Every finding on record at Prairie Manor Care Center

Based on observation, interview, and document review, the facility failed to ensure assist bars attached to the bed were assessed and reassessed for specific hazards and risks and in accordance with manufacturer's guidelines for 4 of 4 residents (R19, R17, R24, R14) reviewed for assistive devices. Findings include:R19's quarterly Minimum Data Set (MDS) assessment, dated 4/28/25, identified severely impaired cognition, and physical behavior daily during the seven day lookback period. R19 was dependent for bed mobility and transfers and had a diagnosis of unspecified dementia with behavioral disturbances. R19's Cognitive Loss Care Area Assessment (CAA) dated 8/6/24, identified a diagnosis of dementia and extensive assist was required with ADLs (activities of daily living). R19 had verbal and physical behaviors directed at staff when assisting with ADLs. R19's care plan dated 5/8/25, identified assist bar on bed to aid in bed mobility and positioning, and lacked an assessment of specific hazards and risks. R19's progress notes identified: - 2/13/25 at 12:18 p.m., staff assessed bruising to R19's right side of jaw/chin measuring 1.5 centimeters (cm) diameter; dark brown/blue with surrounding yellow. On left side of face/neck there is very light streaking yellow bruising noted approximately three by two inches (in). A potential cause of bruising to right side could be from the assist bar on her bed. - 10/18/24 at 4:03 p.m., staff noted bruise to R19's left hand, top of left hand between thumb and forefingers. Area in line with where resident could have bumped hand on bed rail. Resident is known to be combative at times. Area measured 3 in. in diameter. Area is dark blue in color with yellowing to outside edges. R19's Point Click Care (PCC; the facility's electronic medical record) lacked assessments addressing specific hazards and risks of assist bars. During an observation on 6/30/25 at 12:50 p.m., R19 was in bed with one 1/4 length assist bar on the right side of head of bed with the brand name Accora. During an interview on 6/30/25 at 7:06 p.m., nursing assistant (NA)-C stated R19 might reach for the assist bar when staff assisted to turn side to side, however, R19 did not use them to turn and if she did, would sometimes not let go. NA-C did not think R19 knew what the assist bar was for. NA-C stated R19 was dependent on staff for bed mobility. During an interview on 7/1/25 at 10:28 a.m., NA-B stated R19 did not typically use the assist bars for bed mobility, and would sometimes grab onto the bar. During an observation on 7/1/25 at 1:00 p.m., NA-D and NA-E assisted R19 into bed using the full body lift. Once R19 was laid in bed, NA-D and NA-E assisted R19 to roll side to side. R19 did not participate in bed mobility or use the assist bar. NA-E stated R19 usually did not use the assist bar to participate in bed mobility or transfers. R17R17's annual MDS assessment, dated 4/1/25, identified severely impaired cognition and no behaviors. R17 was dependent for bed mobility and transfers and had a diagnosis of Alzheimer's disease. R17's Cognitive Loss CAA dated 4/1/25, identified a diagnosis of dementia and short term (STM) and long term memory (LTM) loss were present. R17 was unable to answer questions on the Brief Inventory of Mental Status assessment and was unable to make decisions when given two choices. R17 required extensive assistance with ADLs. R17's care plan dated 4/14/25, identified assist bars on bed to aid in bed mobility and positioning, and lacked an assessment of specific hazards and risks. R17's progress note dated 10/26/24 at 1:49 p.m., identified R17 was dependent on three staff during transfers. R17 was unable to hold onto hand bar (assist bar) when transferring, she would attempt to hold on but let go. She was unable to bear her weight and lost balance resulting in a fall. R17's PCC records lacked assessments addressing specific hazards and risks of assist bars. During an observation on 6/30/25 at 3:34 p.m., R17's bed had one 1/4 length assist bar on each side of the head of bed, model Joerns F025. During an interview on 7/1/25 at 10:28 a.m., nursing assistant (NA)-B stated R17 did not use her rails for bed mobility and R17 mostly laid still when staff assisted with rolling side to side in bed. During an observation on 7/2/25 at 8:20 a.m., NA-G and NA-D assisted R17 into bed from her wheelchair using the full body mechanical lift. The NA's gave instructions to R17 to turn in bed, however, R17 did not participate, the NA's stated R17 does not use the assist bars anymore for bed mobility. R24R24's quarterly MDS assessment, dated 5/28/25, identified severely impaired cognition and rejection of care one to three days during the seven day lookback period. R24 was independent with rolling left to right in bed and required partial/moderate assistance for chair/bed to chair transfers. R24's Self-Care and Mobility CAA dated 9/11/24, identified she transferred with one assist and self-transferred sometimes. R24 was able to move herself in bed sometimes and staff needed to assist other times. R24's care plan dated 6/5/25, identified assist bars on bed to aid in bed mobility and positioning, but lacked an assessment of specific hazards and risks. R24's PCC records lacked any assessments addressing specific hazards and risks of assist bars. During an observation on 6/30/25 at 1:43 p.m., R24's bed had one 1/4 length assist bar on each side of the head of bed, model Joerns F025. During an interview on 7/1/25 at 1:18 p.m., NA-F stated R24 needed directions to grab on the assist bar during transfers and bed mobility, and she could use them consistently with direction. R14R14's annual MDS assessment, dated 4/9/25, identified moderately impaired cognition and rejection of care one to three days in the seven day lookback period R17 required partial/moderate assistance to roll left to right in bed and for transfers. R17 had diagnoses of stroke and hemiplegia (paralysis) on right dominant side. R14's Self Care and Mobility CAA dated 4/9/25, identified one staff was required for transfers and bed mobility, and he was unable to ambulate. R14's care plan dated 4/22/25, assist bars on bed to aid in bed mobility and positioning, but lacked an assessment of specific hazards and risks. PCC records lacked any assessments addressing specific hazards and risks of assist bars. During an observation on 6/30/25 at 3:31 p.m., R14's bed had one 1/4 length assist bar on each side of the head of bed, model Joerns F025. During an interview on 6/30/25 at 7:10 p.m., NA-A stated R14 used the assist bars in his bed for bed mobility and if they were loose, she would update maintenance. During an interview on 7/1/25 at 12:20 p.m., the maintenance assistant (MA) stated upon receiving a referral from nursing to install assist bars, prior to installation; maintenance staff would ensure the assistive devices match up with the bed model. MA stated annually maintenance inspections were completed of the beds and assistive devices, however, this was not documented. During an interview on 7/1/25 at 1:11 p.m., the physical therapy assistant (PT)-A stated she reviewed the therapy records of R19, R17, R24, R14, and therapy had not provided recommendations for the assist bars. During an interview on 7/1/25 at 3:05 p.m., registered nurse (RN)-B stated residents with assistive devices such as side rails had quarterly assessments to check for proper fit and function, risks, and benefits. RN-B reviewed R19, R17, R24, and R14's paper charts and PCC records and could not find the quarterly assistive devices assessments. During an interview on 7/1/25 at 3:35 p.m., the nurse manager (NM) stated side rails would be assessed by nursing quarterly to include ability, risks, and benefits of use. The NM stated this process was not conducted on the smaller assist bars (such as Joern's and Accora models). The NM stated maintenance would ensure the assist bars were appropriate for the beds and mattresses during installation. During an interview on 7/2/25 at 8:24 a.m., the environmental services director (ESD) stated there was no documentation to support it, but their department checked the security of the assist bars when the bed belonged to a discharged resident, if a new bed was delivered, or if a bed was deep cleaned. The ESD stated they utilized the product manuals, however, only the Joern's bed and assist bar manual and the Accora bed manual were available. The ESD did not have a manual for the Accora assist bars. The ESD said to check for entrapment zones, he thought they referred to an OSHA (Occupational Safety and Health Administration) document, however, there was no documentation available. During an interview on 7/2/25 at 12:22 p.m., the director of nursing (DON) stated assist bars and grab bars carried a potential risk of injury, falls, and strangulation (entrapment). The DON stated there was not a formal process to assess for the risks of assist bars, however, they had a process in place if larger side rails were in use. The DON stated if there was an incident potentially related to an assistive devices, the device and resident should have been assessed and reassessed to determine if the device was needed. The Joerns bed user manual bed dated 2007, provided by the facility, identified the following risks and hazards warning: An optimal bed system assessment should be conducted on each resident/patient by a qualified clinician or medical provider to ensure maximum safety of the resident/patient. The assessment should be conducted within the context of, and in compliance with, the state and federal guidelines related to the use of restraints and bed system entrapment guidance, including the Clinical Guidance for the Assessment and Implementation of Side Rails published by the Hospital Bed Safety Workgroup of the U.S. Food and Drug Administration. The Joerns assist bar manual dated 2008, provided by the facility, identified the following risks and hazards: When assessing the risk for entrapment, consider the bed, mattress, head foot boards assist devices and other accessories as a system. It is also extremely important to review the resident/patients physical and mental condition and initiate an appropriate individual care plan to address entrapment risk. The Accora bed user manual dated 2003, provided by the facility, identified the following risks and hazards: Patients, or users, should be risk assessed to ensure they are able to understand this manual and to operate the bed safely without risk to themselves or others. The bed manual lacked instructions for the assist bar assessments. The Accora assist bar manual dated 2004, provided by the Accora company via email on 7/2/25 at 11:39 a.m., identified the following risks and hazards: Patients, or users, should be risk assessed to ensure they are able to understand this manual and to operate the assist bars safely without risk to themselves or others. The facility's Side Rail policy dated 2/9/21, identified the following procedure:Half side rails would be used to aid with resident mobility and/or positioning only.An assessment would be completed prior to using a bed with half side rails on it. The resident would be assessed for the risk of entrapment from bed rails prior to installation.Would attempt to use appropriate alternatives prior to installing a side or bed rail.Risks and benefits would be discussed with resident and/or family.A consent form would be signed before use and kept in resident's chart under Care Plan section.A doctor's order would be obtained before use of a half side rail.An assessment would be completed quarterly for the safe use of the half side rail and it would be determined if the risks continue to outweigh the benefits.Half side rail use will be added to the care plan.Prior to side rail use, maintenance must ensure correct installation, use, and maintenance of bed rails, and ensure that the bed's and mattress dimensions are appropriate.The policy lacked a process for assistive devices (such as assist bars) other than 1/2 side rails, and lacked a process to check manufacturer's guidelines for specific risks and hazards.

Based on interview and document review, the facility failed to provide completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN CMS 10055) to 2 of 2 residents (R3 and R24) reviewed whose Medicare Part A coverage ended and then remained in the facility.Findings include:A review of R3's SNF ABN document provided by the facility indicated R3 Medicare benefits ended on 4/10/25 and beginning on 4/11/25 , R3 may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. we estimate that these services will cost you $ SEE BUSINESS OFFICE per day/item of service. The form did not include an estimate cost for services. A review of R24's SNF ABN document provided by the facility indicated R24 Medicare benefits ended on 4/11/25 and beginning on 4/12/25 , R24 may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. we estimate that thses services will cost you $ SEE BUSINESS OFFICE per day/item of service. The form did not include an estimate cost for services. Interview on 7/1/25 at 1:00 p.m., Business office manager (BOM) indicated [NAME] had ever asked her for an amount to add to a resident's SNF ABN. She indicated she would inform any resident or their responsible party if they asked. She indicated either the Minimum Data set (MDS) nurse or social services were the party that completed the SNF ABN. Interview on 7/1/25 at 1:30 p.m. Registered Nurse (RN) -A indicated she was the MDS nurse and she completed the SNF ABN form. She indicated that she did not know that an monetary amount needed to be completed on the SNF ABN form. The form is completed with see business office. She verified all SNF ABNs were completed with that information.Review of the Form instructions Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS 10055 (2024) indicated:D. Estimated Cost Section.In this section, the SNF enters the estimated cost of the corresponding care that may not be covered by Medicare. The SNF should enter an estimated total cost or a daily, per item, or per service cost estimate. SNF's must make a good faith effort to insert a resonable cost estimate for the care . If for some reason the SNF is unable to provide a good faith estimate of projected costs of care at the time of SNF ABN delivery, the SNF should indicate in the cost estimate that no cost estimate is available. This should not be a routine or frequent practice.Interview on 7/1/25 at 2:30 p.m. R24's family member, indicated she knew the amount because she is employed at the facility, but no information was given in writing on the form.Interview on 7/2/25 at 8:00 a.m., R3 indicated he did not remember being told an amount that he would have to pay to stay in the facility.

Based on observation, interview and document review the facility failed to comprehensively assess for and use the compatible mechanical lift with mechanical lift sling to ensure safe transfers for 1 of 1 residents (R18) observed and reviewed for safe transfers. This had the potential to affect five residents (R4, R8, R9, R18, R24) residing in the facility who used the same practice for mechanical lift transfers. Findings include: R18's quarterly Minimum Data Set (MDS), dated [DATE], indicated R18 had severe cognitive impairment, was dependent on staff for all activities of daily living (ADLs) and required a mechanical lift for transfers. R18's Weights, dated 7/2/24, in the electronic medical record (EMR) indicated R18 had lost 32 pounds in the past 6 months, approximately 15% of her body weight with a current weight of 187 pounds. R18's care plan, printed 7/2/24, indicated R18 required physical staff assist of two with VOLARO hoyer [mechanical] lift and size large (black trim cross leg sling) or the ARJO lift with (green trim) size large sling. R18's progress notes, dated 4/1/24 - 7/1/24, indicated R18 had two falls from a mechanical lift on 4/14/24 and 6/1/24. R18's progress note, dated 4/14/24, indicated R18 was transferring from her bed to wheelchair via a mechanical lift and two staff members when R18 got ahold of the leg straps and started viciously shaking them. R18 was up in the air when one of the leg straps came out of the hook holding it in place causing R18 to fall from the mechanical lift and was lowered to the ground. R18's progress note, dated 6/1/24, indicated R18 slid out of the hoyer [mechanical lift] sling and was lowered to the floor. During an interview on 7/1/24 at 9:45 a.m., nursing assistant (NA)-D stated R18 required assistance with two staff for transfers via a mechanical lift. NA-D stated R18 often had aggressive behaviors during transfers. NA-D stated she was present with R18 on 4/14/24, when R18 grabbed the sling straps and started shaking them. NA-D stated R18 was up in the mechanical lift and fell into the chair when the sling strap came lose. NA-D further stated the facility used multiple types of mechanical lifts and slings. During an interview on 7/1/24 at 9:50 a.m., the director of nursing (DON) stated the restorative nurses and the assistant director of nursing (ADON) were responsible to assess what mechanical lift and sling were appropriate for a resident to use. The DON stated a resident would be reassessed for proper sling size if a concern was noted or a change in condition but not necessarily from weight loss alone. The DON stated R18 was using the proper care planned mechanical lift and sling when she fell on [DATE], however the mechanical lift was found to have a broken clip that may have contributed to the sling coming loose, and after the second fall on 6/1/24 the sling was changed to a less slippery sling. The DON further stated the maintenance department provided routine maintenance of the mechanical lifts and nursing staff was educated on checking the clips on the mechanical lifts prior to use. During an interview on 7/1/24 at approximately 1:00 p.m., the ADON stated after R18's fall on 6/1/24, a different sling and mechanical lift was put in place to see if it would prevent R18 from wiggling out of the sling. The ADON further stated they had not had the mechanical lift or sling companies out to the facility to do education with the staff on how to properly use the mechanical lifts and slings to prevent further falls from a mechanical lift. The DON stated approximately 3 weeks ago she realized the facility was using three different types of slings and mechanical lifts, so each resident using a mechanical lift was assessed by the ADON for proper sling sizing. During interview on 7/1/24 at 3:10 p.m., (via email) the DON confirmed R18 was using a Volaro brand mechanical lift with Tollos brand sling when she fell from the mechanical lift on 4/14/24 and 6/1/24. The DON further confirmed while they had changed the mechanical lift and sling for R18, other residents in the facility were still using a combination of the Volaro brand mechanical lifts and Tollos brand slings. During an interview on 7/1/24 at 4:17 p.m., (via email) a Tollos (sling) Representative (TR) and the Tollos Clinical Educator (TCE) stated Tollos had not tested their slings to be used with the Volaro mechanical lifts and stated the most important aspect of using a Tollos sling with any other equipment would be if the facility received proper training for safe use. The TCE further stated Tollos does not make a recommendation in this regard because the possible combinations and uses would be numerous and could be unsafe in some situations. We would need to evaluate each individual use. During an interview on 7/2/24 at 8:55 a.m., a Volaro mechanical lift representative (VR) stated Volaro does not recommend, as a manufacturer, the use of other branded slings with their lifts. The VR stated he had seen other slings on the Volaro lifts that may have appeared to have a strong hold but created unsafe gaps in the sling where it should wrap the resident for safety to prevent a resident from slipping out. The VR further stated their slings were specifically designed to fit their mechanical lifts. During an interview on 7/2/24 at 10:27 a.m., the DON stated they had processes in place to review quarterly what slings and mechanical lifts a resident was using to ensure appropriateness, but have not had any facility wide education on what staff should look for to determine if a mechanical lift or sling was not appropriate for a resident. The ADON stated she determined the Volaro brand mechanical lifts and the Tollos sling were appropriate to use together by visual inspection but did not reach out to the mechanical lift and sling companies for education or to assess if they were appropriate and safe to use together. An undated policy titled Lifts & Transfers indicated the facility used a variety of mechanical lifts and slings for both sit to stand and full lift purposes and each resident would be assessed for an appropriate lift and sling based on the resident's height, weight, and body circumference.

Based on observation and interview the facility failed to ensure a container of oranges was stored off the floor to protect from contamination. This had the potential to affect all residents who consumed food served from the main kitchen. Findings include: During the initial kitchen tour of facility with cook (C-A) on 6/30/24 at 10:16 .m., a cardboard box of oranges was observed on the floor of the walk-in refrigerator next to wire racking containing refrigerated food. C-A stated, no it should not be on the floor. During interview with dietary director (DD) on 6/30/24 at 1:55 p.m., DD stated, the oranges should not have been on the floor of the fridge. We got a shipment on Friday [6/28/24] and . they should have been put up on a shelf in the fridge. During interview with C-C on 7/2/24 at 8:48 a.m., C-C stated, oranges should not be on the floor [sic] cause that is contamination [sic] and should be 6 inches off the floor. We go through a lot of oranges here too. That is not ok. Undated facility policy titled Perishable Food Storage Areas state, 1. All items must be stored at least 6 inches off the floor.

Based on observation, interview, and document review the facility failed to ensure care plans, which the facility used to communicate Enhanced Barrier Precautions (EBP), were revised for 4 of 4 residents (R10, R16, R24, R31) who were reviewed for care plans and who had been placed on EBPs designed to reduce the spread of multidrug-resistant organisms (MDRO's). Findings include: The Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Ref: QSO-24-08-NH dated March 20, 2024, documented Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and glove use during high contact resident care activities. In addition, EBP are indicated for residents with any of the following: -Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Also, Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Guidance also documented, 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. During facility entrance conference on 6/30/24 at 10:15 a.m., a list of residents on EBP was requested. The facility's infection control preventionist (ICP) provided surveyors with a list identifying R10, R16, R24, and R31 who were on EBP. R10's quarterly Minimum Data Set (MDS) dated [DATE], identified admission to facility on 10/26/20, dependence on staff for toileting hygiene, required substantial assistance with dressing and bathing, and had diagnoses of obstructive uropathy (impaired urine flow), urinary tract infection, and Parkinson's disease. Furthermore, R10 had an indwelling catheter (tube system used to drain urine from the bladder). R10's care plan (CP) and Kardex (nursing assistant care instructions) downloaded 6/30/24 failed to document EBP status. R16's annual MDS dated [DATE], identified admission to facility on 4/5/23, was dependent on staff for eating, toileting, personal hygiene, dressing and bathing, and had diagnoses of neurogenic bladder (impaired bladder control), Alzheimer's, and arthritis. Furthermore, R16 was on hospice and had an indwelling catheter. R16's CP and Kardex downloaded 6/30/24, failed to indicate EBP status. R24's significant change in status MDS dated [DATE], identified admission to facility on 11/12/20, was dependent on staff for toileting, bathing, and lower body dressing, and had diagnoses of neurogenic bladder, paraplegia (limb paralysis), and seizure disorder. Furthermore, R24 had an indwelling catheter. R24's CP and Kardex downloaded 6/30/24 failed to indicate EBP status. R31's quarterly MDS dated [DATE] identified admission to facility on 8/14/23, was dependent on staff for toileting hygiene, and lower body dressing, and had diagnoses of obstructive uropathy, renal failure, and anxiety. Furthermore, R31 had an indwelling catheter. R31's CP and Kardex downloaded 6/30/24 failed to indicate EBP status. During observation on 6/30/24 at 11:27 a.m., R10, R16, R24, and R31 had doors with posted signage indicating infection control precautions with instructions for staff to apply and remove personal protective equipment (PPE) for EBP. In addition, these rooms had PPE carts outside their doors. During observation and interview with LPN-A on 7/1/24 at 8:41 a.m., LPN-A stated she worked full time and was familiar with all the residents of the facility. LPN-A stated the expectation of staff was to find information on individual resident care needs, including assistance required for transfers, hygiene, diet, infections including EBP [status] or contact precautions, is in the report book (nursing communication book), [Kardex] and in the care plan. LPN-A reviewed in R10's electronic medical record (EMR) and reviewed R10's care plan and Kardex and verified they both lacked R10's EBP status. LPN-A walked to alcove near entrance of facility and pointed to a blue colored 3 ring binder labeled, Communication folder. LPN-A reviewed the nursing communication book and verified it lacked EBP status for R10, R16, R25, and R31. LPN-A stated updates to resident care plans, Kardex's, including information regarding EBP status are the responsibility of the director of nursing (DON), assistant director of nursing (ADON) who is also the ICP of facility or nurse manager. During interview with nursing assistant (NA)-A on 7/1/24 at 10:33 a.m., NA-A stated he had worked at facility full time for three years. NA-A stated the expectation of nursing staff was to receive verbal report at the beginning of every shift and, look in the communication folder. If there is changes it should be in the Kardex [also]. NA-A reviewed R10, R16, R25, and R31 care plans, Kardex's, and the nursing communication board and stated, Nope, I don't see anything about precautions for any of those residents [to receive verbal report at the beginning of every shift] .I don't know why they are on those precautions though so I would have to ask the nurse about that. During interview with NA-B on 7/1/24 at 9:18 a.m., NA-B stated she was full time and worked at facility for seven months. NA-B stated the expectation of nursing staff was to receive verbal report at the beginning of every shift and to look in the Kardex for each resident to determine the assistance needed. If there were changes in status I would look in the communication book every time I work. [If any resident is on] EBP or contact precautions, we are told in the morning meeting, and communication book. I expect [EBP status] to be in the Kardex. NA-B reviewed the EBP status for R10, R16, R25, and R31 and verified it was not in their care plans, Kardex's, and communication book. [It] should be though. During interview with ICP on 7/1/24 at 9:50 a.m., ICP verified she was also the facility's assistant director of nursing. ICP stated facility's method of communication to staff regarding EBP included updating individualized care plans, Kardex's, and the nursing communication book. ICP reviewed R10, R16, R25, and R31's care plans, Kardex's and the nursing communication book and verified all lacked information on EBP status. All of them [R10, R16, R25, and R31's care plans, Kardex's, and the nursing communication book] were updated today. [Updates] should have been put in the Kardex's, [care plans] and communication binder when they were put on precautions, but it wasn't. ICP stated unfamiliar staff such including agency staff would not be informed of resident care needs unless the care plan, Kardex's and communication book were accurate. ICP stated, It's important for all staff to know [resident EBP status]. Facility policy titled state, The care plan will be updated from a Registered Nurse, Social Services, Dietary, or Activities with any changes in resident care as needed. In addition, A Kardex will be completed with each care plan update to ensure staff are notified of a change in the care plan. Staff will also be notified of changes made to the care plan via the nursing communication book.

