Every finding on record at Park Manor of South Belt

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (Resident #1) of 5 residents reviewed for infection control. -CNA C failed to thoroughly and properly clean Resident #1 during incontinent care. -CNA C failed to wear full PPE when providing incontinent care for Resident #1 on EBP. This failure placed residents at risk for cross contamination, skin irritation, discomfort, and infections. Findings included: Record review of Resident #1's face sheet dated 12/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and 03/06/25. Resident #1's diagnoses included the following: paraplegia (loss of muscle function, movement, or feeling in the lower half of the body), contracture (tightening and stiffening of muscles restricting joint movement) of muscle, multiple sites, chronic respiratory failure, gastrostomy, elevated white blood cell count, gastrostomy (surgical procedure creating an opening into the stomach for long-term enteral{nutrition, fluids, or medication delivered directly into the digestive tract due to someone not being able to take anything by mouth} feeding)and obstructive and reflux uropathy (blockage of urine flow). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7, indicating that Resident #1's cognition was severely impaired. Section GG-Functional Abilities of the MDS reflected that Resident #1 required substantial/maximal assistance with toileting hygiene. Section H-Bladder & Bowel reflected that Resident #1 was frequently incontinent of urine and bowel. Record review of Resident #1's Comprehensive Care Plan dated 05/30/23 revised 08/12/24 reflected that resident was being care planned for Enhanced Barrier Precautions- at risk for infection r/t wounds and indwelling medical device. The interventions included the following: -Educate staff/resident/family on the proper use of PPE and hand hygiene at point of care. -Wear gloves and gown during high-contact care activities for resident indwelling medical devices, wounds, and colonized or infection within the CDC targeted MDRO. Record review of Resident #1's Comprehensive Care Plan dated 11/08/25 revealed that resident was being care planed for incontinence of urine r/t impaired mobility, contractures and loss of bladder control with an intervention that included the following: check resident during rounds and as required for incontinence.wash, rinse, and dry perineum (area of the body between the thighs, located between the genitals and anus {opening through which feces is exited from the body}) Record review of Resident #1's Physician Order Summary Report for November 2025 reflected the following orders: -Dated 03/06/25 Check GT placement prior to feeding and/or medication administration by aspirating of gastric contents -Dated 11/19/25 Mid line IV (long, thin, soft plastic tube inserted into a vein in the arm where the tip of the device rest in a larger, deeper vein, away from the heart): flush line with 10ml's of NS before and after administration of IV medication every shift for maintenance care/infection prevention of IV therapy. Record review of Resident #1's MAR for month of November 2025 reflected that the facility was following the above physician orders. Observation on 11/26/25 at 2:25PM revealed Resident #1 door had EBP signage instructing staff to place on PPE that consisted of gown and gloves regarding care for resident (s). CNA C entered Resident #1's room to provide incontinent care. Resident #1's brief was incontinent of urine. CNA C washed her hands and placed gloves on only. CNA C proceeded to provide incontinent care for Resident #1. Resident was observed having a gastrotomy tube and an IV line to right upper arm. During incontinent care, CNA C did not clean resident groin or penis instead, CNA C repositioned resident to his left side to clean resident buttocks using disposable wipes. CNA C cleaned Resident #1's buttocks not from front to back but towards resident scrotum (the sac of skin that holds and protects the testicles (two egg shaped structures that rest behind the penis that produce sperm in the male). CNA C placed a clean brief on Resident #1, gathered the soiled materials, left the room to dispose of the soiled materials inside the soiled linen room, and sanitized her hands. Interview on 11/26/25 at 3:00PM with CNA C said she had been working at the facility for 1-month full time on the 6:00AM-2:00PM shift. CNA C said by not wearing a disposable gown when she provided incontinent care for Resident #1, it placed the resident at risk for germs. CNA C said when providing incontinent care for residents, she was supposed to clean the resident from front to back. CNA C said if the resident (s) was not provided correct incontinent care, it would place the resident at risk for germs. CNA C refused to talk further with surveyor and walked away. Interview on 11/26/25 at 3:05PM with the DON revealed she and another nurse were both Infection Preventionists. The DON said the staff should be placing on PPE when proving direct care for all residents on EBP (enhanced barrier precautions) for infection control. The DON said EBP was for residents that had the following: foley catheters, gastrostomy tubes, and any resident that had an invasive site procedure done. The DON stated CNA C had come to her asking did she have the state surveyor come and talk to her. The DON said she told CNA C no and that CNA C was disrespectful towards her and walked away. The DON said CNA C had completed all her training regarding resident care including incontinent care. The DON said she had to terminate CNA C effective immediately. Record review of the facility's policy on Perineal care for male residents revised October 2010 reflected in part: .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.For a male resident.washing the perineal area starting with urethra and working outward.wash and rinse urethra area using a circular motion.continue to wash the perineal area including the penis, scrotum and inner thighs.instructor assist the resident to turn on side.wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks.dry thoroughly. Record review of the facility's policy on Enhanced Barrier Precautions dated April 01, 2024 reflected in part: . Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing, bathing/showering, transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, Wound care: any skin opening requiring a dressing. Record review of the facility's policy on Infection Control Guidelines for all Nursing Procedures revised in August 2012 reflected in part: .Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials.

Based on observation, interview, and record review, the facility failed in accordance with state and local laws, to store all drugs and biological in locked compartments under proper temperature controls for medications storage for 1 (Resident #1) of 5 residents reviewed for medication storage. -LVN A left normal saline flushes at Resident #1's bedside. This failure placed residents at risk for infections related to contamination and safety precautions.Findings included: Record review of Resident #1's face sheet dated 12/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and 03/06/25. Resident #1's diagnoses included the following: paraplegia (loss of muscle function, movement, or feeling in the lower half of the body), contracture (tightening and stiffening of muscles restricting joint movement) of muscle, multiple sites, chronic respiratory failure, gastrostomy, elevated white blood cell count, gastrostomy (surgical procedure creating an opening into the stomach for long-term enteral{nutrition, fluids, or medication delivered directly into the digestive tract due to someone not being able to take anything by mouth} feeding)and obstructive and reflux uropathy (blockage of urine flow). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 7, indicating that Resident #1's cognition was severely impaired. Section N-Medications revealed that Resident #1 was receiving antibiotics including IV medications (method of delivering fluids, medications, or nutrients directly into the vein). Record review of Resident #1's Comprehensive Care Plan dated 04/19/24 revised 08/12/24 reflected the resident was not care planned for antibiotic IV antibiotic therapy or mid-live IV. Further review reflected resident was care planned for Enhanced Barrier Precaution, and he was at risk for infection r/t wounds and indwelling medical device. An intervention included wearing a gown during high contact care activities. Record review of Resident #1's Physician Order Summary Report for November 2025 reflected the following orders: -Dated 11/19/25 Mid line IV: flush line with 10ml's of NS before and after administration of IV medication every shift for maintenance care/infection prevention of IV therapy. -Dated 11/19/25 Ceftriaxone (antibiotic used to treat wide variety of serious bacterial infections) 1 gm one time a day for 10 days. -Dated 11/21/25 Invanz (Ertapenem-antibiotic used for bacterial infection) 1gm intravenously for 10 days. -Dated 11/28/25 Vancomycin (antibiotic) 1 gm IV one time a day for PNA for 3 days. Record review of Resident #1's MAR for the month of November 2025 reflected that the following orders were being following: -Dated 11/19/25 Mid line IV: flush line with 10ml's of NS before and after administration of IV medication every shift for maintenance care/infection prevention of IV therapy. -Dated 11/19/25 Ceftriaxone (antibiotic used to treat wide variety of serious bacterial infections) 1 gm one time a day for 10 days. -Dated 11/21/25 Invanz (Ertapenem-antibiotic used for bacterial infection) 1gm intravenously for 10 days. -Dated 11/28/25 Vancomycin (antibiotic) 1 gm IV one time a day for PNA for 3 days. Observation on 11/26/25 at 2:09PM revealed Resident #1 was resting in bed quietly. There was a pole on the right side of Resident #1's bed with an empty 100 ml bag hanging on the pole with IV tubing connected to the bag. The bag read Ertapenem 1gm infuse over 1 hour. The bag was dated 11/26/25. Further observation revealed Resident #1 had an IV to his upper right arm. The date on the IV dressing read 11/19/25. There were two- 10 cc normal saline syringes on the right side of Resident #1's bed sitting on the nightstand. One of the syringes was in an unopen plastic wrapper and the other one had been open with 5 cc's of fluids inside of the syringe. Interview on 11/26/25 at 2:16PM with LVN A, after observing the normal saline flushes at Resident #1's bedside, revealed she said normal saline was considered a medication and should not be stored at the bedside. LVN A said this placed Resident #1 at risk for something but did not know what. LVN A said she forgot to remove the normal saline flushes from resident's bedside. Interview on 11/26/25 at 3:05PM the DON said normal saline flushes were considered medication. The DON said it was not okay to leave normal saline flushes at the resident's bedside. The DON did not say when ask what risk it could place the resident for but that the risk was minimal. Record review of the facility's policy on Medication Storage revised April 2007 reflected in part: .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on interview and record review the facility failed to thoroughly investigate and report findings to the State Survey Agency within 5 working days of the incident and the corrective action taken if the alleged violation was verified for 9 (Resident #39, Resident #44, Resident #79, CR #1, CR #2, CR #3, CR #4, CR #5, CR #6) of 18 residents reviewed for abuse. The facility failed to conduct a thorough investigation when discrepancies were found between the MAR and narcotic reconciliation sheets for Resident #39, Resident #44, Resident #79, CR #1, CR #2, CR #3, CR #4, CR #5, and CR #6 that were not found in the facility's investigation report. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain, and a decreased quality of life. Findings included: Record review of the provider investigation report written by the Administrator dated 4/2/25 documented RN B noticed that RN A had not followed proper protocol for checking out a narcotic medication. The DON and ADON conducted the investigation. Upon further investigation, RN B and RN C noticed that RN A had forged their signatures for PRN narcotics multiple times. The DON and ADON interviewed RN A, and the report stated RN A refused to answer questions. RN A was asked to take a drug test, the drug was positive for cocaine and opiates. RN A was placed on suspension pending investigation and later terminated. The investigation revealed only 2 residents were impacted by this action, Resident #39 and Resident #44. Resident #39 and Resident #44 were interviewed and stated they did not request the PRN narcotic in question and not administered the narcotic medication. Resident #39 and Resident #44 were assessed by the nursing team, no adverse effects were found on either resident. Record review of Resident #39's face sheet dated 6/25/25 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region without neurogenic claudication (a condition where the spinal canal in the lower back narrows), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), spinal stenosis cervical region (a condition where the spinal canal in the neck narrows, compressing the spinal cord and nerves) and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Record review of Resident #39's most recent quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 13 indicating cognition was intact. Further review of the quarterly MDS assessment indicated Resident #39 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of Resident #39's February 2025 MAR indicated Resident #39's Norco was not administered 2/4/25-2/27/25. However, on 2/1/25-1 tablet, 2/2/25-2 tablets, 2/3/25-1 tablet, and 2/28/25- 1 tablet was administered. Record review of Resident #39's March 2025 MAR indicated Resident #39's Norco was not administered 3/1/25-3/12/25, 3/14/25-3/19/25, 3/21/25-3/24/25, and 3/26/25- 3/30/25. However, on 3/13/25-1 tablet, 3/20/25-1 tablet, 3/25/25-1 tablet, and 3/31/25-1 tablet were administered. Record review of Resident #39's narcotic reconciliation log for Norco indicated 81 doses were administered on 2/10/25, 2/12/25- 2/27/25, 3/1/25-3/2/25, 3/6/25-3/7/25, 3/11/25, 3/17/25- 3/21/25, 3/24/25- 3/27/25 and 3/31/25. Interview on 6/26/25 at 12:33 pm. with the DON, she said RN B texted her because she saw her name was on the narcotic count sheet for Resident #44's oxycodone on 3/31/25. RN B said she had not administered oxycodone. The DON said when she conducted her investigation, she focused on residents in the 200 hall, which were long term residents. She said she pick some residents from the 300 hall, which were short-term. She said RN A worked both halls. The DON said she chose residents who were alert and went back a couple of months on the narcotic count sheets. She said she noticed a few counts were off here and there and then ramped up for the month of March. Interview on 6/27/25 at 3:03 p.m. with the DON and Administrator. The DON said she was not aware of any issues with controlled substances other than the incident with RN A that was self-reported. The DON said she was not aware of the missing 56 tablets of hydrocodone for Resident #39 for the month of February. The Administrator and DON said the facility had addressed the issues of controlled substances by giving in-services to staff and daily clinical reviews of the narcotic count sheets. The DON said the expectation for nurses when administering narcotics was, they should sign the narcotic out, indicate pain level, and document on the MAR. The DON said if nurses see that the narcotic count was off, they should notify her. The DON said to prevent future issues with narcotic counts the facility will continue to monitor. The DON said the risk to the resident when a narcotic was not documented on the MAR would be minimal risk because the nurses check the narcotic count sheet before administering the medication. The DON said the risk to the resident when a pain medication was not given to the resident would be the resident could have pain and the doctor would have to be notified. Record review of facility document titled Investigation Best Practices, not dated read in part . 4. Determine 'when' the incident occurred (time or time frame). 9. Complete a comprehensive record review, which may include . Medication Administration Records . Record review of the Abuse and Neglect policy dated April 2007 read in part . 4. The physician and staff will help identify risk factors for abuse within the facility . for example, problems related to staff knowledge, skill, or performance that might affect how the residents are being cared for .

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 9 (Resident #39, Resident #44, Resident #79, CR #1, CR #2, CR #3, CR #4, CR #5, CR #6) of 18 residents reviewed for pharmacy services. The facility failed to ensure the reconciliation of controlled drug sheets compared to MAR for Resident #39, Resident #44, Resident #79, CR #1, CR #2, CR #3, CR #4, CR #5, CR #6 to ensure every controlled drug that was administered and documented as administered in the MAR reflected the correct quantity on the controlled drug/disposition form. These failures could place residents at risk of medication error and drug diversion due to not reconciling every shift nor accounting for all controlled drugs administered and/or wasted. Findings included: Record review of Resident #39's face sheet dated 6/25/25 indicated she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region without neurogenic claudication (a condition where the spinal canal in the lower back narrows), vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), spinal stenosis cervical region (a condition where the spinal canal in the neck narrows, compressing the spinal cord and nerves) and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). Record review of Resident #39's most recent quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 13 indicating cognition was intact. Further review of the quarterly MDS assessment indicated Resident #39 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of Resident #39's comprehensive care plan dated 8/20/24 indicated she had potential for pain secondary to lumbar and cervical stenosis with interventions that included: administer analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and observe/document for side effects of pain medication. Record review of Resident #39's physician orders with a start date 6/29/24, indicated she was prescribed Norco oral tablet 7.5- 325mg, 1 tablet by mouth every 6 hours as needed for moderate pain. Record review of Resident #39's February 2025 MAR indicated Resident #39's Norco was not administered 2/4/25-2/27/25. However, on 2/1/25-1 tablet, 2/2/25-2 tablets, 2/3/25-1 tablet, and 2/28/25- 1 tablet was administered. Record review of Resident #39's March 2025 MAR indicated Resident #39's Norco was not administered 3/1/25-3/12/25, 3/14/25-3/19/25, 3/21/25-3/24/25, and 3/26/25- 3/30/25. However, on 3/13/25-1 tablet, 3/20/25-1 tablet, 3/25/25-1 tablet, and 3/31/25-1 tablet were administered. Record review of Resident #39's narcotic reconciliation log for Norco indicated 81 doses were administered on 2/10/25, 2/12/25- 2/27/25, 3/1/25-3/2/25, 3/6/25-3/7/25, 3/11/25, 3/17/25- 3/21/25, 3/24/25- 3/27/25 and 3/31/25. Interview on 6/24/25 at 2:45 pm, Resident #39 remembered she was told RN A was charting medication that was given to her but did not receive it. Resident #39 could not recall if she was in pain around that time because she said she received her pain medication whenever she requested it. Record review of Resident #44's face sheet dated 6/24/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of acute chronic systolic heart failure, respiratory failure, hematemesis (vomiting blood), multiple sites of contracture of muscle, chronic pain, and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #44's most recent quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 10 indicating cognition was moderately impaired. Further review of the quarterly MDS assessment indicated Resident #44 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of Resident #44's comprehensive care plan dated 6/26/24 indicated he had risks for potential complications associated with pain r/t chronic pain bilateral lower leg contracture with interventions that included: administer analgesia as per orders, evaluated the effectiveness of pain interventions, and observe for side effects of pain medication. Record review of Resident #44's physician orders with a start date of 2/15/25, indicated he was prescribed oxycodone HCL oral tablet 20mg, 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #44's March 2025 MAR indicated Resident #44's oxycodone was not administered on 3/5/25, 3/12/25, 3/17/25, 3/24/25, and from 3/27/25-3/31/25. However, on 3/1/25-3/4/25-6 tablets, 3/6/25-3/11/25-10 tablets, 3/13/25-3/16/25-7 tablets, 3/18/25-3/23/25-13-tablets, 3/25/25-3/26/25-3 tablets were administered. Record review of Resident #44's narcotic reconciliation log for oxycodone indicated 10 doses were administered from 3/23/25- 3/25/25, 3/26/25-3/27/25, 3/29/25, and 3/31/25. Interview on 6/24/25 at 2:53 pm, with Resident #44, he said he remembered hearing a nurse was signing out for meds, he could not recall which nurse. Resident #44 said he did not have any issues dealing with pain around that time. Resident #44 said his pain medications were PRN, and he knew he was receiving the correct pill because he was able to identify it as a little white pill. Record review of Resident #79's face sheet dated 6/27/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Type 2 diabetes, chronic osteomyelitis (an infection in a bone that can affect one or more parts of a bone), Stage 4 pressure ulcer of right hip, and Stage 4 pressure ulcer of left hip. Record review of Resident #79's most recent quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 15 indicating cognition was intact. Further review of the quarterly MDS assessment indicated Resident #79 did not receive a scheduled pain medication regimen or PRN pain medications in the last five days. Record review of Resident #79's comprehensive care plan dated 6/5/25 indicated he had not been care planned for pain interventions. Record review of Resident #79's physician orders with a start date of 11/19/24 indicated he was prescribed Tramadol HCL tablet 50 mg every 6 hours as needed for pain. Record review of Resident #79's February 2025 MAR indicated Resident #79's Tramadol was not administered from 2/1/25- 2/2/25, 2/4/25, 2/6/25- 2/10/25, 2/12/25-2/13/25, and from 2/16/25- 2/28/25. However, on 2/3/25-1 tablet, 2/5/25-1 tablet, 2/11/25-1 tablet, 2/14/25-1 tablet, and 2/15/25- 1 tablet was administered. Record review of Resident #79's narcotic reconciliation log for tramadol indicated 3 doses were administered between 2/3/25-2/4/25, and 2/12/25. Interview on 6/26/25 at 4:53 pm, Resident #79 he said he had chronic pain from neuropathy. Back in February, he was told by a couple of nurses he did not have pain medication. When asked if the nurses still worked at the facility he responded, I'd rather not say. Resident #79 said the way he found out he had pain medication was he requested for his medical records. Resident #79 said he has not had any issues receiving his pain meds after he requested his records. Record review of CR #1's face sheet dated 6/26/25 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of spinal stenosis lumbar region without neurogenic claudication (a condition where the spinal canal in the lower back narrows), polyosteoarthritis (arthritis that affects five or more joints at the same time), stiffness of unspecified joint, osteomyelitis of vertebra (a rare bone infection that inflames and infects a spinal disc), and burn of first degree of right thigh. Record review of CR #1's most recent comprehensive MDS assessment indicated he had a BIMS score of 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #1 received a scheduled pain medication regimen and PRN pain medications in the last five days. Record review of CR #1's comprehensive care plan dated 3/15/25 indicated he had not been care planned for pain interventions. Record review of CR #1's physician orders with a start date of 3/21/25 indicated he was prescribed Tramadol HCL oral tablet 50 mg, every 6 hours as needed for pain. Record review of CR #1's March 2025 MAR indicated CR #1's tramadol was not administered from 3/22/25-3/23/25, and 3/30/25. However, on 3/21/25- 1 tablet, 3/24/25-1 tablet, 3/25/25- 1 tablet, 3/26/25-3 tablets, 3/27/25- 1 tablet, 3/28/25- 3 tablets, 3/29/25-3 tablets, and 3/31/25- 3 tablets were administered. Record review of CR #1's narcotic reconciliation log for tramadol indicated 8 doses were administered from 3/22/25-3/23/25, 3/27/25, and from 3/29/25- 3/30/25. Record review of CR #2's face sheet dated 6/26/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of sepsis, Type 2 diabetes, thyrotoxicosis (a rare and life-threatening condition that occurs when the thyroid gland releases a large amount of thyroid hormones in a short period), hyperlipidemia (a condition in which there are high levels of fat particles in the blood). Record review of CR #2's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #2 did not receive a scheduled pain medication regimen or PRN pain medications in the last five days. Record review of CR #2's comprehensive care plan dated 3/27/25 indicated she had pain with interventions that included: administer analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of pain interventions. Record review of CR #2's physician orders with a start date of 3/26/25 indicated she was prescribed hydrocodone-acetaminophen oral tablet 7.5- 325 mg tablet every 6 hours as needed for pain. Record review of CR #2's March 2025 MAR indicated CR #2's hydrocodone was not administered from 3/26/25-3/27/25 and from 3/29/25-3/30/25. However, on 3/28/25- 1 tablet and 3/31/25- 3 tablets were administered. Record review of CR #2's narcotic reconciliation log for hydrocodone indicated 7 doses were administered between 3/27/25- 3/30/25. Record review of CR #3's face sheet dated 6/26/25 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of secondary malignant neoplasm of liver, malignant neoplasm of colon, Type 2 diabetes, pain in right shoulder. Record review of CR #3's most recent comprehensive MDS assessment dated [DATE] indicated he had a BIMS score 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #3 received a pain medication regimen in the last five days. Record review of CR #3's comprehensive care plan dated 2/27/25 indicated he had not been care planned for pain interventions. Record review of CR #3's physician orders with a start date of 3/6/25 indicated he was prescribed tramadol HCL oral tablet 50 mg every eight hours as needed for pain management. Record review of CR #3's March 2025 MAR indicated CR #3's tramadol was not administered on 3/6/25, 3/8/25-3/9/25, and from 3/11/25-3/31/25. However, on 3/7/25-1 tablet, 3/10/25-1 tablet was administered. Record review of CR #3's narcotic reconciliation log for tramadol indicated 5 doses were administered between 3/8/25 thru 3/9/25. Record review of CR #4's face sheet dated 6/26/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction, end stage renal disease, hyperlipidemia. Record review of CR #4's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #4 received PRN pain medications and received non-medication intervention for pain in the last five days. Record review of CR #4's comprehensive care plan dated 3/11/25 indicated she had not been care planned for pain interventions. Record review of CR #4's physician orders with a start date of 3/12/25 indicated she was prescribed hydrocodone-acetaminophen oral tablet 5- 325 mg every 6 hours as needed for pain. Record review of CR #4's March 2025 MAR indicated CR #4's hydrocodone was not administered from 3/15/25- 3/22/25, and from 3/24/25- 3/31/25. However, from 3/12/25 thru 3/14/25- 5 tablets, and 3/23/25- 1 tablet was administered. Record review of CR #4's narcotic reconciliation log for hydrocodone indicated 4 doses were administered between 3/22/25 thru 3/23/25. Record review of CR #5's face sheet dated 6/26/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of unilateral primary osteoarthritis-right knee, Type 2 diabetes with diabetic neuropathy. Record review of CR #5's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score of 15 indicating cognition was intact. Further review of the comprehensive MDS assessment indicated CR #5 received a scheduled pain medication regimen, received PRN pain medications, and received non-medication intervention for pain in the last five days. Record review of CR #5's comprehensive care plan dated 3/12/25 indicated she had pain r/t osteoarthritis, right artificial knee joint replacement/swelling with interventions that included: administer analgesia as per orders, anticipate the resident's need for pain relief, evaluate the effectiveness of pain interventions. Record review of CR #5's physician orders with a start date of 3/11/25 indicated she was prescribed hydrocodone-acetaminophen oral tablet 10- 325 mg every 6 hours as needed for moderate pain. Record review of CR #5's March MAR indicated CR #5's hydrocodone was not administered on 3/11/25, 3/16/25, 3/19/25-3/20/25, 3/22/25-3/23/25, and from 3/27/25 thru 3/31/25. However, on 3/12/25- 1 tablet, 3/13/25- 1 tablet, 3/14/25, 1 tablet, 3/15/25- 1 tablet, 3/17/25-1 tablet, 3/18/25- 1 tablet, 3/21/25- 1 tablet, 3/24/25- 1 tablet, 3/25/25- 2 tablets, and 3/26/25- 1 tablet was administered. Record review of CR #5's narcotic reconciliation log for hydrocodone indicated 2 doses were administered on 3/17/25 and 3/28/25. Record review of CR #6's face sheet dated 6/26/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cellulitis of right lower limb, acute kidney failure, Type 2 diabetes. Record review of CR #6's most recent comprehensive MDS assessment dated [DATE] indicated she had a BIMS score of 10 indicated cognition was moderately impaired. Further review of the comprehensive MDS assessment indicated CR #6 did not receive a scheduled pain medication regimen or PRN pain medications in the last five days. Record review of CR #6's comprehensive care plan dated 4/14/25 indicated she had potential for pain r/t diabetes mellitus, CHF, history of recurrent falls, and osteoarthritis with interventions that included: administer pain meds as ordered, evaluate the effectiveness of pain interventions, observe/document for side effects of pain medication. Record review of CR #6's physician orders with a start date of 11/6/24 indicated she was prescribed tramadol HCL oral tablet 50 mg every 6 hours as needed for pain management. Record review of CR #6's February 2025 MAR indicated CR #6's tramadol was not administered from 2/1/25- 2/2/25, 2/5/25-2/8/25, and from 2/10/25-2/28/25. However, on 2/3/25-1 tablet, 2/4/25- 1 tablet, and 2/9/25- 1 tablet was administered. Record review of CR #6's March 2025 MAR indicated CR #6's tramadol was not administered from 3/1/25-3/6/25, 3/8/25, 3/11/25, 3/15/25- 3/26/25, and from 3/28/25- 3/31/25. However, on 3/7/25- 1 tablet, 3/9/25- 1 tablet, 3/10/25- 1 tablet, 3/12/25- 1 tablet, 3/13/25- 1 tablet, 3/14/25- 1 tablet, and 3/27/25- 1 tablet was administered. Record review of CR #6's narcotic reconciliation log for tramadol indicated 3 doses were administered on 2/14/25, and from 3/10/25 thru 3/11/25. Interview on 6/25/25 at 3:03 p.m. with the Nurse Practitioner for pain management. She said she was not aware of narcotics missing. The NP said Resident #39 was prescribed Norco for spinal stenosis and chronic knee pain. The NP said for Resident #44, he was prescribed Oxycodone for pain in his back, hips, and knees. The NP said there was not an increase for pain medication for Resident #39 and Resident #44 for the month of March. She said residents were at risk for increased pain if pain medications were not administered. The NP said when medications are not documented on the MAR, residents were at risk of oversedation if they got too many pain meds. Interview on 6/25/25 at 10:21 a.m. with RN A, she said the DON called her and spoke to her about PRN medications and signing out for other nurses. RN A said she would do the counts at the beginning of her shift with the morning nurse, RN C, and do counts at the end of her shift with different night nurses. She said RN B was the night nurse that was there most of the time. RN A said she worked 200 hall and sometimes cover the 300 hall. RN A said sometimes the narcotic count would not match because staff would forget to sign off on the narcotic sheet. RN A said the DON would have her and other nurses go back and sign the narcotic sheet as far back as a week. RN A said the DON suspended her on 4/1/25 for failing to follow facility policy when administering narcotics and changing times and dates of narcotics given. RN A never returned to the facility because she said she did not agree with what the DON accused her of, it was her word against the DON. Interview with RN B on 6/25/25 at 12:13 p.m. She said she was the night nurse and worked from 10 p.m. to 6 a.m. RN B said she noticed her name was forged on the count sheet on 4/1/25 at 12:00 a.m. RN B said she counted the medications with the evening nurse, she was not sure if it was RN A. RN B said she notified the ADON and DON as soon as she noticed her signature was forged. RN B said when she administered pain medication she always signed in the system and signed on the narcotic sheet. She said documented PRN medications and pain scale for the residents. RN B said the narcotic count sheet and MAR should match. She said the risk to the resident if they did not get their pain meds was the resident would still be in pain. RN B said the DON would need to be notified if there was a discrepancy between the narcotic count sheet and MAR. Interview on 6/25/25 at 12:45 p.m. with RN C, she said RN A signed out narcotics under her name a few times, she said it was mostly under a night shift nurse's name. RN C said she signed out medications as soon as it was administered. For instance, if she gave a narcotic at 11:06 pm she would sign for it at 11:06 pm. RN C said she had to go back and sign the narcotic sheet because she would get busy. She said sometimes she would have to go back a day or so to sign the narcotic sheet. RN C said the narcotic count sheet should match the MAR. She said the nurses counted narcotics at the beginning and end of shift. RN C said she did not see any discrepancies for the month of March. RN C said the risk to the resident when they did not receive their medication would be their pain would be harder to control. She said the risk to the resident when the narcotic count sheet is signed but not documented on the MAR would be overdose. Interview on 6/26/25 at 12:33 pm. with the DON, she said RN B texted her because she saw her name was on the narcotic count sheet for Resident #44's oxycodone on 3/31/25. RN B said she had not administered oxycodone. The DON said when she conducted her investigation, she focused on residents in the 200 hall, which were long term residents. She said she pick some residents from the 300 hall, which were short-term. She said RN A worked both halls. The DON said she chose residents who were alert and went back a couple of months on the narcotic count sheets. She said she noticed a few counts were off here and there and then ramped up for the month of March. Interview on 6/27/25 at 3:03 p.m. with the DON and Administrator. The DON said she was not aware of any issues with controlled substances other than the incident with RN A that was self-reported. The DON said she was not aware of the missing 56 tablets of hydrocodone for Resident #39 for the month of February. The Administrator and DON said the facility had addressed the issues of controlled substances by giving in-services to staff and daily clinical reviews of the narcotic count sheets. The DON said the expectation for nurses when administering narcotics was, they should sign the narcotic out, indicate pain level, and document on the MAR. The DON said if nurses see that the narcotic count was off, they should notify her. The DON said to prevent future issues with narcotic counts the facility will continue to monitor. The DON said the risk to the resident when a narcotic was not documented on the MAR would be minimal risk because the nurses check the narcotic count sheet before administering the medication. The DON said the risk to the resident when a pain medication was not given to the resident would be the resident could have pain and the doctor would have to be notified. Record review of the Controlled Substances policy dated 12/2012 read in part . 9. Nursing staff must count controlled medications at the end of each shift . the nurse coming on duty and the nurse going off duty must make the count together . they must document and report and discrepancies to the Director of Nursing Services . Record review of the Documentation of Medication Administration policy dated 4/2007 read in part . 1. A nurse . shall document all medications administered to each resident's medication administration record .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 residents (Resident #69 and Resident #8) of 6 residents reviewed for Infection Control. -LVN B failed to follow proper hand hygiene while providing treatment to Resident #69's wounds on her lower legs. -Resident #69 had an open wound but was not on Enhanced Barrier Precautions. -The facility failed to ensure CNA D followed proper infection control, for Resident # 8 during incontinent care. CNA D failed to clean from front to back when the resident was incontinent of stool. These failures placed residents at risk for cross contamination and the spread of infection. Findings included: Resident #69 Record review of the admission Record for Resident #69 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, mild cognitive impairment, anxiety disorder, and abnormal findings of blood chemistry. Record review of a Change in Condition Evaluation for Resident #69, dated 06/23/25, revealed the resident exhibited increased edema to her left lower leg. The Summary section read, in part, .pt left leg +2 edema and right leg +1 edema There is increased weeping in left leg. The Evaluation was signed by LVN B. Record review of the Weekly Skin Review for Resident #69, dated 06/24/25, revealed her left lower leg had red/pink dry skin patches. The measurements were reflected as 9.5 x 9.0 x 0.2 cm. The right leg had redness surrounding a weeping scabbed wound. The report read, in part, .Res has new weeping wound to LLE, previously pink dry patchy skin. Res had change in condition, 3+ bilateral lower ext edema present. Consulted with wound care specialist _____ [Physician A] on tx plan over the phone, ordered - cleanse with ns/wc pat dry apply vashe gauze apply ABD pad, cover with kerlix dressing qd . Observation and interview on 06/24/25 at 10:30 a.m. with Resident #69 revealed she said she had hit her leg on the shower chair, and it never healed. She said it gets blistered, then pops. She said the facility did not cover it. She said her family member sister had asked for wound care to come, but she has not been seen by wound care. Observation at that time revealed both of her feet were edematous. There was an open area on her left lower leg that had multiple blistered and burst blisters visible. Open bloody areas were visible. The wound was not covered. There was scant bloody drainage visible on the sheet. Observation on 06/24/25 at 10:58 a.m. revealed LVN B provide wound care for Resident #69 . There was no Enhanced Barrier Precautions sign on the door. LVN B placed some barrier cream in a 30 cc cup. She did not wash her hands, and donned gloves. With her gloved hand, LVN B applied barrier cream to Resident #69's wound on her left leg. Observation revealed there was drainage visible on the right leg wound. Without sanitizing her hands, LVN B used the same gloves to apply barrier cream to the open area on the right leg. The surveyor asked LVN B if there was drainage from the right leg wound. LVN B answered, A little. LVN B doffed her gloves and washed her hands. The Surveyor asked LVN B if it was ok to apply the barrier cream to the right leg wound with the same gloves as she used on the left. LVN B responded, No. Cross contamination. In an interview on 06/24/25 at 12:05 p.m., LVN C, (the facility Infection Control Nurse) said Resident #69 should be on Enhanced Barrier Precautions (EBP) if the wound was open. LVN C then observed Resident #69 and said she would place her on EBP. In an interview on 06/25/25 at 1:20 p.m., LVN C said LVN B should have washed her hands and changed gloves after treating Resident #69's left leg, before treating the right leg. She said if the wound on the left leg was infected, it could spread to the wound on the right leg. In an interview on 06/25/25 at 1:45 p.m., the DON said if the wound was open, LVN B should have washed her hands and changed gloves after treating Resident #69's left leg. She said the risk would be the spread of infection. Resident #8 Record review of Resident #8's face sheet undated reflected date of admission was 5/25/2023 and readmitted [DATE]. Resident #8's diagnoses Alzheimer's Disease, Cellulitis (common and potentially serious bacterial infection of the skin) of face, personal history of urinary tract infections, dementia, and anxiety Record review of Resident #8's care plan dated 04/04/2025 revealed:.Focus: Resident #8 had bladder incontinence related to dementia and the inability to hold her urineGoals: Resident's risk for septicemia (serious bloodstream infections) will be minimized/prevented by prompt recognition and treatment of urinary tract infection symptomsInterventions: The resident used disposable briefs change as needed Record review of Resident #8's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score was three indicating severe impairment in cognition. Section H (Bladder and Bowel) reflected resident was frequently incontinent of bowel and bladder. Resident #8 was dependent in staff for toileting hygiene. Observation on 06/25/2025 at 10:08 AM during incontinent care for Resident #8 by CNA D assisted by LVN A and LVN B,. Resident #8 was positioned on her right side. Resident # 8 had a soft stool at her anal area. CNA A wiped from the resident's anal area moving to her front peri area for five separate wipes. In an interview on 06/25/2025 at 10:23 AM CNA D stated she was supposed to wipe away from the uterus. CNA D stated she wiped toward the uterus . CNA D stated the resident did have stool and she wiped her 5 times toward the front. The CNA was in-serviced about 2 weeks ago. She stated she was nervous. CNA D stated the risk to the resident was an infection. In an interview on 06/25/2025 at 10:28AM LVN A stated she witnessed CNA D wipe Resident #8 in the wrong direction. LVN A stated she witnessed the resident had stool and the CNA wiped the stool toward the front of the resident. LVN A stated the risk was infection. In an interview on 06/25/2025 at 11:32 AM LVN B stated she witnessed the CNA wipe Resident #8 from back to front for 5 wipes. LVN B stated she should have wiped front to back. LVN B stated she saw the resident was incontinent of stool and the CNA wiped from back to front. The risk was infection. In an interview on 06/25/2025 at 1:03 PM LVN C stated she had been the infection control preventionist for five years. LVN C stated the CNAs were in-serviced annually and as needed for incontinent care. LVN C stated proper cleaning for incontinent care was from front to back. The LVN stated if the CNA cleaned back to front that was incorrect technique and the risk was contamination and infection. To prevent this they we would increase in-services on peri care. In an interview on 06/25/2025 at 4:13 PM the Administrator stated he heard the resident was cleaned by wiping in the right direction. He said the risk was infection. They would try to prevent by re-inservicing. 1. Record review of the The facility policy Handwashing/Hand Hygiene (revised August 2015) read, in part, .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .h. Before moving from a contaminated body site to a clean body site during resident care;

