Every finding on record at Riverside Lifelong H & R Warwick Forest

Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 17 residents (Resident #8) in the survey sample, which constituted harm. The findings included: The facility staff failed to provide adequate supervision to ensure Resident #8 was safe from falling while ambulating, which constituted harm. Resident #8 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #8 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included unspecified nondisplaced fracture of the second cervical vertebra, nondisplaced intertrochanteric fracture of the right femur, vascular dementia, and muscle weakness. The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/6/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 03 out of a possible 15. This indicated Resident #8’s cognitive abilities for daily decision making were severely impaired. A review of section “GG” (Functional Abilities and Goals) dated 11/6/24 of Resident #8’s Minimum Data Set (MDS) coded the resident as partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for Walk 10 feet (once standing, the ability to walk at least 10 feet in a room, corridor, or similar space), partial/moderate assistance for Walk 50 feet with two turns, and partial/moderate assistance for Walk 150 feet. A care plan problem dated 1/14/24 read, risk for falls. The goal read, resident will be free of falls. The interventions included assist resident with ambulation and transfers, utilizing therapy recommendations. Determine Residents ability to transfer. If fall occurs, alert provider. If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. If Resident is a fall risk, initiate fall risk precautions. A synopsis of an event dated 12/20/24 revealed that Resident #8 had an unwitnessed fall in another resident's room. The resident was lying in the corner of the room with his head against the heater and his walker on top of him. The resident was sent to the emergency room and was diagnosed with a closed nondisplaced fracture of the second cervical vertebra and a closed nondisplaced intertrochanteric fracture of the right femur. On 8/22/25 at 10:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 stated that Resident #8 had an unwitnessed fall on 12/20/24 in another resident's room and was not being supervised by facility staff. LPN #5 also stated that she was the only Nurse working with two Certified Nursing Assistants (CNA) in the memory unit during this shift. LPN #5 further said that there was not enough staff to provide care for the residents on the memory care unit. LPN #5 lastly stated, “We have asked, asked, and asked, and they would never give us 3 (three) CNAs on the memory care unit. With only three staff members working, residents are unable to be supervised as they should be. This could have absolutely prevented falls such as (Resident name).” On 8/22/25 at 12:30 PM, an interview was conducted with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator stated that Resident #8 was coded in section “GG” (Functional Abilities and Goals) dated 11/6/24 as requiring partial/moderate assistance for ambulating. The MDS Coordinator also stated that partial/moderate assistance means that the staff should lay hands on the resident such as on the elbow, hand, arm, the walker, or even using a gait belt while the resident is ambulating. The MDS Coordinator further stated that the staff should have been assisting and supervising Resident #8 with ambulation. On 8/22/25 at 1:36 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that Resident #8 was not being supervised when he had an unwitnessed fall with injuries. CNA #1 also stated that the staff did not know that Resident #8 required partial/moderate assistance for ambulating. CNA #1 further stated that information such as this is not communicated to the CNAs. On 8/22/25 at 2:10 PM, an interview was conducted with the Certified Occupational Therapy Assistant. The Certified Occupational Therapy Assistant stated that Resident #8 was a fall risk and required supervision for functional transfers and ambulation on the memory care unit. The Certified Occupational Therapy Assistant also stated that Resident #8 required supervision using his front-wheeled walker and needed occasional verbal cues while using his front-wheeled walker. The Certified Occupational Therapy Assistant further stated that Resident #8 required supervision for safety while ambulating to prevent a fall. A review of Resident #8's Interdisciplinary Therapy Screen dated 11/24/24 at 12:04 PM read: Ambulation: Comments: supervision using FWW with occasional VC to use walker. Safety/Restraint Issues: fall risk Additional Comments: Per Nursing and Chart review: Patient is at baseline and continues to require Minimal assistance with all ADLs and supervision for functional transfers and ambulation on the unit. No change in functional status. No therapy needs at this time. A review of Resident #8's nurse's note dated 12/20/24 at 6:22 PM read: Resident was observed lying on the floor in room [ROOM NUMBER]. Resident was lying in the corner of the room with his head against the heater and his walker on top of him. Resident complaining of right leg and hip pain. Skin tear noted to his right elbow. Pillow placed behind residents head and RN supervisor called to assess resident. Resident calling out in pain when right leg manipulated. Per RN supervisor Send resident to ER Emergency transfer . RP called and notified. Resident transported via EMS stretcher at 1800. On call provider notified of transfer. A review of Resident #8's nurse's note dated 12/20/24 at 6:47 PM read: Fall Details: Date / Time of Fall: 12/20/2024 5:15 PM Fall was not witnessed. Fall occurred elsewhere. Other fall location: another resident's room. Activity at the time of fall: unknown. Reason for the fall was evident. Reason for fall: resident was stuck between the dresser and the wall. Did an injury occur as a result of the fall: Yes. Injury details: skin tear to right elbow and right hip pain Did fall result in an ER visit/hospitalization: Yes. ER Visit/Hospitalization Details: sent to ER for eval Provider: message left for on call provider. and in communication book Time notified: 12/20/2024 Notified of: fall with possible injury to right hip Fall Details Note: Resident was observed lying on the floor in room [ROOM NUMBER]. Resident was lying in the corner of the room with his head against the heater and his walker on top of him. Resident complaining of right leg and hip pain. Skin tear noted to his right elbow. Pillow placed behind residents head and RN supervisor called to assess resident. Resident calling out in pain when right leg manipulated. Per RN supervisor Send resident to ER Emergency transfer . RP called and notified. Resident transported via EMS. A review of Resident #8’s General Hospital Discharge summary dated [DATE] read: Assessment and Plan: closed nondisplaced fracture of second cervical vertebra, and closed nondisplaced intertrochanteric fracture of right femur. (Resident name) is a [AGE] year-old Caucasian gentlemen with a history of dementia who presented to the emergency department after sustaining an unwitnessed fall at his memory care unit where he resides. The patient sustained multiple traumatic injuries. For this reason the Trauma service was contacted regarding admission. On 8/25/25 at approximately 1:05 PM, a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, Assistant Chief Nursing Officer, and Director of Clinical Education. An opportunity was offered to the facility’s staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on observation, resident and staff interviews and review of facility documentation the facility staff failed to ensure resident care and services were provided in accordance with accepted standards of clinical practice for medication administration for 1of 17 residents. Resident #11.Findings included: For Resident #11, the facility staff failed to administer her scheduled Gabapentin (a seizure medication commonly used for neuropathic pain) on 2/17/24 at 8:00 PM, 2/18/24 at 8:00 AM, midday and 8:00 PM, 2/19/24 at 8:00 AM and midday as ordered by the physician.Resident #11 was originally admitted to the facility on [DATE] with diagnoses including but not limited to: hypertension, major depressive disorder, chronic pain, insomnia, muscle spasms, reduced mobility, anxiety, treatment for malignant neoplasm right kidney, cardiomegaly, polyneuropathy, chronic pulmonary disease, morbid (severe) obesity due to excessive calories, osteoporosis, atrial fibrillation and peripheral vascular disease. On the most recent MDS (Minimum Data Set) a Quarterly Assessment with ARD (assessment reference date) of 5/13/25, Section C: Cognitive Patterns was coded as 15 out of 15, as cognitively intact. This indicates Resident #11 cognitive ability for daily decision making is intact. On 8/19/25 approximately 1:00 PM an interview was conducted with Resident #11 to review incident of her scheduled Gabapentin not administered on 2/17/24 through 2/19/24. During the interview Resident #11 initially stated she had never missed any medications. I shared with her the report from the Ombudsmen where the resident had left her a message on 2/19/24 stating she had not received her Gabapentin on evening of 2/17/24 through 2/19/24. She replied, Oh, yes, I call her all the time about lots of things. I remember now, that was a long time ago. Yes, I didn't get them for a few days. When asked about any pain she experienced as a result of the missing Gabapentin she stated, No, not that I remember, my pain is always about the same. I have arthritis. When asked why she was still in bed at 1:00 PM in the afternoon she replied, Oh, they usually get me up in the mornings, but I fell asleep again after breakfast, so they let me sleep in. I have problems with insomnia, so they let me sleep a little longer in the mornings sometimes. I asked her how her pain was today, and she replied, Oh it's ok today. Further interview about if she had any other incidents about missing her Gabapentin and she replied, Oh, they are late sometimes with my morning Gabapentin but that about it. I asked her why she was prescribed Gabapentin, and she replied, I have nerve pain. On 8/19/25 at 1:30 PM a control drug count was completed on 2 of the medication carts on the Rehab Unit with LPN#2 and LPN# 3 to verify medications were available. A review of physician orders revealed Resident #11 had an order for Gabapentin 300 MG Give 1 capsule by mouth three times a day for Neuropathy Start Date 2/2/24. A review of the medication administration record for 2/17/24 through 2/19/24 revealed: 2/17/24 at 8:00 PM coded as 9 [Code 9 means See nurses Notes] 2/18/24 at 8:00 AM, midday and 8:00 PM coded as 9 2/19/24 at 8:00 AM - blank/hole in the medication administration record, midday dose coded 9A review of the progress notes for code 9 revealed:2/17/24 at 8:43 PM, the nurse documented that she re-ordered the Gabapentin 2/18/24 at 8:00 AM, no explanation of code 9 2/18/24 at 2:01 PM, no explanation of code 9 2/18/24 at 10:02 PM the nurse documented new script needed 2/19/24 at 8:25 AM the nurse documented MD (physician) was notified about resident's missing Gabapentin. There is a current order with 90 refills remaining signed on 2/2/24 by the MD (physician), however, [name redacted] pharmacy provider is stating she does not have an active order. 2/19/24 at 1:36 PM, (midday dose) medication order noted, no explanation of code 9 2/19/24 at 6:36 PM, nurse documented Received a one-time pull code to administer Gabapentin 300mg. Spoke with (name redacted) physician and he stated to give the resident her scheduled Gabapentin 300mg at HS. On-coming nurse made aware.A review of the Medication Administration Record for assessment of Resident #11's pain revealed:2/17/24 No pain 2/18/24 No pain 2/19/24 No pain until night shift, and nurse assessed as a 5 out of 10 for pain in the right lower backOn 8/20/25 at approximately 12:45 PM, an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on what code 9 meant on the Medication Administration Record, and the DON replied, the nurse is to document an explanation in the progress notes. A request for the Medication Administration and When Medications are not Available Policies. At 3:27 PM, the Assistant Director of Nursing provided a copy of the facility's Medication Administration Policy #6562. On page 1 of 5 pages, the policy revealed Medications will be administered in accordance with regulatory guidelines, infection control, and clinical practice standards. On page 4 of 5 pages, Procedure #14. revealed Medication Refusal - Remember to document the non-administration of scheduled doses. Document medication not administered in the electronic medical record and the reason. #15. Revealed When medication errors occur, they must be reported to the physician and resident representative notifications and have post monitoring documented as indicated. A review was conducted with the Assistant Director of Nursing of the facility document Managing Unavailable Medications revealed:1. 1. Check the next day Paxit bags (dispensing package for medications) for unavailable medication. Per the ADON, Gabapentin would be in a blister pack card as it is a controlled medication. 2. 2. Check the STAT box for unavailable medication. According to the ADON, the facility has a Cubex (an on-site pharmacy cabinet containing selected medications available by phone call to the pharmacy, which requires obtaining a code to remove the medication with an active order). She confirmed Gabapentin is available in the Cubex.3. 3. Contact the pharmacy for the status of delivery. If medication will be delivered within the needed timeframe, document on the (name redacted) pharmacy provider Contact Log.4. 4. Contact the pharmacy for the status of delivery. If medication will not be delivered within the needed timeframe, document in the (name redacted) pharmacy provider Contact Log as well. 5. 5. Contact the provider for an alternative order and an order to discontinue the medication and restart the order when it will be available.6. 6. Consider a STAT run from the pharmacy (stat runs may take up to 4 hours to arrive at the facility; consider the time the medication is due).NOTE: If a medication is not administered as ordered, this is a medication error and the provider and resident must be notified and documented. Do not document medication unavailable, or simply not administer the medication or treatment. It is a standard of practice in nursing that provider orders are followed. If they are not able to be followed due to a lack of availability, you must contact the provider for additional guidance. On 8/20/25 at 1:45 PM, an interview was conducted with the Director of Pharmacy at (name redacted), the facility's pharmacy provider. He stated, The pharmacy had a valid order that was sent on 2/2/24 for 45 capsules of Gabapentin (a 15-day supply). A new order was received on 2/19/24 after receiving a new script and was dispensed to the facility on 2/20/24. He reported that the nurse did call the pharmacy on 2/19/24 for a pull code to obtain an emergency 1st dose from the Cubex (an on-site pharmacy cabinet containing select medications available utilizing a phone call to the pharmacy and obtaining a code to remove the medication with an active order). He stated the facility does not have an automatic refill with controlled drugs, therefore requiring that the nurse contact the pharmacy for a re-order. On 8/20/25 at 2:36 PM, another interview was conducted with Resident #11 regarding the 6 doses of Gabapentin not administered on 2/17/24 through 2/19/24 to clarify her pain level due to the missing doses. Resident #11 replied, I don't distinguish my pain any differently for that time than any other time. The medication is built up in my system, so it helps control my pain. It was reviewed with her what the Ombudsmen had reported that she had expressed to her about having lots of pain with the missing doses, and she replied, Oh, honey, I was just so mad and upset that they didn't have my medicine, and giving me the excuse that the pharmacy hadn't sent it. Like I said, I didn't notice my pain any differently than any other time as I have chronic pain. The resident was asked if she had any further issues with her Gabapentin, and she said, No, not really, just sometimes it seems a bit late, but they are doing pretty good most of the time.The Administrator was made aware of the concerns on 8/25/25 during the end of day meeting and no further information was provided.

Based on Observation, staff interview, clinical record review, and facility document review the facility staff failed to provide necessary documents for two Residents receiving hospice care (Resident #15, and 6) in a survey sample of 17 Residents. 1. The Facility staff failed to provide Hospice nurses' notes and wound care measurements pertaining to Resident #15. Resident #15 was initially admitted to the facility on [DATE] and readmitted on [DATE] from the community. The current diagnoses included cerebral vascular disease. The admission, significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated that Resident #15's cognitive abilities for daily decision making were severely impaired. In sectionGG(Functional Abilities) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, eating, toileting, personal hygiene. In section “M” (Skin Conditions), the number of stage 2 pressure ulcers =1. Number of unstageable with slough/eschar =1. The care plan dated [DATE] read: Resident #15 has a terminal prognosis as of [DATE] prior to admission to the facility r/t Nutritional marasmus with hospice service. The Goal is to maintain comfort through the review date of [DATE]. The interventions are to Adjust provision of ADLS to compensate for resident's changing abilities, Encourage participation to the extent the resident wishes to participate, Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain, Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. On [DATE] at approximately 12:05 pm, Licensed Practical Nurse (LPN) #6 was approached by two surveyors concerning hospice notes not found in the medical records. LPN #6 was asked for hospice notes dated [DATE] -[DATE]. [DATE] at approximately 1:00 pm., approached LPN #6 concerning the hospice notes and other documents not found in the resident’s medical records. LPN #6 stated that she will look for the communication binder that the hospice nurse writes in. [DATE] at approximately 1:38 pm., the administrator said that the hospice notes should be in the resident’s binder. [DATE] at approximately 1:45 pm., LPN #6 presented the surveyor with the Hospice Nurse Binder for Resident #15. A review of the Hospice Nurse’s binder revealed a care plan and other documents, but no nurses' notes were found. On [DATE] at approximately 4:15 pm, an interview was conducted with the Hospice Nurse/Case Manager. The Hospice Nurse/Case Manager said, “We document in our system if the facility wants them (notes), we will fax them over. I mostly update the facility nurse who takes care of the resident.” The Hospice Nurse also said that the resident’s daughter keeps her informed because she doesn’t hear from the facility. The Hospice Agreement was executed on the 9th day of [DATE]: RECORDS: 1. Maintenance and Retention of Records-The nursing home and hospice shall prepare and maintain complete and appropriate medical records concerning each hospice patient. 2.Content: The clinical record shall contain past and current findings for each hospice patient. 3. Access: Subject to applicable law, nursing home and hospice shall each permit the other to review and make photocopies of the medical record. On [DATE], a pre-exit interview was conducted at approximately 11:40 am. The above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. No additional information was provided. 2. The Facility staff failed to provide Hospice nurses’ notes and the comprehensive care plan in the electronic clinical record for Resident #6. Resident #6 was originally admitted to the facility on [DATE] and admitted to Hospice on [DATE], with diagnoses of, but not limited to, Alzheimer’s disease with late onset, hypertension, unsteadiness on feet, major depressive disorder, history of falls, and terminal agitation. Resident #6 expired in the facility on [DATE]. Resident #6’s most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of [DATE] was a Quarterly Assessment. The MDS coded Resident #6 with a BIMS (Brief Interview for Mental Status) score of 99 out of 15 possible points, indicating the resident was unable to complete the interview. The cognitive assessment revealed that Resident #6 had memory problems related to short- and long-term memory, and that Resident #6 was severely impaired in making daily decisions. Section GG(Functional Abilities) of the MDS coded Resident #6 as requiring substantial/maximal and dependent with bed mobility, transfers, eating, toileting, and personal hygiene. The care plan dated [DATE] revealed: Resident #6 had a terminal prognosis r/t Alzheimer's disease, decreased PO intake, declining health, and heart failure. The resident was admitted to hospice as of [DATE]. Resident discharged from hospice services as of [DATE]. The resident was readmitted to hospice services as of [DATE]. The interventions included working cooperatively with the hospice team to ensure that the residents’ spiritual, emotional, intellectual, physical, and social needs were met. Work with nursing staff to provide maximum comfort for the resident. On [DATE], at 1:00 PM, the Administrator was interviewed and asked about the hospice notes care plan not found in the resident’s clinical record. The administrator stated that the hospice notes and care plan should be in the resident’s binder. The Hospice Nurse Binder for Resident #6 was reviewed and revealed a care plan and other documents, but no nurses’ notes were found. On [DATE] at approximately 9:00 AM, an interview was conducted with the Hospice Nurse/Case Manager. The Hospice Nurse/Case Manager said, “We document in our system if the facility wants them (notes), we will fax them over. I mostly update the facility nurse who takes care of the resident.” The Hospice Agreement was executed on the 9th day of [DATE]: RECORDS: 1. Maintenance and Retention of Records-The nursing home and hospice shall prepare and maintain complete and appropriate medical records concerning each hospice patient. 2.Content: The clinical record shall contain past and current findings for each hospice patient. 3. Access: Subject to applicable law, nursing home and hospice shall each permit the other to review and make photocopies of the medical record. On [DATE], during the end-of-day meeting, the Administrator, Director of Nursing, Assistant Director of Nursing, Assistant Chief Nursing Officer, and Director of Clinical Education were notified of the concerns and findings. No further information was provided prior to exit.

Based on observations, resident interviews, staff interviews, and review of the clinical record, the facility staff failed to manage acute pain secondary to fractures for 1 of 17 residents (Resident #1) in the survey sample. The findings included: Resident #1 was initially admitted to the facility 8/13/25, after an acute care hospital stay for a fall with fractures. The resident's current diagnoses included fibromyalgia, acute on chronic lower back pain, a right distal radius fracture, and status post L4 - L5 lumbar laminectomy with fixation and TLIF pedicle screw fixation on 08/07/25. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed; therefore, the following information was obtained from the N Adv - Clinical admission dated 8/13/25. The assessment revealed the resident was alert and oriented three times. The resident communicated verbally; her speech was clear, and she was able to understand and be understood when speaking. The following self-care information was documented in the nurse's notes by the MDS Coordinator: Mobility: Upper extremity (shoulder, elbow, wrist, hand): Impairment on one side. Lower extremity (hip, knee, ankle, foot): No impairment. Roll left and right: admission Performance: Supervision or touching assistance. Sit to lying: admission Performance: Supervision or touching assistance. Lying to sitting on side of bed: admission Performance: Supervision or touching assistance. Sit to stand: admission Performance:Dependent. Chair/bed-to-chair transfer: admission Performance: Dependent. Toilet transfer: admission Performance: Dependent. Tub/shower transfer: admission Performance: Not attempted due to medical condition or safety concerns. Car transfer: admission Performance: Not attempted due to medical condition or safety concerns.On 8/19/25 at 12:37 PM, Resident #1 was observed seated in a chair at the bedside, wearing a back brace and a right hand splint daily. An interview was conducted with the resident. The resident stated that her pain was not being treated effectively, and whenever she requests pain medication, the nurses bring it when they want to. The resident further said she had chronic back pain, degenerative joint disease, old back fractures, osteoporosis, and fibromyalgia, which was maintained at home with Acetaminophen. The resident stated that the pain she currently had could not be treated with Acetaminophen, for it was too severe.The resident said she had a recent fall at home, which resulted in a vertebral fracture and a right wrist fracture, and she had not walked since the fall. The resident stated during the interview that she was experiencing pain in her back, right hip, thigh, and knee. She further stated she was administered Oxycodone 5 milligrams (mg) three times each day, but was no longer receiving the medication, and no one explained to her why. The resident also stated she was not sleeping because of the pain, and her appetite had plummeted because the pain was so severe. The resident stated she was taking Trazodone at home to sleep, and if she was receiving it at the rehabilitation facility, it was not working.On 8/20/25, at approximately 10:50 AM, Resident #1 was revisited. She was seated at the bedside and again complained of the pain she was experiencing. On 8/21/25 at approximately 1:00 PM, Resident #1 was observed in bed. The resident continued to complain about the pain she was experiencing in her back and along her right side. A review of the resident's Medication Administration Record (MAR) revealed the resident had an order dated 8/13/25 through 8/19/25 for Acetaminophen tablet 325 mg two tablets by mouth every 6 hours as needed for mild pain, which was administered for three doses. The resident received a new order dated 8/19/25, at 1:00 PM for Acetaminophen tablet 500 mg, two tablets by mouth three times a day for pain. On 8/14/25, through 8/22/25, a Lidocaine Pain Relief External Patch 4% was ordered to be applied to the resident's back topically two times a day for pain. This order was reordered on 8/22/25. On 8/14/25, at 8:00 PM, an order was obtained for Pregabalin 50 mg capsules, give one capsule by mouth two times a day for pain. This order was discontinued on 8/19/25, at 11:56 AM and another order was obtained for Pregabalin 75 mg capsules, give one capsule by mouth two times a day for pain. The Medical Director (MD) stated during an interview by phone on 8/25/25 at 12:21 PM, that the Acetaminophen, Lidocaine patch, and Pregabalin were ordered to treat Fibromyalgia pain, which is a challenging pain to treat. Also on 8/13/25 through 8/18/25, the resident had an order for Oxycodone HCl 5 MG (give 2.5 mg) by mouth every 8 hours as needed for pain. The resident received nine administrations for pain rated four through nine. On 8/18/25 at 3:15 PM, the resident received an order for Oxycodone HCl 5 MG (Give 2.5 mg) by mouth every 8 hours as needed for pain. The resident received a dose on 8/19/25 at 8:27 AM for pain rated ten out of ten.From 8/18/25 at 8:26 AM through 8/19/25 at 8:27 AM, Tylenol was the only pain medication received. On 8/19/25, a one-time dose of Oxycodone HCl 5 mg (give 0.5 tablet by mouth) was administered at 3:22 PM for pain rated ten out of ten. On 8/19/25, at 12:00 PM another order was received for Oxycodone HCl 5 mg, give one tablet by mouth every 4 hours as needed for pain. Fourteen doses were administered for pain rated five to ten out of ten.On 8/22/25 at 9:00 PM, an order was obtained for Oxycodone HCl ER 12 Hour Abuse-Deterrent Tablet 10 mg, give one tablet by mouth every 12 hours for severe pain for 5 days.An interview was conducted with the interim Rehabilitation Director (RD) on 8/20/25 at 12:25 PM. The RD stated that most of the time, a resident's therapy schedule is posted for staff to view and to ensure medication is administered to the resident accordingly. The RD also stated that Resident #1 had weight-bearing restrictions secondary to a compression fracture of the lower vertebra and a right wrist fracture resulting from a fall. The RD stated that the rehabilitation team communicated the resident's ability to transfer to the nursing staff by writing on the whiteboard in the resident's room. The RD further stated that the resident required one person's assistance to transfer to the wheelchair and to use the transfer bar to transfer to the toilet. A review of Resident #1's rehabilitation progress notes revealed that the resident did not miss any therapy days until 8/21/25. On 8/14/25, she exhibited nonverbal signs of pain. On 8/15/25, the resident was limited by pain. On 8/18/25 and 8/19/25, the resident complained of back pain, and on 8/20/25, she complained of left hip pain. The RD stated that whenever the resident experienced pain, the therapist reported it to nursing. The therapy documentation for 8/22/25 stated the resident continued to show improvement, but she was limited by back pain.On 8/21/25 at approximately 12:54 PM, an interview was conducted with Licensed Practical Nurse (LPN) #12. LPN #12 stated she had administered pain medication to the resident earlier, and she had not reported any further pain, but she would follow up with the resident.On 8/25/25 at 10:50 AM, the above information was shared with the Administrator, Director of Nursing (DON), the Assistant DON, two Unit Managers, and the Assistant Chief Nursing Officer. The Rehabilitation Unit Manager stated that she visits the resident daily, and she had never complained of pain to her.

