Every finding on record at Rex Rehab & Nursing Care Center

Based on record review and staff interviews, facility failed to have accurate advanced directive documentation throughout the medical record for 1 of 5 residents reviewed for advanced directives (Residents #25). The findings included: Resident #25 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and hypertension.Her admission Minimum Data Set assessment dated [DATE] revealed Resident #25 was cognitively intact.The electronic medical record profile indicated Resident #25's code status as do not resuscitate. Review of the advanced care planning notes, which are progress notes, in Resident #25's medical record indicated she did not have an advanced directive.A Medical Orders for Scope of Treatment (MOST) form dated [DATE] for Resident #25 stated attempt CPR (cardio-pulmonary resuscitation) and full scope of treatment.Review of Resident #25's physician's orders revealed there was no order addressing code status.An interview was conducted on [DATE] at 3:34 PM with the Social Worker (SW) who stated Resident #25's code status was do not resuscitate. The SW could not explain why the electronic record profile stated a code status of do not resuscitate while the MOST form stated attempt CPR and full scope of treatment.An interview was conducted on [DATE] at 4:00 PM with the resident and she stated she wished to have a code status of do not resuscitate.An interview was conducted on [DATE] at 3:45 PM with the Director of Nursing (DON). The DON could not explain why Resident #25's medical record showed a discrepancy regarding her code status with the electronic medical record profile and the MOST form in the chart. She reported in an emergency she believed staff would follow the electronic medical record profile which indicated do not resuscitate. The DON stated she would ensure the code status was corrected throughout the medical record which would be a do not resuscitate.