Based on observation, interview and record review, the facility failed to ensure that a resident who enters the facility with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #78) of 19 residents reviewed for catheters, as evidenced by: -Resident #78 did not have a STATLOCK (catheter stabilization device) to secure Foley catheter (flexible tube inserted into bladder to drain urine). This failure placed the residents at risk of their Foley catheters getting dislodged, unwanted pain, trauma, infections, and decreasing their quality of life. Resident # 78 Record review of Resident #78's admission face sheet undated revealed a [AGE] year-old-male admitted to the facility on [DATE]. Resident diagnoses included pressure wound stage IV (damage to skin and underlying tissue related to pressure), paraplegia ( paralysis of the lower half of the body), neuromuscular dysfunction of the bladder (nerves controlling he bladder are damaged leading to difficulties storing and emptying the bladder). Record review of Resident #78's admission MDS dated [DATE] reflected a BIMS score of 15 which indicated the resident's cognition was intact. Further review section H (Bowel bladder) reflected that resident had an indwelling catheter. Record review of Resident #78's Comprehensive Care Plan dated 05/29/2025 reflected: Focus: Resident had a foley catheter related to neurogenic bladder. Goal: Resident would remain catheter trauma free Interventions: check tubing for kinks each shift Record review of Resident #78's Physician Order for 06/01/2025 reflected the following order: -Dated 05/29/2025 Foley catheter size_16Fr and balloon size_10 cc for neurogenic bladder (nerves controlling he bladder are damaged leading to difficulties storing and emptying the bladder).change -Foley catheter care every shift and as needed. Observation and interview on 06/24/2025 at 12:45 PM revealed Resident #78 in bed awake, alert, and oriented. Resident # 78 had a foley drainage bag hanging on the right side of his bed. The observation revealed the catheter tubing was laying over his right leg without a Statlock (catheter stabilization device that secures a catheter in place, helps to minimize catheter movement and accidental removal) to prevent Foley tubing from accidently being dislodged or pulling on the tube. Resident #78 stated he did not have anything currently holding the tubing in place to his leg and he stated he never had anything. In an interview on 06/25/2025 at 3:56 PM the DON stated catheter tubes were to be secured in place with a statlock. The purpose of the statlock was to keep the tube from pulling causing injury to the resident's urethra. The DON stated if a CNA finds a resident without the tube secured, they were to notify the nurse. To prevent this from happening again they can make it standard protocol on the Medication Administration Record/ Treatment Administration Record so it will have to be assessed daily. In an interview with the Administrator on 06/25/2025 at 4:10 PM he stated he knew the tube was to be secured to help minimize the risk of injury from it moving. The Administrator stated it was best practice to secure the tube and they can add it to the MAR. In an interview on 06/26/2025 at 9:20 AM CNA D stated if she saw a resident and the catheter was not secured she would notify the nurse. The CNA stated the purpose of the tube being secured was to keep the tube from pulling. CNA D stated in the past she did see Resident #78 not have his tube secured and she did notify the nurse. In an interview on 06/26/2025 at 9:36 PM LVN E stated if a resident did not have a statlock she would get one. LVN E stated the purpose was to prevent the tube pulling and damage Record review of the facility policy on Catheter Care, Urinary revised April 2010 reflected in part: The purpose of this procedure is to prevent urinary tract infections . 2. Ensure that the catheter remains secured with a securement device such as a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh) .

Based on observation, interview, and record review, the facility failed to maintain medical records in accordance with accepted medical standards and practices and failed to maintain medical records for 2 residents (Resident #69 and Resident #11) that were accurately documented. -LVN B initialed Resident #69's treatments as been completed prior to the treatments being provided. -Resident #69 had bilateral edema that was not being charted correctly. -LVN B changed documentation after being asked about Resident #69's edema. -LVN B initialed Resident #11's treatment as been completed prior to the treatments being provided. These failures placed residents at risk for not receiving care and worsening of skin conditions. Findings included: Resident #69 Record review of the admission Record for Resident #69 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, mild cognitive impairment, anxiety disorder, and abnormal findings of blood chemistry. Observation and interview on 06/24/25 at 10:30 a.m. with Resident #69 revealed she said she had hit her leg on the shower chair, and it never healed. She said it gets blistered, then pops. She said the facility did not cover it. She said her family member had asked for wound care to come, but she has not been seen by wound care. Observation at that time revealed both of her feet were edematous. There was an open area on her left lower leg that had multiple blistered and burst blisters visible. Open bloody areas were visible. The wound was not covered. There was scant bloody drainage visible on the sheet. Record review of a Change in Condition Evaluation for Resident #69, dated 06/23/25, revealed the resident exhibited increased edema to her left lower leg. The Summary section read, in part, .pt left leg +2 edema and right leg +1 edema There is increased weeping in left leg. The Evaluation was signed by LVN B. Record review on 06/24/25 at 10:48 a.m. of the June 2025 TAR for Resident #69 revealed the treatment Apply barrier cream to bilateral lower extremities qd one time a day for Skin Integrity. Had been initialed as completed by LVN B. LVN B had also documented Resident #69 had zero edema on 06/23/25 and in the morning of 06/24/25. In an interview on 06/24/25 at 10:52 a.m. with LVN B, revealed she said Resident #69 had edema. LVN B said she had addressed it with the doctor yesterday. She said Resident #69 was receiving wound care. LVN B said the wound care Resident #69 was receiving was a barrier cream. LVN B said she had not applied the barrier cream yet today. When asked if the initials on the TAR indicating the 06/24/25 treatment had already been completed were hers, she acknowledged they were. LVN B pulled up Resident #69's TAR on the computer and again said she had not completed the treatment yet. The TAR had her initials in the box for 06/24/25 indicating the treatment had been done. She said she was supposed to sign the TAR after the treatment was completed. In an interview on 06/24/25 at 4:32 p.m., the DON said Resident #69's legs have been like that since November. She said Resident #69's edema was probably 3 to 4. In an interview on 06/24/25 at 4:40 p.m., LVN C, (the facility Infection Control Nurse) said Resident #69 usually had edema. She assessed Resident #69's edema and said Top of left foot pitted. Slow rebound. Left is greater than right. Pitting in both. In an interview on 06/24/25 at 4:45 p.m. LVN B said Yes, I saw her [Resident #69]. She has edema every day. That doesn't happen overnight. I always chart in the morning. She said she would change her entry in the TAR. Record review on 06/25/25 at 11:19 a.m. of the June 2025 TAR for Resident #69 revealed the resident's edema documentation for 06/24/25 morning assessment was changed from 0 to 3+. The edema for the mid-day assessment had been changed from 0 to 2+. Resident 11 Record review of the admission Assessment for Resident #11 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included contractures of both legs, muscle wasting and atrophy, and muscle weakness. Record review of the Quarterly MDS assessment for Resident #11, dated 05/20/25 revealed she had severely impaired cognition. Record review of the Care Plan for Resident #11 revealed she had very high risk for developing pressure sores. One of the interventions read, in part, .Apply creams as ordered. Record review on 06/24/25 at 11:18 a.m. of the June 2025 TAR for Resident #11 revealed LVN B had initialed she had applied barrier cream to Resident #11's bilateral buttocks and sacral area that morning. In an interview on 06/24/25 at 11:22 a.m. LVN B said she did not apply the barrier cream to Resident #11, even though she signed that she did. She said the CNAs apply it. Observation and interview on 06/24/25 at 11:37 a.m. revealed LVN B was at Resident #11's bedside. She said she had not observed the resident's sacral area yet today. The nurse loosened Resident #11's brief. There was no barrier cream on the resident. When the surveyor informed LVN B she had already initialed the barrier cream had been applied, LVN B said I'm not going to say anything else. In an interview on 06/25/25 at 1:20 p.m., LVN C said the nurse should document after the treatment wasis provided or at that time if she was at the cart. The risk was, that if she got called off to a code or something, the other nurse may not know to do the treatment. In an interview on 06/25/25 at 1:45 p.m., the DON said the nurse should sign/initial the TAR during the activity, and some sign it right before they enter the resident's room. The Survey team requested the policy regarding documentation, no policy was provided by the facility.

Based on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for kitchen sanitation --the facility stored expired food items in the dry goods storage area This failure placed residents at risk of complications from foodborne illness and compromised health status. Findings include: Observation of the dry goods storage area on [DATE] at 9:05 am revealed (10) 12-ounce cans of evaporated milk on a shelf with expiration date of [DATE]. The Dietary Manager said the cans of evaporated milk should not be on the shelf since they were past the expiration date. She said the cans were received in November, and it was an oversight that they were still on the shelf and took the cans off the shelf and put them in the trash. She said the staff member who took the deliveries would check the expiration dates. The Dietary Manager said the risk of someone ingesting expired milk could be death. In an interview on [DATE] at 12:20 pm, the DON said the cans of evaporated milk should not be on the shelf since they were expired. She said risk of someone ingesting expired milk could be gastrointestinal (stomach) issues. Record review of the facility policy Food Storage: Dry Goods, revised ,d+[DATE], revealed: all dry goods will be appropriately stored in accordance with the FDA Food Code

Based on interviews, and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 6 residents (Resident #307), reviewed for the Drug Regimen Review (DRR). The facility failed to review and act on, Resident #307's allergy to sertraline, reported by the pharmacist as a high priority on the DRR report, dated 2/24/23. 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. The findings included: Record review of resident #307's face sheet, printed 3/3/23, revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of fracture of left femur (fracture of the left thigh bone), wedge compression fracture of unspecified thoracic vertebra (fracture of the vertebra in the spine that is in the chest area, that causes a wedge shape), nontraumatic intracerebral hemorrhage (bleeding in the brain, not caused by injury), pleural effusion (fluid between the tissues that line the lungs and the chest cavity), dysphagia (trouble swallowing), muscle weakness, muscle wasting and atrophy (muscles become smaller from nonuse), hypertension (high blood pressure), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out simple tasks), repeated falls, and acute kidney failure (sudden/short onset of kidneys not working properly). Per original face sheet, seen on 3/2/23, sertraline was one of the allergies listed. Once the Surveyor brought the allergy concern to the facility's attention at the end of the day on 3/2/23, the facility removed the allergy listed on the face sheet. Record review of resident #307's initial MDS dated [DATE], revealed a BIMS score of 5 out of 15, indicating severe impairment with cognition. Also, on question N2001 of the MDS it asked, Did a complete drug regimen review identify potential clinically significant medication issues? The answer was marked as No - No issues found during review. Record review of resident #307's Care Plan dated 2/22/23 revealed Ms is at risk for allergic reaction r/t allergies to the following: .sertraline . Ms .will have no allergic reactions through the next review date: Monitor for signs and symptoms of possible allergic reactions such as: hives, rash, swelling, watery eyes, wheezing and report finding to MD as indicated. Notify MD if patient has an allergic reaction to new medications or food for further instructions. Provide MD and other medical professionals a list of allergies when reviewing medications. Review list of allergies prior to administration of medications. The Care Plan also revealed the resident has withdrawn and uses antidepressant medication. At risk for side effects. She will be free from discomfort or adverse reactions related to antidepressant therapy through the review date: Behavior monitoring for withdrawn medication; sertraline document # of behaviors exhibited during the shift. Give antidepressant medication ordered by physician. Report to nurse s/sx of following: mood change, change in normal behavior, hallucinations/delusions, suicidal ideations, withdrawal, constipation, decline in function/adls. Also revealed in Care Plan, Ms .has impaired cognitive function/impaired thought processes r/t Alzheimer's. She will improve decision making ability by next review date: Administer meds as ordered. Observe/document/report to MD any changes in cognitive function, specifically changes in: .Review medications and observe possible causes of cognitive deficit: new medications or dosage increases .drug interactions, errors or adverse drug reactions, drug toxicity. Record review of resident #307's history and physical received from the hospital, with date of visit 2/12/23, revealed sertraline was one of the resident's allergies. Record review of resident #307's facility Admission note dated 2/21/23, listed sertraline was one of her allergies. Record review of resident #307's physician orders revealed an order with a start date of 2/22/23, for Sertraline HCL 50mg tablet, Give 1 PO QD for depression. Resident #307 also had a physician's order with a start date of 2/22/23 for monitoring side effects of antidepressant medication every shift, and to chart all appropriate codes: 0=none, 1=sedation/drowsiness, 2=increased falls/dizziness, 3=hypotension (low blood pressure), 4=anxiety/agitation, 5=blurred vision, 6=sweating/rashes, 7=weakness, 8=headache, 9=dystonia (involuntary muscle contraction), 10=urinary retention/hesitancy, 11=anticholinergic symptoms (dry mouth, constipation, bowel obstruction, dilated pupils, decreased sweating), 12=cardiac abnormalities, 13=tremors, 14=appetite chg/wt chg, 15=insomnia, 16=confusion, 17=tardive dyskinesia (uncontrollable, repetitive movements of the face, torso, and other parts of the body), 18=suicidal ideation every shift. Record review of facility's DRR revealed a report dated 2/24/23 from the pharmacist, marked high priority that stated, Resident #307 has an allergy listed to sertraline and is receiving sertraline. Please review. The report was reviewed and signed by the DON, but undated. Record review of resident #307's MAR for February 2023 revealed she received Sertraline HCL 50mg 1 PO QD for depression, on 2/21/23 through 2/28/23 at 6:00am. Record review of resident #307's MAR for March 2023 revealed she received Sertraline HCL 50mg 1 PO QD for depression, on 3/1/23, 3/2/23, and 3/3/23 at 6:00am. There were no records of any documentation in resident #307's chart that stated the sertraline allergy was reviewed by the facility or Medical Doctor, or if it was okay to continue the medication. There also were no records of documentation in the chart between the facility and the family regarding the allergy before the Surveyor notified the facility about the concern on 3/2/23. An interview with the NP on 3/2/23 at 4:30pm revealed resident #307 had sertraline listed as an allergy in her chart in the EMR, however the NP was not sure what the allergy was to the medication. The NP also confirmed the resident was taking sertraline even though it was listed as an allergy in her chart. The Surveyor showed the NP the DRR report dated 2/24/23, with the DON's signature on it. Per the NP she had no knowledge of the DRR and was never told about it. Also, per the NP, the facility staff should have contacted her or the doctor, through phone, fax, or the communication book, and she was not aware of any contact. The NP said confusion was a symptom of an allergic reaction, and garbled/incoherent speech could be a component of that. The NP said the reason the resident was taking sertraline, even though it was listed as an allergy, was because she was taking it at the hospital and the facility continued it when she got to the facility. Per the NP, the facility restarted the sertraline the resident was taking at the hospital, and because the hospital was giving it, the resident most likely did not have a true allergic reaction. The NP said it could have been that the resident did not like one of the side effects, or something that was normal for the medication, and if there was not a true allergy listed or identified, they continued the medication. Per the NP, this was just a theory, as she was not sure if this is what happened. However, the NP stated the facility should have notified her of the discrepancy right away. An interview with the DON on 3/3/23 at 12:00pm revealed that if there was a change in the resident's status, the facility reported it to the attending provider or to the Medical Director. Per the DON the Medical Director's office was right across the street from the facility, so he was at the facility all the time. Also, the DON stated the facility had the Director's cell phone number, and the doctors at the facility were attentive and easy to communicate with. Per the DON, to ensure orders for medication monitoring were implemented, there were 2-3 different people that checked the orders. The DON stated the admitting nurse first put the orders in, the DON checked the orders second, the MDS nurse checked them, and finally the ADON checked the orders. So, per the DON, orders went through several checks for mistakes. The DON stated the staff performed walking rounds and even the managers would make rounds, to assess for significant adverse consequences to the residents. She stated the staff also gave good end of shift reports, and the nurses sent residents to the hospital if they felt like they did not improve and required interventions they did not need before. The DON also stated assessments (like if the resident had a reaction or side effect) were important, and performed often, to decide if medication needed to be initiated, continued, reduced, discontinued, or otherwise modified. Per the DON the facility evaluated residents all the time, to see if modification of medication was necessary, and it was a group effort. She stated anyone in the facility, could and would, speak up and say something if they noticed the resident acted different. When asked about the DRR process, the DON stated the physicians did not review it right away, and it could take a few days or be something the facility investigated. When the DRR report with the DON's signature on it, was shown to her, the DON stated the facility started giving sertraline to resident #307 because the resident received the medication at the hospital. The DON stated she spoke to the family, and they confirmed the resident was not allergic to sertraline. The Surveyor explained to the DON that there was no documentation in Resident #307's chart indicating any communication with family, nor was there any documentation in the chart that the MD had reviewed the DRR report of the allergy. The DON stated the allergy was addressed and confirmed, and that she had spoken to the physician about it, because her signature was at the bottom of the DRR. However, per the DON, I guess there's no documentation from the doctor saying that he knew about it and that it was ok. The DON stated the risk of taking the medication if she was allergic to it, would be an allergic reaction, and an allergic reaction could cause grogginess or sleepiness. Record review of the facility's Medication Regimen Reviews policy (revised April 2007) read in part: The Consultant Pharmacist shall review the medication regimen of each resident at least monthly. Policy Interpretation and Implementation: 1. The Consultant Pharmacist will perform a medication regimen review for every resident in the facility . 5. The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible. 6. As part of the MRR, the Consultant Pharmacist will: a. Evaluate whether any medication in a drug regimen present potentially significant drug-drug or drug-food interactions; b. Determine if the resident is receiving the correct medications as ordered; . e. Be alert to medications with potentially significant medication-related adverse consequences and to actual signs and symptoms that could represent adverse consequences; and f. Identify medication errors, including those related to documentation. 7. The Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report. 8. The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician, and will document such contacts. If the Physician does not provide pertinent response, or the Consultant Pharmacist identifies that no action has been taken, he/she will then contact the Medical Director, or-if the Medical Director is the Physician of Record-the Administrator . 10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. Record review of the facility's Charting and Documentation policy (revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation: .2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; . d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Record review of the facility's Administering Medications policy (revised March 2011) read in part: Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions . 4. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns . 7. The following information must be checked/verified for each resident prior to administering medications: a. Allergies to medications; .