Based on observation, resident and staff interviews and review of facility documentation the facility failed to provide pharmaceutical services to assure the accurate acquiring, receiving, dispensing and administration of drugs to meet the needs of each the resident for 1 of 17 residents. Resident #11.Findings included: For Resident #11, the facility staff failed to administer her scheduled Gabapentin (a seizure medication commonly used for neuropathic pain) on 2/17/24 at 8:00 PM, 2/18/24 at 8:00 AM, midday and 8:00 PM, 2/19/24 at 8:00 AM and midday as ordered by the physician.Resident #11 was originally admitted to the facility on [DATE] with diagnoses including but not limited to: hypertension, major depressive disorder, chronic pain, insomnia, muscle spasms, reduced mobility, anxiety, treatment for malignant neoplasm right kidney, cardiomegaly, polyneuropathy, chronic pulmonary disease, morbid (severe) obesity due to excessive calories, osteoporosis, atrial fibrillation and peripheral vascular disease. On the most recent MDS (Minimum Data Set) a Quarterly Assessment with ARD (assessment reference date) of 5/13/25, Section C: Cognitive Patterns was coded as 15 out of 15, as cognitively intact. This indicates Resident #11 cognitive ability for daily decision making is intact. On 8/19/25 approximately 1:00 PM an interview was conducted with Resident #11 to review incident of her scheduled Gabapentin not administered on 2/17/24 through 2/19/24. During the interview Resident #11 initially stated she had never missed any medications. I shared with her the report from the Ombudsmen where the resident had left her a message on 2/19/24 stating she had not received her Gabapentin on evening of 2/17/24 through 2/19/24. She replied, Oh, yes, I call her all the time about lots of things. I remember now, that was a long time ago. Yes, I didn't get them for a few days. When asked about any pain she experienced because of the missing Gabapentin she stated, No, not that I remember, my pain is always about the same. I have arthritis. When asked why she was still in bed at 1:00 PM in the afternoon she replied, Oh, they usually get me up in the mornings, but I fell asleep again after breakfast, so they let me sleep in. I have problems with insomnia, so they let me sleep a little longer in the mornings sometimes. I asked her how her pain was today, and she replied, Oh it's ok today. Further interview about if she had any other incidents about missing her Gabapentin and she replied, Oh, they are late sometimes with my morning Gabapentin but that about it. I asked her why she was prescribed Gabapentin, and she replied, I have nerve pain. On 8/19/25 at 1:30 PM a control drug count was completed on 2 of the medication carts on the Rehab Unit with LPN#2 and LPN# 3 to verify medications were available. A review of physician orders revealed Resident #11 had an order for Gabapentin 300 MG Give 1 capsule by mouth three times a day for Neuropathy Start Date 2/2/24. A review of the medication administration record for 2/17/24 through 2/19/24 revealed: 2/17/24 at 8:00 PM coded as 9 2/18/24 at 8:00 AM, midday, and 8:00 PM coded as 9 2/19/24 at 8:00 AM - blank/hole in the medication administration record, midday dose coded 9A review of the progress notes for code 9 revealed:2/17/24 at 8:43 PM the nurse documented that she re-ordered the Gabapentin 2/18/24 at 8:00 AM no explanation of code 9 2/18/24 at 2:01 PM no explanation of code 9 2/18/24 at 10:02 PM the nurse documented new script needed 2/19/24 at 8:25 AM the nurse documented MD (physician) was notified about resident's missing Gabapentin. There is a current order with 90 refills remaining signed on 2/2/24 by the MD (physician), however, (name redacted) pharmacy provider is stating she does not have an active order 2/19/24 at 1:36 PM (midday dose) medication order noted, no explanation of code 9 2/19/24 at 6:36 PM, nurse documented Received a one-time pull code to administer Gabapentin 300mg. Spoke with (name redacted), the physician, and he stated to give the resident her scheduled Gabapentin 300mg at HS. On-coming nurse made aware.On 8/20/25 at approximately 12:45 PM, an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on what code 9 meant on the Medication Administration Record, and the DON replied, The nurse is to document an explanation in the progress notes. A request for the Medication Administration and When Medications are not Available Policies. At 3:27 PM, the Assistant Director of Nursing provided a copy of the facility's Medication Administration Policy #6562. On page 1 of 5 pages, the policy revealed Medications will be administered in accordance with regulatory guidelines, infection control, and clinical practice standards. On page 4 of 5 pages, Procedure #14. revealed Medication Refusal - Remember to document the non-administration of scheduled doses. Document medication not administered in the electronic medical record and the reason. #15. Revealed When medication errors occur, they must be reported to the physician and resident representative notifications and have post monitoring documented as indicated. A review was conducted with the Assistant Director of Nursing of the facility document Managing Unavailable Medications revealed:11. Check the next day Paxit (dispensing package for medications) for unavailable medication. Per the ADON Gabapentin would me in a blister pack card as it is a controlled medication. 22. Check the STAT box for unavailable medication. Per the ADON, the facility has a Cubex (an on-site pharmacy cabinet containing selected medications available utilizing a phone call to the pharmacy and obtaining a code to remove the medication with an active order). She confirmed Gabapentin is available in the Cubex.33. Contact the pharmacy for status of delivery. If medication is delivered within the needed timeframe, document on the (name redacted) pharmacy provider Contact Log.44. Contact the pharmacy for status of delivery. If medication will not be delivered within the needed timeframe, document in the (name redacted) pharmacy provider Contact Log as well.5 5. Contact the provider for an alternative order and an order to discontinue the medication and restart the order when it will be available.6 6. Consider a STAT run from the pharmacy (stat runs may take up to 4 hours to arrive at the facility, consider the time the medication is due). NOTE: If a medication is not administered as ordered, this is a medication error and provider and resident must be notified and documented. Do not document medication unavailable, or simply not administer the medication or treatment. It is a standard of practice in nursing that provider orders are followed. If they are not able to be followed due to lack of availability, you must contact the provider for additional guidance. On 8/20/25 at 1:45 PM, an interview was conducted with the Director of Pharmacy at (name redacted) the facility's pharmacy provider. He stated the pharmacy had a valid order that was sent on 2/2/24 for 45 capsules of Gabapentin (a 15- day supply). A new order was received on 2/19/24 after receiving a new script and dispensed to the facility on 2/20/24. He reported that the nurse did call the pharmacy on 2/19/24 for a pull code to obtain an emergency 1st dose from the Cubex (an on-site pharmacy cabinet containing select medications available utilizing a phone call to the pharmacy and obtaining a code to remove the medication with an active order). He stated the facility does not have an automatic refill with controlled drugs therefore requiring that the nurse contact the pharmacy for a re-order. On 8/20/25 at 2:36 PM another interview was conducted with Resident #11 regarding the 6 doses of Gabapentin not administered on 2/17/24 through 2/19/24 to clarify her pain level due to the missing doses. Resident #11 replied, I don't distinguish my pain any differently for that time than any other time. The medication is built up in my system, so it helps control my pain. A review with conducted with her what the Ombudsmen had reported that she had expressed to her about having lots of pain with the missing doses and she replied, Oh, honey I was just so mad and upset that they didn't have my medicine and giving me excuse that the pharmacy hadn't sent it. Like I said I didn't notice my pain any differently then as any other time as I have chronic pain. She was asked had she had any further issues with her Gabapentin, and she said, No, not really just sometimes it seems a bit late, but they are doing pretty good most of the time.The Administrator was made aware of the concerns on 8/25/25 during the end-of-day meeting, and no further information was provided.

Based on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to notify the resident's family representative of two pressure ulcers identified on 7/09/25 for 1 of 17 residents (Resident #15), in the survey sample. Resident #15 was initially admitted to the facility on [DATE] and readmitted on [DATE] from the community. The current diagnoses included cerebral vascular Disease. The admission, significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #15 cognitive abilities for daily decision making were severely intact.In sectionGG(Functional Abilities) the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, eating, toileting, personal hygiene. In section M (Skin Conditions) Number of stage 2 pressure ulcers =1. Number of unstageable with slough/eschar =1.The care plan dated 7/24/25 read: the resident has pressure injuries and the potential for pressure injury development r/t Hx of ulcers, Immobility, incontinence, and end-of-life process. Unstageable to sacrum and Stage 2 to sacrum (resolved 7/24/25). The Goals for the resident included: Pressure ulcer will show signs of healing and remain free from infection through review date. The Interventions for the resident included: Inform the resident/family/caregivers of any new area of skin breakdown and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate.A review of an incident dated 7/09/25, Late Entry at 10:30 am, read: Resident was found on the floor of her room on the fall mat. Family has been contacted and notified as well as providers. Will continue to monitor. The timeline revealed the following: 1.7/09/25-Resident had a fall around 10:30 am. Family was notified of the fall. (According to the incident note. The family was notified of a fall that occurred on 7/09/25, but wasn't notified of an advanced-stage pressure ulcer nor a stage 2 pressure ulcer on the resident's sacrum and buttocks, which was identified hours after the resident's fall.2.7/09/25- Unstageable wound to the sacral area and stage 2 wound to the buttocks identified at 7:11 am. A review of a Skin/Wound Note Effective Date: 07/09/2025 at 7:11 pm., read: The resident presents with an unstageable wound to the sacral area and stage 2 wound to the buttock from shearing. Treatment order applied to prevent deterioration; however, hospice was notified. Awaiting a call back to verify or change the wound treatment order.According to the medical records, Resident #15's daughter was not notified on 7/09/25 concerning the staff identifying the two pressure ulcers that were later found in the evening around 7:11 pm. According to the medical records, the resident's daughter was notified of the resident having a fall on the morning of 7/09/25 at 10:30 am.On 8/21/25 at approximately 12:22 pm., a phone call was made to Resident #15's daughter (Resident Representative) concerning her wounds. She said that she was informed that her mother had a bedsore about three weeks ago. On 8/21/25 at approximately 4:40 pm., an interview was conducted with LPN #6. LPN #6 said that the unstageable sacral wound was first identified on 7/09/25, as well as the stage 2 wound on the resident's buttocks. LPN #6 also said that she was not working on 7/09/25 and had assumed the resident's daughter had been notified of the wounds, but after conducting a chart audit, she did not see that the daughter had been contacted initially, but she notified her on 7/21/25. LPN #6 also mentioned that the Director of Nursing (DON) notified hospice on 7/09/25. LPN #6 also said that it's not acceptable to first identify a wound as unstageable.On 8/22/25 at approximately 4:40 pm., an interview was conducted with the Director of Nursing (DON). The DON said that on 7/09/25, Resident #15's sacral area had yellow slough, and the buttocks had a sheared area. The DON also mentioned that she had called Hospice, not the resident's daughter.On 8/25/25, a pre-exit interview was conducted at approximately 11:40 am. The above findings were shared with the Administrator, Director of Nursing, and Corporate Consultant. They had no comments and voiced no further concerns regarding the above information

Based on resident interviews, staff interviews, and review of the clinical record, the facility staff failed to provide toileting upon request for 1 of 17 residents (Resident #2) in the survey sample. The findings included: Resident #2 was initially admitted to the facility on [DATE], after an acute care hospital stay. The resident's current diagnoses included an L2 - L5 laminectomy and fusion, and left upper extremity edema secondary to a left cephalic vein superficial vein thrombosis.The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed; therefore, the following information was obtained from the N Adv - Clinical admission dated 8/12/25. The assessment revealed the resident had mild cognitive impairment (some confusion). The Mobility assessment dated [DATE] revealed: Upper extremity (shoulder, elbow, wrist, hand): No impairment. Lower extremity (hip, knee, ankle, foot): No impairment. Wheelchair (manual or electric). Roll left and right: admission Performance: Partial/moderate assistance. Sit to lying: admission Performance: Partial/moderate assistance. Lying to sitting on the side of the bed: admission Performance: Partial/moderate assistance. Sit to stand: admission Performance: Dependent. Chair/bed-to-chair transfer: admission Performance: Dependent. Toilet transfer: admission Performance: Not attempted due to medical condition or safety concerns. Tub/shower transfer: admission Performance: Not attempted due to medical condition or safety concerns. Car transfer: admission Performance: Not attempted due to medical condition or safety concerns. A note on the whiteboard in the resident's room on 8/21/25 stated she required two persons assistance with transfers using the [NAME] Stedy lift.On 8/19/25 at 12:46 PM, Resident #2 was observed seated in a chair at bedside with her back brace lying on the bed. Resident #2 stated that she was constipated, but currently she had diarrhea. The resident further stated she had awakened with diarrhea up her back. The resident stated that she knows when she needs to use the toilet, but she was encouraged to wear an incontinence brief in case she had another accident. The resident also stated that most of the time, she was unable to get the staff to respond in time for her to utilize the toilet. The resident stated she frequently had an accident because the nurses are unable to locate the lift ([NAME] Stedy) they use to transfer her with, or there is no nurse to assist the assigned nurse. Resident #2 stated that she will need to be able to toilet herself before returning home, as she will not have anyone to assist her. On 8/21/25 at 1:10 PM, the resident stated the toileting concerns had not changed, and she was still wearing incontinence briefs.An interview was conducted with the interim Rehabilitation Director (RD) on 8/20/25 at 12:25 PM. The RD stated that the rehabilitation team communicated the resident's ability to transfer to the nursing staff by writing on the whiteboard in the resident's room.On 8/25/25 at 10:50 AM, the above information was shared with the Administrator, Director of Nursing (DON), the Assistant DON, two Unit Managers, and the Assistant Chief Nursing Officer. The Administrator stated that there are sufficient [NAME] lifts in the facility, and each unit has one to two lifts. The Administrator also stated that two persons are not required to use the [NAME] lift; therefore, she would follow up on the reason the instructions were for two persons.