Based on observations, record review, facility neighbor, resident, and staff and physician interviews the facility failed to provide the necessary supervision to prevent a severely cognitively impaired resident (Resident #52) who was at high risk for falls from exiting the interior of the facility through an unlocked door leading to an enclosed exterior courtyard. On 1/14/24 an individual who resided in a nearby home heard Resident #52 yelling for help and Neighbor #1 and Neighbor #2 crossed over the fence into the facility's courtyard and found Resident #52 dressed in a night gown lying face down on the brick paved ground. Resident #175 was shivering and kept saying I'm so cold. Her temperature was 90.9 degrees Fahrenheit (F) which was indicative of hypothermia (a condition where the body's temperature drops below 95 degrees F which can result in death). This deficient practice affected 1 of 3 residents reviewed for accidents. Findings included: Resident #52 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident #52's care plan revealed in part a problem area initiated on 8/19/21 of fall risk. The goal, with an expected end date of 2/20/24, was for Resident #52 to have no injury related to falls through the next review. Interventions included 8/24/23 draw labs for medical evaluation, and 9/12/23 recheck the auto lock brake function on WC. A review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She did not exhibit wandering behaviors. She had no functional limitation in range of motion of her upper and lower extremities. She used a wheelchair (WC) and a walker for mobility. Resident #52 required supervision for bed mobility, transfers, and walking at least 50 feet with making 2 turns. She had 2 or more falls with injury during the assessment period. Resident #52 did not use a wander/elopement alarm. A review of the wandering risk assessment for Resident #52 dated 11/7/23 revealed she did not wander or have a history of wandering. She did not elope or have a history of elopement. She was currently cognitively impaired and had impaired decision making skills. On 5/14/24 at 3:49 PM an interview with the MDS Coordinator indicated a wandering risk assessment was conducted for each resident every time an MDS assessment was completed and as needed. The MDS Coordinator stated the wandering risk assessments the facility used did not result in a score or draw a conclusion, but the IDT team discussed them, and decided whether or not a wander alarm was indicated for the resident. She further indicated Resident #52 had MDS assessments on 8/8/23, and again on 11/7/23 and she was discussed during the interdisciplinary team meetings (IDT) that occurred for each MDS. She reported although Resident #52 was assessed to have impaired cognition and impaired decision making skills on these wandering risk assessments, she had no episodes of wandering behavior, and a wander guard alarm had not been indicated for her. A review of a fall risk assessment for Resident #52 dated 1/8/24 revealed she was at high risk for falls. A review of a nursing progress note for Resident #52 dated 1/15/24 at 1:30 AM written by Nurse #1 revealed at 11:55 PM two men (Neighbor #1 and Neighbor #2) came to the nurse saying they heard a resident yelling for help, so they climbed through the fence and found the resident lying on the ground face downward. The nurses immediately organized a search to make sure all residents were in their bed but found that Resident #52 was not in her bed. The Neighbors had helped her to sit on a chair. On assessment, a minor scratch was noted between Resident #52's right thumb and index finger. She was shivering. An extra blanket was supplied. Her temperature was initially 90.9 degrees F (a normal body temperature is 98.6 degrees F). She was alert, verbal and in good spirits but shivering. The physician was notified and ordered first aid to right thumb area. The police and facility security were also in the building. On 5/14/24 a review of the Weather Underground website revealed the outdoor air temperature where the facility was located on 1/14/24 at 11:51 PM was 41 degrees F. On 5/16/24 at 12:09 PM a telephone interview was conducted with Neighbor #1 who found Resident #52 on 1/14/24. He indicated he lived in an apartment next door to the facility. He stated on 1/14/24 around 11:30 PM his wife told him she heard someone calling for help. He reported it was dark and cold out, and at first, he was not going to do anything. He further indicated he went outside and saw his neighbor (Neighbor #2) and asked him if he also heard someone calling for help. He stated his neighbor told him he heard it too, and they walked over and looked through the fence that bordered the facility courtyard. Neighbor #1 stated they saw a woman (Resident #52) lying face down on the brick paved walkway. He reported Neighbor #2 slipped through the fence and he himself jumped over. He stated they helped the woman up and assisted her to walk over and sit on a bench. He indicated Neighbor #2 gave the woman his coat. He stated the woman had some scrapes but no other injuries he could see, she was shivering, and she just kept saying, I'm so cold. He indicated they left the woman on the bench, went inside through an unlocked door, told the first person they saw that a woman was outside, and asked for some blankets. He indicated this person just asked them how they got into the building. He stated another staff member came out with a WC and helped the woman into the building. On 5/14/24 at 4:25 PM a telephone interview with Nurse #1 indicated she was familiar with Resident #52 and assigned to her care on 1/14/24 from 11:00 PM until 7:00 AM. She stated Resident #52 was cognitively impaired and at times could walk with her walker, and other times used her WC for mobility. She went on to say it was not unusual for Resident #52 to walk out into the hall on her shift, but she would just walk Resident #52 back to her room and assist her into bed. Nurse #1 stated Resident #52 had never tried to go outside by herself that she knew of prior to the 1/14/24 incident. Nurse #1 stated that evening, she had gotten her report at the nurses station, her back had been to the hallway, and she had not seen Resident #52 walk by. She reported that night (1/14/24), two men (Neighbor #1 and Neighbor #2) had come into the facility and asked her to follow them because there was a resident in the courtyard. She further indicated she had been very taken aback because she had not known how they got into the facility. Nurse #1 stated she had immediately announced for everyone to check all their resident rooms, went to check all her resident rooms, and in about 2 minutes realized Resident #52 was not in her bed. She stated Resident #52 had been wearing a long sleeved cotton night gown and either gripper socks or house slippers. Nurse #1 stated it was very cold outside and Resident #52 had been shivering, but she was not wet. She stated Resident #52 was assessed and her temperature was very low. She stated she covered her with blankets, let the physician know, and monitored Resident #52 continuously, taking her temperature frequently until her temperature came back up to normal. She reported she then assisted Resident #52 back to bed. On 5/14/24 at 8:14 PM a follow-up telephone interview with Nurse #1 stated she had not seen Resident #52 while she was in the courtyard. She indicated when she ran down to the courtyard on 1/14/24, Neighbor #1 and Neighbor #2 and an NA had already brought Resident #52 into the building in a WC. She stated Resident #52 felt cold to the touch and was shivering but she was talking. Nurse #1 stated the physician told her to warm Resident #52 up, continue taking her temperature, and if it didn't come up to send Resident #52 to the hospital. She indicated she monitored Resident #52 continuously and rechecked her temperature until it came up. On 5/14/24 at 5:55 PM, in a telephone interview, NA #1 indicated on 1/14/24 she worked from 11:00 PM until 7:00 AM. She stated she was not assigned to Resident #52 on 1/14/24. She explained after reporting to work when she was coming down the hall to her assigned area, she saw Resident #52 near the nurses station. She reported she spoke with Resident #52 and helped her back to her room. She further indicated Resident #52 had not needed anything, and she helped Resident #52 get into bed, covered her up with blankets, and left her room. NA #1 stated she was familiar with Resident #52, and it was not unusual to see Resident #52 up that late walking, so she had not felt the need to report the behavior to a nurse. She went on to say she had not seen Resident #52 the rest of the night. She further indicated she had no reason to check the courtyard door to see if it was locked, because the courtyard was dark at night, and she never went out there on her shift. On 5/15/24 at 12:11 PM a telephone interview with NA #2 indicated she worked the 11:00 PM to 7:00 AM shift on 1/14/24. She stated on 1/14/24 at about 11:30 PM two men (Neighbor #1 and Neighbor #2) came knocking on the glass Activity Room exit door which was beside the courtyard door. She further indicated Nurse #4 responded to them and reported Neighbor #1 and Neighbor #2 said there was someone lying on the patio. NA #2 stated when she got out to the courtyard, it was dark, but she could see Neighbor #1 and Neighbor #2 walking Resident #52 back towards the facility with one man on either side of Resident #52. She went on to say Resident #52 was having a hard time walking, so she ran to get a WC. She stated she did not ask Neighbor #1 and Neighbor #2 whether or not Resident #52 was on the ground when they found her. She reported one of the men had given Resident #52 their jacket, but Resident #52 was still shivering. She further indicated she got Resident #52 to the nurses station and took her full vital signs. NA #2 stated Resident #52's oral temperature was around 90 degrees F. She stated Nurse #1 was present and they got Resident #52 covered in blankets. She further indicated after she took Resident #52's vital signs, Nurse #1 attended to Resident #52, and she went back to her own assignment. NA #2 stated the facility's exit doors had alarms which would go off if someone tried to exit through them when they were locked, or if a resident was wearing a wander guard alarm. She went on to say there were no alarms going off that night. She further indicated she was familiar with Resident #52. NA #2 stated Resident #52 did at times walk by herself, but she would be redirected, and her needs attended to, and she would be assisted to sit back down in her WC. She indicated she had never seen Resident #52 try to exit the facility. She further indicated Resident #52 had never expressed to her a desire to leave the facility. Documentation by NA #3 of vital signs including temperature revealed on 1/15/24 at 12:40 AM her oral temperature was 97.3 degrees F and on 1/15/24 at 1:25 AM her oral temperature was 98.7 degrees F. A review of a physician's progress note dated 1/16/24 written by Physician #2 revealed on the evening of 1/14/24 Resident #52 wandered out of the facility into an enclosed courtyard. The resident had fallen. She was found on the ground face down. She was brought back to her room. There was some right hip discomfort. X-rays (radiologic imaging studies) were pending. The resident did not recall wandering. A review of the hip x-ray results for Resident #52 dated 1/16/24 revealed there were no new fractures or dislocations. A review of the facility's undated timeline of the event, provided by the Administrator on 5/14/24, revealed in part the following: The courtyard door should be open from 7:00AM to 9:00 PM. On 1/14/24 at approximately 11:14 PM Resident #52 walked with her walker from her room to the courtyard exit door and exited into the courtyard. At approximately 11:46 PM two men (Neighbor #1 and Neighbor #2) entered the building through the courtyard door to inform staff that a resident had fallen in the courtyard, they heard her yelling for help, and jumped the fence. Upon assessment, Resident #52 had a small skin tear. She was wearing only her night gown and socks. Her vital signs were obtained, and her body temperature was low. She was provided extra blankets and monitored. X-rays were ordered and were negative. The physician and her family were notified. Management was notified. A wander guard band was placed on Resident #52 on 1/15/24 and verification was done to determine it locked down the courtyard door. On 5/14/24 at 1:31 PM, in an interview, the Administrator stated there had been one incident where Resident #52 went out into the courtyard at night unsupervised and had fallen. She went onto say she had watched video surveillance footage of this. She reported the video footage showed on 1/14/24 Resident #52 was seen coming out of her room with her walker, walking to the end of her hall, and looking out the exit door. The Administrator stated Resident #52 was then seen walking back past the nurses station where NA #1 intercepted Resident #52 and walked with Resident #52 back to her room. She stated NA #1 was seen exiting Resident #52's room at 11:08 PM. She indicated at 11:11 PM Resident #52 was seen coming back out of her room, walked past the nurses station where the nurses were getting report, and at 11:14 PM the footage showed Resident #52 reach the courtyard door. The Administrator stated there were no cameras in the courtyard, so she was not able to see Resident #52 go through the courtyard door but at 11:46 PM two men were seen on the footage entering the building through the courtyard door. On 5/14/24 at 4:04 PM a follow up interview with the Administrator indicated the facility's video footage currently only went back to 3/15/24, and the footage from the event on 1/14/24 could no longer be viewed. On 5/14/24 at 1:43 PM a follow-up interview with the Administrator she indicated Resident #52 had not been assessed on her most recent wandering risk assessment prior to the event to be at risk for wandering. She stated if Resident #52 had been wearing a wander guard alarm on 1/14/24, she would not have been able to exit through the courtyard door. On 5/14/24 at 3:30 PM a follow-up interview with the Administrator indicated the MDS Coordinator conducted a wandering risk assessment quarterly and as needed for residents. She stated normally, the courtyard door locked down automatically from 9:00 PM and opened up again at 7:00 AM daily. She went on to say the facility had a new wander guard system installed in October of 2023 and after the installation, the front doors, which were on the same timer, were working okay. She further indicated she had no reason to suspect the courtyard door was not functioning properly. On 5/16/24 at 8:18 PM a follow-up interview with the Administrator indicated on 10/26/23, work was completed to install a new wander guard system. She stated she did not know whether the courtyard door had been locking as it was scheduled to after this date, because she had no reason to suspect they were not locking until the incident with Resident #52 occurred on 1/14/24. She further indicated it was determined the likely cause of the courtyard door lock failure was the wander guard system and the system which locked the door were not connected. The Administrator stated there was a wire in the wander guard system that wasn't connected properly, and she had to coordinate with the security system company and the wander guard provider to come back and connect the wires properly in order for the security system for the facility to be able to lock the doors. On 5/14/24 at 4:05 PM an interview with the Director of Nursing (DON) indicated she watched the video footage of Resident #52's incident on 1/14/24. She stated she recalled that Resident #52 had been wearing a long sleeved cotton night gown and slippers that covered her toes. She indicated Nurse #1 had called her at the time of the incident to notify her and let her know that she had spoken with Physician #1 who told Nurse #1 to warm Resident #52 up, monitor her temperature and if it didn't start to come up to send her out to the hospital. The DON stated she had come in early the next morning on 1/15/24 at about 5:30 AM and a wander guard alarm was placed on Resident #52. She further indicated Resident #52's usual routine was to get up around 1:00 AM to 2:00 AM and peek out her door, but she would usually just turn around and go back to bed. She stated she was not aware of any other time Resident #52 exited unsupervised from the facility. On 5/15/24 at 11:37 AM a telephone interview with Nurse #3 indicated she worked on 1/14/24 from 3:00 PM until 11:00 PM as an NA, and then 11:00 PM until 7:00 AM as a Nurse. She stated on the 3PM-11PM shift on 1/14/24 she saw Resident #52 self-propelling her WC in the hallway, but the NA who was assigned to Resident #52 was monitoring her. She indicated this was not unusual for Resident #52. She further indicated Resident #52 could walk with her walker, and was at high risk for falls, as she would get up without asking for assistance. Nurse #3 stated in the past, she might have just assisted Resident #52 into bed, or into her chair after seeing to her needs and Resident #52 seemed to comprehend when she told her not to get up by herself. Nurse #3 stated the minute she turned her back, Resident #52 