Based on observation, interview and document review the facility failed to comprehensively assess and reassess a resident's history of abuse and trauma, behavioral symptoms, triggers, and interventions to minimize physical and verbal aggression during cares for 1 of 1 resident (R18) reviewed for behavioral management. Findings include: R18's quarterly Minimum Data Set (MDS), dated [DATE], indicated R18 was admitted to the facility on [DATE] and had severe cognitive impairment. The MDS further indicated R18 was dependent on staff for all activities of daily (ADLs) and had verbal behavioral symptoms daily and physical behavioral symptoms 4-6 days of the 7 day look back period. R18's diagnoses list, printed 7/2/24, indicated R18 had multiple medical diagnoses including unspecified dementia with behavioral disturbances and other specified mental disorders due to known physiological condition. R18's medication administration record (MAR), dated 5/24/24, indicated R18 received several medications including Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves] and bipolar disorder [severe mood swings]) 50 milligrams (MG) by mouth every morning and bedtime related to unspecified dementia with behavioral disturbance, dated 6/4/24 and escitalopram oxalate (used to treat depression and generalized anxiety disorder) 10 mg by mouth one time a day related to dementia with behavioral disturbance, dated 3/26/24. The orders also contained an order to monitor mood and behaviors d/t [due to] increase Seroquel 6/5 - every shift for 4 weeks. R18's care plan, printed 7/2/24, with revisions since admission, indicated problematic manner in which resident acts characterized by ineffective coping in unfamiliar environment. Agitation as e/b calling out and yelling at staff with cares related to: Dementia, cognitive decline, history of physical and emotional abuse. Can become very anxious at times and call out/verbalize with phrases such as: You're hurting me You're going to drop me I'm slipping I'm not safe. Has swatted and pinched staff and makes threats to hurt staff. History of yelling, swearing, and showing unwanted hand gestures when being provoked by other residents. History of yelling, swearing, hitting and attempts to bite staff during cares. The care plan contained the following interventions, that had not been updated since R18's admission despite them being ineffective in decreasing R18's care planned behaviors; Be sure you have the resident's attention before speaking or touching. Staff to maintain calm approach, provide support listening, reassurance and verbal cues with transfers and cares, Keep schedules and routine predictable and inform resident ahead of time before attempting cares, Monitor for verbal/nonverbal indicators of pain and report to nurse for further assessment if noted, Refer to transferring/toileting care plans. Staff to provide verbal cues and use 2a [assistance] with mechanical lift to ensure safety, Remove resident from public area when behavior is disruptive/unacceptable. Talk to resident in low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity offer food/fluid, toilet, nurse to assess for pain, ask resident about her farm or horses. R18's medication administration record (MAR) and treatment administration record (TAR), dated 6/24, lacked any documentation of non-pharmacological interventions or as needed medication to address R18's frequent and continued verbal and physical behaviors. R18's progress notes from 5/1/24 to 7/1/24, also lacked any non-pharmacological interventions but indicated R18 had behaviors on the following days and two falls from a mechanical lift; On 5/1/24 it was documented R18 was still very combative towards staff during cares. On 5/2/24 it was documented R18 was still very combative and using abusive language during cares. On 5/3/24 it was documented R18 was still very combative and using abusive language during cares. On 5/6/24 it was documented R18 continues to scream out at staff during cares. Swings out and hits at them, kicks, refuses cares, yells 'you're hurting me, ow that hurt!' Swears at staff and calls them names. Yells 'shut up' frequently when staff are providing cares. Behaviors do subside once cares are completed, after a bit. Is content when sitting in dining room or when lying in bed. Refuses care or yells during cares each time. R18's skilled nursing notes from 5/9/24 - 5/16/24 indicated R18 has continued to yell and strike out at staff during cares daily. On 5/14/24 it was documented under RN Behavior Note nursing continues to note (R18) has behaviors of screaming, yelling, use of abusive language and Hx (history) of being combative with ADLs and transfers. Primarily has almost daily behaviors of yelling and using abusive language with cares due to anxiety and fear. Explanation of task, calm approach, different staff, speaking in a calm voice is usually effective in allowing task to be fulfilled and behaviors do not continue once task is complete. On 5/18/24 it was documented R18 continues to yell and hit out with cares. On 5/23/24 it was documented in a Care Conference note R18 continues to have behaviors daily of yelling out, swearing and accusatory behaviors. At times does attempt to hit out at staff. Staff continues to try interventions, effectiveness varies. Resident is followed by Rural Psych Associates. On 5/24/24 it was documented R18 was yelling out and grabbing with am (morning) cares. On 5/28/24 it was documented yelling/screaming, grabbing, pinching/scratching/spitting, abusive language, threatening behaviors was documented by the nursing assistants. On 6/1/24 it was documented R18 fell out of the hoyer lift during transfer. (An additional fall from the hoyer lift was documented on 4/14/24.) On 6/4/24 it was documented R18 was seen by Rural Psych and Seroquel was increased to 50 mg twice a day. On 6/12/24 it was documented R18 was yelling at staff while cares are being completed. On 6/14/24 it was documented R18 continued to yell and is combative with cares. On 6/16/24 it was documented R18 was yelling and combative with am (morning) cares. On 6/29/24 it was documented R18 was yelling, pinching, and hitting the nursing assistants during cares. On 6/30/24 it was documented R18 was yelling during cares. On 7/1/24 it was documented R18 was yelling during care. R18'2 EMR had evidence of medication changes to attempt to help with behaviors but lacked a comprehensive reassessment of specific triggers and interventions that have been attempted and worked or attempted and not worked to control R18's anxiety surrounding personal cares due to a history of abuse, despite current interventions being ineffective. R18's Psychosocial History and Assessment, dated 9/1/22, indicated R18 had a history of abuse by her son and a family history of alcohol. The form indicated R18 did not have a history of mental health problems and lacked any initial observations of mood, personality, behavior, etc. R18's EMR indicated R18 was seen by Rural Psychiatry Associates three times on 5/2/24, 5/9/24 and 6/4/24. The notes indicated R18 continued to have aggressive behaviors but lacked any recommendations for staff on interactions with R18 or non-pharmacological interventions despite continued behaviors. R18's Rural Psych note, dated 5/2/24, indicated the chief complaint was aggressive behaviors and agitation during care. The note indicated R18 presented with behavioral issues during care activities, exhibiting aggressive behaviors, yelling, and screaming when touched or moved. The note indicated R18 had a history of trauma and abuse from her father and husband. R18's Rural Psych note, dated 5/9/24, indicated R18 had no changes in behavior. R18's Rural Psych note, dated 6/4/24, indicated R18's calling out seems to have improved minimally but she was more physically resistive. During observation on 7/1/24 at 9:03 a.m., R18 was sitting out at the breakfast table in the main dining area, resting calmly with her eyes closed. During an interview on 7/1/24 at 9:45 a.m., nursing assistant (NA)-D stated R18 had behaviors when being transferred or while staff were doing personal cares with her. NA-D stated she had been working with R18 since November 2023 and R18's aggressive behaviors seemed to be getting worse, stating R18 kicked, hit and punched at staff during cares and used foul language. During an interview on 7/2/24 at 10:43 a.m., NA-D stated she tried to treat all residents the same but she would be more understanding if she knew a resident had a history of abuse. NA-D she had heard that R18 may have had something in her past but nothing that she was certain of. During observation and interview on 7/1/24 at 10:10 a.m., NA-A, NA-B and NA-D were transferring R18 from her wheelchair to her hospital bed via hoyer lift. R18 was very agitated, yelling and screaming, I want to go home! Don't touch me! I don't like that guy! They broke my butt and it hurt! R18 was observed trying to reach out and grab staff. NA-A attempted to talk to R18 in a calm, reassuring voice which was ineffective in calming R18 down. No other non-pharmacological interventions were observed during cares. R18 was provided incontinent care and transferred back to her wheelchair via hoyer lift. NA-A stated they documented R18's behaviors in Tasks but it was limited to check boxes therefore limiting what they could document. During an interview on 7/1/24 at 1:05 p.m., licensed practical nurse (LPN)-B stated R18's behaviors mostly centered around cares. LPN-B stated documentation for mood and behavior was on R18's MAR but non-pharmacological interventions were not, stating usually for residents with behavior who were taking antipsychotic medications, non-pharmacological interventions would be on the MAR to allow staff to note which interventions were used and effective. LPN-B stated nothing really works for R18's behaviors, stating when she was first admitted to the facility, R18 talked more and LPN-B was aware of a history of some sort of abuse but she was unaware of specifics because nothing was care planned regarding the specifics of R18's history of abuse. During an interview on 7/1/24 at 1:12 p.m., social services director (SSD) stated she assisted with assessing care planning a residents' potential history of abuse or trauma. The SSD stated when R18 was first admitted she was more cognitively intact and reported physical abuse by her father and husband and the SSD believed there was some financial abuse by her son. The SSD stated they did not have a formal reassessment process to track what interventions effective or did not, stating interventions will work for one resident and not another. The SSD confirmed interventions had not been updated since R18's admission on how to help control R18's aggressive behaviors, stating she used to like to talk about the farm she grew up on and horses but she had declined cognitively to the point so no longer remembered and was living in the past where her abuse was current to her. The SSD further stated the intervention to provide R18 with her [NAME] doll was no longer working. The SSD stated they have been trying to find triggers but her aggression seems to be just during cares. During an interview on 7/2/24 at 10:16 a.m., the director of nursing (DON) stated social services was responsible for the initial psychosocial assessment and that quarterly the nurses would complete a Behavior Note in progress notes that assessed dose reduction of medications, oral intake, and cognitive status. (The assessment lacked a look at specific interventions and triggers for behaviors.) The DON stated she was aware of R18's aggressive behaviors as her office was across the hall from R18's room and she could hear her yelling with cares daily. The DON confirmed R18 lacked a comprehensive assessment and reassessment of her history of abuse and trauma and a reassessment of interventions despite care planned interventions being ineffective. A facility policy titled Behavioral Health Services Policy, dated 8/31/17, indicated behavioral health encompasses a resident's whole emotional and mental well-being: and it was the policy of the facility to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and to ensure that a resident whose assessment did not reveal a mental/psychological disorder did not display decreased social interaction or increased withdrawn, angry or depressive behaviors unless the resident's clinical conditions demonstrated that this was unavoidable.

Based on observation, interview, and document review, the facility failed to ensure routine hygiene cares (i.e., nail care) was provided for 1 of 2 residents (R10) reviewed for activities of daily living (ADLs) and whom was dependent on staff to complete such cares. Findings include: R10's quarterly Minimum Data Set (MDS), dated [DATE], identified R10 had moderate cognitive impairment and demonstrated no delusional thinking. Further, the MDS outlined R10 required partial or moderate assistance with personal hygiene and did not have diabetes mellitus. R10's care plan, printed 6/30/24, identified R10 had Parkinson's Disease and required assistance with bathing due to impaired mobility. A series of goals were listed which included, To be neat[,] clean and odor free, along with multiple interventions such as bathing three times a week, physical assist of one for bathing, and foot care services for toenails as needed. The care plan lacked any guidance or direction on fingernail care including what, if any, preference for length R10 had or how often they should be checked or clipped. On 6/30/24 at 12:53 p.m., R10 was observed seated in his wheelchair while in his room. R10 had a visible tremor at times along with several long fingernails present on his left hand with the nail edge being multiple millimeters (mm) in length and some nails having a faint, dark coloration debris present under the nail bed. R10 stated he needed his nails clipped and added aloud, They [staff] come around to clip your toe nails but not your fingernails. R10 stated he was getting his scheduled bathing completed but only one staff member ever asks about clipping his fingernails adding, Most of the time, its one girl [staff]. R10 stated he hadn't seen the staff member lately but reiterated he would like the nails clipped. R10's POC (Point of Care) Response History, dated 6/3/24 to 6/28/24, identified the recorded support provided to R10 to complete bathing. This recorded a total of 12 episodes of bathing with R10 needing, at minimum, physical assistance in part of the task. However, R10's corresponding POC Response History, dated 6/3/24 to 6/28/24, listed a follow-up question to be completed which asked, Were fingernails cut[?], and staff could record a yes, no, refusal or unavailability. A total of 12 episodes were recorded with each response being marked, No. There were no recorded refusals of the care. R10's progress notes, dated 6/3/24 to 6/30/24, identified multiple notes labeled, Skin Wound Check, with sections to be completed by the nurse including, Fingernails & toenails trimmed: [answer recorded]. The most recent entries were recorded as: 6/12/24: Fingernails & toenails trimmed: no. 6/17/24: Fingernails & toenails trimmed: no refused. 6/19/24: Fingernails & toenails trimmed: no. 6/21/24: Fingernails & toenails trimmed: nails are clean and appropriate. 6/24/24: Fingernails & toenails trimmed: no. 6/26/24: Fingernails & toenails trimmed: no. However, the completed notes lacked information on how long the nails were (including what parameters were used to determine 'appropriate') or what, if any, re-approach effort was made on 6/17/24 to clip R10's nails with a refusal of care. Further, the medical record was reviewed and lacked evidence R10 had his fingernails clipped or trimmed since early June 2024, despite having long nails readily visible (i.e., 6/30/24 when observed). On 7/1/24 at 10:16 a.m., nursing assistant (NA)-C stated they had worked at the campus for a couple years and were aware of R10's care needs. NA-C explained R10 received help with bathing three times a week and nail care was usually done by the bath aide, however, R10 seemed to only like certain staff members or someone he trusts. NA-C stated they did not think R10 was diabetic but expressed aloud, I think they nurse does them [clips nails] for him. NA-C then observed R10's fingernails at the surveyor request. R10's fingernails remained long as they had been observed prior (6/30/24) and NA-C stated aloud, I think they're pretty long and need some clipping. R10 reiterated he wanted them clipped just not too short. NA-C stated any nail care completed by the NA staff, including offers and refusals of such, would be charted in the POC. NA-C stated the nail length appeared like it had been one or two months I think since they had last been clipped. When interviewed on 7/1/24 at 10:23 a.m., licensed practical nurse (LPN)-A explained nail care for a non-diabetic resident would typically be completed by the NA who helped with bathing on their scheduled bath days. LPN-A stated the NA will complete a bath sheet which is then provided to the nurse working who enters the information into the progress notes (i.e., Skin Wound Check). LPN-A verified any refusals of offered nail care should also be recorded. LPN-A then went and observed R10's fingernails and, upon return, stated aloud, They are long. LPN-A stated R10 did just again say he wanted them clipped and expressed it looked like it had maybe [been] a couple weeks since they were last clipped or trimmed. LPN-A stated nail care should be completed routinely to reduce the risk of bacterial growth under the nails. On 7/1/24 at 11:43 a.m., registered nurse manager (RN)-A stated they had just updated R10's care plan to reflect nail length preference adding the NA did just file them after reviewing them. RN-A explained nail care was usually completed with scheduled bathing but could also be done as needed. RN-A stated they had spoken with some other staff members and voiced they decided maybe adding clarity to the bath sheets would help ensure nail care wasn't missed moving forward as the language may be confusing to the aides. RN-A verified R10 likely needed help to complete fingernail clipping due to his Parkinson's Disease and expressed nail care should be done to promote good hygiene, reduce the infection risk, and also reduce the risk of him scratching himself with long nails. A provided Nail Trimming Policy and Procedure, dated 1/2022, identified staff may complete basic nail care for residents which included trimming. A procedure was listed with a step-by-step process to complete the actual task of nail care, however, the policy lacked information on how nail care would be documented or how often such care was to be offered or provided. An additional ADL Policy, dated 11/2016, identified the facility must provide care and services in accordance with F310 (sun-setted regulation for ADL care). The policy outlined ADL(s) included hygiene care (i.e., bathing, grooming) and directed, Staff will complete documentation in POC every shift describing the amount of care needed to complete each ADL.

Based on interview and document review, the facility failed to assess, implement care and interventions, and provide timely notification for change in condition to a provider for an unresponsive resident (R1) that delayed care resulting in risk of seizure, coma, or death to 1 of 3 residents (R1). Additionally, the facility failed to assess, implement care and interventions, and provide timely notification for a change condition to a provider for a resident (R1) who, during a transfer between two surfaces, felt a pop sensation near her right knee, and afterwards reported severe pain, and could no longer bear weight. The immediate jeopardy began on [DATE] when R1 was unresponsive during morning cares at approximately 8:00 a.m., was not assessed by a nurse until 9:00 a.m., was not continuously monitored, and was transferred to the hospital at 12:14 p.m., and was identified on [DATE]. The director nursing, with the administrator on the phone, was notified of the immediate jeopardy on [DATE] at 11:38 a.m. The immediate jeopardy was removed on [DATE], at 6:00 p.m., but noncompliance remained at the lower scope and severity level of a D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm, that is not immediate jeopardy. Findings include: R1 was admitted to the facility on [DATE], with diagnoses of pneumonia, chronic respiratory failure with hypercapnia (too much carbon dioxide in the blood),and chronic obstructive pulmonary disease. R1's Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, assist of two staff for bed mobility, transfers, toileting, and set-up assistance for eating. R1's care plan dated [DATE], indicated R1 had shortness of breath with exertion, chronic obstructive pulmonary disease (COPD), pneumonia, and pulmonary hypertension, but lacked indication of history of hypercapnia or interventions related to the diagnosis. R1's face sheet printed dated [DATE], identified, R1's code status was DNR/DNI (do not resuscitate/ do not intubate (a tube inserted in mouth to keep airway open), but did not have orders for limited treatments. During an interview on [DATE] at 11:30 a.m., family member (FM)-A stated there were two events recently for R1 in which care was delayed. FM-A stated the first incident was on [DATE], when a nursing assistant (NA) transferred R1, R1's right leg twisted during the transfer, and R1 could no longer bear weight on the right leg because the pain was intolerable. FM-A stated R1 was transferred to the hospital on [DATE] due to the pain and was diagnosed with a tibial fracture on the right leg. FM-A stated the second incident was [DATE], when R1 was found unresponsive at around 7:30 a.m., but not sent to the hospital until several hours later. FM-A further stated, They should have called me. I would have asked them to send her right away. She had several episodes where her CO2 [carbon dioxide] was too high. Additionally, FM-A stated, Now she is in the hospital taking pain meds, strong antibiotics, has a urinary infection, and maybe a blood infection. R1's progress note on [DATE] at 5:14 p.m., indicated R1 may transfer with assist of one per physical therapy recommendations. During an interview on [DATE] at 3:16 p.m., nursing assistant (NA)-D stated on [DATE] at about 3:00 p.m., during a pivot transfer to a chair, R1's knee made a pop sound, R1 yelped, and said her knee hurt. The pop was loud. She [R1] hollered out, it was horrible. She was definitely in pain. NA-D stated he and other NA tried to assist R1 to a standing position later, but R1 could not stand up and bear weight on her right leg anymore. NA-D stated when he transferred R1 on previous work shift, R1 could bear weight on the right leg, and could transfer without an EZ Stand. NA-A acknowledged he did not inform licensed practical nurse (LPN)-C about the incident when it occurred. Additionally, NA-D stated when R1 went to bed around 9:00 p.m., R1 stated her pain was rated at a ,d+[DATE], and NA-D reported that finding to LPN-C. During an interview on [DATE] at 2:59 p.m., NA-C stated on [DATE] at bedtime, she and NA-D tried to help R1 stand to pivot transfer, and NA-C stated, [R1] said she couldn't stand, she said, 'I can't, I can't.' [R1] sounded like she was in pain. [R1] was trying to get up with her lift chair and said, 'I'm trying, I'm trying. I can't. NA-C stated she reported the problem to LPN-C who instructed NA-C to use an EZ Stand (a transfer-assist unit which actively engages the patient in the standing process, thus reducing the need for caregiver assistance) and have R1 stand only on her non-injured leg for the transfer. NA-C stated she and NA-D put R1 to bed using the EZ Stand as instructed and noticed R1's right leg was slightly swollen at that time. During an interview on [DATE] at 2:39 p.m., LPN-C stated R1 reported to her before supper on [DATE], around 3:00 p.m., R1 felt a pop in her right leg near the knee during a pivot transfer at around 3:00 p.m., that same day. LPN-C stated she assessed the leg and there was no bruising or swelling, I just know it hurt her to move on it. LPN-C explained she did not ask R1 to rate her pain, but instead relied on facial expressions to determine it was not severe pain, and further stated, I just used my judgement. R1 did not ask for pain medication, but LPN-C offered Tylenol because R1 stated the leg bothered her when she stood on it. LPN-C further acknowledged R1 did not normally have pain in her right leg when standing, the aide reported R1 had pain when R1 stood. LPN-C further stated, I thought it was a possibility [R1] was injured, but thought at that time of night, I didn't think I needed to send her for an X-ray. I did not report it to the provider or family. I just put in a progress note, monitored it, and charted what I did. R1's progress note dated [DATE] at 8:30 p.m., written by LPN-C indicated R1 complained of right knee discomfort immediately following a transfer from recliner to wheelchair earlier in the day and further indicated R1 thought she injured the knee while pivoting. Ice was applied, R1 refused Tylenol, and the note indicated the nurse would continue to monitor R1. R1's progress noted dated [DATE] at 10:52 p.m., indicated 1000 mg Tylenol was administered, but lacked a pain rating. In review of R1's record on [DATE] between 3:00 p.m. and 10:00 a.m. on [DATE], it was not evident a comprehensive assessment or monitoring of R1's injury was completed that would include observation of the lower extremity, range of motion, or comprehensive pain assessments. During an interview on [DATE] at 2:33 p.m., LPN-A stated she assessed R1's right knee on [DATE] between 9:30 a.m. and 10:00 a.m., and found the right knee was swollen and warm. LPN-A further stated the night nurse, registered nurse (RN)-C informed her in morning report RN-C iced the area on night shift, R1 complained of pain on evening shift, and was unable to bear weight on it, even though R1 was noted to be assist of one staff for transfers. LPN-A stated, I don't know why she wasn't sent to the hospital on the 2nd. [February 2nd.]. It was warm to the touch and really big when I saw it, so I sent her in. R1's progress note written by LPN-D on [DATE] at 10:18 a.m., indicated staff reported R1 was unable to stand the prior evening ([DATE]) due to right knee pain, and was transferred to bed with a mechanical lift. The progress indicated R1's right knee was swollen and warm to touch, and R1 complained of pain rated as ,d+[DATE]. Additionally, the note indicated R1 requested staff notify her family member (FM), and subsequently R1's FM requested R1 transfer to the hospital. R1's progress note dated [DATE] at 10:38 a.m., indicated R1 left the facility by ambulance. During an interview on [DATE] at 11:06 a.m., physical therapy assistant (PTA)-A stated R1, at baseline, had no pain in her knees. During an interview on [DATE] at 11:22 a.m. occupation therapist (OT)-A stated if R1 had no pain, and then complained of pain up to a rating of ,d+[DATE], was a concern. During an interview on [DATE] at 12:57 p.m., LPN-D stated if R1 heard a pop, had subsequent pain, and couldn't bear weight, the change in condition should have been reported to a provider. R1's progress noted dated [DATE] at 7:54 p.m., indicated R1 returned from the hospital at 5:20 p.m., with a right fractured tibial plateau (a break of the larger lower leg bone below the knee that breaks into the knee joint itself.) During an interview on [DATE] at 11:59 a.m., NA-F stated if she heard a pop during a transfer and then the resident complained of pain, then there could be a problem and it should be reported to the nurse. Additionally, NA-F stated if a resident was found unresponsive, she would report it to a nurse immediately. R1's progress note dated [DATE] at 8:51 p.m., indicated R1 required assistance of one staff for bed mobility, dressing, and hygiene and R1 was able to communicate needs. R1's progress note [DATE] at 12:04 a.m., indicated R1 was alert and able to make her needs known. R1's progress note dated [DATE] at 12:05 a.m., indicated RN-C administered oxycodone HCl (opioid pain medication) 5 mg (milligrams). R1's progress noted dated [DATE] at 5:28 a.m., indicated RN-C rated R1's pain as ,d+[DATE] and indicated the dose of oxycodone was effective. During an interview on [DATE] at 2:00 p.m., NA-B stated she assisted NA-A to boost R1 up in bed on [DATE], around 7:00 a.m., and noticed R1 was unresponsive. NA-B stated she didn't know R1 well, but didn't think that was normal for R1, inquired about it to licensed practical nurse (LPN)-A, who said she tried to awaken R1, but R1 did not wake up. NA-B stated, I was surprised with the boost she didn't make any noise. I carried on caring for my people after that. When I worked with her before, she was already awake and already had her pills and breakfast by 8:00 a.m. During an interview on [DATE] at 2:15 p.m., nursing assistant (NA)-A stated on [DATE] NA-A entered R1's room between 7:30 and 8:00 a.m., R1 was not responding and was really out of it. NA-A stated she provided morning cares for approximately 30 minutes and even though R1 did not respond or react in any way she did not notify the nurse. NA-A stated LPN-A looked in the room around 8:00 a.m. and then left again. NA-A further stated it was not until after morning cares were complete around 8:30 a.m. she reported to LPN-A that R1 was unresponsive. During an interview on [DATE] at 12:28 p.m., LPN-A stated on [DATE] at approximately 8:00 a.m., NA-A was in R1's room providing morning care, and R1 was still asleep. LPN-A acknowledged she did not assess R1 at that time but acknowledged R1 was typically out of bed by 8:00 a.m. LPN-A further stated at approximately 8:30 a.m., during another check, LPN-A saw NA-A change R1's incontinent pad, and at that time NA-A reported R1 was unresponsive. LPN-A returned to R1's room at approximately 9:00 a.m. to assess vital signs and since the registered nurses (RN) had gone to report, LPN-A did not alert RN-A to R1's condition until after report, around 9:30 a.m. R1's vital signs (VS) were stated to be within normal limits but were not recorded in the medical record until [DATE] as a late entry and were as follows: blood pressure ,d+[DATE], pulse 79 beats per minute, respirations 16/ min, temperature 97.6 F, and blood oxygen (O2) saturation 97%. LPN-A acknowledged she did not contact the provider or family. During an interview on [DATE] at 12:07 p.m., LPN-B stated R1 had a routine in the morning in which R1 turned on the call light between 7:00 a.m. and 7:30 a.m., wanted two of her medications, and then wanted to sit up in bed or in her wheelchair for breakfast. LPN-B further stated it would be odd for R1 to be asleep at 9:00 a.m. and had not ever refused medications. Additionally, LPN-B stated NA-A should not have continued cares for an unresponsive resident, and instead, should have notified a nurse immediately, and the nurse should have called 911 immediately upon knowing R1 was unresponsive. R1's progress noted dated [DATE] at 11:55 a.m., indicated RN-A noted she was notified by LPN-A R1 was lethargic and did not awaken for morning medications, vital signs (VS) were taken by LPN-A and were normal, and R1 was not arousable with a sternal rub. RN-A notified the director of nursing (DON), who advised RN-A to call the on-call provider. RN-A called the facility's medical service to inquire who was covering the facility as the regular provider was out ill. RN-A was advised at 11:00 a.m., about which provider to call, and left a voice mail for that provider at 11:08 a.m. The covering provider called back at 11:47 a.m., and advised RN-A to discontinue R1's oxycodone, administer Narcan (medication used to reverse the effects of opioid overdose), and transport R1 to the hospital via ambulance if the Narcan was ineffective. R1's record lacked evidence R1 was continuously monitored or assessed between 8:00 a.m. and 12:00 p.m. when EMS (emergency medical services) arrived. A progress note dated [DATE] at 12:22 p.m., indicated emergency medical services (EMS) arrived around 12:06 p.m., administered two doses of Narcan with no response from R1, family was notified, and R1 left via ambulance at 12:14 p.m. R1's progress noted dated [DATE] at 12:44 p.m., indicated emergency medical services (EMS) arrived around 12:06 p.m., two doses of Narcan were administered with no response from the resident except one moan after the first dose, R1's son was then notified, and R1's son questioned if R1's carbon dioxide (CO2) levels were elevated as R1 had a history of elevated CO2 levels. R1 was transferred to the hospital via ambulance. During an interview on [DATE] at 11:18 a.m., emergency medical technician (EMT)-A stated the emergency medical services (EMS) report from the incident indicated on [DATE], at 7:30 a.m., when staff checked on R1, R1 was somnolent, not arousable, completed daily cares, and then began escalating the concern. EMT-A stated, per the EMS report, around 11:30 a.m. staff was advised to call EMS, and EMS staff felt there was a delay in care to R1. Additionally, EMT-A stated upon arrival to the hospital, R1's lab work was abnormal and showed prolonged inadequate breathing during this event. R1's ambulance service run report dated [DATE] at 12:00 p.m., indicated emergency medical services (EMS) arrived to find R1 unresponsive with agonal breath sounds (when someone who is not getting enough oxygen is gasping for air), and staff reported R1 had been in that condition since 5:30 a.m. this was not able to be corroborated through interview nor record review. R1's Hospital record identified R1 was admitted to the ICU on [DATE] with very high C02 levels. R1 was transferred to a medical floor on [DATE], and then returned to facility on [DATE]. Labs completed identified R1's C02 levels were greater than 100 milliequivalents per liter (mEq/L), with normal levels between 23 to 29 mEq/L. During an interview on [DATE] at 5:22 p.m., R1 stated, My carbon dioxide in my body was building up. I imagine I could have died that way. That has happened three times. With my knee, it was a lot of pain when it happened. It was really bad. The pain that night was a ,d+[DATE]. I was offered Tylenol and they put the cold pack on it. That helped a little bit. I had to distract myself after that. During an interview on [DATE] at 8:47 a.m., RN-A stated NA-A should have reported to the nurse when she found R1 unresponsive. RN-A further stated LPN-A notified her on [DATE] at about 9:30 a.m. that R1 was unresponsive, and then RN-A performed a sternal rub which R1 did not respond to and checked pedal pulses and found them to be present and normal. RN-A reported to the director of nursing, and then a provider was called. The regular provider was not able to be reached, however RN-A did not call senior services until 11:00 a.m., after talking to the director of nursing (DON) to inquire about a covering provider. She then called the provider that was indicated as on-call. During an interview on [DATE] at 4:48 p.m., nurse practitioner (NP)-A stated the expectation when a resident was found unresponsive was call 911, then call the provider, and reiterated staff should not wait for a provider to respond. Additionally, NP-A stated staff should have checked R1's vital signs right away. During an interview on [DATE] at 3:35 p.m., medical director stated when a resident is found unresponsive, checking vital signs would be the first step to help triage the urgency of the situation, and if there was a true emergency, waiting for a provider was a delay in care. During an interview on [DATE] at 5:42 p.m., the hospital physician who discharged R1, MD-B, stated the duration of time would matter if R1 was found unresponsive at 7:30 a.m., and was not assessed until 9:00 a.m., and further stated R1's Intensive Care Unit (ICU) time and course of treatment may have been different and less, and R1 might not have needed the Bi-pap (positive airway pressure) if staff had not delayed care. MD-B further stated VS should have been checked right away when R1 was found unresponsive. During an interview on [DATE] at 9:27 a.m., the DON stated the expectation was for staff to report change in condition right away, a nurse would perform an assessment as soon as the change in condition was noted, nursing staff would call 911 and family. The Change in Condition Policy dated [DATE], indicated nursing staff will notify the primary physician and/or the on-call MD and the resident/ responsible party or family member immediately with any significant change in the resident's physical, mental, or psychosocial status, for example, a deterioration in health, mental, or psychological status in either life-threatening conditions or clinical complications (development of a stage 2 pressure sore, onset or recurrent periods of delirium, recurrent UTI [urinary tract infection], or onset of depression etc.). The immediate jeopardy that began on [DATE], was removed on [DATE], after it was verified the facility updated R1's care plan to include hypercapnia and related interventions, reviewed like residents' care plans and updated them as needed, provided education to licensed nurses about the signs and symptoms of hypercapnia, provided education to all staff about recognizing and reporting a resident change in condition, and posted information at nursing desks about how to reach on-call providers. The noncompliance remained at the lower scope and severity level of a D-isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm, that is not immediate jeopardy.