Based on resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to provide dialysis care and services to three of nine facility dialysis residents; Residents #72, #60, and #120. The findings include: 1. For Resident #72, the facility staff failed to include pre-dialysis vital signs on the communication sheet from the facility to the dialysis center on four of nine dialysis visits. Resident #72 was admitted to the facility on [DATE] and discharged on [DATE]. The resident had nine dialysis visits during her stay. A review of the clinical record revealed a physician's order dated 11/14/23 documented, DIALYSIS - Attends Dialysis (address of dialysis center) every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday). A review of the dialysis communication sheets revealed that four of the nine times the resident had dialysis while at the facility, the sheets were missing the vital signs from the facility to the dialysis center: On 11/17/23, the vital signs that were written were crossed off with error documented. There was no new set written in. On 11/29/23, 12/4/23 and 12/6/23, there were no vital signs documented on the communication sheet from the facility to the dialysis center. The area was left blank. On 12/8/23 at 8:20 AM, an interview was conducted with LPN #9 (Licensed Practical Nurse). She stated that the communication sheets should be filled out each time the resident goes to dialysis. She stated that there is also a form in the electronic health record system that can be filled out after dialysis. She stated that if the form to dialysis was not filled in then the facility is not providing efficient communication to the dialysis center. A policy regarding dialysis care and services was requested. None was provided. Instead, the facility referred the survey team to an external source for information the survey team did not have access to. On 12/7/23 at 4:50 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. 42183 2. For Resident #60, the facility failed to provide dialysis communication from the facility to the dialysis center. Resident #60 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), DM, CVA (cerebrovascular accident) and hypertension. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/31/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bathing, bed mobility, transfer, dressing, hygiene and eating. A review of the comprehensive care plan dated 11/7/23 revealed, FOCUS: Resident needs dialysis (hemodialysis) HD three days a week on Monday, Wednesday and Friday related to renal failure. INTERVENTIONS: Monitor/document/report as needed for signs/symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Revised interventions dated 12/7/23 revealed, Monitor dialysis access site left arm every shift for bleeding or signs/symptoms of infection. If observed, notify provider and document. A review of the physician orders dated 9/24/23, revealed, DIALYSIS - Attends Dialysis on Monday-Wednesday-Friday for dialysis time at 0515. Assess fistula for bruit and thrill every shift. NOTIFY PROVIDER immediately if not present. Every shift for fistula. Discontinue date of orders 10/5/23. Resident continued to go to dialysis Monday-Wednesday-Friday. A review of Resident #60's dialysis communication book revealed, missing documentation 34 out of 41 dialysis appointments. September 2023: 9/1, 9/6, 9/11, 9/18, 9/20, 9/22, 9/27; October 2023: 10/2, 10/6, 10/9, 10/11, 10/13, 10/16, 10/18, 10/20, 10/23, 10/25, 10/27, 10/30; November: 11/1, 11/3, 11/6, 11/8, 11/10, 11/13, 11/15, 11/17, 11/20, 11/22, 11/24, 11/27, 11/29 and December: 12/1 and 12/4. A review of Resident #60's TAR (treatment administration record) for October, November and to December 6, 2023, for a total of 61-day shifts, 61-evening shifts and 61-night shift. Resident #60 was either sleeping or unavailable for interview. An interview was conducted 12/7/23 at 12:05 PM with LPN (licensed practical nurse) #5. When asked the process for sending a resident to dialysis, LPN #5 stated, there is paperwork we complete and send to the dialysis center, with updated resident information. When asked what care is provided for a dialysis resident, LPN #5 stated, we monitor their fistula site for bleeding, bruit and thrill. When asked where this is documented, LPN #5 stated, it is on the TAR. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. According to the facility, they follow Elsevier Clinical Skills for dialysis care. No further information was provided. No further information was provided prior to exit. 42106 3. For Resident #120 (R120), the facility staff failed to evidence complete dialysis care and services. On the most recent MDS (minimum data set) assessment, a quarterly assessment with an ARD (assessment reference date) of 11/23/2023, the resident scored 15 of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section O documented R120 receiving dialysis services. On 12/5/2023 at 2:49 p.m., an interview was conducted with R120 in their room. R120 stated that they went to dialysis outside of the facility three days a week on Mondays, Wednesdays and Fridays. R120 stated that the dialysis staff cared for the dialysis access that they had on the left side of their chest and the facility staff don't mess with it. R120 stated that the facility staff did not assess them or check vital signs when they returned from dialysis. R120 stated that the dialysis center had recently changed their dialysis time and they had switched from early morning to after breakfast. The comprehensive care plan for R120 documented in part, (Name of R120) requires hemo-dialysis [sic] r/t (related to) end stage renal failure. Date Initiated: 10/20/2022. Revision on: 07/18/2023. Under Interventions it documented in part, Check and change dressing daily at access site. Document. Date Initiated: 10/20/2022 . The physician orders for R120 documented in part, - 10/12/2023 Record Post-dialysis vitals every evening shift every Mon, Wed, Fri. - 10/12/2023 Record Post-dialysis weight every evening shift every Mon, Wed, Fri. - 10/12/2023 Take Pre-dialysis vitals every day shift every Mon, Wed, Fri. The eTAR (electronic treatment administration record) for R120 dated 11/1/2023-11/30/2023 failed to evidence pre-dialysis vital signs on 11/6/2023 and 11/15/2023 and post-dialysis vital signs on 11/3/2023, 11/13/2023, 11/20/2023 and 11/27/2023. It further failed to evidence post-dialysis weight on 11/3/2023, 11/10/2023, 11/13/2023, 11/20/2023, 11/22/2023 and 11/27/2023. The eTAR for R120 dated 12/1/2023-12/31/2023 failed to evidence post- dialysis vital signs on 12/1/2023 and 12/4/2023. It further failed to evidence post-dialysis weight on 12/1/2023 and 12/4/2023. The eTAR documented NA on those dates, the eTAR legend/chart codes failed to evidence the meaning of NA. Review of the clinical record for R120 failed to evidence documentation of care of the dialysis catheter provided by facility staff, pre-dialysis vital signs, post-dialysis vital signs or post-dialysis weights on the dates listed above. The eTAR documented NA on those dates, the eTAR legend/chart codes failed to evidence the meaning of NA. On 12/7/2023 at 8:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2, clinical coordinator. LPN #2 stated that dialysis residents were monitored by obtaining their vital signs pre and post dialysis and monitoring their weight. LPN #2 stated that the facility staff did not provided any treatment or dressing change to R120's dialysis access. She stated that the gauze dressing was applied at dialysis and the site was cared for by the dialysis staff. She stated that the nursing staff monitored the area for any changes or drainage every shift and would notify the dialysis center or provider if any were observed. She reviewed R120's care plan documenting the intervention to check and change the access site dressing daily and stated that it was not accurate and needed to be revised. She reviewed the eTAR dated 11/1/2023-11/30/2023 and stated that the vital signs and weights should be documented on the eTAR or in the clinical record. She stated that she did not know what the NA meant on the eTAR's and that there should be vital signs and weights in the spaces where the NA was. On 12/7/2023 at 4:36 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the concern. No further information was obtained prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of written RP (responsible party) notification was provided when four of 60 residents in the survey sample who were transferred to the hospital, Residents #49, Resident #58, Resident #8 and Resident #60. The findings include: 1. The facility staff failed to evidence provision of required written RP (responsible party) notification at the time of discharge for Resident #49. Resident #49 was transferred to the hospital on 10/16/23 and 11/7/23. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing and supervision for bed mobility, transfer, dressing, hygiene and eating; independent for locomotion. A review of the comprehensive care plan dated 7/3/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, limited assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. There was no evidence of provision of required written RP notification when Resident #49 was sent to the hospital on 10/16/23 and 11/7/23. A review of the progress note dated 10/16/23 at 5:09 PM, revealed, Nursing observations, evaluation, and recommendations are: Resident bumped into a chair with her motorized wheelchair. A hematoma formed on RLE (right lower extremity). It was evaluated by in house Provider who wants patient to go to ED (emergency department) due to infected hematoma to RLE. A review of the progress note dated 11/7/23 at 10:23 AM, revealed, Today, nursing requested for patient to be seen for right leg nodule increased in size, firm to touch and painful. Patient is sitting up in wheelchair ready dressed for her eye appointment at 12 noon. patient stated right leg is infected and painful. discussed will transfer back to emergency room for evaluation and drain hematoma surgically since procedure cannot be done at the facility. Nursing made aware that patient can be sent out when she comes back from her eye appointment. An interview was conducted on 12/6/23 at 3:00 PM with LPN (licensed practical nurse) #4. When asked for evidence of written RP notification, LPN #4 stated, we call the RP and document it, but we do not provide any written notification. I do not know who does this. An interview was conducted on 12/6/23 at 3:10 PM with OSM (other staff member) #1, the social worker. When asked for evidence of written RP notification, OSM #1 stated, we do not provide written notification. I do not know what the nurses do. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. A review of the facilities Transfer and Discharge policy revealed, Before a facility transfers or discharges a resident, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. No further information was provided prior to exit. 2. The facility staff failed to evidence provision of required written RP notification at the time of discharge for Resident #58. Resident #58 was transferred to the hospital on 11/22/23. Resident #58 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), dysphagia and acute respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/7/23, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility; limited assistance for transfers and supervision for eating. A review of the comprehensive care plan dated 8/22/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, total dependence x 2 transfers, extensive assist x1: bed mobility, dressing, toileting and personal hygiene. There was no evidence of provision of required written RP notification when Resident #58 was sent to the hospital on 11/22/23. A review of the progress note dated 11/22/23 at 2:15 PM, revealed, Patient was assessed by NP (nurse practitioner). NP ordered to send patient out via emergent, related to hypoxia with slight shortness of breath, oxygen saturation at 88% via 4 liters nasal cannula. Patient tested positive for COVID 11/21/23. An interview was conducted on 12/6/23 at 3:00 PM with LPN (licensed practical nurse) #4. When asked for evidence of written RP notification, LPN #4 stated, we call the RP and document it, but we do not provide any written notification. I do not know who does this. An interview was conducted on 12/6/23 at 3:10 PM with OSM (other staff member) #1, the social worker. When asked for evidence of written RP notification, OSM #1 stated, we do not provide written notification. I do not know what the nurses do. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to evidence provision of required written RP notification at the time of discharge for Resident #8. Resident #8 was transferred to the hospital on 10/31/23. Resident #8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), neurogenic bladder and paraplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/17/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A review of the comprehensive care plan dated 1/30/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, overbed trapeze, extensive assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. There was no evidence of provision of required written RP notification when Resident #49 was sent to the hospital on 10/31/23. A review of the progress note dated 10/31/23 at 9:56 AM, revealed, Neurological Status Evaluation: Seizure Nursing observations, evaluation, and recommendations are: Primary Care Provider Feedback: physician was present in room during seizure activity, transport to ED. An interview was conducted on 12/6/23 at 3:00 PM with LPN (licensed practical nurse) #4. When asked for evidence of written RP notification, LPN #4 stated, we call the RP and document it, but we do not provide any written notification. I do not know who does this. An interview was conducted on 12/6/23 at 3:10 PM with OSM (other staff member) #1, the social worker. When asked for evidence of written RP notification, OSM #1 stated, we do not provide written notification. I do not know what the nurses do. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to evidence provision of required written RP (responsible party) notification at the time of discharge for Resident #60. Resident #60 was transferred to the hospital on 8/16/23. Resident #60 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), DM, CVA (cerebrovascular accident) and hypertension. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/31/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bathing, bed mobility, transfer, dressing, hygiene and eating. A review of the comprehensive care plan dated 5/30/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, limited assist x1: dressing, toileting, showers, incontinence care and personal hygiene. Extensive assist x1: transfers. There was no evidence of provision of required written RP notification when Resident #60 was sent to the hospital on 8/16/23. A review of the progress note dated 8/16/23 at 5:09 PM, revealed, Resident was sent to the ER from dialysis due to bleeding coming from his fistula site. An interview was conducted on 12/6/23 at 3:00 PM with LPN (licensed practical nurse) #4. When asked for evidence of written RP notification, LPN #4 stated, we call the RP and document it, but we do not provide any written notification. I do not know who does this. An interview was conducted on 12/6/23 at 3:10 PM with OSM (other staff member) #1, the social worker. When asked for evidence of written RP notification, OSM #1 stated, we do not provide written notification. I do not know what the nurses do. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to develop and/or implement the care plan for seven of 60 residents in the survey sample, Residents #59, #70, #49, #115, #60, #23, and #134. The findings include: 1. For Resident #59 (R59), the facility staff failed to develop a care plan for the resident's ADL (activities of daily living) needs. On R59's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 10/10/23, R59 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). On 12/6/23 at 10:23 a.m., R59 was observed sitting up in bed. He stated he received assistance from the facility staff for his daily needs, including dressing, bathing, and personal hygiene. A review of R59's comprehensive care plan dated 12/1/22 revealed no information related to the assistance the resident requires for ADL performance. On 12/7/23 at 8:19 a.m., RN (registered nurse) #2, the MDS coordinator, was interviewed. She stated the MDS staff open up the comprehensive care plan as soon as possible after a resident is admitted . She stated she interviews the resident, interviews staff members, reviews the information from the hospital, and looks at the diagnosis list, physician's orders, and assessments from the facility staff to formulate the comprehensive care plan. After reviewing R59's care plan, she stated she did not see his ADL assistance anywhere on the document. She stated his ADL assistance should have been included on the care plan. On 12/07/23 at 4:33 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the chief nursing officer, were informed of these concerns. A review of the facility policy, Comprehensive Care Planning, revealed, in part: The facility must work with the resident and their representative, if applicable, to understand and meet the resident's preferences, choices, and goals while they are at the facility .The facility must establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. A comprehensive care plan must be developed and implemented no later than day 21 of the resident's admission to the facility .The facility must develop care plans that describe the resident's medical, nursing, physical, mental, and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences. Care plans must include person-specific, measurable objectives and timeframes in order to evaluate the resident's progress toward their goal(s). No further information was provided prior to exit. 2. For Resident #70 (R70), the facility staff failed to develop a care plan for the resident's use of an anticoagulant. A review of R70's physician's orders December 2023 MAR (medication administration record) revealed R70 was receiving Eliquis, and anticoagulant, every day. A review of R70's care plan dated 9/11/23 failed to reveal any information related to the resident's receiving an anticoagulant. On 12/7/23 at 8:19 a.m., RN (registered nurse) #2, the MDS coordinator, was interviewed. She stated the MDS staff open up the comprehensive care plan as soon as possible after a resident is admitted . She stated she interviews the resident, interviews staff members, reviews the information from the hospital, and looks at the diagnosis list, physician's orders, and assessments from the facility staff to formulate the comprehensive care plan. After reviewing R70's care plan, she stated she did not see the resident's anticoagulant anywhere on the document. She stated the anticoagulant should be included in the care plan. On 12/07/23 at 4:33 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #3, the chief nursing officer, were informed of these concerns. No further information was provided prior to exit. 42183 3. The facility staff failed to implement the comprehensive care plan for medications as ordered for Resident #49. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing and supervision for bed mobility, transfer, dressing, hygiene and eating; independent for locomotion. A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is prescribed fluoxetine for diagnosis of major depressive disorder. Resident is on anticoagulant therapy (Eliquis) related to Atrial fibrillation. INTERVENTIONS: Administer medications as ordered by provider. Monitor for side effects and effectiveness. Administer ANTICOAGULANT medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. A review of the physician orders dated 12/4/22, revealed Fluoxetine CAP 40MG (milligram) Give 1 capsule orally one time a day for Depression; and 6/19/23 orders revealed, ELIQUIS TAB 5MG (milligram), Give 1 tablet orally two times a day for Afib (atrial fibrillation). An interview was conducted on 12/5/23 at 3:40 PM with Resident #49. Resident #49 stated, in November, they did not give me my anticoagulant and my antidepressant for several shift. A review of the November 2023 MAR (medication administration record) revealed, ELIQUIS TAB 5MG Give 1 tablet orally two times a day for Afib, was coded 9-other see progress note for 11/12/23 8 AM and 9 PM and 11/13/23 at 8 AM; and Fluoxetine 40 mg give 1 capsule orally one time a day for depression was coded 9-other see progress note for 11/13/23 8 AM. A review of the progress note dated 11/12/23 at 9:14 AM, revealed ELIQUIS TAB 5MG Give 1 tablet orally two times a day for Afib. Medication not given; Pharmacy did not send. Pharmacy notified; 11/13/23 at 9:30 AM revealed ELIQUIS TAB 5MG Give 1 tablet orally two times a day for Afib. Reorder; 11/13/23 at 9:31 AM revealed Fluoxetine CAP 40MG Give 1 capsule orally one time a day for Depression. Reorder. An interview was conducted 12/7/23 at 12:05 PM with LPN (licensed practical nurse) #5. When asked if the care plan reveals to administer medications as ordered and there is no evidence of the administration, is the care plan implemented, LPN #5 stated, no, it is not being followed. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to implement the comprehensive care plan for dialysis care as ordered for Resident #60. Resident #60 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), DM, CVA (cerebrovascular accident) and hypertension. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/31/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bathing, bed mobility, transfer, dressing, hygiene and eating. A review of the comprehensive care plan dated 11/7/23 revealed, FOCUS: Resident needs dialysis (hemodialysis) HD three days a week on Monday, Wednesday and Friday related to renal failure. INTERVENTIONS: Monitor/document/report as needed for signs/symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Revised interventions dated 12/7/23 revealed, Monitor dialysis access site left arm every shift for bleeding or signs/symptoms of infection. If observed, notify provider and document. A review of the physician orders dated 9/24/23, revealed, DIALYSIS - Attends Dialysis on Monday-Wednesday-Friday for dialysis time at 0515. Assess fistula for bruit and thrill every shift. NOTIFY PROVIDER immediately if not present. Every shift for fistula. Discontinue date of orders 10/5/23. Resident continued to go to dialysis Monday-Wednesday-Friday. A review of Resident #60's dialysis communication book revealed, missing documentation 34 out of 41 dialysis appointments. September 2023: 9/1, 9/6, 9/11, 9/18, 9/20, 9/22, 9/27; October 2023: 10/2, 10/6, 10/9, 10/11, 10/13, 10/16, 10/18, 10/20, 10/23, 10/25, 10/27, 10/30; November: 11/1, 11/3, 11/6, 11/8, 11/10, 11/13, 11/15, 11/17, 11/20, 11/22, 11/24, 11/27, 11/29 and December: 12/1 and 12/4. A review of Resident #60's TAR (treatment administration record) for October, November and to December 6, 2023, for a total of 61-day shifts, 61-evening shifts and 61-night shift. Resident #60 was either sleeping or unavailable for interview. An interview was conducted 12/7/23 at 12:05 PM with LPN (licensed practical nurse) #5. When asked if the care plan reveals to assess the bruit and thrill and there is no evidence of the assessment, is the care plan implemented, LPN #5 stated, no, it is not being followed. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 5. The facility staff failed to implement the comprehensive care plan for dialysis care as ordered for Resident #115. Resident #115 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: PTSD (post-traumatic stress disorder), CVA (cerebrovascular accident) and hemiplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/24/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility, transfer, dressing, hygiene and eating. A review of Section I: Medical Diagnosis: I6100. Post Traumatic Stress Disorder (PTSD)-coded yes. A review of the comprehensive care plan dated 8/10/23 revealed, FOCUS: Resident has a potential for alteration in wellbeing related to history of trauma, diagnosis of PTSD. INTERVENTIONS: Provide resident with supportive care and services to promote a sense of safety, well-being and positive self-image. Staff will use the appropriate screening tools and assessments to recognize past trauma and will make referrals, as necessary. Consult pastoral care, as needed. An interview was conducted on 12/5/23 at 3:15 PM with Resident #115. When asked about trauma or stress, Resident #115 stated, there is nothing to talk about. I do not want to talk about it. An interview was conducted 12/7/23 at 12:05 PM with LPN (licensed practical nurse) #5. When asked if the care plan reveals to provide interventions related to PTSD and there is no evidence of any interventions, is the care plan implemented, LPN #5 stated, no, it is not being followed. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 31753 6. For Resident #23 (R23), the facility staff failed to implement the resident's comprehensive care plan for pain. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/14/23, the resident scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. A review of R23's clinical record revealed a physician's order dated 3/15/23 for acetaminophen (Tylenol) 325 milligrams- give 650 milligrams by mouth every six hours as needed for pain. R23's comprehensive care plan dated 8/29/23 documented, (R23) is at risk for pain r/t (related to) a history of polio, UC (ulcerative colitis). Anticipate the resident's need for pain relief and respond immediately to any complaint of pain . On 12/5/23 at 4:16 p.m., R23 was lying in bed. The resident stated her right leg was hurting and the facility staff had not done anything for her pain. A note signed by the nurse practitioner on 12/5/23 documented, Seen today in bed resting. She is alert and following commands. She denies any fevers or chills. She complains of right leg pain and requests for pian [sic] medicine, discussed will ask nurse to medicate . Further review of R23's clinical record failed to reveal acetaminophen was administered to the resident and failed to reveal non-pharmacological interventions were offered to the resident. On 12/6/23 at 8:29 a.m., R23 was lying in bed. The resident stated the staff still had not done anything to treat her leg pain. On 12/6/23 at 2:43 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the nurse who cared for R23 on 12/5/23 when the nurse practitioner wrote the note). LPN #4 stated the purpose of the care plan is to know how to care for the resident. LPN #4 stated nurses implement the care plan by checking physician's orders and she was not sure if she could see residents' care plans in the computer system. LPN #4 stated that on 12/5/23, she was not aware of R23's right leg pain, and the nurse practitioner never reported the pain to her or asked her to medicate the resident. On 12/6/23 at 5:10 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. 29125 7. For Resident #134 the facility staff failed to follow the comprehensive care plan for monitoring for the use of psychotropic medications. A review of the clinical record revealed a physician's order dated 9/13/23 for Trazodone (1) Oral Tablet 50 MG, Give 0.5 mg by mouth at bedtime for per psych. A review of the clinical record revealed a physician's order dated 9/13/23 for Risperdal (2) Oral Tablet 0.5 MG (milligrams) (Risperidone) Give 1 tablet by mouth at bedtime for psychotic disturbance. Further review failed to reveal any orders for staff monitoring for the use of Trazodone, including monitoring for signs and symptoms of depression, effectiveness, side effects and adverse reactions; and for the use of Risperdal, including behavior, effectiveness, side effects, and adverse reactions to an antipsychotic medication. A review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for August 2023 through December 2023 was conducted. There was no line item for the use of Trazodone that included signs and symptoms of depression, effectiveness, side effects and adverse reactions for documenting that the required monitoring was done. Also, there was no line item for monitoring for the use of Risperdal that included behaviors, side effects and adverse reactions for documenting that the required monitoring was done. A review of the progress notes failed to reveal consistent evidence that staff were monitoring for the use of Trazodone, including signs and symptoms of depression, effectiveness, side effects and adverse reactions. The progress notes also failed to reveal consistent evidence that staff were monitoring the use of Risperdal, including behavior, effectiveness, side effects, and adverse reactions to an antipsychotic medication. A review of the comprehensive care plan included one dated 8/9/23 for (Resident #134) uses psychotropic medications (Trazodone and Risperdal) medications) r/t (related to) Disease process (Vascular Dementia Severe with Psychotic Disturbances). This care plan included an intervention dated 5/1/23 for Monitor/document/report PRN (as-needed) any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (Extrapyramidal symptoms) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. On 12/6/23 at 4:31 p.m., an interview was conducted with RN (Registered Nurse) #1. RN #1 stated the purpose of the care plan is that, It tells the story of the resident. It's how we communicate residents' individual needs. On 12/8/23 at 8:20 AM, an interview was conducted with LPN #9 (Licensed Practical Nurse). When asked if the care plan included to monitor and document, and there isn't consistent documentation of monitoring then was the care plan being followed, she stated that she believed it was being followed if they chart by exception any noted behaviors. She stated it would be more efficient if there was an order to check off for monitoring. The facility policy, Care Planning documented, .Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. On 12/7/23 at 4:50 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. (1) Trazodone is used to treat depression. Information obtained from https://medlineplus.gov/druginfo/meds/a681038.html (2) Risperdal is an antipsychotic. Information obtained from https://medlineplus.gov/druginfo/meds/a694015.html