would be up standing trying to walk by herself. She stated she had never seen Resident #52 attempt to exit the facility. She went on to say she had never heard Resident #52 say she wanted to leave the facility. Nurse #3 stated she herself had never tried the courtyard doors in the evening prior to the 1/14/24 incident to see if they were locked. On 5/15/24 at 12:31 PM a telephone interview with Physician #1 indicated he was on call the night of 1/14/24 when he was notified that Resident #52 had been found outside after having fallen. He stated Resident #52 had a small cut on her hand, her temperature was around 90 degrees F, and she was shivering. He reported rather than put Resident #52 through the trauma of being sent to the hospital, they attempted to get her temperature up at the facility. He further indicated 98.6 degrees F orally was a normal body temperature. Physician #1 stated at 90 degrees F, that was a bit low and potentially early hypothermia. He went on to say Resident #52's heart rate had not been elevated, and her breathing had not been affected. He further indicated he felt she might have needed to be outside another hour or two before the potential consequences for her would have been serious. Physician #1 stated a body temperature of 90 degrees F to 95 degrees F was mild hypothermia, below 90 degrees F was moderate hypothermia, and below 82 degrees F was severe hypothermia. He indicated the nurse had been monitoring Resident #52's temperature appropriately, Resident #52's temperature had been trending in the right direction, and she had not suffered any consequences from the event. On 5/15/24 at 12:39 PM a telephone interview with NA #6 indicated she worked on 1/14/24 from 11:00 PM until 7:00 AM. She stated she did not observe the event, and when she saw Resident #52, she was at the nurses station having her vital signs taken. She went on to say Resident #52 was shivering because she was so cold, and she had blankets on. She further indicated she was familiar with Resident #52. NA #6 stated Resident #52 was a fall risk and had interventions in place such as a low bed, and an NA sitting outside her door if she was having a restless night. She indicated at times the NA assigned to Resident #52 would take her to the television room, get her a snack and sit with her watching television until Resident #52 got sleepy. On 5/15/24 at 1:10 PM a telephone interview with NA #3 indicated she was assigned to care for Resident #52 on 1/14/24 on the 11:00 PM to 7:00 AM shift and was familiar with her. She stated Resident #52 had behaviors where she would get up and walk unassisted and come out into the hall. She went on to say she would monitor Resident #52 frequently, walk with her, ask her what she needed, meet her needs, and redirect her assisting her to sit in her WC. She further indicated some nights if Resident #52 was restless, she would sit with her in the television room until Resident #52 got sleepy. NA #3 stated Resident #52 was a fall risk and she checked on her frequently throughout the night. She stated she did not observe the event that on 1/14/24. She reported when she got to work at 11:00 PM on 1/14/24 she began her rounds on her assigned residents. She indicated she had not yet gotten to Resident #52's room and was in another room assisting a resident when she was notified there was a resident outside. On 5/15/24 at 2:37 PM an interview with the facility's Maintenance Director indicated he had been working at the facility for two years. He stated he was familiar with the event that occurred with Resident #52 on 1/14/24. He reported there had been a company at the facility within the last 6 months working on the system that alarms for residents who have a band that sets off an alarm if they attempt to go outside. He further indicated he was not aware that this company disrupted the timing of the automatic locking of the courtyard door, or he would have put a system in place that included a magnetic alarm that sounded when the door was open. He stated the courtyard door had been on a timer that automatically locked it down from 9:00 PM until 7:00 AM prior to the disruption. He went on to say this was supposed to happen automatically. He indicated the courtyard door had been the only door affected by the disruption to the system. On 5/15/24 at 4:19 PM Resident #52 was observed in bed. She had a wander guard alarm in place to her right ankle. An interview with Resident #52 at that time indicated she did not recall going out by herself to the courtyard and falling. The Administrator was notified of Immediate Jeopardy on 5/15/24 at 10:39 AM. The Administrator provided the following corrective action plan with a compliance date of 1/16/24: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #52 was immediately brought in and assessed by Nurse #1. Resident #52's axillary temp was 90.9 Fahrenheit (F) and noted Resident #52 was shivering. Resident #52 was provided with blankets as Resident #52 stated she was cold. Nurse #1 promptly notified the Medical Director of the incident and the Resident #52's current condition. The Medical Director instructed Nurse #1 to monitor Resident #52's temperature and if it did not return to normal to send the Resident #52 to the Emergency Department. Resident #52 was alert and in good spirits per Nurse #1's notes. Resident #52 only displayed shivering. Resident #52's temp at 12:40AM on 1/15/2024 was 97.3F, heart rate of 72, blood pressure of 157/84, respirations at 20, and oxygen saturation of 99 percent. Resident #52 was reassessed at 1:25AM with a temperature of 98.7F, heart rate of 77, respirations at 18, and blood pressure at 152/78. At 1:30AM Nurse #1 notified Resident #52's son via phone of the incident, Resident #52's condition and the action taken to care for and monitor Resident #52. Resident #52 was monitored closely by Nurse #1 throughout the shift. Resident #52's vital signs at 8:20AM on 1/15/2024 was a temperature at 98.1F, heart rate of 70, respirations at 18 and blood pressure at 121/60. Nurse #1 maintained direct supervision of Resident #52 for the first hour and when Resident #52 returned to their room Nurse #1 implemented frequent rounding on Resident #52. All nurses increased rounding frequency on all residents in the facility. At 2:00AM Nurse #1 called the Director of Nursing to escalate the incident that occurred. The Director of Nursing returned her call at 4:30AM and Nurse #1 provided information regarding the incident, Nurse #1 stated that the Resident #52 was stable, confirmed that all residents were safe and in their rooms. Nurse #1 notified the Director of Nursing that local police and security personnel had been on site following the entrance of two unidentified males into the facility and cleared the scene after finding it safe. On 1/15/2024, the Administrator made the executive decision to place a wander guard pendant on Resident #52, which was placed on Resident #52 at approximately 8:00AM. On 1/15/2024, at 9:36AM, the Minimum Data Set Coordinator updated the care plan by adding the 'Long Term Care Wander Guard' care plan for Resident #52. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All mobile residents without a wander guard pendant had the potential to be affected. On 1/14/2024 at approximately 11:45PM, nursing staff conducted a search of the facility and determined all residents were accounted for except for Resident #52 who was not in their room. Following the search, nursing assistants and nurses increased frequency of rounding on all residents. On the morning of 1/15/24, it was determined by the Administrator that the courtyard doors' remote locking system did not lock as intended. On 1/15/2024 at 7:40AM, the Administrator notified the Protective Services Director and the [NAME] President that the courtyard doors were found to not be locking properly. The Administrator also notified the wander guard company and placed a ticket for repair. The remote locking system unlocks the doors to the facility at 7AM for normal operations, because of this, no immediate action was taken to secure doors as they were unlocked for normal operations. In the afternoon of 1/15/2024 the Director of Nursing, Director of Protective Services, and the Administrator met via phone to conduct an 'Event After Action Report' to develop an action plan and monitoring processes. The 'Event After Action Report' identified the need to implement an alarm system for the courtyard doors to prepare for nightshift. At approximately 3PM, The Maintenance Director placed an auditory alarm on each courtyard door so that if the door opened, an alarm would sound and notify staff. On 1/16/2024, the Director of Protective Services assessed the courtyard doors and tested the access control lock feature, which revealed it was failing. Following this assessment, the Administrator placed another ticket with the company that installed the wander guard system. On 1/17/2024, the wander guard company arrived at the facility, but was unable to correct the issue because the installation company needed to be present. On 1/19/2024, the installation company arrived and stated that both the remote locking system staff and installation company were needed to resolve the issue. The Administrator coordinated with both companies and on 1/22/2024, the installation company and remote locking system staff were able to correct the connection that prevented the courtyard doors from locking. Prior to releasing the door back to normal operations, the access control company retested the doors to confirm the issue was repaired. The courtyard doors had audible alarms in place from 1/15/2024 until 1/22/2024, while awaiting the remote locking system to be repaired. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: On 1/22/2024, a new procedure was implemented by the Administrator, or designee, to coordinate with the remote locking system team to test the remote locking system after any work is completed on the doors that have the remote locking system in place, which includes the facility's front door, courtyard door one, and courtyard door two. Going forward, this test will be completed before the vendor leaves the premises and before releasing the door back into normal operation. On 1/22/2024, the Administrator provided education on the new procedure to the Director of Protective Services (leader for the remote locking system team), and the Director of Nursing. The facility has a process for all staff to receive updates through a shift report with information disseminated by the Director of Nursing to the Team Leaders. The shift report is a document that includes talking points by the Team Leaders to communicate important information with staff at the beginning of their shift. On 1/15/2024 the Director of Nursing updated the shift report to include the information about the incident that occurred with the failed remote locking mechanism and that an attached manual audible alarm on the doors leading to the courtyard was being used until the remote locking mechanism could be fixed. The Director of Nursing educated the on-site Evening Team Leader about the failed remote locking mechanism and that an attached manual alarm was being used. From 3:00pm on 1/15/2024 forward no staff worked without knowing about the failed remote locking mechanism and the use of an attached manual audible alarm on the doors leading to the courtyard was being used until the remote locking mechanism could be fixed. On 1/22/2024 the Administrator trained the Clinical Manager to perform the remote locking control audits. Later that same day, the Clinical Manager trained the four Nursing Assistants (NA) designated to perform the remote locking control audits. The four NAs were educated prior to performing the audits. On 2/13/2024 the decision was made by the Administrator to change the responsible staff to night shift nurse team leaders to begin performing the weekly audits based on staffing availability. On 2/13/2024 the Administrator educated all evening and night shift nurse team leaders on how to perform the remote locking control audits prior to them performing the weekly audits. During orientation all staff receive education regarding the chain of command used to escalate safety concerns, including concerns with security of the facility. Staff are educated to escalate to the Team Leader, Director of Nursing and/or the Administrator. The Staff Department Coordinator is responsible for providing this education to staff prior to the staff working in the facility. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: The monitoring plan, determined by the 'Event After Action Report', started with daily audits beginning when the door locks were repaired, and the auditory alarms removed. After three weeks of audits showing no failures, the audits became weekly. Specific dates are as follows: On 1/15/2024, the courtyard doors had an alarm in place that would alert staff if the door was opened. On 1/22/2024, once the doors were fixed, the temporary alarms were removed, and nightly audits were completed by a lead nursing assistant until 2/10/2024. The week of 2/11/2024 the nightshift nurse team leader began weekly audits to ensure that the doors remain locked at night. The audits collected, in addition to the new procedure, are reported out to the Quality Assurance and Performance Improvement (QAPI) committee monthly by the Administrator. The QAPI committee determines the frequency of monitoring required based on audit results. All action items were discussed at the February 29, 2024, QAPI meeting. Members of the QAPI committee include: Administrator, Medical Directors, Director of Nursing, Pharmacist Consultant, Business Office Manager, Rehabilitation Director, Rehabilitation Team Lead, Staff Development Infection Control Nurse, Activities Coordinators, Dietary Manager, Wound Nurse, Admissions Director, Dietician, MDS coordinators, Health Information Management HIM Specialist, Administrative Assistant, Business Office Assistant. Include dates when corrective action will be completed: Alleged immediate jeopardy removal date and compliance date: 1/16/2024. Validation of the corrective action plan was completed on 5/17/24. This included interviews with the Director of Protective Services, the DON, the Evening Team Leader, two NAs who worked after 1/15/24, the Clinical Manager, one NA who was des [TRUNCATED]

Based on record review and staff interviews the facility failed to complete a recapitulation of stay for 2 of 2 residents reviewed for a planned discharge from the facility to home (Resident #79 and Resident #146). Findings included: 1. Resident #79 was admitted to the facility on [DATE] and discharged home on 3/07/24. The discharge Minimum Data Set, dated dated dated [DATE] revealed Resident #79 was coded as cognitively intact. Review of Resident #79's electronic health record revealed a discharge summary completed by different disciplines dated 3/07/24. Further review of the discharge summary revealed that it did not include the required components of the recapitulation of stay and a final summary of the resident's status at discharge to include customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, continence, skin conditions, dental status, physical function, and structural problems. An interview on 5/15/24 at 3:30 PM with the Social Worker (SW) revealed that she completed her section of the discharge summary and was unaware if anyone ensured all sections of the discharge summary were completed. An interview on 5/16/24 at 11:45 AM with the Administrator revealed that she was aware of the requirements for the recapitulation summary and stated that the facility utilized the electronic system form titled After Visit Summary. She stated that she did not realize that the After Visit Summary did not contain the required components. The Administrator stated that each discipline completed their discharge section and there was no one person responsible for ensuring all sections were completed. 2. Resident #146 was admitted to the facility on [DATE] and discharged home on 10/21/23. The discharge Minimum Data Set, dated dated dated [DATE] revealed Resident #146 was coded as cognitively intact. Review of Resident #146's electronic health record revealed a discharge summary completed by different disciplines dated 10/21/23. Further review of the discharge summary revealed that it did not include the required components of the recapitulation of stay and a final summary of the resident's status at discharge to include customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, continence, skin conditions, dental status, physical function, and structural problems. An interview on 5/15/24 at 3:30 PM with the Social Worker (SW) revealed that she completed her section of the discharge summary and was unaware if anyone ensured all sections of the discharge summary were completed. An interview on 5/16/24 at 11:45 AM with the Administrator revealed that she was aware of the requirements for the recapitulation summary and stated that the facility utilized the electronic system form titled After Visit Summary. She stated that she did not realize that the After Visit Summary did not contain the required components. The Administrator stated that each discipline completed their discharge section and there was no one person responsible for ensuring all sections were completed.

Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to obtain orders for the use of supplemental oxygen for 1 of 1 resident reviewed with oxygen (Resident #133). Findings included: Resident #133 was admitted to the facility on [DATE] with diagnoses which included shortness of breath and acute kidney failure. Resident #133's admission Minimum Data Set was in progress. Review of Resident #133's care plan last updated 5/14/24 revealed a problem for impaired gas exchange. The goal was that the resident maintained adequate gas exchange as evidenced by oxygen saturation within normal limits and absence of hypoxia through the next review. The interventions included monitoring for signs and symptoms of hypoxia and administer oxygen as ordered. Review of the physician orders revealed no order for supplemental oxygen use. An observation made on 5/13/24 at 2:25 PM revealed that Resident #133 wore oxygen via nasal cannula at 2 liters per minute. An observation made on 5/14/24 at 8:50 AM revealed that Resident #133 wore oxygen via nasal cannula at 2 liters per minute. An observation made on 5/15/24 at 11:29 AM revealed that Resident #133 wore oxygen via nasal cannula at 2 liters per minute. An interview on 5/15/24 at 11:19 AM with Nurse #5 revealed that Resident #133 wore supplemental oxygen for comfort. She confirmed that there was no physician's order for oxygen for Resident #133. She stated that there should be an order and she did not know why there was no order. An interview on 5/15/24 at 2:42 PM with Nurse Practitioner #1 revealed that Resident #133 should have an order for supplemental oxygen and she did not know why there was no order. An interview on 5/16/24 at 11:45 AM with the Administrator revealed that Resident #133 should have an order for supplemental oxygen. She stated that she thought the Nurse Practitioner had just forgotten to enter the order.

Based on observations and staff interviews the facility failed to secure resident medications stored in an unattended and unlocked medication cart (Wing D) for 1 of 5 medication carts. The findings included: A continuous observation was conducted of the Wing D medication cart on 5/16/24 at 9:50 AM through 9:56 AM. The cart was parked midway down the hall with the drawers of the cart facing out. The medication cart was observed with the lock not engaged as evidenced by the red dot on the lock being visible. There was no staff member with the medication cart. Four staff members, one resident, and 2 visitors were observed walking past the unlocked medication cart. Nurse #2 came out of a resident room and returned to the medication cart at 9:56 AM. Nurse #2 was asked to open the top drawer and realized she had left the medication cart unlocked. Nurse #2 stated she usually locked her cart and revealed it should be locked any time she was not using it. An interview with the Director of Nursing (DON) on 05/16/24 09:59 AM was completed. The DON stated the medication cart should have been secured and locked unless the nurse was present at the cart. The DON further stated that the nurse assigned to the medication cart was responsible for it and ensuring that it was secured. An interview with the Administrator on 05/16/24 10:02 AM revealed medication carts should not be unlocked unless the Nurse was standing in front of it. The Administrator stated the nurse assigned to that medication cart was responsible for it for their entire shift.

Based on observation and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the 3/23/23 recertification and complaint survey in the area of Medication Storage (F761). This deficiency weas cited again on the current recertification and complaint survey of 5/17/24. The continued failure of the facility during 2 federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance program. The findings included: This tag is cross referenced to: 1. 761: Based on observations and staff interviews the facility failed to secure resident medications stored in an unattended and unlocked medication cart (Wing D) for 1 of 5 medication carts. During the recertification and complaint investigation survey of 3/23/23 the facility was cited for failing to keep medications secure. An interview was conducted with the Administrator on 5/17/24 at 12:14 PM. The Administrator stated constant rounds were still being conducted throughout the day in response to the survey of 2023. She reported medication storage rooms and medication carts continued to be monitored daily to ensure they were secure and nurses were being reminded of this. She indicated it was unfortunate that a medication cart had still been found unlocked.

Based on record review, observation and staff interviews, the facility failed to date food items opened and placed in the walk-in refrigerator and discard expired food items stored for use in 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents. The facility also failed to date leftover food items and discard expired food items stored for use in 1 of 3 resident nourishment refrigerators located in the recreation center of the facility. Finding included: 1. On [DATE] at 10:04 a.m. during the initial tour of the kitchen with the Dietary Supervisor, the following food items were observed in the walk-in refrigerator: * Small sandwich size ham slices wrapped in clear plastic wrap dated [DATE]. The slice of ham on top was observed with a light tan discoloration to one half of the slice while the other half was observed with a pale pink color. The Dietary Supervisor stated the ham was sliced for sandwiches and was good for 3 days once open from the original package and dated [DATE]. The Dietary Supervisor discarded the ham slices in the trash. *Opened package of corn beef wrapped in clear plastic wrap. There was no date written on the clear plastic wrap. The original package for the corn beef read best if froze by [DATE]. The Dietary Supervisor stated food items were to be dated when placed in the refrigerator and discard the corn beef in the trash. * A meal tray, that was observed not labeled with a date, contained two plastic sectional plates: one with lettuce and chicken salad and one with lettuce and potato salad and a chicken salad sandwich on a small plate wrapped with clear plastic wrap. There was no date written on the two plastic sectional plates, and there was no date written on the chicken salad sandwich. The Dietary Supervisor stated the two sectional plates and the chicken salad sandwich were made during the weekend for dinner, and food items were to be dated when placed in the refrigerator. On [DATE] at 11:41 a.m. in an interview with Dietary Supervisor, he stated dietary cooks were responsible for checking the walk-in refrigerator at the beginning and end of their shift and he also went through the walk-in refrigerator in the morning checking for expired food items. He explained on the morning of [DATE] during the initial tour of the kitchen, he had not checked the walk-in refrigerator for expirations because he was putting up stock (food items) received that morning. On [DATE] at 1:53 p.m. in an interview with the Dietary Manager, he stated Dietary Cooks were responsible for labeling and dating cooked and opened food items placed in the walk-in refrigerator. On [DATE] at 2:06 p.m. in an interview with Dietary Cook #1, she stated all dietary staff placed food items in the walk-in refrigerator, and all food items required a date written on the food item when placed in the walk-in refrigerator. She explained she checked food items for dates and expiration dates when removing food items from the walk-in refrigerator to cook. She stated if a date was not written on the food item, the food item did not look right and was not used within 3 days of the written date on the food item, food items were discarded from the walk-in refrigerator. 2. On [DATE] at 8:03 a.m., a resident nourishment refrigerator was observed located in the recreation center with old brown dried liquid stains on the shelves in the refrigerator. A sign on the freezer door read, All prepared food must be labeled with name, date, time and room number. The refrigerator was cleaned nightly and if food was not labeled as stated, the items would be thrown away. Prepared food was only good for 24 hours. The following items were observed in the resident nourishment refrigerator: * A container of chicken salad labeled with room [ROOM NUMBER] and Resident #300's last name. There was no expiration date or date when placed in the refrigerator written on the container of chicken salad. * A bottle of salad dressing with an expiration date [DATE] in a plastic bag with Resident #301's room [ROOM NUMBER] and her first and middle name and last initial written on the outside of the plastic bag. On [DATE] at 8:08 a.m. in an interview with Nurse #2, she explained the resident nourishment refrigerator located in the recreation center was used to store resident's foods. She stated family members placed food items in the refrigerator and have been shown and asked to label items placed in the refrigerator. She explained when she checked the resident nourishment refrigerator that morning, she requested housekeeping to clean the refrigerator. She stated the night shift staff were responsible for checking the resident nourishment refrigerators each night and discarding food items not labeled, dated and used in 24 hours. She stated Resident #301 had been discharge from the facility and discarded the expired bottle of salad dressing in the trash. Nurse #2 stated she would check with Resident #300 on the date for the chicken salad. On [DATE] at 5:30 a.m. in an interview with Nurse #3, he explained the resident nourishment refrigerator located in the recreation center was checked by the 11 p.m. to 7 a.m. nurse assigned the A and B wing, and on the 11 p.m. to 7 a.m. shift on [DATE], he was assigned to the F-wing hall. He stated as the team leader for the 11 p.m. to 7 a.m. shift, he was responsible for ensuring the resident nourishment refrigerator in the recreation center was checked nightly, and on the 11 p.m. to 7 a.m. shift [DATE], the resident nourishment refrigerator was not checked. He said foods items were to be labeled with date and name, and food items were to be discard if not used within 24 hours. On [DATE] at 5:33 a.m. in an interview with the Director of Nursing, she stated food items were to be dated and labeled with resident's name when placed in the resident nourishment refrigerator, and the 11 p.m. to 7 a.m. nursing staff were responsible in checking the resident nourishment refrigerators nightly and removing any food items not used within 24 hours.

Based on observations, resident representative and staff interviews, and record review, the facility failed to assist Resident #55 and their representative in locating missing hearing aids, as well as in making appointments, and arranging for transportation to replace the lost devices. This occurred for 1 of 1 sampled resident (Resident #55) reviewed for hearing/vision. The findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including confusion, dehydration, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #55 revealed he had adequate hearing with hearing aids. He was coded as moderately cognitively impaired without any rejection of care behaviors. Review of Resident #55's active care plan (dated 12/10/21) revealed he had impaired verbal communication defined by word finding difficulty related to neuromuscular development. Interventions included: use appropriate adaptive equipment and provide tools necessary to communicate. An observation and interview of Resident #55 on 3/20/23 at 10:21 AM revealed he was not wearing his hearing aids. Resident #55 stated he did not know where they were. A sign was posted on the closet doors of Resident #55's room that read: please ensure patient's hearing aids are taken out at night and charged and then placed back in his ears in the morning. An observation and interview of Resident #55 on 3/21/23 at 8:56 AM revealed he was not wearing his hearing aids. Resident #55 stated he did not know where they were. A sign was posted on the closet doors of Resident #55's room that read: please ensure patient's hearing aids are taken out at night and charged and then placed back in his ears in the morning. An interview with Nurse Aide (NA) #1 on 3/22/23 at 9:06 AM revealed he had not seen Resident #55's hearing aids for a while. He stated he was not sure how long they had been missing, but Resident #55 was supposed to wear them every morning. Nurse #1 was interviewed on 3/22/23 at 10:27 AM, and she revealed the Nurse Aides on Resident #55's hall told her the hearing aids have been lost for quite some time and his family was aware. During an interview with Resident #55's responsible party (RP) on 03/22/23 at 10:47 AM, he revealed the hearing aids had been missing for the last 6 months. He stated he did not know where they were, and the facility had not provided any further information. The RP indicated the facility did not offer him or Resident #55 a hearing appointment/services for new hearing devices. The Director of Nursing (DON) was interviewed on 3/22/23 at 10:58 AM, and she revealed the Clinical Manager told her she had just heard about Resident #55's missing hearing aids. The DON stated she was not aware that the hearing aids were missing. Staff were expected to report the missing hearing aids immediately, so that a search would have been initiated. If the search resulted in nothing found, then the facility would have needed to figure out how to replace the items. During an interview with the Clinical Manager on 3/22/23 at 12:48 PM, she revealed when Resident #55's hearing aids were lost 6 months ago the RP tried to find the warranty for replacement but was unable to locate the paperwork. She stated the RP never got back to her about the warranty details. The Clinical Manager indicated she called the hearing aids company before the interview, and she will be able to reorder the hearing aids without the warranty paperwork. An interview was conducted with the Administrator on 3/22/23 at 1:39 PM, and she revealed she did not know why Resident #55's missing hearing aids were not filed as a grievance. The Administrator indicated if someone discovered Resident #55's hearing aids were missing, then they should have notified her and she would have filed a grievance. She stated the Clinical Manager should have notified her when it happened to address the issue in a timely manner.

Based on observation and staff interviews the facility failed to keep medications secured by storing over-the-counter medications in an unoccupied storage room that had the door propped open with boxes for 1 of 6 storage rooms inspected (the main hall storage room). Findings included: On 03/21/23 at 1:30 PM the main hallway storage room door was observed to have the door propped open with boxes. There were 12 unopened bottles of Zinc 50 Milligram tablets and 3 unopened bottles of ResaQuad capsules stored on a shelf. These items were visible from the hallway and the storage room was unoccupied. In an interview with the Central Supply Aide on 03/21/23 at 1:55 PM she stated she understood propping the door open to the storage room could lead to a resident or a staff person taking items out of the room, specifically the over-the-counter medications. She verbalized understanding that all medications were to be stored in a locked room. She stated she usually kept the storage room door locked but she was busy and it was easier to leave the door open because she was coming back to unpack more boxes and distribute supplies. In an interview with the Administrator on 03/22/23 at 10:45 AM she stated all medications were stored in the medication room that was locked. She noted that where the Zinc and ResaQuad were left unlocked was a central receiving supply room. The medications would have been distributed to the locked medication room by the Central Supply Aide. She stated the door to the central receiving supply room should not have been propped open because anyone could have accessed the items. She concluded all medications were to be stored in a locked room.