Based on interview and document review, the facility failed to provide timely notification for change in condition to a provider and family for an unresponsive resident (R1) and for the same resident (R1) who, during a transfer between two surfaces, felt a pop sensation near her right knee, and afterwards reported severe pain, and could no longer bear weight. Findings include: R1 was admitted to the facility on [DATE] with diagnoses of pneumonia, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, acidosis, and neuropathy. R1's Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment, assist of two staff for bed mobility, transfers, toileting, and set-up assistance for eating. R1's care plan dated 2/9/24, indicated R1 had shortness of breath with exertion, chronic obstructive pulmonary disease (COPD), pneumonia, and pulmonary hypertension, and required the assistance of two for most activities of daily living (ADLs). During an interview on 2/9/24 at 11:30 a.m., family member (FM)-A stated there were two events recently for R1 in which the family was not notified timely. FM-A stated the first incident was on 2/2/24, when a nursing assistant (NA) transferred R1, R1's right leg twisted during the transfer, and R1 could no longer bear weight on the right leg because the pain was intolerable. FM-A stated he was not notified of the incident until R1 was transferred to the hospital on 2/3/23. FM-A stated the second incident was 2/6/24, when R1 was found unresponsive at around 7:30 a.m., but he was not notified of the change in condition until 11:58 a.m., and further stated, She could have been gone in that amount of time. I wasn't told about it until after they sent her to the hospital. They should have called me. I would have asked them to send her right away. R1's progress note on 2/2/24 at 10:26 p.m., indicated R1 complained of right knee discomfort immediately following transfer from recliner to wheelchair, R1 stated she thought she injured it while pivoting, ice was applied but refused Tylenol, and the nurse would continue to monitor. The progress note lacked notification to family or a provider of the change in condition. R1's progress note on 2/3/24 at 10:18 a.m., indicated staff reported R1 was unable to stand the prior evening due to right knee pain, and was transferred to bed with a mechanical lift. The progress indicated R1's right knee was swollen and warm to touch, and R1 complained of pain rated as 10/10. Additionally, the note indicated R1 requested staff notify her son, and subsequently R1's son requested R1 transfer to the hospital. During an interview on 2/9/24 at 2:39 p.m., LPN-C stated R1 reported to LPN-C before supper on 2/2/24, around 3:00 p.m., R1 felt a pop in her right leg near the knee during a pivot transfer at around 3:00 p.m., that same day. LPN-C stated she assessed the leg and there was no bruising or swelling, I just know it hurt her to move on it. LPN-C stated she did not ask R1 to rate her pain, but instead relied on facial expressions to determine it was not severe pain, and further stated, I just used my judgement. LPN-C stated R1 did not ask for pain medication, but LPN-C offered Tylenol because R1 stated the leg bother her when she stood on it. LPN-C further acknowledged R1 did not normally have pain in her right leg when standing, the aide reported R1 had pain when R1 stood, and LPN-C stated, I thought it was a possibility [R1] was injured, but thought at that time of night, I didn't think I needed to send her for an X-ray. I did not report it to the provider or family. I just put in a progress note, monitored it, and charted what I did. During an interview on 2/9/24 at 2:33 p.m., LPN-A stated she assessed R1's right knee on 2/3/24 between 9:30 a.m. and 10:00 a.m., and found the right knee was swollen and warm. LPN-A further stated the night nurse, registered nurse (RN)-C informed her in morning report RN-C iced the area on night shift, R1 complained of pain on evening shift, and was unable to bear weight on it, even though R1 was noted to be assist of one staff for transfers. LPN-A stated, I don't know why she wasn't sent to the hospital on the 2nd. [February 2nd.]. It was warm to the touch and really big when I saw it, so I sent her in. R1's progress noted dated 2/3/24 at 7:54 p.m., indicated R1 returned from the hospital at 5:20 p.m., with a right fractured tibial plateau (a break of the larger lower leg bone below the knee that breaks into the knee joint itself.) During an interview on 2/9/24 at 2:15 p.m., nursing assistant (NA)-A stated on 2/6/24 NA-A entered R1's room between 7:30 and 8:00 a.m., R1 was not responding and was really out of it. NA-A stated she provided morning cares for approximately 30 minutes and even though R1 did not respond or react in any way she did not notify the nurse. NA-A stated LPN-A looked in the room around 8:00 a.m. and then left again. NA-A further stated it was not until after morning cares were complete around 8:30 a.m. NA-A reported to LPN-A R1 was unresponsive. During an interview on 2/12/24 at 12:28 p.m., LPN-A stated on 2/6/24, LPN-A entered R1's room for the first time that shift around 8:00 a.m., and found R1 snoring and sleeping, so LPN-A returned around 8:30 a.m., saw the NA changing R1's pad, and at that time NA-A reported R1 didn't respond at all during cares. LPN-A acknowledged she returned to R1's room at approximately 9:00 a.m., reported to RN-A around 9:30 a.m., and acknowledged she had not called a provider of the family. R1's progress noted on 2/6/24 at 11:55 a.m., indicated RN-A noted she was notified by LPN-A R1 was lethargic and did not awaken for morning medications, vital signs (VS) were taken by LPN-A and were normal, and R1 was not arousable with a sternal rub. RN-A notified the director of nursing (DON), who advised RN-A to call the on-call provider. RN-A called the medical service to inquire who was covering the facility as the regular provider was out ill. RN-A was advised at 11:00 a.m., about which provider to call, and left a voice mail for the provider at 11:08 a.m. The covering provider called back at 11:47 a.m., and advised RN-A to discontinue oxycodone, administer Narcan (medication used to reverse the effects of opioid overdose), and transport R1 to the hospital via ambulance if the Narcan was ineffective. The progress note lacked mention of a call to a provider or family. R1's progress noted on 2/6/24 at 12:44 p.m., indicated emergency medical services (EMS) arrived around 12:06 p.m., two doses of Narcan were administered with no response from the resident except one moan after the first dose, R1's son was notified, and R1's son questioned if R1's carbon dioxide (CO2) levels were elevated as R1 had a history of elevated CO2 levels. During an interview on 2/13/24 at 8:47 a.m., RN-A stated NA-A should have reported to the nurse when she found R1 unresponsive. RN-A further stated LPN-A notified her on 2/6/24 at about 9:30 a.m. that R1 was unresponsive, and then RN-A performed a sternal rub which R1 did not respond to and checked pedal pulses and found them to be present and normal. RN-A reported to the director of nursing, and then a provider was called. The regular provider was not able to be reached, however RN-A did not call senior services until 11:00 a.m. to inquire about a covering provider. She then called the provider that was indicated as on-call. During an interview on 2/12/24 at 4:48 p.m., nurse practitioner (NP)-A stated the expectation when a resident was found unresponsive was call 911, then call the provider, and reiterated staff should not wait for a provider to respond. During an interview on 2/13/24 at 9:27 a.m., the director of nursing stated the expectation was for staff to report change in condition right away, a nurse would perform an assessment as soon as the change in condition was noted, and nursing staff would call 911 and family. The Change in Condition Policy dated 1/28/21, indicated nursing staff will notify the primary physician and/or the on-call MD and the resident/ responsible party or family member immediately with any significant change in the resident's physical, mental, or psychosocial status, for example, a deterioration in health, mental, or psychological status in either life-threatening conditions or clinical complications (development of a stage 2 pressure sore, onset or recurrent periods of delirium, recurrent UTI [urinary tract infection], or onset of depression etc.).

Based on interview and record review, the facility failed to ensure a care conference was held related to a significant change for 1 of 1 residents (R7) reviewed for care planning. Findings include: R7's significant change Minimum Data Set (MDS) dated [DATE], indicated admitted on [DATE], was cognitively intact, and received therapy services related to a fall with fracture. R7's care conference signature sheet indicated his last care conference was held 5/31/23. R7's progress note dated 7/7/23, indicated significant change MDS was initiated related to the ending of therapy services. R7's record contained no evidence of care conference completed as a result of the significant change. When interviewed on 9/11/23 at 5:32 p.m., R7 stated he did not recall having a care conference in July. When interviewed on 9/13/23 at 12:11 p.m., the social worker (SW) stated the MDS coordinator scheduled the assessment and care conference completion due dates. She invited and set up the care conference meetings with residents and/or their representative. SW stated R7's record lacked evidence of a care conference or why it was not completed. When interviewed on 9/13/23 at 1:21 p.m., Registered Nurse (RN)-A stated she scheduled the MDS assessments and care conferences. The social services invited residents and families. RN-A stated all departments were invited to attend. It was important to involve all disciplines in the care planning process. RN-A stated R7's care conference must have been missed with the significant change. When interviewed on 9/13/23 at 1:21 p.m., the director of nursing confirmed R7's significant chance care conference was missed. It was important to maintain regular care conferences to maintain quality and resident focused care and to be proactive with resident changes in condition. The facility policy Person Centered Care Plan dated 3/29/20, identified the resident care plan will be reviewed and updated quarterly, annually and with a significant change. The policy also identified The care plan will be reviewed during care conferences with residents and family to ensure it is based upon the resident wishes for their care.