Based on clinical record review, staff interview and facility document review it was determined that the facility staff failed to ensure that pharmacy recommendations were reviewed and implemented in a timely manner for three of five residents reviewed for unnecessary medications, Resident #24, Resident #39 and Resident #41. The findings include: 1. For Resident #24 (R24), the facility staff failed to act on pharmacy medication regimen review recommendations in a timely manner. A review of the monthly pharmacy medication regimen reviews for R24 documented a consultation report for R24 dated 6/6/2023. The report documented in part, .Resident is currently on Olanzapine 20mg (milligram) daily. An A1c (Hemoglobin A1C blood test to measure average blood sugar over the past 3 months) was obtained 5/30/23, which resulted 9.3%. Currently, there are no orders for any antidiabetic medications. Recommendation(s): At this time, would it be appropriate to consider evaluation for potential initiation of an antidiabetic agent? The area for Physician/Prescriber response was observed to be blank. An additional monthly pharmacy report dated 7/11/2023 documented the same request to consider an antidiabetic medication. The area for Physician/Prescriber Response was observed to be blank on the report. Attached to the consultation report was a medical recertification provider note dated 8/24/2023 which documented in part, .Patient is a (age and sex of R24) LTC (long term care) resident seen in hallway today for recertification and due to recommended GDR (gradual dose reduction) of diazepam and elevated blood glucose . Diagnosis, Assessment and Plan: Diabetes mellitus type 2- likely contributed to by medication, specifically depakote. Recommend addition of metformin and monitor. Will titrate up from 500mg ER (extended release) daily to try and minimize GI (gastrointestinal) side effects . The physician orders for R24 documented in part, .Metformin HCL ER (extended release) Oral Tablet Extended Release 24 Hour 1000 MG (Metformin HCl) Give 2 tablet by mouth one time a day for DM2 (diabetes mellitus type 2). Order Date: 08/24/2023. Start Date: 09/08/2023. The eMAR (electronic medication administration record) dated 8/1/2023-8/31/2023 documented the Metformin starting on 8/25/2023. On 12/7/2023 at 2:53 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the pharmacist completed her monthly medication reviews and forwarded her recommendations via email to ASM #2 and the providers' nurse. ASM #2 stated the providers' nurse shared the recommendations with the providers and sometimes the providers would give their nurse orders to put into the computer system and then sit down later and complete the pharmacy recommendation forms. ASM #2 stated the facility has had a lot of providers in the last year. ASM #2 stated for a while, the facility did not have any nurse practitioners and the doctors were trying to handle all the pharmacy recommendations but got bogged down so there were gaps [periods of time] when pharmacy recommendations were not addressed. The facility policy, Medication Regimen Review dated 5/16/2023 documented in part, .The medication regimen of each resident is reviewed by a licensed Pharmacist according to Federal, state and local regulations as well as current standards of practice. The pharmacist must report any irregularities to the Attending Physician, the facility's Medical Director and Director of Nursing. These reports must be acted upon in a manner that meets the needs of the resident .For non-Urgent recommendations, the facility and Attending Physician must address the recommendation(s) in a timely manner that meets the needs of the resident- but no later than their next routine visit to assess the resident- and the Attending Physician should document in the medical record . On 1/26/2023 at 1:37 p.m., ASM (administrative staff member) #1, the president/CEO, ASM #2, the director of executive administration and ASM #3, the director of nursing were made aware of the above concern. No further information was provided prior to exit. 2. For Resident #39 (R39), the facility staff failed to act on pharmacy medication regimen review recommendations in a timely manner. A review of the monthly pharmacy medication regimen reviews for R39 documented a consultation report for R39 dated 9/12/2023. The report documented in part, .The resident has an order for Ipratropium Bromide Nasal Soln (solution) 0.06% (42 MCG/spray) 1 spray in each nostril three times a day for vasomotor rhinitis. Ordered 4/24/2023. Recommendation(s): Would it be appropriate to reduce the frequency of administration to BID (twice a day)? . The area for Physician/Prescriber Response was observed to be blank. Two additional monthly pharmacy reports dated 10/13/2023 and 11/14/2023 documented the same request to reduce the frequency of the Ipratropium Bromide nasal spray. The area for Physician/Prescriber Response was observed to be blank on both reports. Attached to the three reports was a copy of a physician order dated 11/21/2023 which documented the Ipratropium nasal spray ordered twice a day. A review of the monthly pharmacy medication regimen reviews for R39 documented a consultation report for R39 dated 9/12/2023. The report documented in part, .The resident currently has an order for Venlafaxine Hcl ER 150 mg daily. PMH (primary medical history) is significant for Depression. Recommendation(s): Please consider a gradual dose reduction . The area for Physician/Prescriber Response was observed to be blank. Two additional monthly pharmacy reports dated 10/13/2023 and 11/14/2023 documented the same request to consider a gradual dose reduction of the Venlafaxine. The area for Physician/Prescriber Response was observed to be blank on both reports. Attached to the three reports was a copy of a psychiatric consultation dated 11/29/2023 which documented a medication review and clinical rationale for not attempting a gradual dose reduction at that time. The physician orders for R39 documented in part, 8/31/2022 Venlafaxine ER CAP 150MG Give 1 tablet orally in the morning for depression . On 12/7/2023 at 2:53 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing. ASM #2 stated that the pharmacist completed her monthly medication reviews and forwarded her recommendations via email to ASM #2 and the providers' nurse. ASM #2 stated the providers' nurse shared the recommendations with the providers and sometimes the providers would give their nurse orders to put into the computer system and then sit down later and complete the pharmacy recommendation forms. ASM #2 stated the facility has had a lot of providers in the last year. ASM #2 stated for a while, the facility did not have any nurse practitioners and the doctors were trying to handle all the pharmacy recommendations but got bogged down so there were gaps [periods of time] when pharmacy recommendations were not addressed. On 1/26/2023 at 1:37 p.m., ASM (administrative staff member) #1, the president/CEO, ASM #2, the director of executive administration and ASM #3, the director of nursing were made aware of the above concern. No further information was provided prior to exit. 31753 3. For Resident #41 (R41), the facility staff failed to act on pharmacy recommendations regarding milk of magnesia (1) and pantoprazole (2) in a timely manner. A review of R41's clinical record revealed a medication regimen review completed by the pharmacist on 8/17/23 that documented recommendations to clarify a milk of magnesia order and to reduce a PPI (proton pump inhibitor- pantoprazole). Pharmacy recommendations from the pharmacist to the attending physician/prescriber dated 8/17/23, 9/11/23 and 10/11/23 documented, The resident is ordered the following Prn (as needed) medication: MILK OF MAG SUSP (suspension) 1200MG (milligrams)/15ML (milliliters). Give 30 ml orally as needed for Constipation. There is no frequency of administration for this prn order. Recommendation(s): Please indicate a specific frequency for PRN use. The physician did not address the recommendations until 10/25/23. A physician's order dated 10/25/23 documented, MILK OF MAG SUSP 1200MG/15ML- Give 30 ml orally every 24 hours as needed for Constipation. Pharmacy recommendations from the pharmacist to the attending physician/prescriber dated 8/17/23, 9/11/23 and 10/11/23 documented, PMH (Past Medical History) includes GERD (Gastroesophageal Reflux Disease). Currently ordered Pantoprazole 40mg Daily. Dose of the Pantoprazole reduced form 40mg BID (twice a day) to Daily on 1/4/2023. Recommendation(s): If appropriate, please consider further reduction to 20mg Daily before breakfast. The physician did not address the recommendations until 10/25/23. A physician's order dated 10/25/23 documented, Pantoprazole Sodium Oral Tablet Delayed Release 20 MG- Give 1 tablet by mouth one time a day for GERD. On 12/7/23 at 2:53 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the pharmacist completes her monthly medication reviews and forwards her recommendations via email to ASM #2 and the providers' nurse. ASM #2 stated the providers' nurse shares the recommendations with the providers and sometimes the providers will give their nurse orders to put into the computer system then sit down later and complete the pharmacy recommendation forms. ASM #2 stated the facility has had a lot of providers in the last year. ASM #2 stated for a while, the facility did not have any nurse practitioners and the doctors were trying to handle all the pharmacy recommendations but got bogged down so there were gaps [periods of time] when pharmacy recommendations were not addressed. On 12/7/23 at 4:55 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. References: (1) Milk of magnesia is used to treat constipation. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601073.html (2) Pantoprazole is used to treat gastroesophageal reflux disease. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a601246.html

Based on staff interview, clinical record review, and facility document review, it was determined that the facility staff failed to ensure that one of sixty residents in the survey sample, Resident #134, was free of unnecessary psychotropic medications. The findings include: 1. For Resident #134 the facility staff failed to evidence an appropriate diagnosis for the use of Trazodone (1), and failed to ensure consistent monitoring for the use of Trazodone and Risperdal (2), including behavior monitoring, effectiveness, side effects, and adverse reactions to an antipsychotic and an antidepressant medication. A review of the clinical record revealed a physician's order dated 9/13/23 for Trazodone Oral Tablet 50 MG, Give 0.5 mg by mouth at bedtime for per psych. A review of the clinical record revealed a physician's order dated 9/13/23 for Risperdal Oral Tablet 0.5 MG (milligrams) (Risperidone) Give 1 tablet by mouth at bedtime for psychotic disturbance. Further review failed to reveal any orders for staff monitoring for the use of Trazodone, including monitoring for signs and symptoms of depression, effectiveness, side effects and adverse reactions; and for the use of Risperdal, including behavior, effectiveness, side effects, and adverse reactions to an antipsychotic medication. A review of the MAR (Medication Administration Record) and TAR (Treatment Administration Record) for August 2023 through December 2023 was conducted. There was no line item for the use of Trazodone that included signs and symptoms of depression, effectiveness, side effects and adverse reactions for documenting that the required monitoring was done. Also, there was no line item for monitoring for the use of Risperdal that included behaviors, side effects and adverse reactions for documenting that the required monitoring was done. A review of the progress notes failed to reveal consistent evidence that staff were monitoring for the use of Trazodone, including signs and symptoms of depression, effectiveness, side effects and adverse reactions. The progress notes also failed to reveal consistent evidence that staff were monitoring the use of Risperdal, including behavior, effectiveness, side effects, and adverse reactions to an antipsychotic medication. A review of the comprehensive care plan included one dated 8/9/23 for (Resident #134) uses psychotropic medications (Trazodone and Risperdal) medications) r/t (related to) Disease process (Vascular Dementia Severe with Psychotic Disturbances). This care plan included an intervention dated 5/1/23 for Monitor/document/report PRN (as-needed) any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (Extrapyramidal symptoms) (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. On 12/8/23 at 8:20 AM, an interview was conducted with LPN #9 (Licensed Practical Nurse). When asked about monitoring residents for behaviors, effectiveness, side effects and adverse reactions, she stated that after meds are given, the residents are monitored for side effects and if they are having behaviors. She said that there should be an order for follow up documentation like a check off, but it isn't there. She stated that they chart by exception, so it is assumed that if there isn't anything documented then there wasn't any issues. She stated that it would be more efficient if there was a check off. When asked about the diagnosis for the Trazodone being per psych she stated that was not an appropriate diagnosis and that it was probably written wrong. A policy for psychotropic meds - monitoring was requested. The facility policy that was provided, Antipsychotic Gradual Dose Reduction documented, check/validate for appropriate dx (diagnosis) for all residents on antipsychotics; review targeted behaviors for recommendation r/t (related to) GDR; monitor for SE (side effects) and ADRs (adverse drug reactions) or drug/drug interactions ensure there is an order for Behavior Observed. Nursing should be notified to revise the order if Behavior Observed is not listed. This is necessary in order for nursing to document any resident behaviors On 12/7/23 at 4:50 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey. (1) Trazodone is used to treat depression. Information obtained from https://medlineplus.gov/druginfo/meds/a681038.html (2) Risperdal is an antipsychotic. Information obtained from https://medlineplus.gov/druginfo/meds/a694015.html

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to serve food in a palatable manner from one of one facility kitchens. The findings include: On 12/6/23 at 11:21 AM, tray line observation was conducted with OSM #9 (Other Staff Member) the Dietary Manager. The temperatures were taken of the tray line lunch meal. The following temperatures were obtained for the main meal: Meatballs was 179 degrees Noodles was 176 degrees Mixed vegetables was 183 degrees Florentine tomato soup was 167 degrees On 12/6/23 at 12:47 PM the cart with the test tray was taken to the [NAME] unit. Staff started serving trays at 12:53 PM. At 1:11 PM after all residents were served, temperatures for the test tray food items were obtained by OSM #9 as follows: Meatballs was 121 degrees. This was a 57 degree drop in temperature. Noodles was 113 degrees. This was a 63 degree drop in temperature. Mixed vegetables was 117 degrees. This was a 66 degree drop in temperature. Florentine tomato soup was 128 degrees. This was a 39 degree drop in temperature. Two surveyors and OSM #9 tasted all items. It was agreed that the flavor was acceptable. However, it was agreed by all three that the meatballs and mixed vegetables were only at room temperature at best and the noodles were cold. The facility policy Organization and Leadership: Food and Nutrition Services documented, The goal is to provide palatable, well-balanced, safe and nutritious meals that meets the nutritional needs and special dietary needs of residents and patient On 12/6/23 at 5:15 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in one of one facility kitchens. The findings include: On 12/5/23 at 11:10 AM a tour of the kitchen was conducted with OSM #9 (Other Staff Member) the Dietary Manager. In the walk-in refrigerator, a box of garlic bread was observed with the plastic bag open, exposing the bread to the elements of the refrigerator environment. OSM #9 stated that it should be sealed to protect it. The facility policy Food and Nutrition Services Infection Control, Food Safety and Sanitation Policy was reviewed. This policy documented, .J. Food will be stored in a manner to avoid deterioration in quality by drying out, freezer burning or change in color On 12/6/23 at 5:15 PM at the end-of-day meeting, ASM #1 (Administrative Staff Member) the Administrator and ASM #2 the Director of Nursing were made aware of the findings. No further information was provided by the end of the survey.

Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to evidence bed inspections for four of 60 residents in the survey sample, Residents # 49, Resident #58, Resident #60 and Resident #8. The findings include: 1.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #49. Resident #49 was observed in bed with bilateral half bed rails on 12/6/23 at 7:30 AM and 12/7/23 at 8:00 AM. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing and supervision for bed mobility, transfer, dressing, hygiene and eating; independent for locomotion. A review of the comprehensive care plan dated 7/3/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, limited assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. A review of the facility's Bed Safety Inspection Log and Bed Safety Inspection revealed no bed inspections since 2021. On 12/6/23 at 8:20 AM, surveyor observed two maintenance staff performing bed inspections on the Chesapeake Unit. An interview was conducted on 12/6/23 at 8:25 AM with OSM (other staff member) #11, the maintenance staff. When asked what inspections were being conducted, OSM #11 stated, we have not done the bed inspections since COVID. We could not get into resident rooms due to isolation. We are doing them now. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. A review of the facility's Bed Rail / Side Rail Entrapment policy, revealed, Before bed rails are installed, the facility will check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible, since most bed rails and mattresses are purchased separately from the bed frame. Prior to using any model of bed in the facility, designated staff will validate the bed inspection has been completed annually. No further information was provided prior to exit. 2.The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #58. Resident #58 was observed in bed with bilateral half bed rails on 12/5/23 at 1:00 PM, 12/6/23 at 8:30 AM and 12/7/23 at 9:00 AM. Resident #58 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), dysphagia and acute respiratory failure. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/7/23, coded the resident as scoring a 05 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility; limited assistance for transfers and supervision for eating. A review of the comprehensive care plan dated 8/22/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, total dependence x 2 transfers, extensive assist x1: bed mobility, dressing, toileting and personal hygiene. A review of the facility's Bed Safety Inspection Log and Bed Safety Inspection revealed no bed inspections since 2021. On 12/6/23 at 8:20 AM, surveyor observed two maintenance staff performing bed inspections on the Chesapeake Unit. An interview was conducted on 12/6/23 at 8:25 AM with OSM (other staff member) #11, the maintenance staff. When asked what inspections were being conducted, OSM #11 stated, we have not done the bed inspections since COVID. We could not get into resident rooms due to isolation. We are doing them now. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 3. The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #60. Resident #60 was observed in bed with bilateral half bed rails on 12/5/23 at 12:00 PM, 12/6/23 at 2:30 PM and 12/7/23 at 8:30 AM. Resident #60 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: ESRD (end stage renal disease), DM, CVA (cerebrovascular accident) and hypertension. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/31/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring limited assistance for bathing, bed mobility, transfer, dressing, hygiene and eating. A review of the comprehensive care plan dated 5/30/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, limited assist x1: dressing, toileting, showers, incontinence care and personal hygiene. Extensive assist x1: transfers. A review of the facility's Bed Safety Inspection Log and Bed Safety Inspection revealed no bed inspections since 2021. On 12/6/23 at 8:20 AM, surveyor observed two maintenance staff performing bed inspections on the Chesapeake Unit. An interview was conducted on 12/6/23 at 8:25 AM with OSM (other staff member) #11, the maintenance staff. When asked what inspections were being conducted, OSM #11 stated, we have not done the bed inspections since COVID. We could not get into resident rooms due to isolation. We are doing them now. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit. 4. The facility staff failed to perform bed rail inspections for the use of positioning / assist bars for Resident #8. Resident #8 was observed in bed with bilateral half bed rails on 12/5/23 at 12:10 PM, 12/6/23 at 8:30 AM and 12/7/23 at 8:20 AM. Resident #8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), neurogenic bladder and paraplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/17/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A review of the comprehensive care plan dated 1/30/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, overbed trapeze, extensive assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. A review of the facility's Bed Safety Inspection Log and Bed Safety Inspection revealed no bed inspections since 2021. On 12/6/23 at 8:20 AM, surveyor observed two maintenance staff performing bed inspections on the Chesapeake Unit. An interview was conducted on 12/6/23 at 8:25 AM with OSM (other staff member) #11, the maintenance staff. When asked what inspections were being conducted, OSM #11 stated, we have not done the bed inspections since COVID. We could not get into resident rooms due to isolation. We are doing them now. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit.

Based on resident and staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of providing ADLs (activities of daily living) care to maintain abilities for two of 60 residents, Resident #49 and Resident #8. 1.The findings include: The facility staff failed to provide evidence of bathing and showers for Resident #49. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing and supervision for bed mobility, transfer, dressing, hygiene and eating; independent for locomotion. A review of the comprehensive care plan dated 7/3/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, limited assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. A review of October 2023 shower ADL documentation revealed that three of eight days are missing: 10/11, 10/14 and 10/18. A review of November 2023 shower ADL documentation revealed that five of nine days are missing: 11/1, 11/8, 11/15, 11/18 and11/22. An interview was conducted on 12/7/23 at 12:30 PM with CNA (certified nursing assistant) #2. When asked where bathing and showers are documented, CNA #2 stated, we document our showers in PCC (Point Click Care) there is no book. When asked what it indicates if there are blanks in the documentation, CNA #2 stated, the bathing and showers were not done. When asked what it indicates if NA is documented, CNA #2 stated, that is not applicable, that does not make any sense. An interview was conducted on 12/7/23 at 4:00 PM with CNA #3. When asked where showers are documented, CNA #3 stated, they are documented in PCC. When asked what it indicates if there are blanks in the documentation, CNA #3 stated, it means that the showers were not done. An interview was conducted on 12/8/23 at 8:15 AM with CNA #4. When asked the frequency of showers and where they are documented, CNA #4 stated, they are twice a week and are documented in PCC. When asked what it indicates if there are blanks in the documentation, CNA #4 stated, it was not done. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. A review of the facility's Routine Care and Activities of Daily Living policy revealed, Provision of care and services will be based on a comprehensive assessment and consistent with resident needs and choices. Documentation of routine care and activities of daily living will be documented in the EMR (electronic medical record) touchscreen and will align with definitions in the state's RAI (Resident Assessment Instrument) manual. Residents who are unable to carry out activities of daily living will receive the necessary services to maintain and maximize their functional abilities. No further information was provided prior to exit. 2. The findings include: The facility staff failed to provide evidence of bathing and showers for Resident #8. Resident #8 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: DM (diabetes mellitus), neurogenic bladder and paraplegia. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 10/17/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing, bed mobility, transfer, dressing, hygiene and limited assistance for eating. A review of the comprehensive care plan dated 1/30/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, overbed trapeze, extensive assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. A review of September 2023 shower ADL documentation revealed that six of eight days are missing: 9/6, 9/13, 9/16, 9/20, 9/23 and 9/27; personal hygiene/grooming documentation revealed that five of 30 days are missing: 9/2, 9/4, 9/8, 9/23, and 9/25. A review of October 2023 shower ADL documentation revealed that five of nine days are missing: 10/6, 10/10, 10/17, 10/27 and 10/31; personal hygiene/grooming documentation revealed that six of 31 days are missing: 10/6, 10/10, 10/17, 10/26, 10/27 and 10/31. A review of November 2023 shower ADL documentation revealed that one of seven days are missing: 11/17; personal hygiene/grooming documentation revealed that five of 24 days are missing: 11/12, 11/14, 11/17, 11/19 and 11/25. An interview was conducted on 12/7/23 at 12:30 PM with CNA (certified nursing assistant) #2. When asked where bathing and showers are documented, CNA #2 stated, we document our showers in PCC (Point Click Care) there is no book. When asked what it indicates if there are blanks in the documentation, CNA #2 stated, the bathing and showers were not done. When asked what it indicates if NA is documented, CNA #2 stated, that is not applicable, that does not make any sense. An interview was conducted on 12/7/23 at 4:00 PM with CNA #3. When asked where showers are documented, CNA #3 stated, they are documented in PCC. When asked what it indicates if there are blanks in the documentation, CNA #3 stated, it means that the showers were not done. An interview was conducted on 12/8/23 at 8:15 AM with CNA #4. When asked the frequency of showers and where they are documented, CNA #4 stated, they are twice a week and are documented in PCC. When asked what it indicates if there are blanks in the documentation, CNA #4 stated, it was not done. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. No further information was provided prior to exit.

Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure reasonable accommodation of needs for one of 60 residents in the survey sample, Resident #19. The findings include: For Resident #19 (R19), the facility staff failed to ensure their roommates personal belongings did not hinder their ability to leave the room if they chose. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 9/14/2023, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. The assessment documented R19 being dependent on staff for bed to chair transfers, utilizing a manual wheelchair and dependent on staff to wheel at least 50 feet with two turns. On 12/5/2023 at 12:59 p.m., an interview was conducted with R19 in their room. R19 was observed in bed in their room on the right side of a semi-private room near the window. When asked about staff assisting them to get out of bed when they wanted to get up, R19 stated that they did not get out of bed often but liked to get up on Wednesdays to go out of the facility to (Name of outside health program). R19 stated that they did not go every Wednesday but liked to go out when they felt up to it but the nursing staff had told them that they could not get their wheelchair past their roommate's Christmas tree to get them out of the room to go to the appointments so they had not gone recently. R19 stated that staff had to use a mechanical lift to get them up and had to have the wheelchair right by the bed and could not fit the chair past the end of the roommate's bed and the Christmas tree so she had not gotten out of bed recently. Observation of R19's roommates side of the room revealed an approximately 5 foot tall artificial Christmas tree at the foot of their bed with glass ornaments and tinsel with approximately 14 inches space between the end of the bed and the tree branches. When asked where their wheelchair was stored, R19 stated that the staff stored the wheelchair somewhere outside of the room and they were not exactly sure where. R19 stated that the tree had been up for at least two weeks and they had not gone to the appointment last Wednesday because the office was closed. R19 stated that they were hoping to be able to go on 12/6/2023. On 12/6/2023 at 3:50 p.m., an interview was conducted with R19 in their room in bed. R19 stated that staff did not offer to get them out of bed for the appointment that day and they had forgotten about them. R19 stated that they would have gone if anyone had offered to get them out of bed and to the appointment. The comprehensive care plan for R19 documented in part, (Name of R19) has an ADL (activities of daily living) self-care performance deficit r/t (related to): Amputation left aka (above the knee amputation) . Date Initiated: 09/27/2023. Revision on: 09/27/2023. The progress notes for R19 documented in part, - 11/15/2023 09:06 (9:06 a.m.) Note Text : (Name of staff) at (Name of outside health program) called an informed (Name of R19) refused to attend (Name of outside health program). (Name of staff) at (Name of outside health program) informed that (Name of R19) needed a new prescription for her Percocet tab 2.5 mg (milligram)-325 mg. - 11/1/2023 11:45 (11:45 a.m.) Note Text : (Name of staff) at (Name of outside health program) informed (Name of R19) refused to attend (Name of outside health program). No reason given. The clinical record failed to evidence documentation of any refusals to attend the program after 11/15/2023 or documentation of R19 attending the program. On 12/7/2023 at 8:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2, clinical coordinator. LPN #2 stated that R19 was followed by the provider at the (Name of outside health program) and refused to go often. She stated that she followed up with R19 every week and encouraged them to attend and participate. She stated that she did not speak with R19 on 12/6/2023 because she was not working on the unit that day. She stated that she was not aware of any issues getting R19 up and out of the room, that the wheelchair was stored in an alcove area behind the dining room. She stated that R19 used a manual wheelchair and required nursing staff to push them. She stated that since R19 had been refusing to go to (Name of outside health program), they had stopped coming to pick them up every Wednesday and she would communicate with the DON (director of nursing) for the program when R19 planned to go ahead of time to set up the transportation. She stated that the medical provider from the program came to the facility quarterly to see R19 for re-certifications. On 12/7/2023 at 9:06 a.m., a request was made to LPN #2 to observe them take R19's wheelchair into the room to the bedside. LPN #2 identified a manual bariatric wheelchair located in an alcove behind the dining area on the unit as R19's wheelchair. She pushed the wheelchair to R19's room and entered the doorway to the area where the foot of the roommate's bed and the Christmas tree were and stated that the wheelchair would not fit through the opening. She stated again that R19 always refused to go to (Name of outside health program) and to get out of bed and she felt that R19 may be using the Christmas tree as an excuse why they were not getting out of bed and the CNA would never leave them in the bed because of the tree. She stated that if R19 asked to get out of bed they would have to move the Christmas tree each time. On 12/7/2023 at 9:10 a.m., an interview was conducted with CNA (certified nursing assistant) #5. CNA #5 stated that they did not offer for R19 to go out to (Name of outside health program) on 12/6/2023 and normally the resident would ask them to get out of bed when they wanted to go. She stated that R19 did not tell them that they wanted to go on 12/6/2023 so they had not gotten them up. When asked how the wheelchair would fit in and out of the room, CNA #5 stated that they would have to move the roommate's bed first. When asked what would be done if they had an emergency and needed to evacuate, CNA #5 stated that it would be difficult. On 12/7/2023 at 2:53 p.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing. ASM #2 stated that R19 frequently refused to get out of bed and attend (Name of outside health program). She stated that the nursing staff had a schedule and they should ask R19 and offer for them to attend at least twice. She stated that R19 should not have to ask to attend, that R19 does not always refuse and the staff should be encouraging them to get out of bed and there should not be any barriers to get in and out of the room. On 12/7/2023 at 1:57 p.m., an interview was conducted with OSM (other staff member) #3, facilities director. OSM #3 stated all residents should be able to get in and out of their rooms. He used a tape measure and measured R19's bariatric wheelchair identified by LPN #2 and stated that it was 30 inches wide. He measured the distance between R19's roommate's bed and the Christmas tree and stated that it was 17 inches and stated that the tree needed to be taken down. The facility policy, Resident Rights and Responsibilities dated 6/20/2023 documented in part, .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents . On 12/7/2023 at 4:36 p.m., ASM #1, the administrator, ASM #2, the director of nursing, and ASM #3, the chief nursing officer were made aware of the above concern. No further information was presented prior to exit.