Based on interview and record review the facility failed to immediately inform the physician and/or Resident/Responsible Party (RP) when there was a need to alter treatment for 2 of 4 residents reviewed for notification of changes. (Residents #2 and #3) - The facility failed to notify the physician and RP Residents #2 and #3 did not receive medications when admitted from the hospital. This failure could place residents at risk of not having notifications made for health related issues. Findings included: 1. Review of the face sheet dated 02/26/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included Hepatitis B (viral liver infection), hepatocellular carcinoma (HCC) (liver cancer) with brain metastases (spread to the brain), atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (high blood pressure), thyrotoxicosis (too much thyroid hormone), and type 2 diabetes (condition that affects the way the body processes blood sugar). Record review of the hospital Discharge Instructions dated 02/23/23 indicated Resident #2: - had left occipital hemorrhagic HCC (bleeding in the brain from liver cancer) with no surgical management and currently on dexamethasone, Keppra (levetiracetam), and valproic acid, and - he was to receive the following medications: - dexamethasone (anti-inflammatory medication) daily for 3 days with next dose due 02/24/23 at 09:00 a.m.; - insulin glargine (to treat diabetes) daily with next dose due 02/24/23 at 08:00 a.m.; - levetiracetam (anti-convulsant medication) every 12 hours with next dose due 02/23/23 at 09:00 p.m.; - metoprolol (high blood pressure medication) every 12 hours with next dose due 02/23/23 at 09:00 p.m.; - divalproex (anti-convulsant medication) twice daily with next dose due 02/23/23 at 09:00 p.m.; - alprazolam (anti-anxiety medication) daily with next dose due 02/24/23 at 09:00 a.m.; - cholestyramine (cholesterol medication) daily for 14 days with next dose due 02/24/23 at 09:00 a.m.; - entecavir (antiviral medication to treat Hepatitis B) daily 2 hours before or after a meal with next dose due 02/24/23 at 08:00 a.m.; - icosapent (cholesterol medication) every 12 hours with next dose due 02/23/23 at 09:00 p.m.; - irbesartan (high blood pressure medication) daily with next dose due 02/24/23 at 09:00 a.m.; - tenovir (Vemlidy (antiviral medication to treat Hepatitis B) daily with next dose due 02/24/23 at 09:00 a.m.; and - Trazodone (antidepressant) at bedtime with next dose due 02/23/23 at 09:00 p.m Record review of the February 2023 MAR indicated Resident #2 did not receive the following medications on 02/23/23 at 09:00 p.m.: - icosapent with documentation left blank, - Keppra (levetiracetam) with documentation left blank, - metoprolol with documentation left blank, - divalproex with documentation marked X, and - Trazodone with documentation marked X. Record review of the Progress Notes for Resident #2 indicated on 02/23/23 there was no documentation for the 09:00 p.m. medication missed doses and no documentation the physician or RP was notified. Record review of the Admission form dated 02/23/23 indicated Resident #2 arrived to the facility at 08:00 p.m There was no documentation of the physician, or the RP being notified of missed doses of medications. Record review of the February 2023 MAR indicated Resident #2 did not receive the following medications on 02/24/23 at 09:00 a.m.: - icosapent with 9=other See Nurse Note for documentation, - insulin glargine with documentation left blank, - alprazolam with 9=other See Nurse Note for documentation, - cholestyramine with 9=other See Nurse Note for documentation, - dexamethasone with 9=other See Nurse Note for documentation, - entecavir with 9=other See Nurse Note for documentation, - irbesartan with 9=other See Nurse Note for documentation, and - tenovir with 9=other See Nurse Note for documentation. Documentation of his vital signs indicated his blood pressure was 109/58, pulse was 74, and temperature was 97.9 (all within normal limits). Record review of the Progress Notes dated 02/24/23 for Resident #2 indicated the following: - at 09:07 a.m. a Medication Administration Note indicated the Entecavir oral tablet 0.5 mg give 1 tablet by mouth one time a day was not available. - at 09:07 a.m. a Medication Administration Note indicated the Icosapent Ethyl oral capsule 1 GM give 2 capsules by mouth every 12 hours was not available. - at 09:09 a.m. a Medication Administration Note indicated the Tenofovir Alafenamide Fumarate oral tablet 25 mg give 1 tablet by mouth one time a day was not available. - at 09:09 a.m. a Medication Administration Note indicated the Irbesartan oral tablet 300 mg give 1 tablet by mouth one time a day was not available. - at 09:23 a.m. a Medication Administration Note indicated Dexamethasone oral tablet 4 mg give 0.5 tablet by mouth one time a day was awaiting medication from the pharmacy. - at 09:23 a.m. a Medication Administration Note indicated Cholestyramine Light oral powder 4GM/dose give 4 grams by mouth one time a day was awaiting medication from the pharmacy. - at 01:38 p.m. a Medication Administration Note indicated the alprazolam oral tablet 0.5 mg give 1 tablet by mouth one time a day was awaiting medication from the pharmacy. There was no documentation of the physician, or the RP being notified of missed doses of medications. Record review of the Skilled Nurse Note dated 02/24/23 for Resident #2 had no indication the physician or RP were notified of the missed doses of medications. At 10:37 p.m. he complained of a headache and was administered Tylenol 325 mg. His temp was 97.9, pulse was 65 and regular, and his blood pressure was 148/61 (all within normal limits). Record review of the February 2023 MAR indicated Resident #2 did not receive the following medications on 02/25/23 at 09:00 a.m.: - cholestyramine with 9=other See Nurse Note for documentation - entecavir with 9=other See Nurse Note for documentation - tenovir with 9=other See Nurse Note for documentation. Documentation of his vital signs indicated his blood pressure was 142/82, pulse was 70, and temperature was 97.6. Record review of the Progress Notes date 02/25/23 for Resident #2 indicated the following: - at 09:51 a.m. a Medication Administration Note indicated the Tenofovir Alafenamide Fumarate oral tablet 25 mg Give 1 tablet by mouth one time a day was pending pharmacy delivery. - at 09:52 a.m. a Medication Administration Note indicated the Cholestyramine Light oral powder 4 GM/dose give 4 grams by mouth one time a day was pending pharmacy delivery. There was no documentation of the physician, or the RP being notified of missed doses of medications. Record review of the Skilled Nurse Note dated 02/25/23 for Resident #2 had no indication the physician or RP were notified of the missed doses of medications. He was resting with no signs or symptoms of distress or discomfort. Record review of the February 2023 MAR indicated on 02/26/23 at 09:00 a.m. Resident #2 did not receive tenovir with 9=other See Nurse Note for documentation. Documentation of his vital signs indicated his blood pressure was 132/70, pulse was 78, and temperature was 97.7 (all within normal limits). Record review of the Progress Notes for Resident #2 indicated on 02/26/2023 at 09:43 a.m. a Medication Administration Note indicated the Tenofovir Alafenamide Fumarate oral tablet 25 mg give 1 tablet by mouth one time a day was pending pharmacy delivery. There was no documentation of the physician, or the RP being notified of missed dose of medication. Record review of the Skilled Nurse Note dated 02/26/23 for Resident #2 had no indication the physician or RP were notified of the missed doses of medications. During an observation and interview on 02/26/23 at 10:15 a.m. Resident #2 was in bed. He was clean, neat, and had no odors. He did not appear to be in any distress or discomfort. Wife was at the bedside. Neither the resident nor his wife could speak English. Surveyor asked if okay and gestured a thumbs up and the resident gestured a thumbs up. His wife nodded her head yes in agreeance with him. During an interview on 02/26/23 at 01:15 p.m. the ADON said Resident #2's medications had to have insurance approvals and delayed the medications being filled. She said the DON gave approval for the last medication to be filled. She said the physician was to be notified immediately when a medication was not available to administer to determine what they want to do. During an interview and record review on 02/26/23 at 01:25 p.m. the ADON provided surveyor with an e-mail dated 02/24/23 at 01:58 p.m. indicated the DON gave approval for 15 days of medication at a time for Resident #2's Vemlidy (tenovir). The ADON said the date was Friday and she did not know why the medication still was not here. During an interview on 02/26/23 at 01:45 p.m. LVN A said the MAs did not let her know Resident #2's medications were not all here yesterday or today. She said she only worked the weekend and did not receive in report of medications not delivered by the pharmacy. She said she had just called the physician of the medication missed doses at this time because the CN should notify the physician of missed doses to determine what needs to be done. She said she received an order to administer the medication when available from the pharmacy. She said she could have even contacted the family to bring Resident #2's from home because of the type of medication it was. She said the MA not informing her was a discussion she had with the ADON and DON. During an interview on 02/26/23 at 02:20 p.m. the DON said she did not know why the medication had not been sent by the pharmacy when it was approved by her to be sent. She said there was a communication breakdown between her staff and the pharmacy also. 2. Review of the face sheet dated 02/26/23 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain), atrial fibrillation (an irregular and often very rapid heart rhythm), hypotension (low blood pressure), and type 2 diabetes (condition that affects the way the body processes blood sugar). Record review of the hospital Discharge Instructions dated 02/23/23 indicated Resident #3: - chronic kidney disease stage 3, a bone tumor, intracerebral hemorrhage, and severe sepsis with septic shock (immune system has an extreme reaction to an infection) - he was to receive the following medications: - clopidogrel (antiplatelet medication) daily with next dose due 02/24/23 at 09:00 a.m., - rifampin (to treat Tuberculosis) every 8 hours for 14 days with next dose due 02/23/23 at 04:00 p.m., - allopurinol (used to treat acid buildup from improper kidney function) daily with next dose due 02/24/23 at 09:00 a.m., - dapagliflozin (to treat diabetes) daily with next dose due 02/24/23 at 09:00 a.m., and - metformin (to treat diabetes) daily with a meal with next dose due 02/24/23 at 09:00 a.m Record review of the February 2023 MAR indicated Resident #3 did not receive rifampin on 02/23/23 at 11:00 p.m. Record review of the admission form dated 02/23/23 indicated Resident #3 arrived at the facility at 06:49 p.m. There was no documentation of the physician, or the RP being notified of the missed dose of medication. Record review of the Progress Notes dated 02/23/2023 for Resident #3 indicated: -at 11:15 p.m. a Medication Administration Note rifampin oral capsule 150 mg give 2 capsules via PEG-Tube every 8 hours for tuberculosis for 14 Days was to be delivered by pharmacy. There was no documentation of the medication was administered. -at 11:56 p.m. his blood sugar was 119. There was no documentation of the physician or RP being notified of the missed doses of medications. Record review of the February 2023 MAR indicated Resident #3 did not receive rifampin on 02/24/23 at 07:00 a.m Record review of the Progress Notes dated 02/24/2023 at 02:52 p.m. indicated for Resident #3's Medication Administration Note rifampin oral capsule 150 mg give 2 capsules via PEG-Tube every 8 hours for tuberculosis for 14 Days was awaiting medication from pharmacy. There was no documentation of the physician or RP being notified of the missed dose of medication. Record review of the February 2023 MAR indicated Resident #3 did not receive the following medications on 02/24/23: - allopurinol morning dose with documentation left blank, - clopidogrel morning dose with documentation left blank, - dapagliflozin morning dose with documentation left blank, and - metformin morning dose with documentation left blank. Documentation on the MAR indicated his temperature was 97.3 Record review of the Progress Notes dated 02/24/2023 for Resident #3 had no indication why the medications were not administered or notification of the physician and RP of the missed doses of medications. At 07:49 a.m. his blood sugar was 90. Record review of the Skilled Nurse Note dated 02/24/23 for Resident #3 had no indication the physician or RP were notified of the missed doses of medications. During an observation and interview on 02/26/23 at 10:25 a.m. Resident #3 was in bed. He was clean, neat, and had no odors. He did not appear to be in any distress or discomfort. He was not able to speak English. Surveyor asked if okay and gestured a thumbs up and resident nodded his head yes. During an interview on 02/26/23 at 01:25 p.m. MA B said initial doses of medications were administered by the CNs not the MAs. She said if a medication dose was missed because the medication was received yet she was to notify the CN so they could contact the pharmacy and the physician. During an interview on 02/26/23 at 01:30 p.m. RN C said initial doses of medications were administered by the CNs. She said if a medication was not able to be given due to unavailable from the pharmacy the CN should contact the physician/NP to let them know a dose of medication would be missed. She said documentation should be in the Nursing Progress Notes or the Skilled Nurse Note. She said there should also be something on the nursing 24-hour report to make the oncoming nurse aware. During an interview on 02/26/23 at 02:20 p.m. the DON said the physician was to be notified immediately when a resident had a missed dose of medication or a change the medication was needed. An Ordering Medication policy, Physician Order policy, and Change in Condition policy were requested upon entrance. Surveyor was provided with a Medication Utilization and Prescribing policy and a Medication and Treatment Orders Policy. Both policies had no significant information.

Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for 2 of 4 residents (Residents #2 and # 3) reviewed for significant medication errors. - The facility failed to ensure medications were received from the pharmacy in a timely manner for Residents #2 and #3 when admitted from the hospital and resulting in missed doses of the medications. This failure could place residents at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. Findings included: 1. Review of the face sheet dated 02/26/23 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included Hepatitis B (viral liver infection), hepatocellular carcinoma (HCC) (liver cancer) with brain metastases (spread to the brain), atrial fibrillation (an irregular and often very rapid heart rhythm), hypertension (high blood pressure), thyrotoxicosis (too much thyroid hormone), and type 2 diabetes (condition that affects the way the body processes blood sugar). Record review of the hospital Discharge Instructions dated 02/23/23 indicated Resident #2: - had left occipital hemorrhagic HCC (bleeding in the brain from liver cancer) with no surgical management and currently on dexamethasone, Keppra (levetiracetam), and valproic acid, and - he was to receive the following medications: - dexamethasone (anti-inflammatory medication) daily for 3 days with next dose due 02/24/23 at 09:00 a.m.; - insulin glargine (to treat diabetes) daily with next dose due 02/24/23 at 08:00 a.m.; - levetiracetam (anti-convulsant medication) every 12 hours with next dose due 02/23/23 at 09:00 p.m.; - metoprolol (high blood pressure medication) every 12 hours with next dose due 02/23/23 at 09:00 p.m.; - divalproex (anti-convulsant medication) twice daily with next dose due 02/23/23 at 09:00 p.m.; - alprazolam (anti-anxiety medication) daily with next dose due 02/24/23 at 09:00 a.m.; - cholestyramine (cholesterol medication) daily for 14 days with next dose due 02/24/23 at 09:00 a.m.; - entecavir (antiviral medication to treat Hepatitis B) daily 2 hours before or after a meal with next dose due 02/24/23 at 08:00 a.m.; - icosapent (cholesterol medication) every 12 hours with next dose due 02/23/23 at 09:00 p.m.; - irbesartan (high blood pressure medication) daily with next dose due 02/24/23 at 09:00 a.m.; - tenovir (Vemlidy (antiviral medication to treat Hepatitis B) daily with next dose due 02/24/23 at 09:00 a.m.; and - Trazodone (antidepressant) at bedtime with next dose due 02/23/23 at 09:00 p.m Record review of the February 2023 MAR indicated Resident #2 did not receive the following medications on 02/23/23 at 09:00 p.m.: - icosapent with documentation left blank, - Keppra (levetiracetam) with documentation left blank, - metoprolol with documentation left blank, - divalproex with documentation marked X, and - Trazodone with documentation marked X. Record review of the Progress Notes for Resident #2 indicated on 02/23/23 there was no documentation for the 09:00 p.m. medication missed doses and no documentation the pharmacy was contacted for the missing medications. Record review of the Admission form dated 02/23/23 indicated Resident #2 arrived to the facility at 08:00 p.m There was no documentation of the pharmacy being notified of missed doses of medications. Record review of the February 2023 MAR indicated Resident #2 did not receive the following medications on 02/24/23 at 09:00 a.m.: - icosapent with 9=other See Nurse Note for documentation, - insulin glargine with documentation left blank, - alprazolam with 9=other See Nurse Note for documentation, - cholestyramine with 9=other See Nurse Note for documentation, - dexamethasone with 9=other See Nurse Note for documentation, - entecavir with 9=other See Nurse Note for documentation, - irbesartan with 9=other See Nurse Note for documentation, and - tenovir with 9=other See Nurse Note for documentation. Documentation of his vital signs indicated his blood pressure was 109/58, pulse was 74, and temperature was 97.9 (all within normal limits). Record review of the Progress Notes dated 02/24/23 for Resident #2 indicated the following: - at 09:07 a.m. a Medication Administration Note indicated the Entecavir oral tablet 0.5 mg give 1 tablet by mouth one time a day was not available. - at 09:07 a.m. a Medication Administration Note indicated the Icosapent Ethyl oral capsule 1 GM give 2 capsule by mouth every 12 hours was not available. - at 09:09 a.m. a Medication Administration Note indicated the Tenofovir Alafenamide Fumarate oral tablet 25 mg give 1 tablet by mouth one time a day was not available. - at 09:09 a.m. a Medication Administration Note indicated the Irbesartan oral tablet 300 mg give 1 tablet by mouth one time a day was not available. - at 09:23 a.m. a Medication Administration Note indicated Dexamethasone oral tablet 4 mg give 0.5 tablet by mouth one time a day was awaiting medication from the pharmacy. - at 09:23 a.m. a Medication Administration Note indicated Cholestyramine Light oral powder 4GM/dose give 4 gram by mouth one time a day was awaiting medication from the pharmacy. - at 01:38 p.m. a Medication Administration Note indicated the alprazolam oral tablet 0.5 mg give 1 tablet by mouth one time a day was awaiting medication from the pharmacy. There was no documentation of the pharmacy being contacted about the medications. Record review of the Skilled Nurse Note dated 02/24/23 for Resident #2 had no indication the pharmacy was contacted of the missed doses of medications. At 10:37 p.m. he complained of a headache and was administered Tylenol 325 mg. His temp was 97.9, pulse was 65 and regular, and his blood pressure was 148/61 (all within normal limits). Record review of the February 2023 MAR indicated Resident #2 did not receive the following medications on 02/25/23 at 09:00 a.m.: - cholestyramine with 9=other See Nurse Note for documentation - entecavir with 9=other See Nurse Note for documentation - tenovir with 9=other See Nurse Note for documentation. Documentation of his vital signs indicated his blood pressure was 142/82, pulse was 70, and temperature was 97.6. Record review of the Progress Notes date 02/25/23 for Resident #2 indicated the following: - at 09:51 a.m. a Medication Administration Note indicated the Tenofovir Alafenamide Fumarate oral tablet 25 mg Give 1 tablet by mouth one time a day was pending pharmacy delivery. - at 09:52 a.m. a Medication Administration Note indicated the Cholestyramine Light oral powder 4 GM/dose give 4 gram by mouth one time a day was pending pharmacy delivery. There was no documentation of the pharmacy was contacted for the missing medications. Record review of the Skilled Nurse Note dated 02/25/23 for Resident #2 had no indication the pharmacy was contacted for the missing medications. He was resting with no signs or symptoms of distress or discomfort. Record review of the February 2023 MAR indicated on 02/26/23 at 09:00 a.m. Resident #2 did not receive tenovir with 9=other See Nurse Note for documentation. Documentation of his vital signs indicated his blood pressure was 132/70, pulse was 78, and temperature was 97.7 (all within normal limits). Record review of the Progress Notes for Resident #2 indicated on 02/26/2023 at 09:43 a.m. a Medication Administration Note indicated the Tenofovir Alafenamide Fumarate oral tablet 25 mg give 1 tablet by mouth one time a day was pending pharmacy delivery. There was no documentation the pharmacy was contacted for the missing medications. Record review of the Skilled Nurse Note dated 02/26/23 for Resident #2 had no indication the pharmacy was contacted for the missing medications. During an observation and interview on 02/26/23 at 10:15 a.m. Resident #2 was in bed. He was clean, neat, and had no odors. He did not appear to be in any distress or discomfort. Wife was at the bedside. Neither the resident nor his wife could speak English. Surveyor asked if okay and gestured a thumbs up and the resident gestured a thumbs up. His wife nodded her head yes in agreeance with him. During an interview on 02/26/23 at the ADON said Resident #2's medications had to have insurance approvals and delayed the medications being filled. She said the DON gave approval for the last medication to be filled. She said the physician was to be notified immediately when a medication was not available to administer to determine what they want to do. During an interview and record review on 02/26/23 at the ADON provided surveyor with an e-mail dated 02/24/23 at 01:58 p.m. indicated the DON gave approval for 15 days of medication at a time for Resident #2's Vemlidy (tenovir). The ADON said the date was Friday and she did not know why the medication still was not here. During an interview on 02/26/23 at 01:45 p.m. LVN A said the MAs did not let her know Resident #2's medications were not all here yesterday or today. She said she only worked the weekend and did not receive in report of medications not delivered by the pharmacy. She said she had just called the physician of the medication missed doses at this time because the CN should notify the physician of missed doses to determine what needs to be done. She said she received an order to administer the medication when available from the pharmacy. She said she could have even contacted the family to bring Resident #2's from home because of the type of medication it was. She said the MA not informing her was a discussion she had with the ADON and DON. During an interview on 02/26/23 at 02:20 p.m. the DON said she did not know why the medication for Resident #2 had not been sent by the pharmacy when it was approved by her to be sent. She said there was a communication breakdown between her staff and the pharmacy also. 3. Review of the face sheet dated 02/26/23 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage (bleeding into the substance of the brain), atrial fibrillation (an irregular and often very rapid heart rhythm), hypotension (low blood pressure), and type 2 diabetes (condition that affects the way the body processes blood sugar). Record review of the hospital Discharge Instructions dated 02/23/23 indicated Resident #3: - chronic kidney disease stage 3, a bone tumor, intracerebral hemorrhage, and severe sepsis with septic shock (immune system has an extreme reaction to an infection) - he was to receive the following medications: - clopidogrel (antiplatelet medication) daily with next dose due 02/24/23 at 09:00 a.m., - rifampin (to treat Tuberculosis) every 8 hours for 14 days with next dose due 02/23/23 at 04:00 p.m., - allopurinol (used to treat acid buildup from improper kidney function) daily with next dose due 02/24/23 at 09:00 a.m., - dapagliflozin (to treat diabetes) daily with next dose due 02/24/23 at 09:00 a.m., and - metformin (to treat diabetes) daily with a meal with next dose due 02/24/23 at 09:00 a.m Record review of the February 2023 MAR indicated Resident #3 did not receive rifampin on 02/23/23 at 11:00 p.m. Record review of the admission form dated 02/23/23 indicated Resident #3 arrived at the facility at 06:49 p.m. There was no documentation of the physician, or the RP being notified of the missed dose of medication. Record review of the Progress Notes dated 02/23/2023 at 11:15 p.m. indicated a Medication Administration Note rifampin oral capsule 150 mg give 2 capsules via PEG-Tube every 8 hours for tuberculosis for 14 Days was to be delivered by pharmacy. There was no documentation of the medication was administered. There was no documentation of the physician or RP being notified of the missed doses of medications. At 11:56 p.m. his blood sugar was 119. Record review of the February 2023 MAR indicated Resident #3 did not receive rifampin on 02/23/23 at 07:00 a.m Record review of the Progress Notes dated 02/24/2023 at 02:52 p.m. indicated a Medication Administration Note rifampin oral capsule 150 mg give 2 capsules via PEG-Tube every 8 hours for tuberculosis for 14 Days was awaiting medication from pharmacy. There was no documentation of the pharmacy was contacted for the missing medication. Record review of the February 2023 MAR indicated Resident #3 did not receive the following medications on 02/24/23: - allopurinol morning dose with documentation left blank, - clopidogrel morning dose with documentation left blank, - dapagliflozin morning dose with documentation left blank, and - metformin morning dose with documentation left blank. Documentation on the MAR indicated his temperature was 97.3 Record review of the Progress Notes dated 02/24/2023 for Resident #3 had no indication why the medications were not administered, or notification of the pharmacy was contacted for the missing medications. At 07:49 a.m. his blood sugar was 90. Record review of the Skilled Nurse Note dated 02/24/23 for Resident #3 had no indication the pharmacy was contacted for the missing medications. During an observation and interview on 02/26/23 at 10:25 a.m. Resident #3 was in bed. He was clean, neat, and had no odors. He did not appear to be in any distress or discomfort. He was not able to speak English. Surveyor asked if okay and gestured a thumbs up and resident nodded his head yes. During an interview on 02/26/23 at 01:25 p.m. MA B said initial doses of medications were administered by the CNs not the MAs. She said if a medication dose was missed because the medication was received yet she was to notify the CN so they could contact the pharmacy and the physician. During an interview on 02/26/23 at 01:30 p.m. RN C said initial doses of medications were administered by the CNs. She said the facility had an E Kit they could pull medications from if the medication had not arrived from the pharmacy and if the medication was in the E Kit. She said if a medication had not been received from the pharmacy, then she would call to find out what the holdup was. She said if a medication was not able to be given due to unavailable from the pharmacy the CN should contact the physician/NP to let them know a dose of medication would be missed. She said documentation should be in the Nursing Progress Notes or the Skilled Nurse Note. She said there should also be something on the nursing 24-hour report to make the oncoming nurse aware. During an interview on 02/26/23 at 02:20 p.m. the DON said she knows there had been a shortage of rifampin but did not know why follow up was not done by staff or the pharmacy to let them know. She said there seemed to be a communication issue between her staff and with the pharmacy. She said the residents missing the medications they missed are significant medications and a medication error was to be filled out.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for 1 (Residents #1) of 4 residents reviewed for quality of life. -The facility failed to ensure Resident #1 received the name brand prescription medication for her seizures specifically ordered by her physician. This deficient practice could contribute to residents decline in physical and psychosocial well-being. Finding included: Record review of a face sheet dated 02/26/23 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), post traumatic seizures (a sudden, uncontrolled burst of electrical activity in the brain that result from brain damage caused by physical trauma), conversion disorder with seizures or convulsions (a condition where a mental health issue disrupts how your brain works), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of a physician order dated 11/05/21 indicated Resident #1 had an order for Lamictal (name brand). It was electronically signed by the physician on 11/06/21. Record review of the MDS dated [DATE] indicated Resident #1 had adequate hearing without a hearing device, had adequate vision with corrective lenses, her speech could be unclear, she was usually able to make herself understood, she understood others clearly, she was cognitively intact with a Brief Interview for Mental Status score of 15 out of 15, she had no behaviors, and had diagnoses of cerebral palsy, seizure disorder, and depression. Record review of the Care Plan dated 01/19/23 indicated Resident #1 had Cerebral Palsy and history of seizures with potential for complications associated with seizure activity. Interventions were initiated on 01/19/23. Noted an intervention of seizure medication as ordered by doctor was initiated on 02/22/2023. Record review of an e-mail provided by the ADON dated 02/22/23 indicated the pharmacy was requesting an approval or denial to charge the facility for Resident #1's Lamictal for a 6 day supply it read in part .Generic is covered, but note indicates prescriber wants brand Reason for charge: Not covered by Medicaid Record review of the Progress Notes dated 02/22/23 for Resident #1 had no indication the physician was notified of the change in the medication. Record review of a physician order dated 02/22/23 indicated Resident #1 had an order for lamotrigine (generic for Lamictal). It was electronically signed by the physician on 02/26/23. Record review of the February 2023 MAR indicated Resident #1 had a new order for lamotrigine and was administered the lamotrigine twice daily on 02/22, 20/23, 02/24, 02/25, and one dose on 02/26. According to the Texas Preferred Drug List effective January 26, 2023 Preferred drugs are medications recommended by the Texas Drug Utilization Review Board for their efficaciousness, clinical significance, cost-effectiveness, and safety. Formulary: Everyone in Medicaid adheres to the same formulary. The Medicaid formulary includes legend and over-the-counter drugs .Preferred Drug List: HHSC arranges the Medicaid Preferred Drug List by the therapeutic class and contains a subset of many, but not all, drugs on the Medicaid formulary. Drugs identified on the PDL as preferred are available without prior authorization unless clinical prior authorization is associated with the drug. Some drugs are subject to both non-preferred and clinical prior authorizations. HHSC makes PDL changes twice a year during January and July. HHSC will announce other changes based on exceptional circumstances Anticonvulsants: PA Criteria (client must meet at least one of the listed PA criteria): All of the agents in the Anticonvulsants class are preferred . Lamictal name brand was listed. According to the Texas Health and Human Services Vendor Drug Program accessed on 02/26/23 at https://www.txvendordrug.com/formulary/formulary-search/drugs/lamictal-100-mg-tablet-37 Drug Details General Brand Name: LAMICTAL 100 MG TABLET Generic Name: lamotrigine Manufacturer: GLAXOSMITHKLINE NDC: 00173064460 Package size: 60EA Drug Information Family Planning drug: No Diabetic Supply Drug: No HTW drug: No HTWPlus drug: No Long-acting reversible contraception product: No Refill-to-soon Utilization*: 75% Specialty Drug +: No Drug Pricing Retail Pharmacy Cost: 20.85373 Retail Pharmacy Eff Date: 01/17/2023 Specialty Pharmacy Cost: 20.48878 Specialty Pharmacy Eff Date: 01/17/2023 Long-term Care Pharmacy Cost: 20.35324 Long-term Care Pharmacy Eff Date: 01/17/2023 340B Rate: 9.32834 Program Coverage Medicaid Effective date: 03/01/2002 Compound-only use: No PDL PA Required: No PDL Class: ANTICONVULSANTS FFS Clinical PA Required ++: No Part B Cost-share Drug**: No Part D Wrap-around Drug***: No Premium Preferred Generic Incentive ++: No During an observation and interview on 02/26/23 at 10:55 a.m. Resident #1 was clean, well-groomed with no unpleasant odor. She was playing on her computer. She did not exhibit any distress. Resident #1 said she had an issue with her seizure medication. She said the MA on Wednesday (02/22/23) told her she noticed she did not have the resident's seizure medication Lamictal. She said the MA reported to the CN. She said the CN called the pharmacy and they said it was no longer paid for by Medicaid. She said the generic was sent instead on 02/22/23. She said when she tried the generic of the Lamictal in 2009 she had a reaction to it and was put in the hospital at which time they told her family she had a reaction to the generic. She said she contacted Medicaid on 02/22/23 and they told her the Lamictal was still on their list of medications they will pay for. She said she talked with the ADON and was told the pharmacy sent information that Medicaid no longer covered the Lamictal. She said she was afraid not take something because her seizures can get bad enough that she had to be placed in a medical coma. She said she was not taking the full dose she normally has because she was afraid to take the full dose but she was afraid of having a seizure so she did not refuse the medication. During an observation and interview on 02/26/23 at 01:25 p.m. MA B said she worked weekends only and was not aware of the change in Resident #1's Lamictal until she came on duty yesterday. She said she had worked at the facility for several years and Resident #1 had always been on the name brand Lamictal. MA B pulled Resident #1's medication card. The medication was Lamotrigine (generic) and not the Lamictal (name brand). During an interview on 02/26/23 at 01:30 p.m. RN C said she worked the weekends only and Resident #1 made her aware of the issue with the Lamictal yesterday. She said as far as she knew according to the resident the ADON and DON were handling the situation with the pharmacy and the medication. During an interview on 02/26/23 at 02:00 p.m. the Corporate Nurse said he had contacted the pharmacy but because it was the weekend the supervisors were not available. During an interview on 02/26/23 at 02:20 p.m. the DON said she was told on 02/22/23 about the issue with the medication and had spoke with the pharmacy at the time and was told the name brand was no longer covered by Medicaid. She said she thought Resident #1 had been on the generic medication before and had no issues. She said she did not realize the resident had a previous reaction to the medication.

