Every finding on record at Riverside Valley of Journey

Based on observation, record review and staff interview the facility failed to ensure a Resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was true for one (1) of three (3) pressures reviewed for care. Resident Identifier: #1 Facility Census: #84Findings include:1) Resident #1On 12/18/25 at 9:50 AM observation found that Resident #1 had the following wound treatments for the left thigh and sacrum ordered by the Physician.Left Thigha) Cleanse area to left thigh with vashe (wound cleanser) pat dry, apply silvasorb, cover with calcium alginate, and cover with foam dressing. Change daily and as needed (PRN), every day shift for wound care.Sacrumb) Wound to sacrum. Cleanse with in house wound care (IHWC). Pat dry. Lightly pack with iodoform, place calcium alginate with silver and cover with silicone foam border. Change daily and PRN every day shift for wound care.On 12/18/25 at 9:55 AM upon observation of the sacral wound with Unit Manager, Licensed Practical Nurse (LPN) #67 it was found the resident had no dressing in place. The resident had also had a bowel movement which caused the wound to be dirty. LPN #67 stated she would clean the resident and have the Residents' nurse place a dressing. At 3:10 PM when the Surveyor was preparing to recheck wound, the orders and the Treatment Administration Record (TAR) it was noted the wound to the residents left thigh had also been completed. With the assistance of the Director of Nursing (DON) and Registered Nurse (RN) #35 observation found that the left thigh dressing had not been completed but had been checked off on the TAR as being complete. According to RN #35, it was her initials on the TAR indicating the dressing had been completed when it had not. This was confirmed with the DON at this time as well.The Care Plan review revealed the following: FOCUS: The Resident has altered skin integrity related to areas of sacrum, foot and leg with continued risk r/t hemiplegia, and CV disease with end of life services with Hospice.GOAL: The Resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Resident will not develop further skin impairment through next review.INTERVENTIONS:Administer medications as ordered. Monitor/document for side effects and effectiveness.Administer treatments as ordered and monitor for effectiveness. If the resident refuses treatment confer with the resident. IDT, and family to determine why and try alternative methods to gain compliance. Document alternative methods. Monitor nutritional status. Serve diet as ordered, monitor intake and record. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated.On 12/18/25 at 3:45 PM it was confirmed with the DON that the dressings had not been completed as per the Physician's orders at which time she agreed.

Based on observation and staff interview the facility failed to follow Physicians orders and maintain standard of nursing care for tube feeding syringe and graduate. This was a random opportunity for discovery. Resident Identifier: # 1 Facility Census: #84Findings include:a) Resident #1On 12/18/25 at 3:10 PM observation found the tube feeding syringe and graduate container at bedside used for tube feeding flushes, residual checks and tube feeding administration were not dated. The resident had a current order for:1) Enteral Feed Order: every day and night shift Check tube placement before initiation of formula, medication administration and flushing tube. 2) Jevity 1.5 237 mls 6 times daily to provide 2139 Kcals, 90gr protein, 720 ml free water. Flush with 60 mls water before and after feeding for a total of 1800 mls six times a day. 3) Change enteral irrigation syringe and graduate every night shift. According to Registered Nurse #35 the syringe/graduate is to be dated every day and discarded after 24 hours. This is a standard of nursing care for tube feeding and a Physicians order. On 12/18/25 at 3:15 PM it was confirmed with the Director of Nursing the syringe or graduate were not dated when they should have been. She agreed at this time.

e) Resident #139 A review of Resident #139's medical record on 07/02/25 found the resident was sent to the hospital on [DATE] after facility staff discovered he was smoking an illegal drug in his room at his facility. The resident reported to staff that he had swallowed the drug therefore they sent him to the emergency room via ambulance. The initial review of the reportable incident found the only issue identified was the residents illegal drug use in the facility. An interview with Nursing Home Administrator (NHA) on the morning of 0702/25 confirmed the resident was sent to the hospital on [DATE] and he was not permitted to return to the facility. When asked if they issued the resident a 30 day discharge notice the facility initially was uncertain if they did or not. During this interview the NHA stated, the main reason Resident #139 was not permitted to return was because as he was on his way out the door he made a statement that he would get a gun an shoot everyone when he came back. The NHA stated, He is already proven he can get illegal substances and we felt he could probably get a gun if he wanted to. When asked why none of the statements contained in the reportable incident indicated this he stated, We probably have some more statements. When asked why the medical record was void of any nursing notes related to this incident he stated, That's when we switched companies and they are probably on paper in medical records. The surveyor requested any documentation related to this incident. At the time of exit this information from the medical record was not provided. Later in the afternoon on 07/02/25 the NHA provided two (2) staff statements which were not in the original reportable incident provided to the surveyor earlier in the day. The NHA stated he was not sure why they were not in the file with the other statements. Both statements detailed the residents threat to bring a gun and shoot everyone. The NHA was then asked to provide the 30 day notice which was issued to Resident #139. He later provided a notice dated 09/03/24. This notice indicated the resident was being discharged to the local hospital due to the safety of individuals in the facility was endangered due to clinical or behavioral status of the resident. The facility wrote in the area provided threats to life of staff and residents. In the area where the resident signature should have been the facility wrote 'Dropped off to hospital upon discharge did not receive signed copy back. The NHA was asked if this was delivered to the resident or just left at the hospital. The NHA replied, We just left it at the hospital. The NHA was then asked to provide evidence this notice was sent to the Ombudsman as required at the time it was issued. On the morning of 07/07/25 the NHA provided an email dated 10/21/24 which was sent by the regional ombudsman's to the NHA. In this email the ombudsman requested a copy of the discharge notice. The NHA stated, I'm sure we sent it in response to this email but I can't find it because that social worker no longer works here and it was in the old email system. A telephone interview with the regional long term care ombudsman on 07/07/25 at 05:31 PM confirmed they never received a copy of the Transfer/Discharge notice. She indicated she first became aware of the issue in October of 2024 when the social worker from the hospital contacted her to request assistance. She indicated she requested the notice of transfer/discharge on [DATE] and 10/21/24. She stated, they never received the notice until this morning when the NHA emailed it. The ombudsman indicated that she spoke with the resident and he confirmed he never received the notice. 07/02/25 09:38 AM Stated that this was a repeat occurrence it was probably mid 2023. I would say that it had three or four times. Since we had changed the sheets it was on the floor next to his be and in his sheets. He was leaving the facility that day he threatening to come back and shoot everybody. Not ideal. He denied consistently until the last incident on 09/01/24. He indicated to the staff that he had swallowed. The NHA confirmed they did not issue a discharge notice because he was threatening to shoot everybody. We could not let him come back because he stated he was going to bring a gun back and kill everybody. And have illegal items in the building. Based upon record review, staff interviews, and an interview with the State Long Term Care Ombudsman, the facility failed to provide documentation verifying the Ombudsman received notification of the transfer or discharge of residents. This was found to be true in five (5) out of five (5) residents reviewed for discharge and hospitalization during the long term care survey process. Resident identifiers: #79, #2, #54, #37, #139. Facility Census: 84. Findings included: a) Resident #79 Resident #79 was transferred to an acute care facility on 05/11/25, due to abnormal vital signs. The Resident returned to the long term care facility on 05/17/25 The resident does not have capacity to make own medical decisions. On 07/02/25 at 9:18 AM, the surveyor requested to see verification of an acute transfer notice being provided to the Resident's representative, and verification of a copy being sent to the State Long Term Care Ombudsman. On 07/02/25 mid afternoon, the Nursing Home Administrator (NHA) brought a fax confirmation of the notice being provided to the Ombudsman on 07/02/25 at 12:12 PM. Thus, the ombudsman was not notified until after the surveyor requested to see verification. When asked about why the notice was just now being sent, the NHA stated they could not find verification that it had been sent at the time of transfer. On 07/08/25 at approximately 1:00 PM, discussion with Staff # 110, verified the notice was not sent to the Ombudsman until 07/02/25. b) Resident #2 Resident #2 was transferred to an acute care facility on 02/11/25 for shortness of breath, and abnormal pulse. Resident was admitted to the acute care facility and returned to the long term care facility on 02/14/25. Resident has capacity to make his own medical decisions. On 07/03/25 at 10:18 AM, the surveyor requested to see verification of an acute transfer/discharge notice being provided to the Resident, as well as verification the notice was sent to the Office of the State Long Term Care Ombudsman. The Notice of Transfer form was given to resident at time of transfer to hospital. On 07/07/25 at 12:10 pm, the Nursing Home Administration provided a copy of the transfer notice, and stated there is no documentation to support that ombudsman was sent a copy of the notice of transfer. Per interview with the Regional [NAME] President of Clinical Services on 07/07/25 at 1:45 PM, there was no additional information she could provide. c) Resident # 54 Resident #54 was transferred to an acute care facility on 03/31/25 due to abnormal vital signs. The Resident was transported by EMS. Due to a diagnosis of severe sepsis, the Resident was admitted . The resident returned to the long term care facility on 04/07/25. Resident does not have capacity to make her own medical decisions. On 07/02/25 mid-morning, the surveyor requested to review the Notice of Acute Transfer or Discharge form for 04/07/25 for the Resident, as well as verification the Notice was sent to the Office of the State Long Term Care Ombudsman. On 07/03/25 mid-afternoon, the NHA provided a copy of a fax coversheet sent to the Ombudsman at 07/02/25 at 3:01 PM. Thus, the Ombudsman was not notified in a timely manner about the transfer. Notification was not provided until the surveyor asked for it. Per interview with the Regional [NAME] President of Clinical Services on 07/07/25 at 1:45 PM, there was no additional information she could provide. On 07/08/25 at approximately 12:45 PM, Staff #110, provided a copy of a Bed Reservation Approval form, which had been sent to with the Resident to the hospital, with a copy sent to the Resident's Representative, and verified the notice was not sent to the Ombudsman until 07/02/25. d) Resident #37 On 4/27/25, the family requested Resident #37 be sent to an acute care facility. Resident was admitted , returning to the long term care facility on 05/01/25. On 07/07/25 at 1:07 PM, the surveyor requested from the facility the acute transfer/discharge letter, as well as verification of the notice being sent to the Office of the State Long Term Care Ombudsman. On 07/07/25 at 4:00 PM, the DON provided a copy of a form, Bed Reservation Approval. This form had been sent with the Resident to the acute care facility, with a copy mailed to the Resident's representative. During this conversation, the DON stated the other information was not available. On 07/08/25 at approximately 1:00 PM, discussion with Staff # 110, verified she could not locate where a copy had been sent to the Ombudsman.

Based on observation and staff interview the facility failed to ensure food was stored and prepared in a safe and sanitary manner. This failed practice has the potential to effect more than an isolated number of residents. Facility Census: 84. Findings Include: a) Initial tour of the Kitchen An initial tour of the kitchen upon entrance of the facility on 07/01/25 at 9:00 AM found the walk-in refrigerator had one gallon of milk with best by date June 26, 2025. Certified Dietary Manager CDM #16 reported that the milk deliverer will take it back when he comes to deliver fresh milk if it was date and placed seperately from the food good for consumption. I expressed that it was not currently separate from the milk in date to be used and she marked it and separated it for pick up and set it aside. b)Tour of the nourishment rooms on the floors on 07/02/25. At 10:57 AM observed the East Nourishment room. Twelve (12) packages of individually wrapped saltine crackers with no dates inside of a plastic bag with no dates and not labeled were located in the drawer. There were 34 individual packages of saltines inside of a drawer with no expiration dates. There were also twenty two (22) packages of individually wrapped graham crackers in a plastic container that was not labeled. Licensed Practical Nurse #57 acknowledged. At 11:00 AM it was observed in the [NAME] Nourishment room that nine (9) individually wrapped, undated, graham crackers in a plastic container with no labels or dates were in the nourishment drawer along with twenty three (23) individually wrapped packs of saltines in a plastic bag with no dates and not labeled. Interviewed CDM #16 0n 07/02/25 at 11:13 AM who acknowledged that the graham crackers and saltines were not dated/labeled in the nourishment rooms or in the boxed they arrived in. They will contact the distributer and label them. c)Observation of serving line in kitchen on 07/02/25. Observed Dietary Aide #49 wrapping silverware and prepping food with no beard net 12:00 PM to 12:10 PM on 07/02/25. CDM #16 acknowledged that he was not wearing it and reported that he just got here. d) Facility Policy titled Healtcare Services Group, Inc. and its subsidiaries HCGS POLICY 018, Food Storage: Dry Goods, Procedure number 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. e) Facility Policy titled Healthcare Service Group, Inc. and its subsidiaries HCSG Policy 024, Staff Attire, Procedure 1. All staff members will have their hair off the shoulders, confined in a hair net or cap and facial hair properly restrained.

d) Resident #24 On 07/01/25 at 1:16 PM, Nursing Assistant (NA) #91 was observed removing Resident #24's tray from her room. It did not appear that the resident had eaten much of the food. The silverware on the tray had not been unwrapped from the napkin. When questioned, NA #91 stated the resident was able to feed herself. On 07/02/25, review of Resident #24's electronic health records, specifically the task report for amount eaten/fluids consumed at meals, showed documentation the resident had eaten 76 to 100 percent (%) of lunch on 07/01/25. The medical records also confirmed the resident could feed herself after set up. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was mentally intact. On 07/02/25 at 3:14 PM, the Director of Nursing (DON) was informed of the surveyor's observation that Resident #24 had not eaten 76 to 100% of her lunch meal on 07/01/25. The DON stated she would check to see if the resident had later eaten a different meal at lunchtime.No further information was provided through the completion of the survey process. Based on observation, record review and staff interview the facility failed to ensure the medical record was complete and accurate four (4) of 31 sampled residents reviewed during the long term care survey process. Resident Identifiers: #55, #140, #72, and #24. Facility Census: 84. The facility failed to have complete and accurate records. Findings Include: a) Resident #55 A review of Resident #55's medical record found she required neurological assessments to be completed on 01/03/25, 04/21/25, 06/24/25 and 06/28/25. The facility was asked to provide the surveyor with a copy of the neurological assessments for the aforementioned dates. A review of the neurological assessments provided found, the assessment consists of 25 occasions were a neurological assessment should be completed beginning with the initial assessment and proceeding as follows: 1. Initial 2. 15 minute evaluation #1 3. !5 minute evaluation #2 4. 15 minute evaluation #3 5. 15 minute evaluation #4 6. 30 minute evaluation #1 7. 30 minute evaluation #2 8. 30 minute evaluation #3 9. 30 minute evaluation #4 10. 1 hour evaluation #1 11. 1 hour evaluation #2 12. 1 hour evaluation #3 13. 1 hour evaluation #4 14. 4 hour evaluation #1 15. 4 hour evaluation #2 16. 4 hour evaluation #3 17. 4 hour evaluation #4 18. 8 hour evaluation #1 19. 8 hour evaluation #220. 8 hour evaluation #321. 8 hour evaluation #422. 8 hour evaluation #523. 8 hour evaluation #624. 8 hour evaluation #7 25. 8 hour evaluation #8. A review of the provided assessments found the following when a nurse other than the nurse completing the assessment entered it into the electronic medical record giving that nurse entered the assessment completed the assessment:-- Assessments began on 01/03/25 and the following sections were entered by the former Assistant Director of Nursing 03/11/25:10. 1 hour evaluation #1 11. 1 hour evaluation #2 12. 1 hour evaluation #3 13. 1 hour evaluation #4 14. 4 hour evaluation #1 15. 4 hour evaluation #2 16. 4 hour evaluation #3 17. 4 hour evaluation #4 18. 8 hour evaluation #1 19. 8 hour evaluation #220. 8 hour evaluation #321. 8 hour evaluation #422. 8 hour evaluation #523. 8 hour evaluation #624. 8 hour evaluation #7 25. 8 hour evaluation #8. -- Assessments which began on 04/21/25 found the former Assistant Director of Nursing (ADON) documented the following assessments on 04/28/25:1. Initial 2. 15 minute evaluation #1 3. !5 minute evaluation #2 4. 15 minute evaluation #3 5. 15 minute evaluation #4 6. 30 minute evaluation #1 7. 30 minute evaluation #2 8. 30 minute evaluation #3 9. 30 minute evaluation #4 10. 1 hour evaluation #1 11. 1 hour evaluation #2 12. 1 hour evaluation #3 13. 1 hour evaluation #4 14. 4 hour evaluation #1 15. 4 hour evaluation #2 16. 4 hour evaluation #3 17. 4 hour evaluation #4 18. 8 hour evaluation #1 19. 8 hour evaluation #220. 8 hour evaluation #321. 8 hour evaluation #422. 8 hour evaluation #523. 8 hour evaluation #624. 8 hour evaluation #7 25. 8 hour evaluation #8. -- Assessments which began on 06/24/25 found the current Staff Development Coordinator entered the following section on 06/27/25:19. 8 hour evaluation #220. 8 hour evaluation #321. 8 hour evaluation #422. 8 hour evaluation #523. 8 hour evaluation #624. 8 hour evaluation #7 25. 8 hour evaluation #8. -- Assessments which began on 06/28/25 found the current Staff Development Coordinator entered the following sections on 07/02/25:1. Initial 2. 15 minute evaluation #1 3. !5 minute evaluation #2 4. 15 minute evaluation #3 5. 15 minute evaluation #4 6. 30 minute evaluation #1 7. 30 minute evaluation #2 8. 30 minute evaluation #3 9. 30 minute evaluation #4 10. 1 hour evaluation #1 11. 1 hour evaluation #2 12. 1 hour evaluation #3 13. 1 hour evaluation #4 14. 4 hour evaluation #1 15. 4 hour evaluation #2 16. 4 hour evaluation #3 17. 4 hour evaluation #4 18. 8 hour evaluation #1 19. 8 hour evaluation #220. 8 hour evaluation #321. 8 hour evaluation #422. 8 hour evaluation #523. 8 hour evaluation #624. 8 hour evaluation #7 25. 8 hour evaluation #8. An interview with the Director of Nursing found, some nurses will complete the assessments on paper instead of putting them into the electronic medical record then one of the nurses in administration will enter them into the electronic medical record. She was asked if they maintained the paper copies to show which nurse actually completed the assessments and she confirmed they did not. She stated once they enter them they shred them. b) Resident #72An observation at approximately 3:00 PM of 07/02/25 found Resident #72's mighty shake unopened sitting on a tray in the dining room. This was labeled to indicate it was the residents 2:00 pm mighty shake. A review of Resident #72's medical record on 07/02/25 at approximately 4:30 PM it was discovered the nurse had documented Resident #72 consumed 50 percent of her 2:00 pm mighty shake. An observation with the Director of Nursing (DON) immediately following this discovery confirmed the might shake was still sitting on the tray in the dining room unopened. The DON took the mighty shake and asked Registered Nurse #9 why she had documented 50 percent when it was unopened. She stated, the nurse aide told me she had drank 50 percent. c) Resident #140An observation at 11:14 AM on 07/01/25 found his 10:00 AM Mighty Shake was sitting on his over the be table. The straw inserted into the mighty shake was unwrapped all except the top (where the resident would drink from) the paper was still over the top of the straw. At 11:48 AM the same mighty shake was still on the over the bed table and the paper was still on the top of the straw. A review of the Medication Administration Record (MAR) while in the resident room it was discovered Licensed Practical Nurse (LPN) #111 had documented Resident #140 had consumed 50 percent of his 10:00 AM mighty shake. LPN #111 was requested to come to the residents room. Upon entering LPN #111 was asked if this resident drank 50 percent of his mighty shake as reflected on the medication administration record (MAR) she stated, Yes. Once the paper covering the top of the straw was pointed out she picked up the mighty shake and confirmed Resident #140 had not consumed 50 percent of the drink.