Based on review of facility's documentation and staff interview, it was determined that the facility failed to promote and facilitate the resident's right to self-determination by promoting resident's choice in transferring to wheelchair for one of 60 residents in the survey sample, Resident #154. The findings included: Resident #154 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: diabetes mellitus (DM), paraplegia and gangrene. The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/19/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, dressing and hygiene; supervision for eating and total dependence for transfers and bathing. A review of the comprehensive care plan dated 5/22/23, which revealed, FOCUS: Resident has paraplegia. INTERVENTIONS: Assist with ADLs and locomotion as required. An interview was conducted with Resident #154 on 12/5/23 at 12:30 PM. Resident #154 stated, they do not transfer me to my wheelchair every day. In my motorized wheelchair, I can go to the activity room, dining room and just travel around. An interview was conducted on 12/7/23 at 2:00 PM with LPN (licensed practical nurse) #7. When asked if a resident's choices are being honored if the resident is dependent on staff for transfers to the wheelchair and is not transferred to the wheelchair daily, LPN #7 stated, no, the resident's choices are not being honored. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. According to the facility's Resident Rights and Responsibilities policy, which revealed, Self-Determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to: The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. No further information was provided prior to exit.

Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide evidence of required resident information when a resident is transferred to the hospital, for one of 60 residents in the survey sample, Residents #49. The findings include: The facility staff failed to evidence provision of required resident information to a receiving facility at the time of discharge for Resident #49. Resident #49 was transferred to the hospital on 10/16/23 and 11/7/23. Resident #49 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), cellulitis, ASCVD (atherosclerotic cardiovascular disease) and PVD (peripheral vascular disease). The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 11/28/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bathing and supervision for bed mobility, transfer, dressing, hygiene and eating; independent for locomotion. A review of the comprehensive care plan dated 7/3/23 revealed, FOCUS: Resident desires to remain in facility to receive continued services. INTERVENTIONS: Provide services according to care plans in an effort to enhance optimum well-being. Siderails x2, limited assist x1: dressing, toileting and personal hygiene. Extensive assist x1 showers and incontinence care. There was no evidence of clinical documents sent with the resident to the hospital on 10/16/23 and 11/7/23. A review of the progress note dated 10/16/23 at 5:09 PM, revealed, Nursing observations, evaluation, and recommendations are: Resident bumped into a chair with her motorized wheelchair. A hematoma formed on RLE (right lower extremity). It was evaluated by in house Provider who wants patient to go to ED (emergency department) due to infected hematoma to RLE. A review of the progress note dated 11/7/23 at 10:23 AM, revealed, Today, nursing requested for patient to be seen for right leg nodule increased in size, firm to touch and painful. Patient is sitting up in wheelchair ready dressed for her eye appointment at 12 noon. patient stated right leg is infected and painful. discussed will transfer back to emergency room for evaluation and drain hematoma surgically since procedure cannot be done at the facility. Nursing made aware that patient can be sent out when she comes back from her eye appointment. An interview was conducted on 12/6/23 at 3:00 PM with LPN (licensed practical nurse) #4. When asked for evidence of clinical documentation sent to the hospital for Resident #49, LPN #4 stated, we go through the transfer document list and send those documents, but we do not keep any documentation of that. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. A review of the facilities Transfer and Discharge policy revealed, Identify Information provided to the receiving provider which at a minimum will include: All information necessary to meet the resident's needs, which includes, but may not be limited to: Resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; Diagnoses and allergies; Medications (including when last received); and Most recent relevant labs, other diagnostic tests, and recent immunizations. No further information was provided prior to exit.

Based on observations, staff interview, clinical record review and facility document review, it was determined the facility staff failed to provide an accurate MDS (minimum data set) assessment for two out of 60 residents in the survey sample, Resident #192 and Resident #129. The findings include: 1.The facility staff failed to complete an accurate MDS (minimum data set), a discharge assessment for Resident #192. Resident #192 was sampled during the closed record review for transfer to hospital. Resident #192 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: COPD (chronic obstructive pulmonary disease), chronic bronchitis and acute kidney failure. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 10/8/23, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of Section A: Identification Information: A2105. Discharge Status, 04. Short term general hospital (acute care). A review of the comprehensive care plan dated 10/5/23 revealed, FOCUS: The resident is independent for meeting emotional, intellectual, physical, and social needs. INTERVENTIONS: Resident will maintain involvement in cognitive stimulation, social activities at her leisure as she is willing and able to tolerate through review date. A review of the nursing progress note dated 10/8/23 at 11:49 AM revealed, Resident left facility against medical advice with daughters. Original copy of AMA form with patient's signature is in her chart. On call provider made aware. A review of the facility's Against Medical Advice (AMA form), reveals Resident #192 signed form on 10-8-23. An interview was conducted on 12/7/23 at 1:48 PM with RN (registered nurse) #2, the MDS coordinator. When asked to review the discharge information on Resident #192, RN #2 stated, yes, it documents that she went the hospital, let me check, no she did not go to the hospital, so it must be a coding error. When asked what standard is followed for completing the MDS, RN #2 stated, we follow the RAI. On 12/7/23 at 4:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nursing officer were made aware of the findings. According to the RAI (resident assessment instrument) MDS Section A2100 OBRA Discharge Assessment: Steps for Assessment: Review the medical record including the discharge plan and discharge orders for documentation of discharge location. Coding Instructions: Select the 2-digit code that corresponds to the resident's discharge status. Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home. Code 02, another nursing home or swing bed: if discharge location is an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care or rehabilitation services for injured, disabled, or sick persons. Includes swing beds. Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons. No further information was provided prior to exit. 42106 2. For Resident #129 (R129), the facility staff failed to maintain an accurate MDS (minimum data set) assessment regarding the use of restraints. On the most recent MDS assessment, a quarterly assessment, with an ARD (assessment reference date) of 9/7/2023, R129 was coded as using a trunk restraint less than daily in bed. On 12/6/2023 at 11:08 a.m., an observation was made of R129 in bed in their room, no trunk restraint was observed. Additional observations on 12/6/2023 at 2:48 p.m., 12/7/2023 at 8:22 a.m. and 12/7/2023 at 3:12 p.m. of R129 in bed revealed no trunk restraint in place. Review of R129's clinical record failed to evidence documentation of trunk restraint usage. On 12/7/2023 at 8:26 a.m., an interview was conducted with LPN (licensed practical nurse) #2, clinical coordinator. LPN #2 stated that she worked with R129 and she was not aware of any restraint usage. On 12/7/2023 at approximately 8:15 a.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they followed the RAI (resident assessment instrument) manual when completing the MDS assessments. RN #2 stated that the facility was restraint free and would need to review R129's MDS to determine why it was coded for restraint usage. On 12/7/2023 at 9:19 a.m., RN #2 stated that she had reviewed the quarterly MDS with the ARD of 9/7/2023 and the trunk restraint coding was an error. She stated that R129 had not utilized any restraints. She stated that she had corrected the MDS and resubmitted it. According to the RAI Manual, Version 1.16, dated October 2018, section P0100 documented in the steps for assessment, 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period . On 12/7/2023 at 4:36 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the chief nurse officer were made aware of the concern. No further information was provided prior to exit.

Based on observation, staff interviews, family interview, clinical record review and facility document review the facility staff failed to prevent an avoidable fall for 1 of 59 residents in the survey sample, Resident #121. During the provision of care by staff, the resident fell off the bed and sustained left hip and left femur fractures. Following the fall, the facility staff did a root cause analysis and implemented a plan of correction with a completion date of 1/15/2020. No other falls during provision of care was identified after the completion date. The deficiency is cited as a level 3 isolated, past non-compliance. The findings included: Resident #121 was admitted to the facility on [DATE] with a readmission date of [DATE] following a hospitalization for surgical intervention to the left hip and proximal femur fractures resulting from a fall from the bed on 12/25/19 at the facility. The resident's other [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) prior to the fall was a quarterly with an Assessment Reference Date of 12/11/19. The resident was coded as scoring an 11 out of a possible 15 on the Brief Interview for Mental Status indicating the resident had moderately impaired daily decision making skills. The resident was dependent on two staff for transfers, dependent on one staff for bathing, and extensive assistance of one staff for bed mobility, dressing, toileting and personal hygiene. The resident was frequently incontinent of bladder and always incontinent of bowels. The physician orders dated 7/24/17 included an air mattress with perimeter cover for pressure relief, check function and inflation every shift. The person-centered plan of care effective date of 3/3/17-present identified the resident was at risk for falls and/or history of falls related to, unsteady gait, loss of balance, poor sitting balance/ poor trunk control, short-term memory loss, requires reminders to call for assistance, requires staff assistance for transfers, pain, impaired sensation, unstable/ fluctuating health conditions, diabetes, high blood pressure, use of narcotic [MEDICATION NAME] , incontinence and history of falls. The goal was that the resident will not experience significant injury (i.e., requiring ER visit or hospitalization ) through next review. During each of the survey days 2/18/20, 2/19/20, 2/20/20 and 2/21/20 the resident was observed in bed on a bariatric low air loss mattress. There was no defined perimeter mattress in place; there was no physician's order after readmission for a perimeter cover. A review of the clinical record and facility event report evidenced the resident had a witnessed fall from the bed during ADL (activities of daily living) care on 12/25/19. As a result of the fall the resident sustained [REDACTED]. The resident was transferred to the emergency room for evaluation and admitted . The clinical notes by Licensed Practical Nurse (LPN) #9 dated 12/25/19 read in part: Resident fell out of bed @11:15. CNA (certified nursing assistant) reported to nurse while turning the resident the resident slid to the floor. Left leg in pain 10/10 (intensity of pain 1-10, 10 being the worst) and has 4 abrasions below the L (left) knee and 1 abrasion below the R (right) knee . The facility incident report also documented, Resident fell out of bed @11:15. CNA reported to nurse while turning the resident the resident slid to the floor. CNA#2 who was providing care at the time of the fall was interviewed on 2/21/20 at 12:30 p.m. CNA#2 stated that she was giving the resident a bed bath that morning, she had completed the top part of the resident's body and asked the resident to turn on her left side. She stated after the resident was turned to her side she completed washing her back and rolled the chux pad under the resident's bottom to change it, at this time the resident started scooting her bottom towards the edge of the bed to see something out the window. The resident then slid off the bed feet first. Immediately after the fall the resident began hollering in pain. When asked if the resident was readmitted back to the same room and same bed after hospitalization she stated, Yes. On 2/21/20 at 1:12 p.m., the daughter of the resident was interviewed. She stated she received a phone call from LPN #9 informing her of the fall. She was told that, When the aide (CNA) turned her she was too close to the edge. The hospital discharge summary documentation dated 1/1/20 indicated the resident had a fall while being given a bath per the daughter. The patient had been non-ambulatory for years and was bed-bound. The CT scan showed intramedullary [MEDICAL CONDITION] and proximal femur fracture. The patient was seen in consultation by Orthopedics and underwent cephalomedullary nail replacement of the left hip. On 2/21/20 at 2:30 p.m., the durable medical equipment specialist was interviewed on site. He stated the defined perimeter mattress is an added safety feature to prevent falls from low air loss mattresses. He further stated that the contract with the facility specifically calls for all low air mattresses rented to the facility must have the added safety feature of a defined perimeter mattress. The specialist was asked if Resident # 121 was on a perimeter mattress, after pulling up the order in his system he stated, Yes, since 2017. The specialist was asked to go into the resident's room to ensure the low air loss mattress that the resident was on included the defined perimeter mattress cover. Several minutes later he reported to this inspector that the resident's low air loss mattress did not include the defined perimeter mattress cover. He stated he called his company and one was on it's way. Per the manufacture the Defined Perimeter Mattress Cover creates a raised rail, defined perimeter for enhanced fall prevention, without using patient restraints. The 10 deep static perimeters surround the length of the mattress. On 2/21/20 at 3:02 p.m., the above findings was shared with the Director of Nursing (DON). She stated she was not aware that the resident was not on the perimeter mattress as ordered. When asked what is the purpose of the perimeter mattress she stated, I would suppose an added protection from falls. When asked what the root cause of the fall, she stated, I believe at the time the resident got distracted, she was not paying attention to what she was doing .I think the perimeter mattress would have helped her. A root cause analysis and plan of correction was completed and included resident assessments and staff education. No additional falls during provision of care was identified. The compliance completion date was documented as 1/15/20. The above findings was shared with the Administrator and the Director of Nursing (DON) during the pre-exit meeting conducted on 2/21/20. The facility was afforded ample time to present any additional information prior to exit. No additional information was presented. Past non-compliance.