Based on observation, interview, and document review the facility failed to ensure manufacturer recommendations were followed for a mechanical lift transfers and failed to a comprehensive assessment residents safety when using a mechanical lift. This resulted in immediate jeopardy (IJ) for R1 who used an incorrect harness, had limited ability to bear weight and became suspended in the lift resulting in a T9 spinal fracture. In addition the facility failed to comprehensivly assess safe transfers for appropriate brand of mechanical lift, harness/sling size and type to ensure safe transfers for 4 of 12 residents (R2, R3, R5, R6) that used a mechanical lift. The IJ began on 8/12/22, at 3:15 p.m. when facility staff did not use two staff to transfer R1 in accordance with the care plan, used incorrect lift harness that resulted in R1 to hang from the lift by her underarms resulting in spinal fracture. The administrator and assistant director of nursing (ADON) were notified of the IJ on 8/17/22, at 4:18 p.m. The IJ was removed on 8/19/22, at 4:30 p.m., but non compliance remained at a lower scope and severity of an D with no actual harm with potential for more than minimal harm that was not immediate jeopardy. Findings include: During an interview on 8/17/22, at 1:00 p.m. restorative aide (RA)-B identified the facility had five (5) brands of sit-to-stand mechanical lifts; Invacare -bariatric lift, (2 different models) EZ-Way or EZ-stand, Volaro, Best Care, and a Pro-Assist. On 8/22/22, at 3:00 p.m. RA-B identified the facility had brands of full body lifts; The Tolos (bariatric), PAL, EZ-Way (Hoyer),Volaro, and PURPLE. R1's face sheet indicated a diagnosis of dementia and a history of an upper and lower end right fibula fracture. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severe cognitive impairment and required extensive assist of two persons for transfers where staff provide non weight bearing support. R1 did not walk and used a wheelchair for mobility. R1's care plan for transfers prior to revision on 8/15/22, identified that R1 transferred with 2 assist and the use of EZ-stand for transfers to get out of bed on day shift. Use Hoyer lift (full body lift) to get into bed if needed. May use EZ-stand with assist of 2 staff with toileting. If (R1) is not standing in the EZ-stand appropriately use Hoyer lift and two assist. R1's care plan did not identify an EZ-stand harness size and leg strap, or evidence R1 could use and alternative brand of a standing lift. Further the care plan did not address what size sling would be used with the Hoyer or if another brand of full body lift was appropriate. There was no indication in the medical record a comprensive assessment was completed to determine which mechanical lift including sling/harness R1 required to ensure they were safe during these transfers. R1's nursing progress note, dated, 8/12/2022, identified a nurse was called to R1's room. When nurse arrived, R1 was on the EZ-stand mechanical lift hanging and her right leg was off the platform, knee on the platform. R1's face was red and turning bluish and was placed onto the toilet. Resident was responsive, talking and having back, right knee, bilateral armpit, and bilateral arm pain. Resident unable to rate (pain) she just kept saying it hurts. A nursing assistant (NA) was transferring her with EZ stand and R1's knees buckled and was hanging from the lift belt. Sent to ER for evaluation, left at 3:55 pm by ambulance. Corresponding incident report dated 8/12/22, identified the aforementioned and noted a bruise forming on R1's left wrist. R1's MD visit note, dated 8/17/22, identified visit was for a follow-up following R1's hospital stay and noted the mechanical lift incident that occurred on 8/12/22, that resulted in T9 (thoracic) wedge compression fracture. R1 was placed in a brace. During an interview on 8/16/22, at 5:19 p.m. NA-A verified he was the aide that had transferred R1 with the EZ-stand by himself which resulted in R1's fall. NA-A indicated R1 had been on the toilet, had put the harness around her and did not use the leg strap. When R1 was in a standing position she said oh oh there goes my knee. Her right leg got weak, her body weight brought her down, she ended up on her right knee on the platform. NA-A then called for help on the walkie, two nurses and NA-D arrived, got her back on the toilet, then used a full body lift to get her into bed. NA-A stated he knew R1's care plan said she was supposed to transfer with two-assist, however he was trained to use one with standing and full body lifts. NA-A indicated on some days R1 was more fatigued he used full body lift which which ocurred a few times in the past few months. NA-A indicated he had been a nursing assistant for about 6 months and was not certified. He identified the facility's orientation/training consisted of following another NA trainer, that signed off on everything. NA-A did not recall taking a test for the mechanical lifts. During an interview on 8/16/22, at 4:22 p.m. nursing assistant (NA)-B stated she worked the day of R1's fall. NA-B explained NA-A was transferring R1 from the toilet with the EZ-stand by himself. R1 was supposed to be assisted by two staff because she did not do well on the EZ-stand. NA-B thought R1 should have been a full body lift. NA-B stated NA-A used the walkie to call for help for R1. When she got there, R1 was hanging with her foot off the platform and her face turning purple. R1's right knee had buckled and the lift's leg strap was not used. We got her on the toilet and then used a Hoyer to get her into the bed. During an interview on 8/16/22, at 4:30 p.m. NA-C indicated R1 was supposed to use a standing lift with two staff because R1 could barely stand for 5 seconds; R1 would tell us I can't do this put me down. R1 should have been a full body lift. NA-C stated if there were concerns with transfers, we would report to the nurse and was unaware if nurses were notified R1 had not been tolerating transfers. NA-C confirmed she worked on 8/12/22. NA-C stated NA-A had attempted to transfer R1 by himself. When she arrived in R1's room, R1 was hanging in the lift, and dangling by her armpits by the lift sling. NA-C indicated the lift was lowered and R1 was assisted to the toilet. During an interview on 8/17/22, at 2:36 p.m. NA-C stated we used the harness that was over the machine for R1. During an interview on 8/16/22, at 4:45 p.m. licensed practical nurse (LPN)-A stated R1 was transferred with two assist with a standing lift. LPN-A had never been notified or had heard R1 was weak or not tolerating the standing lift. LPN-A stated she was working at the time of R1's incident. When LPN-A arrived to R1's room, NA-A was standing there, he had not lowered the lift at all. R1's knees were on the platform, her face was purple looking, she was hanging onto the lift grab bars and not bearing any weight, her right leg was kind of sideways, the leg strap was not on, all her weight was being supported by her armpits and the harness. Staff lowered the lift to remove some of the pressure from R1's upper body. LPN-A explained it took three staff to get R1 back onto the toilet. LPN-A stated after the incident, she informed NA-A that R1 transferred with two assist and director of nursing (DON) did verbal coaching with NA-A the same day. That night LPN-A told the aides that they could not do any transfers without a nurse present. LPN-A indicated she had not looked at the harness that had been used on R1 or completed any transfer assessments to determine what lift or harness should be used based on her tranfer ability. During an interview on 8/16/22, at 5:28 p.m. LPN-B stated R1 was a two person assist with EZ-stand because she is heavier and has week knees. LPN-B explained she sometimes helped with R1's transfers she does ok with it, she can't stand too long on it [mechanical lift] is what I know. LPN-A indicated she had not heard of any concerns with R1 and the mechanical lift. During an interview on 8/17/22, at 11:07 a.m. physical therapist (PT) stated the last time therapy assessed R1 for transfers was during the period of 8/19/21 to 9/13/21. At that time, we recommended her to be a two person assist with the Ez-stand and a Hoyer lift for getting out of bed. The reasoning for a two person was mainly R1's ability to follow instructions. PT was unaware of any changes since the recommendation was made. PT stated that they do not routinely assess residents for mechanical lifts unless nursing identified a problem. PT stated she did not hear anything about a decline in R1's transfer status prior to her fall. When R1 got back from the hospital we did not assess R1 because R1 was at her prior ADL level and did not feel the need to re-evaluate her. PT indicated she did not have a progrness note confiirming this, but verbally told the DON. PT stated nursing had changed her to two person assist with a Hoyer even though her ADL status had not changed. PT indicated an unawareness of what criteria nursing used to determine R1 was appropriate for a full body lift. PT stated when therapy evaluated residents the recommendations would be given to the nurse. During an interview on 8/17/22, at 11:26 a.m. DON verified R1's care plan directed two assist was not followed. DON stated her fall investigation consisted of interviewing LPN-A, LPN-B, and NA-A. DON verified she did not interview the other staff present, did not investigate if the correct mechanical lift and lift harness was used. DON confirmed R1's care plan did not identify size of harness R1 required, did not identify an alternative brand of standing lift, and did not address sling size for full body lift. DON assumed the cause of the incident was that R1 became weak and her knee buckled. DON stated, another aide will train in a new aide, then they perform an orientation checklist. the NA's competencies are signed off by the charge nurse or myself. The charge nurse is requied to visualize the competency for transfers with a mechanical device. DON indicated the training checklist does not identify which lift was used and was unaware if competency testing was completed for each brand of mechanical lifts. During an observation and interview on 8/17/22, at 12:30 p.m. DON walked to the mechanical lift storage room. There was one EZ-stand and one Invacare, that were both standing mechanical lift. DON indicated the Invacare was a bariatric lift and did not have the leg strap. DON stated she did not know which lift or harness R1 had a fall from. During an observation and interview on 8/17/22, at 12:41 p.m. LPN-B walked to the mechanical lift storage room, stated R1 was in the Invacare lift when the fall ocurred (8/12/22). LPN-B was not sure which harness was used that day but pointed to a blue extra-large harness with a letter 'I' printed on it with black marker. LPN-B indicated there was not an instruction manual or anything on the lift that would indicate the size of harness a resident would need. LPN-B stated she would not know what size for sure to use for R1 for a safe transfer. The storage room was searched and LPN-B was unable to find another sling for the Invacare lift. During an interivew on 8/17/22, at 1:14 p.m. NA-A, the aide that had transferred R1 on 8/12/22 identiifed he was unware of the brand name of the lift that he used but it was the only one that had a remote control that opened and closed the legs and it did not have the leg strap. NA-A stated he used the green EZ-stand harness. NA-A stated he was pretty sure he used the right harness because it was the one laying over the lift, so it should have been the right one. During an observation and interview on 8/17/22, at 1:56 p.m. NA-F stated R1 routinely used the Invacare lift with the green EZ-stand harness and did not use EZ-stand lift for R1's transfers. NA-F attached the blue extra-large harness to the Invacare lift. Physical therapy assistant (PTA)-A told us that would be way too big for R1, it would not even hold her up. Then NA-F attached the green large EZ-stand harness to see if there was a difference; NA-F stated when they used this one on R1 it was way too small for her. During an interview on 8/19/22, at 3:02 p.m. RA-B stated, the lift that R1 fell out of was the Best Care brand sit to stand lift. RA-B verfied that was the only sit to stand lift with a remote to close and open the legs on it. RA-B stated the two lifts were very similar and may have been why staff were confused on which lift R1 fell from. We have taken them both out of circulation until we can get the maunfacturer instructions and get the right slings for them. R2 R2's significant change, MDS assessment, dated 8/1/22, identified R2's cognition was intact, required assist of one staff with transfers and did not walk. Further indicated that R2 was unsteady and only able to stabilize with human assistance with moving from a seated to standing position, moving on and off the toilet and with a surface-to-surface transfer. R2's care plan dated 8/18/22 identified R2 required assist of one staff for transfers with an EZ-stand lift. The care plan did not identify what EZ-stand harness size or leg strap usage, or identify if R2 could use an alternative brand lift. There is no indication in the medical record a comprensive assessment was completed to determine which mechanical lift including harness R2 required. R3 R3's significant change, MDS assessment, dated 8/1/22, indicated that R3 had severe cognitive impairment, required assist of two staff with transfers and did not walk. Further indicated that R3 was unsteady and only able to stabilize with human assistance with moving from seated to standing position, moving on and off the toilet and with a surface-to-surface transfer. R3's care plan, dated 8/10/22, identified R3 required assist of two staff for transfers with an EZ-stand lift. The care plan did not identify what EZ-stand harness size or leg strap usage, or identify if R3 could use an alternative brand lift. There is no indication in the medical record a comprensive assessment was completed to determine which mechanical lift including harness R3 required. R5 R5's annual, MDS assessment, dated 7/13/22, indicated that R5 had severe cognitive impairment, required total dependence of two staff with transfers and did not walk. R5's care plan dated 8/18/22, identified R5 required assist of two staff for transfers with the Hoyer lift and did not identify what size sling to be used. R5's record lacked a comprehensive transfer assessment that identified what brand of lift and sling size was appropriate for R5. The care plan did not identify what Hoyer (EZ-way brand) sling R5 required and did not identify if R3 could use an alternative brand lift. There is no indication in the medical record a comprensive assessment was completed to determine which mechanical lift including sling size R5 required. R6 R6's admission, MDS assessment, dated 8/15/22, indicated that R6 had intact cognition, required total dependence of two staff with transfers and did not walk. R6's care plan, dated 8/10/22, identified R6 required assist of two staff for transfers with the Hoyer lift, did not identify what size sling to be used. R6's record lacked comprehensive transfer assessment that identified what brand of lift and sling size was appropriate for R6. The care plan did not identify what Hoyer sling R6 required and did not identify if R could use an alternative brand lift. There is no indication in the medical record a comprensive assessment was completed to determine which mechanical lift including sling size R6 required. During an interview on 8/17/22, at 1:00 p.m. restorative aide (RA)-B verified resident care plans did not include the brand of lift to use or sling/harness size. RA-A and RA-B both verified that the Invacare harness do not have weights that correspond to each size. They would have no way of really knowing which harness to use other than to guess. During an interview on 8/17/22, at 1:54 p.m. physical therapy assistant (PTA)-A verified the Invacare lift was bariatric and would be safe to use for R1 as she was heavier. PTA-A stated the newer facility lift machines did not have a leg strap on them, the shin guard was flatter, and there was no incline on the platform, it was flat. PTA-A stated it was not safe to mix different harness/sling brands with different lift brands because the size/shape could vary between brands. PTA-A was not able to articulate which harness R1 would use with the Invacare lift or if it would be appropriate because R1 had to be assessed for that lift. Since there was only the blue extra-large harness in the facility that was too big, so an assessment could not be done. PTA-A further stated, when therapy assessed patients, they always used the EZ-stand brand, and had never worked with the Invacare lift. PTA-A confirmed there was no booklet attached to the machine or any instructions on the lift that identified what size harness a resident would require to use with that lift. PTA-A expected the leg strap to be used for transfers with the EZ-stand unless therapy specifically recommended the resident did not need one. Therapy did not specifically recommend sling/harness sizes. PTA-A was not aware staff were using multiple different brands of sit-to-stand and full body lifts and indicated residents would have to be assessed for appropriateness. During an interview on 8/17/22, at 2:14 p.m. RA-A stated they had five sit to stand lifts in the building and they were all different. RA-A stated we were having problems last month with knowing what slings to use with which full body lift. RA-A and RA-B had marked all the slings that go to each lift. During an interview on 8/17/22, at 2:40 p.m. the ADON stated she was not aware therapy was only using the EZ-Way brand lifts for residents that require the use of mechanical lifts and each lift a resident used would require an assessment. ADON indicated therapy did not recommend size of sling/harness and nursing was not completing assessments to determine appropriate size. She was not aware how or who was determining appropriate sizes of slings/harnesses. ADON verified they did not have any formal process to complete mechanical lift transfer assessments. ADON stated none of the care plans for those residents identified sling/harness size and which brand of lift staff should use. During an interview on 8/19/22, at 2:19 p.m. DON and ADON verified they were aware of the confusion the staff were having with what slings to use with what specific type of mechanical lifts. Restorative nursing staff informed us sometime in July, 2022. DON stated we communicated and educated staff on what specific slings to use for the full body lifts to the staff on July 18, 2022. They had each sling embroidered. The harnesses for the standing lifts were not done because they were made out of a different material and could not be embroidered. Facility nursing communication Reminder, dated 7/18/22, identified. they currently have a few different kind of Hoyer (full body) Lifts. Each lift requires different types of slings for resident safety. Most of the slings have embroidered letter that indicates what machine it is to be used with. Please bear with us as we are still in the process of getting them all embroidered. It goes on to describe each type of full body lift and the proper sling that belongs to it. The brands listed included, Tolos, Pal, EZ-Way, Volaro, and the purple Hoyer lift. This memo did not address assessments, sizing for each sling brand, nor sit to stand lifts and harnesses. During a phone interview on 8/19/22, at 11:18 a.m. Invacare customer service representative (CSR) stated for the Invacare bariatric sit to stand lift, we do not recommend using other slings from other manufacturers as we have not tested them with our lifts. We would not know what would happen. We have two types of slings. One sling wraps around the patient's waist for patients that can bear full weight. The second type of sling we have crosses around the waist and the legs, this sling is for patients who cannot bear full weight or have weak legs. Sizing has to be assessed by a trained clinician, this would entail measurements of the waiste and legs etc; our clinicians are specially trained for this. There should be maintenance done yearly that would be indicated in the owner's manual. The facility did not have a policy/procedure for mechanical lift transfers. The EZ Way stand manufacturer's operating manual included, Safety Notes: EZ Way harnesses are made specifically for EZ Way stands. For the safety of the patient and caregiver, only EZ Way harnesses should be used with EZ Way stands. The manual also directed the following: -For safe operation of the EZ Way Smart Stand(R), operators should watch the training video, read through this manual, complete the competency checklist, and practice on fell ow staff members before use with patients - Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. If a patient does not meet each of these criteria, and EZ Way total body lift must be used. -Harness selection: EZ Way harnesses are designed to be applied or removed with minimum amount of handling of patient. As patients vary in size, shape, and weight these conditions must be taken into consideration when deciding which EZ Way harness and accessories are suitable for each patient's needs. - As patients do vary in size, shape, weight, and temperament, these conditions must be taken into consideration when deciding if the EZ Way Stand in suitable for their needs. -Based on the patient's condition two caregivers may be necessary to use the lift safely. -The manual also included directions on how to position the shin pad and directed to position the patients shins into the shin pad below the knees. The manual directed, Use of Shin Pad Strap: if a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patient's legs. Invacare Lift mannual included: ACCESSORIES WARNING Invacare products are specifically designed and manufactured for use in conjunction with Invacare accessories. Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products. -Invacare slings are made specifically for use with Invacare lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. -Thoroughly read the instructions in this owner ' s manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. Bestcare Sit to Stand manufacturer's manual included: WARNING! Using accessories, detachable parts, or materials not described in the instruction manual MAY RESULT IN SERIOUS INJURIES. Manual also included: -Select a sling that is both practical and comfortable. The sling selected should be one that serves the needs of the patient, while providing the patient with optimal safety. Try the sling straps in various color positions to establish best fit. Always insure the same color straps on each side are attached to lift. Should patients have a larger girth in mid section or back side area try the optional buttock strap to help with initial lift leverage. Facility document, Person Centered Care Plan, undated, identified the policy is to develop a plan of care for every resident at Prairie Manor Care Center to ensure care is given according to resident needs and preference. The immediate jeopardy that began on 8/12/22, was removed on 8/19/22, when it was verified the facility completed the following: -Policy and procedures were reviewed; a new policy for transfers was developed and implemented. -Transfer assessment tool was developed and implemented. -All residents who utilized mechanical lifts were comprehensively assessed for appropriate lift type/brand and the care plans were revised. -All nurses were provided with education on completing transfer assessments. All facility nursing staff were provided education on all the lifts and sling/harness and completed return demonstrations.

Based on observation, interview and document review, the facility failed to follow the Center for Disease Control (CDC) guidance during a COVID-19 outbreak in the facility for 3 of 4 residents (R4, R9, And R23) who were positive for COVID-19 and doors to their rooms were left open, for 2 of 10 staff (NA-A and LA-A)observed to not wear an N95 respirator when entering COVID-19 positive resident rooms and 1 staff (LA)-A who did not remove gloves and wash hands while collecting dirty laundry between resident rooms. Findings include: CDC guidance titled Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection included: -Healthcare personnel (HCP) caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). -Ideally, a resident with suspected [CONDITION(S)]-CoV-2 infection should be moved to a single-person room with a private bathroom while test results are pending. -In general, it is recommended that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. This is especially important for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection being cared for outside of the COVID-19 care unit. However, in some circumstances (e.g., memory care units), keeping the door closed may pose resident safety risks and the door might need to remain open. If doors must remain open, work with facility engineers to implement strategies to minimize airflow into the hallway. COVID-19 is a respiratory disease caused by [CONDITION(S)]-CoV-2, a coronavirus discovered in 2019. The virus spreads mainly from person to person through respiratory droplets produced when an infected person coughs, sneezes, or talks. Some people who are infected may not have symptoms. During the entrance conference on 2/28/22, at 12:51 p.m. the director of nursing (DON) stated there were three residents in isolation in the building for COVID-19 positive status, R4, R9, and R23. These individuals tested positive for COVID-19 on 2/21/22. R28 tested positive for COVID-19 on 3/1/22. A facility document titled Positive Residents - COVID19-Line List was initiated on October 2020 and indicated R4, R9, and R23 had tested positive for COVID-19 on 2/21/22. A facility document titled Positive Workers-COVID19-Line List beginning October 2020, indicated there were two positive staff in December 2021, 23 positive staff in January 2022, and 24 positive staff in February 2022. A facility document titled Data from December 2021 for January QAPI Meeting indicated facility had one positive COVID-19 residents and two positive staff. A facility document titled Data from January 2022 for February QAPI Meeting indicated facility had 20 COVID-19 positive staff. A facility document titled Data from February 2022 for March QA Reporting indicated facility had 14 COVID-19 positive residents and 24 positive staff. During observation on 2/28/22, at 3:09 p.m. R4, R9, and R23's rooms were located on center hall which was not an isolation unit. COVID-19 positive resident rooms were located next to and across from COVID-19 negative resident rooms. During observation on 2/28/22, at 3:09 p.m. R4's room was wide open despite an isolation cart, and a posted sign indicating respiratory precautions and the door was to be closed. At 3:09 p.m. nursing assistant (NA)-A stated R4 had COVID-19 symptoms and was in isolation with results pending, but he was unsure when R4 had been tested . NA-A stated the door was open because the nurse forgot to shut it. NA-A was observed to enter R4's room wearing black surgical mask but did not gown or glove. NA-A informed R4 he was going to shut door due to COVID-19 positive status. NA-A exited room without performing hand hygiene or changing black surgical mask. At 3:15 p.m. the door to R4's room was observed open again and R4 was observed coughing next to open doorway. During observation on 2/28/22, at 3:13 p.m. R23's room had an isolation cart, with a sign indicating respiratory precautions and the door should be shut. Another sign on the door included, leave door open and the door was several inches ajar. During observation on 2/28/22, at 3:15 p.m. R9's room had an isolation cart outside the door with the door fully open. The sign on the door indicated enhanced respiratory precautions and door should be closed. NA-A stated they kept R9's door open at times, stated it was up to her as long as she stays in her room. NA-A stated R9 was not able to get up by herself and was a two person assist. When interviewed on 2/28/22, at 3:23 p.m. DON stated her expectations for a resident in COVID-19 isolation was for staff to wear a gown, gloves and mask, we strongly recommend a N95 and goggles or face shield. DON stated expectation for the resident's door to remain closed at all times, unless it was, stuffy. DON stated they made recommendations based on Minnesota Department of Health and CDC guidelines. When interviewed on 2/28/22, at 3:46 p.m. the administrator stated all staff should be wearing N-95 masks and isolation gowns in COVID-19 positive rooms. During observation on 2/28/22, at 4:12 p.m. doors to the following residents in respiratory isolation were left open: R4, R9, R23. During observation on 2/28/22, at 4:22 p.m. R4 was heard to be audibly coughing while seated in open doorway. When interviewed on 2/28/22, at 4:47 p.m. LPN-A stated full PPE should be worn in COVID-19 positive rooms which included gown, gloves, N95 mask, eyewear, and bins located inside resident rooms to doff PPE. When interviewed on 2/28/22, at 4:54 p.m. LPN-B stated gown, gloves, eyewear, and N95 mask were to be worn for any COVID-19 positive rooms. Facility uses N95 mask up to 5 uses and that PPE is not interchangeable from one resident to the next. When interviewed on 2/28/22, at 5:45 p.m. DON stated facility had not had an adequate supply of N95 masks, the facility just received another 500 N95 masks a week or two ago. The DON stated, prior to this my best guesstimate was we had 50 N95 masks left. The DON stated, we are considering contingency use as it took us a long while to get those 500 masks and maintenance is working on ordering more as they are able, but DON stated they had not reached out to the state for an emergency supply. The DON stated, staff right now should be using an N95 for any COVID-19 positive resident or residents on precautions. The DON stated, it was recommended, and we have given them the option to wear an N95 even if they have not been fit tested . When interviewed on 3/2/22, at 2:21 p.m. Environmental Service Director (EVSD) stated he checked the PPE supplies daily, and had been comfortable with their level of supplies, including N95 masks in the first part of January. EVSD stated he was not aware of any shortage. EVSD had last ordered on 2/22/22 and did not anticipate any problems in keeping an adequate supply of PPE or N95 masks. When interviewed on 3/3/22, at 8:50 a.m. the medical director stated expectation for transmission- based precautions for COVID-19 positive resident care included isolation to a specific hall within the facility. Medical director indicated PPE use to include gloves, gowns, eyewear, and N95 masks. Medical director expressed concern there would be an increase in transmission due to COVID-19 positive residents not isolated from COVID-19 negative residents with doors remaining open to the hallway. When interviewed on 3/3/22, at 10:31 a.m. DON stated expectation is to change surgical mask upon leaving COVID-19 positive room as facility has a surplus of surgical masks at the time. During observation on 3/1/22, at 9:01 a.m. a laundry aide (LA)-A left R9's room wearing a surgical mask and gloves, carrying a bag of soiled laundry. LA-A placed the laundry in the laundry cart. LA-A stated staff needed to wear gowns if a resident was in isolation, but they did not need to use a special mask (N95) or change the surgical mask they had worn into the room. LA-A was not observed to remove her gloves or perform hand hygiene at that time. LA-A pushed the laundry cart from the hall. LA-A touched the door code lock pad with her soiled gloves and exited to the laundry area without sanitizing the code pad. During observation on 3/1/22, at 9:58 a.m. LA-A was observed to go from room to room on the left hallway of the facility gathering bags of soiled personal laundry and placing them in a laundry cart. LA-A did not remove her gloves and perform hand hygiene after leaving one room and entering another, or after finished picking up all the soiled laundry on the unit. LA-A proceeded to the door code lock, typed in the code, used the same soiled gloves, and then proceeded to the soiled laundry room without sanitizing contaminated touch pad. During an observation of the soiled laundry area of the facility on 3/2/22, at 11:01 a.m. two large bins were observed with soiled personal laundry. LA-A stated she sorts the dirty laundry by color after she brings it to the soiled laundry area. LA-A stated, I know you are going to say I should be wearing a gown. The facility has not instructed me to wear a gown when separating dirty laundry unless it was for a resident on isolation. LA-A stated she was the one who did the facility laundry and confirmed she wore her standard uniform while sorting soiled laundry. LA-A stated she was the person responsible for washing the soiled clothing and then folding the clean clothing after it was done. When interviewed on 3/3/22, at 11:37 a.m. the environmental service director (EVSD) stated expectation would be to wear all PPE which includes a gown when sorting dirty laundry as all laundry is considered infectious. EVSD completed training for infection control for housekeeping and laundry staff annually. Annual education and training were completed January 2022 which included wearing gowns when touching dirty laundry. When interviewed on 3/3/22, at 12:23 p.m. DON stated expectation was for all staff to perform hand hygiene upon entering and leaving all resident rooms. The facility policy titled Standard Transmission Based Precautions reviewed December 2019 indicated it is best practice to assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care. -Hand hygiene continues to be the primary means of preventing the transmission of infection. The policy also included: -Wear PPE (gloves, gown, mask) when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur. -A gown may need to be worn if patient is on precautions for droplet or contact precautions. -A mask may need to be worn if patient is on precautions for droplet or airborne measures. This will be implemented by the nurse initiating precaution techniques. The facility policy titled Gloving Policy and Procedure reviewed on 2/5/21 specified disposable gloves are used to protect against the spreading of germs and bacteria from one person to another. The facility policy titled Washing Procedure for Total Isolation Linens and Red Bag Linens revised on 4/18/21, indicated that gown and gloves should be worn when handling dirty linen and that all soiled linen is treated as infectious.

Based on observations, interviews and document review, facility failed to follow their policy to maintain clean and sanitary oxygen tubing for 1 of 1 resident (R28) reviewed for respiratory care. Findings include: R28's admission Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's medication and treatment administration record (MAR/TAR) indicated nurses had signed R28's oxygen tubing had been changed by them on 2/11/22, 2/18/22 and 2/25/22. During observation on 2/28/22, at 1:54 p.m. R28's oxygen tubing had a label on it dated, 2/11. When interviewed on 3/1/22, at 2:09 p.m. nursing assistant (NA)-F looked at R28's oxygen tubing and stated the tubing had last been changed on 2/11/22. NA-F stated the nurses were responsible for changing the oxygen tubing, but she was aware it should be changed every week. When interviewed on 3/1/22, at 2:13 p.m. a licensed practical nurse (LPN)-D stated the oxygen tubing was changed by the night shift nurses, and LPN-D was unsure of when it should be changed; however, LPN-D said the tubing had not been changed as indicated in the MAR/TAR. When interviewed on 3/1/22, at 2:19 p.m. LPN-A stated oxygen tubing should be changed weekly by the night shift and should have a date applied to the tubing indicating when it was last changed. When interviewed on 3/1/22, at 2:23 p.m. LPN-E stated oxygen tubing was changed every Friday and directions for this would be found on the MAR. LPN-E stated any nurse working on the day shift noting tubing had not been changed should change it. When interviewed on 3/1/22, at 2:50 p.m. the director of nursing (DON) stated the facility had an, order set that would flow to the MAR/TAR for oxygen tubing to be changed every Friday on night shift. DON stated an expectation for nurses to place a date on the tubing when it was changed, and to sign the MAR/TAR after this had been completed. DON stated both the extension tubing and the nasal cannula should be changed weekly, and stated a concern for the possibility of bacterial growth in the tubing that might cause resident infection. The facility provided a policy titled Oxygen Therapy dated 3/26/20 indicated, Oxygen Supplies: DME providers recommend changing standard nasal cannula's and masks every week and oxygen tubing every month.

Based on interview and document review, the facility failed to update the staff posting when staffing changed. This had the potential to affect all 30 residents residing at the facility as well as family/visitors. Findings Include: Staff postings and schedules were reviewed from 1/1/22 to 3/3/22; no staff postings were updated when staffing changes occurred on the actual staffing. The Staffing posted 2/22/22, indicated for the night shift for registered nursing assistants (NA) 24 hours. The daily nursing attendance report indicated for the night shift, one NA called in and was not replaced. No changes had been made to reflect the actual hours worked on the Staff posting. The Staffing posted 2/28/22, indicated for the day shift nurse manger 8 hours and for registered nursing assistants (RNA) 32 hours. The daily nursing attendance report indicated for the day shift, one nurse manger called in and was not replaced. For the evening shift a RNA called in and the facility was able to cover all but four hours of the shift. No changes had been made to reflect the actual hours worked on the Staff posting. The Staffing posted 3/2/22, indicated for the evening shift RNA's 30 hours. The daily nursing attendance report indicated for the evening shift, three RNAs called in and the facility was able to replace 14 hours. No changes had been made to reflect the actual hours worked on the Staff posting. During an interview on 3/02/22, at 1:37 p.m. licensed practical nurse (LPN)-C stated she was responsible for updating the staff posting and stated she only updated the census. LPN-C stated she did not update the staff posting when there were changes to the staff schedule. During an interview on 3/02/22, at 1:58 p.m. registered nurse (RN)-A verified the above information and indicated per the facility policy the staff posting should be updated to reflect the changes made to the hours worked with every staffing change. The Daily Census Sheet policy and procedure updated 3/28/2020 indicated, Purpose: To maintain public access to posted information on current resident census and number of staff to providing care on each shift. The hours worked will be updated from the license nurse on duty with every staffing change.