Based on observations and staff interviews the facility failed to label and date opened food items stored in 1 of 2 walk in coolers. The findings included: Review of the facility policy titled Food supply and storage procedures read in part; unused portions: cover, label, date and store above raw foods On 06/03/2019 at 11:00am an observation of the walk-in cooler revealed the following items not labeled and dated when opened: 1. A container of mayonnaise 2. A glass jar of pickles 3. A glass jar of maraschino cherries 4. A gallon of milk. 5. A repackaged sliced cheese 6. A bag of boiled eggs 7. A pack of hotdogs Additionally, the following food items were observed to be in metal containers wrapped in plastic with no label or date: 1. A metal container of sausage gravy 2. A metal container of pureed eggs 3. A metal container of ground sausage 4. A metal container of pureed sausage On 06/03/2019 at 11:14 AM an interview with the food and nutrition coordinator revealed it was facility policy that all food items removed from original packaging would be labeled and dated and leftover food would be clearly labeled and dated before being refrigerated.

Based on observation, resident and staff interviews the facility failed to provide full visual privacy for residents whose privacy curtains were not wide enough for 3 of 6 halls. The findings included: 1. During an observation on 7/16/18 at 11:55 AM the privacy curtain in room # 158 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. The resident in bed B stated that the curtain did not provide her with full visual privacy. During an observation on 7/17/18 at 2:53 PM the privacy curtain in room # 158 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:05 AM the privacy curtain in room # 158 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 2. During an observation on 7/17/18 at 2:52 PM the privacy curtain in room # 157 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:02 AM the privacy curtain in room # 157 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 3. During an observation on 7/17/18 at 2:54 PM the privacy curtain in room # 160 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:12 AM the privacy curtain in room # 160 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 4. During an observation on 7/17/18 at 2:54 PM the privacy curtain in room # 161 between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:12 AM the privacy curtain in room # 161 between bed A and bed was B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 5. During an observation on 7/17/18 at 2:55 PM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:14 AM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 6. During an observation on 7/17/18 at 2:56 PM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:15 AM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 7. During an observation on 7/17/18 at 2:57 PM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 9:17 AM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. In an interview on 7/18/18 at 10:14 AM the Environmental services staff revealed the privacy curtains needed to go all the way round to give the residents full visual privacy. In an interview with the Administrator on 7/18/18 at 10:17 AM he indicated extra privacy curtains were available and would be installed that day. During an interview on 7/18/18 at 10:37 AM the Director of Nursing (DON) stated that when providing resident care, staff ask visitors to step out of the room and close the window blinds to provide residents privacy. 8. During an observation on 7/17/18 at 2:35 PM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 8:43 AM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 9. During an observation on 7/17/18 at 2:30 PM the privacy curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observations on 7/18/18 at 8:40 AM the curtain in room [ROOM NUMBER] between bed A and bed B was short by 6 feet from the end of the privacy curtain to the wall adjacent to the head of bed B. 10. During an observation on 7/17/18 at 1:03 PM the privacy curtain between bed A and bed B in room [ROOM NUMBER] was approximately 12 feet short from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 08:34 AM the privacy curtain between bed A and bed B in room [ROOM NUMBER] was approximately 12 feet short from the end of the privacy curtain to the wall adjacent to the head of bed B. 11. During an observation on 7/17/18 at 1:03 PM the privacy curtain between bed A and bed B in room [ROOM NUMBER] was approximately 12 feet short from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 8:34 AM the privacy curtain between bed A and bed B in room [ROOM NUMBER] was approximately 12 feet short from the end of the privacy curtain to the wall adjacent to the head of bed B. 12. During an observation on 7/17/18 at 1:15 PM the privacy curtain between bed A and bed B in room [ROOM NUMBER] was approximately 8 feet short from the end of the privacy curtain to the wall adjacent to the head of bed B. During an observation on 7/18/18 at 8:37 AM the privacy curtain between bed A and bed B in room [ROOM NUMBER] was approximately 8 feet short from the end of the privacy curtain to the wall adjacent to the head of bed B. In an interview on 7/18/18 at 10:14 AM the Environmental services staff revealed the privacy curtains needed to go all the way round to give the residents full visual privacy. In an interview with the Administrator on 7/18/18 at 10:17 AM he indicated extra privacy curtains were available and would be installed that day. During an interview on 7/18/18 at 10:37 AM the Director of Nursing (DON) stated that when providing resident care, staff ask visitors to step out of the room and close the window blinds to provide residents privacy.

Based on record reviews and staff interviews, the facility failed to notify the responsible person/family member about a resident's room change for one of one sampled residents reviewed. (Resident #25). The findings included: Resident #25 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set ((MDS) dated [DATE], Resident #25's cognition was intact. She required extensive to total assistance in most areas of activities of daily living. Review of the medical record's nursing notes from 12/2/18 through 12/4/18 revealed there was no documentation regarding notification of Resident #25's responsible person/family member abou the resident being moved to another room. Review of a nurse's note dated 12/3/17 at 7:30 AM, read in part, Late entry-Resident moved to another room at 2:00 AM, due to bed malfunction. During an interview on 7/18/18 at 11:40 AM, the Director of Nursing (DON) revealed a nurse had moved Resident #25 to another room temporarily because the resident's bed was broken and the nurse failed to contact Resident #25's responsible person/family member. The DON explained the nurse was educated to ensure resident's family members were contacted anytime a resident was moved to another room, whether temporarily or not. During an interview on 7/18/18 at 3:19 PM, Staff Nurse #1 who worked at night, revealed she assumed another nurse had contacted Resident #25's responsible person/family member about the resident's room change. She said she was not able to talk to another nurse to determine if the nurse had contacted Resident #25's responsible person/family member about the resident's room change. During an interview on 7/19/18 at 10:21 AM, the Administrator revealed his expectation would be whatever was advised about contacting a resident's family regarding a room change.

Based on record reviews and staff interviews, the facility failed to provide the bed hold policy upon transfer to the hospital to 2 of 2 residents reviewed. (Resident #83 and Resident #96). The findings included: 1. Resident #83 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the most recent Significant Change assessment dated [DATE], Resident #83 she was cognitively impaired and required extensive assistance in most areas of activities of daily living. Resident #83 was discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. The resident was also discharged to the hospital on [DATE] and was readmitted on [DATE]. During an interview on 7/18/18 at 9:30 AM Staff Nurse #2 revealed the reason Resident #83 was discharged to the hospital was because she fell and broke her hip. She stated Resident #83 was readmitted to her hall when she returned to the facility from the hospital. Staff Nurse #2 revealed when a resident was discharged to the hospital she usually sent the Medication Administration Record [REDACTED]. She indicated that she did not know anything about the bed hold policy being sent with residents when they were discharged to the hospital. During an interview on 7/18/18 at 2:45 PM, the Unit Manager revealed in reference to the bed hold policy, the Admission's Coordinator would followup with the family the next day. She stated in an emergency situation they did not send a bed hold policy to the hospital with the resident. During an interview on 7/18/18 at 3:25 PM, the Director of Nursing (DON) explained nursing staff usually completed a transfer sheet to send with the resident to the hospital and the next day the Admissions Coordinator would followup with the family regarding the bed hold policy. During an interview on 7/19/18 at 9:48 AM, the Admissions Coordinator revealed in most cases when a resident was discharged to the hospital it was an emergency situation and families were not present. She explained when she found out someone was sent out to the hospital she called the family and gave them the option of holding the bed. She stated sometimes families reached out to them and asked them what to do about the bed and she explained the bed hold policy to them at the time. During an interview on 7/19/18 at 10:20 AM, the Administrator revealed his expectation was that the bed hold policy would be added to the packet when residents were discharged to the hospital. 2. Resident #96 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Discharge assessment dated [DATE], Resident #96's cognition was intact and she required extensive assistance in most areas of activities of daily living. Review of a Staff Nursing note dated 5/2/18, read in part, Patient was complaining of nausea, vital signs: blood sugar: 123, temperature: 99.6, Pulse: 102, blood pressure: 140/58, 02 satuation: 77%, on 3 liters, Physician Assistant notified, changed 02 tank, 02 satuation remained low. EMS (Emergency Medical Services) called. Patient sent to emergency room via ambulance. Physician Assistant and family notified. During an interview on 7/18/18 at 3:25 PM, the Director of Nursing (DON) stated transfer forms were completed by nursing staff and normally the Admissions Coordinator followed up with the family the next day. She explained if the resident was going to the hospital for a procedure, then they would send the bed hold policy. During an interview on 7/19/18 at 9:48 AM, the Admissions Coordinator revealed when a resident was discharged to the hospital in most cases it was an emergency situation and families were not present. She explained when she found out someone was sent out to the hospital she called the family and gave them the option of holding the bed. She stated sometimes families reached out to them and asked what to do about the bed and she explained the bed hold policy to them at the time. During an interview on 7/19/18 at 10:20 AM, the Administrator revealed his expectation was that the bed hold policy would be added to the packet when residents were discharged to the hospital.

Based on observations, record reviews and resident, family and staff interviews the facility failed to accurately code the Minimum Data Set to reflect cognition (Resident #121), range of motion (Resident #160), dental status (Resident #211 and #223), and Level II Preadmission Screening and Resident Review status (Resident #265) for 5 of 26 sampled residents. Findings included: 1. Resident #211 had a [DIAGNOSES REDACTED]. Record review revealed a Dental Care Progress Note dated 12/18/15. It indicated Resident #211's remaining lower teeth were extracted on that date. It also indicated the resident had expressed a desire for upper and lower dentures. Resident #211's annual, comprehensive Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively intact. The Oral/Dental assessment section of the MDS indicated there were no concerns. The MDS did not indicate the resident was edentulous. The Dental Care Progress Note dated 4/11/16, specified initial dental impressions were done for full upper and lower dentures. The Dental Care Progress Note dated 5/31/16 indicated final dental impressions were taken and the dentures would be delivered at the next visit. During an interview on 7/12/2016 at 2:54 PM, Resident #211 stated, They pulled seven teeth at one time. She also indicated she was expecting her dentures to arrive soon. During a follow-up interview on 7/13/2016 at 4:40 PM, Resident #211 specified the last of her teeth were extracted in December 2015. She added, They were pulled 6 months ago so my mouth is healed. and I been eating a pureed diet and l'm ready to chew on something good real soon. MDS Coordinator #2, who had completed the dental portion of the assessment, was unavailable for interview. An interview was conducted on 7/14/2016 at 2:10 PM, with MDS Coordinator #1. She indicated when completing the oral/dental section of the MDS she would expect to review the resident's record and do an oral exam with the resident to ensure accuracy of the assessment. During an interviews on 7/14/2016 at 2:54 PM, the Administrator stated it was his expectation that the assessment would accurately reflect the resident's status. 2. Resident #223 had a history of [REDACTED]. Resident #223's most recent comprehensive Minimum Data Set (MDS) was completed on 9/8/2015. The Oral/Dental assessment section of the MDS indicated there were no concerns. The MDS did not indicate the resident was edentulous. On 7/14/2016 at 9:15 AM, MDS Coordinator #1 stated she had just completed an oral exam on Resident #223. It revealed the resident was edentulous, but she did not know how long that had been the case. MDS Coordinator#1 added she had reviewed the record and a Speech Therapy evaluation in March 2016 also said Resident #223 was edentulous. During an interview on 7/14/16 at 1:12 PM, a family member specified Resident #223 had [MEDICAL CONDITION] 3 years ago and had not had any teeth since that time. The family member confirmed Resident #223 did not have any teeth when he entered the facility in 2015. MDS Coordinator #2, who had completed the dental portion of the assessment, was unavailable for interview. An interview was conducted on 7/14/2016 at 2:10 PM, with MDS Coordinator #1. She indicated when completing the oral/dental section of the MDS she would expect to review the resident's record and do an oral exam with the resident to ensure accuracy of the assessment. During an interviews on 7/14/2016 at 2:54 PM, the Administrator stated it was his expectation that the assessment would accurately reflect the resident's status. 3. Resident #265 had [DIAGNOSES REDACTED]. Record review revealed a letter of Preadmission Screening and Resident Review (PASRR) Level II Determination Notification, dated 1/15/16. The results of this screening and review are used for formulating a determination of need, determination of an appropriate care setting and a set of recommendations for services to help develop an individual's plan of care. Resident #265's admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was not considered by the state PASRR process to have a serious mental illness and/or intellectual disability. A review of the facility's list of Level II PASRR residents, provided on 7/12/2016, revealed Resident #265 was included among the residents named on the list. MDS Coordinator #2, who had completed the PASRR portion of the assessment, was unavailable for interview. An interview was conducted on 7/14/2016 at 2:10 PM, with MDS Coordinator #1. She indicated when completing the PASRR status of the MDS, she would find the information in the front of the resident's record. During an interviews on 7/14/2016 at 2:54 PM, the Administrator stated it was his expectation that the assessment would accurately reflect the resident's status. 4. Resident # 121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 6/14/16 quarterly Minimum Data Set (MDS) indicated Resident #121 was able to understand, be understood and had clear speech in Section B. The Brief Interview for Mental Status (BIMS), found in Section C of the MDS, was not attempted citing the resident was rarely or never understood. MDS Nurse #1 was interviewed on 7/14/16 at 12:46 PM. The MDS Nurse stated the MDS nurses were responsible for the completion of Section B and completion of Section C was the responsibility of the Social Worker (SW). The MDS nurse added it was the responsibility of the person completing each section to make sure the information included was accurate and she was only responsible to make sure the MDS had been completed. MDS Nurse #1 reviewed Section C of Resident 121 ' s MDS and stated the instructions directed staff to attempt completion of the BIMS unless the resident was rarely or never understood. The MDS nurse stated even after reading the instructions for Section C, she was unable to determine if the information entered by the SW was inaccurate since she had not completed that section of the MDS. The MDS nurse stated the information she had entered in Section B was correct, but continued to say she was unable to determine if Section C was inaccurate since she had not completed the section. The SW was interviewed on 7/14/16 at 2:13 PM. The SW stated the MDS training she had received had been when the MDS was first introduced in long term care. She added she was unaware that she was to complete Section C of the MDS based on the answers coded in Section B of the MDS that described the Resident #121 ' s ability to understand and to be understood. The SW reviewed the MDS for Resident #160 and stated based on the answers posted in Section B and the instructions for Section C, her section had been coded inaccurately. 5. Resident #160 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Occupational Discharge summary indicated Resident #160 had a contracture of her left hand. An Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #160 was cognitively intact. She was not identified with functional limitation in range of motion (ROM) of her upper extremities including fingers and her wrist. An observation was made on 7/13/16 at 11:00 AM. Resident #160 was lying in bed with rolled washcloths in her bilateral contracted hands. On 7/14/16 10:25 AM, the Occupational Therapist (OT) was interviewed. She reviewed the most recent OT plan of care and discharge summary and stated based on the assessments, Resident #160 ' s left hand was contracted. On observation at this time, the OT confirmed Resident # 160 ' s right and left hand were contracted. Nursing Assistant #1 was interviewed on 7/14/16 at 10:45 AM. The NA stated she had worked with the resident for the past 3 months on the day shift and confirmed Resident #160 ' s hands had been contracted when she began working with her. Nurse #1 was interviewed on 7/14/16 at 11:27 AM. The nurse confirmed Resident #160 ' s left hand had been contracted since admission. Nurse #2 was interviewed on 7/14/16 at 12:20 PM. She stated she worked with Resident #160 at least 2 days per week and confirmed the resident ' s hands had been contracted for a while. The MDS coordinator was interviewed on 7/14/16 at 1:02 PM. The MDS nurse stated she was responsible for completing Section G of the MDS that addressed range of motion. Information for Section G was gathered from therapy notes, direct observation, and interviews with staff. The MDS nurse stated she had not reviewed the OT notes prior to completion of Resident #160 ' s most recent MDS since she usually only reviewed information written during the assessment period. She stated she had not observed Resident #160 with any contractures of her hand during observations made during the assessment period. The MDS nurse would not confirm an error had been made in failing to document upper extremity contractures for Resident #160.