Based on record review, staff interviews, and family interviews, the facility staff failed to ensure the residents environment remained as free of accident hazards and receive adequate supervision and assistive devices to prevent accidents for two residents (Resident #87 and #47) in the survey sample of 52 residents. 1. The facility identified Resident #87 was a high fall risk. The facility developed a plan of care to prevent avoidable injuries, which included the use of a Hoyer lift with two staff assistance for transfer. The resident was transferred on 02/16/18 by one staff member doing a stand pivot transfer instead of using a Hoyer lift. As a result, Resident #87 sustained an avoidable Right Femur Fracture resulting in harm. 2. The facility staff failed to ensure the assistive device, total lift, was utilized appropriately to prevent Resident #47 from an avoidable fall during a transfer. The findings included: 1. Resident #87 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].*Muscle weakness, *Anxiety disorder and *Dementia without disturbance and *[MEDICAL CONDITION]. *[MEDICAL CONDITION] is a disease that thins and weakens the bones. Your bones become fragile and break easily, especially the bones in the hip, spine, and wrist (https://medlineplus.gov/ency/patientinstructions/ 5.htm). *Muscle weakness is reduced strength in one or more muscles (https://medlineplus.gov/ency/article/ 5.htm). *Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/ 5.htm). *Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/ 5.htm). The most recent Minimum Data Set (MDS) a comprehensive assessment with an Assessment Reference Date (ARD) of 6/12/18 coded the resident with a 02 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In addition, the MDS coded Resident #87 total dependent of two with bathing, personal hygiene, toilet use, dressing and transfers, extensive assistance of one two with bed mobility and extensive assistance of one with eating for Activities of Daily Living. Under section G0400 (Functional Limitation in Range of Motion) was coded for impairment on both side for lower extremity (hip, knee, ankle, foot). The MDS prior to Resident #87's Right Femur Fracture was an Annual Assessment with an ARD date of 1/2/18 coded Resident #87 dependent of two with transfers. Under section G0400 (Functional Limitation in Range of Motion) was coded for impairment on both side for lower extremity (hip, knee, ankle, foot). The review of Resident #87's comprehensive care plan documented Resident #87 is at risk for/has impaired skin integrity due to impaired mobility requires extensive assistance or is dependent in bed mobility and/or transfers. Some of the intervention/approaches to manage goal included use assistance devices for transfer as needed (i.e. *Hoyer lift, sliding board, 2-person assist, etc.). *Mechanical lift (Hoyer lift) used for transfers when a person requires 90-100% assistance to get into and out of bed. A pad fits under the person's body in the bed and connects with chains to the Hoyer lift frame (free-foundation.org/hoyer-lifts). A Fall Risk Assessment was completed on 02-08-18; a resident is determined high risk if score of 10 or above, Resident #87 score was 16. The review of clinical record revealed a Physical Therapy note dated 2/2/17 for the use of a Hoyer lift at this for Resident #87. Review of the clinical nurse's notes evidenced an entry dated 2/17/18 at 6:00 p.m. The nurse documented Resident #87's daughter requested pain medication for resident right leg. Daughter reported resident leg was not elevated; just hanging. Routine pain medication given. Resident placed in bed noted right thigh appear larger than the left, no redness or bruising , heat noted and resident denies pain. Will continue to monitor. Review of the clinical nurse's notes evidenced an entry dated 2/18/18 at 6:20 a.m. The nurse documented Resident #87's right thigh appears bigger in size in comparison to the left. Warm to touch. Resident is in grimacing pain when right leg is moved lightly, MD notified. Review of the clinical nurse's notes evidenced an entry dated 2/19/18 at 12:22 a.m. The nurse documented Resident #87's right thigh remained bigger than the left for day 2. Resident on bedrest during this shift. Pain noted during patient care. Review of the clinical record revealed a Progress Note HPI documented the following on 2/19/18: Patient is seen today in follow up evaluation and management of acute medical problem identified by nursing. Patient had discrete onset Saturday of pain in her right thigh and knee after she was transferred by nurse's aide. Apparently, she was requested to pivot around for positioning. Patient has been screaming out in pain with all passive movement by the staff. Other than the pivot incident, I did not receive any information regarding known accidental injuries or falls. Review of Systems: -Cardiovascular Positive for leg swelling -Musculoskeletal: Positive for gait problem and joint swelling -Musculoskeletal: She exhibits [MEDICAL CONDITION] and tenderness. There is moderate soft tissue swelling from just above the right knee laterally, to the ankle. There is more swelling in the knee area, consistent with a 3+ joint effusion. Sensate to light touch. Plan: -We will get an x-ray of the right hip and femur today. -We will get a venous duplex of the right lower extremity today. -Patient is currently on Noro daily. I will change that to Noro 1-2 every 6 hours as needed -Primary Diagnosis: [REDACTED]. -Reason for Visit: Right lower extremity pain The x-ray report exam dated 2/19/18 impression was an acute nondisplaced fracture of the *right distal femur seen. *Femur fracture (the femur is the thighbone, which extends from the pelvis to the knee. It is the largest and strongest bone in the body). A fracture is a traumatic injury to the bone in which the continuity of the bone tissue is broken (Mosby's Dictionary of Medicine, Nursing & Health Professions 7th Edition.) Review of the clinical notes revealed a Progress note from Hampton Roads Ortho/Sports Medicine dated 2/20/18 at 7:43 a.m. The noted documented she (Resident #87) apparently had some event happen at the nursing home where they tried to stand and turn her. Since then, she has had pain around her right knee. We did just complete care of her in the last year or two for nondisplaced fractures of her contralateral distal femur and her right proximal tibia. X-rays ordered and reviewed today of her right distal femur and showed an impacted distal femoral condylar fracture. Assessment: Right distal femur fracture. This should do well with conservative treatment. We will get her into a knee immobilizer. She (Resident #87) is to be strictly nonweightbearing. A phone interview was conducted with Certified Nursing Assistant (CNA) #16 on 8/4/18 at approximately 11:45 a.m., who stated, On the morning of 2/16/18, I transferred Resident #87 by myself. The surveyor asked, Tell me how did you transfer Resident #87 from the bed to the wheel chair (w/c). The CNA stated, I positioned the resident on the edge of the bed, she sat for a few seconds, then I instructed the resident to grab me around my neck and then on the count of 3 we did a stand pivot transfer into the wheel chair. The CNA also said she placed the wheel chair close to the bed before the transfer. The surveyor asked if she know Resident #87 was a Hoyer lift transfer, she replied, Yes. The CNA stated, When I first started here, we would use the Hoyer lift often but now she does better with the pivot/stand transfer and this really works for her. An interview was conducted with CNA #19 on 8/2/18 at approximately 4:40 p.m. The surveyor asked, How was Resident #87 transferred from the w/c to the bed on 2/17/18 she replied, Resident #87's leg was swollen and she was in pain so we had to do a two person transfer. The surveyor asked, How did you do a two person transfer she replied, One person grabbed her under her armpits and the other person under her legs. The CNA said when she went to lay resident down; she was crying in pain while rubbing her right leg. The CNA said Resident #87's right leg was swollen and she reported it to the nurse. On 08/2/18 at approximately 4:45 p.m., a phone interview was conducted with License Practical Nurse (LPN) #18 via phone. She (LPN) stated on 2/17/18, Resident #87's daughter approached her because Resident #87 was having right leg pain and her leg rest was not on her wheelchair. The LPN said she assessed the resident's right leg; noticed the right leg was larger than the left so she administered pain medication and notified the physician. An employee statement written by CNA #33 dated 2/18/19 documented in part the following: On 2/17/18, I was given an assignment, which included Resident #87. A staff member walked through the assignment with me about each resident around 7:30 a.m. The staff instructed me that resident in room (number) (Resident #87) could be transferred via one person using stand pivot method transfer. CNA stated she proceeded to give resident patient care and upon bathing, she turned right to her right side, the resident started complaining of pain in her right knee. On 08/03/18 at approximately 4:30 p.m., an interview was conducted with CNA #17. The CNA stated she transferred Resident back to bed on 2/16/18 and noticed her right leg was larger than the left and tender to touch; her skin is very fragile so we could not use the Hoyer lift. The CNA said she has never used a Hoyer lift on Resident #87 because as I said, her skin in very fragile and it tears easily. The surveyor asked, How did you transfer Resident #87 back to bed from the w/c on 2/16/18, she replied, We transferred her like a baby, one person got her under her arms and the other under legs, removed the w/c arms and lifted her over to the bed; just like a baby. The surveyor asked, Do you use any type of assistive device doing the transfer, she replied, No. The surveyor asked if she was aware that Resident #87 was a Hoyer lift transfer, she replied, Yes, but transferring her this way works better. The surveyor asked, How are you transferring Resident #87 now, she replied, The same way, one person grabs her under her arms while the other under the legs/thighs, remove the w/c arm and just lift her into the bed. The surveyor asked, Do you use a sheet or lift pad she replied, No, we put the bed in lowest position, place the w/c close to the bed, remove the w/c arm rest and on the count of 3 we lift resident into the bed. An interview was conducted with CNA #36 on 08/3/18 at approximately 4:45 p.m., who stated, I was putting (Resident #87) back to bed with 2 people assist - not using a mechanical lift. The CNA stated the resident kept getting bruises because I skin was breaking. He (CNA) stated, I was told by a nurse that Resident was a lift for transfers but could not recall who told me. The surveyor asked, When resident was transferred manually with two people, how was she being transferred back to bed from the wheel chair he replied, One person grabbed (Resident #87) under her lower thighs and someone else would grab under her armpits and just put her in the bed. The surveyor asked, Was a draw sheet or lift pad being used to assist with the transfer he replied, No; we did not use a draw sheet or anything. The CNA stated, He used the Hoyer lift today to put Resident #87 back to bed. An interview was conducted with the Assistant Director of Nursing (ADON) on 08/03/18 at approximately 5:20 p.m., two surveyors present. The surveyor asked, How is Resident #87 being transferred she (ADON) replied, With a Hoyer lift; this is the safest way. The surveyor informed the ADON; Resident #87 was always being transferred by a Hoyer lift but one-person grabbing Resident #87 under her armpits and the other person under the knees. The surveyor asked is that an appropriate transfer for Resident #87 she replied, Absolutely not, you do not transfer anyone that way; Resident #87 is a mechanical lift with 2 people. The ADON stated, We have an issue- we did not follow safe best practice in the recommendation in transfers for this resident and that a problem - we should have clearly used a mechanical lift - that is our expectations for the CNA's. The ADON stated, We will start immediate education. The ADON also said, I did not do a very good job investigation this incident, I should have done a better job. The review of Resident #87's Certified Nursing Assistant (CNA) care plan documented the following on 8/3/18 at approximately 4:28 p.m., under Transfer/Mobility required assist x 2. The surveyor and ADON reviewed Resident #87's CNA care plan. The surveyor asked, How does the staff know how to transfer Resident #87 correctly by looking at the CNA's Care plan she replied, They do not, it should say to use Hoyer Lift with two assist with transfer/mobility. The review of Resident #87's Transfer/Mobility Status Criteria Form dated for 2/8/18 and 8/15/17 revealed the following: -Lifting to be used; Total lift with fully body sling. -Comments: patient requires two person transfer with Hoyer lift for patient and staff safely d/t fragile skin and inability to demonstrate adequate strength to assist with transfer. The review of Resident #87's Transfer/Mobility Status Criteria Form dated 6/7/18 revealed the following; lifting to be used; total lift with full body sling. The review of Physical Therapy Discharge Summary dated 4/13/17 revealed the following: -Analysis of Functional Outcomes/Clinical Impressions: -Patient (Resident #87) has made limited progress with therapy as a result of extreme anxiety and fearful of falling especially in standing position. -Recommendations: recommend nursing continue to use Hoyer lift for out of bed. Resident #87's ADL verification worksheet was reviewed with the ADON on 08/03/8 at approximately 5:20 p.m., two surveyors present. The ADON stated, The transfer should be a 4/3 for total assistance of two with transfers and not 4/2 for total assistance of one with transfers. An interview was conducted with the Rehab Director on 8/3/18 at 10:25 a.m. She said, (Resident #87) was seen on 4/12/18 for evaluation after her femur fracture with a nonweightbearing status to lower bilateral lower extremities. The surveyor asked, What is the proper technique for transfers with a mechanical lift, she replied, Max assist of 2 for Hoyer lifts; it gives safety for the resident as well as the staff. She proceeded to say that Resident #87 has a history of falls with fractures so a Hoyer lift transfer was recommended for her. The Rehab Director was made aware that Resident #87 was being transferred prior to her fracture doing a stand pivot transfer by the CNA for getting out of bed. She was also made aware that when putting Resident #87 back to bed the two staff members would grab her under her armpits and under knees, place the wheel chair next to the bed, remove the wheel chair arm rest then manually put her in the bed. The Rehab Director stated, The expectation is for the staff to follow the resident Plan of Care for Resident #87 and that is to use the Hoyer lift for all her transfers to and from the bed. The facility's administration was informed of the findings during a briefing on 08/3/18 at approximately 5:35 p.m. The facility did not present any further information about the findings. The facility's Policy titled Transfer Using the Mechanical Lift (Revision 11/15). Policy: Mechanical lifts will be utilized by nursing staff to transfer residents who cannot help themselves, residents who fall, and residents who need repositioning that requires a mechanical lift. The number of staff assisting will transfer using the mechanical lift is dependent on: Conditions that may require more than one person to assist during transfer and will be addressed in the Resident Care Plan. 2. Resident #47 was originally admitted to the facility 7/12/13 and readmitted [DATE] after an acute care hospital stay. The current [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/17/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of 1 person with bed mobility, transfers, toileting, personal hygiene, locomotion, and dressing, total care with bathing. The comprehensive care plan dated 2/10/17 read; Resident has a risk for falls and/or a history of falls related to poor sitting balance, requires staff assistance for transfers, pain, impaired sensation (paralysis, paresis), unsafe behaviors; prefers bed in the high position, unstable fluctuating health conditions, diabetes, hypertension, [MEDICAL CONDITIONS] medication usage, incontinence and history of falls. The goal read; Resident will not experience significant injury (i.e. requiring an emergency room visit or hospitalization through the next review. The interventions included; Keep bed in lowest position for safe transfers, keep bed wheels locked. Keep frequently used items within reach and/or close proximity (i.e. telephone, TV remote, books, water, etc.), If diabetic, monitor blood sugars and treat. Keep call bell within reach, Provided assistive mobility devices as recommended by therapy; report unsafe use to therapy. Use of manual wheel chair and reacher, trapeze to bed. Resident # 47 was observed in bed 7/31/18 at approximately 2:24 p.m. Resident #47 stated she rarely gets out of bed anymore because the last time she got up the staff injured her paralyzed left foot during the transfer and it had been very painful since the event. The resident also stated I've been dropped multiple times and the most recent drop was from the total lift. Resident #47 began crying and stated if they drop me again I may die before my kidneys give out. Review of the clinical record revealed a note dated 7/13/18, which read; resident states that during a lift transfer she felt a pinch on her left leg on 7/11/18. Staff reports no complaints made during the transfer. Area assessed and there is no bruising or broken skin to the left leg. Another clinical note revealed on 12/23/17, the resident was assisted to the floor by Certified Nursing Assistant (CNA) #15 while transferring the resident from the wheelchair to bed. CNA stated resident started slipping out of the hoyer sling. Upon Assessment, noted resident sitting on the floor with her back against the bed. No visible injuries noted. Resident denied any pain or discomfort. Assisted resident up via hoyer lift times 3. Resident remains alert, verbal and able to make her needs known. Will continue to monitor. A telephone interview was conducted with the resident's mother 8/2/18 at approximately 10:30 a.m. The resident's mother stated the facility notifies her of falls and other events but when she desires to discuss falls, or other concerns with the staff during the care plan meeting she is told they will not discussing that in this meeting. An interview was conducted on 8/3/18 at approximately 3:30 p.m., with Certified Nursing Assistant (CNA) #15. CNA #15 stated on 12/23/17 she was transferring the resident alone from the wheel chair to the bed, when the resident began slipping out of the total lift pad. CNA #15 stated it was a frightening experience but she was able to assist the resident to the floor without injuring the resident or herself. CNA #15 also stated she hadn't worked with Resident #47 before and she hadn't been trained in use of the total lift except by watching others. The safety precautions put in place based on the incident report read; educated CNA #15 on the importance of having 2 CNA's present when using the lift. An interview was conducted on 8/3/18, with the Assistant Director of Nursing (ADON) at approximately 4:05 p.m. The Assistant Director of Nursing was able to to present documentation that CNA #15 was educated during orientation on use of the total lift but here was no documentation indicating safety instructions were given to CNA #15 after the 12/23/17 fall. The ADON stated the total lift requires 2 persons to utilize it. The facility's policy titled Transfers using the Mechanical Lift with a review date of 8/17 read; Mechanical lifts will be utilized by nursing staff to transfer residents who cannot help themselves, residents who fall, and residents who need repositioning that requires a mechanical lift. The type of sling used depends on the resident's size, condition and needs, Slings must be washed per facility policy, before using a lift, it must be checked if it is in good working condition. The resident's weight must not exceed the lift's capacity. The number of staff assisting with the transfer using the mechanical lift is dependent on: the manufacturer guidelines - Facility must review guidelines prior to use. Conditions that may require more than one person to assist during transfer and will be addressed in the Resident Care Plan (i.e. bariatric need, uncontrolled body movements, etc.). On 8/3/18 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided.

Based on observation, resident interview, staff interviews, clinical record review, and review of the facility's policy, the facility staff failed to ensure that pain management was provided for 1 of 52 residents (Resident #136), in the survey sample. The facility staff failed to provide effective pain management to Resident #136, by not having the ordered narcotic [MEDICATION NAME] ([MEDICATION NAME]/APAP tablet 5/325 milligrams) readily available for administration, resulting in periods of unnecessary and excruciating pain, constituting harm. The findings included: Resident #136 was originally admitted to the facility 8/1/03 and readmitted [DATE], after an acute care hospital stay. The current [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED], also called spasmodic [DIAGNOSES REDACTED], is a painful condition in which your neck muscles contract involuntarily, causing your head to twist or turn to one side. [DIAGNOSES REDACTED] can also cause your head to uncontrollably tilt forward or backward. A rare disorder that can occur at any age, [DIAGNOSES REDACTED] most often occurs in middle-aged people, women more than men. Symptoms generally begin gradually and then reach a point where they don't get substantially worse. There is no cure for [DIAGNOSES REDACTED]. The disorder sometimes resolves without treatment, but sustained remissions are uncommon. Injecting botulinum toxin into the affected muscles often reduces the signs and symptoms of [DIAGNOSES REDACTED]. Surgery may be appropriate in a few cases. (https://www.mayoclinic.org/diseases-conditions/cervical-[DIAGNOSES REDACTED]/symptoms-causes/syc- 123) The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/21/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #136's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring limited assistance of 1 with dressing and wheel chair locomotion, extensive assistance of 2 people with transfers and personal hygiene, extensive assistance of 1 person with bed mobility and toilet use, and total care with bathing. The resident navigates the facility via an electric scooter. In section J Resident #136 completed the pain interview which revealed she experienced frequent pain rated at a level of 8 out of 10. The resident also stated during the pain interview that the pain affects her daily activities and ability to sleep. The clinical record review revealed, Resident #136 had physician's orders [REDACTED]. Review of the clinical record also revealed; Resident #136 also receives services from a neurologist every 3 months for treatment of [REDACTED]. The active care plan dated 1/4/17 had a problem which read; Resident has a potential for expressed/demonstrated pain/discomfort related to [MEDICAL CONDITION], spasmodic [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], muscle spasm, neck pain. History of bloating and cramping. The goal read; Resident will express or demonstrate that interventions are effectively controlling and/or relieving pain or discomfort. The interventions included; Encourage and assist resident to identify intensity, quality and location of pain. Encourage resident to tell the nurse when pain interventions are not effective. Report to physician when pain interventions are not effective. When as needed medications are being used with consistency; request a review by the physician or pharmacist for benefit of scheduled medication or change in medication or dosage. Assist the resident as needed to position in a manner that is most comfortable, use pillows or other devices as necessary. Offer psychological consult and spiritual support as appropriate and desired by resident and/or family. Offer activities that may refocus resident such as; music, conversation, etc. Review of the Medication Administration Record [REDACTED]. They included repositioning, food/hydration and redirecting with effectiveness but; the medication was still administered. On 7/31/18 at approximately 2:15 p.m. Resident #136 was observed in bed. Resident #136 was barely opening her eyes and holding her head. The resident stated, I'm not getting out of bed for chapel or activities because she I have an excruciating headache and didn't slept all night because my pain medication [MEDICATION NAME] ([MEDICATION NAME]/APAP) wasn't available last evening, this morning or currently, 2:15 p.m. Resident #136, further stated when the pain medication [MEDICATION NAME] ([MEDICATION NAME]/APAP) is available for me to receive at least 3 doses per day the regime is effective but; frequently 9 out of 10 times I experience excruciating pain for the medication isn't available because the nursing staff doesn't order another supply prior to the current supply exhausting. The resident also stated that, the nurses tell me when there is no [MEDICATION NAME] ([MEDICATION NAME]/APAP tablet) available, I can have Tylenol, which is never effective. Prior to the surveyor completing the interview, Resident #136 stated; this is my home and I like it here, pleases help the nurses get my new supply of pain medication in before the current supply runs out. That was the only request she made. Review of the Controlled Drug Receipt/Record/Disposition Form revealed; on 7/26/18, twenty-five [MEDICATION NAME]/APAP tablets were delivered and the supply was exhausted at 4:30 a.m., on 7/31/18 and the next supply wasn't delivered to the facility until approximately 4:30 a.m., 8/1/18. Only one dose was withdrawn from the stat box over the 24 hours the supply was exhausted; that was on 7/31/18, at 2:42 p.m. At 10:46 a.m. Tylenol was administered when the resident requested [MEDICATION NAME]/APAP tablets. On 7/20/18, twenty-five [MEDICATION NAME]/APAP tablets were delivered and the supply was exhausted at 4:46 a.m., on 7/26/18. The next supply wasn't delivered until 9:30 p.m., (16.75 hour later) on 7/26/18. No doses were obtained from the stat box but Tylenol was administered upon the resident's request for [MEDICATION NAME]/APAP tablet on 7/26/18. On 6/28/18, thirty [MEDICATION NAME]/APAP tablets were delivered and the supply was exhausted at 10:19 a.m., on 7/6/18. The next supply arrived to the facility at 7/7/18 at 4:45 a.m. Tylenol was administered 7/6/18 at 5:02 p.m., for pain because [MEDICATION NAME]/APAP tablets were not available in the medication cart. The resident's pain level was 5/10. No doses were obtained from the stat box. On 6/18/18 Tylenol was administered upon the resident's request for [MEDICATION NAME]/APAP tablets for pain at a level 4/10 at 4:29 p.m. On 6/19/18, thirty [MEDICATION NAME]/APAP tablets were delivered. The time of the delivery is unknown but the resident was not administered any of the medication delivered on 6/19/18 until 8:50 a.m., and the supply was exhausted at 9:00 p.m., on 6/25/18. On 5/27/18 twenty-five tablets were delivered and the supply exhausted 6/4/18 at 11:00 p.m. On 6/5/18 a dose was obtained from the stat box at 4:46 a.m. The [MEDICATION NAME]/APAP tablets had not been delivered by 6:15 p.m. therefore; for pain rated 7/10 Tylenol was administered. At 6:26 a.m. on 6/6/18 the medication still had not arrived and Tylenol was again administered for pain rated 8/10. The next supply was delivered 6/6/18. But the exact time is unknown, but the resident received a dose of [MEDICATION NAME]/APAP tablets at 9:38 a.m. An interview was conducted on 8/3/18, at approximately 4:00 p.m., with Licensed Practical Nurse (LPN) #29. LPN #29 stated whenever Resident #136 didn't have the [MEDICATION NAME]/APAP tablets available to be administered the nurses offered Tylenol or [MEDICATION NAME] until the [MEDICATION NAME] was discontinued because the resident wouldn't accept it. LPN #29 was asked if scheduling the [MEDICATION NAME]/APAP tablets had been considered since a care plan intervention was reviewing use and effectiveness of the medication and following up with the physician. LPN #29 stated they had talked with the resident about scheduling the pain medication 8/2/18, and she was going to think about it and give the staff her answer. An interview was conducted with on 8/3/18, at approximately 4:30 p.m., with the Assistant Director of Nursing (ADON). The ADON stated the facility has 1 [MEDICATION NAME]/APAP 5/325 mg tablet available in the Omnicell (medication storage system), 8 [MEDICATION NAME]/APAP 5/325 mg tablets available most days in stat box 2 and (7.5/325 and 10/325) other doses are available if ordered by the physician. The ADON stated when Resident #136's personal [MEDICATION NAME]/APAP tablets were exhausted the nurse should have obtained the medication from the stat box. The process requires the nurse to call the pharmacy, who will review the prescription and give the nurse a code, the nurse will document the authorization code and obtain the medication from the stat box to administer to the resident. The ADON stated a resident should never be in pain because the pain medication isn't available in their personal medication when it is available in the stat boxes. The facility's policy titled Controlled Substances date 6/21/17 read; (name of pharmacy) will not dispense a controlled medication or approve its removal from an onsite store supplied by the pharmacy, until a valid prescription has been received by the pharmacy from the prescriber. Under procedure #2 the policy stated; the prescriber must always provide a complete and valid prescription prior to dispensing of controlled substance medications. It is the facility and prescriber's responsibility to obtain the required prescription needed to meet the needs of the resident. On 8/3/18 at approximately 6:00 p.m., the above findings were shared with the Administrator and Director of Nursing. An opportunity was given for the facility to present additional information but none was provided.