b) Resident #55 A review of Resident #55's medical record found she suffered an unwitnessed fall on 12/11/24 and 12/18/24. According to the incident reports neurological assessments were initiated on both occasions. In the afternoon of 07/7/25 the Director of Nursing (DON) was asked to provide the surveyor with a copy of the neurological assessments for Resident #55 on 12/11/24 and 12/18/24. Later in the afternoon the DON confirmed there were no neurological assessments found for the fall on 12/11/24. She did provide the neurological assessments for 12/18/24. A review of the neurological assessments for 12/18/24 found they were incomplete. The assessment consists of 25 occasions were a neurological assessment should be completed beginning with the initial assessment and proceeding as follows: 1. Initial 2. 15 minute evaluation #1 3. !5 minute evaluation #2 4. 15 minute evaluation #3 5. 15 minute evaluation #4 6. 30 minute evaluation #1 7. 30 minute evaluation #2 8. 30 minute evaluation #3 9. 30 minute evaluation #4 10. 1 hour evaluation #1 11. 1 hour evaluation #2 12. 1 hour evaluation #3 13. 1 hour evaluation #4 14. 4 hour evaluation #1 15. 4 hour evaluation #2 16. 4 hour evaluation #3 17. 4 hour evaluation #4 18. 8 hour evaluation #1 19. 8 hour evaluation #2 20. 8 hour evaluation #3 21. 8 hour evaluation #4 22. 8 hour evaluation #5 23. 8 hour evaluation #6 24. 8 hour evaluation #7 25. 8 hour evaluation #8 Further review of the neurological assessments for Resident #55 which began on 12/18/24 found the following evaluations were not completed as required: 14. 4 hour evaluation #1 15. 4 hour evaluation #2 16. 4 hour evaluation #3 18. 8 hour evaluation #1 19. 8 hour evaluation #2 20. 8 hour evaluation #3 21. 8 hour evaluation #4 22. 8 hour evaluation #5 23. 8 hour evaluation #6 24. 8 hour evaluation #7 25. 8 hour evaluation #8. An interview with the DON confirmed this in the late afternoon of 07/07/25. C) Resident #140 At 2:29 PM on 07/07/25 while passing through the dining room Resident #140 was sitting on the calf rests of his wheelchair. His entire buttocks was off the wheelchair seat an was resting on the wheelchair calf support pads. A lift pad was noted in the wheelchair. He stated the wheelchair was hurting his buttocks and that is why he was trying to get out of the chair. Nurse Aide # 77 and Activities Director #72 took position on either side of the Resident. Nurse Aide #77 grabbed the resident under the arm and by his shorts and AD #72 had the resident under the arm. The surveyor was not in a position to tell what AD #72 did with her other hand. They then lifted the resident from the calf support pads to the seat of his wheelchair. At no time was a licensed nurse present to assess the resident or to give guidance to the nurse aides to ensure Resident #140 was transferred back to his seat safely. A review of the residents care plan found the following intervention related to assistance with activities of daily living: -- · Transfer Assist: Total Dependence x2 staff and a mechanical lift An interview with the Nursing Home Administrator (NHA) confirmed a license nurse did not come into the dining room to assess the resident or to assist the NA's in deciding the best way to get Resident #140 back into the wheelchair. d) Resident #51 Review of Resident #51's physician's orders showed an order written on 05/16/25 for Novolog injection solution 100 unit/ml [milliliter] (Insulin Aspart), inject 5 units subcutaneously three times a day for DM [diabetes mellitus]. Hold for blood sugar less than 140. Resident #51's Medication Administration Records (MARs) were reviewed for June and July 2025. The MARs showed numerous occasions when Resident #51's insulin was given despite the resident's blood glucose being less than 140. These occasions were as follows: - On 06/02/25, insulin was administered at 12:00 PM. The resident's blood glucose was 117 at 11:30 AM. - On 06/04/25, insulin was administered at 8:00 AM. The resident's blood glucose was 115 at 6:00 AM. - On 06/09/25, insulin was administered at 8:00 AM. The resident's blood glucose was 128 at 6:30 AM. - On 06/12/25, insulin was administered at 12:00 PM. The resident's blood glucose was 118 at 11:30 AM. - On 06/13/25, insulin was administered at 5:00 PM. The resident's blood glucose was 126 at 4:30 PM. - On 06/14/25, insulin was administered at 8:00 AM. The resident's blood glucose was 131 at 6:30 AM. - On 06/15/25, insulin was administered at 8:00 AM. The resident's blood glucose was 124 at 6:30 AM. - On 06/18/25, insulin was administered at 12:00 PM. The resident's blood glucose was 122 at 11:30 AM. - On 06/20/25, insulin was administered at 8:00 AM. The resident's blood glucose was 128 at 6:30 AM. - On 06/26/25, insulin was administered at 8:00 AM. The resident's blood glucose was 133 at 6:30 AM. - On 06/26/25, insulin was administered at 12:00 PM. The resident's blood glucose was 101 at 11:30 AM. - On 06/27/25, insulin was administered at 8:00 AM. The resident's blood glucose was 129 at 6:30 AM. - On 06/30/25, insulin was administered at 8:00 AM. The resident's blood glucose was 126 at 6:30 AM. - On 07/01/25, insulin was administered at 8:00 AM. The resident's blood glucose was 114 at 6:30 AM. - On 07/01/25, insulin was administered at 12:00 PM. The resident's blood glucose was 129 at 11:30 AM. - On 07/01/25, insulin was administered at 5:00 PM. The resident's blood glucose was 104 at 4:30 PM. - On 07/04/25, insulin was administered at 12:00 PM. The resident's blood glucose was 138 at 11:30 AM. - On 07/04/25, insulin was administered at 5:00 PM. The resident's blood glucose was 122 at 4:30 PM. - On 07/05/25, insulin was administered at 8:00 AM. The resident's blood glucose was 76 at 6:30 AM. - On 07/05/25, insulin was administered at 12:00 PM. The resident's blood glucose was 134 at 11:30 AM. - On 07/05/25, insulin was administered at 5:00 PM. The resident's blood glucose was 111 at 4:30 PM. - On 07/06/25, insulin was administered at 5:00 PM. The resident's blood glucose was 123 at 4:30 PM. On 07/07/25 at approximately 11:00 AM, the Director of Nursing confirmed the physician's order had not been followed to hold Resident #51's Novalog insulin when the blood glucose was less than 140. No further information was provided through the completion of the survey. Based on record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was true for four (4) out of 31 residents reviewed throughout the Long-Term Care Survey Process. The facility failed to follow physician orders regarding use of wheelchair and an order for staff to encourage Resident #26 to be up and out of bed for the lunch and dinner meals. The facility failed to follow physician orders for insulin administration for Resident #51. The facility failed to complete neurological checks for Resident #33. The facility failed to have a nurse assess Resident #140 following a fall prior to staff intervention. Resident identifiers: #26, #33, and #140 and #51. Facility census: 84 Findings included: a) Resident #26 A record review, completed on 07/07/25 at 11:50 AM, revealed the following physician orders: -Encourage resident to be in high traffic area when up in chair. Make sure leg rests are on and chair is slightly reclines. -Staff to encourage and assist resident to be up in chair and in dining room for lunch and dinner. During an observation of Resident #26 in the dining room on 07/07/25 at 12:10 PM, the Administrator confirmed there were no leg rests on resident's wheelchair and the wheelchair was not slightly reclined. The Administrator stated he believed therapy had recently evaluated the resident but it appeared that the physician order had not been updated to reflect resident's new plan of care. Review of the January 2025 - June 2025 treatment administration records (TARs) revealed the following dates and times the TAR was left blank: 01/18/25 for dinner 01/28/25 for dinner 01/30/25 for dinner 02/03/25 for dinner 03/29/25 for dinner 04/13/25 for dinner 04/24/25 for dinner 05/03/25 for dinner 06/22/25 for dinner During an interview on 07/07/25 at approximately 12:55 PM, the Director of Nursing (DON) acknowledged the dates and times the TAR had been left blank and agreed that according to professional standards of practice the lack of documentation should be interpreted as the task not being done.

Based on observation, record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Contact precautions were not followed for a resident with shingles. This was a random opportunity for discovery. Resident Identifier: #46. Facility census: 84. Findings included: a) Resident #46 The facility's policy titled Transmission-based (Isolation) Precautions, with no implementation date or revision date given, stated for Herpes zoster (shingles), airborne precautions would be followed for disseminated disease, contact precautions would be followed for immunocompromised residents, and standard precautions would be followed for localized disease. The policy further stated for contact isolation the following personal protective equipment (PPE) would be utilized: - Gloves would be worn whenever touching the resident's intact skin or surfaces and articles near the resident. Gloves were to be donned upon entry into the room. - Gowns would be worn whenever anticipating that clothing would have direct contact with the resident or potentially contaminated surfaces or equipment near the resident. Gowns were to be donned upon entry into the room. On 07/01/25 at 12:48 PM, Nurse Aide (NA) #90 was observed taking a lunch tray into Resident #46's room. NA #90 had on gloves but no gown. Resident #46's room door had a Contact Precautions sign on room to his door. The sign stated as follows: Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gowns before room entry. Discard gown before room exit. An Enhanced Barrier Precautions sign was also on the wall next to his room. The sign stated as follows: Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing Bathing/showering Transferring Changing linens Providing hygiene Changing briefs or assisting with toileting Device care or use: Central line, urinary catheter, feeding tube, tracheostomy Wound care: any skin opening requiring a dressing After she left Resident #46's room, NA #90 was asked what type of isolation precautions the resident required. NA #90 stated, I saw that up there (indicating the contact precautions sign) but I didn't see any (PPE) so I thought maybe I only had to wear gloves. PPE was in a caddy on the wall between Resident #46's room and the room next door. On 07/01/25 at 12:51 PM, NA #90 was observed sitting in a chair beside Resident #46, who was in his bed. NA #90 did not have on a gown. The surveyor brought this to the attention to the Director of Nursing, who also observed NA #90 sitting in the chair beside the resident's bed. Review of Resident #46's physician's orders showed the resident had been receiving the medication Valtrex for shingles since 06/30/25. The resident did not have an order for Contact Precautions. The resident did have an order written on 11/11/24 for Enhanced Barrier Precautions due to methicillin-resistant staphylococcus aureus. There was no evidence the resident was immunocompromised. Resident #46's comprehensive care plan showed the following focus written on 06/30/25, Contact Precautions related to shingles. An intervention was to wear gloves and gown when entering the room and remove before exit. On 07/01/25 at 2:11 PM, the Director of Nursing confirmed Resident #46 was on contact precautions due to shingles. The DON stated the resident's shingles lesions have dried and contact precautions would probably be discontinued soon. The DON agreed staff should follow contact precautions for residents with contact precaution signage at their room entrance. A physician's order for the resident to have contact precautions was written on 07/01/25. On 07/02/25 at 10:00 AM, Resident #46's lesions were assessed with Registered Nurse (RN) #40. The resident's lesions were localized to the resident's right side and trunk. The lesions appeared dry with no drainage or open areas present. On 07/03/25, the resident's order for contact precautions was discontinued. No further information was provided through the completion of the survey process.

Based on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating equipment to Resident #24. This was a random opportunity for discovery. Resident Identifier: #24. Facility census: 84. Findings included: a) Resident #24 Review of Resident #24's physician's orders showed an order written on 06/26/25 for the resident to have a two (2) handled cup with all meals. On 07/02/25 at 1:05 PM, Resident #24 was observed eating lunch in her room. She did not have a two (2) handled cup. Her beverage was in a cup with no handles. The resident's tray ticket stated she was to have a two (2) handled cup. Registered Nurse (RN) #9 confirmed Resident #24 did not have a two (2) handled cup with her tray. She stated she would obtain one for the resident. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure residents did not receive foods they were allergic to. This was true for one (1) of three (3) residents reviewed for food allergies. This was found to be an issue of past non-compliance that began on 12/13/24 and ended on 12/19/24. Resident Identifier: #189. Facility census: 84. Findings included: a) Resident #189 On 12/20/24, Resident #189 reported to the Office of Health Facility Licensure and Certification (OHFLAC) that she had been served cranberry juice despite being allergic to cranberries. Review of Resident #189's electronic health records showed she had allergies to cranberry fruit extract and cranberry juice. A progress note written on 12/13/24 stated, Resident was given cranapple juice on accident by CNA [Certified Nursing Assistant]. Resident drank the entire cup and then realized it was indeed cranberry juice. Resident given rescue inhaler and benadryl per nurse pract [practitioner]. Will continue to monitor resident. Resident #189 was monitored and experienced no adverse reactions. Two (2) current residents with food allergies, Residents #34 and #32, were interviewed on 07/02/24 at approximately 10:00 AM. These residents denied receiving foods to which they were allergic. On 07/02/25 at approximately 12:00 PM, Nursing Assistant (NA) #91 was interviewed as she was passing drinks to the residents. She stated there was a list of residents with allergies located in the pantry. She also stated when the kitchen prepared the drink cart, if there were residents with allergies to anything that could be on the drink cart, the kitchen would put that information on a Post-It note on the cart. NA #91 stated there were no such residents in this hallway at this time. On 07/02/25 at approximately 12:10 PM, Nursing Assistant (NA) #29 was interviewed as she was passing drinks to the residents in another hallway. She also stated there was a list of residents with allergies located in the pantry. She also stated when the kitchen prepared the drink cart, if there were residents with allergies to anything that could be on the drink cart, the kitchen would put that information on a Post-It note on the cart. She demonstrated that there were two (2) such notes on the cart. One note indicated Resident #12 was allergic to milk and one note indicated Resident #36 was allergic to apple juice. The residents were identified by their room and bed numbers. On 07/02/25 at 2:17 PM, the Director of Nursing (DON) was interviewed about Resident #189 receiving cranberry juice. The DON stated after this event, staff education was immediately started on 12/13/24. The DON also stated the incident was discussed by the Quality Assurance and Performance Improvement committee. The education was as follows: - When serving drinks, always ask the residents what they want. This will not only give them satisfaction of being able to choose but will also held avoid allergies. - The dietary department will place a Drink Allergy List (as they occur) on the drink cart for staff to refer to. - If a resident requests a drink that the list says they are allergic to, remind them it is on the allergy list and notify the nurse of their request. Do not give them a drink that is on their allergy list. - Always check allergies before providing care, this includes medications, foods/fluids, and products used for care. - If a resident consumes or uses a substance, they are allergic to the nurse needs to perform an immediate assessment and notify the provider. An accompanying in-service sign-in sheet confirmed all staff had been educated. On 07/08/25 at 2:00 PM, the Staff Development Coordinator confirmed education for staff had been completed on 12/19/25. No further information was provided through the completion of the survey process.

b) Resident #12 The facility's policy titled Resident Self-Administration of Medication, with implementation date 02/01/24 and revision date 02/14/24 stated as follows: - A resident may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. The results of the assessment by the IDT would be recorded on the Medication Self-Administration Assessment Form. - Medications for self-administration must be stored in a manner that prevents access by other residents. - Nurses and Aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. On 07/02/25 at 7:52 AM, medication administration to Resident #12 by Registered Nurse (RN) #9 was observed. The resident was noted to have a bottle of calcium carbonate stored in a clear plastic set of drawers by her bedside. The resident stated she had been having nausea and her daughter brought the bottle of calcium carbonate for her. RN #9 asked the resident for permission to take the medication away from her bedside and the resident consented. RN #9 reported the incident to RN #40, who stated she would give the bottle of medication to the resident's daughter and ask the physician to order medication for Resident #12's nausea. No Medication Self-Administration Assessment Form was found in Resident #12's medical records. On 07/07/25 at approximately 2:00 PM, the Administrator stated he did not think Resident #12 had been assessed for medication self-administration. He stated he would provide the medication self-administration form for Resident #12 if an assessment had been performed. No further information was provided through the completion of the survey process. Based on observation an staff interview the faiclity failed to ensure the resident enviroment over which it had control was as free from accident hazards as possible. This was a random opputunity for discovery and had the potential to effect more than a limited numbr of residents. Resident Identifiers: #2 and #12. Facility Census: 84. Findings included: A) Resident #2 On 07/01/25 at 9:51 AM, during a visit to this Resident's room, surveyor observed two disposable razors sitting on top of the air conditioner, and one disposable razor on the sink laying behind the water faucet. Resident was in a private room, with the door open. According to the Resident's MDS assessment, dated 05/23/25, the Resident is dependent on staff to provide personal hygiene, and showers. The Resident has a diagnosis of major depressive disorder and is on an anti-depressant medication. On 07/01/25, at 10:25 AM, during an interview with DON, surveyor requested the DON to accompany her to the Resident's room. Surveyor pointed out the razors, and asked what the facility policy was on having sharps in residents' rooms. The DON stated they are not to be left in the Residents' room, and then picked the disposable razors up and removed them.