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control process designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for 4 out of 6 rooms reviewed for infection control, in that: 1. Facility failed to ensure CNA B wore PPE gown during care of patient in contact isolation. 2. Facility failed to ensure that full sharps containers were removed from resident's rooms and disposed of. These failures could place residents at risk of cross contamination and infection. Findings include: 1. Personal Protective Equipment - PPE Record review of facesheet indicated Resident #5 was a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's order showed he was on tube feeding via Gastrostomy tube (G-tube). Resident #5 was also on antibiotic ([MEDICATION(S)] Capsule 100 MG ([MEDICATION(S)] Monohyd Macro) Give 1 capsule via G-Tube two times a day for [CONDITION(S)] for 7 Days.) for [CONDITION(S)]. Observation and interview on 07/26/2022 at 10:38 a.m., this surveyor donned full PPE (personal protective equipment) and entered room [ROOM NUMBER], Resident #5 was on contact isolation. CNA B was in the room holding and rubbing Resident #5's hand she was not wearing a, only wearing an N95 mask and gloves. This Surveyor asked CNA B what kind of isolation the resident was on and she stated the resident had [CONDITION(S)] ([CONDITION(S)]-resistant Staphylococcus aureus) in her urine. This Surveyor asked why she was not wearing full PPE gown, she stated she was not touching the urine. CNA B said she had been working in the facility less than a year and had been trained on using PPE for infection control purposes. During an interview on 07/26/2022 at 10:46 a.m., the Infection Preventionist -IP said the expectation was for everyone that entered room [ROOM NUMBER] to be in full PPE (gown, gloves and N95), she said the patient had an infection in the urine. She stated further that if anyone was going to work with the patient's urine, they had to use the face shield also because the urine could splash on their face. The IP said the appropriate use of the PPE was a measure to prevent the spread of infection to other residents being cared for by employees. 2 Sharps Container Observation and interview on 07/26/2022 at 10:31 a.m., on 300 hall a sharps container mounted on the wall was full to the tip in rooms 307, 308, 310, and in room [ROOM NUMBER] the sharps container was overflowing - surveyor observed IV start needles with blood in the tubing sitting on the top of the sharps container where it could be grabbed by anyone. This Surveyor called the IP to room [ROOM NUMBER] to observe the overflowing sharps container, the IP stated oh that's not good she unlocked and removed it, she said they were currently changing the sharps containers. The IP said sharps containers should be changed when they get to the full line, about 4 inches below the tip of the container. Observation and interview on 07/26/2022 at 10:46 a.m., the IP was seen entering rooms on the 300 hall and removing the sharps containers. Surveyor asked her who was responsible for removing the sharps containers, she said she would say it was herself who was responsible. When asked about the implication of not removing the sharps containers when due, she said it was a risk for infection and the exposed needles were also risk of harm to the residents. Record review of facility Infection Control policy presented did not specifically address sharps container and PPE.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of seven residents (Resident #1) reviewed for care plans. The facility failed to follow the care plan and place Resident #1's bed in a low position and have a fall mat by her bed while the resident was in bed are care planned. This failure could place residents at risk of injuries, diminished quality of care and services. Findings included: Review of Resident #1's face sheet dated 12/01/21 reflected she was an [AGE] year-old female admitted to the facility on with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS dated 12 /23/2021 revealed the resident required 2 or more staff for physical assistance with transfers, locomotion within unit and bed mobility. Resident used wheelchair to ambulate . MDS revealed the resident had no fall history. Review of Resident #1's record revealed no fall risk assessment. Review of Resident #1's Care Plan dated 01/21 with a revision on 02/24/22 reflected Resident #1 should have a fall mat and low bed in place. In an observation on 02/24/22 at 11:00 AM Resident #1 was observed in bed with no fall mat or low bed in place. In an observation on 02/24/22 at 12:00 PM Resident #1 was observed in bed with no fall mat or low bed in place. In an observation on 02/24/22 at 2:00 PM Resident #1 was observed in bed with no fall mat or low bed in place. In an observation and interview on 02/24/22 at 2:15 PM the Resident #1 was in the bed with not fall mat at bedside. The resident had family visiting. The DON lowered Resident #1's bed, but no fall mat was added at that time. The DON asked the family if the Resident would like a fall mat by her bed. When the DON was asked about the residents fall mat, there was no clear response. In an observation on 02/24/22 at 2:30 PM there was no fall mat by resident #1's bed while the resident was in bed laying down. Interview on 02/24/22 at 1:45 PM , the MDS nurse stated the care plan was updated today about weight bearing status because it needed to be updated since she came back from the hospital on 02/16/22. When she asked the nurse, what does that mean she stated she needed to go through the entire chart and see what needs to be updated on the care plan. The care plan already had that Resident #1 needed to have a low bed and fall mat. In an observation on 02/24/22 at 2: 40 PM the Administrator placed the fall mat by Resident #1 bed. The Administrator stated on 02/24/22 at 2:45 PM Resident #1 should have a fall mat by her bed. Facility policy regarding care plans was requested at this time but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #84) of one resident reviewed for restorative care. The facility failed to provide restorative therapy to Resident #84 per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] This failure placed 30 residents with contractures at risk for decline in range of motion, decreased mobility, and worsening of contractures. Findings included: Record review of Resident #84's MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was totally dependent on 2 staff for transfer assist and most ADLs. He had range of motion impairment on both sides, upper and lower extremities. Record review of Resident #84's care plan dated 9/01/21 and revised on 9/20/21 revealed, Resident #84 has ADL deficits secondary to [CONDITION(S)], ICH or stroke and functional decline. Further noted perform restorative program as indicated. RNA to apply comfy grip hand splints to bilateral hands 2-4 days as tolerated. Document progress weekly and evaluate every month. Record review of Resident #84's physician order, dated 12/2021 revealed RNA to apply comfy grip hand splints to bilateral hands 2-4 hrs a day as tolerated. Passive Range of motion (PROM) before and after splints, every day, start date 09/21/21. Record review of Resident #84's Occupational Therapist Progress and Discharge Summary, dated 8/25/21 revealed, discharged (on 8/25/21) to Long Term Care (facility) with RNA program for contracture management program. Education and Training reflected, appropriate application of Bilateral comfy grip hand Splints Orthotic device application to inhibit flexor tone and prevent contractures. Return demonstration of bilateral upper extremities (BUE), range of motion (ROM), PROM (passive ROM) and bilateral comfy grip hand splints by caregiver/RNA staff. Further noted with the assistance of a device to correct anatomical deviation and RNA training included care and wearing schedule. Written RNA program was given to RNA today, 8/25/21 with accuracy return demonstration. During observation and interview on 12/16/21 at 9:30 am revealed Resident #84 with bilateral hand contractures, and no bilateral grip hand splints in use. He was non-verbal and his response by facial grimace. CNA A stated she had been assigned prior and was familiar with Resident but not regularly assigned to her. CNA A stated she did not know where his hand splints were located and which hand it was to be applied. Interview on 12/16/21 at 10:30 am PT/OT rehab director stated Resident #84's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .T rehab. She added Resident was waiting for the high tilt- back wheelchair, to reduce leaning and maintain positioning, since his wheelchair does not tilt-back. During interview with LVN B on 12/16/21 at 10:40 AM revealed there was no restorative program in place at the facility until September 21, 2021. LVN B stated we did not have RNA in August 2021. She said currently we have one RNA with 30 residents on RNA program. LVN B stated she could not find Resident #84 's restorative sheets signed by RNA that would indicate the RNA program order was followed in August, September, October and November 2021. During interview on 12/16/21 at 10:40 AM LVN B stated we have one RNA that is supposed to perform daily (QD) passive range of motion as ordered before applying, and after applying both hand splints to Resident #84. LVN B stated the one RNA does not work on weekends and occasionally pulled to the floor. LVN B stated it was not consistently done because were short of RNAs and the nurse was supposed to get CNAs to do it. She stated she was MDS nurse and assigned to ensure RNA program was followed by RNA. During interview on 12/16/21 at 11:00 am ADON stated the charge nurse or assigned to Resident #84 was new, and she was unable to contact the RNA, since it was her off-duty. ADON when asked, stated she had not received nor had seen a restorative sheet signed by RNA, that would indicate RNA program order was followed in August, September, October and November 2021. She stated she did not know where the restorative sheets supposed to be turned in, and none was handed to her or to DON. During interview on 12/16/21 at 10:40 am PT/OT rehab director stated we kept Resident #84 on our PT/OT rehab caseload until the last week, since we spent that last whole week training the RNA, and Resident #84 was discharged to RNA program 8/25/21. She said once Resident #84 was off therapy, it was the facility's responsibility to provide follow through of restorative nursing program when he came off their services. During interview on 12/16/21 at 11:00 am ADON acknowledged RNA program was not consistently done and will render staff in-service today. She said RNA received from PT/OT the RNA program training but moving forward PT/OT is going to train not only the RNA, but also the nurse, and the nurse will train the CNAs properly. ADON added next time she would be involved with assisting and monitoring, to ensure the RNA program was followed through. Record review of the Staff In-Service Training, dated 12/16/21, revealed education provided to charge nurse once discharged from therapy services. Delegation then placed to trained CNA. Charge nurse to follow up on task. Nurse to follow-up that RNA has completed RNA task per RNA program order. Splints, ROM, etc. Record review of facility's policy titled Restorative Nursing Care, dated April 2007, read in part, Encouraging and assisting bedfast residents . to prevent contractures and deformities; Assisting residents to adjust to their disabilities, to use their prosthetic devices and to redirect their interest, if necessary.

Based on observation, interview and record review the facility failed to ensure the comprehensive assessment accurately reflected the resident's status (Resident # 59) in resident's reviewed for assessment accuracy. --resident # 59's annual MDS dated [DATE] reflected use of restraints (side rails) when the resident was not using restraints in the facility This failure placed residents at risk of inaccurate assessments and not receiving appropriate care according to their current status. Findings include: Record review of the face sheet for Resident #59 revealed admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 59's annual MDS assessment dated [DATE] revealed a BIMS score of 99 indicating severely impaired cognitive skills for daily decision making, total dependence on staff for all ADL's and bed rails coded as restraints. Record review of Resident # 59's care plan dated 11/24/21 revealed he has ADL deficits secondary to stroke and depended on caregivers for all ADL's. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ side rail to each side of bed for turning and repositioning. Observation of Resident #59 on 12/14/21 at 9:40 am revealed he was in bed, eyes closed, in no apparent distress, with feeding tube infusing formula for nutrition and [CONDITION(S)] enabling him to breathe. His bed had ¼ side rails attached to the side of the bed at the area of the head to enable bed mobility. Observation of his roommate's bed at that time revealed his bed also had ¼ side rails attached to the bed at the area of the head. Observation of Resident # 59 on 12/15 21 at 1:15 pm revealed he was in bed, and a family member was visiting in his room. Resident # 59 was awake but not able to move side to side. In an interview on 12/15 21 at 11:10 am, the DON stated the bed rails for Resident # 59 should not be coded as restraints because they are not restricting his movement, and he is not able to move around in bed. In an interview on 12/15/21 at 2:20 pm, the MDS nurse stated the bed rails should not be coded as restraints since Resident # 59 is not able to move side to side. Further interview revealed the MDS nurse was responsible for coding information in the MDS after she receives assessment information from the nurses. She stated the bed rails were coded as restraints based on information from the nurses, but the bed rails should not be coded as restraints. Record review of facility policy Comprehensive Assessments and the Care Delivery Process, revised December 2016, revealed, in part . objective of the assessment is to obtain, organize, and analyze information about a patient .and adjust interventions . Record review of facility policy Proper Use of Side Rails, revised December 2016, revealed, in part . side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed) .side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .

Based on observation, staff interview and review of facility policy, the facility failed to ensure staff completed hand hygiene in order to maintain infection control. The facility also failed to ensure the proper use of Personal Protective Equipment (PPE) before and after exiting three Resident's (Residents (R) 18, 19, and 20) rooms who were considered Persons Under Investigation (PUI) for exposure to COVID-19. The facility failed to ensure designated containers were available on the COVID-19 unit for soiled linens. Lastly the facility failed to ensure three of three residents (R11, R12 and R15) had signage placed on their doors and PPE placed outside their rooms who were on quarantine status. Findings include: Review of the facility policy titled, Isolation-Categories of Transmission-Based Precautions, revised April 2010 revealed, .Gloves and Handwashing . (1) . wear gloves (clean. non-sterile) when entering the room . (2) While caring for a resident, change gloves after having contact with infective material . (3) Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent . (4) After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the residents' room . In addition, the facility policy revealed . When Transmission-Based Precautions are implemented, the infection Control Coordinator (or designee) shall: .a. Ensure that protective equipment (i.e . gloves, gowns. masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need .Ensure that an appropriate linen barrel or hamper and waste container with the appropriate liner, are placed in or near the resident's room . The policy further revealed to place the appropriate notice on the room entrance door .so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room . During an observation and interview on 09/06/21 at 9:05 AM, Licensed Vocational Nurse (LVN) 1 was observed carrying drawers with PPE in them and isolation signage. LVN1 placed the PPE drawers in R11's room and placed the isolation sign on the outside of R11's door. LVN1 stated R11's roommate (R10) tested positive for COVID-19 and R11 was being placed on precautions. LVN1 stated she became aware of R11's quarantine status on 09/06/21 at 6:20 AM, during morning report. LVN1 said she just noticed the appropriate signage and PPE were not in place for R11's quarantine status. During an interview on 09/06/21 at 9:20 AM, with the Director of Nursing (DON), revealed the facility staff was made aware R10 tested COVID-19 positive on 09/05/21 at 12:09 PM and the resident was moved to the COVID-19 positive unit around 3:00 PM. The DON said there should be signage on the R11's door reviewing what PPE needs to be worn to enter the resident's room. The DON also revealed R12 and R15 were the other two residents who had roommates that recently tested positive for COVID-19. The DON confirmed R12 and R15 rooms did not have the necessary signage or full PPE available during the same time period as R11. Observation on 09/07/21 at 4:35 PM revealed Certified Nursing Assistant (CNA) 1 exited a zippered, plastic barrier that separated the residents who had COVID-19 from the residents who were PUI for COVID-19. CNA1 was wearing a gown, gloves, mask, and face shield upon leaving the COVID-19 unit. CNA1 continued down the hall, carrying an open, clear plastic bag of linens. CNA1 then exited a side door where multiple unlabeled grey barrels were. CNA1 placed the linens in one of the grey bins. When CNA1 re-entered the PUI hall, she did not remove her gloves, or gown, or complete hand hygiene, and entered R18's room. After she exited R18's room she entered R19 and R20's room. She was not observed to have changed her gown, gloves or conduct hand hygiene during the entire observation. There was no observation of CNA1 providing any care to R18, R19, or R20. During an interview on 09/07/21 at 4:40 PM with CNA1 she confirmed she had not removed her gown, gloves, or washed her hands or used hand sanitizer before and exiting the resident's rooms and confirmed she should have done so. During an interview on 09/07/21 at 4:45 PM, with LVN3 revealed CNA1 should have changed her gloves, gown and washed her hands or use hand sanitizer before and after entering or exiting resident rooms.