Based on record reviews and staff interviews the facility failed to complete Care Area Assessments that addressed underlying causes, contributing factors, and risk factors for 2 of 3 residents (Resident #211 and #223) reviewed for dental assessment. Findings included: 1. Resident #211 had a [DIAGNOSES REDACTED]. Record review revealed a Dental Care Progress Note dated 12/18/15. It indicated Resident #211's remaining lower teeth were extracted on that date. It also indicated the resident had expressed a desire for upper and lower dentures. Resident #211's annual, comprehensive Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively intact. The Oral/Dental assessment section of the MDS indicated there were no concerns. The MDS did not indicate the resident was edentulous. Because the Oral/Dental section indicated no concerns, the Dental Care Area Assessment (CAA) did not trigger for further assessment. During an interview on 7/12/2016 at 2:54 PM, Resident #211 stated, They pulled seven teeth at one time. She also indicated she was expecting her dentures to arrive soon. During a follow-up interview on 7/13/2016 at 4:40 PM, Resident #211 specified the last of her teeth were extracted in December 2015. She added, They were pulled 6 months ago so my mouth is healed. and I been eating a pureed diet and l'm ready to chew on something good real soon. MDS Coordinator #2, who had completed the dental portion of the assessment, was unavailable for interview. An interview was conducted on 7/14/2016 at 2:10 PM, with MDS Coordinator #1. She indicated when completing the oral/dental section of the MDS she would expect to review the resident's record and do an oral exam with the resident to ensure accuracy of the assessment. She indicated that completing the Care Area Assessment would ensure discussion among the interdisciplinary team members to see if the resident ' s status required a plan of care. During an interviews on 7/14/2016 at 2:54 PM, the Administrator stated it was his expectation that the assessment would accurately reflect the resident's status. 2. Resident #223 had a history of [REDACTED]. Resident #223's most recent comprehensive Minimum Data Set (MDS) was completed on 9/8/2015. The Oral/Dental assessment section of the MDS indicated there were no concerns. The MDS did not indicate the resident was edentulous. Because the Oral/Dental section indicated no concerns, the Dental Care Area Assessment (CAA) did not trigger for further assessment. On 7/14/2016 at 9:15 AM, MDS Coordinator #1 stated she had just completed an oral exam on Resident #223. It revealed the resident was edentulous, but she did not know how long that had been the case. MDS Coordinator#1 added she had reviewed the record and a Speech Therapy evaluation in March 2016 also said Resident #223 was edentulous. During an interview on 7/14/16 at 1:12 PM, a family member specified Resident #223 had [MEDICAL CONDITION] 3 years ago and had not had any teeth since that time. The family member confirmed Resident #223 did not have any teeth when he entered the facility in 2015. MDS Coordinator #2, who had completed the dental portion of the assessment, was unavailable for interview. An interview was conducted on 7/14/2016 at 2:10 PM, with MDS Coordinator #1. She indicated when completing the oral/dental section of the MDS she would expect to review the resident's record and do an oral exam with the resident to ensure accuracy of the assessment. She indicated that completing the Care Area Assessment would ensure discussion among the interdisciplinary team members to see if the resident ' s status required a plan of care. During an interviews on 7/14/2016 at 2:54 PM, the Administrator stated it was his expectation that the assessment would accurately reflect the resident's status.

Based on observations, staff interviews and record reviews, the facility failed to care plan specific dental needs for 1 of 3 sampled residents (Resident #121) that was reviewed for dental care and failed to care plan the presence of a contracture and contracture management for 1 of 3 residents (Resident #160) reviewed for contractures. Findings included: 1. Resident #121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dental exam and evaluation notes dated 4/11/16 assessed oral cleanliness as unsatisfactory with heavy plaque covering Resident #121's teeth. The resident was identified as dependent on staff for daily oral care. Recommendations for daily oral care included hand holding, head support, retraction of lips and cheeks and to have 2 staff people present to assist with the daily cleaning. Additionally, the dentist recommended using a soft toothbrush and [MEDICATION NAME] toothpaste. The Quarterly Minimum Data Set (MDS), dated [DATE] indicated Resident #121 was severely cognitively impaired. The MDS also indicated the resident required extensive assistance with personal hygiene. Resident #121's care plan, reviewed on 6/16/16, did not include the dental recommendations for oral care. Nursing Assistant (NA) #2 was interviewed on 7/13/16 at 2:25 PM. The NA stated she had not been made aware of any special instructions for Resident #121's oral care and usually used the pink toothettes for cleaning her teeth. NA #3 was interviewed on 7/13/16 at 3:39 PM. The NA stated Resident #121 was not combative and did not refuse care. She stated she provided oral care before bedtime for Resident #121 using either a toothette or a tooth brush. She stated she had received no special instructions for the resident's oral care. Nurse #3 was interviewed on 7/13/16 at 4:00 PM. The nurse reviewed the 4/11/16 dental recommendations and stated the care plan would be revised to reflect the specific oral care techniques by the Clinical Manager that received the order. On 7/13/16 at 4:25 PM, Clinical Manager #1 was interviewed. She stated any recommendation for dental recommendations would be placed on the care guide for the NAs to follow. The Clinical Manager reviewed the 4/11/16 dental recommendations and stated she expected the recommendation to be added to the care plan and the care guide. The care plan revision would be done by either her or the nurse on the hall. The Clinical Manager stated she had not updated the care plan and care guide because she had been unaware of the recommendations. A telephone interview was held with the Director of Operations (DOO) for the contracted dental service on 7/14/16 at 12:03 PM. She stated the Dental Care Oral Exam and Evaluation form was a worksheet and included recommendations the dentist wished the facility to carry out for the resident. The DOO stated it was the intention of the dentist for the recommendations to be followed in order to provide the best oral care for the resident; adding that ' s why the recommendations had been made for Resident #121. The dentist that made the recommendations was out of the office and unavailable for interview. Nurse #2 stated on 7/14/16 at 12:31 PM that she had received no special instructions for completing oral care for Resident #121. MDS nurse #1 was interviewed on 7/14/16 at 12:46 PM. She stated any nurse in the facility could revise the care plan; adding the person that had knowledge of the April 2016 dental consult would be the person expected to revise the care plan with the new recommendations. The MDS nurse stated the care plan team had found the recommendations made by the dentist as restraining; therefore, the care plan and care guide for Resident #121 had not been revised to reflect the recommendations. She stated she had not called the dentist to clarify the dental recommendations and had not advised the dentist the facility had no intentions of complying with the recommendations. The SW was interviewed on 7/14/16 at 2:13 PM. She stated Resident #121 had no care plan for refusing treatment at this time since she had not been informed of any recent refusal of care and the problem had been resolved 2. Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #160 was cognitively intact. She was not identified with contractures or limited range of motion in her upper extremities. The June 2016 Monthly Nursing Summary indicated the resident had contractures/limited range of motion in her arm including shoulder and elbows. There was no indication of hand/wrist contractures. A physician's progress note dated 6/2/16 indicated the resident had [MEDICAL CONDITION] disease and had lost the ability to hold up her head. The MD also noted there was no functional ability in the resident's upper or lower extremities. The resident's care plan, last reviewed on 6/28/16 did not address the resident's current contractures, contracture management and did not include interventions to prevent the development of further contractures. Review of the undated care guide used by the nursing assistants to direct care revealed no documentation for contracture management or prevention. An observation was made on 7/13/16 at 11:00 AM. Resident #160 was lying in bed with rolled washcloths in her bilateral contracted hands. An observation was made and an interview held with the resident on 7/14/16 at 9:53 AM. Resident #160 denied any decline in mobility of any extremity. On 7/14/16 10:25 AM, the Occupational Therapist (OT) was interviewed. On review of OT notes, written more than a year ago, the OT confirmed at that time, Resident #160 had a left hand contracture, but per documentation had no contracture in her right hand. During an observation at the same time, the OT confirmed Resident #160 was contracted in both hands . MDS nurse #1 was interviewed on 7/14/16 at 1:02 PM. She stated all nurses were able to revise care plans as needed and there was not one person responsible to make sure all resident issues were care planned. The Clinical Manager for Resident #160 was interviewed on 7/14/16 at 2:30 PM. She reviewed the care plan for Resident #160 and confirmed there was no care plan for her contractures or contracture management.

Based on observations, staff interviews and record review the facility failed to refer 1 of 2 sampled residents (Resident #160) for therapy services for evaluation and placement of interventions to prevent the development of a right hand contracture. Findings included: Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS), dated [DATE], indicated Resident #160 was cognitively intact. She required extensive/total assistance for activities of daily living. Limitation in functional range of motion (ROM) of the upper extremity was not identified on the MDS. Resident #160 was not coded as receiving any therapy services or restorative services during the assessment period. The June 2016 Monthly Nursing Summary indicated Resident #160 had contractures/limited ROM in her arm including shoulder and elbows. A physician's progress note dated 6/2/16 indicated the resident had a physical condition that had caused her to lose the ability to hold her head up and the physician also noted Resident #160 had no use of her upper extremities or lower extremities. The resident's care plan, last reviewed on 6/28/16 did not address the resident's contractures and did not include interventions to limit decline in existing contractures or prevent further contractures. During an interview with Nurse # 1 on 7/12/16 at 11:30 AM, she stated Resident #160 had bilateral hand contractures and received no ROM or splinting. An observation was made on 7/13/16 at 11:00 AM. The resident was lying in bed with rolled washcloths in bilateral contracted hands. An observation was made and an interview held with the resident on 7/14/16 at 9:53 AM. The resident was lying in bed with her head forward. Her chin was laying on her chest. Rolled washcloths were seen in both hands. The resident stated without the washcloths, she was able to open her hands fully and added she was able to raise her arms above her head. Review of the care guide at this time, found on back of the bathroom door did not address ROM or any interventions to prevent contractures or further contractures. On 7/14/16 at 10:11 AM, the Rehabilitation Department Manager (DDM) stated residents were screened upon referral from the nursing department. She added several weeks ago, staff had been in-serviced and rehabilitation rounding had started. The rounding staff included her and the Director of Nursing (DON). The purpose was to make note of any changes in a resident's positioning or functional abilities. The RDM added Resident #160's name had been added to the list; pointing to a handwritten note above her computer that included the resident's name with the word positioning beside the resident's name. At 10:25 AM on 7/14/16, the Occupational Therapist (OT) was interviewed. She stated splinting was important to prevent contractures and maintain skin integrity and hygiene. The OT reviewed the last OT evaluation for Resident #160 that had been completed over a year prior and stated at the time of the evaluation, Resident #160 had a left hand contracture, but had no right hand contracture. At 10:45 AM, the OT observed Resident #160 and verified the resident was unable to fully extend her right or left hand. On 7/14/16 at 11:03 AM, the RDM and the OT were again interviewed. The OT stated based on the last OT evaluation, Resident #160's right hand contracture had developed in the last year. The RDM stated when she and the DON had made rounds they noticed Resident #160 had not been positioned properly. She acknowledged she had not completed a rounding rehabilitation form for Resident #160. Both the OT and the RDM stated in the year they had been working in the facility, they had not received a referral for a screening or evaluation for Resident #160 and no staff member had informed them of Resident #160's functional decline. An interviewed was held with the Restorative Aide (RA) on 7/14/16 at 11:15 AM. She stated she had worked as a RA for over a year and in that time, Resident #160 had not been on the restorative case load. Nursing Assistant (NA)#1 was interviewed on 7/14/16 at 11:20 AM. The NA stated she had been working with the resident about 3 months. The NA added when she started working with Resident #160, both her right and left hands had been contracted. NA #1 stated during morning care she tried to gently open the resident's hand to make sure the inside of her hand was clean and tried to keep washcloths in the resident's hands. Nurse #1 was interviewed on 7/14/16 at 11:27 AM. Nurse #1 stated she was the primary day shift nurse for Resident #160. She added if a decline in ROM was reported or observed, the observation was expected to be placed in the physician's book and a request for a OT evaluation was made. The nurse added she had not observed a right hand contracture and staff had not reported a decline in ROM to her. Nurse #1 stated she had seen wash cloths in the resident's hands for the past two days. She added they had been placed after the surveyor had asked if Resident #160 received any ROM or splinting for her contractures. On 7/14/16 at 12:20 PM, Nurse #2 was interviewed. She stated she had been working with Resident #160 since her admission. The nurse stated the resident did not have a lot of ROM in any extremity. Nurse #2 stated she knew the resident's hands were contracted. At times, the nurses or the NAs would try to provide ROM or place rolled washcloths in her hands to prevent Resident #160's hands from becoming more contracted. Nurse #1 stated she was unsure when Resident #160's right hand had started to contract and had not received any reports of a decline in ROM. Clinical Manager (CM) #1 was interviewed on 7/14/16 at 2:40 PM. The CM stated the expectation was for any decline in ROM to be reported to the nurse on the hall, who in turn, reports it to the resident's physician. With the physician's orders [REDACTED]. The CM stated while she had not made rounds on a daily basis, she had made rounds but had not noticed the development of Resident #160's right hand contracture. The DON was out of the building and not available for interview.