Based on interview and document review, the facility failed to follow the facility policy and/or physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .). R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Do not wrap too tight. On during the day off at night. R1's hospital discharge summary dated 06/28/21 indicated R1 was admitted to the hospital on 6/25/21, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary indicated while R1 was hospitalized R1's diuretic medication was changed; the new order was [MEDICATION(S)] 10 mg (milligrams) once a day for [CONDITION(S)] for 30 days, indicating a stop date of 7/29/21. R1's facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress noted date 7/9/21 indicated R1 was readmitted back to the hospital on 7/9/21 and R1's hospital discharge summary identified R1 returned to the facility on [DATE]. The discharge summary indicated R1 was supposed to continue to take [MEDICATION(S)] 10 mg daily; the order did not identify a stop date. R1's facility physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes on 7/26/21, identified R1 did not have shortness of breath and bilateral lower extremity [CONDITION(S)]. R1's physician visit dated 7/28/21, identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physical exam indicated R1 had 3+ pitting [CONDITION(S)] in right and left lower legs. R1's weight record identified at the time of the visit R1 weighed 197.0 lbs. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's weight record in conjunction with progress notes from 7/28/21 to 8/9/21. The record identified R1's had an increase in weight and lacked evidence of physician notification and did not include ongoing monitoring and assessment/evaluation of [CONDITION(S)] or fluid volume status. -On 7/29/21, wt. was 197.4 lbs. -On 7/30/21, wt. was 199.6 lbs. -On 7/31/21, wt. was 199.6 lbs. -On 8/1/21, wt. was 199.8 lbs. -On 8/2/21, wt. was 200.2 lbs. -On 8/3/21, wt. was 201.6 lbs. -On 8/7/21, wt. was 201.6 lbs. -On 8/9/21, wt. was 202.8 lbs. R1's record from 7/28/21 to 8/7/21, did not include [CONDITION(S)] monitoring, lacked evaluations of fluid volume status despite documentation of 2 lb. weight gains in 24 hours, and lacked evidence of physician notification in accordance with the facility's Fluid Overload policy dated 2/2021. R1's fluid monitoring note dated 8/7/21, at 2:54 a.m. included She was noted to be having BLE [bilateral lower extremity] [CONDITION(S)]. She also has SOB [shortness of breath] after using toilet. Resident has been steadily gaining wt. for the last few months. Feet elevated in bed and the RLE [right lower extremity] will be wrapped in the morning. R1's progress note dated 8/7/21, at 1:36 p.m. identified R1 did not have shortness of breath or [CONDITION(S)]. R1's care plan dated 8/9/21, did not identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's progress notes dated 8/10/21, indicated R1 was short of breath, had [CONDITION(S)], physician was notified, and R1 was sent to the emergency room for further evaluation. During an interview on 8/26/21, at 8:15 a.m. assistant director of nursing (ADON) stated R1 had history of [CONDITION(S)] and her renal function had been steadily declining; hospice had been recommended on 8/4/21. ADON stated there was a medication error with the [MEDICATION(S)]; it was supposed to be continued after 7/29/21, however, had the [MEDICATION(S)] been administered it likely would have hurt the kidneys more. During an interview on 8/26/21, at 2:13 p.m. director of nursing (DON) indicated it was the facility policy to notify the physician of a 2 lb. weight gain in one day or five pounds in a week. DON indicated residents with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated expectation physicians are notified according to the facility policy and procedures. DON reviewed R1's record and confirmed R1 had a weight gain and indicated the physician should have been notified according to the policy. DON verified the lack of [CONDITION(S)] monitoring and evaluations and indicated the documentation should have been more descriptive. During an interview on 8/26/21, at 3:05 p.m. nurse practitioner (NP) indicated a familiarity of R1's medical history. NP stated she would expect nursing to report the increase in weight and evaluate the swelling in addition to evaluating for other symptoms of fluid overload. R2 During an observation and interview on 8/26/21, at 1:14 p.m. R2 sat in her wheelchair in her room, R2 had on compression stockings and her legs were in the dependent (down) position. R2 stated an awareness of her recent weight gain and stated, I think it's a lot of fluid, I think the fluid is going into my left breast, it feels heavy and sometimes it hurts. R2 indicated she wore compressions socks to improve circulation, stated they seemed harder to get on, and my left leg feels heavy. When asked if nursing measured the amount of swelling by measuring or pushing on her legs with their finger, R2 responded no they don't do that. During an observation and interview on 8/26/21, at 1:20 p.m. licensed practical nurse (LPN)-A stated she was R2's nurse. LPN-A stated she had never used a tape measure to evaluate [CONDITION(S)]. LPN-A requested R2 allow her to check her legs for [CONDITION(S)], R2 consented. LPN-A removed R2 stockings that came up to just below the knee; the skin as indented and red from where the stockings were. R2's left knee and thigh were larger compared to the right. LPN-A stated R2 had trace to 1+ [CONDITION(S)] around the ankle aspects with no pitting [CONDITION(S)] above in the left knee or thigh. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .) Notify provider if weight is greater than 216 lbs. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ½ hour prior to [MEDICATION(S)] on Mondays and Fridays for [CONDITION(S)]. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 did not have cognitive impairment and administered diuretic medication. R2's physician visit dated 7/28/2021, indicated R2's last hospitalization was 11/2019 for heart failure exacerbation. The identified a cardiovascular diet and 2-liter fluid restriction were recommended. R2 had signed a waiver to remove the restriction. Note identified the target weight of 210 lbs. and on physical exam R2 had +2 pitting [CONDITION(S)] in both legs. The note indicated compression and elevation were helping the leg pain, however R2 requested a Biofreeze (analgesic cream) scheduled for leg pain. R2's care plan dated 8/4/21, indicated R2 had CHF. Associated interventions included: Administer medications, oxygen and obtain lab work as ordered, Complete respiratory assessments weekly: include weight, [CONDITION(S)], lung sounds, oxygen saturations, respirations, and any shortness of breath. R2's pacemaker care plan included the intervention to monitor/document/report to MD as needed any signs or symptoms of altered cardiac output or pacemaker malfunction. R2's weight record in conjunction with progress notes from 8/10/21 to 8/26/21. The record identified R2's weight was above 216 lbs. since 8/10/21; record lacked physician notification per physician orders. The record also did not include consistent monitoring or evaluation of [CONDITION(S)] and/or weight gain. -On 8/10/21, wt. was 214.4 lbs. -On 8/11/21, wt. was 216.2 lbs. -On 8/14/21, wt. was 216.6 lbs. -On 8/15/21, wt. was 217.2 lbs. -On 8/17/21, wt. was 218.4 lbs. -On 8/18/21, wt. was 219.4 lbs. -On 8/19/21, wt. was 220.8 lbs. -On 8/21/21, wt. was 218.2 lbs. -On 8/23/21, wt. was 218.8 lbs. -On 8/25/21, wt. was 219.0 lbs. -On 8/26/21, wt. was 221.0 lbs. R2's fluid monitoring note dated 8/7/21, indicated R2's weight was stable and no new [CONDITION(S)] observed. The note had no other information pertaining to the presence of [CONDITION(S)] if any. R2's fluid monitoring note dated 8/14/21, indicated R2's weight was stable at 216.6 [lbs.] and had trace [CONDITION(S)] to BLE [bilateral lower extremities]. The note did not identify location and extent of the [CONDITION(S)] on R2's legs. R2's fluid monitoring note dated 8/21/21, identified R2's weight was stable and R2 had trace [CONDITION(S)] to BLE R2's record between 8/22/21 and 8/26/21, did not include [CONDITION(S)] monitoring and fluid volume status assessment. During an interview on 8/26/21, at 1:23 p.m. LPN-A reviewed R2's progress notes and weights, indicated the last documentation of [CONDITION(S)] monitoring/evaluation was on 8/21/21. LPN-A indicated the note did not identify the location(s) of the [CONDITION(S)] and it could not conclusively be determined if R2's [CONDITION(S)] had worsened. LPN-A indicated an unawareness if the physician was notified pertaining to the weights above 216 lbs. LPN-A indicated that the floor nurses were supposed to notify the charge nurses, then the charge nurses would follow-up. During an interview on 8/26/21, at 1:27 p.m. LPN-B reviewed R2's record and confirmed R2's weight had consistently stayed above 216 lbs. since 8/10/21. LPN-B stated an unawareness if the physician had been notified and confirmed the progress notes did not identify if the physician had been notified. Surveyor informed LPN-B of R2's statements during the interview pertaining to the location of where she felt the fluid build-up. LPN-B indicated an unawareness and stated when she had asked R2 about pain, R2 had denied pain anywhere but LPN-B had not thought to directly ask R2 about fluid gain locations as part of [CONDITION(S)] monitoring or evaluation. During an interview on 8/26/21, at 2:13 p.m. director of nursing (DON) stated education had been provided on [CONDITION(S)] monitoring. DON reviewed R2's record and confirmed the weight gain, stated the physician should have been notified per orders. DON stated the nurse(s) should have identified the increase in weight as they are documenting, would expect increased monitoring and evaluations when there was a weight gain. On 8/26/21, at 3:05 p.m. nurse practitioner (NP) stated she was not aware of R2's weight gain and stated an expectation the facility follows physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . NP indicated she would call and follow-up with the facility with new orders. R3 During an observation and interview on 8/26/21, at 1:48 p.m. R3 sat in his wheelchair in his room; R3 had black compression socks on both legs and his legs were in the dependent (down) position. Both of R3's legs were observed to be edematous from foot to mid-shin area. R3 stated an awareness of a weight gain, and stated he has an increase swelling in his legs. R3 stated he typically only had more swelling in his left leg and small amount in his right, however, his left leg was more swollen than usual. R3 stated he could feel that his legs had more fluid in them. R3 stated that when he got up in the morning his right leg didn't have swelling but would by the end of the day. R3 stated since he was admitted to the facility, he has been sitting up in his chair more and was not elevating his legs during the day. R3 was asked if staff were measuring, his [CONDITION(S)] by using their fingers to press his legs to see if the skin would stay indented, R3 stated no they were not doing that. During an observation and interview on 8/26/21, at 2:05 p.m. assistant director of nursing (ADON) entered R3's room, obtained consent to evaluate R3's [CONDITION(S)]. ADON pulled down R3's socks and took off his shoes. ADON used her fingers to press down in different locations on both of R3's legs; ADON stated R3 had +2 pitting [CONDITION(S)] from foot to knee on the right leg and +3 pitting [CONDITION(S)] from foot to knee on the left leg. R3's admission assessment dated [DATE], identified R3 had +1 pitting [CONDITION(S)] in his upper and lower extremities. The assessment did not identify the exact location and/or extent of the [CONDITION(S)]. R3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .). R3's physician visit dated 7/13/21, identified diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment and Plan for the [CONDITION(S)] included, Will have facility apply bilateral lower extremity compression stockings and encourage patient to elevate lower extremities throughout the day as he is able. R3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan dated 8/4/21, did not identify diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's weight record in conjunction with progress notes were reviewed from 8/5/21 to 8/26/21. The record identified a wt. gain above R3's physician prescribed goal wt. of 285 lbs.; The record did not include ongoing consistent monitoring and comprehensive evaluations/assessment of R3's [CONDITION(S)] and/or weight gains to ascertain fluid volume status. -On 8/7/21, wt. was 285.7 lbs. -On 8/8/21 wt. was 290.0 lbs. -On 8/15/21 wt. was 292.0 lbs. -On 8/19/21 wt. was 292.7 lbs. -On 8/23/21 wt. was 293.4 lbs. -On 8/25/21 wt. was 292.2 lbs. The record lacked physician notification of the weight gain above R1's goal weight and in accordance with the facility's standing orders. R3's progress note dated 8/5/21, indicated R3's weights were stable and continues to have bilateral lower extremity [CONDITION(S)]. The note did not provide any further description of the [CONDITION(S)]. R3's progress notes dated 8/8/21 through 8/10/21, did not identify the weight gain and indicated R3 did not have [CONDITION(S)]. Progress note on 8/11/21, included no new [CONDITION(S)]. Progress notes dated 8/12/21 through 8/26/21, did not identify a weight gain evaluation and indicated R3 did not have [CONDITION(S)]. During an interview on 8/26/21, at 2:13 p.m. director of nursing (DON) stated education had been provided on [CONDITION(S)] monitoring. DON reviewed R3's record and confirmed the weight gain and the lack of [CONDITION(S)] monitoring and evaluation in conjunction with the weight gains. DON stated the nurse should identify the increase in weight as they are documenting, would expect increased monitoring and evaluations when there was a weight gain, and any complete required notification. DON stated an expectation of physician notification when weights were above goal range and/or notify the physician for 2 lb. weight gain in one day or 5 lbs. in a week per facility policy. During an interview on 8/26/21, at 3:05 p.m. nurse practitioner (NP) indicated an unawareness R3 had a weight increase and was not at his goal weight. NP stated she would expect nursing to report the increase in weight and evaluate the swelling in addition to evaluating for other symptoms of fluid overload. NP indicated she would call and follow-up with the facility with new orders. Facility Fluid Overload Monitoring policy dated 2/2021, included the following: Each resident with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician or NP will be notified of any changes or signs and symptoms of fluid overload. Residents that have heart failure/[CONDITION(S)] or other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Weight will be monitored per facility policy-see height and weight policy. If there is a noted weight increase of 2 lbs. or more in a day or 5 lbs. in a week, the nurse assigned to resident will complete a respiratory assessment. If there is an increase in [CONDITION(S)] noted when applying and/or removing ace wraps/compression socks, the nurse assigned to resident will complete a respiratory assessment. Assessment findings will be documented on. MD and/or hospice will be notified immediately of any signs or symptoms of fluid overload such as weight increase of 2 lbs. or more in a day or 5 lbs. in a week, feelings of shortness of breath, low oxygen saturations, increased [CONDITION(S)], increased respirations, or abnormal lung sounds. All residents that are at risk for fluid overload on admission will have a respiratory assessment completed daily for 4 weeks and then will be assessed routinely at a minimum of once a week. If a resident has an increase in weight, the physician will be notified, and monitoring will be initiated immediately and to be completed daily for 1 week. Then will resume weekly assessments once stable.

Based on interview and document review, the facility failed to develop and implement a system to avoid significant medication errors of omission. The facility failed to ensure an adequate system for was in place to assure medications were reordered in a timely manner to be available for administration in accordance with physician orders [REDACTED]. The facility's omission of [MEDICATION NAME] injections (an anticoagulation medication, which helps prevent blood clots from forming) resulted in an immediate jeopardy (IJ) level significant medication error when R1 sustained a stoke and [MEDICAL CONDITION] embolism (PE). The IJ began on 8/2/20, when a physician prescribed order for daily injection of [MEDICATION NAME] was not available in the facility to be administered. R1 did not receive the prescribed [MEDICATION NAME] injection on either 8/2 or 8/3/20. After missing these 2 doses, on 8/4/20, R1 started feeling sick with nausea and vomiting. On 8/5/20, R1 self-reported she was having symptoms of feeling dizzy, headache, and had a small emesis/phlegm which R1 described as symptoms she'd experienced during a previous stroke. R1 was transferred to the emergency room (ER) and was subsequently hospitalized for [REDACTED]. The facility administrator and director of nursing (DON) were notified of the IJ on 8/10/20, at 4:45 p.m. The IJ was removed on 8/11/20, when the facility had implemented an appropriate removal plan. However, non-compliance remained at an isolated scope of actual harm that is not immediate jeopardy (Level G). Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], identified R1 as having intact cognition and requiring extensive assistance with activities of daily living (ADLs). The MDS also indicated R1 received anticoagulation medication during the 7 day assessment review period. R1's admission record indicated R1 had a history of [REDACTED]. R1's care plan included, Resident is currently on anticoagulation therapy related to: history of [MEDICAL CONDITION] embolism. Interventions: Administered anticoagulation medications per MD (medical doctor) orders. R1's physician orders [REDACTED]. R1's medication treatment record indicated R1 did not receive the [MEDICATION NAME] ([MEDICATION NAME])Sodium injections per the physician order [REDACTED]. R1's medication error report (MER) dated 8/5/20 indicated errors were made on 8/2 and 8/3/20. The MER indicated the nurse practitioner was made aware of the errors on 8/5/20, at 4:45 p.m. Medication as ordered [MEDICATION NAME] ([MEDICATION NAME])40 mg/0.4 ml- inject 0.4 ml SQ daily r/t (related to) hx (history) of [MEDICAL CONDITION] embolism. Description of the error: Two doses not given on 8/2 and 8/3/20. Outcome to the resident: Stroke and PE (pulmonary embolism). Resident sent to ER. Corrective action taken: Re-education of all nurses on reordering supply, what to do if no supply, notification to pharmacy for STAT delivery. Measures taken to prevent reoccurrence of similar error(s): Discussed with pharmacy, process for sending partial supply of orders. R1's record revealed there was no notification to the physician or medication error reports completed on 8/2 or 8/3/20 when the facility initially had not administered the [MEDICATION NAME]. R1's nursing progress notes were reviewed and included: -8/3/20 at 8:24 a.m., [MEDICATION NAME] ([MEDICATION NAME]) Sodium Solution 40 MG/0.4ML Inject 0.4 ml subcutaneously one time a day related to PERSONAL HISTORY OF [MEDICAL CONDITION] EMBOLISM (Z86.711) for 28 Days No supply -8/5/20 at 6:17 a.m., Resident experienced nausea this morning. No emesis. She also stated that she wants to see the nurse manager this morning. She wants to know if she is going to have a stroke because she has hard {sik} it before 2010. VS (vital signs) were taken. At this time, no s/s (signs or symptoms) of stroke. Incoming shift and wing nurse notified to monitor resident. Charge nurse will be informed as soon as she comes in to go and check/reassess resident. -8/5/20 at 7:17 a.m., Ambulance was called at 6:54 a.m. and they left with her at 7:17 a.m In route to (emergency department), husband will meet her there. Review of R1's neuro ICU (intensive care unit) admission note dated 8/5/20 included, Chief Complaint: Stroke History of Present Illness: (R1) is a 70 y.o. (year old) right-handed female with a history significant for prior [MEDICAL CONDITION], type 2 diabetes mellitus, [MEDICAL CONDITION], past history of PE (pulmonary embolis 2018, provoked), obesity, recent humorous fracture repair s/p (status [REDACTED].Although she had no focal neurological deficits in the ED (emergency department) given concern for headache reported by patient, she underwent a CT (cat scan) of the head/neck (per outside documentation). This imaging showed likely subacute appearing infarcts in the L>R cerebellum, bilateral parietal lobes. CT abdominal pelvis was obtained given concerns for emesis and possible infection, which identified right lower lobe sub segmental PE which was further confirmed on dedicated CT PE study. Given concerns for subacute cerebrallar infarct, PE and elevated baseline troponin .patient was transferred (to this hospital) for further management . Patient reports that she was instructed to continue [MEDICATION NAME] injections after discharge from Orthopedics in late July for at least 30 days. Which she was initially getting however, for the last 3 or 4 days the facility told her they had run out and she has not been receiving them . The facility's investigative report sent to the State Agency (SA) 8/7/20, included, In investigation of the medication error there was found to be two issues. One issue was with nursing not following the process for when a medication supply is low and how the med error occurred, and one issue with the pharmacy not delivering medications in a timely manner when ordered. Both of the nurses involved with the medication error have received a corrective action. All the nurses have been re-educated that when supply of any medication is starting to get low, it is to be re-ordered right away and a call is to be placed to the pharmacy if we don't have the ordered medication at the time it is scheduled to be given. If the medication is not available in our E-Kit (emergency kit), the pharmacy will need to be called and complete a STAT (immediate) delivery. In addition, if a medication is not given during the shift that it is scheduled to be given, the nurse must then pass this on to the next shift so it can be given when it arrives on the delivery .(R1)did miss two dosages of [MEDICATION NAME] ([MEDICATION NAME]) Sodium Solution 40 MG/0.4 ml subcutaneously one time a day. (R1) missed a dose on August 2nd and on August 3rd. August 5th she was transferred to a (ED at a hospital) and was then transferred to (another hospital from the ED). Her admitting [DIAGNOSES REDACTED]. During an interview on 8/10/20, at 10:41 a.m. licensed practical nurse (LPN)-A stated when she went to give the [MEDICATION NAME] injection the morning of 8/2/20, there was no supply. LPN-A stated she ordered the [MEDICATION NAME] injections through the computer to the pharmacy and let registered nurse (RN)-A know it was unavailable. LPN-A stated there was a little tab to type in messages in Point Click Care that goes to the pharmacy, and said she'd sent a message to the pharmacy to send the [MEDICATION NAME] ASAP (as soon as possible), although no supply was available. LPN-A stated she did not check the e-kit and stated she did not call the pharmacy for a STAT order. LPN-A stated she had never called the emergency pharmacy to obtain a medication and stated she just let the nurse manager know and the nurse manger had told her the pharmacy was open on Sundays and had gone into her office. LPN-A stated she reported to evening shift that R1 did not receive the [MEDICATION NAME] injection because it was not available at the facility. LPN-A stated when a medication dose is ordered during the day shift ,the evening shift nurse was to try to obtain the medication. LPN-A stated R1 was on the [MEDICATION NAME] injections after surgery to help thin her blood. LPN-A acknowledged the concern R1 could develop blood clots if the [MEDICATION NAME] was not administered. During an interview on 8/10/20 at 11:08 a.m., registered nurse (RN)-A stated she worked in the facility on 8/2/20 providing the RN 8 hour coverage. RN-A confirmed LPN-A had reported the [MEDICATION NAME] medication was not available at the facility, and was going to reorder it. RN-A stated she saw LPN-A reorder the medication online through point click care. RN-A stated she knew you can order it (medications) online and stated the pharmacy sends it automatically. RN-A stated LPN-A should have called the pharmacy to get the medication ordered STAT. RN-A stated LPN-A or other med cart nurses should have ordered the [MEDICATION NAME] medication when they noticed the medication was running low. RN-A stated LPN-A had ordered the medication around 2:00 p.m., and stated she thought it was an evening medication administration so thought the medication would be available to give that evening. RN-A stated she was unaware the [MEDICATION NAME] was to be administered at 8:00 a.m. RN-A further stated R1 had a history of [REDACTED]. RN-A stated R1 was to get the [MEDICATION NAME] injections daily for several weeks. RN-A stated R1 ended up in the ER after she started to have stroke symptoms. RN-A stated on 8/5/20 in the morning, they sent R1 in because the patient herself stated she was experiencing symptoms she'd had in the past when she had a stroke. RN-A said they were notified R1 had experienced a second [MEDICAL CONDITION] embolism when they called from the hospital to give report. RN-A stated, I am just sick about this and stated she would have reordered the medication when the supply was down to 3 or 4 doses left. RN-A stated there seemed to be a problem with staff waiting to order a medication, waiting until a resident was out of the medication, or on the weekend, and would then them come to the RN charge to let them know the medication supply was gone. RN-A stated this was not fair to the physician or the resident adding, we need to have communication or a system needs to be implemented so medications are not missed. During an interview on 8/10/20, at 1:43 p.m. LPN-A confirmed having worked on the Friday and Saturday prior to the first missed dose and had administered the [MEDICATION NAME] injection. LPN-A expressed being unable to recall checking to see if the [MEDICATION NAME] refill had been ordered on that Friday or Saturday, and stated she did not order the refill until Sunday morning when there was no dose available to be given. LPN-A stated medications needing refills would normally be ordered a couple days in advance but she had not done that. LPN-A stated medication refills are ordered through the facility's computer system or faxed. LPN-A stated they can check the fax binder, or their computer system to see whether a medication had been ordered for refill. LPN-A stated she had not considered the missed [MEDICATION NAME] dose as a medication error, because it was unavailable, had been reordered and anticipated it would be delivered. LPN-A verified a blood thinner is a critical medication and stated she had communicated to the evening shift nurse that the dose was missed that morning, and a refill ordered. LPN-A said she did not call the pharmacy personally, but stated she assumed the nurse manager would have called the pharmacy. In addition, LPN-A stated she did not notify the physician of the missed dose. LPN-A stated a medication error was considered if dose not given, wrong dose given, or if a medication was given to the wrong resident. LPN-A confirmed it was not expected a medication error report would be completed in this case, even though the medication was not given. LPN-A stated the pharmacy could deliver on weekends if needed. LPN-A stated although it was reported on Monday that R1 was nauseous, there had been no complaints over the weekend. During an interview on 8/10/20, at 1:18 p.m. pharmacist (P-A) stated orders for medication refills are received via fax on a refill sheet, requested over phone, or requested through the computer system. P-A stated if received through computer system or fax on a weekend, the pharmacy would not process the order until Monday. However, if the medication order was called in by phone, the pharmacy would process the refill request and send it out right away. P-A stated the pharmacy normally asked for a 3 day notification for refills, to allow time for insurance issues and medication availability. P-A stated the pharmacy would want to know before the weekend if medication was going to run out. P-A stated refill medications could be delivered the same day if there were no issues. P-A stated during weekdays there was a delivery early afternoon, and one in the evening, and on weekends there was one delivery in the evening if medications were needed. P-A stated there was an on call phone number to call after hours on the weekend. P-A stated they viewed the computer request for R1's [MEDICATION NAME] on Monday 8/3/20. P-A stated the request had been sent on Sunday but no one from facility had called to inform the pharmacist the medication was needed that day. P-A stated it would have been delivered Sunday if the pharmacist had known it was needed. P-A stated only a 10 day supply was sent initially due to the type of insurance the resident had. P-A said it was expected the facility would notify them in advance when a refill was needed. P-A stated they would notify the facility via fax or phone if a medication was not available, or if there was an insurance issue. P-A stated they were working with their corporate office to improve the process of computer requests received on weekends as it was previously not an expectation to process computer requests on weekends. P-A acknowledged computer system requests are being used more now versus faxes or phone calls. An interview was conducted on 8/10/20 at 1:58 p.m., with R1's stroke team physician (STP). STP stated, I will tell you we can never say 100% what caused the stroke or [MEDICAL CONDITION] embolism however, missing 1 or 2 doses significantly increased the risk. Timing of the evidence indicated the stroke and [MEDICAL CONDITION] embolism could have been from the missed doses of [MEDICATION NAME] after she had been clot free from sometime. I do really believe this would not likely have happened if she had received her proper [MEDICATION NAME] scheduled medication. Based on the imaging she had a clot in her brain and [MEDICAL CONDITION] embolism in her lungs. Multiple clots in multiple places after missing her doses of [MEDICATION NAME] make it highly suspicious that the missed doses caused the stroke and [MEDICAL CONDITION] embolism. During an interview on 8/10/20 at 2:28 p.m., family member (FM)-A stated R1 had not been on a maintenance blood thinner prior to surgery. FM-A stated R1 had blood clots in the lungs following a previous surgery on same arm. FM-A stated the physicians had wanted to be careful and wanted R1 to be on a blood thinner. FM-A stated, apparently something happened and R1 did not receive the blood thinner for a couple of days. FM-A stated R1 was still in the hospital, and was planning to go to a rehab center within the hospital rather than returning to the facility. During an interview on 8/10/20 at 2:42 p.m., LPN-D stated they are to order refill on medications when there is 4-5 days left. LPN-D stated they order through computer system or fax. LPN-D stated they would order refills prior to the weekend. LPN-D stated they are to check computer system when medication was low to see if medication was ordered and call the pharmacy directly to order if needed. LPN-D stated there was no procedure but it was just a rule to order medications prior to running out. LPN-D stated there had not been any recent education on medication ordering. LPN-D stated a medication error would include if medications were given at wrong time, wrong dose, wrong route, or missed dose. LPN-D stated if a medication could be life threatening such as a blood thinner not being given, it would be considered a medication error. LPN-D stated they are supposed to notify the physician and complete a medication incident report if a medication error occurs. During an interview on 8/10/20, at 2:52 p.m. LPN-C defined a medication error as missed, wrong resident, wrong time, wrong dose, or wrong route. LPN-C stated they are to complete a medication error form, notify physician and were to monitor and assess the resident. LPN-C stated they were to order refills at least 5 days prior to a medication running out. LPN-C stated when she noticed less than 5 days left of a medication, she would check to make sure the medication was ordered and communicate with staff at report to watch for medication. LPN-C said if a medication was needed over the weekend or as soon as possible, they would call the pharmacy directly. LPN-C stated a missed dose of a medication was a medication error. LPN-C stated there was education on medication ordering and medication errors done upon orientation and recently a printout to read in the communication book. LPN-C stated she did not have to sign to acknowledge having read the communication, but that it was an expectation to read the communication book prior to every shift. During an interview on 8/10/20 at 3:01 p.m., the director of nursing (DON) stated R1 was on [MEDICATION NAME] for the prevention of blood clots and stated it was important for her to receive the medication as ordered so she would not get blood clots. The DON stated she would have expected the staff to order the [MEDICATION NAME] for sure at least when it was getting down to 3 days' worth adding, you do not want to order it when there is one left. The DON also stated she would have expected the nurse to call the pharmacy and get a STAT order when they did not have any medication available in the facility on 8/2, when the medication was not available to be given. The DON stated a medication error report should have been completed on 8/2 and 8/3/20, when the resident missed doses of the [MEDICATION NAME]. The DON further verified the physician was not notified of the missing [MEDICATION NAME] until a medication error report was completed on 8/5/20. The DON stated the physician should have been notified right away for that type of medication omission. The DON stated the missed doses of [MEDICATION NAME] were discovered through chart review and when the nurse management was notified of the missing doses. The DON stated there was not a policy and procedure to implement for ordering medications when getting low, but stated staff were checked off on ordering medications upon hire. The DON stated the facility had immediately completed education with staff following the medication errors. The DON stated they talked to the nurses involved in person and the other nurses were educated through the communication book. The DON stated they (staff) read the communication book everyday in report. The DON verified the facility did not have the nurses sign off they had read the education in the communication book, did not have a post-test, and had not completed any competencies on the education. During an interview on 8/11/20, at 9:56 a.m. LPN-B stated that Monday 8/3/20, had been her first day back to R1's hallway. LPN-B said when she noticed the blood thinner was not available to give, she checked the computer system and saw it had been reordered. LPN-B stated she did not file a medication error report, although stated a missed dose would be considered a medication error. LPN-B stated although the medication was not available at the time it was due, it had been reordered and had been expected to arrive to be able to give. LPN-B stated she did not notify the physician, and stated the medication did not arrive during the day shift. LPN-B stated R1 had not changes or complaints that day. LPN-B stated she was off Tuesday and worked again on Wednesday. LPN-B stated on Wednesday 8/5/20, she was asked by an aide to assess R1 who had reported to the aide she was not feeling well. LPN-B stated it had also been reported by the overnight staff that R1 had not been feeling well. LPN-B stated she assessed R1 around 6:50 a.m. LPN-B stated staff are able to check the computer system to see what date medications were ordered and on which date it was received. LPN-B stated nurses were to call the pharmacy directly if there were any concerns. LPN-B stated they should reorder refills when a medication has 4-5 days supply left. LPN-B stated when medication had less than a few days left, they would check the computer system to assure the medication was reordered. LPN-B stated they were expected to order medications prior to a weekend, and to call pharmacy directly if a medication was needed over the weekend. LPN-B stated a medication error was considered when a medication was not given or given the wrong way. LPN-B stated they are to notify the nurse, complete a report, and call the physician if there is a medication error. LPN-B stated she did not notice the blood thinner had not been given the prior day, and should have completed a medication error report also as the blood thinner dose was missed the day she worked. During an interview on 8/11/20 at 10:17 a.m., trained medication aide (TMA)-A stated she was to check if medication was reordered and call the pharmacy if a medication had not been received or was needed. TMA-A stated that there was a blue section on the medication cards that indicated when to reorder. TMA-A stated there was not a process for checking medications that were low in supply. During a follow-up interview on 8/11/20 at 10:55 a.m., the DON stated that there was no specific process for reordering medications, but the nurses were to assess for need to order medications prior to administration. The DON stated staff were to reorder medications via fax, computer system or to call pharmacy directly if medication was needed immediately. The DON stated if a medication was out and was needed immediately the nurse was to call the pharmacy directly to order. The DON acknowledged that if a medication, including an as needed medication, was needed by a resident but not available, the resident would have to wait until it was delivered by pharmacy to receive it, which could be hours or the next day. The facility's Medication Error Reporting policy last updated 1/22/15, indicated following a medication error the resident should be monitored, a medication error report completed, and notification should be made to the resident's family, physician, and the Department of Health. The policy did not include a definition of a medication error. According to record review and interviews, a medication error report was not completed nor was notification given. The Pharmacy Services Agreement dated 6/16/17, indicated in the reorder schedule that Thrifty White would work with the director of nursing to establish a re-order schedule that would allow the pharmacy adequate time to process refill orders. The agreement also indicated refill orders would be delivered Monday through Friday with a two day turnaround time; Refills ordered on weekends would be delivered with the scheduled delivery on Monday; and in order to reduce the chance for errors, all refill orders should be faxed to the pharmacy on the Thrifty White Reorder Form. The Thrifty White Pharmacy contact and hour of operation undated information, provided by the pharmacy and posted in medication room, included: All new orders must have the original order faxed to the pharmacy; Please fax refill orders to the pharmacy using the Pharmacy Refill Form and reorder labels; Please do not put new orders on the reorder form; Please fax refill orders to the pharmacy by Noon Monday through Friday for same day delivery; and Refill orders faxed to the pharmacy after Noon will be delivered the next business day The Prairie Manor Care Center 28 day cycle fill In-Service undated, included the following: -Any medications not included in the cycle fill must be reordered by nursing. These labels will have a reorder tab for this purpose. This will include the following medications: [REDACTED]. -New orders: fax the original order to pharmacy, for a stat order or emergency medication to fax the order to the pharmacy and follow up with a phone call to alert the pharmacy. -Refills: peel off the reorder tab and place on refill order form and fax to pharmacy, recommended that medications are reordered when there is a 3-5 day supply left to allow for any clarifications or needed prescription renewals (5-7 days for narcotics). -Discontinued and changed orders should be pulled from the exchange. The immediate jeopardy that began on 8/2/20, was removed on 8/11/20, when the facility's removal plan could be verified through interview and document review, to include training with the pharmacy, staff education on when to order medications timely, staff education for when to complete a medication error report, and the facility had developed a policy and procedure for medication reordering and trained staff on it.

