negative findings found by staff will be corrected with continued education provided to involved staff. 4. All appropriate staff will be in-serviced on the actions above. Following is a list of all in-servicing completing pertaining to the alleged deficient practice: 1. All staff will be in-serviced on the facility side rail policy and procedure. 2. All nursing staff will be in-serviced on the side rail assessment including completion and how often it is to be completed. 3. All nursing staff will be in-serviced obtaining si

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure sores for 2 of 4 residents reviewed for pressure sores. (Residents #s 59 and 78) 1. On re-admission from the hospital on [DATE], Resident #59 had a pressure sore to her left buttock documented as open, but no stage noted. The pressure sore worsened to unstageable. The facility did not provide ordered wound care for 12 days and did not administer stress tab with zinc supplements (promote wound healing) as ordered for 13 days. 2. Resident #78 developed a Stage II pressure sore to his left lateral foot. The pressure sore worsened to unstageable. The facility did not provide ordered wound care for 4 days. This failure likely contributed to the worsening of pressure sores for Resident #s 59 and 78. This failure could place 3 residents with pressure ulcers at risk for developing new pressure sores or worsening of existing pressure sores. Findings included: 1. Physician orders [REDACTED]. An admission MDS dated [DATE] indicated Resident #59 was cognitively impaired, dependent on staff for all ADLs, and was frequently incontinent of urine. The MDS identified the resident as being at risk for developing pressure sores, but had none as of 10/03/13. Nursing notes dated 12/16/13 indicated Resident #59 was transferred to the hospital and admitted with pneumonia/[MEDICAL CONDITION]. The nursing notes indicated on 12/21/13 Resident #59 returned to the facility with a pressure sore to her left buttock measuring 15.0 cm x 11.0 cm with an open area of 3.2 cm x 2.2 cm. The weekly skin condition evaluation sheet for Resident #59 dated 12/21/13 did not identify a stage, but noted it was wet/raw. No other information was documented. Re-admission orders [REDACTED]. Treatment administration records for Resident #59 dated December 2013 indicated no treatment was administered to the left buttock. The weekly skin report dated 12/28/13 for Resident #59 noted the open area of the pressure sore to the left buttock was a Stage II and had increased in size. It measured 6.0 cm x 0.3 cm. A telephone order for Resident #59 dated 01/01/14 noted stress tablet with zinc daily, but the MARs for Resident #59 dated January 2014 indicated the medication had not been administered as of 01/14/13. A telephone order for Resident #59 dated 01/02/14 noted to clean the right and left buttock with wound cleanser, pat dry, apply [MEDICATION NAME] (gel used to maintain moisture to dry wounds), and cover with gauze and [MEDICATION NAME] (transparent dressing). Treatment administration records for Resident #59 dated January 2014 indicated the treatment was initiated on 01/02/14, 12 days after she was readmitted with the pressure sore to her left buttock. The weekly skin report dated 01/04/14 for Resident #59 noted the open area of the pressure sore to the left buttock worsened to a Stage III and increased in size measuring 6.3 cm x 4.5 cm x 0.3 cm depth. Resident #59 had a care plan for the left buttock initiated 01/09/14 and a risk for skin breakdown care plan dated 01/08/14. During an observation and interview on 01/15/14 at 8:33 a.m., Resident #59's open area of the pressure sore to the left buttock was unstageable and measured 4.5 cm x 4.6 cm. The DON said the open area of the pressure sore had worsened and had an odor. The DON then said the pressure sore did not have an odor last week. 2. Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #78 was cognitively impaired, dependent on staff for all ADLs, and was incontinent of bowel/bladder. The MDS noted Resident #78 had pressure sores. The weekly skin report dated 01/04/14 for Resident #78 indicated he developed a pressure sore to his left lateral foot. The pressure sore was a Stage II and measured 2.0 cm x 2.0 cm x 0.3 cm in depth. A telephone order for Resident #78 dated 01/04/14 noted to clean the left lateral foot with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with a foam dressing every shift until healed. The order noted the [DIAGNOSES REDACTED]. Treatment administration records for Resident #78 dated January 2014 noted the pressure sore was not treated until 01/08/14. During an observation and interview on 01/16/14 at 9:18 a.m., the DON and ADON performed wound care for Resident #78. The DON measured the pressure sore was unstageable and measured 1.3 cm x 1.4 cm x less than 0.3 cm in depth. During an interview on 01/16/14 at 9:32 a.m., the DON said Resident #78 developed the pressure sore to his left lateral foot in the facility. She said the sore was a Stage II when it was discovered, but was now unstageable. The website for the National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 01/20/14 indicated: "Category/Stage II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguinous (serum/blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. *Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as " the body's natural (biological) cover " and should not be removed." An undated Decubitus Ulcer-Prevention and Treatment policy noted, "...The nurse is responsible for notifying physician of decubitus stages I-IV and carrying out the treatment of [REDACTED]. The CMS 672 dated 01/13/14 indicated 3 residents had pressure sores.