Based on record review, resident interview, staff interview, review of facility policy, and review of the facility investigation report, the facility failed to ensure one of four residents (Resident (R)5, was free from misappropriation of personal funds by a Certified Nurse Assistant (CNA). This affected one of four residents reviewed for misappropriation of funds. Findings include: Review of the Profile tab in the Electronic Health Record (EHR), R5 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the facility investigation report dated 02/07/21 at 8:15 PM, revealed at 5:00 PM, R5 reported to a staff RN his bank card was missing. The report further revealed R5 was cognitively intact, interviewable, and had the capacity to make his own decisions. R5 had notified his bank of the missing card and found three charges had been made without his authorization, totaling approximately $200. The investigation report revealed Administration interviewed all staff on the hall including CNA2. Written statements were collected and CNA2 was suspended. On 02/08/21, CNA2 called the facility and admitted to the Administrator he had taken R5's bank card and had charged three different times for gas, food and groceries. CNA2 was terminated from employment. A police report was filed however, R5 did not press charges. CNA2 asked the facility to keep his paycheck and to reimburse the resident for the charges. In an interview on 09/07/21 at 11:04, R5 stated he did not know CNA2 well, however he had taken care of him several times, since his admission, and he was someone he trusted. R5 further stated it did upset him his money was taken; however, it had been paid back and for that he was happy. In an interview on 09/07/21 at 12:30 PM the Director of Nursing (DON) revealed the misappropriation of R5's money was confirmed, and she was the one who reported it to the State Agency (SA). Review of the facility policy, titled, Reporting abuse to Facility Management, revised December 2009, revealed, Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on closed record review and staff interview, the facility failed to ensure all necessary documentation of discharge was in the medical record to ensure a safe and effective discharge for one of four sample residents (Resident (R) 9) who were reviewed for discharge. Findings include: Review of the Profile tab in the closed Electronic Medical Record (EMR), revealed R9 was admitted to the facility on [DATE] and discharged on [DATE]. R9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR, dated 09/24/20, R9 had a Brief Interview of Mental Status (BIMS) interview, which indicated that he had moderately impaired in cognition. Review of a late entry Progress Note, in the resident's closed EMR, dated 09/24/20 at 2:56 PM revealed the nurse had called and spoken with R9's wife about being discharged to the assisted living. The assisted living was notified and accepted the resident as well as the Social Worker at a local hospital was in agreement. They were notified of the resident's escalation in behaviors which would warrant discharge as the nursing staff had not been able to care for him because of his refusal of care this morning, which included medications and behaviors. The resident's wife stated he could be discharged to the assisted living. A discharge packet was made which included instructions for medication administration. Review of a Progress Note, in the resident's closed EMR, dated 09/24/20 at 4:05 PM revealed R9 was discharged from the facility with his IV (intravenous) medications as well as his regular medications. Dressing supplies for the surgical amputation of his toes were given to the driver. Review of the R9's closed EMR revealed no documentation the physician was notified of the residents discharge, there was no AMA (Against Medical Advice) paperwork to indicate he knew of the risks of discharge from the facility, there were no instructions on how to care for his surgical wounds, instructions on care of his IV and how to administer his IV medications and what home health agency would be providing care at home. There was no documentation the facility had called and set up DME (Durable Medical Equipment) for his home. In a phone interview on 09/07/21 at 9:21 AM, Registered Nurse (RN)6 (who according to the Director of Nursing (DON), was acting as the Social Worker in the facility) revealed she was not in the building at the time R9 discharged from the facility; however, the Social Worker at the hospital called on 9/25/20 (a day after discharge) and stated she would take care of everything and, we were not to have any more contact with the resident. RN6 could not remember if she had called R9's physician regarding the discharge. RN6 confirmed it was the facility's policy to notify the physician regarding discharges whether they were resident-initiated, or facility-initiated, as well as document the notification in the record. RN6 further stated if the physician agrees to the discharge, then we set-up home health, and contact the DME company to provide whatever the resident might need at home. Interview on 09/08/21 at 9:07 AM, with RN4 and the DON revealed RN4 revealed after review of the resident's closed record, the Social Worker at the local hospital was notified of him going back to the assisted living, she was also notified of the behaviors and refusal of care. Transportation was arranged and provided. A discharge packet was made with instructions. RN4 stated the facility did not set up home health as the Social Worker at the hospital said she would take care it. The DON stated the resident was sent with his medications, and the resident indicated he wanted to go home. She stated it was a resident-initiated discharge. The DON confirmed there was no documentation of AMA paperwork or any documentation stating the resident wanted to go home in the resident's EMR. She further revealed she did not think the physician needed to be notified of a resident-initiated discharge. In a phone interview on 09/08/21 at 11:58 AM, the Nurse Practitioner revealed it was his expectation to be notified of any discharges.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 5 residents (Resident #1) and 2 of 7 staff (Staff #1 and Staff #2) reviewed for infection control. The facility failed to screen staff and visitors for symptoms of COVID-19 prior to permitting entrance. The facility failed to ensure temperatures were documented for essential caregivers prior to permitting entrance. These failures could place facility residents at risk for being exposed to infection and decline in health. Findings include: Observation and interview on 12/4/20 at 9:30 am upon entrance, an unidentified staff member entered the building prior to the surveyor. She walked to the screening table and filled out the log labeled staff. The Administrator in Training took her temperature, she sanitized her hands, and walked into the facility. He did not ask her any screening questions or review the log. He then took the surveyor's temperature and provided hand sanitizer. The surveyor reviewed the screening log and found there was a column that read respiratory risk questionnaire. He said, That's if you're having any symptoms like coughing, fever and those things. When asked where the questionnaire was he said it was not required. An unidentified female staff member walked up and said, We don't do those anymore and walked off. Record review of the visitor screening log dated 12/4/20 revealed the following sections on the log: Staff Name, International travel (yes/no), Out of state travel (yes/no), Respiratory risk questionnaire complete (yes/no), Visit restricted (completed by screener, yes/no). Temperatures were written on the side of the form. Only one of the four visitors answered Yes to respiratory risk questionnaire complete. Record review of the staff screening log dated 12/4/20 revealed the following sections on the log: Staff Name, International travel (yes/no), Out of state travel (yes/no), Respiratory risk questionnaire complete (yes/no), Visit restricted (completed by screener, yes/no). Temperatures were written on the side of the form. Seven of nine staff who signed in on the log answered yes to respiratory risk questionnaire complete. Staff #1 and #2 did not fill out the questionnaire. Record review of an undated/blank COVID-19 Risk Questionnaire read in part, Visitor name, date . All resident visitors will complete a risk questionnaire prior to resident visit. Any visitor not meeting the screening criteria will not be allowed to visit the resident. The Questionnaire asked if the visitor had COVID-19 symptoms or temperature, if the vistor had contact in the last 14 days with someone who had COVID-19 or had symptoms, or if the visitor has tested positive for COVID-19 in the past 10 days. During an interview on 12/4/20 at 9:40 am, the DON said the regular screener woke up late and the Administrator in Training was covering until she came in. When asked if Administrator in Training was trained on the screening process she said he was trained by the Infection Preventionist who was currently not in the building. During an interview on 12/4/20 at 9:50 am, Administrator in Training said he received training on the screening process with the Administrator. He said when somebody entered the building they sanitize their hands, he took their temperature, and they filled out the screening log. When asked where the completed screening questionnaires were kept for the visitors he said he was not sure. When asked where the completed screening questionnaires were kept for the staff he picked up a binder labeled staff. Observation and record review on 12/4/20 at 10:20 am revealed there were three binders on the screening table. One for visitors, staff, and essential caregivers. In the visitor binder there were blank COVID-19 Risk Questionnaires. There were no completed questionnaires. The staff binder had logs separated by each staff member. The logs were not filled out for the staff who had recently signed in. Resident #1 Record review of the essential caregiver's binder on 12/4/20 revealed it was separated by the caregiver's name. COVID-19 Risk Questionnaire for Resident #1's essential visitor dated 12/3/20 revealed there was no recorded temperature. During an interview on 12/4/20 1:20 pm, when asked the screening process for visitors/staff/essential caregivers the DON said the process was Basically the same. She said people who entered the facility were to perform hand hygiene, sign in, received a temperature check, and the screener asked additional questions. When asked what additional questions were asked she said there was a questionnaire that the screener would go over that included COVID symptoms. She said if they exhibited any symptoms or had a fever they were not permitted to enter the facility. She said a temperature check and absence of symptoms was required to be documented for everyone and the screener must review all answers before allowing entrance. Record review of the facility's undated COVID policy revealed Facility will actively verify absence of fever and respiratory symptoms when employees report to work - beginning of their shift. Document temperature, absence of shortness of breath, new or change in cough and sore throat.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 was transferred using mechanical lift with two people assistance, as required in her plan of care, resulting in an avoidable accident with injury. Resident #1 complained of pain following the transfer without use of mechanical Lift and an x-ray confirmed a right [MEDICAL CONDITION]. This failure affected 1 resident and placed 3 other residents who were dependent on staff for transfers at risk for injury during improper transfer procedure. Findings include: Record review of Resident #1's clinical record revealed an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed Resident #1 required extensive assistance and 2 person transfer. Resident #1 had a BIMS score of 08 indicating moderate cognitive impairment. Record review of Resident #1's Care Plan initiated 4/5/17 revealed Resident #1 was to be transferred with the mechanical lift with 2 person assist and Resident # 1 had a right above the knee amputation (AKA). Interview on 4/10/18 at 2:17pm Resident #1's family member revealed that Resident #1 left a voicemail message on 4/4/18 stating that staff hurt her while transferring her after her shower. The family member called the facility and spoke with the DON on 4/5/18 who revealed that the x-ray order was just received and she would call her with the results. The DON called her later and stated that Resident #1 had a [MEDICAL CONDITION]. The family member said while at the orthopedic appointment Resident #1 revealed staff were yanking on her and made her hurt her leg. Interview on 4/10/18 at 12:12pm Dr. V, the orthopedic physician, stated he spoke with staff at the facility and they revealed that Resident #1 was hurt during a transfer. Dr. V revealed he followed protocol by reporting the incident, but did not see any evidence of abuse. Dr. V said Resident # 1 had some dementia, but could make needs known. Observation and interview on 4/10/18 at 12:23pm Resident # 1 was oriented to person and place. The resident was in bed, clean and groomed well. Resident # 1 denied pain. When asked by surveyor how she hurt her leg, Resident # 1 revealed that after she had a shower four staff members were pushing and pounding on her during a transfer back to bed. Resident #1 stated when she got hurt, there was no lift. She revealed the staff were pulling me and banging my leg. Resident # 1 revealed that she did not know if staff tried to hurt her and she does not feel threatened. She said she told her family member and the orthopedic doctor about the incident. Interview on 4/10/18 at 12:35pm CNA C revealed that after Resident # 1 had her shower on 4/4/18, staff was going to transfer her to the wheelchair but couldn't because Resident #1 had a bowel movement and the sling for the mechanical lift was dirty. CNA C revealed CNA E, CNA B, and LVN R were also there to assist and they decided to transfer Resident #1 to the bed to clean her before transferring her to the wheelchair. CNA C revealed the lift was not used and they manually transferred Resident #1 to the bed using the sling only. CNA C revealed Resident #1's right leg with the AKA hit the bed first and Resident #1 started complaining of pain. CNA C stated they cleaned Resident #1 and transferred her to the wheelchair using the lift. She stated she went to break after that because it was not her resident and she was only there to help with transfer. Interview on 4/10/18 at 12:46pm LVN R revealed she was there when the staff put Resident #1 in the shower chair to go take a shower and the lift was used. LVN R revealed she was not there when they put Resident # 1 back in bed. LVN R revealed CNA E reported to her that Resident #1 was complaining of pain after being transferred. LVN R stated when she came in to assess Resident #1 she denied pain. LVN R revealed the next day Resident # 1 complained of pain and she told her she would notify the doctor to get x-rays and medicated Resident #1 for pain. She said the physician and family member were notified. Interview on 4/10/18 at 1:03pm CNA E revealed Resident # 1 was transferred to the shower chair and assisted with a shower with no problems. She stated after the shower they were about to transfer Resident #1 to the wheelchair when they realized she had a bowel movement. CNA E stated CNA C, CNA B and LVN R assisted with the transfer. CNA E revealed the lift was not used when they transferred Resident # 1 to the bed from the shower chair in order to clean her. CNA E revealed they cleaned Resident #1 and used the lift to transfer her to the wheelchair. CNA E revealed Resident #1's right leg went down first on the bed during the transfer and Resident #1 complained of pain at that time. Additional interview for clarification on 4/10/18 at 1:50pm with LVN R revealed she was there for the transfer from the bed to the wheelchair following Resident #1's shower, but was not there when they transferred Resident #1 to the bed from the shower chair so she does not know if the lift was used. She revealed that the lift was used to transfer Resident #1 from the bed to the wheelchair. LVN R revealed that when she came in, Resident # 1 denied pain. Additional interview for clarification on 4/10/18 at 2:05pm with CNA C revealed that they noticed that they could not use the lift to transfer Resident # 1 to the bed because the sling was not positioned properly. She revealed that she was sure that the lift was not used to transfer Resident #1 to the bed from the shower chair because they tried and it would not work because of the position of the sling. Interview on 4/10/18 at 1:34pm the DON revealed that the lift should have been used for all transfers because Resident #1 is heavy and hard to transfer. The DON revealed she was notified of the x-ray results and contacted Resident #1's family member. Resident #1's familly member agreed not to send Resident #1 to the hospital and stated they would like for her to see the orthopedic doctor the next day. Record review of nurses' notes revealed the following in part: -4/5/18, 7:38am. Assess resident upon arrival this AM she complained of right hip pain when turning and positioning to change her brief. No bruising or swelling noted. Nurse practitioner notified and gave new orders; STAT bilateral hip x-ray. Tylenol 2 tabs was administered. No signs/symptoms of acute distress or discomfort noted at this time. (Family member) informed of the above. Will continue to monitor. Vital signs 133/84(blood pressure), 91(heart rate), 98.2(temperature), 18(respirations). -4/5/18, 9:50am. Bilateral hip and pelvis results received: bones osteoporotic, acute right intertrochanteric femoral neck fracture. MD notified and gave new orders. Appointment for Orthopedic, Tylenol #3 with [MEDICATION NAME] every 8 hours for 7 days for pain. (family member) aware of the above. Will continue to monitor Record review of Radiology report dated 4/5/18 revealed the following impression: -Bones are osteoporotic -The findings suggest the acute right intertrochanteric femoral neck fracture. The femoral head is medially angulated. Record review of the facility policy titled Lifting Machine, Using a Portable (Revised (MONTH) 2007) revealed the following in part: -The purpose of this procedure is to help lift residents using a manual lifting device -Review the resident's care to assess for any special needs of the resident -The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, 2 nursing assistants will be required to perform the procedure. Record review of the facility policy titled Two Person Transfer, revised (MONTH) 2011, revealed the following in part: Manual lifting of residents shall be eliminated when feasible. The facility's CMS 672 dated 4/10/18 listed 4 residents who were dependent on staff for transfers.

Based on observation, interview, and record review, the facility failed to ensure the right to voice grievances without fear of discrimination or reprisal was provided for 1 of 5 residents reviewed for resident rights, as evidenced by: Resident #1 made a complaint regarding his pain medication. Immediately afterwards the facility began crushing his medications and spoon-feeding them to him, which he found demeaning; and This failure affected one resident and placed the remaining 52 residents who received pain medications at risk of feeling fearful to make complaints and at risk of a decline in psychosocial well-being. Intakes # 6 and # 3 Findings include: Record review of Resident #1's admission sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Quarterly MDS dated [DATE] revealed he had no communication or behavior problems. His BIMS score was 14, which indicated he was cognitively intact. Resident #1 required extensive assistance of two or more persons for bed mobility, transfers and toilet use. Record review of Resident #1's care plan dated 11/28/15 revealed a problem of pain secondary to [MEDICAL CONDITION] with muscle spasms. The goal was to have Resident #1 verbalize adequate relief of pain . the interventions read in part .11/10/15-[MEDICATION NAME] 10/325mg tab 1 by mouth every six hours as needed for pain. 11/17/15- [MEDICATION NAME] 10/325mg tab 1 by mouth every six hours around the clock .administer pain medications as ordered .evaluate the effectiveness of pain interventions . Observation and interview on 12/22/15 at 10:48 a.m. revealed Resident #1 lying in bed in his room. He said on 12/6/15 at 9:23pm he woke up and asked for a pain pill. Resident #1 said when LVN A brought his pill he was lying on his side. He said he asked the LVN A to turn the light on so he could see his medicine but she refused, saying it would wake his roommate. LVN A put the pill in his mouth and he said when it hit his tongue it had a specific taste. He said LVN A pushed water into his mouth. Resident #1 said the pill had a coating and his pain pill did not, so he spit it out. He said he hit the call light and an aide walked in. He asked the aide for LVN A. When LVN A came in, Resident #1 said he told her it was not his pain pill. He said LVN A told him it was a different pack and could have come from another manufacturer. Resident #1 said he felt as though they were just bumping heads so he decided to keep the pill and wait for the morning staff. When they came on he asked to speak to the charge nurse, RN B, and he showed her the pill. Resident #1 said RN B told him it was definitely not a pain pill. During the same interview on 12/22/15 at 10:48 a.m., Resident #1 said when the Administrator came in on Monday, 12/7/15, the Administrator told him he heard Resident #1 had pills in a pill case before. Resident #1 said the Administrator told him it looked like an antibiotic he had spit out earlier to swap out for a pain pill at night. Resident #1 said his toe was infected and he wanted it to heal, so he would not have done that. He also said he did not ask for a replacement for it. The Resident said he was told by the Administrator that the facility staff was going to start crushing his pills. Resident #1 said he did not want that. He became very emotional while recounting this, tearing up and asking for a minute to compose himself. Resident #1 was not able to talk for a few minutes. When he resumed, Resident #1 said he was so mad about the pills being crushed that his muscle spasms and depression both got worse as a consequence because it was so degrading . Resident #1 said the Administrator told him that was what they did with criminals in prison. Resident #1 said That was degrading. The Resident continued that the staff had to spoon-feed him the pill mixture, which he said was was even more degrading. Resident #1 again became upset talking about the issue. He said it took him two years to teach himself to do so because of the paralysis, but that he could feed himself independently now. Resident #1 again started crying and said the staff called me a liar regarding the pain pill. Resident #1 said the DON told him recently that they decided for Christmas to stop crushing his pills. Resident #1 had to wipe the tears from his face with his sheet. Resident #1 said the Administrator told him the general census among the staff was that he could not be trusted with pills. Resident #1 said he felt bombarded and punished for speaking up. Resident #1 said he knew how serious the accusation against LVN A was. He said another reason he did not like having his medications crushed was that he had no way of telling what they were. Even if somebody showed them to him before they crushed them, they could go out in the hall and crush something else. During an interview on 12/22/15 at 12:55 p.m. the DON said if the staff took a grievance they would turn it in to the Administrator, who was in charge of the grievances. She said if someone presented a problem she could not take care of immediately it was a grievance. The DON said Resident #1 had his pills changed many times and he was trying to hide one in his pillow. She said one night Resident #1 accused a nurse of not giving him his pain medication, and that he waited for the day shift to turn the pill over. The DON said the pill appeared to be Bactrim but was not Resident #1 ' s pain pill. The DON also said LVN A offered to do a drug test but the DON said the facility did not have any on hand. The DON said she did not know why Resident #1 ' s complaint was not written up as a grievance. She said RN B handled it and it appeared to be resolved at that point. The DON said Resident #1 ' s medications were being crushed for a little while; maybe a week. She said we thought we shouldn ' t do that so we went back to whole. The DON said she did realize that Resident #1 found crushing his medications offensive. She said Resident #1 agreed to let facility staff check his mouth after medications were given. In an interview on 12/22/15 at 1:11 p.m. when asked what determined a grievance the Administrator said, When they come and talk to me I guess. That ' s a good question. When asked why Resident #1 ' s complaint was not in the grievance book the Administrator said he had notes on that issue. He said there was no follow-up needed because the facility investigated it. The Administrator said typically when there ' s a situation when we are investigating something I ' m not going to write a grievance. In regards to the incident the Administrator said Resident #1 was saying he did not get his [MEDICATION NAME]. The Administrator said three nurses looked at the pill Resident #1 gave them. He said when LVN A gave Resident #1 the pill at 3:00 a.m. the Resident asked the nurse if it was the right pill. The Administrator said the nurse put the pill in Resident #1 ' s mouth and the Resident took the pill out. The Administrator said Resident #1 did not let LVN A know he spit the pill out; the Resident waited until the next morning to tell anyone. The Administrator said some time before the incident with Resident #1 happened the staff found a pill in his pillowcase and turned it in to a nurse. The Administrator said that some of the staff who worked at the facility also worked at a facility where Resident #1 previously resided. The Administrator said those employees told him Resident #1 had a history of holding on to drugs. He said he talked to the Ombudsman and the Ombudsman agreed with the facility staff crushing Resident #1 ' s medications to make sure Resident #1 took them. The Administrator said we felt he was saving his meds and trying to get more [MEDICATION NAME]. The Administrator said he knew Resident #1 was not happy with getting his medications crushed. The Administrator said they went back to giving them to him whole. He said he did not ask why the resident was not happy getting his medications crushed. The Administrator said the only reason they started crushing the medications was because the nurses were unhappy with the situation and Resident #1 ' s history of behavior. The Administrator said he talked to the QA nurse. She thinks it was a dignity issue. The Administrator said he and the DON talked about discontinuing crushing Resident #1 ' s medications and the Administrator said he would do it if the nurses felt comfortable. He said he did not know crushing his medications was offensive to Resident #1 and thought the Resident did not tell anyone that he felt that way. He added that after talking to the QA nurse they discontinued crushing Resident #1 ' s medications. The Administrator said there was no grievance. He said he did not know why he did not do a grievance. The Administrator said with Resident #1 it was the history of employees knowing him from previous facilities. The Administrator said there was no documentation from the previous facilities regarding Resident #1 ' s history with trying to keep pain medications. He said he was told Resident #1 had tried to save pain pills twice since he ' d been in the current facility. Record review of the statement dated 12/21/15 written by LVN E read I have previously worked with (Resident #1) as his nurse. At the time I also passed him his medications. I was also warned that he wouuld hide his pain medications and stock them Many time he would ask me to just leave his pain medications and he would take later. I always told him that I could not do that. There was no mention of observation of the resident with the pills. Record review of progress notes from 9/1/15 to 12/22/15 revealed no notes regarding Resident #1 trying to hoard medications or being found with pills in his pillowcase or elsewhere. A telephone interview was attempted with the Ombudsman on 12/22/15 15 4:50 p.m. A message was left. During a telephone interview on 12/30/15 at 9:06 a.m. the Ombudsman said the Administrator told him about crushing pills for Resident #1 and he just listened and did not say anything. He said he may have nodded his head when the Administrator said they were doing it because the resident was not taking his pills as given but he did not give permission or say anything else. The Ombudsman said he would not give any particular opinion until he talked to both parties and he had not talked to Resident #1 at that point. The Ombudsman said he talked to Resident #1 at a later time and Resident #1 said repeatedly that he felt disrespected and degraded by having his medications crushed. During an interview on 12/22/15 at 5:10 p.m. the Administrator said he had been at the facility for only a month and a half. He said regarding Resident #1 ' s medications being crushed, they realized it was an issue and put the meds back where they were. Review of voicemail revealed the Ombudsman had called back on 12/28/15, when Surveyor was not in the office. A return call was again attempted on 12/29/15 at 2:32 p.m. and another message was left for the Ombudsman. During a telephone interview on 12/30/15 at 9:06 a.m. the said he talked to Resident #1 and Resident #1 said repeatedly that he felt disrespected and degraded by having his medications crushed. During a telephone interview on 12/30/15 at 10:47 a.m. LVN A said Resident #1 told a CNA he wanted something for pain. She said she punched the pill from the card and said it was a narcotic. LVN A said Resident #1 ' s room was fairly dark. She said the resident did not say anything to her at that time. LVN A said about 15 minutes later a CNA asked her if she had given Resident #1 the pill yet. LVN A said she went to see the resident who told her he thought she had given him the wrong pill. LVN A said she asked Resident #1 if he would like to see the card the pill was punched from and he said no; that nothing would be done about it anyway. LVN A said the next morning at shift change a CNA from the 6 a.m. to 2 p.m. shift brought the pill to the desk. LVN A said the CNA said Resident #1 told her that was the pill LVN A gave him the previous night. She said it was white and oblong like the one she gave Resident #1 the previous night but the coating had partially worn off and the pill was broken in half. LVN A said she did not break the pill in half. Record review of physician orders [REDACTED]. Orders on 12/21/15 read Discontinue Crush all meds every shift. Reason: spoke with resident and he will show the nurses and MA ' s his mouth after medication administration. Resident was unhappy with his medications being crushed and dislikes applesauce and does not like pudding either. Record Review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's pysician order dated 8/8/15 read [MEDICATION NAME] 10/325mg tablet- give one tablet by mouth every six hours as needed for pain. Record review of Progress Note dated 12/7/15 read in part: Resident has a history of trying to hoard medications to take several at a time due to long time narcotic drug usage.residents (sic) medications to be crushed from now on, since resident was found to have a [MEDICATION NAME] hiding in his pillow case in the past. Resident is not happy about his medication being crushed. Record review of Progress Note dated 12/13/15 read in part: resident requested to speak with manager. Resident stated he doesnt (sic) want his pills crushed. He stated it is deamening (sic) Record review of Progress note dated 12/19/15 read in part: pt continues to express frustration with the pain pill being crushed. Record review of the facility ' s Resident Rights policy dated October 2009 read in part: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: e. Voice grievance and have the facility respond to those grievances; .3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Record review of the facility ' s Grievances/Complaints - Staff Responsibility policy revised December 2008 read in part: Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident . the staff member is encouraged to guide the resident . as to how to file a written complaint with the facility . 2. Staff members will inform the resident or the person acting on the resident ' s behalf that he or she may file a grievance or complaint with the Administrator or other government agencies.without fear of threat or any other form of reprisal. 4. All alleged abuse, mistreatment, neglect . will be reported to the Administrator immediately (not more than twenty-four (24) hours after the alleged incident). Review of the facility ' s Order Listing Report revealed 53 residents received pain medications.

Based on observation, interview, and record review the facility failed promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality for 1 of 5 residents reviewed for dignity (#1) in that: Based on observation, interview, and record review, the facility failed to ensure the right to voice grievances without fear of discrimination or reprisal was provided for 1 of 5 residents reviewed for resident rights, as evidenced by: Resident #1 made a complaint regarding his pain medication. Immediately afterwards the facility began crushing his medications and spoon-feeding them to him, which he found demeaning; and This failure affected one resident and placed the remaining 52 residents who received pain medications at risk of feeling fearful to make complaints and at risk of a decline in psychosocial well-being. Intakes # 6 and # 3 Findings include: Record review of Resident #1's admission sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Quarterly MDS dated [DATE] revealed he had no communication or behavior problems. His BIMS score was 14, which indicated he was cognitively intact. Resident #1 required extensive assistance of two or more persons for bed mobility, transfers and toilet use. Record review of Resident #1's care plan dated 11/28/15 revealed a problem of pain secondary to [MEDICAL CONDITION] with muscle spasms. The goal was to have Resident #1 verbalize adequate relief of pain . the interventions read in part .11/10/15-[MEDICATION NAME] 10/325mg tab 1 by mouth every six hours as needed for pain. 11/17/15- [MEDICATION NAME] 10/325mg tab 1 by mouth every six hours around the clock .administer pain medications as ordered .evaluate the effectiveness of pain interventions . Observation and interview on 12/22/15 at 10:48 a.m. revealed Resident #1 lying in bed in his room. He said on 12/6/15 at 9:23pm he woke up and asked for a pain pill. Resident #1 said when LVN A brought his pill he was lying on his side. He said he asked the LVN A to turn the light on so he could see his medicine but she refused, saying it would wake his roommate. LVN A put the pill in his mouth and he said when it hit his tongue it had a specific taste. He said LVN A pushed water into his mouth. Resident #1 said the pill had a coating and his pain pill did not, so he spit it out. He said he hit the call light and an aide walked in. He asked the aide for LVN A. When LVN A came in, Resident #1 said he told her it was not his pain pill. He said LVN A told him it was a different pack and could have come from another manufacturer. Resident #1 said he felt as though they were just bumping heads so he decided to keep the pill and wait for the morning staff. When they came on he asked to speak to the charge nurse, RN B, and he showed her the pill. Resident #1 said RN B told him it was definitely not a pain pill. During the same interview on 12/22/15 at 10:48 a.m., Resident #1 said when the Administrator came in on Monday, 12/7/15, the Administrator told him he heard Resident #1 had pills in a pill case before. Resident #1 said the Administrator told him it looked like an antibiotic he had spit out earlier to swap out for a pain pill at night. Resident #1 said his toe was infected and he wanted it to heal, so he would not have done that. He also said he did not ask for a replacement for it. The Resident said he was told by the Administrator that the facility staff was going to start crushing his pills. Resident #1 said he did not want that. He became very emotional while recounting this, tearing up and asking for a minute to compose himself. Resident #1 was not able to talk for a few minutes. When he resumed, Resident #1 said he was so mad about the pills being crushed that his muscle spasms and depression both got worse as a consequence because it was so degrading . Resident #1 said the Administrator told him that was what they did with criminals in prison. Resident #1 said That was degrading. The Resident continued that the staff had to spoon-feed him the pill mixture, which he said was was even more degrading. Resident #1 again became upset talking about the issue. He said it took him two years to teach himself to do so because of the paralysis, but that he could feed himself independently now. Resident #1 again started crying and said the staff called me a liar regarding the pain pill. Resident #1 said the DON told him recently that they decided for Christmas to stop crushing his pills. Resident #1 had to wipe the tears from his face with his sheet. Resident #1 said the Administrator told him the general census among the staff was that he could not be trusted with pills. Resident #1 said he felt bombarded and punished for speaking up. Resident #1 said he knew how serious the accusation against LVN A was. He said another reason he did not like having his medications crushed was that he had no way of telling what they were. Even if somebody showed them to him before they crushed them, they could go out in the hall and crush something else. During an interview on 12/22/15 at 12:55 p.m. the DON said if the staff took a grievance they would turn it in to the Administrator, who was in charge of the grievances. She said if someone presented a problem she could not take care of immediately it was a grievance. The DON said Resident #1 had his pills changed many times and he was trying to hide one in his pillow. She said one night Resident #1 accused a nurse of not giving him his pain medication, and that he waited for the day shift to turn the pill over. The DON said the pill appeared to be Bactrim but was not Resident #1 ' s pain pill. The DON also said LVN A offered to do a drug test but the DON said the facility did not have any on hand. The DON said she did not know why Resident #1 ' s complaint was not written up as a grievance. She said RN B handled it and it appeared to be resolved at that point. The DON said Resident #1 ' s medications were being crushed for a little while; maybe a week. She said we thought we shouldn ' t do that so we went back to whole. The DON said she did realize that Resident #1 found crushing his medications offensive. She said Resident #1 agreed to let facility staff check his mouth after medications were given. In an interview on 12/22/15 at 1:11 p.m. when asked what determined a grievance the Administrator said, When they come and talk to me I guess. That ' s a good question. When asked why Resident #1 ' s complaint was not in the grievance book the Administrator said he had notes on that issue. He said there was no follow-up needed because the facility investigated it. The Administrator said typically when there ' s a situation when we are investigating something I ' m not going to write a grievance. In regards to the incident the Administrator said Resident #1 was saying he did not get his [MEDICATION NAME]. The Administrator said three nurses looked at the pill Resident #1 gave them. He said when LVN A gave Resident #1 the pill at 3:00 a.m. the Resident asked the nurse if it was the right pill. The Administrator said the nurse put the pill in Resident #1 ' s mouth and the Resident took the pill out. The Administrator said Resident #1 did not let LVN A know he spit the pill out; the Resident waited until the next morning to tell anyone. The Administrator said some time before the incident with Resident #1 happened the staff found a pill in his pillowcase and turned it in to a nurse. The Administrator said that some of the staff who worked at the facility also worked at a facility where Resident #1 previously resided. The Administrator said those employees told him Resident #1 had a history of holding on to drugs. He said he talked to the Ombudsman and the Ombudsman agreed with the facility staff crushing Resident #1 ' s medications to make sure Resident #1 took them. The Administrator said we felt he was saving his meds and trying to get more [MEDICATION NAME]. The Administrator said he knew Resident #1 was not happy with getting his medications crushed. The Administrator said they went back to giving them to him whole. He said he did not ask why the resident was not happy getting his medications crushed. The Administrator said the only reason they started crushing the medications was because the nurses were unhappy with the situation and Resident #1 ' s history of behavior. The Administrator said he talked to the QA nurse. She thinks it was a dignity issue. The Administrator said he and the DON talked about discontinuing crushing Resident #1 ' s medications and the Administrator said he would do it if the nurses felt comfortable. He said he did not know crushing his medications was offensive to Resident #1 and thought the Resident did not tell anyone that he felt that way. He added that after talking to the QA nurse they discontinued crushing Resident #1 ' s medications. The Administrator said there was no grievance. He said he did not know why he did not do a grievance. The Administrator said with Resident #1 it was the history of employees knowing him from previous facilities. The Administrator said there was no documentation from the previous facilities regarding Resident #1 ' s history with trying to keep pain medications. He said he was told Resident #1 had tried to save pain pills twice since he ' d been in the current facility. Record review of the statement dated 12/21/15 written by LVN E read I have previously worked with (Resident #1) as his nurse. At the time I also passed him his medications. I was also warned that he wouuld hide his pain medications and stock them Many time he would ask me to just leave his pain medications and he would take later. I always told him that I could not do that. There was no mention of observation of the resident with the pills. Record review of progress notes from 9/1/15 to 12/22/15 revealed no notes regarding Resident #1 trying to hoard medications or being found with pills in his pillowcase or elsewhere. A telephone interview was attempted with the Ombudsman on 12/22/15 15 4:50 p.m. A message was left. During a telephone interview on 12/30/15 at 9:06 a.m. the Ombudsman said the Administrator told him about crushing pills for Resident #1 and he just listened and did not say anything. He said he may have nodded his head when the Administrator said they were doing it because the resident was not taking his pills as given but he did not give permission or say anything else. The Ombudsman said he would not give any particular opinion until he talked to both parties and he had not talked to Resident #1 at that point. The Ombudsman said he talked to Resident #1 at a later time and Resident #1 said repeatedly that he felt disrespected and degraded by having his medications crushed. During an interview on 12/22/15 at 5:10 p.m. the Administrator said he had been at the facility for only a month and a half. He said regarding Resident #1 ' s medications being crushed, they realized it was an issue and put the meds back where they were. Review of voicemail revealed the Ombudsman had called back on 12/28/15, when Surveyor was not in the office. A return call was again attempted on 12/29/15 at 2:32 p.m. and another message was left for the Ombudsman. During a telephone interview on 12/30/15 at 9:06 a.m. the said he talked to Resident #1 and Resident #1 said repeatedly that he felt disrespected and degraded by having his medications crushed. During a telephone interview on 12/30/15 at 10:47 a.m. LVN A said Resident #1 told a CNA he wanted something for pain. She said she punched the pill from the card and said it was a narcotic. LVN A said Resident #1 ' s room was fairly dark. She said the resident did not say anything to her at that time. LVN A said about 15 minutes later a CNA asked her if she had given Resident #1 the pill yet. LVN A said she went to see the resident who told her he thought she had given him the wrong pill. LVN A said she asked Resident #1 if he would like to see the card the pill was punched from and he said no; that nothing would be done about it anyway. LVN A said the next morning at shift change a CNA from the 6 a.m. to 2 p.m. shift brought the pill to the desk. LVN A said the CNA said Resident #1 told her that was the pill LVN A gave him the previous night. She said it was white and oblong like the one she gave Resident #1 the previous night but the coating had partially worn off and the pill was broken in half. LVN A said she did not break the pill in half. Record review of physician orders [REDACTED]. Orders on 12/21/15 read Discontinue Crush all meds every shift. Reason: spoke with resident and he will show the nurses and MA ' s his mouth after medication administration. Resident was unhappy with his medications being crushed and dislikes applesauce and does not like pudding either. Record Review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's pysician order dated 8/8/15 read [MEDICATION NAME] 10/325mg tablet- give one tablet by mouth every six hours as needed for pain. Record review of Progress Note dated 12/7/15 read in part: Resident has a history of trying to hoard medications to take several at a time due to long time narcotic drug usage.residents (sic) medications to be crushed from now on, since resident was found to have a [MEDICATION NAME] hiding in his pillow case in the past. Resident is not happy about his medication being crushed. Record review of Progress Note dated 12/13/15 read in part: resident requested to speak with manager. Resident stated he doesnt (sic) want his pills crushed. He stated it is deamening (sic) Record review of Progress note dated 12/19/15 read in part: pt continues to express frustration with the pain pill being crushed. Record review of the facility ' s Resident Rights policy dated October 2009 read in part: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: e. Voice grievance and have the facility respond to those grievances; .3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Record review of the facility ' s Grievances/Complaints - Staff Responsibility policy revised December 2008 read in part: Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident . the staff member is encouraged to guide the resident . as to how to file a written complaint with the facility . 2. Staff members will inform the resident or the person acting on the resident ' s behalf that he or she may file a grievance or complaint with the Administrator or other government agencies.without fear of threat or any other form of reprisal. 4. All alleged abuse, mistreatment, neglect . will be reported to the Administrator immediately (not more than twenty-four (24) hours after the alleged incident). Review of the facility ' s Order Listing Report revealed 53 residents received pain medications.