Based on interview and document review the facility failed to ensure residents were free from abuse for 1 of 3 residents (R1) reviewed for abuse. R1 who had cognitive impairment and was yelled at and physically threatened with a closed fist by a staff member. These practices had the potential to effect all residents residing in the facility. Findings include The facility Abuse Prevention Plan dated 12/16/2016, included the following definitions: -Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. -Verbal abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability, Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. During an interview on 5/15/2020, at 7:40 a.m. HSK-A said prior to 5/10/20, R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/10/20, R1 had been sitting in his wheelchair in the doorway of his room, she asked R1 to back up so she could get in but R1 did not move out of the way. HSK-A added, He claims he's hard of hearing. HSK-A thought R1 had selective hearing. HSK-A stated she again asked R1 to move, R1 told her he did not hear her. HSK-A stated, then all of a sudden R1 kicked HSK-A on the right shin just below the knee. HSK-A said it hurt and indicated it made her upset. HSK-A then said, I clenched my fist and hugged it to my chest area and told him, You can't do that, you can't do that to me. HSK-A said RN-A had been standing behind her, RN-A walked just inside the room where she had been standing and told her, you can't threaten him. HSK-A had told the nurse she was trying to clean his room. HSK-A said RN-A repeated to leave the room. HSK-A said, RN-A had directed her two or three times. HSK-A indicated RN-A had provided coaching, had instructed her not to go anywhere near R1, and has followed the direction since then. HSK-A stated she did not think her fist was close to R1's face, it happened so fast, when R1 kicked her she had been about one foot away, but was 5 feet away when she had the fist. During an observation and interview on 5/14/2020, at 3:30 p.m. R1 laid in his bed quietly. R1 was noted to have significant hearing loss demonstrated by the surveyor had to repeat questions and raise voice so it would be audible to R1. R1 stated he was doing well, and did not have any concerns with the staff. A Vulnerable Adult report submitted to the State Agency on 5/10/2020, at 6:34 p.m. alleged emotional/mental abuse by a staff member; Registered nurse (RN)-A witnessed Housekeeping (HSK)-A standing in front of R1 angry with a closed fist, telling R1 not to kick her in a threatening manner. According to the report, RN-A had to request HSK-A to leave R1's room and not to have any further contact with R1. Following the incident R1 was upset, however later had forgotten about the incident. According to the report HSK-A told RN-A, R1 had kicked her. RN-A demonstrated to HSK-A what she had seen, HSK-A admitted to having her fist in his face. I did not realize I was that close to him. The report indicated RN-A provided HSK-A coaching, and the incident was reported to HSK-A's supervisor. R1's Admission Record dated 5/18/2020, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's communication Care Area Assessment (CAA) dated 3/20/20, included, Resident has moderate difficulty hearing and does wear hearing aids bilaterally; speaker must still increase volume and speak clearly. Resident has clear speech, makes himself understood, and usually understands others; does have confusion at times. R1's care plan included R1 was a vulnerable adult and was at medium risk for being abused related to dementia, cognitive deficient. Interventions included approach resident in a calm, friendly manner. Re-approach resident later if safe to leave resident, and/or have a different person attempt to approach resident if resident is irritable, Monitor resident for safety in regard to abuse and neglect and make reports to appropriate staff person or agency according to current facility policy. R1 required one staff physical assistance for transfers, and self-propelled in the wheelchair. R1 had behaviors of sexually inappropriate comments, wandering into other resident rooms, foul language, spitting on floors, repetitive statements, and playing with remote in dining room. Interventions included remove resident from public area when behavior is disruptive/unacceptable. Talk to resident in low pitch, calm voice to decrease/eliminate desired behavior and provide diversional activity. Staff will intervene when necessary to avoid conflict with AW [sic] and other residents who become frustrated. R1's progress note dated 5/10/2020, at 10:23 a.m. included Incident was noted between resident and housekeeper at 0930 [9:30 a.m.]. Nurse Manager intervened for resident safety. Director of nursing (DON) social services, and administrator notified of incident. VA report completed. Will continue to monitor resident for signs and symptoms of emotional distress. During an interview on 5/14/2020 at 9:49 a.m. environmental services manager (EVS) stated he received the email on 5/11dated 5/10/20. EVS indicated HSK-A made physically threatening gestures and statements towards R1; HSK-A got in his [R1's] face and said [to R1] don't ever touch me again. EVS stated RN-A had to tell HSK-A to leave R1's room twice. EVS stated on 5/11, he met with HSK-A, HSK-A admitted to the incident, HSK-A was provided verbal coaching, was suspended for three days during the investigation, and she was assigned vulnerable adult education. EVS stated he was not sure if other residents or staff were interviewed as part of the investigation. EVS, indicated that in April 2019, there had been an allegation of physical abuse when she jokingly swatted another resident's upper arm, however the allegation was not substantiated. During an interview on 5/14/2020, at 11:15 a.m. director of nursing (DON) stated all staff completed abuse and dementia care training upon hire, annually, and as needed. DON stated she had been notified after the incident had occurred by RN-A, and that HSK-A's behavior towards R1 was verbally and physically threatening and constituted verbal/emotional abuse. DON indicated after she was notified, licensed social worker (LSW)-A contacted RN-A to get the details, and had filed the VA report to the State Agency. DON stated HSK-A was not sent home after the incident and should have been, HSK-A was suspended the next day 5/11/20 was assigned abuse education. DON indicated HSK-A was scheduled back to work today[5/14/20]. DON indicated HSK-A was also put on a personal improvement plan where she would have increased supervision and routinely audited, in addition, the facility's quality assurance committee would be involved. During an interview on 5/14/2020, at 11:38 a.m. RN-A confirmed she had witnessed the incident between HSK-A and R1 on 5/10/2020. RN-A stated around 9:30 a.m. she had been walking down the hallway checking on residents and saw R1 sitting in his wheelchair just inside his room. HSK-A was slightly bending towards R1's wheelchair with a closed fist in his face yelling something about not kicking her ever again. Her fist was right there in his face, it was very alarming, not a good situation. RN-A stated she feared for R1 and was not sure what HSK-A would do, she appeared very angry. RN-A indicated wanting to get HSK-A away from R1. RN-A stated she immediately told HSK-A you need to get away and move, however, HSK-A lingered and did not listen, RN-A stated she had to repeat her instructions and HSK-A was mad. RN-A stated right after the incident, R1 was noticeably upset, so she had assisted R1 to call his wife. RN-A stated the phone call settled R1 and after the call, R1 did not remember the incident. RN-A stated she reported the incident to DON and LSW-A. RN-A stated she provided verbal coaching to HSK-A, instructed HSK-A to stay away from R1, and supervised her the rest of the shift. During an interview on 5/15/2020, at 9:32 a.m. R1's power of attorney (POA) stated an unawareness of the incident and had not been notified. POA stated, R1 sometimes had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 5/15/2020, at 9:45 a.m. LSW-A stated an awareness of the incident between HSK-A and R1. LSW-A stated she had been made aware on 5/10/10, by the DON. LSW-A stated she called RN-A to get the details of the incident, LSW-A indicated the allegation constituted abuse and needed to be reported to the State Agency. Facility policy Abuse Prevention Plan dated 12/16/2016, indicated all residents would be free from abuse and outlined steps the facility would take to reduce the risk of resident abuse. The plan included, facility shall establish and enforce an ongoing abuse prevention plan. Each resident has the right to be free from all types of abuse, including mental abuse.A lack of response by the resident does not mean that mental abuse did not occur and you should evaluate how a reasonable person would react under such circumstances. Mental abuse may occur through either verbal or nonverbal conduct, which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Identification: identification of abuse happens when staff, residents, family members, and/or visitors report suspicion of possible abuse or neglect. Each time social services makes a vulnerable adult report or is aware of a report that has been filed regarding a residents, past reports are reviewed to track possible trends.

Based on interview and document review the facility failed to timely submit allegations of verbal abuse to the State Agency for 3 of 3 residents (R1, R2, R3) reviewed for abuse. Findings include: R1 A Vulnerable Adult report submitted to the State Agency on 5/10/2020, at 6:34 p.m. alleged emotional/mental abuse by a staff member that had occurred on 5/10/2020, at 9:30 a.m. According to the report, registered nurse (RN)-A witnessed housekeeper (HSK)-A standing in front of R1 angry with a closed fist, telling him not to kick her in a threatening manner. During an interview on 5/14/2020, at 11:15 a.m. director of nursing (DON) stated she had been notified after the incident had occurred by RN-A, and that HSK-A's behavior towards R1 was verbally and physically threatening and constituted verbal/emotional abuse. DON indicated after she was notified, licensed social worker (LSW)-A was notified, LSW-A then contacted RN-A to get the details, and then LSW-B filed the VA report to the State Agency. During an interview on 5/15/2020, at 10:40 a.m. LSW-B stated an awareness of the incident and had been notified by LSW-A on 5/10/2020 around 12:15 p.m., she had followed up with RN-A, discovered RN-A had not been able to file the report, and notified RN-A that she would do it. When asked what the federal reporting requirements were, LSW-B stated, immediately not more than 24-hours. R1 During an interview on 5/14/2020, at 9:09 a.m. staff (S)-A said, Yes, not to long ago. when asked Have you ever been witness to or have knowledge of staff to resident abuse?. S-A witnessed nursing assistant (NA)-B yelling at R1 to shut-up and go back into your room. S-A stated NA-B sounded very angry. S-A said she reported the incident to the supervisor and S-A indicated that S-B had also witnessed the incident. During an interview on 5/14/2020, at 9:33 a.m. S-B confirmed she had witnessed the incident between NA-B and R1, however, did not know date or time the incident occurred but had been within the last month. S-B stated she witnessed R1 coming out of his room, NA-B yelled at him in a strong aggressive voice You have to stay in your room, you don't listen. S-B stated R1 yelled back at NA-B then NA-B walked away. S-B stated the interaction was not appropriate, and did not feel that NA-B's raised voice had to do with R1's hearing deficit and felt it was more than that. During an interview on 5/14/2020, at 9:49 a.m. S-A's supervisor could not recall that incident being reported to them, but could not say that it wasn't. Supervisor stated, that when there was an allegation of abuse the DON was supposed to be immediately notified. R2 and R3 During an interview on 5/14/2020, at 10:25 a.m. unidentified staff member (USM)-C said USM-C had raised concerns about fell ow staff regarding verbal abuse to R2 and R3 . USM-C stated about a month ago USM-C reported to charge nurse and the director of nursing (DON) a concern regarding NA-F's interaction with R2 and R3. USM-C stated on that day, NA-F was upset with R2 because she had an episode of bowel incontinence that smelled really bad. USM-C stated NA-F yelled at R2 that it stunk in the room and asked her why she had done that and in the same raised voice asked her why she couldn't tell staff before she pooped herself. USM-C stated R2 was visibly upset from the comments; she became quiet when usually was talkative and would joke around. USM-C stated NA-F has gotten upset with other residents who have bowel incontinence that had to clean it up and would comment about the smell in front of the resident. USM-C added, R3 has a medical problem and drooled all the time; while assisting NA-F with walking R3 down the hallway, NA-F made remarks about R3's drooling right in front of R3, stated could not quote NA-F, however remembered NA-F cursing that the drooling was disgusting. USM-C was not sure if the incident was reported to the State Agency or was investigated. During an interview on 5/14/2020, at 11:15 a.m. DON stated an unawareness of the incident between NA-F, R2 and R3, NA-B and R1 and therefore a vulnerable adult report was not submitted DON stated an expectation is staff immediately report incidents that could constitute abuse. DON indicated she should have been notified of the incident so a report and investigation could be completed.

Based on interview and document review the facility failed to ensure abuse prohibition policy and procedures identified appropriate reporting procedures according to Federal Regulations. Findings include: The facility's Abuse Prevention Plan dated 8/1/2019, was inconsistent with the Federal reporting requirements for abuse and directed staff to report abuse within 2-hours if the abuse the events that caused the allegation resulted in serious bodily injury. The plan included: Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, no later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury or no later than 24 hours if the events that cause the allegation do not result in serious bodily injuries, including injuries of unknown source and misappropriation of property according to current regulation, including those involving the posting of an unauthorized photograph or recording of a resident on social media. An undated facility Check List for VA (vulnerable adult) Investigation and Reporting directed staff if the allegation was reportable, Within 24 hours report to state and county. During an interview on 5/15/2020, at 9:45 a.m. when asked what the federal reporting requirements were, licensed social worker (LSW)-A stated, immediately or within 24 hours depending on what the situation was. During an interview on 5/15/2020, at 10:40 a.m. when asked what the federal reporting requirements were, (LSW)-B stated, immediately not more than 24-hours. During an interview on 5/15/2020, at 1:15 p.m. director of nursing (DON) stated it had been identified that the Vulnerable Adult reporting checklist was wrong and directed staff to report within 24-hours to the State Agency and should reflect the Federal requirement for reporting. State Operations Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities last revised 11/22/17, included, Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made.

According to observations and interview, the facility failed to ensure a clean heating vent in a commons area where activities and dining occurred; this had the potential to affect any resident or visitor who might choose to dine in that area or attend activities. Findings include: During an observation on 12/16/19, at 5:45 p.m. the facility maintenance director was overheard to say they had just fixed the heat flow. The air flow was felt to be briskly flowing from a ceiling vent located above the sitting area near the facility television and couch, and immediately next to the dining area. The air movement was strong enough to turn a ceiling fan located over a table next to the sitting area and window. The grate over the ceiling vent was observed to be covered with a thick layer of dust. During an observation on 12/17/19,at 9:47 a.m. and 11:38 a.m. the vent over the sitting area continued to blow air strongly over the sitting area and into the nearby dining area. Air movement could be felt when standing by the dining tables. The grate remained uncleaned. During an observation and interview on 12/17/19, at 2:09 p.m. the assistant director of nursing (ADON) who was responsible for infection control in the facility confirmed the grate covering the air vent was soiled with dust. ADON stated she had concerns about this as the air movement could spread dust or contamination to resident food in the dining area. The air flow continued to be blowing quite strongly. A policy related to vent cleaning was requested. The facility provided a document titled Inspect Exhaust Fans for Proper Operation and Clean if Necessary. The document indicated this had been done on 12/11/19; however, the items listed to serviced were: exhaust fans in bathrooms, shower rooms, soiled and clean utility rooms, janitor closets, kitchen and sink and laundry areas and oxygen room, and failed to include vents in the commons area. A list of tasks due the week of the survey was provided and did not include a cleaning of the vent in the commons area. A list of tasks due in the month included exhaust fans-inspect exhaust fans for proper operation and clean if necessary, but did not include which exhaust fans or if the heating vent was included as an exhaust fan.