Based on record review and staff interview, the facility failed to ensure Activities of Daily Living (ADL) care was provided to dependent residents. One (1) of two (2) residents reviewed for the care area of Activities of Daily Living had not received twice weekly showers. Resident Identifier: #74. Facility Census: 84. a) Resident #74 Review of the facility's shower schedule showed Resident #74 was to receive showers on Mondays and Thursdays. Review of Resident #74's bathing task reports for May 2025 showed the resident had received a shower on 05/19/25, a full body bed bath on 05/19/25, and partial baths on the remaining Mondays and Thursdays of the month. Review of Resident #74's bathing task reports for June 2025 showed the resident had received showers on 06/19/25, 06/23/25, 06/26/25, and 06/30/25, a full body bed bath on 06/16/25, and partial baths on the remaining Mondays and Thursdays of the month. The resident was non-interviewable and dependent on staff for activities of daily living care. On 07/07/25 at approximately 11:00 AM, the Director of Nursing (DON) stated the task report documentation may have been incorrect. The DON stated Nurse Aides also complete handwritten shower sheets for bathing activities. The handwritten shower sheets were provided and showed the resident had received showers on 05/07/25, 05/14/25, 05/19/25, 05/26/25, and 06/29/25. The shower sheets also showed the resident had received a bed bath on 05/01/25. The shower sheet confirmed the resident had received bed baths on 05/08/25, 05/12/25, and 05/15/25. However, the handwritten shower sheets showed the resident received a bed bath on 05/22/25 instead of the shower indicated on the task report. The handwritten shower sheets also showed the resident had received showers on 06/05/25 and 06/14/25. The handwritten shower sheets confirmed the other showers and bed baths for June 2025 documented on the task report. The combination of task report and shower sheet documentation showed Resident #74 had not received showers from 05/08/25 through 05/13/25, which was a six (6) day period. The combination of task report and shower sheet documentation showed Resident #74 had not received showers from 06/06/25 through 06/13/25, which was an eight (8) day period. The above findings were discussed with the Director of Nursing on 07/07/25 at approximately 3:00 PM. No further information or documentation was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure a complete and accurate care plan in the area of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #51. Facility census: 84. Findings included: a) Resident #51 Review of Resident #51's physician orders showed an order written on 05/02/25 for Remeron oral tablet (Mirtazapine), give 7.5 mg [milligrams] by mouth one (1) time a day for appetite stimulant. Review of Resident #51's comprehensive care plan showed the following focus, The resident uses antidepressant medication (Remeron) r/t [related to] Depression. The focus was initiated on 05/02/25. Interventions were as follows: - Administer antidepressant medications as ordered by physician. Observe for side effects and effectiveness. - Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs. - Encourage to express feelings during interactions and observe for non verbal signs of depression, report and document if noted, notify MD [physician] if concerned, refer to psych as needed. - Monitor/document/report PRN [as needed] adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea and vomiting], dry mouth, dry eyes Review of Resident #51's diagnoses did not show a diagnosis of depression. A Dietician Comprehensive Nutritional Evaluation performed on 06/12/25 documented the resident had 11.3% weight loss within the last 180 days and Remeron had been initiated the previous month to support increased appetite. On 07/07/25 at approximately 11:00 AM, the Director of Nursing confirmed Resident #51's comprehensive care plan was incorrect and should have indicated the resident was receiving the medication Remeron for appetite stimulation and not depression. No further information was provided through the completion of the survey process.

Based on observation, U.S. Pharmacopeia, and staff interview, the facility failed to ensure all medical supplies in the medication storage room were stored in accordance with manufacturers recommended standards. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 80 Findings included: a) Inspection of Medication Storage Room East on 07/31/24 at 11:02 AM, accompanied by Registered Nurse (RN) #69. Observation of the medication storage refrigerator log revealed that the PM refrigerator for 07/30/24 had not been recorded. RN # 69 confirmed that the temperature had not been logged. b) Inspection of Medication Storage Room West, on 07/31/24 at 11:14 AM, accompanied by Licensed Practical Nurse (LPN) #40. LPN stated that this medication room was not used for storage of anything other than supplies and IV solutions. The medication room thermometer revealed a temperature of 80 degrees Fahrenheit. LPN #40 confirmed that the temperature of the room was at 80 degrees Fahrenheit. Review of the medication room temperature log revealed that the medication room temperature fluctuated between 80 to 82 degrees Fahrenheit. Inspection of the medications stored in the medication cart revealed ten (12) bags of 0.9% Normal Saline (1000) milliliters, and 8 (eight) bags of Metronidazole Injection, USP 500mg/100 mL (5mg/mL). A review of the manufacturers storage temperature recommendation revealed that these IV medications were required to be stored at 20 - 25 degrees Centigrade (60 to 77 degrees Fahrenheit). U. S. Pharmacopeia (USP) Chapter 1079 provides guidance concerning storage, distribution, and shipping of pharmacopeial preparations. It states that there is great risk associated with medication being compromised by exposure to temperatures beyond the safe temperature range determined by the manufacturer. The loss of efficacy can result in many issues compromising the health of the patient. The chapter further explains the temperature ranges for drugs stored at the following requirements: Room Temperature Storage: 20 C - 25 C Cool Storage: 8 C - 15 C Refrigerator Storage: 2 C - 8 C Freezer Storage: -25 C - 10 C

49751 Based on record review and staff interviews the facility failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASSR). This was found true for two (2) of five(5) residents reviewed during the long term care survey process. Facility Census: 80 Resident identifiers: #22, and #26. Findings included: a) Resident #22 Record review on 07/30/24 for Resident #22 found the PASSR completed on 11/04/16 to have coded diagnosis of Cerebral infarction, Hemiplefie, adjustment disorder with disturbance, and cognitive communication deficit and ataxic gate. further record review found Resident #22 also has Major depressive disorder that was diagnosed on [DATE]. On 7/30/24 at 12:30 PM the Director of Nursing (DON) confirmed the diagnoses of Major Depressive disorder should have been identified on the PASSR. b) Resident #26 Record review for resident #26 and found the PASSR completed on 02/13/24 contained diagnosis of Schizophrenic disorder, and affective bipolar disorder. further record review found Resident #26 also has Major depressive disorder that was diagnosed on [DATE]. On 7/30/24 at 12:30 PM the Director of Nursing (DON) confirmed the diagnoses of Major Depressive disorder should have been identified on the PASSR.

Based on staff interview and record review the facility failed to complete a comprehensive assessment for mood and behavior. This was true for six (6) of 25 residents reviewed during the Long-Term Survey Process. Resident identifiers: #44, #47, #34, #71, #4 and #54. Facility Census: 80. Findings Included: a) Resident #44 On 07/31/24 during record review of Resident #44 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/19/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. During an Interview on 07/31/24 at 1:55 PM the Cooperate Nurse verified the section C and D was not completed for Resident #44s 06/19/24 MDS assessment. b) Resident #47 On 07/31/24 during record review of Resident #47 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/30/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. During an Interview on 07/31/24 at 1:55 PM the Cooperate Nurse verified the section C and D was not completed for Resident #47s 06/30/24 MDS assessment. c) Resident # 34 On 07/31/24 during record review of Resident #34 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/18/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. During an Interview on 07/31/24 at 1:55 PM the Cooperate Nurse verified the section C and D was not completed for Resident #34s 06/18/24 MDS assessment. 45173 e) Resident #4 On 07/31/24 at 2:15 PM, a record review was completed for Resident #4. The review found the MDS dated [DATE] was incomplete. Section C entitled, Cognitive Patterns had no information regarding the BIMS, without this score the status of cognition is unknown. On 07/31/24 at approximately 3:00 PM, the Corporate Nurse was interviewed regarding section C. The Corporate Nurse stated, the MDS assessments are done remotely and maybe that is why it is incomplete. f) Resident #54 On 07/31/24 at 2:25 PM, a record review was completed for Resident #54. The review found the MDS dated [DATE] was incomplete. Section C entitled, Cognitive Patterns had no information regarding the BIMS, without this score the status of cognition is unknown. On 07/31/24 at approximately 3:00 PM, the Corporate Nurse was interviewed regarding Section C. The Corporate Nurse stated, the MDS assessments are done remotely and maybe that is why it is incomplete. 49465 d) Resident #71 A record review on 07/30/24 at 2:35 PM, revealed that Resident #71 Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/17/24 section C{cognitive pattern} and Section D {mood} was not filled out for the quarter and had no Brief interview for mental status (BIMS) Further record review of Physicians Determination of Capacity shows that Resident #71 had capacity. During an interview on 07/31/24 at 1:59 PM, the Corporate Nurse (CN) stated, I don't have an answer. Let me see what I can find out. The CN later confirmed that Resident #71 was not assessed properly.

Based on observation, policy review and staff interview the facility failed to provide a clean comfortable home like environment. These practices were found in more than a limited area of the facility. residents reviewed for environment during the Long-Term Care Survey Process. Sixteen (16) resident rooms had a black substance on the heating/cooling unit. Windowsills and doorjambs were covered in a black substance. The resident's bathroom was not maintained in a sanitray conditin. Room Numbers: #99, #100, #101, #102, #103, #104, #105, #107, #131, #132, #133, #134, #136, #138, #109, #110. Resident identifiers: #43, #75, #32, and #69. Facility census: 80. Facility census: 80. Findings included: a) Resident #32 The initial observation, on 07/30/24 at 1:00 PM, of Resident #32's room revealed a double door that went out into the courtyard. The entire door jamb of the door was covered with buildup of a black substance. The black substance was also found to be around the receptacle and the air conditioning unit. Further observation revealed dry hard food products and dust webs under the wardrobe. During an interview on 08/01/24 at 9:42 AM, The Housekeeping Supervisor (HS), went to the room with the surveyor to look at the substance. HS stated, Oh, yes that is a lot of buildup. We will work on it. A policy review on read as follows: Subject 5- step daily patient room cleaning 4. All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur. A review of the Housekeeping cleaning schedule shows that Resident #32's room was to be cleaned daily using the 5-step daily patient room cleaning. b) Resident #69 During the initial observation on 07/30/24 at 1:00 PM of Resident #69's room revealed three big windows that joined together. The windowsill was covered in a black substance that appeared dry in some spots and wet in others. During an interview, on 08/01/24 at 9:42 AM, The Housekeeping Supervisor (HS), went to the room with the surveyor to look at the substance. HS stated, Oh, yes that is a lot of buildup. We will work on it. A policy review on 08/01/24 at 10:30 AM reads as follows: Subject 5- step daily patient room cleaning 2. As you enter the room, work clockwise around the room hitting all surfaces. Table tops, headboards, window sills, and chairs should all be done. A review of the Housekeeping cleaning schedule revealed that Resident #69's room was supposed to be cleaned daily using the 5-step daily patient room cleaning. c) Rooms Observation during the morning on 07/30/24 of room [ROOM NUMBER], #100, #101, #102, #103, #104, #105, #107, #131, #132, #133, #134, #136, #138, #109, #110 found a black spotted substance on the heating and cooling units (P-Tac) On 07/30/24 at around 11:00 AM, the Maintenance Director also confirmed the presence of debris in the heating and cooling unit. He stated that cover / vents would be clear of debris and the black substance today. 50795 d) Resident #43 At approximately 12:22 PM on 07/30/24, an interview was conducted with Resident #43 concerning the care they received at the facility. With the permission of the resident, inspection of the resident's restroom revealed a bed pan in a plastic bag that was suspended from a grab bar in the restroom. The suspended bed pan was dangling in the trash can. The trash can was piled high with trash, and the bedpan was almost covered in trash. Further inspection revealed a band of black grime at the base of the commode, where the commode met the floor. Upon being brought to the attention of Registered Nurse (RN) #78, she confirmed that the bed pan wasn't supposed to be in the trash can. e) Resident #75 During an interview on 07/03/24 at 1:22 PM, Resident #75 stated that the faucet at her hand-sink did not work well. Turning on the hot water revealed a very low flow into the sink. Maintenance Director (MD) #62 confirmed that the water flow was inadequate and proceeded to work on it and replace the aerator in the faucet. The water flow was strong after the repair. Inspection of the resident's restroom revealed a band of black grime at the base of the commode. Further inspection also revealed the bucket of the bedside commode in the shower area. The bucket was observed with dried residue coating its base. LPN #40 confirmed that the bucket had not been cleaned and should not be in the shower area. She further stated that she thought the housekeeping staff were responsible for cleaning the restroom.

Based on record review and staff interview, the facility failed to revise a care plan for one (1) of 24 residents. Resident #53 regarding the cardiopulmonary (CPR) status. Resident Identifiers: #53. Facility Census: 80. Findings Include: a) Resident #53 On [DATE] at 11:40 AM, a record review was completed for Resident #53. The review found a focus area of I choose to have CPR. An intervention was listed as I prefer to be left alone with my family. On [DATE] at 11:55 AM, the Director of Nursing (DON) was notified. The DON stated, I don't know why this intervention is under this focus area .we will get it corrected. 50795

Based on record review, and staff interview, the facility failed to ensure a Resident had a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (24) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #44. Facility census: 80. Findings included: a) Resident #44 A review of the current Diagnosis List showed the diagnosis of Schizophrenia. A continued review revealed the current care plan did not contain a diagnosis of Schizophrenia or monitoring. On 07/31/24 at 2:06 PM during an Interview with the Director of Nursing (DON), she confirmed the current care plan did not reflect the resident's need.

Based on staff interview and record review the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for Resident #20 when the original PASARR had expired. This failed practice was found true for (1) one of (5) five residents reviewed for PASARR during the Long-Term Care Survey Process. Resident identifier: #20. Facility census: 80. Findings included: a) Resident #20 A record review on [DATE] at 2:51 PM, revealed that Resident #20 was admitted to the facility on [DATE] and had a PASARR completed on [DATE]. Further record review showed that Resident #20's PASARR was marked for 3 months or less. During an interview on [DATE] at 3:20 PM, The Director of Nursing (DON) stated, We do know we have a problem with PASARR'S. I just started an audit on them. DON confirmed that the PASARR for Resident #20 had expired.

Based on record review and staff interview, the facility failed to transmit residents assessments for a discharge. This failed practice was found true for one (1) of two (2) residents reviewed under the Facility Tasks during the Long Term Care Survey and hat the potential to affect a limited number of residents residing in the facility. Facility census:80. Resident Identifier: #45 Findings included: a) Resident #45 On 07/31/24 at approximately 11:20 AM record review of Resident #45's The Minimum Data Set (MDS) { standardized assessment tool that measures health status in nursing home residents} reveaeld on 03/27/24 a discharge MDS was completed, and not transmitted/accepted. During staff interview on 07/31/24 at approximately 1:00 PM the Director of Nursing confirmed the discharge MDS should have been transmitted within 14 days after a facility completes a resident's assessment.