Based on observation, interview, and record review, the facility failed to promptly resolve grievances for one of 5 residents (Resident #1) reviewed for residents rights in that: Resident #1 made a complaint regarding his pain medication. Immediately afterwards the facility began crushing his medications and spoon-feeding them to him, which he found demeaning; and This failure affected one resident and placed the remaining 52 residents who received pain medications at risk of feeling fearful to make complaints and at risk of a decline in psychosocial well-being. Intakes # 6 and # 3 Findings include: Record review of Resident #1's admission sheet revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Quarterly MDS dated [DATE] revealed he had no communication or behavior problems. His BIMS score was 14, which indicated he was cognitively intact. Resident #1 required extensive assistance of two or more persons for bed mobility, transfers and toilet use. Record review of Resident #1's care plan dated 11/28/15 revealed a problem of pain secondary to [MEDICAL CONDITION] with muscle spasms. The goal was to have Resident #1 verbalize adequate relief of pain . the interventions read in part .11/10/15-[MEDICATION NAME] 10/325mg tab 1 by mouth every six hours as needed for pain. 11/17/15- [MEDICATION NAME] 10/325mg tab 1 by mouth every six hours around the clock .administer pain medications as ordered .evaluate the effectiveness of pain interventions . Observation and interview on 12/22/15 at 10:48 a.m. revealed Resident #1 lying in bed in his room. He said on 12/6/15 at 9:23pm he woke up and asked for a pain pill. Resident #1 said when LVN A brought his pill he was lying on his side. He said he asked the LVN A to turn the light on so he could see his medicine but she refused, saying it would wake his roommate. LVN A put the pill in his mouth and he said when it hit his tongue it had a specific taste. He said LVN A pushed water into his mouth. Resident #1 said the pill had a coating and his pain pill did not, so he spit it out. He said he hit the call light and an aide walked in. He asked the aide for LVN A. When LVN A came in, Resident #1 said he told her it was not his pain pill. He said LVN A told him it was a different pack and could have come from another manufacturer. Resident #1 said he felt as though they were just bumping heads so he decided to keep the pill and wait for the morning staff. When they came on he asked to speak to the charge nurse, RN B, and he showed her the pill. Resident #1 said RN B told him it was definitely not a pain pill. During the same interview on 12/22/15 at 10:48 a.m., Resident #1 said when the Administrator came in on Monday, 12/7/15, the Administrator told him he heard Resident #1 had pills in a pill case before. Resident #1 said the Administrator told him it looked like an antibiotic he had spit out earlier to swap out for a pain pill at night. Resident #1 said his toe was infected and he wanted it to heal, so he would not have done that. He also said he did not ask for a replacement for it. The Resident said he was told by the Administrator that the facility staff was going to start crushing his pills. Resident #1 said he did not want that. He became very emotional while recounting this, tearing up and asking for a minute to compose himself. Resident #1 was not able to talk for a few minutes. When he resumed, Resident #1 said he was so mad about the pills being crushed that his muscle spasms and depression both got worse as a consequence because it was so degrading . Resident #1 said the Administrator told him that was what they did with criminals in prison. Resident #1 said That was degrading. The Resident continued that the staff had to spoon-feed him the pill mixture, which he said was was even more degrading. Resident #1 again became upset talking about the issue. He said it took him two years to teach himself to do so because of the paralysis, but that he could feed himself independently now. Resident #1 again started crying and said the staff called me a liar regarding the pain pill. Resident #1 said the DON told him recently that they decided for Christmas to stop crushing his pills. Resident #1 had to wipe the tears from his face with his sheet. Resident #1 said the Administrator told him the general census among the staff was that he could not be trusted with pills. Resident #1 said he felt bombarded and punished for speaking up. Resident #1 said he knew how serious the accusation against LVN A was. He said another reason he did not like having his medications crushed was that he had no way of telling what they were. Even if somebody showed them to him before they crushed them, they could go out in the hall and crush something else. During an interview on 12/22/15 at 12:55 p.m. the DON said if the staff took a grievance they would turn it in to the Administrator, who was in charge of the grievances. She said if someone presented a problem she could not take care of immediately it was a grievance. The DON said Resident #1 had his pills changed many times and he was trying to hide one in his pillow. She said one night Resident #1 accused a nurse of not giving him his pain medication, and that he waited for the day shift to turn the pill over. The DON said the pill appeared to be Bactrim but was not Resident #1 ' s pain pill. The DON also said LVN A offered to do a drug test but the DON said the facility did not have any on hand. The DON said she did not know why Resident #1 ' s complaint was not written up as a grievance. She said RN B handled it and it appeared to be resolved at that point. The DON said Resident #1 ' s medications were being crushed for a little while; maybe a week. She said we thought we shouldn ' t do that so we went back to whole. The DON said she did realize that Resident #1 found crushing his medications offensive. She said Resident #1 agreed to let facility staff check his mouth after medications were given. In an interview on 12/22/15 at 1:11 p.m. when asked what determined a grievance the Administrator said, When they come and talk to me I guess. That ' s a good question. When asked why Resident #1 ' s complaint was not in the grievance book the Administrator said he had notes on that issue. He said there was no follow-up needed because the facility investigated it. The Administrator said typically when there ' s a situation when we are investigating something I ' m not going to write a grievance. In regards to the incident the Administrator said Resident #1 was saying he did not get his [MEDICATION NAME]. The Administrator said three nurses looked at the pill Resident #1 gave them. He said when LVN A gave Resident #1 the pill at 3:00 a.m. the Resident asked the nurse if it was the right pill. The Administrator said the nurse put the pill in Resident #1 ' s mouth and the Resident took the pill out. The Administrator said Resident #1 did not let LVN A know he spit the pill out; the Resident waited until the next morning to tell anyone. The Administrator said some time before the incident with Resident #1 happened the staff found a pill in his pillowcase and turned it in to a nurse. The Administrator said that some of the staff who worked at the facility also worked at a facility where Resident #1 previously resided. The Administrator said those employees told him Resident #1 had a history of holding on to drugs. He said he talked to the Ombudsman and the Ombudsman agreed with the facility staff crushing Resident #1 ' s medications to make sure Resident #1 took them. The Administrator said we felt he was saving his meds and trying to get more [MEDICATION NAME]. The Administrator said he knew Resident #1 was not happy with getting his medications crushed. The Administrator said they went back to giving them to him whole. He said he did not ask why the resident was not happy getting his medications crushed. The Administrator said the only reason they started crushing the medications was because the nurses were unhappy with the situation and Resident #1 ' s history of behavior. The Administrator said he talked to the QA nurse. She thinks it was a dignity issue. The Administrator said he and the DON talked about discontinuing crushing Resident #1 ' s medications and the Administrator said he would do it if the nurses felt comfortable. He said he did not know crushing his medications was offensive to Resident #1 and thought the Resident did not tell anyone that he felt that way. He added that after talking to the QA nurse they discontinued crushing Resident #1 ' s medications. The Administrator said there was no grievance. He said he did not know why he did not do a grievance. The Administrator said with Resident #1 it was the history of employees knowing him from previous facilities. The Administrator said there was no documentation from the previous facilities regarding Resident #1 ' s history with trying to keep pain medications. He said he was told Resident #1 had tried to save pain pills twice since he ' d been in the current facility. Record review of the statement dated 12/21/15 written by LVN E read I have previously worked with (Resident #1) as his nurse. At the time I also passed him his medications. I was also warned that he wouuld hide his pain medications and stock them Many time he would ask me to just leave his pain medications and he would take later. I always told him that I could not do that. There was no mention of observation of the resident with the pills. Record review of progress notes from 9/1/15 to 12/22/15 revealed no notes regarding Resident #1 trying to hoard medications or being found with pills in his pillowcase or elsewhere. A telephone interview was attempted with the Ombudsman on 12/22/15 15 4:50 p.m. A message was left. During a telephone interview on 12/30/15 at 9:06 a.m. the Ombudsman said the Administrator told him about crushing pills for Resident #1 and he just listened and did not say anything. He said he may have nodded his head when the Administrator said they were doing it because the resident was not taking his pills as given but he did not give permission or say anything else. The Ombudsman said he would not give any particular opinion until he talked to both parties and he had not talked to Resident #1 at that point. The Ombudsman said he talked to Resident #1 at a later time and Resident #1 said repeatedly that he felt disrespected and degraded by having his medications crushed. During an interview on 12/22/15 at 5:10 p.m. the Administrator said he had been at the facility for only a month and a half. He said regarding Resident #1 ' s medications being crushed, they realized it was an issue and put the meds back where they were. Review of voicemail revealed the Ombudsman had called back on 12/28/15, when Surveyor was not in the office. A return call was again attempted on 12/29/15 at 2:32 p.m. and another message was left for the Ombudsman. During a telephone interview on 12/30/15 at 9:06 a.m. the said he talked to Resident #1 and Resident #1 said repeatedly that he felt disrespected and degraded by having his medications crushed. During a telephone interview on 12/30/15 at 10:47 a.m. LVN A said Resident #1 told a CNA he wanted something for pain. She said she punched the pill from the card and said it was a narcotic. LVN A said Resident #1 ' s room was fairly dark. She said the resident did not say anything to her at that time. LVN A said about 15 minutes later a CNA asked her if she had given Resident #1 the pill yet. LVN A said she went to see the resident who told her he thought she had given him the wrong pill. LVN A said she asked Resident #1 if he would like to see the card the pill was punched from and he said no; that nothing would be done about it anyway. LVN A said the next morning at shift change a CNA from the 6 a.m. to 2 p.m. shift brought the pill to the desk. LVN A said the CNA said Resident #1 told her that was the pill LVN A gave him the previous night. She said it was white and oblong like the one she gave Resident #1 the previous night but the coating had partially worn off and the pill was broken in half. LVN A said she did not break the pill in half. Record review of physician orders [REDACTED]. Orders on 12/21/15 read Discontinue Crush all meds every shift. Reason: spoke with resident and he will show the nurses and MA ' s his mouth after medication administration. Resident was unhappy with his medications being crushed and dislikes applesauce and does not like pudding either. Record Review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's pysician order dated 8/8/15 read [MEDICATION NAME] 10/325mg tablet- give one tablet by mouth every six hours as needed for pain. Record review of Progress Note dated 12/7/15 read in part: Resident has a history of trying to hoard medications to take several at a time due to long time narcotic drug usage.residents (sic) medications to be crushed from now on, since resident was found to have a [MEDICATION NAME] hiding in his pillow case in the past. Resident is not happy about his medication being crushed. Record review of Progress Note dated 12/13/15 read in part: resident requested to speak with manager. Resident stated he doesnt (sic) want his pills crushed. He stated it is deamening (sic) Record review of Progress note dated 12/19/15 read in part: pt continues to express frustration with the pain pill being crushed. Record review of the facility ' s Resident Rights policy dated October 2009 read in part: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: e. Voice grievance and have the facility respond to those grievances; .3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Record review of the facility ' s Grievances/Complaints - Staff Responsibility policy revised December 2008 read in part: Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated. 1. Should a staff member overhear or be the recipient of a complaint voiced by a resident . the staff member is encouraged to guide the resident . as to how to file a written complaint with the facility . 2. Staff members will inform the resident or the person acting on the resident ' s behalf that he or she may file a grievance or complaint with the Administrator or other government agencies.without fear of threat or any other form of reprisal. 4. All alleged abuse, mistreatment, neglect . will be reported to the Administrator immediately (not more than twenty-four (24) hours after the alleged incident). Review of the facility ' s Order Listing Report revealed 53 residents received pain medications.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect in providing necessary services to 2 of 10 residents reviewed for neglect (Residents #5 and #22) in that: - Resident #22 had multiple falls at the facility. A fall on 5/28/14 resulted in loss of consciousness, a hematoma, contusions, laceration, and multiple sutures and a hospitalization , including intensive care unit (ICU) stay. The facility did not thoroughly investigate the causes of his falls, including possible medication regimens and toileting needs; and implement changes in his care plan. - Resident #5 had while trying to use the restroom at night, resulted in a fracture. She had additional falls on 5/17/14, 5/23/14, and on 5/27/14, all after 6:30 p.m. The facility did not properly assess her needs, thoroughly investigate the causes of falls including possible medication regimens and toileting needs; and implement effective changes in care plans. An IJ was identified on 6/6/14 at 2:24 p.m. While the IJ was removed on 6/11/14 at 2:43 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 2 residents and placed an additional 101 residents at risk of neglect in the event injuries were not properly investigated. Findings include: Record review of the undated facility policy titled "Reporting/Investigating Resident Accidents/Incidents" revealed "...3. All accidents or incidents involving residents must be thoroughly document in the resident's medical record. Such documentation as, a minimum, must include: a. A description of what happened, including witness accounts; b. A description of action taken; c. A description of the medical treatment administered, if any; d. A description of the resident's response to the treatment, if any; e. A description of the resident's progress; f. A description of the preventative measures implemented to prevent such accident/incident from recurring; ..." Record review of another undated facility policy and procedure prohibiting abuse and neglect revealed: "6. The DNS or his/her designee, shall initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrences, where appropriate. ..." Record review of Resident #22's Admission Record revealed he was [AGE] years old and was originally admitted to the facility on [DATE]; discharged to the hospital on [DATE] for a fall with injuries and was re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #22's Minimum Data Set (MDS) assessment, dated 03/25/14, reflected he required extensive assistance of one person for transfers. The MDS reflected he was "not steady, only able to stabilize with staff assistance" when he was moving from seating to standing position, moving on and off the toilet, and for surface-to-surface transfers. He was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS reflected the resident had one fall with no injury since admission. Record review of a Progress Note (PN) dated 12/18/13 at 7:26 a.m. revealed "Client was found on floor, after suffering an unwitnessed fall, suffered skin abrasion to the right upper eye." Record review of a PN dated 02/19/14 revealed "Resident was found in his room on his buttocks on the floor, next to his nightstand, with his right had (sic) behind his back and hold on to his bed with his left hand. Resident stated he was trying to get out of bed to go to the bathroom." Review of the Resident #22's Order Summary Report (OSR), dated 05/03/14 at 3:33 p.m. revealed Resident #22 was ordered [MEDICATION NAME] Patch (9.5 mg (milligrams) per 24 hours) once daily for Dementia (side effects include dizziness, muscle weakness, tiredness). The OSR reflected he was to receive [MEDICATION NAME] ER (Extended Release) 250 mg daily as a Mood Stabilizer. The OSR reflected he was to receive [MEDICATION NAME] (antipsychotic medication) 12.5 mg every 12 hours as needed (PRN) (side effects include confusion, dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position, sleepiness or unusual drowsiness). Record review of a PN dated 05/12/14 revealed the resident was found on the floor next to his bed. The PN reflected "There were no signs of injury present. The resident stated that his back was sore." Observation of Resident #22 on 06/06/14 at 8:50 a.m. revealed he was sitting on the side of his bed, leaning forward and putting on his shoes. The bed was a standard-level bed. He had a golf-ball-sized hematoma on the left side of his head, in the temple area. The hematoma had intact sutures, and had a purple coloration. No staff was in the room with him. There was a pressure-type alarm on his bed. He was not sitting on the alarm pad and the alarm was not sounding. Observation on 06/06/14 at 8:50 a.m. revealed the front of Resident #22's trousers were soaked from the groin area to his knees. The resident stood and transferred himself to his wheelchair. The wheels of the wheelchair were not in the locked position. The resident then stood up and pulled up his trousers, then sat back down in the wheelchair. Resident #22 appeared to be unsteady when standing and transferring. He propelled himself into the hallway and down the hall. Resident #22's room was the farthest room from the nurses' station on the hall. Observation on 06/06/14 at 8:55 a.m. revealed Licensed Vocational Nurse (LVN) J standing at a medication cart in the hallway. LVN J stated the bed alarm for Resident #22 had been functioning earlier in the day. LVN J went to Resident #22's room to check the alarm. After picking up the alarm control box, LVN J tapped forcefully on the box a few times, and the alarm sounded. LVN J stated that the power switch had been in the off position. Observation at that time revealed that the bed alarm was audible in the hallway, but was not audible from the nurses' station. Observation on 06/06/14 at 9:27 a.m. revealed Resident #22 in his wheelchair in his room, beside the bed. There were no staff in the room. There was no alarm on the wheelchair. The resident stood up and turned away from the bed and attempted to sit on the bed, but the side rail was up, hindering the resident. The resident appeared to be very unsteady, so the call light was activated for him by the surveyor. Observation and interview on 06/06/14 at 9:32 a.m. revealed Certified Nurse Aides (CNA) AT and S entered the room. CNA S stated "They told me to get him up because he kept trying to transfer himself." The two CNAs transferred the resident to bed, turned on the bed alarm, and placed a mat next to the bed. In an interview on 06/06/14 at 9:37 a.m., LVN J was asked if the resident was lying on the same alarm that appeared to be faulty earlier. LVN J acknowledged that it was. In an interview on 06/06/14 at 9:45 a.m., Resident #22's family member stated the resident's mobility had slowly been declining, and that he had been using a wheelchair for years. The family member stated, "When he gets to falling it's like he wants out (of bed). It's because of bathroom issues." The family member did state that the facility had offered to move the resident to a room closer to the nurses' station. The family member stated that another family member had requested the bed alarm. The family member stated that Resident #22 had fallen at the facility on the previous Wednesday (05/28/14). Record review of Resident #22's clinical record revealed no toileting trial or evidence of participation in a toileting program. Record review of the Accident/Incident Report Log presented by the facility on 06/03/14 revealed no entries reflecting Resident #22 had any falls. In an interview with the Director of Nurses (DON) on 06/06/14 at 12:40 p.m., the DON was asked for all of the Accident/Incident (A/I) Reports for Resident #22 since November of 2013. The DON stated that she could not retrieve incidents from the computer by using resident names. The DON stated that she could retrieve the two most recent, because she knew the dates. The DON was asked how she conducted tracking and trending of falls at the facility. The DON stated that the facility would use the same Accident/Incident Report that was presented to the surveyors. When asked how the facility would know how many falls a resident had and what interventions had been put into place, the DON replied, "I can run a Log by the time period." The DON presented A/I Reports dated 05/28/14 and 05/29/14 (incorrect date, should reflect 05/28/14). When asked if there were any additional A/I Reports for Resident #22, the DON replied, "Maybe he hasn't fallen other than that." Record review of the A/I Report dated 05/29/14 (incorrect date, should be 05/28/14) at 6:25 p.m. revealed the resident was discovered to be on the floor of his room, and was noted to have a hematoma and laceration on his left eyebrow area. The resident received a CT (Computerized Tomography) Scan was conducted, and was 'negative' for internal injury. Record review of the second A/I Report, also dated 05/28/14 at 6:25 p.m., revealed "...res (resident) on floor on left side, laceration to left eyebrow larger than from previous fall ..." The A/I Report reflected the resident was sent to the emergency room (ER). Record review of the hospital Initial History and Physical (H&P) dated 05/28/14 at 10:30 p.m. revealed "Admit Diagnosis: [REDACTED]. Location: Left - Frontal .5 cm (centimeter) - 1 cm, Parietal .5 cm - 1 cm. Altered Mental Status (Acute Factors: Loss of Consciousness < 24 hrs (hours) (Co-morbidities: Chronic Hypertension)." The H&P reflected "Plan: Due to the high probability of imminent or life threatening deterioration, the patient requires ICU (Intensive Care Unit) level care." The H&P also reflected "This evaluation required 35 minutes of neurosurgical care time, including time for comprehensive patient examination, review of relevant clinical data, and formation/discussion of a detailed treatment plan in this patient with potentially life threatening intracranial conditions." Record review of the Care Plan dated 6/05/14 revealed "Resident #22 has a potential for falls secondary to decreased balance and poor safety awareness." The Revision Date was reflected as 01/08/14. Interventions were reflected as: 1. "When falls occur, attempt to determine cause of falls, remove any potential causes if possible. 2. "Bed in low position and call light within reach when in bed." And 3. "Observe for, and record and report environmental factors that impact fall risk." On 06/06/14 at 6:00 p.m. the DON presented Incident Reports for falls on 12/18/13, 02/19/14, 05/12/14, 05/28/14, and 05/29/14 (incorrect date, should be 05/28/14). Record review of Resident #22's facility Accident Reports relating to the above dates revealed no referrals to the pharmacist or physician for medication review. Resident #5 Record review of Resident #5's admission sheet revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a fall with fracture. Her [DIAGNOSES REDACTED]. Record review of Resident #5's hospital history and physical dated 4/14/14 revealed she was admitted to the hospital on [DATE] after she had fallen while transferring unassisted to or from the commode. She had sustained a left femoral neck (uppermost part of the thigh bone) fracture in the fall. Record review of Resident #5's admission MDS dated [DATE] revealed she required extensive assistance of one person for transfers, ambulation, dressing, and bathing. She was occasionally incontinent of bowel and bladder. This assessment indicated she had no falls since being admitted to the facility. Record review of Resident #5's care plan Dated 4/2/14: Focus = ADL deficit, as evidence by assistance with dressing, grooming, bathing, transfers, mobility and ambulation. Goals = Resident will complete dressing, grooming and mobility tasks with setup/modified independence during next assessment period. Target date 7/12/14. The interventions included what would be done for Resident #5 with dressing, bathing, and therapy. There was no mentioned of staff assisting Resident #5 during transfers. Record review of Resident #5's care plan Dated 4/14/14: Focus = The resident has had an actual fall with injury, unsteady gait, poor balance. Approaches (in their entirety) = Post fall interventions: (1) staff to assist resident with transfers PRN (as needed) responsible staff = CNA. (2) PT consult for strength and mobility. Dated 4/15/14: Focus = Potential for new/additional falls secondary to decreased strength/balance and history of falls resulting in left [MEDICAL CONDITION]. Approaches (in their entirety) = (1) Assist to rise sit to stand and pivot in chair. Reminders as needed to use arms, grab bars and rails to assist with transfers. (2) Bed in low position, call bell within reach (revised 4/25/14). (3) Encourage to call for assistance with toileting and transfers (revised 4/25/14). (4) Therapy as ordered (revised 4/25/14). (5) Wheelchair when out of bed (revised 4/25/14). Dated 6/6/14: The facility indicated they provided Resident #5 skid proof socks after the 5/23/14 fall and she began antibiotic therapy on 5/29/14 after the 5/27/14 fall. During an interview on 6/5/14 at 10:48 a.m. with Resident #5 when asked about her fall on 4/8/14, she said that she did not remember falling down. Record review of Resident #5's physician orders [REDACTED].(side effects include sleepiness and dizziness); [MEDICATION NAME] 5/325 mg every 6 hours as needed for pain (side effects include dizziness and lightheadness); [MEDICATION NAME] XL, for hypertension, 25 mg. two times per day (side effects include confusion dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position). Record review of the facility's incidents and accidents report revealed Resident #5 had falls on 4/8/14 at 9:00 p.m., 5/17/14 at 8:30 p.m., 5/23/14 at 6:23 p.m., and on 5/27/14 at 7:00 p.m. Record review of Resident #5's facility Accident Reports relating to the above dates revealed no referrals to the pharmacist or physician for medication review. Record review of the facility's Falls Investigations Worksheets for the dates above revealed the facility acknowledged Resident #5 received antihypertensive and cardiovascular medications, but there were no recommendations to review these medications with the physicians or pharmacists. Record review of Resident #5's Clinical Assessment Report Daily Skilled Nurse's Notes dated 4/8/14 revealed: Physical Functioning - 6b. Toilet use: Support provided. 2. One person physical assist. Record review of Resident #5's clinical record revealed no toileting trial or evidence of participation in a toileting program until after the IJ was called. An IJ was identified on 6/6/14 at 2:24 p.m. and the Administrator was informed at that time. A Plan of Removal (PoR) for the IJ was submitted 6/7/14 and after revisions was accepted on 6/10/14 at 3:31 p.m. The PoR included: 1. By 6/9/14, the facility completed training all staff in the newly created Falling Star program and the procedure for Accidents and Incidents - Investigation and Reporting and Safety and Supervision of Residents. 2. Between 6/6/14 and 6/10/14, the Medical Director trained nurses and CNAs to identify fall risk and high-risk medications. He addressed common causes for falls including age, hypertension, diabetes mellitus, dementia, depression, aggression, and [MEDICAL CONDITION]. He trained them about the types of drugs that increased the risk of falls. 3. On 6/6/14, all CNAs and Nurses were trained to properly use the behavior documentation. 4. On 6/6/2014 the facility and the contracted consultant Pharmacy initiated and audit on residents currently residing in the facility that sustained a fall in the past 30 days and/or are currently taking psychoactive medications to rule out use of medication as a contributing factors to their falls. Residents meeting these criteria received a medication regimen review. Any concerns or recommendations identified will be care planned within 72 hours of receiving results from the pharmacist. a. 6/7/14 Residents #5 and #22 were reviewed by the pharmacist b. 6/7/14, Resident #5 was seen by her physician who discontinued her [MEDICATION NAME] c. 6/7/14, Resident #22's PRN [MEDICATION NAME] was discontinued by his physician d. 6/7/14, Resident #22's routine [MEDICATION NAME] was discontinued by his physician 5. The following care plan changes were made for Resident #5: 6/8/14: Toilet per toileting program and PRN 6/9/14: Continue to monitor vital signs, including BP/Pulse and report abnormal/fluctuations in vitals. 6/10/14: Assist with toileting before and after meals, when getting up for day and when assisting to bed at bedtime. 6/10/14: Encourage and remind to call for assistance with toileting and transfers 6/10/14: Offer to assist back to bed after/between meals because she sometimes complains of being tired (9:30 a.m. -10:30 a.m.; 1:30 p.m. - 2:30 p.m. and 6:30 p.m. - 7:30 p.m.). 6/10/14: Offer toileting during routine rounds during bedtime The following care plan changes were made for Resident #22: 6/8/14: Encourage to spend time in common areas and scheduled activities when not providing care. 6/8/14: Contacted therapy for coping mechanisms to improve safety/function - Therapy evaluation was completed on 6/9/14. 6/8/14: Review medications and potential drug interaction with condition changes, falls, and hospitalization , and with MDS schedule. 6/8/14: Mat on floor beside bed. 6/8/14: Encourage rest periods between meals. 6/9/14: Take to toilet before and after meals. Take to toilet when assisting to get up in a.m. and at bedtime. 6/9/14: Continue to monitor labs and vital signs including BP and pulse and to report any fluctuations or changes of vital signs to the physician. Monitor labs for therapeutic levels and report abnormal findings. 6/9/14: Chair alarm 6/9/14: Bed alarm 6/10/14: RNA to do transfer training with Resident #22 6 days per week. 6/10/14: RNA program for ambulation - Ambulate with RNA for 5-10 feet with walker once daily 6 days per week. 6/10/14: Discourage from wearing dark glasses. 6/10/14: After alternative non-pharmacological interventions fail (i.e., 1:1, offer activities, offer toileting, offer food, etc.) to alter behaviors that could potentially lead to injury to self or others, contact physician, and if PRN psychoactive medications are ordered give one time only dose of medication. DNS or designee will reassess resident the following day for additional interventions (i.e.: psych services, routine medications interventions, in-patient stay, etc.). 6. The facility will initiate a medication regimen review for every resident who sustains a fall for which the medication regimen had the potential to be a contributing factor to the resident's fall(s). The pharmacist will initiate the medication regimen review and the resulting care plan changes will occur within 72 hours. This will begin 6/9/14. The facility plans to continue this practice as standard operating procedure (no end date). 7. Prior to admission of a new resident the DNS/designee will review the residents clinical record to identify possible safety risk and note residents fall history in effort to prevent any occurrences and address any medical needs. Any residents with a known fall within 30 days of admission will be placed on Falling Star Program. A list of medications will be sent to pharmacist upon admission for all admitting residents. This will begin 6/9/14. The facility plans to continue this practice as standard operating procedure (no end date). 8. On 6/9/14 Administrator and DON provided training to nurse managers, charge nurses, CNAs, therapy, maintenance, dietary, Housekeeping, Activities, and Office Staff regarding policies and procedures for Accidents and Incidents - Investigation and Reporting as well as Safety and Supervision of Residents (see attached policies). These policies cover the investigation and reporting process, making the environment as free from accidents as possible, resident safety and supervision, and assistance to prevent accidents. Another in-service will be delivered on 6/11/14 and 6/13/14 to instruct employees that were not in attendance on 6/9/14. 9. Care plan updates will be communicated to the CNAs via Kardex. Examples of care plan updates communicated to the CNAs using the Kardex regarding Residents #5 and #22 were included in the plan as an attachment. The surveyors confirmed that the Plan of Removal had been implemented sufficiently to remove the IJ by: Record review of the in-service training forms dated between 6/6/14 and 6/10/14 revealed that -Staff had completed training about the procedures and implementation of the Falling Star program; the procedures and implementation of the Procedure for Accidents and Incidents - Investigation and Reporting and Safety and Supervision of Resident; and behavior documentation. -Staff had completed training provided by the Medical Director about medications and other risks for falls. -The results of the pharmacy regimen reviews revealed both physician orders [REDACTED].#5 and #22. Record review Residents #5 and 22's updated care plans and Kardex' revealed they had been modified according to the Plan of Removal. On 06/06/14 at 6:00 p.m. the DON presented A/I Reports and Falls Investigation Reports for Resident #22, dated 12/18/13, 02/19/14, and 05/12/14. In an interview with the DON on 06/07/14 at 1:55 p.m., she stated that all PRN (as needed) antipsychotic medications had been discontinued. The DON stated that the facility Medical Director had conducted in-services with the staff regarding Falls and Medications. The DON stated that the Medical Director had reviewed all residents who had a history of [REDACTED]. No time frame was provided. The DON stated that copies of medication profiles of all residents with falls in the past 30 days were faxed to the Consulting Pharmacist. The DON stated that Managers would conduct follow-ups on a daily basis for three days for each resident who had a fall. Observation on 06/07/14 at 2:00 p.m. revealed Resident #22 had moved to the room closest to the nurses' station. The resident was not in the room. There was a low bed in the room. Observation on 06/09/14 at 11:00 a.m. revealed Resident #22 was in his room, lying in a low bed. There was a mat on the floor next to the bed. The call light was within reach. Observation on 06/10/14 at 9:15 a.m. revealed Resident #22 to be in his wheelchair in the Hall 200 hallway. A wheelchair alarm was observed to be on the wheelchair. Observations between 6/6/14 and 6/11/14 revealed that the care planned interventions were in place. The Administrator and the DON were informed on 6/11/14 at 2:43 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. The CMS 672 listed a census of 103 residents.