Based on observation, interview, and document review the facility failed to provide adequate pain management for 1 of 1 resident (R31), who was on hospice. The lack of pain management resulted in significant uncontrollable abdominal pain resulting in harm for R31. Findings include: R31's facility Admission Record dated 1/17/19, included [DIAGNOSES REDACTED]. R31's significant change Minimum Data Set ((MDS) dated [DATE], indicated R31 did not have cognitive impairment, under palliative care, and required expensive assistance from two or more staff members for bed mobility, transfers, dressing, toilet use, and hygiene. The MDS indicated R31 had shortness of breath with exercise and when sitting at rest. The MDS indicated [REDACTED]. R31's undated care plan included, Resident has elected the hospice benefit, nursing facility and hospital will communicate establish, and agree upon a coordinated plan of care, reflecting the hospice philosophy. Interventions included: pain and other uncomfortable symptoms will be addressed appropriately following hospice and nursing facility care plan, continue thorough communication with Hospice nursing social worker, refer to PAIN care plan nursing, and refer to working (paper) HOSPICE care plan. R31's facility pain care plan included: Resident is at risk for pain related to [MEDICAL CONDITION] arthritis, [MEDICAL CONDITION] and depression; goal of resident will be free from signs and symptoms of pain as evidenced by resident verbalization of relief and engaging in desired activities. Pain interventions included: Administer pain medications as per MD orders and note the effectiveness, report any unresolved pain to physician, encourage resident to verbalize pain, monitor and report any noted non-verbal signs of discomfort, give as needed medications for breakthrough as per MD orders and note the effectiveness. Pain interventions also included non-pharmacological interventions such ass rest, position change for comfort, music, diversional activity, massage, heat, or cold packs. Directed staff to perform pain assessments quarterly and as needed. R31's (MONTH) Medication Administration Record [REDACTED] -[MEDICATION NAME] 20 milligram/milliliter (mg/ml); 0.5 ml sublingually every two hours as needed for severe pain 7-10 of 10 (0-10 scale) 10 mg total.-included non-pharmalogical interventions (start date 1/7/19, discontinued 1/8/19) -[MEDICATION NAME] ([MEDICATION NAME]) 50 mg by mouth every 6 hours as needed for pain or sever pain of pain 7-10 on 0-10 scale-order included non-pharmalogical interventions (start date 12/31/18, discontinued 1/10/19) -[MEDICATION NAME] 1.0 mg/ml; 1 ml by mouth every two hours as needed for pain- order included non-pharmalogical interventions (start date 1/8/19, discontinued 1/14/19) -[MEDICATION NAME] liquid 1.0 mg/ml; 1.0 ml by mouth every one hour as needed for pain-order included non-pharmalogical interventions (start date 1/14/19, discontinued 1/16/19) -[MEDICATION NAME] liquid 1.0 mg/ml; 1.0 ml by mouth three times a day scheduled and every one hour as needed for pain related to [MEDICAL CONDITION] arthritis and palliative care-order included non-pharmalogical interventions (start date 1/16/19) -Tylenol 500 milligrams (mg) by mouth four times a day (start date 9/18/18, and discontinue date 1/16/19) During an interview on 1/15/19, at 12:57 p.m. R31 laid in bed with oxygen on, R31's abdomen was distended and legs were [MEDICAL CONDITION]. R31 stated her abdomen was filling with fluid and had increased since readmission to the facility and stated her legs felt heavy and were more swollen than they had ever been. R31 stated she enrolled in hospice on 1/7/19, she indicated she had been hospitalized multiple times for [MEDICAL CONDITIONS], and had just recently stopped [MEDICAL TREATMENT]. R31 stated one of the reasons she opted for hospice is because her body was shutting down, was having a lot of pain, and just wanted to be comfortable. R31 stated her pain in the hospital was very well managed and thought it would be continued to be managed in the facility. R31 stated on three separate occasions since re-admission she had requested pain medications however, was told by the nursing staff, it was not time to have them yet, and you have to wait. R31 indicated she could not recall the date of the first instance when her pain medication was not given. R31 stated the first time she told the nurse her abdominal pain was 47 on a scale of 0-10 (10 being the worst pain). R31 indicated the nurse told her she could not have the pain medication yet, because it had not been two hours since the last time she had received it, and offered her nothing else other than Tylenol, and stated which is nothing more than a glorified aspirin and Tylenol was not going to do anything for the pain that she was in. R31 then stated she thought the the 2nd time I was told to wait because it wasn't time yet happened a few days after the first time. R31 stated she thought the second time was on Friday or Saturday night (1/11 or 1/12), she asked for the pain medication at around 7:00-7:30 p.m. R31 stated the nurse told her you know (R31) when a doctor gives an order for [REDACTED]. R31 stated she felt like an ant, and that her pain meant nothing to anybody. R31 stated it was half hour before she could have her next dose. R31 stated she just started crying wanted to cry herself to sleep, or pass out just so the pain would stop. R31 then stated, this dying thing isn't all what it's cracked up to be. R31 stated with tears in her eyes, there was no [MEDICATION NAME], instead it was lecture; the doctor said . the doctor said she was a hospice volunteer for [AGE] years and that this wasn't what it was supposed to be, if the patient was in pain then we would find a way to get pain medications for our patients. R31 stated, to her knowledge her hospice nurse was not called to communicate her uncontrolled pain with the current dose/time of pain medication. R31 stated the last time she requested pain medication was last night, when the nurse told her again, I had to wait and it wasn't time yet. R31 stated, I had it, and couldn't take it anymore, I was in so much pain!, R31 stated, she called the hospice nurse herself to report her pain, and the hospice nurse called the facility and changed her medication so she could have it every hour instead of every two hours. R31 stated, I shouldn't have had to do that! the facility staff should have done that. R31 stated she did not feel like there was good coordination of care at all and there was a lack of communication to the hospice agency. During an interview on 1/ 15/19, at 1:05 p.m. R31's family member (FM)-2, verified R31 had told her of these issues. FM-2 stated they arrived at the facility on Sunday (1/13) at around 10:40 a.m. FM-2 stated upon arrival R31 was in a lot of pain and was rating her pain 10/10. FM-2 stated R31 had not had pain medication at all throughout the night. FM-2 stated she went out to ask the nurse for pain medication for R31 and was told by the nurse that R31 had to try a hot pack first, but then later brought in pain medication 5 minutes later. FM-2 stated she did not think R31's hospice nurse had been contacted about the R31's bouts of uncontrolled pain, and the pain medication not being effective. During an interview on 1/15/19, at 1:10 p.m. R31's (FM)-1 stated, that was one of the biggest decisions why we opted for hospice because they (hospice) reassured us that she would remain comfortable, that was the biggest thing, her pain would be managed and pain medications were adjusted as needed right away in order to control any pain. FM-1 indicated he thought there was clearly a miscommunication between the nursing home staff and the hospice agency. FM-1 stated the nursing home staff were supposed to communicate R31's pain control needs to the hospice and when the pain medications seemed not to be working. FM-1 stated, he didn't think that happened. FM-1 indicated a facility nurse did talk to him regarding the concerns however, did not feel that it resolved the situation yesterday morning (1/14/19) because R31 ended up having to call hospice herself later that night just to get herself pain medications. (PN) dated 1/7/19, at 3:36 p.m. included:: Resident returned from hospitalization today at 12:05. Resident arrived via ambulance/stretcher. She was hospitalized at Austin/ Mayo from 1/3-1/7/19 for heart failure. Resident has elected to enroll in Hospice. Reports that she has had trouble sleeping when in hospital due to discomfort. She denies pain at this time, but reports history of abdominal discomfort rated 10/10 at worst. She reports that pain medications in use are currently effective. Nursing to continue to monitor resident and update MD/Hospice if needed. MAR- 1/7/19, at 3:29 p.m. [MEDICATION NAME] adminsitered for pain rated 10/10, non-pharm of music, and was not effective PN dated 1/7/19, included: Should be noted that Austin Mayo Hospice arrived shortly after resident did this afternoon to admit resident to Hospice. Hospice RN she reviewed resident's medications and noted that she has current orders for [MEDICATION NAME] 20 mg/mL concentrated solution which is contraindicated d/t her impaired kidney function per her current baseline. Hospice did place order request to physician at time of admission noting it was requested that the [MEDICATION NAME] order be discontinued and a new order for [MEDICATION NAME] be obtained. Resident was taking [MEDICATION NAME] at the hospital and had been tolerating it well while also noting administrations effective. Hospice nurse assured nursing that she would have the updated orders faxed to facility as soon as they were available. Nursing will update order summary once received. PN dated 1/7/19, at 5:45 p.m. included: Resident also notified nursing that she was still having pain and wanted to know if she could have anything at this time. Nursing explained to resident that she currently only has [MEDICATION NAME] ordered as PRN pain relief noting her contraindications; stated Hospice was in the process of having this medication changed to [MEDICATION NAME] if possible; noted that no changes had been made as of yet. Resident stated understanding and requested that nursing administer her PRN [MEDICATION NAME] at this time, regardless of the risks noting she is fully aware of risks, as she is having pain at this time and has already received PRN [MEDICATION NAME] approx 2 hrs ago noting no relief from that medication. Nursing did place a call to Austin Mayo Hospice to inquire the status of the order requests, specifically checking on whether [MEDICATION NAME] had been ordered or if nursing would be administering the current PRN [MEDICATION NAME], per her request. Hospice did inform nursing that no changes had yet been made with d/c orders further instructing nursing to administer PRN [MEDICATION NAME] for pain at request/per indications of resident. Will ensure [MEDICATION NAME] order has been updated to order summary and will request that her wing nurse administer this medication at this time d/t pain. [DATE]/7/19, at 7:00 p.m. [MEDICATION NAME] administered for pain rated of 8/10, non-pharm of diversional activity, and was not effective [DATE]/8/19, at 1:54 p.m. [MEDICATION NAME] administered for pain rated 10/10, non-pharm of rest, and was not effective. PN indicated R31 requested for pain all over body, and hospice nurse instructed to give. [DATE]/8/19, at 4:03 p.m. [MEDICATION NAME] administered for pain rated 10/10, and was not effective-PN indicated given for pain unrelieved by rest, soft lighting, meditation and heat. MAR1/8/19, at 8:22 p.m. [MEDICATION NAME] administered for pain 10/10, was effective-PN indicated follow-up pain score was 8 and the medication was ineffective. PN did not identify ongoing measures to relieve pain. [DATE]/9/19, at 10:21 a.m. [MEDICATION NAME] administered for pain 9/10, was not effective-PN indicated requested for lower back pain, refused [MEDICATION NAME]. PN did not identify ongoing measures to relieve pain. [DATE]/9/19, at 12:59 p.m. [MEDICATION NAME] administered for pain rated 9/10, non pharm of diversional activity, and was not effective- PN did not identify location and/or ongoing measures to relieve pain. [DATE]/9/19, at 3:04 p.m. [MEDICATION NAME] administered for pain 9/10, was not effective. PN indicated administration related to left abdominal pain unrelieved with non-pharmacological interventions and did not identify ongoing measures to relieve pain. MAR1/9/19, at 7:13 p.m. [MEDICATION NAME] administered for pain 9/10, was effective. PN indicated given for pain' no location was identified. PN 1/10/19, included Austin mayo Hospice RN is at facility this AM and had reviewed resident's chart as well as visited with her prior to speaking to nursing. Hospice nurse informed nursing that she was planning to request resident's ordered Aspirin and [MEDICATION NAME] be d/c'd d/t her currently taking [MEDICATION NAME] and noting that her recently ordered PRN [MEDICATION NAME] has been working effectively, per resident's statement to Hospice, noting she has not been using or needing her [MEDICATION NAME] as of recently. [DATE]/10/19, at 1:05 p.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN did not identify location of pain [DATE]/10/19, at 5:40 p.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN indicated pain all over [DATE]/10/19, at 8:01 p.m. [MEDICATION NAME] administered for pain 8/10, was effective. PN did not identify location of pain [DATE]/11/19, at 7:51 a.m. [MEDICATION NAME] administered for pain 5/10, was effective. PN did not identify location of pain [DATE]/11/19, at 11:43 a.m. [MEDICATION NAME] administered for pain 4/10, was effective PN did not identify location of pain [DATE]/11/19, at 1:46 p.m. [MEDICATION NAME] administered for pain 5/10, was effective. PN did not identify location of pain [DATE]/12/19, at 10:57 a.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN indicated left abdominal pain PN dated 1/12/2019, at 12:58 p.m. included: Spoke with resident at this time regarding pain medications. Resident's (family member) was at facility earlier today and reported that resident had some concerns with her pain medications last evening. Spoke with R31 at this time. She reports that approx. 9:30pm last eve she reported discomfort to nursing staff. A warm blanket was given/offered to her to try for abdominal discomfort. R31 reports that she had wanted pain medications but fell asleep. She reports she had pain through night but did not alert nursing. (R31) denies pain at this time when asked. She reports she did receive pain medications today and they are effective. She reports that help has been wonderful. She also reports that warm blanket is ineffective for her pain and would rather have pain meds when needed. Resident denies any mistreatment, and reports she understands use of non medication interventions at times. Communication given to staff to continue to monitor pain closely and reassess pain interventions frequently and offer pain meds as ordered. Education to (R31) to continue to alert staff if pain meds are needed [DATE]/12/19, at 3:04 p.m. [MEDICATION NAME] administered for pain 10/10, was effective-PN did not identify location of pain. [DATE]/12/19, at 8:07 p.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN identified non-pharm measures used and did not identify location of pain [DATE]/12/19, at 10:15 p.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN included R31 had abdominal pain 42/10. Declined all offers of non-pharm's. Being on hospice I'm supposed to get the strongest medication abdomen is soft with no reaction to palpation. Bowel sounds present in all quadrants. PN dated 1/13/19, at 8:51 a.m. included: Quarterly Pain Assessment Note Text: Assessment for hospital return/significant change for the period of 1/7-1/14. Resident returned from hospitalization on ,[DATE] and is currently enrolled with hospice. She has [MEDICATION NAME], Tylenol and Pregabalin ordered for discomfort. She is currently resting in bed at this time. She reports having pain over the last 5 days when asked. Pain is frequent and severe at times 10/10. She reports that pain meds help with discomfort. Resident is able to report the presence of pain as needed. She reports difficulty sleeping at times d/t pain as well as limiting day to day activities. Abdominal discomfort is reported as location of pain. Nursing continues to monitor for verbal and non verbal indications of pain and offer pain medications as needed. See MAR for non pharmalogical interventions as well. Nursing to continue to monitor and update MD/Hospice as needed with any increased pain or concerns. [DATE]/13/19, at 10:40 a.m. [MEDICATION NAME] administered for pain 8/10, was effective. PN did not identify location of pain [DATE]/13/19, at 4:32 p.m. [MEDICATION NAME] adminsitered for pain 10/10, was effective. PN did not identify location of pain [DATE]/13/19, at 9:09 p.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN did not identy location of pain,and indicated R31 was lying in bed, quested medication fro re-occurring pain rated 10, had warm blanket on. [DATE]/14/19, at 640 a.m. [MEDICATION NAME] administered for pain 6/10, was effective. PN did not identify location of pain [DATE]/14/19, at 11:35 a.m. [MEDICATION NAME] administered for pain 5/10, was not effective. PN did not identify location of pain [DATE]/14/19, at 2:14 p.m. [MEDICATION NAME] administered for pain 5/10, was effective. PN did not identify location of pain [DATE]/14/19, at 6:00 p.m. [MEDICATION NAME] administered for pain 10/10 was not effective. PN did not identify location of pain PN 1/14/19, at 7:40 p.m. included Received phone call from nurse from hospice. Stated Resident called and stated that her pain medication is being withheld, and that we are refusing to give it to her. Nurse explained to hospice nurse that the order we have for her [MEDICATION NAME] is every 2 hours PRN, and her last dose was administered at 6:00 p.m., and that the next dose can be given at 8:00 p.m Hospice nurse stated she would call to the doctor to get an order for [REDACTED].>[DATE]/4/19, at 7:55 p.m. [MEDICATION NAME] adminsitered for pain rated 10/10. PN indicated R31 requested additional [MEDICATION NAME] after one hour of receiving 6:00 p.m. dose. Hospice gave order for every one hour. [DATE]/15/19, at 12:45 a.m. [MEDICATION NAME] administered for pain 10/10, unknown effectiveness. PN did not identify location of pain. [DATE]/15/19, at 3:21 a.m. [MEDICATION NAME] administered for pain 10/10, was effective. PN indicated was asleep at the time of last assessment and pain was now in her back. [DATE]/15/19, at 11:38 a.m. [MEDICATION NAME] administered for pain 10/19 was effective- PN indicated abdominal discomfort. [DATE]/15/19, at 2:19 p.m. [MEDICATION NAME] administered for pain 10/10 unknown effectiveness. PN indicated abdominal discomfort. [DATE]/15/19, at 7:17 p.m. [MEDICATION NAME] administered for pain 10/10 was effective. PN did not identify location of pain. [DATE]/16/19, at 1:45 a.m. [MEDICATION NAME] adminsitered for pain 10/10 was effective. PN indicated for abdominal discomfort [DATE]/16/19, at 9:27 a.m. [MEDICATION NAME] administered for pain 10/10 unknown effectiveness [DATE]/16/19, at 3:19 p.m. [MEDICATION NAME] administered for pain 10/10 dose was not effective. PN indicated her pain was 45/10 in in left lower abdomen. R31's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an observation on 1/16/19, at 9:36 a.m. R31 laid in bed with oxygen on 2L, had facial grimaces, and was near tears. R31's facial complexion was pale, had increased respiratory rate, and was breathing through her mouth. R31 stated she had a lot of bladder and abdominal pain and rated her pain 52 out of 10, was short of breath, and took a lot of medications for breathing, R31 stated she had her pain medication a couple of hours ago, stated she had asked licensed practical nurse (LPN)-A, ten minutes ago for pain medication. R31 stated, I just want a pain medication, so I can go back to sleep. It hurts. During an interview on 1/16/19, at 9:53 a.m. LPN-B stated LPN-A took a break and would be back shortly. During an observation on 1/16/19, at 10:16 a.m. R31 laid in her bed with her oxygen on 2L, continued to display facial grimaces, and complexion pale, however, respiratory rate had slowed, and R31 stated breathing had improved. R31 stated she continued to be in a lot of pain and had not received any pain medications yet. During an observation on 1/16/19, at 10:26 a.m. R31 put on her call light, nursing assistant (NA)-A entered R31's room. R31 told NA-A she needed pain medication. At 10:27 a.m. NA-A communicated to LPN-A- R31 wanted pain medication. During an observation and interview on 1/16/19, at 10:37 a.m. LPN-A administered R31 pain medication and stated R31 had abdominal pain and rated pain 10/10. LPN-A stated R31 had not previously asked for pain medication from her and she was just made aware. LPN-A stated she had given her morning medication around 7:30 a.m. and was doing fine. During an observation and interview on 1/16/19, at 12:09 p.m. NA-E was assisting R31 to reposition in bed. R31's cheeks were rosy and was not pale. R31 stated her pain was much better. R31 indicated the nurse had not returned to the room the check on her. During an interview on 1/16/19, at 1:00 p.m. hospice supervisor registered nurse -(HSRN) stated she had not been aware of the high pain ratings after R31 was admitted to hospice and the doses given were not effective. Pain documentation and pain ratings were reviewed with HSRN; HSRN stated the multiple high pain levels R31 was reporting at times was concerning and the medication regimen should have been adjusted for more coverage. HSRN questioned if a long acting pain medication should be used or her doses increased. HSRN stated the expectation the facility call the hospice nurse and communicate the ineffectiveness of the pain medication in order to get new orders. HSRN found it very concerning the facility did not call and report to the hospice nurse about the effectiveness of the medication or that R31 had high levels of pain before the next dose could be given. HSRN indicated the facility is routinely educated on communication about pain medication effectiveness. HSRN stated one of the primary goals of hospice is to ensure the patient is comfortable. During an interview on 1/16/19, at 2:01 p.m. hospice registered nurse (HRN)-1 stated she was R31's case manager and admitted R31 to hospice. HRN stated when R31 was in the hospital she received [MEDICATION NAME] intravenously and confirmed she had good pain control. HRN indicated R31's discharge orders were for her to have [MEDICATION NAME] and [MEDICATION NAME] for pain control. HRN then stated during the admission R31 and family indicated pain control and comfort was a priority. HRN indicated when she had discussed the pain control regimen/medications the plan was to discontinue the [MEDICATION NAME] and start the [MEDICATION NAME] the following day. HRN stated she faxed a prescription to the pharmacy the day of admission on 1/7/19, to start on 1/8/19. HRN stated when she came for her second visit on 1/10/19, she reviewed R31's nursing notes from 1/7 through 1/10 and identified the documentation on the MAR indicated [REDACTED]. HRN stated during the time of the interview, R31 didn't have any pain, and indicated if she had pain in discomfort during the interview her response may have been different. HRN stated she was not aware R31 had called hospice the other day for an increase in pain medication and would be reviewing her medication regiment today. During an interview on 1/16/19, at 2:31 p.m. LPN-C verified she had been the nurse on duty the night R31 called hospice and indicated a trained medication assistant was passing medication down that hallway. LPN-C stated that evening R31 put on her call light, NA answered the calllight, and came into the nursing station where her and the TMA were at. LPN-C indicated, the NA reported R31 requested pain medication, TMA stated she could not yet have it and it was too early, then the TMA walked down to R31's room and informed her that it was too early for her to have the pain medication. LPN stated she had not gone down to the room and performed a pain assessment. LPN-C stated shortly after the TMA arrived back tot he nursing station, the hospice nurse called with new [MEDICATION NAME] orders; R31 could have the [MEDICATION NAME] every hour as needed. LPN-C stated was out of the TMA's scope of practice to perform a pain assessment and could only obtain a pain rating to communicate to the nurse. LPN-C stated if pain medication was not effective after the dose was given and/or if the pain medication was not [MEDICATION NAME] until the next as needed dose could be given, hospice or on-call physician was supposed to be contacted. LPN-C stated depending on the pain medication given nurses were supposed to check back anywhere between 15-30 minutes to assess whether the pain medication was effective or not. LPN-C then asked LPN-A if there was any as needed medications that needed to be followed up on. LPN-A stated the only as needed medication that she had given was to R31. LPN-C then referenced R31's MAR indicated [REDACTED]. LPN-C stated she would have to document unknown. During an interview on 1/16/19 at 2:51 p.m. LPN-C was asked about the 9:26 a.m. administration time, as LPN-C stated she could not remember exactly what time she had administered the dose. LPN-C confirmed she had not assessed R31's pain after she had administered the dose in order to ascertain effectiveness. During an interview on 1/16/19, at 3:46 p.m. director of nursing (DON) reviewed R31's pain documentation, and indicated the pain assessments were incomplete, if the dose was documented as ineffective there should have been more follow-up documentation that indicated what relieved the pain. DON stated hospice and/or the physician should have been notified if the pain medication was not working and it was not ok to tell someone they have to wait for the next dose, other non-pharmalogical intervention should be attempted and documented and if the pain is not relieved then the physician should be contacted. DON stated when as needed pain medications are administered it was an expectation that the pain is re-assessed between 15-30 minutes after administration and ongoing to ensure comfort.