Based on observation, staff interview, and record review, the facility neglected to provide care consistent with standards of practice for Resident # 40. Facility staff neglected to provide care consistent with standards of practice for the procedure for lifting and transferring a resident, after the resident rolled out of bed. This had the potential to cause physical harm, pain, mental anguish, and/or emotional distress which resulted in neglect for Resident #40. This was a random opportunity for discovery. Resident identifier: #40. Facility census: 67. The facility was notified of the IJ (Immediate Jeopardy) at 6:00 PM on 11/02/21. The facility submitted their initial abatement plan of correction (POC) at 7:44 PM on 11/02/21 and was forwarded to the State Office for review. The State Office requested revision and the POC was approved at 8:43 PM on 11/02/21. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 2:51 PM on 11/03/21. The IJ started on 11/02/21 at 6:00 PM and ended on 11/03/21 at 2:51 PM. The facility's approved abatement POC consisted of the following: Action steps to be completed by the nursing home to remove the allegation of Immediate Jeopardy: 1. Immediate reporting of allegation by Resident #40 that she was thrown into bed and that staff was tired of picking (her) up off the floor. 2. Interview all residents to identify all other residents with allegations of abuse. 3. Complete new transfer evaluation / assessment on all residents. 4. Update care plans for all residents based on new transfer evaluations / assessments. 5. Add to PCC (point click care) / POC (plan of care) task list specific information about how each resident is to be transferred, based on each resident's new transfer evaluation / assessment. 6. Educate all direct care nursing staff on location of information regarding how to transfer a resident on the PCC / POC task list. 7. Educate all direct care staff on how to safely transfer a resident found on the floor (e.g., assist to stand if able; use of mechanical lift if not contraindicated by resident's medical condition or not able to position legs of mechanical lift; lift sheet transfer). 8. Items #1 through #7 will be completed by 6:00 p.m. on 11/03/21. 9. Any direct care staff not available to complete training identified at Items #6 and #7 (e.g., PRN {as needed} staff; staff on PTO [paid time off] ) must complete this training prior to returning to the floor. 10. Monitoring activities will include: a) Director of Nursing / designee will audit the medical records of all new admissions / readmissions within 72-hours of admission, to verify completion of transfer evaluation / assessment and verify the resident's 48-hour care plan and Kardex address the manner in which each resident is to be transferred based on that evaluation. b) MDS Nurse / designee will audit the medical records of all existing residents quarterly and upon significant change in condition, to verify completion of transfer evaluation / assessment and verify the comprehensive care plan and Kardex address the manner in which each resident is to be transferred based on that evaluation. c) Staff Development Coordinator / designee will observe 10 direct care staff members weekly x 4 weeks to verify that staff is transferring residents in accordance with their care plan and Kardex. d) Director of Nursing / designee will audit the medical records of all residents after each fall/found on floor event, to verify that staff used correct method for transferring resident off floor safely, based on resident's medical condition. e) Social Services Manager / designee will interview all residents within 72-hours of admission, quarterly thereafter, and as needed to identify and address allegations of abuse / neglect. f) The QAPI Committee will review the effectiveness of the above activities monthly x 3 months, then quarterly thereafter and implement additional corrective actions as needed. All corrective action involving Resident #40 will be completed by 8:00 PM on 11/02/21, which includes completion of new transfer evaluation/transport, revised care plan, addition to transfer info in POC task list, resident education of all direct care staff who are correctly in the facility on how to safely transfer a resident found on the floor. Once the IJ was abated on 11/02/2021 at 8:00 PM, the deficient practice remained and the scope and severity (S/S) was decreased from a J to an E. A deficient practice remained for Resident # 40. The facility's failure to appropriately transfer/lift Resident #40 created an immediate jeopardy situation. This failure created a situation where the resident was at risk of serious injury and harm, such as a dislocation of shoulder joints, fracture to wrists, arms, ankles, legs, injury to the back, or dropping the resident. In addition, the facility failed to have Resident #40's record adequately identify his/her transfer needs for staff. Interviews revealed staff were not aware of the appropriate transfer method or the number of staff needed to transfer or lift Resident #40. Findings included: a) Resident #40 On 11/02/21 at 11:30 AM, this surveyor was walking down the hall with the Director Of Nursing (DON) when Resident #40 was heard shouting, help, help. When this surveyor and the DON entered room [ROOM NUMBER], Resident #40 was found with her left shoulder resting on a mattress in the floor on the left side of the bed. The Residents legs and hips remained on the bed. (The Resident has a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was written on 09/23/21, after the resident had episodes of rolling out of the bed.) The DON asked this surveyor to go and get a nurse at the nurse's station. This surveyor returned to the Resident's room with Registered Nurse (RN) #45 who was located at the nurse's station. Upon return to room [ROOM NUMBER], this surveyor found the DON and (Licensed Practical Nurse) LPN #26 in the room. Resident #40 was lowered to where her full body was resting on the mattress on the floor by RN #45 and LPN #26. RN #45 grasped the resident by both wrists with her hands and LPN #26 grasped the Resident by the ankles with her hands then attempted to place the resident back in the bed. This position placed all of Resident #40's weight on her upper and lower extremities. When RN # 45 and LPN #26 were unable to place Resident #40 in bed in this manner, the DON intervened and placed one hand under Resident #40's legs and her other hand under the small of the Resident's back to assist Resident #40 back in bed. On 11/02/21 at 12:30 PM, in an interview with the DON, when asked about Resident #40 and how should a Resident be lifted from the floor, the DON asked, should we have gotten a lift? In addition, the DON said, I saw RN #45 struggling, so I stepped in to help. Resident #40 was admitted to the facility on [DATE]. Primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident is currently receiving Hospice services at the facility which started on 09/24/21. On 10/03/21 the Resident was ordered [MEDICATION(S)] 5-325 mg every 6 (six) hours as needed for pain. Resident #40 has received [MEDICATION(S)] daily since 10/28/21. Review of the current care plan revised on 08/18/21 found a focus/problems: Resident has an ADL (activities of daily living) self-care performance deficit related to cerebral ischemia, dementia, [CONDITION(S)], kyphosis, bowel, and bladder incontinence. Interventions included: The Resident requires assistance by staff and a gait belt to move between surfaces. At times resident requires more assistance from staff. Staff to assist as needed. Resident receives antidepressant medication ([MEDICATION(S)]) related to depression due to end of life. Resident has a behavior problem related to calling out, restlessness, and anxiety. Interventions included: Explain all procedures before starting and allow the resident time to adjust to changes. Resident has chronic pain related to spondylopathy (disease or disorder of the vertebrae) and kyphosis (curvature of the spine.) A review of the care plan revised on 11/02/21 found the Resident has ADL interventions/task for transfer that reads the resident requires mechanical lift with assist of 2 (two) for transfers. A review of an incident report dated 11/02/21 at 1:17 PM reads a nursing description as follows Resident rolled from her bed in lowest position to the mattress in the floor on the left side of the bed. Resident assess for injury, denies pain, no apparent injury noted. Resident returned to bed via 3 (three) nurses and positioned in bed. RP (responsible party) notified of of incident. Resident description reads as follows Resident said she was trying to reach the roommates television to turn it off. On 11/02/21 at 3:25 PM, RN #45 was asked, how does staff know how to transfer this resident? RN #45 stated, based on the care plan it will tell you how many people you need to lift or transfer. Assistance with 2 and a gait belt is on care plan but the Resident may need additional assistance if staff doesn't feel comfortable they can use lift Resident #40 depending on the situation. When asked how would a nursing assistant know how to transfer this resident? RN #45 stated, nurses do transfer assessments or they can go to orders or therapy orders regarding transfers. The orders/care plan reflect the use of a gait belt and two staff. This would be an appropriate transfer from surface because she can pivot with a gait belt. If the resident is laying on a mattress and staff are trying to get her up, what would be the correct procedure? RN #45 stated there is, no protocol to follow - nursing judgement. On 11/02/21 at 4:00 PM, NA #35 was asked, how do you know how to transfer residents? NA #35 stated I would talk with a nurse or talk with the resident. On 11/02/21 at 4:10 PM, NA #57 was asked how do you know how to transfer residents? NA # 57 stated I would go to the chart and go to transfer and see how you are to transfer the resident NA # 57 demonstrated how this is done by accessing a Kiosk mounted on the wall in the hallway. In an interview on 11/02/21 at 4:12 PM, when asked about Resident #40's lift from the floor this morning, the Administrator confirmed she had heard about the incident. No additional information was provided at this time. A review of the medical records revealed a Physician Determination of Capacity form, dated 09/12/21, that read Resident # 40 demonstrates incapacity to make medical decisions due to [CONDITION(S)] (cerebral vascular accident). The nature of the incapacity is long term memory deficit and lack of safety awareness. Expected duration of the incapacity was long term. A further review of the medical record reveals a Minimum Data Set (MDS) section C, Brief Interview for Mental Status (BIMS) noting the resident scored a 9. An interpretation of BIMS of 9 (nine) is moderate impairment. On 11/02/2021 at 5:00 PM, in an interview with Residen t#40 when asked how staff assisted her to bed after a fall earlier that day. Resident #40 stated, they pick her up under her shoulders and grab her by her feet and, throw me in bed. When asked if this was painful, Resident #40 stated, sometimes. When asked if she could recall the names of staff who assisted her in this manner were, Resident #40 stated, (2) two overweight nurses on day shift said they are tired of picking me up off the floor all the time. She further stated the comment was not said in a joking manner and, it happens all the time. 11/02/21 in-service for staff reviewed the following information: Information on residents method of transfer can be found under the task list and/or kardex (POC). If a resident is found in the floor, a nurse must assess for injury immediately. If there is no injury and resident cannot stand and transfer out of the floor, you may transfer with mechanical lift. If a mechanical lift is contraindicated, you may transfer via 4 (four) person lift. If a mechanical lift is contraindicated, you may transfer via 4 (four) person lift transfer. Avoid transferring via extremities. A review of facility provided documentation titled, Sava Senior Care Four-person lift sheet transfer Revised: May 21, 2021 states, Maintaining the patient's proper body alignment (back straight, head in a neutral position, and extremities in a functional position) helps reduce the risk of patient injury during transfer. On 11/03/2021 at 11:40 AM, during an interview with the Facility Physician (FP) # 120, when asked what was the proper way to lift a resident from floor to bed? FP #120 stated it was OK to lift under arms and by the legs; however, he stated that each Resident needed an individualized plan. He said he assessed Resident #40 and no injury was found. FP #120 stated that Resident #40 has a pretty good short term memory. The facility's failure to appropriately transfer/lift Resident #40 created an immediate jeopardy situation. This failure created a situation where the resident was at risk of serious injury and harm, such as a dislocation of shoulder joints, fracture to wrists, arms, ankles, legs, injury to the back, or dropping the resident. In addition, the facility failed to have Resident #40's record adequately identify his/her transfer needs for staff. Interviews revealed staff were not aware of the appropriate transfer method or the number of staff needed to transfer or lift Resident #40. No additional information was provided during the survey through the exit conference.

Based on staff interviews, resident interviews, observations, family interviews and medical record reviews the facility failed to ensure their facility assessment reflected the care required by their patient population. The facility was required to consider the types of diseases, physical and cognitive condition and other pertinent facts that were present within their patient population to ensure they had competent staff in the facility to meet the needs of the patient population. Issues were found in the following areas: Notification of changes, quality of care, freedom from neglect and nursing services. Deficient practices found reflected the nursing staff were not competent in the skills necessary to ensure the residents needs were met. Issues were idienfieid with residents with [MEDICAL CONDITION] disorders, acute change in health status, hallucinations and pressure ulcers. These deficient practices had the potential to affect more than an isoalted number of residents. Resident identifiers: #3, #20, #2, #5, and #7. Facility census: 83. Findings included: a) Resident #5 Notification of changes An interview, with Resident #5's Medical Power of Attorney (MPOA), on 10/14/18 at 6:00 PM, revealed Resident #5 had a (computed tompography (CT) scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, X-ray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP 'family nurse practicioner' and MPOA 'medical power of attorney.' New orders given for CT w/o (without) contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF 'out of facility' for CT scan via (name of ambulance company) per stretcher with 2 attendants. Further review of progress notes did not reveal any evidence indicating the MPOA was informed of the results of the CT. The CT scan report dated 08/03/18 did have hand written notes showing the family nurse practicioner was notified and that there was a new order for an orthopedic consult. However, there was no note to reflect the MPOA was notfieid of the CT results. On 10/15/18 at 11:38 AM Licensed Practical Nurse (LPN) #72 and Scheduler #16 looked through the resident's thinned medical record and located the results of the CT. There was no evidence the facility had informed the MPOA of the results. LPN #72 and Scheduler #16 confirmed the facility had no evidence to support they had informed Resident #5's MPOA of the results from the CT. A review of the facility's survey history revealed a complaint survey completed on 08/17/18 resulted in a deficient practice at F580 (notification of changes). Turning and Repositioning A review of Resident #5's treatment sheet revealed an order to turn and reposition the resident every two (2) hours due to increased risk of skin breakdown. Care plan review revealed Resident #5 had been treated for [REDACTED]. The care plan reflected the resident was incontinent of bowel and bladder and moved around in bed by sliding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was totally dependent for bed mobility. Multiple observations on 10/10/18 between 9:00 AM and 1:00 PM revealed Resident #5 was positioned with pressure off his right side. An interview with Nurse Aide (NA) #50 at 1:00 PM on 10/10/18 revealed the nursing staff were supposed to turn/reposition Resident #5 every two (2) hours but sometimes they were not able to do this due to staffing issues. Observations of Resident #5 on 10/10/18 at 1:48 PM revealed Resident #5 was positioned with pressure off his left side. Continued observations between 1:48 PM and 6:00 PM revealed the resident in the same position with pressure off his left side. On 10/10/18 at 6:06 PM an interview with Registered Nurse (RN) #34 the RN said she would fix that when she was told the resident had been on the right side with pressure off the left side for the multiple observations between 1:48 PM and 6:00 PM. During a family interview on 10/14/18 at 6:00 PM Resident #5's family member said the resident had experienced a terrible pressure ulcer while at the facility. An interview with wound care RN #31 on 10/10/18 at 10:47 AM revealed Resident #5's wound was on the coccyx and had originated in (MONTH) (YEAR). The resident was on a wound VAC (vacuum assisted closure) for about eight (8) months. A review of the treatment record for (MONTH) (YEAR) revealed an order dated 07/10/18. The order indicated the resident would be turned every (two) hours, every shift due to an increased risk of skin breakdown. On 10/02/18 there was no documenation showing the resident had been turned on 7:00 AM - 7:00 PM shift. On 10/03/18 there was no documentation showing the resident had been turned every two (2) hours on 7:00 PM -7:00 AM shift. On 10/05/18 there was no documentation the resident had been turned during 7:00 AM -7:00 PM shift. On 10/06/18 there was no documentation the resident had been turned during 7:00 PM -7:00 AM shift. On 10/07/18 there was no documentation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/09/18 there was no documentation to reflect the resident was turned during 7:00 AM-7:00 PM or 7:00 PM-7:00 AM. On 10/13/18 there was no documenation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/14/18 there was no documenation the resident had been turned during 7:00 AM-7:00 PM shift. The resident's care plan reflected a focus area related to the resident's pressure ulcer to the right and left coccyx. The care plan indicated the resident was at risk for further skin breakdown related to imobility, refusal to turn and reposition, incontineince of bowel and bladder. Staff interview and record review as well as observations did not reflect the resident's refusal to be turned/repositioned. b) Resident #3 A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, revealed the [MEDICATION NAME] gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two nursing staff, Licensed Practical Nure (LPN) #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] gel ([MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing Unit, 0n 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] gel was not available. LPN #55 attempted to request the [MEDICATION NAME] gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] gel may have been locked up in the Director of Nursing's office. An interview on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the (name) Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the (name) Pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility had not sent the request for a current order and script to the pharmacy. On 10/10/18, at 2:35 PM, after consultation with the State Agency a determination of Immediate Jeopardy was identified. The facility failed to ensure that emergency medication was provided to a Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 8:44 PM. The facility implemented in services for direct care staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for Intramuscular (IM) [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was available in the emergency cart. On 10/11/18, at 11:55AM, the Administrator Designee and RN #150 brought a prescription container of [MEDICATION NAME] gel to the surveyor. The Administrator Designee, stated that it was not where the Director of Nursing (DoN) had told her to look but after the DoN thought about it, she had us to break the lock to get it. The [MEDICATION NAME] gel produced by the Administrator Designee and RN#150 had an original date of 06/14/17 with a note to discard after 06/15/18. Both the Administrator Designee and RN #150 verified there was no current medication available in the facility to be used in case Resident #3 sustained a [MEDICAL CONDITION] greater than 5 minutes requiring medication to be administered. Further interviews, on 10/16/18, at 10:35 AM with Reigstered Nurse (RN)#110, verified meds are pulled based on discard date and RN#106 added only meds to be destroyed are in the nurse's office (DoN) and that was where the outdated [MEDICATION NAME] was found. Further review of the medical record revealed Resident #3 had documentation of a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. The facility failed to provide [MEDICAL CONDITION] care that documented: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity as noted in Resident #3's care plan. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] gel available for the Resident. The current physician's orders [REDACTED].) A review of the laboratory section of the medical record revealed no documented results for the [MEDICATION NAME] level ordered for (MONTH) (YEAR). An interview, on 10/15/18, at 2:30 PM with LPN #7, revealed no results were received and placed on the medical record. Upon further investigation, LPN #7 stated the lab had not been drawn according to the laboratory book. Additionally, the repeat Ammonia level ordered 08/20/18 was not done. Review of the available labs, revealed Resident #3 had previously had higher levels than normal of [MEDICATION NAME]/[MEDICATION NAME] Acid at level 110 (normal range indicated 50-100 MCG/ML) {microgram/ milliliter} and Ammonia levels at level 40 (normal range indicated as 9.0-33.0 UMOL/L) {micromole per liter}. On 10/16/18, at 6:20 PM, an interview with the Administrator and Social Service Director/Administrator Designee, revealed no knowledge on the deficient practice of the facility failing to provide timely and adequate medical care to Resident #3 who experienced [MEDICAL CONDITION]. The administrator stated, I have no history to provide information on that. The Social Service Director/Administrator Designee added, I am not aware either. c) Resident #7 Resident #7 expressed he was having hallucinations when he was interviewed during the tour on 10/09/18 at 9:58 AM. He stated staff did not listen to him when he had expressed this concern many times. A review of the medical record on 10/10/18 at 10:00 AM revealed Resident #7 was taking an antidepressant medications. One of the interventions listed was to monitor adverse reactions such as hallucinations that could be a side effect. Discussion with Administrator Designee (AD) #51 at 10:35 a.m on 10/10/18 revealed AD #51 was not aware of the resident having hallucinations and that he would be sccheduled to be seen by the physician on a visit next week. A review of a nursing summary report dated 10/01/18 did not show that halluciantions had been identified as a concern to monitor. Review of the care plan, on 10/10//18 and 10/11/18 at 9:30 AM, did not show that hallucination had been identifed as an actual problem which needed to be monitored and treated once it was noted as an adverse reaction. d) Resident #20 Review of records, on 10/10/18 at 10:15 AM, revealed some of Resident#20's [DIAGNOSES REDACTED]. Review of records revealed the resident had a vagal stimulator to be used during [MEDICAL CONDITION] activity. Vagal refers to the vagus nerve the longest nerve in the autonomic nervous system in the human body, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). According to the [MEDICAL CONDITION] Foundation, Vagus nerve stimulation (VNS) prevents [MEDICAL CONDITION] by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a pacemaker for the brain. A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. If a person is aware of when a [MEDICAL CONDITION] happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain. For some people this may help stop [MEDICAL CONDITION]. A magnet is used to activate or deactivate the device. Review of Resident#20's care plan, on 10/10/18 at 10:15 AM, revealed a focus area of impaired Neurological status related to [MEDICAL CONDITION] disorder. Interventions included Give medications as ordered. Observe/document for effectiveness and side effects. Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No shortwave diathermy. The same intervention related to [MEDICAL CONDITION] activity concerning the vagal stimulator is under the focus of risk for falls. The intervention, Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No short-wave Diathermy. Date Initiated: 06/15/17. Review of records for Resident#20, on 10/10/18 at 2:00 PM, revealed an order for [REDACTED]. Review of the medicine administration record (MAR) revealed no [MEDICATION NAME] was given in the month of (MONTH) or (MONTH) (YEAR). The MAR showed in the month of (MONTH) one (1) dose was given on 08/27/18, indicating [MEDICAL CONDITION] activity had occurred. No details concerning the [MEDICAL CONDITION] activity occurring on 08/27/18 was found in the record; no description on how long the [MEDICAL CONDITION] lasted, or if the vagal stimulator was used, or what interventions or precautions were used other than the ordered medication. On 10/10/18 at 2:40 PM, interview with Registered Nurse (RN#105) assigned to care for the resident on 10/10/18, revealed RN#105 was not aware the resident had a vagal stimulator or what a vagal stimulator even was. RN#105 said this was her first day at the facility, that she was from a sister facility and did not know the residents. This surveyor suggested that perhaps another nursing staff that regularly worked at the facility and who was familiar with the resident, show this surveyor and the assigned RN#105 responsible for the care of Resident#20, the resident's vagal stimulator and the appropriate way to use it. Licensed Practical Nurse (LPN#72) showed this surveyor and RN#105 the procedure to use the vagal stimulator if the resident had a [MEDICAL CONDITION]. LPN#72 felt the resident's upper left chest and showed RN#105 the outline of the implanted vagal stimulator, then LPN#72 showed RN#105 the magnet hanging on the back of the resident's wheel chair that is used to operate the vagal stimulator. LPN#72 said there was also a magnet on the cart. LPN#72 said, the resident has been at the facility for ten (10) years and if he is having a [MEDICAL CONDITION], you swipe the magnet over the implanted vagal stimulator one (1) time, and only one (1) time. RN#105 said she had never came across one of those (vagal stimulator) before in her nursing career (RN#105 said she had been a RN since (MONTH) (YEAR), but a LPN for several years). On 10/10/18 at 5:45 PM, review of orders revealed an order dated 03/30/17, If resident has [MEDICAL CONDITION] activity last greater than 3 minutes, then RN to swipe magnet once over VNS Generator. If needed, can repeat after 5 minutes. Avoid swiping magnet immediately after single swipe. Notify physician and RP (representative) of use. Another order dated 3/31/2017 revealed, Device: Keep vagal Stimulator (used during [MEDICAL CONDITION] activity) in plain sight and handy at all times. Use vagal stimulator if he has more than one [MEDICAL CONDITION] in a row by rubbing magnet on left upper chest. No short-wave diathermy, microwave diathermy, therapeutic ultrasound diathermy. Every shift for [MEDICAL CONDITION] On 10/10/18 at 3:37PM, interview with RN#44 Staff Development, revealed when asked for records on all training given to staff concerning a vagal stimulator. RN#44 said, We don't have anyone in the building with a vagal stimulator. RN#44 said she has not done any training on vagal stimulators since she has had the job since the last part of (MONTH) (YEAR). The Staff Development RN#44 said she would look at previous records, prior to her having the position, to see if there ever was any training given concerning [MEDICAL CONDITION] or vagal stimulators. Interview with RN#44 Staff Development, on 10/10/18 at 4:17 PM after RN#44's review of training back through (YEAR), revealed no training on [MEDICAL CONDITION] or vagal stimulators. When asked again if anyone in the facility had a vagal stimulator, RN#44 replied, No one. This surveyor informed RN#44 that Resident#20 had a vagal stimulator. RN#44 left the room and came back a little while later and said, she was the only one that was not aware the resident had a vagal stimulator, that she had spoken to staff and everyone else knew about it and how to use it. When RN#44 was asked what model vagal stimulator the resident had, and how long he had had it, she was unable to say, but said she would try to find out. At the time of exit the facility had not given this surveyor the information on the model of the vagal stimulator or how long Resident #20 had it. On 10/10/18 at 7:35 PM, interview with LPN#47, evening shift nurse assigned to the resident revealed the LPN was not aware Resident #20 had a vagal stimulator or what a vagal stimulator was. When asked what the nurse would do if the resident had a [MEDICAL CONDITION] LPN#47said she would give him his PRN (as needed) medicine for [MEDICAL CONDITION]. When asked what the care plan intervention meant by Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. The LPN did not know, and said she had never seen any device bedside, and was unable to describe what a vagal stimulator was. An interview with Resident Care Specialist, also known as a Nurse Aide (NA) NA#35, on 10/10/18 at 7:40 PM, revealed NA#35 considered the Resident#20 total care. NA#35 said the resident needed a lot of care and he did have [MEDICAL CONDITION]. Upon inspection of the resident's wheel chair with NA#35, this surveyor pointed to the magnet attached to the back of the wheel chair and asked NA#35 what it was. NA#35 replied it was a wheel chair alarm, that a lot of residents had them so that staff would know when they stood up out of their wheel chairs. e) Resident #2 admitted originally on 05/19/18 status [REDACTED]. Resident had capacity. resident had a history of [REDACTED]. Review of records, on 10/09/18 at 11:15 AM, revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) 8/22/18. The resident had adequate hearing and vision, clear speech, can make self-understood and understands. Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 15 indicating the resident was cognitively intact with no impairment. The resident needed extensive assistance with activities of daily living (ADLs), except supervision with meals and is totally dependent for bathing. Pertinent [DIAGNOSES REDACTED]. On 10/09/18 at 1:05 PM review of record revealed a late entry situation background assessment recommendation (SBAR) Change in Status dated 09/22/18 at 4:40 PM. Review of SBAR Summary revealed documented vitals signs (blood pressure, temperature, pulse, and respirations) were taken on 09/19/18. The oxygen saturation noted was taken 09/18/18. Nurses note stated, What I think is going on with the resident is: has received first Cemo for metastisis of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Additional Nursing Notes as applicable: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The hospital requested by family was not the nearest hospital to the facility. The family had to request resident be sent for evaluation. When reviewing the SBAR summary and SBAR no vital signs (VS) were recorded at the time the resident was having a change of condition, accept in a nurse's note a recorded temperature taken one time. The District Director of Clinical Services said the system pulls the last recorded VS into a note when no new VS are entered. Review of the SBAR dated the day Resident #2 was sent to the ED, 09/22/18, showed VS from 09/19/18, and oxygen saturation noted was taken 09/18/18. There were no recorded current VS reflecting the resident's actual status at the time of the change in condition. The instructions included on the SBAR were 1. Evaluate the resident, 2. Check vital signs, 3. Review record, 4. Review and interact care path or acute change in condition file card, and 5. Have relevant information available and reporting. The SBAR noted the situation is a change in condition noted as confusion with change in vials (written as typed) starting on 09/22/18. Stayed the same since change started with no change in symptoms. This condition, symptom, or sign has not occurred before. On the SBAR section 'Other relevant information', it was noted had family in from out of town all morning was laughing and taking pictures. Under section 'B' of the form under number three (3) instructions say (Be sure this is the most current set of vital signs that goes with your evaluation of the resident) The vital signs recorded on the form was actually taken on 09/19/18, the change in condition occurred on 09/22/18. The change in the resident's condition included increased confusion and slurred speech. The RN assessment revealed I think the problem may be has received first Cemo for metastisis (typed as written) of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Nursing Notes for additional information on change of condition: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The physician was notified on 09/22/18 at 12:15 PM. Review of Hospital Emergency Department documentation dated 09/22/18, revealed at the time of the initial examination the resident was only alert to self, was hypotensive, and had elbow pain and swelling. She was treated for [REDACTED]. A chest x-ray was concerning for pneumonia. She did respond to IV fluid hydration and was no longer hypotensive. The resident required hospitalization for IV antibiotics. The resident's blood pressure was significantly lower than usual and she was hypotensive with a systolic of 70's. According to the family this afternoon she began having decreased alertness and became slightly altered. Throughout the evening she continued to become more altered and less responsive. The family noticed the residents left elbow was significantly more swollen and tender. (The resident had a [MEDICAL CONDITION] arm earlier in the month) On 10/16/18 at 12:55 PM, review of hospital discharge summary dated 09/29/18, revealed Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The admitting [DIAGNOSES REDACTED]. Primary discharge [DIAGNOSES REDACTED]. Notations in the hospital records revealed, . The family notice that the wound appeared to be red and somewhat tender, and in addition notice that she had mental status changes today.and family asked that she be transferred for further evaluation The patient was initially hypotensive (low blood pressure) on arrival with elevated temperature, . On 10/16/18 at 3:11 PM, interview with Director of Legal Operations, the District Director of Clinical Services, Administrator, and interim Assistant Director of Nursing (ADON), revealed the SBAR was the documentation concerning what led up to sending Resident to the Emergency Department for evaluation. The Director of Legal Operations said the family was the ones that requested the resident be sent, and asked this surveyor if she had read the SBAR. This surveyor confirmed the SBAR dated 09/22/18 had been reviewed. The Director of Legal Operations said, The resident had been laughing earlier with the family, it was the family that requested the resident be sent. This surveyor said, Yes, the family did request the resident be sent, but don't you think nursing staff should have assessed and intervened without the family having to make the request, considering the condition the resident was in when she arrived at the hospital? No reply was made to the surveyor's question. After a pause, the Director of Legal Operations asked, Have you seen the hospital record? This surveyor replied, Yes, I have them. After another pause, the Director of Legal Operations said, I just wanted to know in case you wanted me to get them for you. f) Interviews On 10/16/18 at 6:30 PM the District Direct of Quality Services said the facility had identified [MEDICAL CONDITION] disorders as part of the population they cared for. The District Director of Quality Services had no further comment on how the facility had used their assessment to ensure their staff recieved training pertinent to ensuring residents with [MEDICAL CONDITION] disorders, mental health care issues, acute changes in medical condition and pressure ulcer wounds received the assessment, monitoring, care and services needed to improve and/or maintain their highest physical, mental and psychosocial well being.