Based on complaint investigation, observations, clinical record reviews, staff interviews, resident interviews, family interviews the facility staff failed to ensure that a resident who entered the facility without pressure ulcers (bed sores) did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 6 of 52 Residents in the survey sample (Resident #20, #5, #7, #4, #19 and #3). Substandard quality of care was identified during the survey for these residents. 1. The facility staff failed to prevent and identify a new pressure ulcer from developing prior to it developing to an advanced stage of unstageable on 02/07/16 which constituted harm for Resident #20. In addition Resident #20 was observed during the survey without any pressure reducing devices in the geri chair and without floating heels per the physician orders [REDACTED]. 2. The facility staff failed to identify Resident #5's Left heel pressure sore prior to it developing to an advanced stage (unstageable) on 2/4/16, which constituted harm. In addition, the Facility Staff failed to implement physician ordered cup socks for pressure relief. 3. The facility staff failed to identify Resident #7's *ischium pressure ulcer prior to an advanced stage (unstageable) which constituted harm for this resident, as well as initiate and ensure the appropriate wound care protocol was in place for the management of a resident with *slough covered pressure ulcers. In addition, the facility staff failed to initiate and ensure the appropriate wound care protocol was in place, as well as provision of pressure relief surfaces per plan of care. 4. Resident #4 was readmitted to the facility on [DATE] without a pressure ulcer. The facility staff failed to consistently evaluate the resident's clinical condition, pressure ulcer risk factors and skin assessments. As a result, the resident was found to have an advanced staged pressure ulcer to the sacrum on 1/5/16; constituting harm for this resident. Furthermore, the facility staff failed to administer treatment as ordered and failed to ensure off loading of pressure was conducted to promote healing. 5. The facility staff failed to identify Resident #19 sacral pressure ulcer prior to an advanced stage III which constituted harm for this resident. In addition, the resident was not turned and repositioned per plan of care. 6. The facility staff failed to intiate and the ensure pessure relief interventions for Resident #3 to prevent worsening of her coccyx (tail bone) pressure area from a partial thickness skin loss to a Stage III with slough (dead tissue) which constituted harm for this resident. The findings included: 1. The facility staff failed to prevent and identify a new pressure ulcer from developing to an advanced stage of unstageable on 02/07/16 which constituted harm for Resident #20. Resident #20's 14 day MDS (Minimum Data Set - an assessment protocol) with an ARD (assessment reference date) of 01/05/16 coded Resident #20 with a 00 BIMS (Brief Interview for Mental Status) which indicated a severely impaired mental status. The MDS coded Resident #20 as requiring extensive assistance with two staff person assistance for Transfers, Eating, Hygiene, Bathing, and Toileting. Resident #20 was coded as requiring extensive assistance with one staff person assistance for ambulation. Resident #20 was coded as at Risk for Pressure Ulcers and noted that Resident #20 had zero pressure ulcers upon admission. Resident #20 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. A physician note dated 12/22/15 noted Resident #20 was admitted to the facility on [DATE] from a local hospital with a chief complaint of Urinary Tract Infection, [MEDICAL CONDITION] and progressive weakness. Resident #20 has a medical history of [REDACTED].#20 having a pressure ulcer at any stage. A Braden Risk Assessment completed on 12/22/15 scored Resident #20 at a 10 which indicated a high Risk for skin breakdown. A Nursing Assessment for Resident #20 dated 12/22/15 documented no breakdown on the skin assessment. A nurses note dated 01/29/16 at 15:45 (3:45 p.m.) documented that Resident #20 was transferred to another unit and showed an abrasion to left shin, scab to outer leg and did not indicate any pressure ulcers at time of transfer. A Transfer Clinical Handoff Checklist and Worksheet dated 01/29/16 noted abrasion to left shin. This form did not note any pressure ulcers present upon transfer to (name of unit). On the 47th day after admission into the Nursing Facility a nursing note of 02/07/16 at 16:45 (4:45 p.m.) noted: area to resident sacrum dried measure 2 cm (centimeter) x 1.5 cm x 0.5 cm; area noted with slough in center and surrounded on right side black in color measuring 3 cm x 2 cm. noted by LPN (licensed practical nurse) #11. *Unstageable Pressure Ulcer: an inflammation, sore, or ulcer in the skin over a bony prominence. It results from ischemic [MEDICAL CONDITION] of the tissues caused by prolonged pressure on them. **Unstageable: suspected deep tissue injury but unable to stage due to the coverage of the wound bed by slough and/or eschar. Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Eschar: black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding. **Definitions were derived from Minimum Data Set (MDS) Assessment-Version 3.0. Resident #20's care plan dated 12/22/15 noted area of concern: Potential for impaired skin integrity: with approaches/interventions as followed: Inspect skin and report any bruises, open areas, or discolorations; encourage resident to re-position or provide assistance with turning and repositioning as needed, Offer assistance with toileting and/or provide incontinence care promptly when soiled; encourage resident to maintain nutritional and fluid balance; report use of ill-fitting or unsafe equipment; report use of ill fitting shoes; apply skin barrier cream per order/protocol; use preventative measures for positioning and pressure relief in accordance with facility policy. Resident #20's care plan dated 01/05/16 Indwelling Catheter; Urinary Tract Infection noted the following approaches: Observe for changes in skin integrity in the perineal area; report to licensed nurse for assessment, including redness, excoriation, rash, blisters, etc. Resident #20's care plan dated 02/07/16 noted sacrum pressure ulcer. The care plan noted assess at least weekly for effectiveness of treatment: notify physician of decline or failure to improve. Physician orders [REDACTED]. Also, physician orders [REDACTED]. A final physician order [REDACTED]. Review of Resident #20's clinical record revealed skin assessments documented for the following dates. 12/22/15; 1/12/16/; 1/26/16; 1/29/16; 2/7/16; 2/10/16 Skin assessments were not noted as ordered weekly for the week of January 4, 2016, January 18, 2016 and February 1, 2016 and were not provided by the administration as requested. The CARE's report (a facility report designated to enhance assessment of Pressure Ulcers) dated 02/07/16 noted the following: CARE's report page 1-2 Specific Event Type Wound Location of Skin Event on Body 7-3 p.m. (day shift) Shift completed treatment and measurement BUTTOCK-LEFT BUTTOCK-RIGHT SACRUM Present on Admission? No Type Person Affected Resident Factors Contributing to Event: Immobility Incontinence: Urine (note this resident at time of this assessment had a foley catheter Incontinence: Stool Nutrition Pressure to Skin/Tissue Immediate Actions Reported: Application of Dressing Application of Ointment/Medication Assistance offered (accepted) Consult ordered Notified Appropriate Management and/or Staff Notified Nurse Notified Patient/Family Member/ Next of Kin Notified Physician/NP (nurse practitioner) Nutrition/Hydration Intervention Brief Factual Description 7-3P Staff found wound, notified MD (medical doctor Team, and immediately completed wound treatment on patient. Wound measurements 2 cm (centimeters) x 1.5 cm x 0.5 cm. Wound bed gray, gray slough and right side of wound has black area measured 3x2 cm. Dietary and RP (responsible party) notified as well. CARE's Report page 3 Person Affected Conditions [MEDICAL CONDITION] neurological disease Fragile Skin Inappropriate/unsafe behavior Incontinence Malnutrition Short-term memory loss Unaware of safety hazards Environment/Situational Conditions Unknown Initial Ulcer Progress Report of 02/07/16 noted wound as: Partial Thickness, 0 pain, Size Length by Width by Depth: 2 cm. x 1.5 cm x 0.5 cm 0 undermining/tunneling/sinus tract 0 drainage 0 odor Wound bed Gray Slough Wound edges/peri wound right side of wound black area 3.2 A note of the Physician #2 dated 02/08/16 at 2:44 p.m., noted the following: Wound Type Unstageable Pressure Ulcer Location: Sacrum Length 4 cm Width 2.2 cm Undermining and Tunneling none Exudate: serosanquinous Amount: scant Wound Bed: 20% slough, 10% [MEDICATION NAME], 70% darkened nonblanchable skin-DTI (deep tissue injury) Current treatment: Santyl Allevyn New Treatment: skin prep, santyl, allevyn daily Observations were made on Resident #20 on the following dates: 2/11/16 at approximately 10 a.m., Resident #20 was observed to be sitting in his chair (geri chair) with no cushions for pressure relief measures (as care plan indicated to be used for pressure relief ) and heels were directly pressing into the foot rest of the geri chair. 2/11/16 at approximately 1 p.m. Resident #20 was rolled into his room and transferred to his bed so a wound care observation could be observed with LPN #11. The surveyor noted the wound base to have black tissue on both sides with pink tissue noted between the two areas of black tissue. On 02/11/16 the surveyor asked to see Resident #20's heels as they were observed pressing into the air mattress and had been observed at two other times (2/11/16 approximately 10 a.m. and 2/11/16 approximately 1 p.m.) pressing into the foot rest of the geri chair. Resident #20's socks were removed and no skin breakdown was observed; however, both heels were noted pink and were blanchable. The nurse providing the wound care at this time LPN (licensed practical nurse) #11 when asked to describe the heels, stated: They are blanchable pink areas. There was no pressure relief cushion or device in the geri chair that Resident #20 was sitting as were documented in the care plan (to have pressure relief). A 02/16/16 Physicians orders documented the following: Float bilateral heels Apply heel protectors while in bed when available On 02/16/16 at approximately 1:55 p.m. Resident #20 was observed sitting just outside of the nursing station in his geri chair with his heels pressing into the foot rest of the geri chair. The surveyor asked RN (registered nurse) #2 to expose the heels for observation. Resident #20 was transported to his room where the Left Heel was observed to be pink with a dime size soft yellow area in the center. RN #2, when asked what she thought was the problem causing the new area of alteration of skin integrity to Resident #20's heels, she stated: because they are pressing into the chair. He needs pressure relief. RN 2 created pressure relief by elevating the heels with a pillow. When RN #2 was asked how often she felt her staff turned and repositioned she stated: We do the best we can. The Director of Nursing on 2/12/16 approximately at 1:35 p.m. when asked what she felt the break in the process was for Resident #20 to develop an unstageable pressure ulcer she stated: feel the area wasn't monitored closely enough and missing weekly assessments. Review of policy and Procedure entitled Skin Integrity Prevention and Care - Focus on Pressure Ulcers with last revision date of 05/13 documented the following: Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. The policy and procedure notes preventative protocols as followed: (not all are noted) Residents will be provided pressure reducing devices for beds and chairs. Additional devices may be used to support positioning and to redistribution of weight. Residents who require assistive devices to promote repositioning will be provided such devices and staff assistance as needed. The policy and procedure under section Treatment Protocols noted but are not limited to all: Change position frequently (recommended at least 3 or 4 times per shift) when resident is in bed or chair. Use bony prominence protectors (elbow, heels, knees, etc.) or other devices to minimize friction and shear and reduction of pressure on those areas (float heels, wedge between knees, etc). Resident #20 admitted on [DATE] without pressure ulcers was on 02/07/16 forty-seven days after admission to have an advanced unstageable pressure ulcer. This fact constituted harm for this resident and also indicated substandard care. The Administration (Administrator, Director of Nursing, Quality Support #3, Dr. #3, and the management/corporate team) were updated on the findings during a briefing conducted on 02/16/16 at approximately 11:30 a.m. No further information was presented. 2. The facility staff failed to identify Resident #5's Unstageable left heel pressure sore prior to it developing to an advanced stage on 2/4/16 which constitutes harm. In addition the facility staff failed to implement physician ordered cup socks on 2/5/16 for pressure relief until 2/12/16. Resident #5 was an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED].*Unstageable Left Heel Pressure Ulcer, *[MEDICAL CONDITION], *Dementia, and *Protein Calorie Malnutrition. *Right [MEDICAL CONDITION]: a break in one of the 3 bones that make up the hip bone. *Unstageable Pressure Ulcer: an inflammation, sore, or ulcer in the skin over a bony prominence. It results from ischemic [MEDICAL CONDITION] of the tissues caused by prolonged pressure on them. **Unstageable: suspected deep tissue injury but unable to stage due to the coverage of the wound bed by slough and/or eschar. Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Eschar: black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding. **Definitions were derived from Minimum Data Set (MDS) Assessment-Version 3.0. *[MEDICAL CONDITION]: a condition characterized by progressive mental deterioration, often with confusion, memory failure, disorientation, restlessness, speech disturbances, inability to carry out purposeful movement, and hallucinosis. *Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. *Protein Calorie Malnutrition: a wasting condition resulting from a diet inadequate in either protein or energy (calories) or both. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was a Significant Change assessment with an Assessment Reference Date (ARD) of 10/6/15 with a Brief Interview for Mental Status (BIMS) indicating that the resident is rarely or never understood. Resident #5 was also coded to have long and short term memory problems and is moderately impaired in cognitive skills for daily decision making. Under functional status Resident #5 is extensive two person assist for activities of daily living to include bed mobility and transfers. Under functional limitation in range of motion the resident is coded to have impairment on one side in the lower extremity. Under mobility devices resident #5 is coded as normally uses a wheelchair. Resident #5 was not coded for pressure ulcers on this assessment. Resident #5's Acute/Temporary-Resident Care Plan-Interdisciplinary was reviewed and noted to have the following entry dated 2/5/16 which documented in part, read as follows: Problem: L (left) heel light purple circular area-skin intact. Goal: Healing of pressure area-prevention of further pressure issues. Intervention: Apply cup socks as prescribed-pressure relief, float heels when in bed. Resident #5's last Braden Scale-For Predicting Pressure Sore Risk was completed on 1/7/16 with a total score of 14, which indicated the resident was at a moderate risk for developing pressure ulcers. The weekly Licensed Nurse Head to Toe Skin Observations for Resident #5 were reviewed on the following dates: 1/5/16, 1/12/16, 1/19/16, 1/26/16, and 2/2/16 all indicating that Resident #5 had No Abnormalities and No Breakdown. During a clinical record review for Resident #5 a four page Initial Ulcer Progress Report was identified which was dated 2/4/16. The Initial Ulcer Progress Report documented in part, read as follows: Page 1 Location of Wound: (L) left heel Date of development: 2/4/16 Acquired (in facility) Size: 1 centimeter X 1.9 centimeters (cm) Wound Bed: Eschar Page 2 Identified risk and potential causative factors (that apply in the last 7 days): Change in positioning devices-Geri chair Change in activity level Requiring more assistance with: Repositioning in bed/chair, Shifting weight independently, Eating. Resident conditions that impact risk: decreased mobility, cognitive impairment. Check Interventions currently in place and Date all new interventions to protect, treat and prevent another: Position off wound when possible, Float heels, Heel/elbow protectors to reduce friction, Weekly head to toe body audits. Page 3 Summary of lower extremity ulcer evaluation: 1 X 1.9 cm light purple discoloration circular. No evidence of discomfort when examined. MD (doctor) saw terms eschar present. Response: any other compounding factors that relate to this wound- Non-ambulatory, in a geri-chair, removes shoes which could be causing pressure. Heel protectors applied Bila (bilaterally) Page 4 Notification to Provider: Request treatment of [REDACTED]. Provider visit to assess wound. Check to indicate area is completed: *Provider notification of ulcer observation and investigation. *[DIAGNOSES REDACTED]. *Wound logs updated to identify etiology as diagnosed by provider. *Responsible Party notified of final [DIAGNOSES REDACTED]. *Current care plan validated and reflects interventions that are appropriate to causative and risk factors of wound and the plan reflects review and revision. *Provider orders, ulcer log sheets and care plans indicates same location and type of wound. The above report was signed and dated on 2/4/16 by RN (registered nurse) #3 Unit Manager for Resident #5. Resident #5's WEEKLY PRESSURE ULCER PROGRESS REPORT was reviewed and documented in part, read as follows: Location of Pressure Ulcer L (left) heel ulcer (Eschar) Acquired Date of Development: 2/4/16 Date: 2/4/16 Stage: Unstageable Size: 1.0 cm X 1.9 cm Wound Bed: E (eschar) Wound edges/peri wound: circular Wound Progress: New Date: 2/8/16 Stage: Unstageable Size: 1.0 cm X 1.3 cm Wound Bed: Dry Wound edges/peri wound: Blanchable per MD (doctor) Both of the above entries were completed by RN#3 Unit Manager for Resident #5. On 2/11/16 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) by Surveyor #1. She stated with every identified pressure ulcer, the nurse who finds it fill out the Rcares report, the Initial Ulcer Progress Report (page 1) that describes the wound appearance, the reverse side of the progress report that identified risk and potential causative factors that applied in the last 7 days, check any interventions currently in place and date new one implemented to protect and prevent additional areas from developing, as well as call the physician and Responsible Party (page 2). She stated the nurse who finds the wound can enter into the electronic system whether the wound is Partial Thickness Skin Loss, Full Thickness Skin Loss, Eschar or Slough covered wounds, Non-Blanchable areas, Purple areas, Skin tears, Abrasions, Lacerations, or blisters; and a set of physician standing orders pop up which is electronically signed by the nurse and sent to the physician for their electronic signature. She then added that pages 3 and 4 are filled out by the Unit Manager/Nurse Mentor by the next business day if not on the same day that included a detailed Ulcer investigation, staging of the wound, review all documentation, proper notifications made and ensure the proper treatment was ordered and implemented. She stated the lists of wounds are split up between two doctors and they will see them if necessary, document, review and make any changes to treatment orders. The DON also said, I expect that prevention interventions are in place to avoid pressure areas, and if we find any; they are at an early stage so we can treat them and successfully heal them. Finding areas first identified as unstageable, III's and IV's with eschar and/or slough is never acceptable. It means something has not been done to prevent them. A clinical record review of a physician progress notes [REDACTED].#5 documented in part, read as follows: Nursing Home Visit: follow up wound History of Present Illness: Flagged by nursing to evaluate wound on patient's left heel. Geriatric Physical Exam: Skin: Location: left lower heel, Patient has a 1 X 1.9 cm eschar on left heel medial to the calcaneus midline. Eschar stable. Onset Date: 2/4/2016. Assessment: Heel Ulcer Discussion and Plan: Ulcer-eschar stable. Area cleaned with peri-wound. Patient would benefit from cup socks to reduce friction at area of ulcer. Wound Care Orders: Wound: This patient has been identified as having an area of eschar or slough on his/her left lower heel. Treatment Order: The following treatment plans have been approved for management of resident's with Eschar/Slough covered areas. Heel/Foot area: Intact Eschar with no drainage -Cleanse Eschar area and perimeter with normal saline and apply Skin Prep every shift. -Assess affected area every shift for changes, and/or signs and symptoms of infection. -Notify provider when eschar's perimeter separates from surrounding tissue. -Avoid positioning directly on area. Additional Order: Cup socks for patient daily. A clinical record review of a physician progress notes [REDACTED].#5 documented in part, read as follows: Nursing Home Visit: Follow-up visit wound History of Present Illness: This [AGE] year old presents with a chief complaint of wound. Flagged by nursing to evaluate wound on patient's left heel. Location: left heel Measurements: Length-1 cm, Width-1.3 cm, Depth-0 cm Wound Edges: attached Continue heel protector socks - reviewed with husband importance of prevention - all questions answered. Assessment: Heel Ulcer Follow-Up Wound Care Orders: Wound #1: Unstageable on left heel, change treatment to the following: Cleanse with normal saline Pat dry Apply [MEDICATION NAME] Cover with dressing allevyn Q (every) daily and PRN (as needed) On 2/11/16 at 2:45 p.m., an interview was conducted with the DON and one of the attending physicians by Surveyor #1. For the purposes of identification, this attending physician will be referred to as Physician #1. The DON stated in mid January 2016, they knew their pressure ulcer numbers were increasing and she obtained this information from 6 months of tracking, their Clinical Operations Report (COR) and their Quality Assessment and Assurance report. They stated they talked with the Unit Managers, attending physicians and Assistant Director of Nurses about wound protocols and discrepancies between the nurses and the physicians regarding measurements and descriptions of pressure ulcers. She stated she expected the Unit Managers/Nurse Mentors to correct the licensed nurse's assessment, determine the wound Stage and implement appropriate standing orders, but felt it would be good if the Unit Manager's assessments and Staging could correlate with the physicians. She stated it was something they are working on and currently selected wounds are seen by the physician on Mondays and Wednesdays. She stated sometimes there is a delay with the Unit Manager evaluating the wounds due to a weekend, but could not explain why supervisors could not make wound evaluations to ensure accuracy and prompt treatment. The DON stated she expected the Certified Nursing Assistants (CNA) to complete Stop and Watch forms for any resident changes to include changes in skin integrity. The DON stated the form is a method by which the CNA can document what she sees and proof that she has informed the licensed nurse of the visual changes. The DON stated they are still working on what the checks and balances should be and based on what had been currently revealed by the survey team related to pressure ulcers, The process and system is broken and I have to figure out why it is broke and put in place a check and balance that will not fail. The facility RCare event reporting system documentation dated 2/4/16 for Resident #5's Left heel wound was reviewed and documented in part, read as follows: Additional Investigation: Care Plan Review- Change/Modify Care Plan Notification of Management- Yes Initial Investigation Notes: MD evaluated small circular pressure area left heel. Shoes removed and will obtain pressure relieving cupped socks. Initial Investigation Completed By: Name (RN#3 Unit Manager for Resident #5). Resolution and Outcomes: Non ambulatory and when awake stays in a geri chair, shoes removed and will obtain pressure relieving socks. Transition of Care Issue. Resident #5 was observed up in the geri chair by surveyor on 2/9/16 at 2:00 p.m., 2/10/16 at 1:00 p.m., 2/11/16 at 4:00 p.m., and 2/12/16 at 11:30 a.m. without the presence of cup socks/heel protectors on the left or the right heel at anytime. On 2/12/16 at 11:30 a.m. Resident #5 was up in the dining room with her spouse in her geri chair. Resident #5's spouse was asked if the surveyor could observe the resident's left heel. The resident's spouse agreed. After taken to her room, LPN #4 removed Resident #5's left sock. There were no cup socks/heel protectors on the resident. Resident #5's left heel presented with a medial dime size hard black eschar area. LPN #4 was asked, Where are her cup socks/heel protectors? LPN #4 stated, I'm not sure, I have been off for 2 weeks and I just got back. On 2/12/16 at 12:00 noon RN #3 Unit Manager for Resident #5 was asked about the physician ordered cup socks/heel protectors and made aware that they had not been observed on her all week. RN #3 Unit Manager stated, They have been ordered, on 2/5/16 the cup sock was ordered, but they have not been received. I can put a heel protector on her until they come in. RN #3 Unit Manager immediately obtained Posey Knitted Heel Protectors from the unit supply room and put them on Resident #5. On 2/12/16 at 12:15 p.m. an interview was conducted with the Director of Nursing, and the Quality Assurance Support Nurse. The surveyor asked, What is a cup sock and do you carry them? The Director of Nursing stated, I've never heard of a cup sock. The Quality Assurance Support Nurse stated, I would say it is a heel protector. The Director of Nursing agreed with the Quality Assurance Support Nurse. The Director of Nursing was made aware of the observations of Resident #5 without any physician ordered pressure relieving device for the heels and that RN #3 Unit Manager had stated that they were ordered on [DATE]. The Director of Nursing stated, This should have been taken care of at the level of the order and the doctor questioned because we don't have cup socks. They should have applied the heel protectors we carry. On 2/12/16 at 1:00 p.m. RN #3 Unit Manager presented an order for [REDACTED].>ADDITIONAL ORDERS: d/c (discontinue) cup socks, wear posey knitted heel protectors daily. On 2/16/16 at 4:05 p.m., an interview was conducted with the Staff Development Director by Surveyor #1. She stated there were four days of orientation and she taught the licensed staff, as well as the certified staff how to document what they see regarding skin changes and prevention of pressure ulcers. She stated she taught the licensed staff how to investigate skin problems to include pressure ulcers. She said she taught the licensed nurses how to fill out the appropriate forms to include the 4 page assessment for pressure ulcers (measurements/full thickness/partial thickness), wound care/dressing changes, the Rcares report, documentation on skilled and non-skilled residents. She stated she did not routinely schedule training on the pressure ulcer documentation, filling out the forms and pressure ulcer assessments unless there is a problem; she will then do inservicing. She stated the product company for wound care products and devices will do some inservices. The Facility policy titled Skin Integrity Prevention and Care-Focus on Pressure Ulcers revised on 5/2013 documented in part, read as follows: Purpose: The nursing facility has a commitment to provide care and services for residents with the intent a resident does not develop pressure ulcers unless clinically unavoidable. The facility is also committed to identify other skin integrity issues and provide treatment for [REDACTED]. * Promote the prevention of pressure ulcer development; * Promote the healing of all skin integrity issues that are present (including prevention of infection to the extent possible); and * Assist the provider in investigation of etiology of the skin concern to provide the appropriate treatment and plan of care. *Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or more of the following: evaluate the resident's clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognize standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Specific Procedure/Requirements: 5