Based on observation, interview and record review, the facility failed to maintain an environment free from accidents and hazards for 2 of 10 residents reviewed for falls (Residents #5 and #22) in that: - Resident #22 had multiple falls at the facility. A fall on 5/28/14 resulted in loss of consciousness, a hematoma, contusions, laceration, and multiple sutures and an 8 day hospitalization , including an intensive care unit (ICU) stay. The facility did not thoroughly investigate the causes of his falls, including possible medication regimen and toileting needs; and implement changes in his care plan. - Resident #5 had while trying to use the restroom at night, resulted in a fracture. She had additional falls on 5/17/14, 5/23/14, and on 5/27/14, all after 6:30 p.m. The facility did not properly assess her needs, thoroughly investigate the causes of falls including possible medication regimen and toileting needs; and implement effective changes in care plans. An IJ was identified on 6/6/14 at 2:24 p.m. While the IJ was removed on 6/11/14 at 2:43 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. Non Immediate Jeopardy --Resident #2 required staff to feed her. The resident was in a Geri-chair and was positioned low in the chair instead of sitting up while being fed by staff. --Resident #2 was transferred from her Geri-chair to the bed using a mechanical lift by CNA AC and the Central Supply Clerk. They locked the wheels on the lift while lifting the resident. -Resident #14 had a physician's orders [REDACTED]. A sign was posted over her bed that she could not have straws. - 2 rooms with residents using oxygen were without oxygen signs. - The unlocked Clean Utility room cabinet included bins of single use foam shaving cream, baby lotion, and mouthwash. -Emergency call light cord was wrapped around the grab bar in the bathroom of room 109. These failures affected 4 residents and placed an additional 87 residents at risk of aspiration, choking, hospitalization , and death and an additional 11 residents at risk for injury during transfers . These failures also placed 2 residents at risk of being unable to call for assistance from the restroom in the event of an emergency. Findings include: Resident #22 Record review of Resident #22's Admission Record revealed he was [AGE] years old and was originally admitted to the facility on [DATE], and re-admitted to the facility on [DATE] after a fall with injuries. His [DIAGNOSES REDACTED]. Record review of Resident #22's Minimum Data Set (MDS) assessment, dated 03/25/14, reflected he required extensive assistance of one person for transfers. The MDS reflected he was "not steady, only able to stabilize with staff assistance" when he was moving from seating to standing position, moving on and off the toilet, and for surface-to-surface transfers. He was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS reflected the resident had one fall with no injury since admission. Record review of a Progress Note (PN) dated 12/18/13 at 7:26 a.m. revealed "Client was found on floor, after suffering an unwitnessed fall, suffered skin abrasion to the right upper eye." Record review of a PN dated 02/19/14 revealed "Resident was found in his room on his buttocks on the floor, next to his nightstand, with his right had (sic) behind his back and hold on to his bed with his left hand. Resident stated he was trying to get out of bed to go to the bathroom." Review of the Resident #22's Order Summary Report (OSR), dated 05/03/14 at 3:33 p.m. revealed Resident #22 was ordered Exelon Patch (9.5 mg (milligrams) per 24 hours) once daily for Dementia (side effects include dizziness, muscle weakness, tiredness). The OSR reflected he was to receive Depakote ER (Extended Release) 250 mg daily as a Mood Stabilizer. The OSR reflected he was to receive Seroquel (antipsychotic medication) 12.5 mg every 12 hours as needed (PRN) (side effects include confusion, dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position, sleepiness or unusual drowsiness). Record review of a PN dated 05/12/14 revealed the resident was found on the floor next to his bed. The PN reflected "There were no signs of injury present. The resident stated that his back was sore." Observation of Resident #22 on 06/06/14 at 8:50 a.m. revealed he was sitting on the side of his bed, leaning forward and putting on his shoes. The bed was a standard-level bed. He had a golf-ball-sized hematoma on the left side of his head, in the temple area. The hematoma had intact sutures, and had a purple coloration. No staff was in the room with him. There was a pressure-type alarm on his bed. He was not sitting on the alarm pad and the alarm was not sounding. Review of a Physician ' s Telephone Order (TO) dated 06/04/14 revealed " Provide bed alarm per family request. " The Care Plan, dated 06/05/14, did not address the bed alarm. Observation on 06/06/14 at 8:50 a.m. revealed the front of Resident #22's trousers were soaked from the groin area to his knees. The resident stood and transferred himself to his wheelchair. The wheels of the wheelchair were not in the locked position. The resident then stood up and pulled up his trousers, then sat back down in the wheelchair. Resident #22 appeared to be unsteady when standing and transferring. He propelled himself into the hallway and down the hall. Resident #22's room was the farthest room from the nurses' station on the hall. Observation on 06/06/14 at 8:55 a.m. revealed Licensed Vocational Nurse (LVN) J standing at a medication cart in the hallway. LVN J stated the bed alarm for Resident #22 had been functioning earlier in the day. LVN J went to Resident #22's room to check the alarm. After picking up the alarm control box, LVN J tapped forcefully on the box a few times, and the alarm sounded. LVN J stated that the power switch had been in the off position. Observation at that time revealed that the bed alarm was audible in the hallway, but was not audible from the nurses' station. Observation on 06/06/14 at 9:27 a.m. revealed Resident #22 in his wheelchair in his room, beside the bed. There were no staff in the room. There was no alarm on the wheelchair. The resident stood up and turned away from the bed and attempted to sit on the bed, but the side rail was up, hindering the resident. The resident appeared to be very unsteady, so the call light was activated for him by the surveyor. Observation on 06/06/14 at 9:32 a.m. revealed Certified Nurse Aides (CNA) AT and S entered the room. CNA S stated "They told me to get him up because he kept trying to transfer himself." The two CNAs transferred the resident to bed, turned on the bed alarm, and placed a mat next to the bed. In an interview on 06/06/14 at 9:37 a.m., LVN J was asked if the resident was lying on the same alarm that appeared to be faulty earlier. LVN J acknowledged that it was. In an interview on 06/06/14 at 9:45 a.m., Resident #22's family member stated the resident's mobility had slowly been declining, and that he had been using a wheelchair for years. The family member stated, "When he gets to falling it's like he wants out (of bed). It's because of bathroom issues." The family member did state that the facility had offered to move the resident to a room closer to the nurses' station. The family member stated that another family member had requested the bed alarm. The family member stated that Resident #22 had fallen at the facility on the previous Wednesday (05/28/14). Record review of Resident #22's clinical record revealed no toileting trial or evidence of participation in a toileting program. Record review of the Accident/Incident Report Log presented by the facility on 06/03/14 revealed no entries reflecting Resident #22 had any falls. In an interview with the Director of Nurses (DON) on 06/06/14 at 12:40 p.m., the DON was asked for all of the Accident/Incident (A/I) Reports for Resident #22 since November of 2013. The DON stated that she could not retrieve incidents from the computer by using resident names. The DON stated that she could retrieve the two most recent, because she knew the dates. The DON was asked how she conducted tracking and trending of falls at the facility. The DON stated that the facility would use the same Accident/Incident Report that was presented to the surveyors. When asked how the facility would know how many falls a resident had and what interventions had been put into place, the DON replied, "I can run a Log by the time period." Review of the Accident/Incident log presented by the DON on 06/03/14 revealed no documentation of falls by Resident #22. The DON presented A/I Reports dated 05/28/14 and 05/29/14 (incorrect date, should reflect 05/28/14). When asked if there were any additional A/I Reports for Resident #22, the DON replied, "Maybe he hasn't fallen other than that." Record review of the A/I Report dated 05/29/14 (incorrect date, should be 05/28/14) at 6:25 p.m. revealed the resident was discovered to be on the floor of his room, and was noted to have a hematoma and laceration on his left eyebrow area. The resident received a CT (Computerized Tomography) Scan was conducted, and was 'negative' for internal injury. Record review of the second A/I Report, also dated 05/28/14 at 6:25 p.m., revealed "...res (resident) on floor on left side, laceration to left eyebrow larger than from previous fall ..." The A/I Report reflected the resident was sent to the emergency room (ER). Record review of the hospital Initial History and Physical (H&P) dated 05/28/14 at 10:30 p.m. revealed "Admit Diagnosis: [REDACTED]. Location: Left - Frontal .5 cm (centimeter) - 1 cm, Parietal .5 cm - 1 cm. Altered Mental Status (Acute Factors: Loss of Consciousness < 24 hrs (hours) (Co-morbidities: Chronic Hypertension)." The H&P reflected "Plan: Due to the high probability of imminent or life threatening deterioration, the patient requires ICU (Intensive Care Unit) level care." The H&P also reflected "This evaluation required 35 minutes of neurosurgical care time, including time for comprehensive patient examination, review of relevant clinical data, and formation/discussion of a detailed treatment plan in this patient with potentially life threatening intracranial conditions." Record review of the Care Plan dated 6/05/14 revealed "Resident #22 has a potential for falls secondary to decreased balance and poor safety awareness." The Revision Date was reflected as 01/08/14. Interventions were reflected as: 1. "When falls occur, attempt to determine cause of falls, remove any potential causes if possible. 2. "Bed in low position and call light within reach when in bed." And 3. "Observe for, and record and report environmental factors that impact fall risk." Review of the Falls Investigation Worksheet presented by the DON on 06/06/14 at 6:00 p.m. for Resident #22 ' s fall on 12/18/13 revealed " Recommendations/Interventions. Client was stressed to please always use call light. The same document reflected the resident exhibited cognitive impairment. Review of the Falls Investigation Worksheet presented by the DON on 06/06/14 at 6:00 p.m. for Resident #22 ' s fall on 05/12/14 revealed " Recommendations/Interventions. Resident will be monitored closely, and reminded to call for help when needed. " The same document reflected the resident exhibited cognitive impairment and had Alzheimer ' s Disease. On 06/06/14 at 6:00 p.m. the DON presented Incident Reports for falls on 12/18/13, 02/19/14, 05/12/14, 05/28/14, and 05/29/14 (incorrect date, should be 05/28/14). Record review of Resident #22's facility Accident Reports relating to the above dates revealed no referrals to the pharmacist or physician for medication review. Resident #5 Record review of Resident #5's admission sheet revalued she was [AGE] years old and was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a fall with fracture. Her [DIAGNOSES REDACTED]. Record review of Resident #5's hospital history and physical dated 4/14/14 revealed she was admitted to the hospital on [DATE] after she had fallen while using the commode. She had sustained a left femoral neck (uppermost part of the thigh bone) fracture in the fall. Record review of Resident #5's admission MDS dated [DATE] revealed she required extensive assistance of one person for transfers, ambulation, dressing, and bathing. She was occasionally incontinent of bowel and bladder. This assessment indicated she had no falls since being admitted to the facility. Record review of Resident #5's physician orders [REDACTED]. pain (side effects include dizziness and lightheadness); Toprol XL 25 mg. two times per day (side effects include confusion dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position). Record review of the facility's incidents and accidents report revealed Resident #5 had falls on 4/8/14 at 9:00 p.m., 5/17/14 at 8:30 p.m., 5/23/14 at 6:23 p.m., and on 5/27/14 at 7:00 p.m. Record review of Resident #5's facility Accident Reports relating to the above dates revealed no referrals to the pharmacist or physician for medication review. Record review of the facility's Falls Investigations Worksheets for the dates above revealed the facility acknowledged Resident #5 received antihypertensive and cardiovascular medications, but there were no recommendations to review these medications with the physicians or pharmacists. No documentation of the investigation itself or possible causative factors or possible interventions to show what the facility did as a result of the falls. Record review of Resident #5's care plan Dated 4/14/14: Focus = The resident has had an actual fall with injury, unsteady gait, poor balance. Approaches (in their entirety) = Post fall interventions: (1) staff to assist resident with transfers PRN (as needed) responsible staff = CNA. (2) PT consult for strength and mobility. Dated 4/15/14: Focus = Potential for new/additional falls secondary to decreased strength/balance and history of falls resulting in left hip fracture. Approaches (in their entirety) = (1) Assist to rise sit to stand and pivot in chair. Reminders as needed to use arms, grab bars and rails to assist with transfers. (2) Bed in low position, call bell within reach (revised 4/25/14). (3) Encourage to call for assistance with toileting and transfers (revised 4/25/14). (4) Therapy as ordered (revised 4/25/14). (5) Wheelchair when out of bed (revised 4/25/14). Dated 6/6/14: The facility indicated they provided Resident #5 skid proof socks after the 5/23/14 fall and she began antibiotic therapy on 5/29/14 after the 5/27/14 fall. Record review of Resident #5's clinical record revealed no toileting trial or evidence of participation in a toileting program until after the IJ was called. An IJ was identified on 6/6/14 at 2:24 p.m. and the Administrator was informed at that time. A Plan of Removal (PoR) for the IJ was submitted on 6/7/14 and after revisions was accepted on 6/10/14 at 3:31 p.m. The PoR included: 1. By 6/9/14, the facility completed training all staff in the newly created Falling Star program and the procedure for Accidents and Incidents - Investigation and Reporting and Safety and Supervision of Residents. 2. Between 6/6/14 and 6/10/14, the Medical Director trained nurses and CNAs to identify fall risk and high-risk medications. He addressed common causes for falls including age, hypertension, diabetes mellitus, dementia, depression, aggression, and psychosis. He trained them about the types of drugs that increased the risk of falls. 3. On 6/6/14, all CNAs and Nurses were trained to properly use the behavior documentation. 4. On 6/6/2014 the facility and the contracted consultant Pharmacy initiated and audit on residents currently residing in the facility that sustained a fall in the past 30 days and/or are currently taking psychoactive medications to rule out use of medication as a contributing factors to their falls. Residents meeting these criteria received a medication regimen review. Any concerns or recommendations identified will be care planned within 72 hours of receiving results from the pharmacist. a. 6/7/14 Residents #5 and #22 were reviewed by the pharmacist b. 6/7/14, Resident #5 was seen by her physician who discontinued her Temazepam c. 6/4/14, Resident #22's PRN Seroquel was discontinued by his physician d. 6/7/14, Resident #22's routine Seroquel was discontinued by his physician 5. The following care plan changes were made for Resident #5: 6/8/14: Toilet per toileting program and PRN 6/9/14: Continue to monitor vital signs, including BP/Pulse and report abnormal/fluctuations in vitals. 6/10/14: Assist with toileting before and after meals, when getting up for day and when assisting to bed at bedtime. 6/10/14: Encourage and remind to call for assistance with toileting and transfers 6/10/14: Offer to assist back to bed after/between meals because she sometimes complains of being tired (9:30 a.m. -10:30 a.m.; 1:30 p.m. - 2:30 p.m. and 6:30 p.m. - 7:30 p.m.). 6/10/14: Offer toileting during routine rounds during bedtime The following care plan changes were made for Resident #22: 6/8/14: Encourage to spend time in common areas and scheduled activities when not providing care. 6/8/14: Contacted therapy for coping mechanisms to improve safety/function - Therapy evaluation was completed on 6/9/14. 6/8/14: Review medications and potential drug interaction with condition changes, falls, and hospitalization , and with MDS schedule. 6/8/14: Mat on floor beside bed. 6/8/14: Encourage rest periods between meals. 6/9/14: Take to toilet before and after meals. Take to toilet when assisting to get up in a.m. and at bedtime. 6/9/14: Continue to monitor labs and vital signs including BP and pulse and to report any fluctuations or changes of vital signs to the physician. Monitor labs for therapeutic levels and report abnormal findings. 6/9/14: Chair alarm 6/9/14: Bed alarm 6/10/14: RNA to do transfer training with Resident #22 6 days per week. 6/10/14: RNA program for ambulation - Ambulate with RNA for 5-10 feet with walker once daily 6 days per week. 6/10/14: Discourage from wearing dark glasses. 6/10/14: After alternative non-pharmacological interventions fail (i.e., 1:1, offer activities, offer toileting, offer food, etc.) to alter behaviors that could potentially lead to injury to self or others, contact physician, and if PRN psychoactive medications are ordered give one time only dose of medication. DNS or designee will reassess resident the following day for additional interventions (i.e.: psych services, routine medications interventions, in-patient stay, etc.). 6. The facility will initiate a medication regimen review for every resident who sustains a fall for which the medication regimen had the potential to be a contributing factor to the resident's fall(s). The pharmacist will initiate the medication regimen review and the resulting care plan changes will occur within 72 hours. This will begin 6/9/14. The facility plans to continue this practice as standard operating procedure (no end date). 7. Prior to admission of a new resident the DNS/designee will review the residents clinical record to identify possible safety risk and note residents fall history in effort to prevent any occurrences and address any medical needs. Any residents with a known fall within 30 days of admission will be placed on Falling Star Program. A list of medications will be sent to pharmacist upon admission for all admitting residents. This will begin 6/9/14. The facility plans to continue this practice as standard operating procedure (no end date). 8. On 6/9/14 Administrator and DON provided training to nurse managers, charge nurses, CNAs, therapy, maintenance, dietary, Housekeeping, Activities, and Office Staff regarding policies and procedures for Accidents and Incidents - Investigation and Reporting as well as Safety and Supervision of Residents (see attached policies). These policies cover the investigation and reporting process, making the environment as free from accidents as possible, resident safety and supervision, and assistance to prevent accidents. Another in-service will be delivered on 6/11/14 and 6/13/14 to instruct employees that were not in attendance on 6/9/14. 9. Care plan updates will be communicated to the CNAs via Kardex. Examples of care plan updates communicated to the CNAs using the Kardex regarding Residents #5 and #22 were included in the plan as an attachment. The surveyors confirmed that the Plan of Removal had been implemented sufficiently to remove the IJ by: Record review of the in-service training forms dated between 6/6/14 and 6/10/14 revealed that -Staff had completed training about the procedures and implementation of the Falling Star program; the procedures and implementation of the Procedure for Accidents and Incidents - Investigation and Reporting and Safety and Supervision of Resident; and behavior documentation. -Staff had completed training provided by the Medical Director about medications and other risks for falls. -The results of the pharmacy regimen reviews revealed both physician orders [REDACTED].#5 and #22. Record review Residents #5 and 22's updated care plans and Kardex' revealed they had been modified according to the Plan of Removal. On 06/06/14 at 6:00 p.m. the DON presented A/I Reports and Falls Investigation Reports for Resident #22, dated 12/18/13, 02/19/14, and 05/12/14. In an interview with the DON on 06/07/14 at 1:55 p.m., she stated that all PRN (as needed) antipsychotic medications had been discontinued. The DON stated that the facility Medical Director had conducted in-services with the staff regarding Falls and Medications. The DON stated that the Medical Director had reviewed all residents who had a history of [REDACTED]. No time frame was provided. The DON stated that copies of medication profiles of all residents with falls in the past 30 days were faxed to the Consulting Pharmacist. The DON stated that Managers would conduct follow-ups on a daily basis for three days for each resident who had a fall. Observation on 06/07/14 at 2:00 p.m. revealed Resident #22 had moved to the room closest to the nurses' station. The resident was not in the room. There was a low bed in the room. Review of a pharmacy Evaluation Review for Resident #22, dated 06/07/14, revealed " suggest a dose reduction for Seroquel which may decrease risk for falls ... " Observation on 06/09/14 at 11:00 a.m. revealed Resident #22 was in his room, lying in a low bed. There was a mat on the floor next to the bed. The call light was within reach. Review of an Incident Report dated 06/09/14 at 6:42 p.m. revealed Resident #22 " was found on the bathroom floor. " The report reflected, " He had used the toilet as evidenced by ... " Review of the Rehabilitation Screen dated 06/10/14 revealed " Recommend possible bowel/bladder schedule ... " Observation on 06/10/14 at 9:15 a.m. revealed Resident #22 to be in his wheelchair in the Hall 200 hallway. A wheelchair alarm was observed to be on the wheelchair. Observations between 6/6/14 and 6/11/14 revealed that the care planned interventions were in place. The Administrator and the DON were informed on 6/11/14 at 2:43 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. Non-Immediate Jeopardy Resident #2 Feeding: Record review of Resident #2's admission sheet revealed she was [AGE] years old and was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Her [DIAGNOSES REDACTED]. bladder, and aphasia. Record review of Resident #2's History and Physical dated 5/23/14 revealed additional [DIAGNOSES REDACTED]. Record review of Resident #2's initial MDS assessment dated [DATE] revealed she had severely impaired cognitive skills for daily decision making. She required extensive assistance of two staff for bed mobility. She required the extensive assistance of one staff for eating. She was totally dependent on two staff for transfers. Observation on 6/3/14 at 11:51 a.m. of Resident #2 revealed she was in the dining room in her Geri-chair. She was positioned low in a reclined position in the chair instead of sitting up. RNA CU was feeding the resident and giving her fluids through a straw. RNA CU looked up and said, "I can't put her legs down." She then continued to feed the resident in the same position. Observation on 6/4/14 at 12:00 p.m. of Resident #2 revealed she was in the dining room in her Geri-chair being fed by RNA CS. The resident was in an almost flat position low in the chair with her head bent up against the back of the chair. The top of the resident's shoulders were at the level of the arm rests of the chair. During an interview on 6/4/14 at 12:13 p.m. with SLP she was asked to observe Resident #2. She said they encourage staff to have the resident more upright. She said the resident was positioned more upright yesterday. She looked at the positioning and said the throat was upright and said, "...at least her head isn't totally back." When asked about the positioning she said the lower they are the more at risk they are of food/fluids going down the airway. She said the more reclined the resident is it opens up the airway more. She said she would go speak to the RNA now. She then went over and three staff repositioned the resident. Record review of Resident #2's Restorative Care Program Eating form dated as effective 11/16/13 revealed, "...Approach/Recommendations for Implementation of Above Goals:..Position Resident properly for meals..." The goals documented were to maintain the resident's ability to safely swallow/eat and to prevent choking episodes. An additional approach handwritten on the form with a star by it was to make sure the resident is sitting at a 90 degree angle in her Geri-chair. The form was signed by SLP A and dated 11/15/13. Record review of Resident #2's plan of care dated 5/23/14 for nutrition and activities of daily living revealed the plan of care did not address positioning the resident upright while feeding. On 6/5/14 the facility provided a revised plan of care dated 6/5/14 which revealed the updated of positioning the resident upright while feeding. Mechanical Lift Transfer: Observation on 6/4/14 at 1:20 p.m. revealed Resident #2 being transferred from her Geri-chair to her bed by CNA AC and the Central Supply Clerk. The staff locked the rear wheels of the lift while actively lifting the resident. Record review of the user's manual for the lift dated 2011 revealed, "...!...WARNING...(company name) does not recommend locking of the rear casters of the patient lift when lifting an individual. Doing so could cause the lift to tip and endanger the patient and assistants. (company name) does recommend that the rear casters be left unlocked during lifting procedures to allow the patient lift to stabilize itself when the patient is initially lifted from a chair, bed or any stationary object. ..." During an interview on 6/5/14 at 11:43 a.m. with CNA A when asked if staff were supposed to lock the rear wheels on the lift when lifting a patient, she said yes. When asked if she had access to the user's manual she said it was kept in the office of the Central Supply Clerk. She said they received training on the lift during orientation. She said she had been trained to "always" lock the wheels of the lift when lifting. During an interview on 6/5/14 at 3:40 p.m. with the Central Supply Clerk who said she was previously the lead CNA, said she was taught to lock the wheels. When asked if she had read the user's manual she said no. She was shown the manual and was asked to read it. She read the manual and said, "Ok." She said CNA A did all of the training now. During an interview on 6/5/14 at 5:15 p.m. with the DON when the observation of the transfer was discussed she said the user's manual only recommended locking the wheels but did not mandate it. The DON was told that if she had documentation indicating locking the wheels was safe, it would be accepted for review. The DON did not provide any additional information prior to exit on 6/11/14. During a telephone interview on 6/6/14 at 9:05 a.m. with a Representative A of the manufacturer of the mechanical lift, he said whenever lifting or loading the patient if you were alone, you can lock the wheels only long enough to hook up the sling. He said the wheels needed to be unlocked before, during, and while lowering a patient or the lift could tip over. He said keeping the wheels unlocked was what allowed the lift to center. Record review of the facility's policy and procedure Using a Portable Lifting Machine revised April 2007 revealed the policy and procedure did not address the need to lock the wheels when lifting the resident according to the manufacturer's recommendations. The policy and procedure was not written in accordance with the specifications required by the specific equipment in use by the facility. Record review of the facility history and staff key revealed the facility was cited on 8/30/12 for performing mechanical lift transfers while locking the back wheels. The DON was the same person at that time as well as one of the additional staff observed performing the transfer on 8/30/12 and 6/4/14. Resident #14 Record review of Resident #14's admission sheet revealed she was admitted to the facility on [DATE] and was readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #14's quarterly MDS assessment dated [DATE] revealed she received a score of 5 on her brief interview for mental status indicating she had severe cognitive deficit. She required the limited assistance of one staff for eating. She was receiving a mechanically altered therapeutic diet. Record review of Resident #14's June 2014 Physician order [REDACTED]. Observation on 6/3/14 at 10:56 a.m. of Resident #14 revealed she was in her room in bed with her eyes closed. There was a sign posted over her bed which read, "Swallowing Precautions. Diet: Regular; thin liquids. No Straws!