Based on record review, staff interview, pharmacy interview, and observation, the facility failed to ensure that one (1) of 25 sampled residents was free of any significant medication errors. The facility failed to administer emergency [MEDICAL CONDITION] medication to a resident during a [MEDICAL CONDITION]. On 10/10/18, at 2:35 PM, after consultation with the State Agency, a determination of Immediate Jeopardy was identified at Riverside Health and Rehab Center. The facility failed to ensure that emergency medication was provided to Resident #3 in accordance with physician's orders [REDACTED]. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, noted the [MEDICATION NAME] Gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two nursing staff, LPN #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] Gel ( [MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing Unit, 0n 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] Gel was not available. LPN #55 attempted to request the [MEDICATION NAME] Gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] Gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] Gel may have been locked up in the Director of Nursing's office. An interview on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the (name) Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] Gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the contracted pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility has not sent the request for a current order and script to the pharmacy. Further review of the medical record revealed Resident #3 had a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] Gel available for the Resident and had not been available to administer. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 08:44 PM. The facility implemented in services for direct car staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for IM [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was readily available in the Emergency cart. After the removal of the immediate jeopardy, a deficient practice remained for this requirement of failing to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Resident identifiers: Resident identifier: #3. Facility census: 83. Findings included: a) Resident #3 A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, revealed the [MEDICATION NAME] gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two (2) nursing staff, Licesned Practical Nurse (LPN) #105 and LPN #55, at this time, verified the medication was not documented on the medication administration record (MAR) and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] gel ( [MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing Unit, 0n 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] gel was not available. LPN #55 attempted to request the [MEDICATION NAME] gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] gel may have been locked up in the Director of Nursing's office. An interview on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the (name) Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the (name) Pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility has not sent the request for a current order and script to the pharmacy. On 10/11/18, at 11:55AM, the Administrator Designee and RN#150 brought a prescription container of [MEDICATION NAME] gel to the surveyor. The Administrator Designee, stated that it was not where the Director of Nursing had told her to look but after she thought about it, she had us to break the lock to get it. The [MEDICATION NAME] gel produced by the Administrator Designee and Registered Nurse (RN) #150 had a date an original date of 06/14/17 with a Discard After 06/15/18. Both the Administrator Designee and RN #150 verified there was no current medication available in the facility to be used in case Resident #3 sustained a [MEDICAL CONDITION] greater than 5 minutes requiring medication to be administered. Further interviews, on 10/16/18, at 10:35 AM with RN#110 verified meds are pulled based on discard date and RN#106 added only meds to be destroyed are in the nurse's office (DON) and there is where the outdated [MEDICATION NAME] was found. Further review of the medical record revealed Resident #3 had documentation of a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. The facility failed to provide [MEDICAL CONDITION] care that documented: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity as noted in Resident #3s care plan. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] Gel available for the Resident #3 and during a time with the medicaiton was not available.