Based on observation, interview and document review the facility failed to ensure comprehensive nursing care was completed for monitoring [MEDICAL CONDITION] (excess fluid in the tissue), respiratory status and pain management for 1 of 1 resident (R31) on hospice services. In addition the facility failed to coordinate with hospice services when R1 expressed severe, uncontrolled abdominal with ineffective pain management that resulted in actual harm for R31. Furthermore, the facility failed to consistently assess and monitor weights, respiratory status, and [MEDICAL CONDITION] for 3 of 3 resident (R8, R6, R4) who had [MEDICAL CONDITION] (weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) and/or had respiratory distress. Findings include: R31's facility Admission Record dated 1/17/19, included [DIAGNOSES REDACTED]. R31's hospital After Visit Summary indicated R31 was admitted to the hospital on [DATE] and was discharged back to the facility with a referral to hospice 1/7/19. A hospital physician visit note dated 1/6/19, indicated R31 had been recently discharged from the hospital after being treated for [REDACTED]. The note indicated she had also had an earlier hospital admission for urinary tract infection [MEDICAL CONDITION]/[MEDICAL CONDITION] and NSTEMI. The not also included: patient continues to be short of breath, but improved with [MEDICAL CONDITION], her [MEDICAL CONDITION] is poorly controlled, she continues to have wheezing. Note further included: extensive conversation about goals of care and her wishes, she says she is ready to be at home with lord. She is preferring to be comfortable rather than doing aggressive treatment and she knows this a recurrent problem and would not want any further treatment for [REDACTED]. On exam: 2+ [MEDICAL CONDITION] in bilateral lower extremities. Lung sounds: poor air entry in both lungs, with crackles at lung base and minimal wheezing. R31's Hospice Initial Plan of Care and Service Agreement dated 1/7/19, indicated the admission [DIAGNOSES REDACTED]. Hospice services included: skilled nursing two times a week and as needed and once a week hospice aide. initial goal: comfort care and coordinate comfort cares with nursing home staff. R31's Hospice Facility Care Plan dated 1/7/19, included focuses of care, outcomes, interventions and designations of responsibilities between the hospice agency and facilty staff. The care plan indicated the admitting [DIAGNOSES REDACTED]. -Problem/needs: Resident has a terminal illness with prognosis of six months or less. The outcomes (goal) included: Resident will receive comfort care according to hospice philosophy and Anticipate changes in patient condition related to terminal status as patient declines. The following interventions were designated as the nursing facility's responsibility: Notify hospice of any change in condition, nursing facility to provide room and board. The interventions designated to hospice included: hospice interdisciplinary team to provide services based on the identified needs of the resident, Hospice on-call service available 24 hours/day 7 days a week, and Hospice will be financially responsible for all medications related to terminal illness. Intervention designated to hospice and nursing facility included: develop a coordinated care plan. -Problem/needs: Alteration in comfort. Outcomes included: resident will report that the pain is reduced to a personally desired pain goal and Resident's family will verbalize understanding and comfort with the resident's pain management plan. Interventions designated to the facility included: instruct resident/family on the cause of pain in the terminally ill and administer pain medications as ordered by MD. The interventions designated to both the hospice and nursing facility included: Assess and clarify resident's pain utilizing a pain rating scale and perform ongoing pain assessment to determine if pain management is meeting the resident's pain relief goal. Problem/needs: Potential for alteration in cardiac/respiratory status. Outcomes included: Resident will report that dyspnea is reduced to level personally desired and resident will report chest pain optimally managed. Interventions designated to the facility included: monitor and report [MEDICAL CONDITION] in legs. Interventions designated for both hospice and nursing facility included: assess status cardiac/respiratory, oxygen comfort per MD order, and head of bed up to maximize respiratory function. R31's Hospice Care Notes dated 1/8/19, included terminal [DIAGNOSES REDACTED]. The clinical progression of illness: Symptoms/Severity: severe shortness of breath with fluid retention in abdomen, abdominal pain. Frequent pain her mid abdomen that goes around back to her kidneys as well. [MEDICATION NAME] worked while she was in the hospital. Plan was to change her back to that instead of the [MEDICATION NAME] she was discharged her with. The note also indicated R31 was short of breath with talking or any body movement and has been using oxygen as needed. Weight 216.26 lbs. R31's significant change Minimum Data Set ((MDS) dated [DATE], indicated R31 did not have cognitive impairment, under palliative care, and required extensive assistance from two or more staff members for bed mobility, transfers, dressing, toilet use, and hygiene. The MDS indicated R31 had shortness of breath with exercise and when sitting at rest. The MDS indicated [REDACTED]. R31's undated care plan included, Resident has elected the hospice benefit, nursing facility and hospice will communicate establish, and agree upon a coordinated plan of care, reflecting the hospice philosophy. Interventions included: pain and other uncomfortable symptoms will be addressed appropriately following hospice and nursing facility care plan, continue thorough communication with Hospice nursing social worker, refer to PAIN care plan nursing, and refer to working (paper) HOSPICE care plan. -R31's pain care plan included: Resident is at risk for pain related to [MEDICAL CONDITION] arthritis, [MEDICAL CONDITION] and depression; goal of resident will be free from signs and symptoms of pain as evidenced by resident verbalization of relief and engaging in desired activities. Pain interventions included: Administer pain medications as per MD orders and note the effectiveness, report any unresolved pain to physician, encourage resident to verbalize pain, monitor and report any noted non-verbal signs of discomfort, give as needed medications for breakthrough as per MD orders and note the effectiveness. Pain interventions also included non-pharmacological interventions such ass rest, position change for comfort, music, diversional activity, massage, heat, or cold packs. Directed staff to perform pain assessments quarterly and as needed. -R31's respiratory focus included: [MEDICAL CONDITION] problems [MEDICAL CONDITION] and heart failure uses oxygen continuously and has a [MEDICAL CONDITION] at night, with a goal of resident's oxygen saturation will remain within normal limits for the resident. Interventions included: administer medication, and obtain lab work as ordered, encourage resident to report any signs/symptoms of dyspnea to nursing, monitor and report to nursing and MD any note changes/problems with resident breathing i.e changes in pulse oximetry reading, any adventitious lung sound, respiratory rate, and cough. Interventions also included nebulizer treatments 4 times daily, order for oxygen 2-4 liters per minute via nasal cannula to ensure comfort and relief of shortness of breath. Care plan also directed staff to apply ace wraps to both legs every morning and remove them at bedtime to maintain circulation throughout lower legs during the day. During an interview on 1/15/19, at 12:57 p.m. R31 laid in bed with oxygen on, R31's abdomen was distended and legs were [MEDICAL CONDITION]; R31 stated her abdomen was filling with fluid and had increased since readmission to the facility, her legs were more swollen then they had ever been and felt heavy. R31 stated she just enrolled in hospice on 1/7/19, she indicated she had been hospitalized multiple times for [MEDICAL CONDITIONS], and had just recently stopped [MEDICAL TREATMENT]. R31 stated one of the reasons she opted for hospice is because her body was shutting down, was having a lot of pain, and just wanted to be comfortable. R31 stated her pain in the hospital was very well managed and thought that once she was readmitted to the facility her pain would continue to be well managed however, that had not been the case. R31 stated on three separate occasions since re-admission she had requested pain medications however, was told by the nursing staff, it was not time to have them yet, and you have to wait. R31 indicated she could not recall the date of the first instance when her pain medication was not given, but remembered telling the nurse her pain was 47 on a scale of 0-10 (10 being the worst pain). R31 stated she had a lot of abdominal pain because of the fluid accumulation. R31 indicated the nurse told her she could not have the pain medication yet, because it had not been two hours since the last time she had received it, and offered her nothing else other than Tylenol which is nothing more than a glorified aspirin and it was not going to do anything for the pain that she was in. R31 then stated the 2nd time she was told I had to wait, because it wasn't time yet stated she waited 15-20 minutes before her next dose of pain medication was given. R31 stated, to her knowledge her hospice nurse was not called to communicate her uncontrolled pain with the current dose/time of pain medication. R31 then stated she thought the second time was on Friday or Saturday night (1/11 or 1/12), she asked for the pain medication at around 7:00-7:30 p.m. R31 stated the nurse told her you know (R31) when a doctor gives an order for [REDACTED]. R31 stated she felt like an ant, and that her pain meant nothing to anybody. R31 stated it was half hour before she could have her next dose. R31 stated she just started crying wanted to cry herself to sleep, or pass out just so the pain would stop. R31 then stated, this dying thing isn't all what it's cracked up to be. R31 stated with tears in her eyes, there was no [MEDICATION NAME], instead it was lecture; the doctor said . the doctor said she was a hospice volunteer for [AGE] years and that this wasn't what it was supposed to be, if the patient was in pain then we would found a way to get pain medications for our patients. R31 stated the last time she requested pain medication was last night, when the nurse told her again, I had to wait and it wasn't time yet. R31 stated, I had it, and couldn't take it anymore, I was in so much pain!, R31 stated, she called the hospice nurse herself to report her pain, and the hospice nurse called the facility and changed her medication so she could have it every hour instead of every two hours. R31 stated, I shouldn't have had to do that! the facility staff should have done that. R31 stated she did not feel like there was good coordination of care at all and there was a lack of communication to the hospice agency. R31's family member (FM)-2 verified R31 had told her of these issues. FM-2 stated they arrived at the facility on Sunday (1/13) at around 10:40 a.m. FM-2 stated upon arrival R31 was in a lot of pain and was rating her pain 10/10. FM-2 stated R31 had not had pain medication at all throughout the night. FM-2 stated she went out to ask the nurse for pain medication for R31 and was told by the nurse that R31 had to try a hot pack first, but then 5 minutes later brought in pain medication. FM-2 stated she did not think R31's hospice nurse had been contacted about the R31's bouts of uncontrolled pain, and the pain medication not being effective. R31's (FM)-1 stated, that pain control was one of the biggest decisions why we opted for hospice because they (hospice) reassured us that she would remain comfortable, that was the biggest thing, her pain would be managed and pain medications were adjusted as needed right away in order to control any pain. FM-1 indicated he thought there was clearly a miscommunication between the nursing home staff and the hospice agency. FM-1 stated the nursing home staff were supposed to communicate R31's pain control needs to the hospice and when the pain medications seemed not to be working. FM-1 stated, he didn't think that ever happened. FM-1 indicated a facility nurse did talk to him regarding the concerns however, did not feel that it resolved the situation yesterday morning (1/14/19) because R31 ended up having to call hospice herself later that night just to get herself pain medications. Stated he talked to the hospice nurse this morning about the incident, stated the hospice nurse told him that the facility should have contacted hospice right away. FM-1 stated hopefully they got it figured out now, the facility has to learn to call the hospice agency when she needs something or when something wasn't working, because the hospice doesn't know, what the facility doesn't tell them. FM-1 stated that this was supposed to be a collaborative effort and hospice relied on the facility staff to tell them what she needs, hospice isn't here every day they (facility staff) are. PAIN R31's record reviewed from 1/7/19 through 1/15/19, lacked evidence of ongoing comprehensive pain assessments and lacked consistent evaluations of effectiveness of pain control modalities. R31's Medication Administration Record [REDACTED]. Documentation on many occurrences indicated the administered pain medication was not effective; the record lacked evidence of ongoing communication with hospice of R31's ongoing high pain ratings and the ineffectiveness of administered pain medications. Furthermore, the record indicated even after a quarterly pain assessment that was completed on 1/13/19, that identified R31 experienced frequent severe pain that interrupted sleep and limited her day-to-day activities, the record lacked evidence the results of the assessment were communicated with hospice and/or pain management interventions were changed or revised in order to obtain R31's goals for pain management, until 1/14/19, when R31 called hospice directly to report her uncontrolled pain and ineffectiveness of pain control regimen. Please refer to F697 for complete detail [MEDICAL CONDITION] and Respiratory assessments and monitoring R31's record lacked documentation of ongoing monitoring and assessments of [MEDICAL CONDITION] in legs and abdomen (per the hospice care plan) despite weight gains, and lacked ongoing respiratory assessments in order to identify changes and/or declines to notify hospice. R31's medication administration (MAR) included physican orders that included daily weight monitoring (start date 6/6/18), ace wraps to be applied to bilateral lower extremities in the morning and removed in the evening from toes to just below the knees (start date 1/1/19), and [MEDICATION NAME] (diuretic medication) 10 mg once a day for fluid overload (start date 12/18/18) weights since hospital readmission: 1/7/19-215.6 pounds (lbs.) 1/8/19-216.0 lbs. 1/9/19-216.0 lbs. 1/10/19-215.2 lbs. 1/11/19-216.2 lbs. 1/12/19-216.2 lbs. 1/13/19-218.0 lbs. 1/14/19-218.2 lbs. 1/15/19-220.0 lbs. R31's record lacked ongoing [MEDICAL CONDITION] monitoring and assessment of the physican ordered treatments of the [MEDICATION NAME] and use of the compression ace wraps for cardiovascular status. PN dated 1/9/19, indicated no acewraps were found in R31's room. PN date dated 1/10/19, indicated registered dietician completed nutritional assessment, R31 now on hospice, has had significant increase in weights after each hospitalization from 197.0 lbs to 216 lbs. Intake varies greatly, continue to monitor weight, intake and acceptance and tolerance of food. R31's MAR further included physician orders [REDACTED]. Although the MAR indicated [REDACTED]. Progress notes reviewed from 1/7/19-1/15/19, included the following respiratory assessment: -PN quarterly respiratory assessment dated [DATE], indicated the physician ordered nebulizer treatments and neb was completed. Lung sounds prior to nebulizer treatment were clear throughout, Oxygen saturation on oxygen 2 lpm was 99% Resident denied shortness of breath. Lung sounds assessed after nebulizer treatment and remained clear. Resident reports nebulizer treatments are effective. During an observation on 1/15/19, at 7:06 p.m. R31 laid in bed on her back with oxygen on 2 lpm, had slight wheezing upon exhalation. R31 requested a pain medication for pain rated 10/10 from registered nurse (RN)-D. Registered nurse did not auscultate lung sounds and the progress notes lacked documention of the respiratory status. During an observation on 1/16/19, at 9:36 a.m. R31 laid in bed with oxygen on 2L, had facial grimaces, and was near tears. R31's facial complexion was pale, had increased respiratory rate, and was breathing through her mouth. R31 stated she had a lot of bladder and abdominal pain and rated her pain 52 out of 10, was short of breath, and took a lot of medications for breathing, R31 stated she had her pain medication a couple of hours ago, stated she had asked registered nurse licensed practical nurse (LPN)-A, ten minutes ago for pain medication. R31 stated, I just want a pain medication, so I can go back to sleep. It hurts. During an interview on 1/16/19, at 9:53 a.m. licensed practical nurse (LPN)-B stated LPN-A took a break and would be back shortly. During an observation on 1/16/19, at 10:16 a.m. R31 laid in her bed with her oxygen on 2L, continued to display facial grimaces, and complexion pale, however, respiratory rate had slowed, and R31 stated breathing had improved. R31 stated she continued to be in a lot of pain and had not received any pain medications yet. During an observation on 1/16/19, at 10:26 a.m. R31 put on her call light, nursing assistant (NA)-A entered R31's room. R31 told NA-A she needed pain medication. At 10:27 a.m. NA-A communicated to LPN-A R31 wanted pain medication. During an observation and interview on 1/16/19, at 10:37 a.m. LPN-A administered R31 pain medication and stated R31 had abdominal pain and rated pain 10/10. LPN-A stated R31 had not previously asked for pain medication from her and she was just made aware. LPN-A stated she had given her morning medication around 7:30 a.m. and was doing fine. During an observation on 1/16/19, at 10:50 a.m. LPN-A asked R31 if she was doing ok, R31 stated, I am better now that I got my pain med! LPN-A administered R31 Tylenol and set up nebulizer equipment. R31 asked LPN-A if there was anything she could do for the burning when she urinated, LPN-A donned gloves and checked perineum however, did not check the catheter placement. LPN-A told R31 they would keep an on it and pulled R31's pants back up. R31 stated to LPN-A her pain level was a 10 right now, the [MEDICATION NAME] helped, and her pain was a 45 before. R31 stated, her left side of her stomach was bubbling and rated the pain 10/10; stated when she coughed my left side of my stomach really hurts, when she urinated the pain level was 45 but when she wasn't there was not pain. R31 stated the pain in her stomach was constant. LPN-A stated she would talk to the nurse manager to see what they could do. During an observation and interview on 1/16/19, at 12:09 p.m. NA-E was assisting R31 to reposition in bed. R31's cheeks were rosy and was not pale. R31 stated her pain was much better. R31 indicated the nurse had not returned to the room the check on her to see if her pain levels had come down since her other medication was administered at 10:50 a.m. During an observation on 1/17/19, at 8:09 a.m. R31 is sat in bed oxygen on 2 lpm, breathing normal with no signs of shortness of breath. R31 stated she felt really tired this morning, and legs feel really swollen. R31's oxygen was removed by nursing assistant (NA)-A, NA-A and NA-F assisted R31 to shower chair. R31 was then wheeled down to the shower room without oxygen on. Once positioned in the shower, R31's head tilted off to her right shoulder, closed her eyes, her tongue slipped slightly out of her mouth. NA-A stated R31 was awfully sleeping today. At 8:20 a.m. R31 continued to be in the shower without oxygen on, R31 stated she feels extra tired today. R31 was now breathing through her mouth and intermittently pursed lip breathing, coughed couple of times, respirations were 22-24 a minute with accessory muscle use/abdominal breathing. At 8:24 a.m. R31 leaned forward so NA-F could wash her back, R31's head remained rested on the right shoulder, as she leaned forward and leaned back; R31 stated her head felt heavy today. R31 continued to breath through open mouth and/or pursed lips. R31's right wrist continued to show indentation of where her watch was prior to being removed for her shower. At 8:33 a.m. R31's respirations continued to be 24-25, had weak moist coughs, lips were slightly purple, intermittently closed eyes, and continued to hold her head to the right side. At 8:35 a.m. R31 assisted NA-F in donning her shirt and R31's respirations increased to 29 after the shirt was put on, R31's lips were no longer a light purple color. At 8:36 a.m. LPN-A walked into the room, donned gloves and applied R31's cream, LPN-A was asked to measure R31's [MEDICAL CONDITION]: LPN-A stated on the left foot and calf had [MEDICAL CONDITION] of 1+ and on the right leg had [MEDICAL CONDITION] of +4 from foot to knee and had firm [MEDICAL CONDITION] from knee to hip. LPN-A donned acewraps to R31's legs. R31 asked if she could go lay down in her bed. NA-A stated to LPN-A R31 has been sleepy. LPN-A took R31 oxygen saturations which was 98% on room air and her heart rate was 107, R31 denied shortness of breath even though she continued to breath through her mouth and had pursed lip breathing. LPN-A did not complete a respiratory assessment and told R31 her nebulizer treatment was set up in her room. NA-A stated she did not always leave oxygen on during showers and would ask the resident if they wanted it left on. During an interview on 1/16/19, at 1:00 p.m. hospice supervisor registered nurse -(HSRN) stated she had not been aware of the high pain ratings after R31 was admitted to hospice and the doses given were not effective. Pain documentation and pain ratings were reviewed with HSRN; HSRN stated the multiple high pain levels R31 was concerning and the medication regimen should have been adjusted for more coverage either with increased dose or with a long acting. HSRN stated the expectation that the facility call the hospice nurse and communicate the ineffectiveness of the pain medication so hospice plan of care could be revised. HSRN found it very concerning the facility did not call and report to the hospice nurse about the effectiveness of the medication and the high pain ratings. HSRN indicated the facility is routinely educated on communication about pain medication effectiveness. HSRN stated one of the primary goals of hospice is to ensure the patient is comfortable. HSRN futher stated that the facility needed to monitor, assess, and document [MEDICAL CONDITION], respiratory status, and kidney function so the hospice nurses can determine care needs and treatments on an ongoing basis to ensure comfort. HSRN indicated that if the facility is not assessing and documenting, the hospice nurses who review the record are not able to accurately able to determine rate of decline, put measures in place proactively, and could impact our overall goal in managing the care and keeping the resident comfortable. HSRN indicated it was very important for the facility to monitor and identify declines in condition or changes in effectiveness of any medication so it could be adjusted accordingly. During an interview on 1/16/19, at 2:01 p.m. hospice registered nurse (HRN)-1 stated she was R31's case manager and admitted R31 to hospice. HRN-1 stated when R31 was in the hospital she received [MEDICATION NAME] intravenously and confirmed she had good pain control. HRN-1 indicated R31's discharge orders were for her to have [MEDICATION NAME] and [MEDICATION NAME] for pain control. HRN-1 then stated during the admission R31 and family indicated pain control and comfort was a priority. HRN-1 indicated when she had discussed the pain control regimen/medications the plan was to discontinue the [MEDICATION NAME] and start the [MEDICATION NAME] the following day 1/8/19. HRN-1 stated when she came for her second visit on 1/10/19, she had reviewed R31's pain documentation record and indicated awareness of ineffectiveness of pain medication, however, R31 had stated no concerns with pain when she was asked so the documentation in the record was not really taken into account. HRN-1 stated she was not aware R31 had called hospice the other day for an increase in pain medication and would be reviewing her medication regiment today. HRN-1 stated she as not aware of any increased [MEDICAL CONDITION], and or abdominal ascites and would expect the facility to document and monitor for worsening. During an interview on 1/16/19, at 2:31 p.m. LPN-C verified she had been the nurse on duty the night R31 called hospice. LPN-C stated that evening R31 put on her call light, NA answered the calllight, and came into the nursing station where her and the TMA were at. LPN-C indicated, the NA reported R31 requested pain medication, TMA stated she could not yet have it and it was too early, then the TMA walked down to R31's room and informed R31 that it was too early for her to have the pain medication. LPN-C stated she had not assessed R31's pain. LPN-C stated shortly after the TMA arrived back tot he nursing station, the hospice nurse called with new [MEDICATION NAME] orders for every one hour. LPN-C stated if pain medications were not [MEDICATION NAME] until the next available dose then hospice and/or physician should be informed. LPN-C stated nurses were supposed to check back anywhere between 15-30 minutes to assess whether the pain medication was effective or not. LPN-C then asked LPN-A if there was any as needed medications that needed to be followed up on. LPN-A stated the only as needed medication that she had given was to R31. LPN-C then referenced R31's MAR indicated [REDACTED]. LPN-C stated she would have to document unknown. During an interview on 1/16/19 at 2:51 p.m. LPN-A was asked about the 9:26 a.m. administration time, as LPN-A stated she had just documented a short time ago that she had administered the dose at 9:26 a.m. and could not remember exactly what time she had administered the dose. LPN-A confirmed she had not assessed R31's pain after she had administered the dose in order to ascertain effectiveness. During an interview on 1/16/19, at 3:46 p.m. director of nursing (DON) reviewed R31's pain documentation, and indicated the pain assessments were incomplete, for doses not effective there should have been follow-up completed and documented. DON stated hospice and/or the physician should have been notified if the pain medication and/or non-pharmacological interventions were not working. DON stated it was not ok to tell someone they have to wait for the next dose. DON indicated when PRN medications were administered it was an expectation that the pain is re-assessed after administration and ongoing to ensure comfort. DON confirmed the facility was doing daily weights, and R31's record lacked [MEDICAL CONDITION] monitoring. DON also indicated respiratory assessments were not documented. DON indicated it was important for monitoring of respiratory function and fluid retention was monitored in order for hospice to determine ongoing care needs were provided in a timely manner. During an interview on 1/17/19, at 6:56 a.m. licensed practical nurse (LPN)-A stated she did not measure and/or evaluate [MEDICAL CONDITION] in R31's legs or abdomen and thought the registered nurses (RNs) did that. During an interview on 1/17/19, at 6:59 a.m. LPN-D stated she did not measure [MEDICAL CONDITION] routinely unless an assessment came up that required a value, stated nursing assistants (NAs) were good about communicating changes. During an interview on 1/17/19, at 10:04 a.m. registered nurse (RN)-A stated she didn't measure R31's [MEDICAL CONDITION] and was not monitored, she had assessed R31's lung sounds before and after a nebulizer treatments, however, respiratory status was not assessed routinely. RN-A stated if pain medications were not effective the hospice should be notified, and pain should be assessed before and a pain medication is given and then evaluated for effectiveness. RN-A stated if the resident was requesting pain medication prior to the next dose, hospice and/or the physician should be contacted. During an interview on 1/17/19, at 10:13 a.m. RN-C stated R31 has never had any issues with [MEDICAL CONDITION] until the last hospitalization and started using ace wraps. RN-C indicated although R31's legs and abdomen were looked at routinely R31's record lacked documentation of that monitoring. RN-C further indicated R31 got short of breath and R31's record lacked evidence of mention of all occurrences and/or completed respiratory assessments during episodes. During an interview on 1/17/19, at 3:35 p.m. R31 sat in her bed with a smile on her face. R31 stated her pain medications were adjusted yesterday; and now she had scheduled [MEDICATION NAME] with meals and she could have as needed doses every hour inbetween the scheduled doses. R31 stated it's going so much better and her pain was finally under control. Mayo Clinic Health System Hospice and Nursing Home Agreement signed and dated by the hospice agency on 9/11/13 included the following: Services to Residents: Section 2.1 Hospice Services. As requested by residents or resident's families Hospice shall provide hospice services to residents who qualify for such services in accordance with hospice criteria for admission to hospice programs. Hospice shall routinely provide all core hospice services (including medical direction and management of the patient, physician services, hospice nursing services, medical social services and counseling directly by hospice employees. The full range of hospice services including medication necessary for palliation of pain and symptoms associated with the terminal illness and related conditions, durable medical equipment and supplies related to hospice patient's terminal illness. Hospice shall be available to provide hospice services as required by law and regulation 24-hours per day, seven days per week. Section 3.3 Home Responsibilities. Home shall furnace to each patient 24 hour room and board services, meet the resident's personal care and nursing needs n coordination with hospice representative, and ensure that the level of care provided is appropriately based on the individual resident needs. With respect to manage (TRUNCATED)