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect in providing necessary services to 2 of 10 residents reviewed for neglect (Residents #5 and #22) in that: - Resident #22 had multiple falls at the facility. A fall on 5/28/14 resulted in loss of consciousness, a hematoma, contusions, laceration, and multiple sutures and a hospitalization , including an intensive care unit (ICU) stay. The facility did not thoroughly investigate the causes of his falls, including possible medication regimen and toileting needs; and implement changes in his care plan. - Resident #5 had while trying to use the restroom at night, resulted in a fracture. She had additional falls on 5/17/14, 5/23/14, and on 5/27/14, all after 6:30 p.m. The facility did not properly assess her needs, thoroughly investigate the causes of falls including possible medication regimen and toileting needs; and implement effective changes in care plans. An IJ was identified on 6/6/14 at 2:24 p.m. While the IJ was removed on 6/11/14 at 2:43 p.m., the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. These failures affected 2 residents and placed an additional 101 residents at risk of neglect in the event injuries were not properly investigated. Findings include: Resident #22 Record review of Resident #22's Admission Record revealed he was [AGE] years old and was originally admitted to the facility on [DATE]; discharged to the hospital 5/28/14 for a fall with injuries and and re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #22's Minimum Data Set (MDS) assessment, dated 03/25/14, reflected he required extensive assistance of one person for transfers. The MDS reflected he was "not steady, only able to stabilize with staff assistance" when he was moving from seating to standing position, moving on and off the toilet, and for surface-to-surface transfers. He was occasionally incontinent of bladder and frequently incontinent of bowel. The MDS reflected the resident had one fall with no injury since admission. Record review of a Progress Note (PN) dated 12/18/13 at 7:26 a.m. revealed "Client was found on floor, after suffering an unwitnessed fall, suffered skin abrasion to the right upper eye." Record review of a PN dated 02/19/14 revealed "Resident was found in his room on his buttocks on the floor, next to his nightstand, with his right had (sic) behind his back and hold on to his bed with his left hand. Resident stated he was trying to get out of bed to go to the bathroom." Review of the Resident #22's Order Summary Report (OSR), dated 05/03/14 at 3:33 p.m. revealed Resident #22 was ordered [MEDICATION NAME] Patch (9.5 mg (milligrams) per 24 hours) once daily for Dementia (side effects include dizziness, muscle weakness, tiredness). The OSR reflected he was to receive [MEDICATION NAME] ER (Extended Release) 250 mg daily as a Mood Stabilizer. The OSR reflected he was to receive [MEDICATION NAME] (antipsychotic medication) 12.5 mg every 12 hours as needed (PRN) (side effects include confusion, dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position, sleepiness or unusual drowsiness). Record review of a PN dated 05/12/14 revealed the resident was found on the floor next to his bed. The PN reflected "There were no signs of injury present. The resident stated that his back was sore." Observation of Resident #22 on 06/06/14 at 8:50 a.m. revealed he was sitting on the side of his bed, leaning forward and putting on his shoes. The bed was a standard-level bed. He had a golf-ball-sized hematoma on the left side of his head, in the temple area. The hematoma had intact sutures, and had a purple coloration. No staff was in the room with him. There was a pressure-type alarm on his bed. He was not sitting on the alarm pad and the alarm was not sounding. Observation on 06/06/14 at 8:50 a.m. revealed the front of Resident #22's trousers were soaked from the groin area to his knees. The resident stood and transferred himself to his wheelchair. The wheels of the wheelchair were not in the locked position. The resident then stood up and pulled up his trousers, then sat back down in the wheelchair. Resident #22 appeared to be unsteady when standing and transferring. He propelled himself into the hallway and down the hall. Resident #22's room was the farthest room from the nurses' station on the hall. Observation on 06/06/14 at 8:55 a.m. revealed Licensed Vocational Nurse (LVN) J standing at a medication cart in the hallway. LVN J stated the bed alarm for Resident #22 had been functioning earlier in the day. LVN J went to Resident #22's room to check the alarm. After picking up the alarm control box, LVN J tapped forcefully on the box a few times, and the alarm sounded. LVN J stated that the power switch had been in the off position. Observation at that time revealed that the bed alarm was audible in the hallway, but was not audible from the nurses' station. Observation on 06/06/14 at 9:27 a.m. revealed Resident #22 in his wheelchair in his room, beside the bed. There were no staff in the room. There was no alarm on the wheelchair. The resident stood up and turned away from the bed and attempted to sit on the bed, but the side rail was up, hindering the resident. The resident appeared to be very unsteady, so the call light was activated for him by the surveyor. Observation and interview on 06/06/14 at 9:32 a.m. revealed Certified Nurse Aides (CNA) AT and S entered the room. CNA S stated "They told me to get him up because he kept trying to transfer himself." The two CNAs transferred the resident to bed, turned on the bed alarm, and placed a mat next to the bed. In an interview on 06/06/14 at 9:37 a.m., LVN J was asked if the resident was lying on the same alarm that appeared to be faulty earlier. LVN J acknowledged that it was. In an interview on 06/06/14 at 9:45 a.m., Resident #22's family member stated the resident's mobility had slowly been declining, and that he had been using a wheelchair for years. The family member stated, "When he gets to falling it's like he wants out (of bed). It's because of bathroom issues." The family member did state that the facility had offered to move the resident to a room closer to the nurses' station. The family member stated that another family member had requested the bed alarm. The family member stated that Resident #22 had fallen at the facility on the previous Wednesday (05/28/14). Record review of Resident #22's clinical record revealed no toileting trial or evidence of participation in a toileting program. Record review of the Accident/Incident Report Log presented by the facility on 06/03/14 revealed no entries reflecting Resident #22 had any falls. In an interview with the Director of Nurses (DON) on 06/06/14 at 12:40 p.m., the DON was asked for all of the Accident/Incident (A/I) Reports for Resident #22 since November of 2013. The DON stated that she could not retrieve incidents from the computer by using resident names. The DON stated that she could retrieve the two most recent, because she knew the dates. The DON was asked how she conducted tracking and trending of falls at the facility. The DON stated that the facility would use the same Accident/Incident Report that was presented to the surveyors. When asked how the facility would know how many falls a resident had and what interventions had been put into place, the DON replied, "I can run a Log by the time period." The DON presented A/I Reports dated 05/28/14 and 05/29/14 (incorrect date, should reflect 05/28/14). When asked if there were any additional A/I Reports for Resident #22, the DON replied, "Maybe he hasn't fallen other than that." Record review of the A/I Report dated 05/29/14 (incorrect date, should be 05/28/14) at 6:25 p.m. revealed the resident was discovered to be on the floor of his room, and was noted to have a hematoma and laceration on his left eyebrow area. The resident received a CT (Computerized Tomography) Scan was conducted, and was 'negative' for internal injury. Record review of the second A/I Report, also dated 05/28/14 at 6:25 p.m., revealed "...res (resident) on floor on left side, laceration to left eyebrow larger than from previous fall ..." The A/I Report reflected the resident was sent to the emergency room (ER). Record review of the hospital Initial History and Physical (H&P) dated 05/28/14 at 10:30 p.m. revealed "Admit Diagnosis: [REDACTED]. Location: Left - Frontal .5 cm (centimeter) - 1 cm, Parietal .5 cm - 1 cm. Altered Mental Status (Acute Factors: Loss of Consciousness < 24 hrs (hours) (Co-morbidities: Chronic Hypertension)." The H&P reflected "Plan: Due to the high probability of imminent or life threatening deterioration, the patient requires ICU (Intensive Care Unit) level care." The H&P also reflected "This evaluation required 35 minutes of neurosurgical care time, including time for comprehensive patient examination, review of relevant clinical data, and formation/discussion of a detailed treatment plan in this patient with potentially life threatening intracranial conditions." Record review of the Care Plan dated 6/05/14 revealed "Resident #22 has a potential for falls secondary to decreased balance and poor safety awareness." The Revision Date was reflected as 01/08/14. Interventions were reflected as: 1. "When falls occur, attempt to determine cause of falls, remove any potential causes if possible. 2. "Bed in low position and call light within reach when in bed." And 3. "Observe for, and record and report environmental factors that impact fall risk." On 06/06/14 at 6:00 p.m. the DON presented Incident Reports for falls on 12/18/13, 02/19/14, 05/12/14, 05/28/14, and 05/29/14 (incorrect date, should be 05/28/14). Record review of Resident #22's facility Accident Reports relating to the above dates revealed no referrals to the pharmacist or physician for medication review. Resident #5 Record review of Resident #5's admission sheet revealed she was [AGE] years old and was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] after a fall with fracture. Her [DIAGNOSES REDACTED]. Record review of Resident #5's hospital history and physical dated 4/14/14 revealed she was admitted to the hospital on [DATE] after she had fallen while transferring unassisted to or from the commode. She had sustained a left femoral neck (uppermost part of the thigh bone) fracture in the fall. Record review of Resident #5's admission MDS dated [DATE] revealed she required extensive assistance of one person for transfers, ambulation, dressing, and bathing. She was occasionally incontinent of bowel and bladder. This assessment indicated she had no falls since being admitted to the facility. Record review of Resident #5's care plan Dated 4/2/14: Focus = ADL deficit, as evidence by assistance with dressing, grooming, bathing, transfers, mobility and ambulation. Goals = Resident will complete dressing, grooming and mobility tasks with setup/modified independence during next assessment period. Target date 7/12/14. The interventions included what would be done for Resident #5 with dressing, bathing, and therapy. There was no mentioned of staff assisting Resident #5 during transfers. Record review of Resident #5's care plan Dated 4/14/14: Focus = The resident has had an actual fall with injury, unsteady gait, poor balance. Approaches (in their entirety) = Post fall interventions: (1) staff to assist resident with transfers PRN (as needed) responsible staff = CNA. (2) PT consult for strength and mobility. Dated 4/15/14: Focus = Potential for new/additional falls secondary to decreased strength/balance and history of falls resulting in left [MEDICAL CONDITION]. Approaches (in their entirety) = (1) Assist to rise sit to stand and pivot in chair. Reminders as needed to use arms, grab bars and rails to assist with transfers. (2) Bed in low position, call bell within reach (revised 4/25/14). (3) Encourage to call for assistance with toileting and transfers (revised 4/25/14). (4) Therapy as ordered (revised 4/25/14). (5) Wheelchair when out of bed (revised 4/25/14). Dated 6/6/14: The facility indicated they provided Resident #5 skid proof socks after the 5/23/14 fall and she began antibiotic therapy on 5/29/14 after the 5/27/14 fall. During an interview on 6/5/14 at 10:48 a.m. with Resident #5 when asked about her fall on 4/8/14, she said that she did not remember falling down. Record review of Resident #5's physician orders [REDACTED].(side effects include sleepiness and dizziness); [MEDICATION NAME] 5/325 mg every 6 hours as needed for pain (side effects include dizziness and lightheadness); [MEDICATION NAME] XL, for hypertension, 25 mg. two times per day (side effects include confusion dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position). Record review of the facility's incidents and accidents report revealed Resident #5 had falls on 4/8/14 at 9:00 p.m., 5/17/14 at 8:30 p.m., 5/23/14 at 6:23 p.m., and on 5/27/14 at 7:00 p.m. Record review of Resident #5's facility Accident Reports relating to the above dates revealed no referrals to the pharmacist or physician for medication review. Record review of the facility's Falls Investigations Worksheets for the dates above revealed the facility acknowledged Resident #5 received antihypertensive and cardiovascular medications, but there were no recommendations to review these medications with the physicians or pharmacists. Record review of Resident #5's Clinical Assessment Report Daily Skilled Nurse's Notes dated 4/8/14 revealed: Physical Functioning - 6b. Toilet use: Support provided. 2. One person physical assist. Record review of Resident #5's clinical record revealed no toileting trial or evidence of participation in a toileting program until after the IJ was called. Record review of the undated facility policy titled "Reporting/Investigating Resident Accidents/Incidents" revealed "...3. All accidents or incidents involving residents must be thoroughly document in the resident's medical record. Such documentation as, a minimum, must include: a. A description of what happened, including witness accounts; b. A description of action taken; c. A description of the medical treatment administered, if any; d. A description of the resident's response to the treatment, if any; e. A description of the resident's progress; f. A description of the preventative measures implemented to prevent such accident/incident from recurring; ..." Record review of another undated facility policy and procedure prohibiting abuse and neglect revealed: "6. The DNS or his/her designee, shall initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrences, where appropriate. ..." An IJ was identified on 6/6/14 at 2:24 p.m. and the Administrator was informed at that time. A Plan of Removal (PoR) for the IJ was submitted 6/7/14 and after revisions was accepted on 6/10/14 at 3:31 p.m. The PoR included: 1. By 6/9/14, the facility completed training all staff in the newly created Falling Star program and the procedure for Accidents and Incidents - Investigation and Reporting and Safety and Supervision of Residents. 2. Between 6/6/14 and 6/10/14, the Medical Director trained nurses and CNAs to identify fall risk and high-risk medications. He addressed common causes for falls including age, hypertension, diabetes mellitus, dementia, depression, aggression, and [MEDICAL CONDITION]. He trained them about the types of drugs that increased the risk of falls. 3. On 6/6/14, all CNAs and Nurses were trained to properly use the behavior documentation. 4. On 6/6/2014 the facility and the contracted consultant Pharmacy initiated and audit on residents currently residing in the facility that sustained a fall in the past 30 days and/or are currently taking psychoactive medications to rule out use of medication as a contributing factors to their falls. Residents meeting these criteria received a medication regimen review. Any concerns or recommendations identified will be care planned within 72 hours of receiving results from the pharmacist. a. 6/7/14 Residents #5 and #22 were reviewed by the pharmacist b. 6/7/14, Resident #5 was seen by her physician who discontinued her [MEDICATION NAME] c. 6/7/14, Resident #22's PRN [MEDICATION NAME] was discontinued by his physician d. 6/7/14, Resident #22's routine [MEDICATION NAME] was discontinued by his physician 5. The following care plan changes were made for Resident #5: 6/8/14: Toilet per toileting program and PRN 6/9/14: Continue to monitor vital signs, including BP/Pulse and report abnormal/fluctuations in vitals. 6/10/14: Assist with toileting before and after meals, when getting up for day and when assisting to bed at bedtime. 6/10/14: Encourage and remind to call for assistance with toileting and transfers 6/10/14: Offer to assist back to bed after/between meals because she sometimes complains of being tired (9:30 a.m. -10:30 a.m.; 1:30 p.m. - 2:30 p.m. and 6:30 p.m. - 7:30 p.m.). 6/10/14: Offer toileting during routine rounds during bedtime The following care plan changes were made for Resident #22: 6/8/14: Encourage to spend time in common areas and scheduled activities when not providing care. 6/8/14: Contacted therapy for coping mechanisms to improve safety/function - Therapy evaluation was completed on 6/9/14. 6/8/14: Review medications and potential drug interaction with condition changes, falls, and hospitalization , and with MDS schedule. 6/8/14: Mat on floor beside bed. 6/8/14: Encourage rest periods between meals. 6/9/14: Take to toilet before and after meals. Take to toilet when assisting to get up in a.m. and at bedtime. 6/9/14: Continue to monitor labs and vital signs including BP and pulse and to report any fluctuations or changes of vital signs to the physician. Monitor labs for therapeutic levels and report abnormal findings. 6/9/14: Chair alarm 6/9/14: Bed alarm 6/10/14: RNA to do transfer training with Resident #22 6 days per week. 6/10/14: RNA program for ambulation - Ambulate with RNA for 5-10 feet with walker once daily 6 days per week. 6/10/14: Discourage from wearing dark glasses. 6/10/14: After alternative non-pharmacological interventions fail (i.e., 1:1, offer activities, offer toileting, offer food, etc.) to alter behaviors that could potentially lead to injury to self or others, contact physician, and if PRN psychoactive medications are ordered give one time only dose of medication. DNS or designee will reassess resident the following day for additional interventions (i.e.: psych services, routine medications interventions, in-patient stay, etc.). 6. The facility will initiate a medication regimen review for every resident who sustains a fall for which the medication regimen had the potential to be a contributing factor to the resident's fall(s). The pharmacist will initiate the medication regimen review and the resulting care plan changes will occur within 72 hours. This will begin 6/9/14. The facility plans to continue this practice as standard operating procedure (no end date). 7. Prior to admission of a new resident the DNS/designee will review the residents clinical record to identify possible safety risk and note residents fall history in effort to prevent any occurrences and address any medical needs. Any residents with a known fall within 30 days of admission will be placed on Falling Star Program. A list of medications will be sent to pharmacist upon admission for all admitting residents. This will begin 6/9/14. The facility plans to continue this practice as standard operating procedure (no end date). 8. On 6/9/14 Administrator and DON provided training to nurse managers, charge nurses, CNAs, therapy, maintenance, dietary, Housekeeping, Activities, and Office Staff regarding policies and procedures for Accidents and Incidents - Investigation and Reporting as well as Safety and Supervision of Residents (see attached policies). These policies cover the investigation and reporting process, making the environment as free from accidents as possible, resident safety and supervision, and assistance to prevent accidents. Another in-service will be delivered on 6/11/14 and 6/13/14 to instruct employees that were not in attendance on 6/9/14. 9. Care plan updates will be communicated to the CNAs via Kardex. Examples of care plan updates communicated to the CNAs using the Kardex regarding Residents #5 and #22 were included in the plan as an attachment. The surveyors confirmed that the Plan of Removal had been implemented sufficiently to remove the IJ by: Record review of the in-service training forms dated between 6/6/14 and 6/10/14 revealed that -Staff had completed training about the procedures and implementation of the Falling Star program; the procedures and implementation of the Procedure for Accidents and Incidents - Investigation and Reporting and Safety and Supervision of Resident; and behavior documentation. -Staff had completed training provided by the Medical Director about medications and other risks for falls. -The results of the pharmacy regimen reviews revealed both physician orders [REDACTED].#5 and #22. Record review Residents #5 and 22's updated care plans and Kardex' revealed they had been modified according to the Plan of Removal. On 06/06/14 at 6:00 p.m. the DON presented A/I Reports and Falls Investigation Reports for Resident #22, dated 12/18/13, 02/19/14, and 05/12/14. In an interview with the DON on 06/07/14 at 1:55 p.m., she stated that all PRN (as needed) antipsychotic medications had been discontinued. The DON stated that the facility Medical Director had conducted in-services with the staff regarding Falls and Medications. The DON stated that the Medical Director had reviewed all residents who had a history of [REDACTED]. No time frame was provided. The DON stated that copies of medication profiles of all residents with falls in the past 30 days were faxed to the Consulting Pharmacist. The DON stated that Managers would conduct follow-ups on a daily basis for three days for each resident who had a fall. Observation on 06/07/14 at 2:00 p.m. revealed Resident #22 had moved to the room closest to the nurses' station. The resident was not in the room. There was a low bed in the room. Observation on 06/09/14 at 11:00 a.m. revealed Resident #22 was in his room, lying in a low bed. There was a mat on the floor next to the bed. The call light was within reach. Observation on 06/10/14 at 9:15 a.m. revealed Resident #22 to be in his wheelchair in the Hall 200 hallway. A wheelchair alarm was observed to be on the wheelchair. Observations between 6/6/14 and 6/11/14 revealed that the care planned interventions were in place. The Administrator and the DON were informed on 6/11/14 at 2:43 p.m. that the IJ was removed; however the facility remained out of compliance at a pattern level and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for its effectiveness. The CMS 672 listed a census of 103 residents.