Based on record review, staff interview, resident interview, pharmacy interview and observation, the facility failed to ensure all treatment and care provided to nine (9) or 25 sampled facility residents and one (1) randomly sampled resident was in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to perform finger stick blood glucose monitoring and give sliding scale insulin if needed as directed by the physician for Resident #4. The facility failed to administer medications in accordance with physician's orders [REDACTED]. The facility failed to follow-up on known side effects of hallucinations of a medication for Resident #7. The facility failed to obtain an order for [REDACTED].#1 and Resident #8. The facility failed to follow a bowel protocol for Resident #42. The facility failed to provide turning and positioning for Resident #5 who was dependent for turning and repositioning and had developed a pressure ulcer. The facility failed to ensure they assessed and monitored Resident #2 when the resident experienced a change of condition. On 10/10/18, at 2:35 PM, after consultation with the State Agency a determination of Immediate Jeopardy was identified at the facility. The facility failed to ensure that emergency medication ([MEDICATION NAME] Gel) was provided to a Resident #3 in accordance with physician's orders [REDACTED]. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, revealed the [MEDICATION NAME] gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two nursing staff, LPN #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] Gel ( [MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing Unit, 0n 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] gel was not available. LPN #55 attempted to request the [MEDICATION NAME] Gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] gel may have been locked up in the Director of Nursing's office. An interview on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the (NAME) Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the contracted pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility has not sent the request for a current order and script to the pharmacy. Further review of the medical record revealed Resident #3 had a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. The facility failed to provide [MEDICAL CONDITION] care that documented: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity as noted in Resident #3s care plan. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] gel available for the Resident and had not been available. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 08:44 PM. The facility implemented in services for direct car staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for IM [MEDICATION NAME] was obtained . IM [MEDICATION NAME] was available in the Emergency cart. After the removal of the immediate jeopardy, a deficient practice remained for this requirement of failing to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Resident identifiers: Resident #3, #4, #6, #7, #1, #8, #42, #5, #20 and #2. Resident identifiers: #3, #4, #6, #7, #1, #8, #42, #5, #20 and #2. Facility census: 83. Findings included: a) Resident #3 A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, revealed the [MEDICATION NAME] gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two nursing staff, LPN #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] gel ( [MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing Unit, 0n 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] gel was not available. LPN #55 attempted to request the [MEDICATION NAME] gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] gel may have been locked up in the Director of Nursing's office. An interview on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the Alexa Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the Alexa Pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility has not sent the request for a current order and script to the pharmacy. On 10/11/18, at 11:55AM, the Administrator Designee and RN#150 brought a prescription container of [MEDICATION NAME] gel to the surveyor. The Administrator Designee, stated that it was not where the Director of Nursing had told her to look but after she thought about it, she had us to break the lock to get it. The [MEDICATION NAME] gel produced by the Administrator Designee and RN#150 had a date an original date of 06/14/17 with a Discard After 06/15/18. Both the Administrator Designee and RN #150 verified there was no current medication available in the facility to be used in case Resident #3 sustained a [MEDICAL CONDITION] greater than 5 minutes requiring medication to be administered. Further interviews, on 10/16/18, at 10:35 AM with RN#110 verified meds are pulled based on discard date and RN#106 added only meds to be destroyed are in the nurses office (DoN) and that was where the outdated [MEDICATION NAME] was found. Further review of the medical record revealed Resident #3 had documentation of a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. The facility failed to provide [MEDICAL CONDITION] care that documented: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity as noted in Resident #3s care plan. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] gel available for the Resident and had not been available. The current physician's orders [REDACTED].) A review of the laboratory section of the medical record revealed no documented results for the [MEDICATION NAME] level ordered for (MONTH) (YEAR). An interview, on 10/15/18, at 02:30 PM with LPN#7, revealed no results were received and placed on the medical record. Upon further investigation, LPN#7 stated the lab had not been drawn according to the laboratory book. Additionally, the repeat Ammonia level ordered 08/20/18 was not done as well. Review of the available labs, revealed Resident #3 had previously had higher levels than normal of [MEDICATION NAME]/[MEDICATION NAME] Acid at level 110 (normal range indicated 50-100 MCG/ML) {microgram/ milliliter} and Ammonia levels at level 40 (normal range indicated as 9.0-33.0 UMOL/L) {micromole per liter}. b) Resident #4 A review of the medical record for Resident #4 revealed physician's orders [REDACTED]. The order was to assist in treating Type II Diabetes with Diabetic [MEDICAL CONDITION]. A review of the medication administration record (MAR) for Resident #4 revealed blood sugar monitoring had not been performed on 10/13/18 for the 11:30 AM check nor the 4:30 PM check. An interview, on 10/15/18, at 04:10 PM, with Registered Nurse (RN) #72, verified the glucose monitoring had not been completed for Resident #4 on the dates in question. c) Resident #6 A review of the medical record for Resident #6 revealed current orders for the following medications: [REDACTED] -[MEDICATION NAME] one time daily used to treat high blood pressure -Aspirin 81milligram (mg) one time daily used to treat hypertension (high blood pressure) -[MEDICATION NAME] one time a day for high cholesterol -[MEDICATION NAME] one time daily used to treat hypertension -[MEDICATION NAME] two times daily used to treat depression -[MEDICATION NAME] two times daily used to treat hypertension -Senna tablet two times daily used to treat constipation -House supplement three times a daily to aide in nutrition On 08/16/18 and 08/17/18, the resident did not receive the daily dose (9:00 AM) of the medications listed above. Additionally, Resident #6 was ordered to have [MEDICATION NAME]injection per sliding scale based on a blood glucose monitoring regimen four times per day. The resident did not have documentation she had received the care for 11:30 AM and 4:30 PM blood glucose monitoring for 08/05/18, 08/6/18, 08/16/18, 08/17/18, and 08/27/18. An interview with LPN #7, on 10/15/18, at 10:52 AM, revealed there was no note indicating the resident had the medication held and was not documented as given on the dates shown verifying the resident had received the care in accordance with the physician's orders [REDACTED]. d) Resident #7. The resident expressed concern that staff did not listen to him when he would indicate that he was having hallucinations. During interview on 10/09/18 at 9:58 AM he expressed having hallucinations and staff did not take his concerns seriously. Discussion with Administrator Designee (AD) #51 at 10:35 AM on 10/10/18 revealed AD #51 was not aware of the resident having hallucinations and that he would be sccheduled to be seen by the physician on a visit next week. According the the care plan of 08/28/18, it showed recevied antidepressant medications and hallucinations were identified as a side effect of this treatment. Staff had not identified this adverse reaction as needing monitored nor identified it as a problem requiring additional treatment. Additional a monthly nursing summary assessment dated [DATE] did not show hallucinations as an identified concern that needed treatment or monitoring. e) Resident #42 On 06/14/18 at 5:45 PM during an interview with Resident #42 the resident explained he had some trouble with his bowels since he came to the facility. The medical record review revealed the resident came to the facility on [DATE]. Review of the documentation survey report revealed Resident #42 had no bowel movements recorded on 10/04/18, 10/05/18, or10/07/18. A medium sized bowel movement was recorded between 11:00 PM and 7:00 AM on 10/08/18. A review of the physician's orders [REDACTED]. The resident also had an order for [REDACTED]. During an interview with Assistant Director of Nursing (ADoN) #106, at 2:26 PM on 10/16/18, the ADoN said the resident had a bowel movement on day four (4) (10/07/18). She did confirm the Milk of Magnesia nor the [MEDICATION NAME] Powder was administered between 10/04/18 and 10/07/18. f) Resident #5 A review of Resident #5's treatment sheet revealed an order to turn and reposition the resident every two (2) hours due to increased risk of skin breakdown. Care plan review revealed Resident #5 had been treated for [REDACTED]. The care plan reflected the resident was incontinent of bowel and bladder and moved around in bed by sliding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was totally dependent for bed mobility. Multiple observations on 10/10/18 between (9:00 AM and 1:00 PM) revealed Resident #5 was positioned with pressure off his right side. An interview with Nurse Aide (NA) #50 at 1:00 PM on 10/10/18 revealed the nursing staff were supposed to turn/reposition Resident #5 every two (2) hours but sometimes they were not able to do this due to staffing issues. Observations of Resident #5 on 10/10/18 at 1:48 PM revealed Resident #5 was positioned with pressure off his left side. Continued observations between 1:48 PM and 6:00 PM revealed the resident in the same position with pressure off his left side. On 10/10/18 at 6:06 PM during an interview with Registered Nurse (RN) #34 the RN said she would fix that when she was told the resident had been on the right side with pressure off the left side for the multiple observations between 1:48 PM and 6:00 PM. A review of the treatment record for (MONTH) (YEAR) revealed an order dated 07/10/18. The order indicated the resident would be turned every (two) hours, every shift due to an increased risk of skin breakdown. On 10/02/18 there was no documenation showing the resident had been turned on 7:00 AM - 7:00 PM shift. On 10/03/18 there was no documentation showing the resident had been turned every two (2) hours on 7:00 PM -7:00 AM shift. On 10/05/18 there was no documentation the resident had been turned during 7:00 AM -7:00 PM shift. On 10/06/18 there was no documentation the resident had been turned during 7:00 PM -7:00 AM shift. On 10/07/18 there was no documentation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/09/18 there was no documentation to reflect the resident was turned during 7:00 AM-7:00 PM or 7:00 PM-7:00 AM. On 10/13/18 there was no documenation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/14/18 there was no documenation the resident had been turned during 7:00 AM-7:00 PM shift. The resident's care plan reflected a focus area related to the resident's pressure ulcer to the right and left coccyx. The care plan indicated the resident was at risk for further skin breakdown related to imobility, refusal to turn and reposition, incontineince of bowel and bladder. Staff interview and record review as well as observations did not reflect the resident's refusal to be turned/repositioned. During a family interview on 10/14/18 at 6:00 PM Resident #5's family member said the resident had experienced a terrible pressure ulcer while at the facility. An interview with wound care RN #31 on 10/10/18 at 10:47 AM revealed Resident #5's wound was on the coccyx and had originated in (MONTH) (YEAR). The resident was on a wound VAC (vacuum assisted closure) for about eight (8) months. Documentation on pressure ulcer records revealed Resident #5 had a Stage IV pressure ulcer to the coccyx that had been surgically debrided by a local wound center. g) Resident #20 Review of records, on 10/10/18 at 10:15 AM, revealed some of Resident#20's [DIAGNOSES REDACTED]. Review of records revealed the resident had a vagal stimulator to be used during [MEDICAL CONDITION] activity. Vagal refers to the vagus nerve the longest nerve in the autonomic nervous system in the human body, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). According to the [MEDICAL CONDITION] Foundation, Vagus nerve stimulation (VNS) prevents [MEDICAL CONDITION] by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a pacemaker for the brain. A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. If a person is aware of when a [MEDICAL CONDITION] happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain. For some people this may help stop [MEDICAL CONDITION]. A magnet is used to activate or deactivate the device. Review of Resident#20's care plan, on 10/10/18 at 10:15 AM, revealed a focus area of impaired Neurological status related to [MEDICAL CONDITION] disorder. Interventions included Give medications as ordered. Observe/document for effectiveness and side effects. Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No shortwave diathermy. The same intervention related to [MEDICAL CONDITION] activity concerning the vagal stimulator is under the focus of risk for falls. The intervention, Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No short-wave Diathermy. Date Initiated: 06/15/17. Review of records for Resident#20, on 10/10/18 at 2:00 PM, revealed an order for [REDACTED]. Review of the medicine administration record (MAR) revealed no [MEDICATION NAME] was given in the month of (MONTH) or (MONTH) (YEAR). The MAR showed in the month of (MONTH) one (1) dose was given on 08/27/18, indicating [MEDICAL CONDITION] activity had occurred. No details concerning the [MEDICAL CONDITION] activity occurring on 08/27/18 was found in the record; no description on how long the [MEDICAL CONDITION] lasted, or if the vagal stimulator was used, or what interventions or precautions were used other than the ordered medication. On 10/10/18 at 2:40 PM, interview with Registered Nurse (RN#105) assigned to care for the resident on 10/10/18, revealed RN#105 was not aware the resident had a vagal stimulator or what a vagal stimulator even was. RN#105 said this was her first day at the facility, that she was from a sister facility and did not know the residents. This surveyor suggested that perhaps another nursing staff that regularly worked at the facility and who was familiar with the resident, show this surveyor and the assigned RN#105 responsible for the care of Resident#20, the resident's vagal stimulator and the appropriate way to use it. Licensed Practical Nurse (LPN#72) showed this surveyor and RN#105 the procedure to use the vagal stimulator if the resident had a [MEDICAL CONDITION]. LPN#72 felt the resident's upper left chest and showed RN#105 the outline of the implanted vagal stimulator, then LPN#72 showed RN#105 the magnet hanging on the back of the resident's wheel chair that is used to operate the vagal stimulator. LPN#72 said there was also a magnet on the cart. LPN#72 said, the resident has been at the facility for ten (10) years and if he is having a [MEDICAL CONDITION], you swipe the magnet over the implanted vagal stimulator one (1) time, and only one (1) time. RN#105 said she had never came across one of those (vagal stimulator) before in her nursing career (RN#105 said she had been a RN since (MONTH) (YEAR), but a LPN for several years). On 10/10/18 at 5:45 PM, review of orders revealed an order dated 03/30/17, If resident has [MEDICAL CONDITION] activity last greater than 3 minutes, then RN to swipe magnet once over VNS Generator. If needed, can repeat after 5 minutes. Avoid swiping magnet immediately after single swipe. Notify physician and RP (representative) of use. Another order dated 3/31/2017 revealed, Device: Keep vagal Stimulator (used during [MEDICAL CONDITION] activity) in plain sight and handy at all times. Use vagal stimulator if he has more than one [MEDICAL CONDITION] in a row by rubbing magnet on left upper chest. No short-wave diathermy, microwave diathermy, therapeutic ultrasound diathermy. Every shift for [MEDICAL CONDITION] On 10/10/18 at 3:37PM, interview with RN#44 Staff Development, revealed when asked for records on all training given to staff concerning a vagal stimulator. RN#44 said, We don't have anyone in the building with a vagal stimulator. RN#44 said she has not done any training on vagal stimulators since she has had the job since the last part of (MONTH) (YEAR). The Staff Development RN#44 said she would look at previous records, prior to her having the position, to see if there ever was any training given concerning [MEDICAL CONDITION] or vagal stimulators. Interview with RN#44 Staff Development, on 10/10/18 at 4:17 PM after RN#44's review of training back through (YEAR), revealed no training on [MEDICAL CONDITION] or vagal stimulators. When asked again if anyone in the facility had a vagal stimulator, RN#44 replied, No one. This surveyor informed RN#44 that Resident#20 had a vagal stimulator. RN#44 left the room and came back a little while later and said, she was the only one that was not aware the resident had a vagal stimulator, that she had spoken to staff and everyone else knew about it and how to use it. When RN#44 was asked what model vagal stimulator the resident had, and how long he had had it, she was unable to say, but said she would try to find out. At the time of exit the facility had not given this surveyor the information on the model of the vagal stimulator or how long Resident #20 had it. On 10/10/18 at 7:35 PM, interview with LPN#47, evening shift nurse assigned to the resident revealed the LPN was not aware Resident #20 had a vagal stimulator or what a vagal stimulator was. When asked what the nurse would do if the resident had a [MEDICAL CONDITION] LPN#47said she would give him his PRN (as needed) medicine for [MEDICAL CONDITION]. When asked what the care plan intervention meant by Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. The LPN did not know, and said she had never seen any device bedside, and was unable to describe what a vagal stimulator was. An interview with Resident Care Specialist, also known as a Nurse Aide (NA) NA#35, on 10/10/18 at 7:40 PM, revealed NA#35 considered the Resident#20 total care. NA#35 said the resident needed a lot of care and he did have [MEDICAL CONDITION]. Upon inspection of the resident's wheel chair with NA#35, this surveyor pointed to the magnet attached to the back of the wheel chair and asked NA#35 what it was. NA#35 replied it was a wheel chair alarm, that a lot of residents had them so that staff would know when they stood up out of their wheel chairs. h) Resident #2 admitted originally on 05/19/18 status [REDACTED]. Resident had capacity. resident had a history of [REDACTED]. Review of records, on 10/09/18 at 11:15 AM, revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) 8/22/18. The resident had adequate hearing and vision, clear speech, can make self-understood and understands. Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 15 indicating the resident was cognitively intact with no impairment. The resident needed extensive assistance with activities of daily living (ADLs), except supervision with meals and is totally dependent for bathing. Pertinent [DIAGNOSES REDACTED]. On 10/09/18 at 1:05 PM review of record revealed a late entry situation background assessment recommendation (SBAR) Change in Status dated 09/22/18 at 4:40 PM. Review of SBAR Summary revealed documented vitals signs (blood pressure, temperature, pulse, and respirations) were taken on 09/19/18. The oxygen saturation noted was taken 09/18/18. Nurses note stated, What I think is going on with the resident is: has received first Cemo for metastisis of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Additional Nursing Notes as applicable: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The hospital requested by family was not the nearest hospital to the facility. The family had to request resident be sent for evaluation. When reviewing the SBAR summary and SBAR no vital signs (VS) were recorded at the time the resident was having a change of condition, accept in a nurse's note a recorded temperature taken one time. The District Director of Clinical Services said the system pulls the last recorded VS into a note when no new VS are entered. Review of the SBAR dated the day Resident #2 was sent to the ED, 09/22/18, showed VS from 09/19/18, and oxygen saturation noted was taken 09/18/18. There were no recorded current VS reflecting the resident's actual status at the time of the change in condition. The instructions included on the SBAR were 1. Evaluate the resident, 2. Check vital signs, 3. Review record, 4. Review and interact care path or acute change in condition file card, and 5. Have relevant information available and reporting. The SBAR noted the situation is a change in condition noted as confusion with change in vials (written as typed) starting on 09/22/18. Stayed the same since change started with no change in symptoms. This condition, symptom, or sign has not occurred before. On the SBAR section 'Other relevant information', it was noted had family in from out of town all morning was laughing and taking pictures. Under section 'B' of the form under number three (3) instructions say (Be sure this is the most current set of vital signs that goes with your evaluation of the resident) The vital signs recorded on the form was actually taken on 09/19/18, the change in condition occurred on 09/22/18. The change in the resident's condition included increased confusion and slurred speech. The RN assessment revealed I think the problem may be has received first Cemo for metastisis (typed as written) of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Nursing Notes for additional information on change of condition: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The physician was notified on 09/22/18 at 12:15 PM. Review of Hospital Emergency Department documentation dated 09/22/18, revealed at the time of the initial examination the resident was only alert to self, was hypotensive, and had elbow pain and swelling. She was treated for [REDACTED]. A chest x-ray was concerning for pneumonia. She did respond to IV fluid hydration and was no longer hypotensive. The resident required hospitalization for IV antibiotics. The resident's blood pressure was significantly lower than usual and she was hypotensive with a systolic of 70's. According to the family this afternoon she began having decreased alertness and became slightly altered. Throughout the evening she continued to become more altered and less responsive. The family noticed the residents left elbow was significantly more swollen and tender. (The resident had a [MEDICAL CONDITION] arm earlier in the month) On 10/16/18 at 12:55 PM, review of hospital discharge summary dated 09/29/18, revealed Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The admitting [DIAGNOSES REDACTED]. Primary discharge [DIAGNOSES REDACTED]. Notations in the hospital records revealed, . The family notice that the wound appeared to be red and somewhat tender, and in addition notice that she had mental status changes today.and family asked that she be transferred for further evaluation The patient was initially hypotensive (low blood pressure) on arrival with elevated temperature, . On 10/16/18 at 3:11 PM, interview with Director of Legal Operations, the District Director of Clinical Services, Administrator, and interim Assistant Director of Nursing (ADON), revealed the SBAR was the documentation concerning what led up to sending Resident to the Emergency Department for evaluation. The Director of Legal Operations said the family was the ones that requested the resident be sent, and asked this surveyor if she had read the SBAR. This su