Based on observation, staff interview, clinical record review and facility document review the facility staff failed to meet professional standards of care by 1) accurately assessing and care planning sufficiently to meet the needs for 1 of 9 residents who was newly admitted (Resident #1) and while administering medications to 1 of 9 residents in the survey sample (Resident #7). While administering Resident #7's routine morning medications the nurse failed to apply the [MEDICATION NAME] (a topical medication patch), leaving it on the bedside drawer. The findings include: 1. The facility staff failed to accurately assess Resident #1's fall risk, complete care planning sufficient to meet the needs of Resident #1 who was a newly admitted resident, to prevent accidents based on the resident's identified history, provide adequate supervision and implement safety devices to prevent a fall resulting in a fractured left orbital, a left facial laceration requiring sutures and a subdural hematoma. Resident #1 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) with an assessment reference date of 7/2/12 assessed the resident as having impaired short-term memory recall (long term memory recall was not checked). The resident had modified cognitive skills for daily decision making. Under [MEDICAL CONDITION] the resident was coded as having inattention fluctuating behaviors ( i.e., easily distracted, out of touch or difficulty following what was said). Resident #1 required extensive assistance of two (2) staff for transfers, bed mobility, and toileting. The resident was not steady and only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfers. Mobility devices used where a wheelchair and walker. Under section J 1700 Fall History the facility indicated they were unable to determine if the resident had a fall in the last month or last 2-6 months. The resident had received hypnotics, antidepressants and antipsychotic medications during the assessment reference date. Review of the attending physicians History & Physical dated 7/2/12 evidenced the following documentation: "...chief complaint of weakness of 4 days duration. Patient was brought to (name of hospital) on 6/28/12 after recent multiple falls over several weeks, decreased appetite, progressive confusion and weakness..." Review of the Fall Risk assessment dated [DATE] scored the resident an 8. A score of 10 or above represents "High Risk". Further review of the Fall Risk Assessment evidenced the nurse failed to capture the resident's intermittent confusion, abnormal gait balance, antihypertensives, [MEDICAL CONDITION] and hypnotics within the last 7 days, and failed to correctly identify predisposing conditions such as [MEDICAL CONDITION] and fracture. The Fall Risk Assessment should have been scored a 20 instead of an 8. Review of the clinical record failed to evidence the facility initiated a plan of care to reduce the risk of falls upon the resident's admission to the facility. A fall risk care plan was not developed until the comprehensive care plan was developed on 7/18/12. Review of the nurses notes evidenced the following documented unsafe behaviors and poor safety awareness for Resident #1: * Day of admission 7/3/12 on 3-11 shift, patient had to be brought to nurses station because of multiple attempts to get OOB (out of bed) (sign for with) out assist. * 7/3/12 @ 9:20 A.M., received resident sitting in wheelchair @ nurses station. Per previous nurse stated resident continuously attempting to get OOB. At 2:00 A.M., resident room mate calling for nurse. Upon entering resident was out of bed ambulating (sign for with) very unsteady gate {sic}. Assisted back to w/c (wheelchair) resident became agitated & combative...has had (sign for no) sleep on 11-7 shift. * 7/5/12 @ 6:00 P.M., the resident was assessed as restless/agitated/confused. 4:30 A.M., getting out of bed, assisted up in w/c. 7:30 P.M., aggressive, combative, states she has to "go home...to get husband....agitated noted swatting @ things not present, gave resident [MEDICATION NAME] 0.5 mg... *7/6/12 @ 5:15 A.M., resident noted by CNA (certified nurse aide) on the floor face down, red blood on the floor, eye glasses on her face...MD paged....5:55 A.M., 911 arrived. On 7/3/12 a urine specimen was collected for urinalyses and culture and sensitively to rule out urinary tract infection. The results came back negative on 7/4/12. The resident was sent the the emergency room on 7/6/12 and was diagnosed with [REDACTED]. The orbital bone is the cavity or socket of the skull in which the eye and its appendages are situated. Review of the clinical record failed to evidence the facility implemented any specific type and frequency of supervision based on the residents individuals needs. Assistive devices were not implemented to prevent accidents until the resident returned from the emergency room . On 7/6/12 at 1:45 P.M., the nurse documented the following; "Will place a low bed, landing strips and concave mattress to minimize any further injury". On 8/3/12 the DON and Corporate Nurse indicated they reviewed the Fall Risk Assessment's for Resident #1. They stated the Fall Risk Assessment was inaccurate. 2. Resident #7 is a [AGE] year old admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The current MDS (Minimum Data Set) with an assessment reference date of 7/04/12 assessed the resident as having long and short-term memory deficits, with modified independent cognitive skills for daily decision making. Resident #7 required extensive assistance of one (1) staff for bed mobility, transfers, toileting and personal hygiene. The resident was assessed as having frequent pain that was described as moderate. The resident was receiving scheduled and PRN (as needed) pain medication. Review of the physician order [REDACTED]. Listed as part of the resident's pain medication regimen was to apply 1 [MEDICATION NAME] 5% once a day to the resident's neck (on for 12 hours and off for 12 hours). A medication pass observation was conducted on 8/3/12 at 8:41 A.M., with registered nurse (RN#1). The nurse was observed preparing medications for Resident #7. Upon entering the resident's room the nurse placed the [MEDICATION NAME] package on the resident's bedside drawer. She then administered the routine PO (by mouth) medications and eye drops. Afterwards the nurse left the resident's room and continued her medication pass. The nurse forgot to apply the [MEDICATION NAME], leaving it at the bedside. The nurse continued to prepare and administer medications for other residents. Thirty minutes later the nurse still had not recognized she had forgotten to apply the [MEDICATION NAME]. The surveyor at this point shared this observation with the nurse, she responded,"Oh, is it still there? Thank you". The nurse then went into Resident #7's room and applied the [MEDICATION NAME]. Review of the facilities policy/ procedure/ standard titled Medication Administration dated 3/84 and revised on 2/10 read as follows: C. Identify Residents * ...never leave any medications at the bedside...

Based on observation, staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to provide adequate supervision and assistive devices to prevent accidents and ensure 3 of 9 residents in the survey sample were free from accidents (Residents #1, #3, and #9). 1. The facility staff failed to accurately assess Resident #1's fall risk, provide adequate supervision and implement assistive devices to prevent a fall resulting in a fractured left orbital, a left facial laceration requiring sutures and a subdural hematoma. 2. The facility staff failed to ensure fall mats were in use and the bedside commode was close to the bed to prevent injury from falls for Resident #3. 3. The facility staff failed to provide adequate supervision and implement assistive devices to promote safety and prevent recurrent falls for Resident #9. The findings include: 1. The facility staff failed to accurately assess Resident #1's fall risk, complete care planning sufficient to meet the needs of Resident #1 who was a newly admitted resident to prevent accidents based on the resident's identified needs, provide adequate supervision and implement safety devices to prevent a fall resulting in a fractured left orbital, a left facial laceration requiring sutures and a subdural hematoma. Resident #1 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS (Minimum Data Set) with an assessment reference date of 7/2/12 assessed the resident as having impaired short-term memory recall (long term memory recall was not checked). The resident had modified cognitive skills for daily decision making. Under Delirium the resident was coded as having inattention fluctuating behaviors ( i.e., easily distracted, out of touch or difficulty following what was said). Resident #1 required extensive assistance of two (2) staff for transfers, bed mobility, and toileting. The resident was not steady and only able to stabilize with staff assistance with moving from a seated to standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfers. Mobility devices used where a wheelchair and walker. Under section J 1700 Fall History the facility indicated they were unable to determine if the resident had a fall in the last month or last 2-6 months. The resident had received hypnotics, antidepressants and antipsychotic medications during the assessment reference date. Review of the attending physicians History & Physical dated 7/2/12 evidenced the following documentation: "...chief complaint of weakness of 4 days duration. Patient was brought to (name of hospital) on 6/28/12 after recent multiple falls over several weeks, decreased appetite, progressive confusion and weakness..." Review of the Fall Risk assessment dated [DATE] scored the resident an 8. A score of 10 or above represents "High Risk". Further review of the Fall Risk Assessment evidenced the nurse failed to capture the resident's intermittent confusion, abnormal gait balance, antihypertensives, psychotropic and hypnotics within the last 7 days, and failed to correctly identify predisposing conditions such as Osteoporosis and fracture. The Fall Risk Assessment should have been scored a 20 instead of an 8. Review of the clinical record failed to evidence the facility initiated a plan of care to reduce the risk of falls upon the resident's admission to the facility. A fall risk care plan was not developed until the comprehensive care plan was developed on 7/18/12. Review of the nurses notes evidenced the following documented unsafe behaviors and poor safety awareness for Resident #1: * Day of admission 7/3/12 on 3-11 shift, patient had to be brought to nurses station because of multiple attempts to get OOB (out of bed) (sign for with) out assist. * 7/3/12 @ 9:20 A.M., received resident sitting in wheelchair @ nurses station. Per previous nurse stated resident continuously attempting to get OOB. At 2:00 A.M., resident room mate calling for nurse. Upon entering resident was out of bed ambulating (sign for with) very unsteady gate {sic}. Assisted back to w/c (wheelchair) resident became agitated & combative...has had (sign for no) sleep on 11-7 shift. * 7/5/12 @ 6:00 P.M., the resident was assessed as restless/agitated/confused. 4:30 A.M., getting out of bed, assisted up in w/c. 7:30 P.M., aggressive, combative, states she has to "go home...to get husband....agitated noted swatting @ things not present, gave resident Haldol 0.5 mg... *7/6/12 @ 5:15 A.M., resident noted by CNA (certified nurse aide) on the floor face down, red blood on the floor, eye glasses on her face...MD paged....5:55 A.M., 911 arrived. On 7/3/12 a urine specimen was collected for urinalyses and culture and sensitively to rule out urinary tract infection. The results came back negative on 7/4/12. The resident was sent the the emergency room on 7/6/12 and was diagnosed with [REDACTED]. The orbital bone is the cavity or socket of the skull in which the eye and its appendages are situated. Review of the clinical record failed to evidence the facility implemented any specific type and frequency of supervision based on the residents individuals needs. Assistive devices were not implemented to prevent accidents until the resident returned from the emergency room . On 7/6/12 at 1:45 P.M., the nurse documented the following; "Will place a low bed, landing strips and concave mattress to minimize any further injury". On 8/3/12 the DON and Corporate Nurse indicated they reviewed the Fall Risk Assessment's for Resident #1. They stated the Fall Risk Assessment was inaccurate. 2. The facility staff failed to ensure fall mats were in place, and the bedside commode was placed close to the bed to prevent injury from falls for Resident #3. Resident #3 is an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS with an assessment reference date of 7/3/12 assessed the resident as scoring a 3 of 15 in the Brief Interview for Mental Status, indicating the resident was severely cognitively impaired. The resident required extensive assistance of two (2) staff for bed mobility, and extensive assistance of one (1) staff for bed transfers, toileting, and personal hygiene. Review of the Resident Fall Risk assessment dated [DATE] scored the resident a 20. A score of 10 or greater indicates the resident is "High Risk" for falls. Review of the interim care plan upon admitted d 6/26/12 identified the resident has a potential for falls. The goal was the resident will not sustain injury from falls. Interventions listed included: 1. Encourage resident to to use call bell and ask for assistance and/ or use assistive device as needed 2. Keep room /hall clutter free 3. Therapy evaluation as ordered by physician 4. Encourage resident to wear non-skid shoes/socks 5. Provide assistance as needed with transfers, ambulation and /or mobility Review of the clinical record evidenced the resident had 3 falls as follows: 1. 7/12/12 resident found on floor in room at 4:30 A.M., was reaching for personal items. resident sustained [REDACTED]. 2. 7/20/12 resident found on floor in room at 12:45 P.M., was trying to get to bedside commode. 3. 7/29/12 resident found on floor in room at 3:50 P.M., resident unable to explain what he was doing prior to fall. Review of the plan of care indicated it was revised to include: 1. 7/24/12-bedside commode close to bed 2. 7/31/12- landing strips, and assure clear path in room On 8/1/12 at 4:19 P.M., on 8/2/12 at 2:45 P.M., and 4:00 P.M., the resident was observed asleep in bed for each of these observations: 1. The landing strips were not observed in the room for use. 2. The resident's bedside commode was left in a corner around to the left of the bed, not close to the bed. 3. The facility staff failed to provide adequate supervision and implement assistive devices to promote safety and prevent falls for Resident #9. Resident #9 a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS (Minimum Data Set) with an assessment reference date of 5/17/12 evidenced the Brief Interview for Mental Status was not performed. The resident's memory and recall ability indicated the resident was able to recall staff names and faces, and that she was in a nursing home. The resident was assessed as having independent decisions regarding tasks of daily living. Under delirium the resident was assessed as having disorganized thinking. No behaviors were identified. Resident #9 required extensive assistance of two (2) staff for bed mobility, transfers, dressing, toileting and personal hygiene. Resident #9 required limited assistance of one (1) staff for ambulation in her room and corridors. The resident was not steady and only able to stabilize with staff assistance with moving on and off the toilet and surface-to-surface transfers (transfer between bed and chair or wheelchair). The resident had functional limitation of range in motion of a lower extremity. Resident #9 was occasionally incontinent of bladder and continent of bowel. The facility identified the resident had a fall since the last admission/entry or reentry of the prior assessment, without injury. Resident #9 was receiving an antipsychotic, antidepressant and antianxiety medication during the assessment reference date. The Fall Risk assessment dated [DATE] scored the resident an 18. A score of 10 or higher indicates the resident is a "High Risk" for falls. Review of the admission interim plan of care (not dated ), identified the resident as having potential for falls. The goal was the resident would not sustain injury from a fall. The interventions listed to achieve the goal was as follows: 1. Encourage the resident to use the call bell and ask for assistance and /or use assistive device as needed. 2. Keep room /hall clutter free 3. Therapy evaluation as ordered by the physician. 4. Encourage resident to wear non-skid shoes/socks. 5. Provide assistance as needed with transfers, ambulation and /or mobility. Review of the nurses notes evidenced the resident was admitted to the unit at 1:00 P.M., on 5/10/12. The nurse documented the resident was alert and orientated "to self only...hx (history) of dementia, sundowners...hx (history) of falls. At 6:50 P.M., the same nurse documented," Resident found on floor beside bed. Resident stated, "I am leaving to go home". No injuries noted. Resident assisted back to bed via lift. Resident Dgt (daughter's name) notified. Resident then transferred to w/c (wheelchair) and seated at nsg (nursing) desk after repeated attempts to continue to get out of bed without assistance. Resident is alert and orientated to self only and unable to understand repeated instructions to stay in bed and to call for assist when needed. Resident remains seated at nsg station for supervision..." Review of the Quality Care Control Sheet dated 5/10/12 recommended the following: 1. Have resident seated in supervised area such as nursing desk and landing strips to the floor. The admission care plan was not revised to include the above recommended interventions to maintain the resident's safety and prevent falls. The following unsafe behaviors and poor safety awareness was exhibited by the resident as documented in the nurses notes: 1. 5/11/12 the 7-3 shift-resident up at nurses station for increased supervision...confused and often tries to get up from chair unassisted 2. 5/12/12 at 6:00 P.M., resident keeps getting OOB (out of bed) talking about getting furniture in room in correct position 3. 5/14/12 at 4:00 P.M., resident OOB in w/c (wheelchair)...continues to try to stand at nurses station 4. 5/16/12 at 4:00 P.M., resting in bed...will try to get out of when she is up... 5. 5/17/12 at 3:00 P.M., resident continues to stand up in w/c... 6. 5/18/12 at 4:3PM., continues to try to stand up in w/c...sitting at nurses station 7. 5/19/12 for 3-11 shift, repeatedly wandering off unit via w/c... The nurses continued to document the repeated behavior of the resident's multiple ongoing attempts to get up out of the wheelchair and or out of bed on 5/19, 5/20, 5/21 and 5/22. Further review of the clinical record evidenced the resident had the following falls: 1. 5/18/12 at 3:15 A.M., the resident was found on the floor in her room near the bathroom; care plan revised to include toileting the resident at beginning of shift 2. 5/22/12 at 11:00 P.M., the resident was found standing up in her room, when staff entered the room the resident fell to the floor; care plan revised to toilet resident before bedtime, and do frequent room checks while in room. 3. 5/23/12 at 12:15 A.M., the resident was found on the floor in her room at the foot of the bed; care plan revised to keep resident at nurses station at all times while awake (note this was already implemented). 4. 5/23/12 at 1:00 P.M., the resident was found on the floor in her room, (after left in the room unsupervised in the wheelchair for lunch). The psychiatrist was called to review the resident's psychotropic medication regimen. For each of the these incidents there was no evidence the facility modified the resident's plan of care to include any other safety devices to be utilized in conjunction with other interventions. Each of the above falls occurred while the resident was alone in her room unsupervised. On 8/2/12 at 4:32 P.M., the above findings for Resident's #1, 3 and 9, and the facilities fall prevention program was discussed with the Director of Nurses (DON). The DON stated the facility no longer utilizes assistive safety devices such as sensor alarms to assist staff with identifying the residents activity (such as attempting to rise up from on surface to another). She stated these devices have not been used in the building for over a year. Instead, the facility focuses on the specific reason for the resident behaviors and from there implement interventions based on the residents needs. The DON indicated education for the resident as well as the responsible party is included. She stated when new interventions are implemented the RP is notified. If an RP requests an alarm they are educated that these devices are not part of the fall prevention program. Review of the facilities Falls Prevention and Management Policy and Procedure dated 7/2000 revised 9/10 read as follows: Purpose: To promote safety by: * Identifying residents at risk for falls by use of fall risk predictors, including resident history, diagnosis, ambulatory status, gait/balance, mental status, medication regimen, elimination status, vision status and systolic B/P. To Prevent falls and/ or further injury by: * Focusing on underlying cause and implementing interventions that focus on that cause: stabilizing medical condition, improving strength, use of adaptive device, teaching, adjusting environment, staff monitoring, and responsiveness II. Fall Management: B. Care of Resident Following a Fall: 9. The nurse will take any immediate measures necessary to prevent a recurrence of a falls and document these measures in the medical record. C. Fall Documentation Standards: 7. Revise care plan. Intervention should be individualized and based on results of assessment and investigation. Interventions on care plan are dated when added or deleted. Fall Prevention Guidelines: Residents with a score of 8 or above or a recent fall; consider these interventions according to resident's individualized needs. This is not an exclusive list: *Keep resident in supervised area * Keep bed in low position with wheels locked *Positioning devices * Low bed *Mat's on floor beside bed *Alarms to remind resident not to stand/exit or to alert staff, Tabs monitor for bed/chair, talking Tabs monitors with family voice, floor monitor that alarms when resident steps on it from bed/chair, alarm at bathroom door to alert staff when resident is trying to toilet without assistance *Soothing music *Diversional activities *Concave mattress COMPLAINT DEFICIENCY

Based on staff interview, clinical record review, facility document review and in the course of a complaint investigation the facility staff failed to ensure 1 of 9 residents in the survey sample was free from a significant medication error (Resident #8). The licensed practical nurse (LPN #6 ) administered Resident #8 five times the amount [MEDICATION NAME](a sleeping medication) ordered by the physician, as a result the resident had a change in condition and required medical emergency care services. The findings include: A Facility Reported Incident (FRI) was sent to the state agency on 7/11/12 reporting a medication error involving Resident #8. An investigation was initiated and the facility determined LPN#6, "accidentally administered a total of 50 mg's [MEDICATION NAME] the resident , and as a result of this error (name of resident) was hospitalized . (LPN#6) was given education and counseling prior to her return to duty. She (LPN#6) is scheduled for an extensive med pass observation with the nurse pharmacy consultant". Further investigation of the significant medication error evidenced the following: Resident #8 is a [AGE] year old admitted to the facility on [DATE] following hospitalization for after care for a lumbar surgery and hypertension. The resident was sent to the emergency roiagnom on [DATE] for a change in condition and returned on 7/11/12 with [DIAGNOSES REDACTED]. An admission MDS was not conducted as the resident had not remained in the facility for greater than 14 days. Review of the 5 day MDS with an assessment reference date of 7/6/12 assessed the resident as having intact long and short-term memory with independent cognitive skills for daily decision making. The resident required extensive assistance of 2 staff for bed mobility, and extensive assistance of 1 staff for transfers, dressing, toileting and personal hygiene. Resident #8 was assessed as receiving scheduled and PRN (as needed) pain medication. Review of the physician orders [REDACTED]. [MEDICATION NAME] 10 mg tablet one by mouth three times a day as needed for muscle spasms. Review of the physician orders [REDACTED].@ HS (hour of sleep) PRN (as needed ) for sleep. According to [MEDICATION NAME] given for [MEDICAL CONDITION]. The recommended dose for short-term treatment is 10 mg orally immediately before bedtime; max dose is 10 mg/day. Review of the Controlled Medication Reconciliation Sheet [MEDICATION NAME] mg evidenced the following: On 7/9/12 at 6:25 P.M., LPN#6 administered 2 tablets (20 mg) [MEDICATION NAME] Resident #8. On 7/9/12 at 9:00 P.M., LPN #6 administered 3 more tablets [MEDICATION NAME](30 mg) to Resident #8. Review of the Controlled Medication Reconciliation Sheet for [MEDICATION NAME] 5 mg evidenced the following: On 7/9/12 LPN#6 administered one (1) 5 mg tablet of [MEDICATION NAME] to Resident #8 at 6:25 P.M. Review of the skilled nursing notes dated 7/9/12 evidenced LPN#6 documented at 6:30 P.M., the resident's blood pressure was 120/80, temperature (T) 98.5, (R) respirations 18 and (P) pulse 80, the resident was in no distress and had no complaints of pain this shift. According to the facilities investigation the significant medication error was discovered during the shift to shift controlled medication reconciliation count at approximately 11:00 P.M., on 7/9/12. The physician was notified. A physician telephone order date 7/9/12 directed the staff to monitor the resident's vital signs throughout the 11-7 shift, "change in VS (vital signs) or LOC (level of consciousness) may send to ED (emergency department)." No time was found on this telephone order. At 11:30 P.M., LPN#6 documented the resident's vital signs as (T) 98.5, (B/P) 107/62, (P) 79 and (R) 21, "able to arouse, w/ (with) verbal stimulation, alert, oriented x 3, denies pain, verbalizes no complaints, verbalized no other abnormalities...at 12:13 A.M. the nurse documented, "Notified (RP name)..." The 11-7 shift documented the following: 12:30 A.M., Resident easy to arouse, groggy, alert VS (T) 97.9, (P) 99, (R) 18, (B/P) 99/62 2:50 A.M., easy to arouse, VS (T) 97.8, (P) 94, (R) 18, (B/P) 99/67 5:30 A.M., VS (T) 97.9, (P) 94, (R) 16, ( B/P) 95/60, pulse ox 92%, the nurse documented, "easy arouse verbally, resident stated, " Where am I? Where is my husband...oriented to name and date of birth, when asked what year it was resident stated, "October 2, 2012" pupils sluggish to respond, slurred speech noted. 5:40 A.M., (name of medical transport) made aware ETA (estimated time of arrival) 30 minutes... 6:35 A.M., (name of medical transport) picked up resident via stretcher... Review of the hospital discharge summary dated 7/11/12 evidenced the following documentation: "Brought into the hospital with altered mental status and somnolence [MEDICATION NAME]. While I do not possess the details, there is concern that she may have received too much Ambien. Is {sic} should be noted she is on other medications that can affect her mental status and alertness including [MEDICATION NAME] for back pain and [MEDICATION NAME]. In the ER had a fall and struck the back of her head and incurred a laceration that required staple placement". Discharge [DIAGNOSES REDACTED]. 1. [MEDICAL CONDITION]-resolved. 2. Scalp laceration. While in the emergency room the resident received [MEDICATION NAME] IV fluids of .9% Normal Saline. The resident was discharged back to the nursing facility on 7/11/12. The resident was discharge to home on 7/21/12. Review of the attending physician discharge summary dated 7/21/12 evidenced the following documentation: "During her stay here she developed some altered mental status and was transferred to emergency room and this was attributed [MEDICATION NAME]". On 8/2/12 at 4:52 P.M., the above findings of the significant medication error and LPN#6's employee record were reviewed with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) evidenced the following: 1. LPN #6 had a previous medication error involving hanging the wrong IV fluids and was counseled and re-educated. 2. LPN #6 was reported to the Board of Health Professionals and the Board of Licensure. 3. LPN #6 resigned prior to receiving an extensive med pass observation with the nurse pharmacy consultant. COMPLAINT DEFICIENCY