Based upon record review and resident, staff and physician interviews, the facility failed to notify the physician immediately after a fall for one of three residents reviewed for falls with injury, Resident #1. Findings included: A review of the quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and had a partial list of [DIAGNOSES REDACTED]. The same quarterly assessment also indicated Resident #1 had no complaint of pain and received no scheduled pain medications. A review of the nursing care plan last updated on 02/23/16 revealed Resident #1 had a goal and interventions in place to address her risk for falls due to her history of falls. The goal included on the care plan was to minimize risk of injury from falls over the next 90 days. On 04/26/16 at 4:30 PM, Resident #1 was observed resting in bed with the head of the bed elevated wearing a black boot on her right lower leg. In an interview with Resident #1 at the time of the observation, Resident #1 explained she had injured her right foot and ankle on 04/21/16 when she fell when she was transferring from her wheelchair to the facility bus seat during an activity outing. Resident #1 stated one of the activity coordinators was assisting her with the transfer, but she felt her own knees buckle up, as she slowly fell on the floor of the bus. Resident #1 stated her right knee and ankle were very painful, but she did not report her pain to the activities coordinators. Resident #1 stated she was seen on 04/25/16 by the orthopedic specialist who told her she would need to wear the boot on her right lower leg and ankle for about a month. A nurse's progress note dated 04/21/16 at 5:45 PM documented that Resident #1 reported to the nurse she had fallen during an outing on the activity bus during a transfer and that she had twisted her right ankle. The writer of the note documented that two activity coordinators confirmed the Resident #1 had fallen on the floor in the bus while transferring her from the bus chair to her wheelchair. The writer further documented that upon her return to the facility, Resident #1 was assisted to her bed and was assessed by the nurse. The same nurse's note documented there was some bruising and swelling to Resident #1's right ankle, that the nurse then notified her physician at 5:40 PM and received new orders for x-rays to the right ankle, right knee, and left shoulder. The writer of the note indicated an attempt was made to call the resident ' s daughter at 5:45 PM, and that the resident ' s son was notified at 5:49 PM. In an interview conducted with one of the activities coordinators (AC) #1 on 04/27/16 at 11:50 AM, she explained that she and the other activity coordinator, AC #2, were assisting residents onto the activity bus to travel to an out-of-town music festival on the morning of 04/21/16. AC #1 explained Resident #1 fell when she (AC #1) was assisting Resident #1 to transfer from her wheelchair to the bus seat. AC #1 stated she immediately called out for AC #2 to come provide assistance as Resident #1 fell , and that AC #2 came and lifted Resident #1 off the bus floor and into the seat. AC #1 stated she asked Resident #1 if she wanted to stay on the bus to go on the outing, or if she would like to get off the bus to stay at the facility. AC #1 stated Resident #1 replied she would prefer to stay on the bus and go to the music festival. AC #1 also stated Resident #1 reported she was okay after the fall and that she did not complain of any pain until after they returned from the music festival around 5:30 PM the same day. AC #1 stated she did not think to call into the facility right after the incident to report Resident #1 had fallen. She also stated Resident #1 was cognitively intact and capable of making her own decisions about her care. AC #2 stated in an interview on 04/27/16 at 12:12 PM that he observed Resident #1 down on the bus floor when he responded to AC #1's call for help. AC #2 explained Resident #1's weight was resting primarily on the heels of her feet while when he saw her, and that she yelled out, My foot! AC #2 also stated he lifted Resident #1 off the bus floor and onto the seat, then asked her if she was okay. AC #2 stated Resident #1 replied she was okay and that she wanted to stay on the bus to go on the outing. AC #2 stated he did not report the fall to anyone in the facility at that time. In an interview on 04/27/16 at 1:00 PM with the nurse who was on duty when Resident #1 returned to the facility after the bus outing, Nurse #1, stated she was completely unaware the resident had fallen. Nurse #1 explained the resident reported to her upon return to the facility at about 5:30 PM on 04/21/16 she had fallen and twisted her ankle while she was on the outing. Nurse #1 stated at first, she thought Resident #1 had fallen on her way back into the facility after the out-of-town outing, but then learned from the activities coordinators she had fallen when she was boarding the bus before it left the facility for the outing. Nurse #1 stated she immediately assessed Resident #1, then called the physician to report the incident and her assessment findings. Nurse #1 added that she called her son and daughter right after she notified the physician. Nurse #1 stated she called her physician a second time after Resident #1 reported she needed something stronger than [MEDICATION NAME] (Tylenol) for her pain. Nurse #1 stated the policy for reporting a resident fall was to report it immediately so that a nursing assessment could take place. Nurse #1 added that the nurse should call the physician immediately after assessing the resident to receive any necessary orders. A review of physician's telephone orders dated 04/21/16 and 04/22/16: 04/21/16: X-ray right ankle and right knee and left shoulder, complaint of pain 04/21/16: [MEDICATION NAME] ([MEDICATION NAME]) 5 milligram/325 milligram, one tablet by mouth every 6 hours as needed for pain. 04/22/16: Transfer to (hospital) for x-ray of right knee, right ankle, foot full 04/22/16: Schedule appointment with orthopedic specialist follow/up right ankle In an interview with the orthopedic physician on 04/27/16 at 3:29 PM, he confirmed he had been consulted to see Resident #1 status [REDACTED]. The orthopedic physician stated Resident #1's x-ray results revealed an old fibula fracture and a new non-displaced medial malleolar fracture. He stated Resident #1 would need to wear a specialized boot at all times for the next 6 weeks to maintain alignment of her ankle and that she should remain non-weight bearing until that time. In an interview with the Director of Nursing (DON) on 04/27/16 at 4:00 PM, she stated that Resident #1's fall should have been reported immediately after the fall so that a nurse could assess the resident at that time, report her findings to the physician, and receive orders for diagnostic tests and treatment. The DON stated the nurse was not able to complete an assessment at the time of the fall because the activity staff did not report the fall until after the residents returned from the outing around 5:30 PM. In an interview with the Administrator and DON on 04/28/16 at 5:00 PM, the Administrator stated the facility had identified the staff's failure to report Resident #1's fall as a problem. The Administrator stated the activity bus was still on the facility grounds when the fall occurred, and that the facility was responsible for her care. The Administrator also stated the two recreation/activities coordinators had been provided with in-service education about reporting falls/incidents, and that Resident #1's nursing care plan had been updated with an intervention for her to remain in her wheelchair for all outings. The Administrator added that there is a rough outline for a plan of correction to address reporting of fall/accidents, but that it was not yet complete. An interview was conducted with Resident #1's primary physician on 04/29/16 at 2:10 PM. The primary physician stated that he would have expected to receive notification of Resident #1's fall immediately after her fall so that he could have provided orders for treatment at that time rather than five or six hours later when she returned to the facility.

Based on record review, resident, staff, and physician interviews, the facility failed to provide a nursing assessment immediately after a fall for one of three residents reviewed for accidents with injury, Resident # 1. Findings included: A review of the quarterly assessment dated [DATE] revealed Resident #1 was cognitively intact and had a partial list of [DIAGNOSES REDACTED]. The same quarterly assessment also indicated Resident #1 had no complaint of pain and received no scheduled pain medications. A review of the nursing care plan last updated on 02/23/16 revealed Resident #1 had a goal and interventions in place to address her risk for falls due to her history of falls. The goal included on the care plan was to minimize risk of injury from falls over the next 90 days. On 04/26/16 at 4:30 PM, Resident #1 was observed resting in bed with the head of the bed elevated wearing a black boot on her right lower leg. In an interview with Resident #1 at the time of the observation, Resident #1 explained she had injured her right foot and ankle on 04/21/16 when she fell when she was transferring from her wheelchair to the facility bus seat during an activity outing. Resident #1 stated one of the activity coordinators was assisting her with the transfer, but she felt her own knees buckle up, as she slowly fell on the floor of the bus. Resident #1 stated her right knee and ankle were very painful, but she did not report her pain to the activities coordinators at that time. She explained she did not want to hold up everyone else who was planning to attend the outing, so she told the activities coordinators she was okay. Resident #1 stated she was seen on 04/25/16 by the orthopedic specialist who told her she would need to wear the boot on her right lower leg and ankle for about a month. A nurse's progress note dated 04/21/16 documented that Resident #1 returned to the facility after an activities outing and that Resident #1 reported she had fallen in the activity bus and had twisted her ankle. The writer further documented that two activity coordinators confirmed that Resident #1 had fallen on the floor of the bus while transferring her from the bus chair to her wheelchair. The note also indicated Resident #1 was assisted to her bed and was assessed by the nurse upon return to the facility. According to the same nurse's progress note, there was some bruising and swelling to Resident #1's right ankle, and the nurse notified her physician and received new orders for x-rays to the right ankle, left knee, and right shoulder. The writer of the note indicated an attempt was made to call the resident ' s daughter at 5:45 PM, and that the resident's son was notified at 5:49 PM. The nurse's progress note was signed by Nurse #1. A review of physician orders [REDACTED]. 04/21/16: X-ray right ankle and right knee and left shoulder, complaint of pain 04/21/16: [MEDICATION NAME] ([MEDICATION NAME]) 5 milligram/325 milligram, one tablet by mouth every 6 hours as needed for pain. 04/22/16: Transfer to (hospital) for x-ray of right knee, right ankle, foot full 04/22/16: Schedule appointment with orthopedic specialist follow/up right ankle In an interview conducted with one of the activity coordinators (AC) #1 on 04/27/16 at 11:50 AM, she stated Resident #1 fell during a transfer from her wheelchair to the activity bus seat when she was preparing to go on an out-of-town outing on 04/21/16 at about 11:30 AM. AC #1 explained Resident #1 was secured in her wheelchair on the bus's lift and was elevated to the bus door level via the hydraulic lift per standard procedure. AC #1 stated Resident #1 was then wheeled onto the bus where her wheelchair was locked next to the bus seat. AC #1 stated Resident #1 grasped around her body per her instruction, then she (AC #1) lifted Resident #1 under her arms to transfer her to the bus seat. AC #1 stated she felt Resident #1 start to lose her grasp around her body, and that she slid down to the floor of the bus as she (AC #1) was supporting her. AC #1 stated she immediately called for assistance from the other activities coordinator (AC #2), who came and lifted Resident #1 off the floor and onto the bus seat. AC #1 stated she had never had any problem with assisting Resident #1 using this method during transfers in the past. AC #1 stated she asked Resident #1 if she was okay after the fall and if she wanted to remain at the facility, but Resident #1 replied she was okay and preferred to stay on the bus to continue on the outing. AC #1 explained she did not think about getting a nurse to assess her before the bus left the facility to go out of town. AC #1 added that she checked on Resident #1 throughout the trip, and that Resident #1 never complained of any pain until they returned to the facility between 5:00 PM and 5:30 PM. AC #2 stated in an interview on 04/27/16 at 12:12 PM that he observed Resident #1 down on the bus floor when he responded to AC #1's call for help. AC #2 explained Resident #1's weight was resting primarily on the heels of her feet while when he saw her, and that she yelled out, My foot! AC #2 also stated he lifted Resident #1 off the bus floor and onto the seat, then asked her if she was okay. AC #2 stated Resident #1 replied she was okay and that she wanted to stay on the bus to go on the outing. AC #2 stated he did not notify anyone in the facility of the fall until the residents returned from their outing late in the afternoon. In an interview on 04/27/16 at 1:00 PM with the nurse who was on duty when Resident #1 returned to the facility after the bus outing, Nurse #1, she stated she was completely unaware the resident had fallen. Nurse #1 explained Resident #1 reported to her upon return to the facility at about 5:30 PM on 04/21/16 she had fallen and twisted her ankle while she was on the outing. Nurse #1 stated she thought Resident #1 had fallen on her way back into the facility after the out-of-town outing, but then learned from the activities coordinators she had fallen when she was boarding the bus before the outing while the bus was still at the facility. Nurse #1 stated she immediately assessed Resident #1, then called the physician to report the incident and assessment findings. She added that she called her son and daughter right after she notified the physician. Nurse #1 stated she called her physician a second time after Resident #1 reported she needed something stronger than [MEDICATION NAME] (Tylenol) for her pain. Nurse #1 stated the policy for reporting a resident fall was to report it immediately so that a nursing assessment could take place. Nurse #1 added that the nurse should call the physician immediately after assessing the resident to receive any necessary orders. An orthopedic physician progress notes [REDACTED].#1 had a new medial malleolar (inner ankle) fracture, nondisplaced, and that the plan was for her to be non-ambulatory and to wear a walking boot to maintain alignment at all times. In an interview with the orthopedic physician on 04/27/16 at 3:29 PM, he confirmed he wrote the progress note on 04/25/16 and that he had been consulted to see Resident #1 status [REDACTED].#1's x-ray results showed an old fibula fracture and a new non-displaced medial malleolar fracture. He stated Resident #1 would need to wear a specialized boot at all times for the next 6 weeks to maintain alignment of her ankle and that she should remain non-weight bearing until that time. In an interview with the Director of Nursing (DON) on 04/27/16 at 4:00 PM, she stated that an assessment should been completed by the assigned nurse immediately after Resident #1's fall per the facility's falls policy. The DON stated the purpose of the assessment was to determine possible injuries so the nurse could report the assessment findings upon notification of the physician. The DON stated the nurse was not able to complete an assessment at the time of the fall because the activity staff did not report the fall until after the residents returned from the outing around 5:30 PM. In an interview with the Administrator and DON on 04/28/16 at 5:00 PM, the Administrator stated the facility had identified the failure to obtain a nursing assessment immediately after Resident #1's fall was due to the activities coordinators' lack of reporting the fall. The Administrator stated the activity bus was still on the facility grounds when the fall occurred, and that the facility was responsible for her care. The Administrator also stated the two activities coordinators had been provided with in-service education about the need to immediately report falls so that a nursing assessment could take place. He added that Resident #1's nursing care plan had been updated on 04/22/16 with an intervention for her to remain in her wheelchair for all outings. The Administrator added that there is a rough outline for a plan of correction related to reporting falls and the need for an immediate nursing assessment, but it had not yet been fully developed. An interview was conducted with Resident #1's primary physician on 04/29/16 at 2:10 PM. The primary physician stated Resident #1's fall should have been reported by the staff at the time of the fall in order for a nurse to provide an immediate assessment for injuries. The primary physician stated he did not think Resident #1's right ankle injury was complicated by the delay in assessment and treatment.