Based on medical record review, physician interview, consultant pharmacist interview, and staff interview, the facility failed to ensure each resident's medication regimen was free of unnecessary medications. The facility failed to ensure residents receiving antihypertensive (high blood pressure) medications were given those medications only when indicated and to avoid the potential for adverse consequences. Additionally, the facility discontinued the parameters for four (4) residents (#1, #3, #12, and #10) who were identified by the physician to not be stable, thereby not ensuring the residents were adequately monitored. This was found for four (4) of fifteen (15) residents identified by the facility as having parameters associated with medication orders, who were administered medications when the medication should have been held. Additionally, Residents #130 and #62 received an antianxiety medication ([MEDICATION NAME]) without evidence nonpharmacologic interventions were implemented before administration of the medication, no monitoring of side effects, and no targeted behaviors which warranted the use of the medications. For Residents #144, #69, and #60, the facility failed to ensure the residents who received antianxiety/antipsychotic medications had appropriate [DIAGNOSES REDACTED]. At 6:28 p.m. on 12/16/15, the administrator (NHA) and director of nursing (DON) were notified of an immediate jeopardy. On 12/16/15 at 7:35 p.m., the State agency confirmed implementation of the plan of correction and the immediacy was removed. At that time, the scope and severity was reduced from a K to an E because of a remaining deficient practice. Resident identifiers: #1, #3, #12, #10, #130, #62, #144, #69, and #60. Facility census: 91. Findings include: a) Resident #1 Medical record review for Resident #1, on 12/15/15 at 10:00 a.m., found a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 160 mmHg (millimeters of mercury - the unit used to measure blood pressures) and less than 90 mmHg for the diastolic blood pressure (DBP). Review of Resident #1's medication administration record (MAR), found blood pressures for the period of 11/01/15 through 11/30/15 as follows: -- 11/01/15 - 9:00 a.m. - 128/74; 9:30 p.m. - 132/70 -- 11/02/15 - 9:00 a.m. - 136/74; 9:30 p.m. - 127/77 -- 11/03/15 - 9:00 a.m. - 130/78; 9:30 p.m. -132/72 -- 11/04/15 - 9:00 a.m. - 140/72; 9:30 p.m. - 140/72 -- 11/05/15 - 9:00 a.m. - 140/68; 9:30 p.m. - 148/72 -- 11/06/15 - 9:00 a.m. - 136/74; 9:30 p.m. - 130/70 -- 11/07/15 - 9:00 a.m. - 134/72; 9:30 p.m. - 132/78 -- 11/08/15 - 9:00 a.m. - 138/82; 9:30 p.m. - 122/70 -- 11/09/15 - 9:00 a.m. - 122/70; 9:30 p.m. - 132/76 -- 11/10/15 - 9:00 a.m. - 140/72; 9:30 p.m. - 140/72 -- 11/11/15 - 9:00 a.m. - 142/76; 9:30 p.m. - 140/80 -- 11/12/15 - 9:00 a.m. - 134/76; 9:30 p.m. - 130/72 -- 11/13/15 - 9:00 a.m. - 140/76; 9:30 p.m. - 138/70 -- 11/14/15 - 9:00 a.m. - 128/76; 9:30 p.m. - 130/70 -- 11/15/15 - 9:00 a.m. - 135/75; 9:30 p.m. - 142/70 -- 11/16/15 - 9:00 a.m. - 140/72; 9:30 p.m. - 130/75 -- 11/17/15 - 9:00 a.m. - 130/75; 9:30 p.m. - 142/70 -- 11/18/15 - 9:00 a.m. - 134/76; 9:30 p.m. - 128/72 -- 11/19/15 - 9:00 a.m. - 136/78; 9:30 p.m. - 140/82 -- 11/20/15 - 9:00 a.m. - 120/72; 9:30 p.m. - 132/78 -- 11/21/15 - 9:00 a.m. - 136/78; 9:30 p.m. - 128/70 -- 11/22/15 - 9:00 a.m. - 130/74; 9:30 p.m. - 144/75 -- 11/23/15 - 9:00 a.m. - 148/79; 9:30 p.m. - 132/72 -- 11/24/15 - 9:00 a.m. - 128/76; 9:30 p.m. - 128/76 -- 11/25/15 - 9:00 a.m. - 132/76; 9:30 p.m. - 132/76 -- 11/26/15 - 9:00 a.m. - 134/72; 9:30 p.m. - 134/72 -- 11/27/15 - 9:00 a.m. - 142/74: 9:30 p.m. - 142/74 -- 11/28/15 - 9:00 a.m. - 148/76; 9:30 p.m. - 137/70 -- 11/29/15 - 9:00 a.m. - 132/74; 9:30 p.m. - 124/72 -- 11/30/15 - 9:00 a.m. - 124/72; 9:30 p.m. - 136/78 This review of Resident #1's BP revealed they were out of the physician ordered parameters on sixty (60) occasions, yet the medication for which the parameters were ordered, was administered. On 12/02/15, the parameters for Resident #1's [MEDICATION NAME] were discontinued. No evidence was found in the resident ' s medical record to indicate the physician had been notified of the resident receiving the medication outside of the physician ordered parameters on sixty (60) occasions. On 12/15/15 at 2:00 p.m., a discussion with Assistant Director of Nursing (ADON) #33 confirmed the blood pressures for Resident #1 and the medication should not have been administered. She agreed there was no evidence of physician notification. Resident #1 was administered [MEDICATION NAME] twice daily outside of the physician established parameters for the period of 11/01/15 through 11/30/15. b) Resident #3 Medical record review for Resident #3, on 12/15/15 at 10:30 a.m., found a physician's orders [REDACTED]. Hold if SBP less than 100. Review of Resident #3's MAR, found blood pressures for the period of 11/01/15 through 11/30/15 as follows: -- 11/15/15 - 98/66 -- 11/16/15 - 90/46 -- 11/19/15 - 99/56 Resident #3 also had an order for [REDACTED]. Hold if HR is less than 60. (The mechanism of action for some medications given for high blood pressure, can also cause slowing of the heart rate.) Review of the Resident #3's MAR, found the HR for the period of 11/01/15 through 11/30/15, was outside of the physician prescribed parameters as follows: -- 11/09/15 - 56 -- 11/10/15 - 56 c) Resident #12 Medical record review for Resident #12, on 12/15/15 at 11:00 a.m., found a physician's orders [REDACTED]. Hold if SBP is less than 140. Review of the Resident #12's MAR, found blood pressures for the period of 11/01/15 through 11/30/15, were outside of the physician prescribed parameters as follows: -- 11/01/15 - 128/74 -- 11/04/15 - 136/72 -- 11/07/15 - 130/70 -- 11/08/15 - 126/72 -- 11/12/15 - 124/68 -- 11/14/15 - 135/70 -- 11/15/15 - 132/76 -- 11/16/15 - 120/67 d) Resident #10 Medical record review for Resident #10, on 12/15/15 at 11:30 a.m., found an order for [REDACTED]. Hold for SBP less than 100 or if HR is less than 60. Review of the Resident #10's MAR, found blood pressures for the period of 11/01/15 through 11/30/15, were outside of the physician prescribed parameters as follows: -- 11/25/15 - 52 -- 11/26/15 - 52 -- 11/27/15 - 52 e) In addition to the medications being administered to Residents #1, #3, #12, and #10 when there was no indication the medication should be administered, medical record review found no evidence the physician was notified of the residents ' blood pressures and/or heart rates were outside of the ordered parameters and the medications were administered. f) Additional record review found three (3) of fifteen (15) residents identified with parameters, had the parameters discontinued on 12/01/15. In an interview with the attending physician, on 12/16/15 at 12:30 p.m., it was learned that at the last Quality Assurance meeting it was discussed to review all residents in the facility who receive antihypertensive/heart medication with parameters. The parameters were not to be discontinued if unstable. He also stated parameters were intended to be followed. He was not aware of any of the medications administered outside of the parameters, nor was he aware the parameters for these residents had been discontinued. He said these residents were not stable, and the parameters should not have been discontinued. Even moderate forms of low blood pressure and/or pulse can cause not only dizziness and weakness but also [MEDICAL CONDITION] and a risk of injury from falls. A severely low blood pressure from any cause can deprive your body of enough oxygen to carry out its normal functions, leading to damage to your heart and brain. g) At 6:28 p.m. on 12/16/15, the administrator (NHA) and director of nursing were notified of an immediate jeopardy. After this was brought to the attention of the facility, Residents #1, #3, #12 and #10's physician was notified immediately of the BPs outside of the ordered parameters. An assessment of the residents including vital signs were completed and new orders were received to reinstate the previously physician established parameters for Residents #1, #3 and #10. For Resident #12, the physician ordered the [MEDICATION NAME] reduced to 160 mg daily due to BP reading being 99/53 when assessed and the attending physician would see the resident on Friday (12/18/15) and report any irregularities to the physician. On 12/16/15 at 7:35 p.m., the State agency confirmed the plan of correction had been implemented and the immediacy was removed. The facility ' s plan of correction response for the removal of immediacy was: In response to the alleged deficient practice on 12/16/15, the facility plan of correction is as follows: Resident #1, Resident #3, Resident #12, and Resident #10 were assessed by Registered Nurse, vital signs were taken, and the physician was notified of results. Physician orders [REDACTED]. 15 residents taking antihypertensive medications have the potential to be affected. The four residents identified above were all that required physician notification. All licensed nurses will be reeducated beginning on 12/16/15 and prior to their next scheduled shift on Blood Pressure/Heart Rate medications with parameters, following the parameters prior to administration and physician notification if indicated. The education will be completed by the Director of Nursing, RN Clinical Educator, Assistant Director of Nursing, or Unit Managers. All residents that have blood pressure/ heart rate medications with parameters will have their MAR's audited daily 5 days a week 1 time a day for 4 weeks to ensure parameter orders are being followed. Then all residents will be monitored 3 times a week 1 time a day for 4 weeks. Then all residents will be monitored 1 time a week for 4 weeks. Monitoring will continue randomly thereafter to ensure compliance. The audit will be completed by Administrative Nurses. The results will be reported to the quality assurance committee monthly with further action completed as necessary. h) Interview with Consultant Pharmacist on 12/18/15 at 1:00 p.m., found she had made recommendations concerning BP medication and parameters since September 2015. She then provided copies of her recommendations for September, October, and November 2015. These recommendations included multiple recommendations for residents receiving BP medication with parameters and residents receiving the medication outside of parameters. Record review found no evidence the pharmacist's recommendations were acted upon. i) Resident #130 Review of Resident #130's medical record on 12/09/15 at 9:00 a.m., revealed a physician's orders [REDACTED]. The order was written on 10/10/15 and on 11/05/15, the order was changed to [MEDICATION NAME] 0.5 mg every eight (8) hours. Further review of Resident #130's Medication Administration Records (MAR) for October 10, 2015 through November 5, 2015, revealed [MEDICATION NAME] was given on the following dates without evidence nonpharmacologic interventions were implemented before administration of the medication. Additionally, there was no monitoring of side effects as well as no documentation of the targeted behaviors which warranted the use of the medication: -- 10/10/15 at 8:17 a.m. and 4:25 p.m. -- 10/11/15 at 8:01 a.m. -- 10/13/15 at 3:54 p.m. -- 10/14/15 at 6:46 a.m. -- 10/15/15 at 12:51 p.m. -- 10/16/15 at 1:25 p.m. and 7:38 p.m. -- 10/17/15 at 7:41 p.m. -- 10/18/15 at 5:10 a.m. and 9:59 p.m. -- 10/19/15 at 3:35 a.m., 10:01 a.m., and 4:00 p.m. -- 10/20/15 at 8:00 a.m., 4:00 p.m., and 10:27 p.m. -- 10/22/15 at 1:26 a.m. -- 10/23/15 at 9:00 a.m. and 8:34 p.m. -- 10/24/15 at 10:08 p.m. -- 10/25/15 at 10:00 a.m. and 5:03 p.m. -- 10/26/15 at 4:26 a.m. and 1:22 p.m. -- 10/28/15 at 3:55 p.m. -- 10/29/15 at 9:59 a.m., 4:15 p.m., and 10:01 p.m. -- 10/30/15 at 3:31 p.m. -- 10/31/15 at 4:12 a.m. and 10:13 p.m. -- 11/01/15 at 6:48 a.m. and 10:18 p.m. -- 11/02/15 at 9:30 a.m. and 6:00 p.m. -- 11/03/15 at 10:00 a.m. and 3:30 p.m. -- 11/04/15 at 6:30 a.m. -- 11/05/15 at 9:30 a.m. Nurses' notes, from 10/10/15 to 11/05/15, were reviewed. There was no documentation the resident was agitated and/or anxious at any time the [MEDICATION NAME] was administered, no documentation of attempts at nonpharmacologic interventions before the administration of the [MEDICATION NAME], and no evidence the side effects were monitored during this time. The ADON was interviewed, at 12:15 p.m. on 12/09/15. She was unable to find documentation the resident exhibited any behaviors to warrant the use of [MEDICATION NAME]. The ADON was also unable to provide evidence of attempts at nonpharmacologic interventions prior to the administration of [MEDICATION NAME]. The behavior sheets were blank for side effect documentation. The director of nursing (DON) was interviewed on the, afternoon of 12/09/15, at approximately 3:00 p.m., and no further information was provided. j) Resident #62 Review of Resident #62's medical record on 12/09/15 at 11:00 a.m., revealed a physician's orders [REDACTED]. The order was written on 01/14/15. Further review of Resident #62's Medication Administration Records for October, November and December 2015, revealed [MEDICATION NAME] was given on the following dates without evidence nonpharmacologic interventions were implemented before administration of the medication. Additionally, there was no monitoring of side effects, as well as no documentation of the targeted behaviors which warranted the use of the medication: -- 10/02/15 at 9:51 p.m. -- 10/04/15 at 6:51 p.m. -- 10/09/15 at 8:45 p.m. -- 10/17/15 at 9:32 p.m. -- 10/20/15 at 9:42 p.m. --10/23/15 at 9:04 p.m. -- 10/24/15 at 9:36 p.m. -- 10/28/15 at 9:30 p.m. -- 10/29/15 at 8:43 p.m. -- 10/30/15 at 7:26 p.m. -- 10/31/15 at 9:02 p.m. -- 11/01/15 at 9:08 p.m. -- 11/02/15 at 9:15 p.m. -- 11/05/15 at 9:35 p.m. -- 11/06/15 at 9:30 p.m. -- 11/11/15 at 9:15 p.m. -- 11/14/15 at 9:46 p.m. -- 11/15/15 at 9:07 p.m. -- 11/16/15 at 9:00 p.m. -- 11/17/15 at 10:18 p.m. -- 11/19/15 at 9:56 p.m. -- 11/20/15 at 9:00 p.m. -- 11/27/15 at 12:29 a.m. and 7:35 p.m. -- 11/29/15 at 9:53 p.m. -- 11/30/15 at 9:00 p.m. -- 12/03/15 at 8:36 p.m. -- 12/04/15 at 7:26 p.m. -- 12/05/15 at 7:56 p.m. -- 12/06/15 at 8:55 p.m. Nurses' notes, from 10/01/15 to 12/06/15, were reviewed. There was no documentation the resident was agitated and/or anxious at any time the [MEDICATION NAME] was administered, no documentation of attempts at nonpharmacologic interventions before the administration of the [MEDICATION NAME], and no evidence of side effects monitored during this time. The ADON was interviewed, at 12:15 p.m. on 12/09/15. She was unable to find documentation the resident exhibited any behaviors to warrant the use of [MEDICATION NAME]. The ADON was also unable to provide evidence of attempts at nonpharmacologic interventions prior to the administration of [MEDICATION NAME]. The behavior sheets were blank for side effect documentation. The director of nursing (DON) was interviewed on the, afternoon of 12/09/15, at approximately 3:00 p.m., and no further information was presented. k) Resident #144 Medical record review at 2:00 p.m. on 12/09/15, found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. Review of the resident's medication administration record for December 2015, found the resident was currently receiving the following medications for [DIAGNOSES REDACTED]. -- [MEDICATION NAME] 25 milligrams (mg) by mouth at bedtime for a [DIAGNOSES REDACTED]. -- Trazdone HCI 100 mg, three (3) tablets by mouth at bedtime for a [DIAGNOSES REDACTED]. -- [MEDICATION NAME] 20 mg by mouth one (1) time a day for a [DIAGNOSES REDACTED]. -- Klonopin 0.5 mg by mouth in the evening related to anxiety disorder, unspecified, hold with sleep or sedation, order date 11/27/15. -- Klonopin 0.5 mg give 0.25 mg by mouth one (1) time a day related to anxiety disorder, unspecified, hold with sleep or sedation, order date 11/27/15. Review of the December 2015, behavior monthly flow sheet found all three (3) medications, [MEDICATION NAME], and [MEDICATION NAME] were listed together on one behavior monthly flow sheet. The flow sheet failed to specify any specific behaviors warranting the use of the medications. The behaviors monitoring sheet directed staff to attach specific behaviors to each medication and daily monitoring of those behaviors warranting the use of the medications. The medication, Klonopin, which was prescribed for anxiety, was not included on the behavior monitoring sheets. At 3:29 p.m. on 12/09/15, the director of nursing (DON) was asked what behaviors the resident exhibited to warrant the use of the above medications. The DON stated, I don't know why and I'm not making up any behaviors. She was asked how the facility could monitor for the effectiveness of the medications without listing the specific behaviors for which the medication was prescribed. At 3:45 p.m. on 12/09/15, Registered Nurse #12, unit charge nurse for Resident #144, confirmed she did not know what behaviors the facility was monitoring because the behavior monitoring sheets were not clear. RN #12 stated she was unaware of any behaviors exhibited by the resident since her admission to the facility. At 3:50 p.m. on 12/09/15, Assistant Director of Nursing #33, provided information from the facility's online drug manual- Epocrates Online. Epocrates defines [MEDICATION NAME] as an antipsychotic, not an antianxiety medication as listed by the facility on the MAR. On 12/10/15 at 9:21 a.m., the DON confirmed she did not know why the resident was receiving the medication, [MEDICATION NAME]. She stated the resident had been at the facility for 20 days and she was admitted with this medication. She confirmed there had been no documentation of any behaviors since the resident's admission to the facility. She stated she was going to have the social worker call the family members to see why the resident was receiving antipsychotic and antidepressant medications. The DON also confirmed [MEDICATION NAME] was an antidepressant and not an antianxiety as listed on the MAR and [MEDICATION NAME] was an antipsychotic medication, not an antianxiety medication as listed on the facility's MAR. The DON stated the pharmacist had not reviewed the resident's drug regimen. At 10:44 a.m. on 12/10/15, Social Worker #37 stated she was trying to find out why the medications were ordered for the resident. She stated she believed the resident had delusions and a psychiatrist ordered the medications. The daughter told her the resident would, give them a hard time, when they took care of her at home before coming to the facility. Before surveyor intervention on 12/09/15 there was no evidence the facility attempted to obtain any background information relating to the use of antipsychotic and antidepressant medications for Resident #144. l) Resident #69 Review of Resident #69's medical record on 12/16/15 at 3:44 p.m., revealed a physician's orders [REDACTED]. The order was written on 06/15/15. Further review of Resident #69's Medication Administration Record for November 2015 through 12/16/15, revealed [MEDICATION NAME] was given on the following dates without evidence nonpharmacologic interventions were implemented before administration of the medication. Additionally, there was no documentation of the targeted behaviors which warranted the use of the medication: -- 11/02/15 at 11:19 a.m. -- 11/03/15 at 10:16 p.m. -- 11/04/15 at 9:09 p.m. -- 11/08/15 at 2:32 p.m. -- 11/18/15 at 11:37 p.m. -- 11/21/15 at 2:12 p.m. -- 11/26/15 at 11:15 p.m. -- 11/27/15 at 11:30 p.m. -- 11/30/15 at 10:48 p.m. -- 12/06/15 at 8:34 p.m. -- 12/12/15 at 1:22 p.m. -- 12/14/15 at 10:13 p.m. Nurses' notes, from 11/01/15 to 12/16/15, were reviewed. There was no evidence the resident was agitated and/or anxious at any time the [MEDICATION NAME] was administered, and no documentation of attempts at nonpharmacologic interventions before the administration of the [MEDICATION NAME]. An interview with the Director of Nursing Services at 11:00 a.m. on 12/17/15 confirmed Resident #69 was administered as needed [MEDICATION NAME] without nonpharmacologic interventions being attempted first. She said that they may have done them, but they did not document that they did, therefore they did not do it. m) Resident #60 Review of Resident #60's medical record on 12/14/15 at 10:12 a.m., revealed a physician's orders [REDACTED]. The order was written on 10/02/15. Further review of Resident #60's Medication Administration Record for 11/2015 through 12/16/15, revealed [MEDICATION NAME] was given on the following dates without evidence non-pharmacological interventions were implemented before administration of the medication. Additionally, as well there was no documentation of the targeted behaviors which warranted the use of the medication: -- 11/20/15 at 9:00 p.m. -- 11/27/15 at 3:54 p.m. -- 12/06/15 at 9:20 a.m., and 11:21 p.m. -- 12/07/15 at 8:06 a.m. Review of nurses' notes for 11/01/15 to 12/16/15 found no evidence the resident was agitated and/or anxious at any time the [MEDICATION NAME] was administered. There was no evidence of attempts at nonpharmacologic interventions before the administration of the [MEDICATION NAME]. An interview with the West Wing Unit Manager Registered Nurse (RN) #51, confirmed the resident was administered as needed [MEDICATION NAME] on the identified dates, without evidence nonpharmacologic interventions were attempted first and failed, and without documentation of the specific behaviors for which this medication was administered.