Based on observations, staff interviews, pharmacy staff interviews and record review, the facility failed to follow established procedures for the acquisition of narcotic medications to ensure that controlled substances (medications) belonging to one resident were not borrowed or used for administration to another resident for 15 of 69 residents (Residents #363, #377, #383, #384, #38, #380, #382, #387, #381, #174, #134, #375, #378, #215, and #150) receiving controlled substances at the time of the survey investigation. The findings included: 1) A review of the facility ' s policy on Medication Administration Guidelines (revised January 2013) included a section titled, II. Documentation, which read, in part: B. Medications Scheduled But Not Administered 3. Medications Not Available (a) Controlled Medications - May not be borrowed even in an emergency. In an emergency, the facility ' s controlled substance kit should be utilized. Resident #363 was admitted to the facility on [DATE]. A review of the resident ' s medical record revealed his medication orders included the following: 5/325 milligrams (mg) oxycodone / acetaminophen (a combination narcotic pain medication) given as two tablets by mouth every 4 hours as needed for pain; may refuse one tablet (ordered on [DATE]). A review of Resident #363 ' s Controlled Drug Records revealed that the last tablet of the resident ' s 5/325 mg oxycodone/acetaminophen was used on 8/18/15 at 6:40 PM. The Controlled Drug Records also indicated a refill of the 5/325 mg oxycodone/acetaminophen tablets was received from the pharmacy on 8/18/15 (no time provided). A review of Resident #376 ' s Controlled Drug Records revealed on 8/18/15 at 7:30 PM, one tablet of 5/325 mg oxycodone/acetaminophen dispensed for Resident #376 was signed out by a nurse and noted as borrowed for (Resident #363). Further review of Resident #376 ' s Controlled Drug Records revealed on 8/18/15 at 11:00 PM, two tablets of 5/325 mg oxycodone/acetaminophen dispensed for Resident #376 were signed out by a nurse and noted as borrowed for (Resident #363). An interview was conducted with the facility ' s Director of Nursing (DON) on 9/2/15 at 11:20 AM. The DON reported the facility recognized there were concerns in regards to the borrowing of controlled substance medications. According to the DON, part of the problem was identified as having a delay in the receipt of medications ordered and having some issues with the backup pharmacy, particularly for new admissions on the rehabilitation halls of the facility. The DON discussed the facility ' s procedure for the ordering (and re-ordering) of narcotic medications. She noted the facility had a small in-house Pyxis machine containing controlled substance medications intended for emergency use; and, these medications could be used when there was a delay in the delivery of a resident ' s medication(s). The DON also reported the facility had plans to transition over to a different contract pharmacy (and back-up pharmacy) between January and March of 2016. In regards to borrowing controlled substance medications from one resident to another, the DON stated, That is not our practice or our policy. The DON assisted in identifying the nurse ' s signature on the Controlled Drug Record. A telephone interview was conducted on 9/2/2015 at 1:34 PM with the facility ' s Consultant Pharmacist. Upon inquiry, the pharmacist reported he had discussed concerns regarding the borrowing of controlled substances with the DON in the past. He reported addressing the issue in February and March 2015 (with the former DON), and most recently in July and August 2015 with the current DON. He recalled having an in-service in June 2015 when he, made it loud and clear it was not acceptable to borrow medications, especially controlled substances. A follow-up interview was conducted on 9/2/2015 at 3:10 PM with the DON. At that time, the DON acknowledged she had been aware of the issues of borrowed narcotics (controlled substance medications), but did not realize it was that bad. A telephone interview was conducted on 9/2/15 at 4:04 PM with the Assistant Pharmacy Manager for the facility ' s contracted pharmacy. During this interview, the Assistant Pharmacy Manager reviewed the procedures for ordering or reordering controlled substance medications for residents. The Assistant Manager reported the process involved faxing the pharmacy a written or hard copy of the signed prescription. Once received, the medication would be sent out. He indicated the cut-off time for request of a controlled substance for same-day delivery was 6:30 PM. Unless the medication was requested as a STAT (urgent) medication, the medication would be received by the facility around 10:00 PM. If the order for a medication was placed after 6:30 PM, the pharmacy phone would automatically roll over to an on-call pharmacy service. This service could arrange to have a courier pick up the hard copy of the prescription and take it to a contracted retail pharmacy. Upon inquiry as to how long this process would take before the medication was received, he stated, Realistically, maybe 1 and 1/2 hours or so .and up to a couple of hours. The Assistant Manager also reported the facility had an in-house Pyxis machine. He noted the Pyxis machine contained a stock of certain controlled medications for emergency use and was intended to help meet the immediate needs of a resident. A telephone interview was conducted on 9/3/15 at 1:06 PM with Nurse #2. Nurse #2 was the nurse identified by the signature on the Controlled Drug Record as having borrowed oxycodone/acetaminophen from Resident #376 to Resident #363 on two separate occasions on 8/18/15. Upon inquiry, the nurse acknowledged she had borrowed controlled substance medications from one resident to another on occasions. Nurse #2 outlined the facility ' s procedures for obtaining a resident ' s medication. She stated if a resident needed a physician-ordered medication that was not currently available for him/her, she first looked for the medication in the facility ' s Pyxis machine; then would call the backup pharmacy to request the medication. Nurse #2 reported the borrowing of controlled substance medications, was not a practice. However, the nurse indicated if the pain medication ordered for a resident was not available from the Pyxis or backup pharmacy in a timely manner, she would go ahead and borrow a medication from another resident. Nurse #2 acknowledged she knew she was not supposed to borrow medications from one resident to another. 2) A review of the facility ' s policy on Medication Administration Guidelines (revised January 2013) included a section titled, II. Documentation, which read, in part: B. Medications Scheduled But Not Administered 3. Medications Not Available (a) Controlled Medications - May not be borrowed even in an emergency. In an emergency, the facility ' s controlled substance kit should be utilized. Resident #377 was admitted to the facility on [DATE]. A review of the resident ' s medical record revealed her medication orders included the following: 5/325 milligrams (mg) oxycodone / acetaminophen (a combination narcotic pain medication) given as two tablets by mouth every 4 hours as needed for pain; may refuse one tablet (ordered on [DATE]). A review of Resident #376 ' s Controlled Drug Records revealed on 8/18/15 at 10:15 PM, two-5/325 mg oxycodone/acetaminophen tablets dispensed for Resident #376 were signed out by a nurse and noted as borrowed for (Resident #377). An interview was conducted with the facility ' s Director of Nursing (DON) on 9/2/15 at 11:20 AM. The DON reported the facility recognized there were concerns in regards to the borrowing of controlled substance medications. According to the DON, part of the problem was identified as having a delay in the receipt of medications ordered and having some issues with the backup pharmacy, particularly for new admissions on the rehabilitation halls of the facility. The DON discussed the facility ' s procedure for the ordering (and re-ordering) of narcotic medications. She noted the facility had a small in-house Pyxis machine containing controlled substance medications intended for emergency use; and, these medications could be used when there was a delay in the delivery of a resident ' s medication(s). The DON also reported the facility had plans to transition over to a different contract pharmacy (and back-up pharmacy) between January and March of 2016. In regards to borrowing controlled substance medications from one resident to another, the DON stated, That is not our practice or our policy. The DON assisted in identifying the nurse ' s signature on the Controlled Drug Record. A telephone interview was conducted on 9/2/2015 at 1:34 PM with the facility ' s Consultant Pharmacist. Upon inquiry, the pharmacist reported he had discussed concerns regarding the borrowing of controlled substances with the DON in the past. He reported addressing the issue in February and March 2015 (with the former DON), and most recently in July and August 2015 with the current DON. He recalled having an in-service in June 2015 when he, made it loud and clear it was not acceptable to borrow medications, especially controlled substances. A follow-up interview was conducted on 9/2/2015 at 3:10 PM with the DON. At that time, the DON acknowledged she had been aware of the issues of borrowed narcotics (controlled substance medications), but did not realize it was that bad. A telephone interview was conducted on 9/2/15 at 4:04 PM with the Assistant Pharmacy Manager for the facility ' s contracted pharmacy. During this interview, the Assistant Pharmacy Manager reviewed the procedures for ordering or reordering controlled substance medications for residents. The Assistant Manager reported the process involved faxing the pharmacy a written or hard copy of the signed prescription. Once received, the medication would be sent out. He indicated the cut-off time for request of a controlled substance for same-day delivery was 6:30 PM. Unless the medication was requested as a STAT (urgent) medication, the medication would be received by the facility around 10:00 PM. If the order for a medication was placed after 6:30 PM, the pharmacy phone would automatically roll over to an on-call pharmacy service. This service could arrange to have a courier pick up the hard copy of the prescription and take it to a contracted retail pharmacy. Upon inquiry as to how long this process would take before the medication was received, he stated, Realistically, maybe 1 and 1/2 hours or so .and up to a couple of hours. The Assistant Manager also reported the facility had an in-house Pyxis machine. He noted the Pyxis machine contained a stock of certain controlled medications for emergency use and was intended to help meet the immediate needs of a resident. A telephone interview was conducted on 9/3/15 at 1:06 PM with Nurse #2. Nurse #2 was the nurse identified by the signature on the Controlled Drug Record as having borrowed oxycodone/acetaminophen from Resident #376 to Resident #377 on 8/18/15 at 10:15 PM. Upon inquiry, the nurse acknowledged she had borrowed controlled substance medications from one resident to another on occasions. Nurse #2 outlined the facility ' s procedures for obtaining a resident ' s medication. She stated if a resident needed a physician-ordered medication that was not currently available for him/her, she first looked for the medication in the facility ' s Pyxis machine; then would call the backup pharmacy to request the medication. Nurse #2 reported the borrowing of controlled substance medications, was not a practice. However, the nurse indicated if the pain medication ordered for a resident was not available from the Pyxis or backup pharmacy in a timely manner, she would go ahead and borrow a medication from another resident. Nurse #2 acknowledged she knew she was not supposed to borrow medications from one resident to another. 3) A review of the facility ' s policy on Medication Administration Guidelines (revised January 2013) included a section titled, II. Documentation, which read, in part: B. Medications Scheduled But Not Administered 3. Medications Not Available (a) Controlled Medications - May not be borrowed even in an emergency. In an emergency, the facility ' s controlled substance kit should be utilized. Resident #383 was admitted to the facility on [DATE]. A review of the resident ' s medical record revealed her medication orders included the following: 5/325 milligrams (mg) oxycodone / acetaminophen (a combination narcotic pain medication) given as one tablet by mouth twice daily as needed for pain (ordered on [DATE]). A review of Resident #363 ' s Controlled Drug Records revealed on 8/19/15 at 9:00 PM, one 5/325 mg hydrocodone/acetaminophen tablet dispensed for Resident #363 was signed out by a nurse and noted as borrowed for (Resident #383). An interview was conducted with the facility ' s Director of Nursing (DON) on 9/2/15 at 11:20 AM. The DON reported the facility recognized there were concerns in regards to the borrowing of controlled substance medications. According to the DON, part of the problem was identified as having a delay in the receipt of medications ordered and having some issues with the backup pharmacy, particularly for new admissions on the rehabilitation halls of the facility. The DON discussed the facility ' s procedure for the ordering (and re-ordering) of narcotic medications. She noted the facility had a small in-house Pyxis machine containing controlled substance medications intended for emergency use; and, these medications could be used when there was a delay in the delivery of a resident ' s medication(s). The DON also reported the facility had plans to transition over to a different contract pharmacy (and back-up pharmacy) between January and March of 2016. In regards to borrowing controlled substance medications from one resident to another, the DON stated, That is not our practice or our policy. The DON assisted in identifying the nurse ' s signature on the Controlled Drug Record. A telephone interview was conducted on 9/2/2015 at 1:34 PM with the facility ' s Consultant Pharmacist. Upon inquiry, the pharmacist reported he had discussed concerns regarding the borrowing of controlled substances with the DON in the past. He reported addressing the issue in February and March 2015 (with the former DON), and most recently in July and August 2015 with the current DON. He recalled having an in-service in June 2015 when he, made it loud and clear it was not acceptable to borrow medications, especially controlled substances. A follow-up interview was conducted on 9/2/2015 at 3:10 PM with the DON. At that time, the DON acknowledged she had been aware of the issues of borrowed narcotics (controlled substance medications), but did not realize it was that bad. A telephone interview was conducted on 9/2/15 at 4:04 PM with the Assistant Pharmacy Manager for the facility ' s contracted pharmacy. During this interview, the Assistant Pharmacy Manager reviewed the procedures for ordering or reordering controlled substance medications for residents. The Assistant Manager reported the process involved faxing the pharmacy a written or hard copy of the signed prescription. Once received, the medication would be sent out. He indicated the cut-off time for request of a controlled substance for same-day delivery was 6:30 PM. Unless the medication was requested as a STAT (urgent) medication, the medication would be received by the facility around 10:00 PM. If the order for a medication was placed after 6:30 PM, the pharmacy phone would automatically roll over to an on-call pharmacy service. This service could arrange to have a courier pick up the hard copy of the prescription and take it to a contracted retail pharmacy. Upon inquiry as to how long this process would take before the medication was received, he stated, Realistically, maybe 1 and 1/2 hours or so .and up to a couple of hours. The Assistant Manager also reported the facility had an in-house Pyxis machine. He noted the Pyxis machine contained a stock of certain controlled medications for emergency use and was intended to help meet the immediate needs of a resident. A telephone interview was conducted on 9/3/15 at 1:06 PM with Nurse #2. Nurse #2 was the nurse identified by the signature on the Controlled Drug Record as having borrowed oxycodone / acetaminophen from Resident #363 to Resident #383 on 8/19/15. Upon inquiry, the nurse acknowledged she had borrowed controlled substance medications from one resident to another on occasions. Nurse #2 outlined the facility ' s procedures for obtaining a resident ' s medication. She stated if a resident needed a physician-ordered medication that was not currently available for him/her, she first looked for the medication in the facility ' s Pyxis machine; then would call the backup pharmacy to request the medication. Nurse #2 reported the borrowing of controlled substance medications, was not a practice. However, the nurse indicated if the pain medication ordered for a resident was not available from the Pyxis or backup pharmacy in a timely manner, she would go ahead and borrow a medication from another resident. Nurse #2 acknowledged she knew she was not supposed to borrow medications from one resident to another. 4) A review of the facility ' s policy on Medication Administration Guidelines (revised January 2013) included a section titled, II. Documentation, which read, in part: B. Medications Scheduled But Not Administered 3. Medications Not Available (a) Controlled Medications - May not be borrowed even in an emergency. In an emergency, the facility ' s controlled substance kit should be utilized. Resident #384 was admitted to the facility on [DATE]. A review of the resident ' s medical record revealed her medication orders included the following: 5/325 milligrams (mg) oxycodone / acetaminophen (a combination narcotic pain medication) given as one and ½ tablets by mouth every four hours as needed for pain; may refuse ½ or one tablet (ordered on [DATE]). A review of Resident #363 ' s Controlled Drug Records revealed on 8/19/15 at 10:00 PM, one 5/325 mg oxycodone/acetaminophen tablet dispensed for Resident #363 was signed out by a nurse and noted as borrowed for (Resident #384). An interview was conducted with the facility ' s Director of Nursing (DON) on 9/2/15 at 11:20 AM. The DON reported the facility recognized there were concerns in regards to the borrowing of controlled substance medications. According to the DON, part of the problem was identified as having a delay in the receipt of medications ordered and having some issues with the backup pharmacy, particularly for new admissions on the rehabilitation halls of the facility. The DON discussed the facility ' s procedure for the ordering (and re-ordering) of narcotic medications. She noted the facility had a small in-house Pyxis machine containing controlled substance medications intended for emergency use; and, these medications could be used when there was a delay in the delivery of a resident ' s medication(s). The DON also reported the facility had plans to transition over to a different contract pharmacy (and back-up pharmacy) between January and March of 2016. In regards to borrowing controlled substance medications from one resident to another, the DON stated, That is not our practice or our policy. The DON assisted in identifying the nurse ' s signature on the Controlled Drug Record. A telephone interview was conducted on 9/2/2015 at 1:34 PM with the facility ' s Consultant Pharmacist. Upon inquiry, the pharmacist reported he had discussed concerns regarding the borrowing of controlled substances with the DON in the past. He reported addressing the issue in February and March 2015 (with the former DON), and most recently in July and August 2015 with the current DON. He recalled having an in-service in June 2015 when he, made it loud and clear it was not acceptable to borrow medications, especially controlled substances. A follow-up interview was conducted on 9/2/2015 at 3:10 PM with the DON. At that time, the DON acknowledged she had been aware of the issues of borrowed narcotics (controlled substance medications), but did not realize it was that bad. A telephone interview was conducted on 9/2/15 at 4:04 PM with the Assistant Pharmacy Manager for the facility ' s contracted pharmacy. During this interview, the Assistant Pharmacy Manager reviewed the procedures for ordering or reordering controlled substance medications for residents. The Assistant Manager reported the process involved faxing the pharmacy a written or hard copy of the signed prescription. Once received, the medication would be sent out. He indicated the cut-off time for request of a controlled substance for same-day delivery was 6:30 PM. Unless the medication was requested as a STAT (urgent) medication, the medication would be received by the facility around 10:00 PM. If the order for a medication was placed after 6:30 PM, the pharmacy phone would automatically roll over to an on-call pharmacy service. This service could arrange to have a courier pick up the hard copy of the prescription and take it to a contracted retail pharmacy. Upon inquiry as to how long this process would take before the medication was received, he stated, Realistically, maybe 1 and 1/2 hours or so .and up to a couple of hours. The Assistant Manager also reported the facility had an in-house Pyxis machine. He noted the Pyxis machine contained a stock of certain controlled medications for emergency use and was intended to help meet the immediate needs of a resident. A telephone interview was conducted on 9/3/15 at 1:06 PM with Nurse #2. Nurse #2 was the nurse identified by the signature on the Controlled Drug Record as having borrowed oxycodone/acetaminophen from Resident #363 to Resident #384 on 8/19/15 at 10:00 PM. Upon inquiry, the nurse acknowledged she had borrowed controlled substance medications from one resident to another on occasions. Nurse #2 outlined the facility ' s procedures for obtaining a resident ' s medication. She stated if a resident needed a physician-ordered medication that was not currently available for him/her, she first looked for the medication in the facility ' s Pyxis machine; then would call the backup pharmacy to request the medication. Nurse #2 reported the borrowing of controlled substance medications, was not a practice. However, the nurse indicated if the pain medication ordered for a resident was not available from the Pyxis or backup pharmacy in a timely manner, she would go ahead and borrow a medication from another resident. Nurse #2 acknowledged she knew she was not supposed to borrow medications from one resident to another. 5) A review of the facility ' s policy on Medication Administration Guidelines (revised January 2013) included a section titled, II. Documentation, which read, in part: B. Medications Scheduled But Not Administered 3. Medications Not Available (a) Controlled Medications - May not be borrowed even in an emergency. In an emergency, the facility ' s controlled substance kit should be utilized. Resident #38 was admitted to the facility on [DATE]. A review of the resident ' s medical record revealed his medication orders included the following: 5 (mg) oxycodone (a narcotic pain medication) given as 1 tablet by mouth every 4 hours as needed for pain (ordered on [DATE]). A review of Resident #240 ' s Controlled Drug Records revealed on 8/22/15 at 10:20 PM, 2 one-half tablets (containing 2.5 mg oxycodone each) dispensed for Resident #240 were signed out by a nurse and noted as borrowed for (Resident #38). An interview was conducted with the facility ' s Director of Nursing (DON) on 9/2/15 at 11:20 AM. The DON reported the facility recognized there were concerns in regards to the borrowing of controlled substance medications. According to the DON, part of the problem was identified as having a delay in the receipt of medications ordered and having some issues with the backup pharmacy, particularly for new admissions on the rehabilitation halls of the facility. The DON discussed the facility ' s procedure for the ordering (and re-ordering) of narcotic medications. She noted the facility had a small in-house Pyxis machine containing controlled substance medications intended for emergency use; and, these medications could be used when there was a delay in the delivery of a resident ' s medication(s). The DON also reported the facility had plans to transition over to a different contract pharmacy (and back-up pharmacy) between January and March of 2016. In regards to borrowing controlled substance medications from one resident to another, the DON stated, That is not our practice or our policy. The DON assisted in identifying the nurse ' s signature on the Controlled Drug Record. A telephone interview was conducted on 9/2/2015 at 1:34 PM with the facility ' s Consultant Pharmacist. Upon inquiry, the pharmacist reported he had discussed concerns regarding the borrowing of controlled substances with the DON in the past. He reported addressing the issue in February and March 2015 (with the former DON), and most recently in July and August 2015 with the current DON. He recalled having an in-service in June 2015 when he, made it loud and clear it was not acceptable to borrow medications, especially controlled substances. A follow-up interview was conducted on 9/2/2015 at 3:10 PM with the DON. At that time, the DON acknowledged she had been aware of the issues of borrowed narcotics (controlled substance medications), but did not realize it was that bad. A telephone interview was conducted on 9/2/15 at 4:04 PM with the Assistant Pharmacy Manager for the facility ' s contracted pharmacy. During this interview, the Assistant Pharmacy Manager reviewed the procedures for ordering or reordering controlled substance medications for residents. The Assistant Manager reported the process involved faxing the pharmacy a written or hard copy of the signed prescription. Once received, the medication would be sent out. He indicated the cut-off time for request of a controlled substance for same-day delivery was 6:30 PM. Unless the medication was requested as a STAT (urgent) medication, the medication would be received by the facility around 10:00 PM. If the order for a medication was placed after 6:30 PM, the pharmacy phone would automatically roll over to an on-call pharmacy service. This service could arrange to have a courier pick up the hard copy of the prescription and take it to a contracted retail pharmacy. Upon inquiry as to how long this process would take before the medication was received, he stated, Realistically, maybe 1 and 1/2 hours or so .and up to a couple of hours. The Assistant Manager also reported the facility had an in-house Pyxis machine. He noted the Pyxis machine contained a stock of certain controlled medications for emergency use and was intended to help meet the immediate needs of a resident. A telephone interview was conducted on 9/3/15 at 1:06 PM with Nurse #2. Nurse #2 was the nurse identified by the signature on the Controlled Drug Record as having borrowed oxycodone from Resident #240 to Resident #38 on 8/22/15. Upon inquiry, the nurse acknowledged she had borrowed controlled substance medications from one resident to another on occasions. Nurse #2 outlined the facility ' s procedures for obtaining a resident ' s medication. She stated if a resident needed a physician-ordered medication that was not currently available for him/her, she first looked for the medication in the facility ' s Pyxis machine; then would call the backup pharmacy to request the medication. Nurse #2 reported the borrowing of controlled substance medications, was not a practice. However, the nurse indicated if the pain medication ordered for a resident was not available from the Pyxis or backup pharmacy in a timely manner, she would go ahead and borrow a medication from another resident. Nurse #2 acknowledged she knew she was not supposed to borrow medications from one resident to another. 6) A review of the facility ' s policy on Medication Administration Guidelines (revised January 2013) included a section titled, II. Documentation, which read, in part: B. Medications Scheduled But Not Administered 3. Medications Not Available (a) Controlled Medications - May not be borrowed even in an emergency. In an emergency, the facility ' s controlled substance kit should be utilized. Resident #380 was admitted to the facility on [DATE]. A review of the resident ' s medical record revealed her medication orders included the following: 10/325 milligrams (mg) hydrocodone / acetaminophen (a combination narcotic pain medication) given as one tablet by mouth every 6 hours as needed for pain (ordered on [DATE]). A review of Resident #379 ' s Controlled Drug Records revealed on 8/16/15 at 1:30 PM, one tablet of 10/325 mg hydrocodone/acetaminophen dispensed for Resident #379 was signed out by a nurse and noted as borrowed for (Resident #380). An interview was conducted with the facility ' s Director of Nursing (DON) on 9/2/15 at 11:20 AM. The DON reported the facility recognized there were concerns in regards to the borrowing of controlled substance medications. According to the DON, part of the problem was identified as having a delay in the receipt of medications ordered and having some issues with the backup pharmacy, particularly for new admissions on the rehabilitation halls of the facility. The DON discussed the facility ' s procedure for the ordering (and re-ordering) of narcotic medications. She noted the facility had a small in-house Pyxis machine containing controlled substance medications intended for emergency use; and, these medications could be used when there was a delay in the delivery of a resident ' s medication(s). The DON also reported the facility had plans to transition over to a different contract pharmacy (and back-up pharmacy) between January and March of 2016. In regards to borrowing controlled substance medications from one resident to another, the DON stated, That is not our practice or our policy. The DON assisted in identifying the nurse ' s signature on the Controlled Drug Record. A telephone interview was conducted on 9/2/2015 at 1:34 PM with the facility ' s Consultant Pharmacist. Upon inquiry, the pharmacist reported he had discussed concerns regarding the borrowing of controlled substances with the DON in the past. He reported addressing the issue in February and March 2015 (with the former DON), and most recently in July and August 2015 with the current DON. He recalled having an in-service in June 2015 when he, made it loud and clear it was not acceptable to borrow medications, especially controlled substances. A follow-up interview was conducted on 9/2/2015 at 3:10 PM with the DON. At that time, the DON acknowledged she had been aware of the issues of borrowed narcotics (controlled substance medications), but did not realize it was that bad. A telephone interview was conducted on 9/2/15 at 4:04 PM with the Assistant Pharmacy Manager for the facility ' s contracted pharmacy. During this interview, the Assistant Pharmacy Manager reviewed the procedures for ordering or reordering controlled substance medications for residents. The Assistant Manager reported the process involved faxing the pharmacy a written or hard copy of the signed prescription. Once received, the medication would be sent out. He indicated the cut-off time for request of a controlled substance for same-day delivery was 6:30 PM. Unless the m