Based on observations, medication administration pass observations, medical record review, review of facility policy, review of facility's investigations, and staff interviews, the facility, in coordination with the licensed pharmacist, failed to provide a narcotic storage system in which the resident's controlled substances were in permanently affixed compartments for storage of controlled drugs in one (1) of two (2) medication rooms, failed to ensure the proper labeling of medications to assure that they were stored safely and were provided to the residents accurately and in accordance with the prescriber's instructions, and failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory for controlled medications to prevent or identify loss or diversion of these medications. There was no evidence the pharmacist evaluated the facility's systems regarding controlled medications to ensure the facility maintained an accurate accounting of all controlled medications and completed periodic reconciliations. The facility failed to ensure/prevent misappropriation of controlled substances for 63 residents who resided in the facility for the time period of [DATE] through [DATE] who received controlled narcotics (pain medication). The facility's failure to follow a systematic approach for receipt and destruction of narcotics placed all residents receiving narcotics at risk for drug diversion and misappropriation of narcotics. The facility's failure to follow policy and procedure and have a systematic approach for receipt and destruction of narcotics constituted an Immediate Jeopardy. The facility was notified of the Immediate Jeopardy at ¿05:38 p.m. on [DATE] Resident identifiers for the original Immediate Jeopardy (all residents who were dispensed and delivered narcotics during [DATE] through [DATE]: Residents #49, #7, #67, #50, #20, #17, #77, #2, #85, #32, #57, #144, #105, #130, #12, #95, #70, #69, #65, #6, #82, #83, #43, #38, #39, #31, #10, #109, #47, #126, #3, #104, #111, #134, #15, #29, #131, #36, #81, #101, #120, #148, #19, #78, #72, #75, #149, #147, #133, #27, #61, #18, #59, #129, #11, #23, #51, #90, #143, #118, #141, #42, and #109. Resident sample identifiers: #32, #17, #32, and #47. On [DATE] at 6:18 p.m., the State agency confirmed the plan of correction had been implemented and the immediacy was removed. At that time, the scope and severity was reduced from a K to an E because of a remaining deficient practice. Injectable Ativan was not stored to include the appropriate accessory and cautionary instructions, did not include the prescriber's instructions, and were not stored in a permanently affixed locked container. This had the potential to affect Residents #81, #1, #85, and #97, and/or any resident residing in the facility with orders for injectable Ativan (a schedule IV benzodiazepine used for the treatment of [REDACTED]. Findings include: a) Residents #49, #7, #67, #50, #20, #17, #77, #2, #85, #32, #57, #144, #105, #130, #12, #95, #70, #69, #65, #6, #82, #83, #43, #38, #39, #31, #10, #109, #47, #126, #3, #104, #111, #134, #15, #29, #131, #36, #81, #101, #120, #148, #19, #78, #72, #75, #149, #147, #133, #27, #61, #18, #59, #129, #11, #23, #51, #90, #143, #118, #141, #42, and #109. Review of medical records throughout the afternoon and evening on [DATE], found discrepancies in the accounting for controlled narcotics (pain medication) for these 63 residents who resided in the facility for the time period of [DATE] through [DATE]. The following four (4) residents are a representative sample of the findings of the discrepancies in the accounting of controlled pain medication: 1. Resident #32 During observation of the medication administration pass on [DATE] at 10:13 a.m., Registered Nurse (RN) #12 administered Norco (pain) 7XXX,[DATE] mg (milligrams) 1 tablet by mouth to Resident #32. Medication reconciliation on [DATE] at 10:00 a.m., found RN #12 failed to document on Resident #32's MAR the Norco 7XXX,[DATE] mg 1 tablet given on [DATE] at 10:13 a.m. On [DATE] at 11:15 a.m., RN #12 and the surveyor reviewed the MAR for Resident #32. RN #12 confirmed the medication (Norco) was not documented. When asked for the Controlled Substance Accountability Sheet (CSAS) for [DATE], RN #12, could not locate the document. At 12:30 p.m. on [DATE], Resident #32's CSAS was requested from the director of nursing (DON) and the assistant director of nursing (ADON). On [DATE] at 5:00 p.m., the ADON and DON confirmed the CSAS sheet for Resident #32 could not be located. At that time, a request was made for the Monthly Controlled Drug Reports (MCDR) from the pharmacy for all narcotics (pain medications) dispensed and received from the pharmacy for the months of September, October, November, and [DATE]. The MCDR was provided on [DATE] at 8:00 a.m. Review of Resident #32's medical record found the Physician's Recapitulation Orders dated [DATE], included orders for Hydrocodone (pain medication - same as Norco) 7XXX,[DATE]mg mg (milligram) every eight (8) hours as needed for pain. Review of the Medication Administration Records (MAR) dated September, October, November, and [DATE] and the MCDRs from the pharmacy found: -- [DATE] - 120 Hydrocodone tablets were received from the pharmacy and six (6) doses were documented on the MAR as administered. There were 118 Hydrocodone tablets unaccounted for. -- [DATE] - 130 Hydrocodone tablets were received from the pharmacy and two (2) doses were documented on the MAR as administered, leaving 128 Hydrocodone tablets unaccounted for. -- [DATE] - 60 Hydrocodone tablets were received from the pharmacy and zero (0) doses were documented on the MAR as administered, leaving 60 Hydrocodone tablets unaccounted for. -- [DATE] - 60 Hydrocodone tablets were received from the pharmacy and one (1) dose was documented on the MAR as administered, leaving 59 Hydrocodone tablets unaccounted for. These findings prompted review of the narcotic medications of three (3) additional residents. 2. Resident #17 Medical record review of the Physician's Recapitulation Orders for Resident #17, dated [DATE], revealed orders for Hydrocodone ,[DATE]mg mg (milligram) every four (4) hours as needed for pain. Review of the Medication Administration Records (MAR) dated September, October, November, and [DATE] and the MCDRs from the pharmacy found: -- [DATE] - 182 Hydrocodone tablets were received from the pharmacy and sixteen (16) doses were documented on the resident's MAR as administered. There were 166 Hydrocodone tablets unaccounted for. -- [DATE] - 150 Hydrocodone tablets were received from the pharmacy and two (2) doses were documented on the MAR as administered, leaving 148 Hydrocodone tablets unaccounted for. -- [DATE] - 120 Hydrocodone tablets were received from the pharmacy and four (4) doses were documented on the MAR as administered to the resident. That left 116 Hydrocodone tablets unaccounted for. -- [DATE] - 60 Hydrocodone tablets were received from the pharmacy and six (6) doses were documented on the MAR as administered, leaving 54 Hydrocodone tablets unaccounted for. 3. Resident #129 Review of Resident #129's medical record found the Physician's Recapitulation Orders dated [DATE], included an order for [REDACTED]. Review of the Medication Administration Records (MAR) dated September, October, November, and [DATE] and the MCDRs from the pharmacy found: -- [DATE] - 50 Hydrocodone tablets were received from the pharmacy, one (1) dose was documented on the MAR as administered, leaving 49 Hydrocodone tablets unaccounted for. -- [DATE] - 30 Hydrocodone tablets were received from the pharmacy and nine (9) doses were documented on the MAR as administered. There were 21 Hydrocodone tablets unaccounted for. -- [DATE] - 30 Hydrocodone tablets were received from the pharmacy and ten (10) doses were documented on the MAR as administered, leaving 20 Hydrocodone tablets unaccounted for. -- [DATE] - 30 Hydrocodone tablets were received from the pharmacy and three (3) doses were documented on the MAR as administered - 27 Hydrocodone tablets were unaccounted for. 4. Resident #47 Review of the Physician's Recapitulation Orders for Resident #47, dated [DATE], revealed orders for Hydrocodone ,[DATE]mg mg every 6 hours as needed for pain. Review of the Medication Administration Record (MAR) dated October, November and [DATE] and the MCDRs from the pharmacy found: -- [DATE] - 52 Hydrocodone tablets were received from the pharmacy and one (1) dose was documented on the MAR as administered. There were 51 Hydrocodone tablets unaccounted for. -- [DATE] - 30 Hydrocodone tablets were received from the pharmacy and 13 doses were documented on the MAR as administered, leaving 17 Hydrocodone tablets unaccounted for. -- [DATE] - 30 Hydrocodone tablets were received from the pharmacy and 17 doses was documented in the MAR as administered, leaving 13 Hydrocodone tablets unaccounted for. b) Review of the facility's policy, Medication Storage in the Facility Controlled Substance Storage, dated ,[DATE], on [DATE] at 8:30 a.m., the policy directed: 4.2: CONTROLLED SUBSTANCE STORAGE. Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulation in the handling of control substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B. Schedule (II-V) medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double-locked) compartment separate from all other medications or per state regulation. Alternately, in a unit dose system, these medications may be kept with other medication(s) if the supply of the medication(s) is minimal and a shortage is readily detectable. The access system to controlled medications is not the same as the system giving access to other medication (the key that opens the compartment is different from the key that opens the medication cart). If a key system is used, the medication nurse on duty maintains possession of the key to controlled substances storage areas. Back-up keys to all medication storage areas, including those for controlled substances, are kept by the director of nursing or designee. C. Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. D. A controlled substance accountability record is prepared by the pharmacy/facility for all Scheduled II, III, IV, and V medications (See 10.12: INDIVIDUAL RESIDENT'S CONTROLLED SUBSTANCE RECORD, although some states require a bound book with numbered pages), including those in the emergency supply. The following information is completed on the accountability form upon dispensing or receipt of a controlled substance or use of a controlled substance from the emergency supply: 1. Name of resident. If applicable. 2. Prescription number, if applicable. 3. Name, strength, and dosage form of medication. 4. Date received. 5. Quality received. 6. Name of person receiving medication supply. E. At each shift change, or when keys are transferred, a physical inventory of all controlled substance, including refrigerated items is conducted by two licensed nurses and is documented. (See 10.14: SHIFT VERIFICATION OF CONTROLLED SUBSTANCES COUNT). The emergency supply may be verified by assuring that the seal on the supply has not been broken. If the seal has been broke to the emergency narcotic supply, then a physical count of the contents must be conducted by two licensed nurses and paperwork must be present to account for any medication removed from the supply ( contents of the emergency narcotic supply is limited by individual state and federal laws). c) On [DATE] at 12:20 p.m., observations of the facility's East side medication room found 75 vials of Ativan 2 mg/ml (milligrams per milliliter) injectable throughout the refrigerator. A permanently affixed storage box was in the refrigerator, but the door was broken. On [DATE] at 12:20 p.m., with the assistance of RN #12 a physical count of the vials of Ativan stored in the refrigerator was completed. The results of this count found: 1. Resident #81 - There were twenty-five (25) vials of Ativan 2 mg/ml for this resident. The last dose was administered on [DATE]. The resident expired prior to the survey. 2. Resident #1 - Eighteen (18) vials of Ativan 2 mg/ml were found. The last documented dose was administered on [DATE]. 3. Resident #85 - Ten (10) vials of Ativan 2 mg/ml were found for this resident. Last documented dose was administered on [DATE] 4. Resident #97 - Eighteen (18) vials of Ativan 2 mg/ml were found and the last dose was administered on [DATE]. 5. Emergency supply - Four (4) vials of Ativan 2 mg/ml were found. The last dose was administered on [DATE]. All of the vials of Ativan were not properly labeled in packaging from the pharmacy. Some vials were loose with no name or directions on the vials and others were placed in plastic bags with just the resident's name on them. Following the observations of the medication room, reviews of the residents' medical records, progress notes, medication administration records, and individual sign out sheets were completed to ascertain when the last doses of Ativan were administered. Unlike the narcotics records, sign out sheets for Ativan were utilized. In an interview on [DATE] at 12:45 p.m., the DON said she was not aware the permanently affixed compartment of the refrigerator was broken. She also confirmed the labels on the vials were missing and the vials were being stored incorrectly.

Based on observation, staff interview, resident interview, record review, and review of the facility's policy for Medication Administration, the facility failed to ensure the resident environment, over which the facility had control, was as free of accident hazards as possible. Observations found medications in a medication cup sitting unattended on Resident #57's over-bed table. Resident #57 did not have an order to self-administer medications, nor was the resident capable of medication self-administration. Additionally, the facility provided a list of fifteen (15) residents who had the potential to wander in and out of other residents' rooms. Four (4) of the fifteen (15) identified residents had known histories of entering other residents' rooms and/or taking other residents' belongings. At 5:50 p.m. on 12/08/15, the Administrator and Director of Nursing (DON) were informed the observed, unattended medications found on Resident #57's over-bed table, placed the resident's identified by the facility, with the potential to wander into Resident #57's rooms, and potentially ingest the unattended medications, in an immediate jeopardy situation. The facility provided a Plan of Correction (POC) at 6:54 p.m. on 12/08/15. A revised POC was accepted at 7:50 p.m. on 12/08/15. The State agency observed for implementation of the POC and found it properly implemented. At 8:10 p.m. on 12/08/15, the immediate jeopardy was removed. At that time the scope and severity of the citation was reduced from a K to an E. Resident #67 was unable to ambulate safely to the bathroom located within his room, due to other resident's assistive devices and/or furniture, which blocked the path and the doorway to the bathroom. Resident identifiers: #57, #23, #60, #97, #102, and #67. Facility census: 91. Findings include: a) Resident #57 An observation on 12/08/15 at 9:35 a.m., found a medication cup containing six (6) pills sitting on Resident #57's over-bed table. Registered Nurse (RN) #51 verified Resident #57 did not have an order, nor was she able to self-administer her own medications. RN #51 further verified the medications were from an evening medication administration pass scheduled to be administered at 8:30 p.m. and 9:00 p.m. The medications found on the resident's over-bed table were verified with RN #51, by visual comparison of the medications found in the room, to the medications contained on the medication cart. The comparison confirmed the medications observed in the medication cup on Resident #57's over-bed table were: 1. Simvastatin 10 mg (Zocor) - a medication used to treat [DIAGNOSES REDACTED] (high cholesterol and lipids). 2. Carvedilol 25 mg (Coreg) - a medication used to treat hypertension (high blood pressure). 3. Donepezil 10 mg (Aricept) - a medication used to treat Alzheimer's Disease. 4. Furosemide 20 mg three (3) tablets for a total of 60 mg (Lasix) - a diuretic medication. Review of the Medication Administration Record (MAR) for Resident #57 confirmed these medications were scheduled to be administered at 8:30 p.m. and 9:00 p.m. Further review of the MAR found the medication Clonidine HCL 0.1 mg (a medication used to treat high blood pressure) was also scheduled to be administered, and was not observed in the medication cup. All seven (7) medications were initialed as administered on 12/07/15. RN #51 said she could not speculate as to why the Clonidine was not in the medication cup. RN #51 agreed the concern was not only for this resident, but also for other residents with the potential to wander into the room, find, and possibly ingest, the medications. Upon request, the facility provided a list of fifteen (15) residents who had the potential to wander in and out of other residents ' rooms. This created a situation where any of the fifteen (15) residents identified by the facility could wander into Resident #57's room and ingest the unattended medications. Further review of the list of fifteen (15) residents, along with staff interviews, and resident interviews identified four (4) residents with a known history of entering other resident's rooms and/or taking other resident's belongings. Of the four (4) residents identified with the potential to wander in and out of other residents ' rooms, and/or take other residents ' belongings, one (1) of those residents, Resident #60, resided in the room adjoining Resident #57 ' s room. Resident #57 ' s room and Resident #60 ' s room shared an adjoining tub room. The bathtub was not used by any of the eight (8) residents who resided in the two (2) rooms, however, one could easily pass through the tub room into the other room without going into the hallway. Resident #57's over-bed table, on which the unattended medications sat, was by the door leading into the shared tub room. On 12/08/15 at 10:30 a.m., when asked about the morning administration of Resident #57's medications, RN #63 said the resident had refused her morning medications. The RN added provided education to the resident regarding the potential risks of refusing medications used to control her (the resident's) elevated blood pressure. The stated she had not noticed the medication cup located on the resident's over-bed table, while at the resident's bedside. At 11:30 a.m. on 12/08/15, review of the facility's policy for Medication Administration, identified the following medication administration step, which was not followed during the administration of Resident #57's medications: --B. Administration, 17) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. At 11:40 a.m. on 12/08/15, during a discussion about the findings regarding the unattended medications found on Resident #57's over-bed table, the Director of Nursing (DON) agreed the unattended medications had not been administered to the resident as ordered by the physician, or as indicated in the facility's policy for Medication Administration. The DON agreed the unattended medications observed on Resident #57's over-bed table presented a potential concern for any wandering residents, who may have found the medications and ingested them. On 12/08/15 at 2:00 p.m., upon inquiry, RN #51 indicated Resident #57 received most meals in her room. The RN said the resident had received breakfast in her room, and agreed both the delivery and retrieval of the resident's meal tray were opportunities for staff to observe the unattended medications. She further indicated there were other opportunities when staff should have observed the unattended medications, such as during the night when resident rounds were completed. When asked how often rounds were completed, RN #51 said they were completed every two (2) hours or more often if needed. At 5:00 p.m. on 12/08/15, upon inquiry, RN #34 indicated she had completed the morning room round of Resident #57 ' s room at approximately 7:15 a.m. on 12/08/15. When asked what she observed for during the morning room rounds, she stated she observed the room from the door and paid particular attention to the top of the wardrobes, the top of the lights, and looked at the floor. When asked if she had identified the medication cup located on Resident #57's over-bed table, she said she had not noticed it, as the over-bed tables were not the focus of her room rounds. On 12/08/15 at 5:15 p.m., when asked how often rounds or bed checks were completed for Resident #57, Nurse Aide (NA) #57 said the resident was to be checked every two (2) hours or more often if needed, because the resident wore briefs and was occasionally incontinent. At 5:50 p.m. on 12/08/15, the Administrator and Director of Nursing (DON) were informed the observed, unattended medications found on Resident #57's over-bed table, placed the residents identified by the facility with the potential to wander into Resident #57's rooms, and ingest the unattended medications, in an immediate jeopardy situation. The facility provided a Plan of Correction (POC) at 6:54 p.m. on 12/08/15. A revised POC was accepted at 7:50 p.m. on 12/08/15. The POC was: Resident #57 was assessed by the Registered Nurse with no negative effects noted from the alleged deficient practice. Resident #57's physician was notified, no new orders received. Residents residing in the facility have the potential to be affected by the alleged deficient practice. All resident rooms were inspected for any medications left at the bedside on 12/08/15 at 10:30 a.m. by the Director of Nursing, Assistant Director of Nursing, and Unit Managers. No residents were found to have medications at the bedside. All licensed nurses will be reeducated beginning on 12/08/15 on the Medication Administration Policy with special focus on observing residents swallowing medication. All licensed nurses will be reeducated prior to working their next scheduled shift. The education will be completed by the Director of Nursing, Assistant Director of Nursing, Clinical Educator, or Unit Managers. A one-on-one reeducation was completed with the nurse who allegedly left the medication at Resident #57's bedside on 12/08/15 at 6:21 p.m. All resident rooms and bedside tables will be monitored 5 days per week 2 times per day for 4 weeks. Then all resident's rooms will be monitored 5 days per week 1 time a day for 4 weeks. Then all resident's rooms will be monitored 3 days per week 1 time a day for 4 weeks. Then all resident's rooms will be monitored 1 time a week for 4 weeks. Monitoring will continue randomly there after to ensure compliance. The audit will be completed by Administrative Nurses and Facility Department Mangers. The results will be reported to the quality assurance committee monthly with further action completed as necessary. The State agency observed for implementation of the POC and found it properly implemented. At 8:10 p.m. on 12/08/15 the immediate jeopardy was abated. On 12/09/15 at 12:40 p.m., upon inquiry RN #51 said the facility utilized the online website epocrates.com, for questions regarding residents' prescribed medications. Review of the online database utilized by the facility found the potential serious side effects, common side effects and patient education regarding the medications observed on Resident #57's over-bed table, as well as the ordered medication, Clonidine: Simvastatin: -- Potential serious side effects to this medication include: unexplained muscle pain, tenderness, weakness; confusion, memory problems; fever, unusual tiredness and dark colored urine; pain and burning during urination; swelling, weight gain, little or no urinating; increased thirst, increased urination, hunger, dry mouth, blurred vision, weight loss; nausea, upper stomach pain, clay colored stools and jaundice. -- Potential common side effects include: headache; joint pain, mild muscle pain; constipation, stomach pain, mild nausea; mild skin rash; sleep problems (insomnia); or cold symptoms such as a stuffy nose, sneezing and sore throat. -- Patient education instructions state, Never take simvastatin in larger amounts . Taking too much of this medication may cause serious or life-threatening side effects. Grapefruit and grapefruit juice may interact with simvastatin and lead to potentially dangerous effects. Carvedilol: -- Potential serious side effects to this medication include: light-headed feeling; slow or uneven heartbeats; swelling, rapid weight gain, feeling short of breath; cold feeling or numbness in fingers or toes; chest pain, dry cough, wheezing, chest tightness, trouble breathing; or high blood sugar. -- Potential common side effects include: weakness, dizziness; diarrhea; dry eyes; tired feeling; or weight gain. -- Patient education instructions state, you should not take carvedilol if you have asthma, bronchitis, emphysema, severe liver disease, or a serious heart condition such as heart block, or slow heart rate. Donepezil: -- Potential serious side effects to this medication include: black, bloody or tarry stools; coughing up blood or vomit that looks like coffee grounds; painful or difficult urination; or seizures. -- Potential common side effects include: nausea, vomiting, diarrhea; loss of appetite; muscle cramps; tired feeling; or sleep problems (insomnia). -- Patient education instructions state, Before taking donepezil, tell your doctor if you have a heart rhythm disorder such as sick sinus syndrome' (slow heartbeats), an enlarged prostrate, urination problems, asthma, obstructive pulmonary disease, or a seizure disorder such as epilepsy. Furosemide: -- The medication furosemide contains a black box warning which states, (typed as written) Fluid and electrolyte depletion - potent diuretic in excessive amounts can cause profound diuresis w/ water/electrolyte depletion; individualize dose and schedule w/ (with) medical supervision. -- Potential serious side effects to this medication include: ringing in the ears, hearing loss; itching, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); severe pain in the upper stomach spreading to the back, nausea and vomiting; weight loss, body aches and numbness; swelling, rapid weight gain, urinating less than usual or not at all; chest pain, new or worsening cough with fever, trouble breathing; pale skin, bruising, unusual bleeding, feeling light-headed, rapid heart rate, trouble concentrating; low potassium (confusion, uneven heart rate, leg discomfort, muscle weakness or limp feeling); low calcium (tingly feeling around the mouth, muscle tightness or contraction, overactive reflexes); headache, feeling unsteady, weak or shallow breathing; or severe skin reactions. -- Potential common side effects include: diarrhea, constipation, stomach pain; dizziness, spinning sensation; or mild itching or rash. -- Patient education instructions state, You should not use this medication if you are unable to urinate .before using this medication, tell your doctor if you have kidney disease, enlarged prostate, urination problems, cirrhosis or other liver disease, an electrolyte imbalance, high cholesterol, gout, lupus, diabetes, or an allergy to sulfa drugs .Do not take more of this medication than is recommended. High doses of furosemide may cause irreversible hearing loss. Clonidine: -- Potential serious side effects of this medication include: fast or pounding heartbeats, tremors; a very slow heart rate (fewer than 60 beats per minute); feeling short of breath, even without mild exertion; swelling, rapid weight gain; confusion, hallucinations; flu symptoms; urination problems; or feeling like you might pass out. -- Potential common side effects include: drowsiness, dizziness; feeling tired or irritable; cold symptoms such as a runny or stuffy nose, sneezing, coughing, sore throat; mood changes; sleep problems (insomnia), nightmares; headache, ear pain; mild fever; feeling hot; constipation, diarrhea, pain in the upper stomach; or dry mouth, increased thirst. -- Patient education instructions state, Tell your doctor if you have heart disease or severe coronary artery disease; heart rhythm disorder, slow heartbeat; low blood pressure; a history of heart attack or stroke; [DIAGNOSES REDACTED] (tumor of the adrenal gland); kidney disease; or if you have ever had an allergic reaction to a clonidine transdermal skin patch . a) Resident #23 At 12:35 p.m. on 12/09/15, when asked which residents had a known history of wandering in and out of other residents' rooms, RN #51 identified Resident #23, who self-propelled throughout the facility in a wheelchair, had a known history of wandering in and out of other resident's rooms and taking their belongings, and hoarding tendencies. Resident #23 resided in a room located diagonally across the hall from Resident #57 ' s room, where the unattended medications were observed. Medical record review on 12/10/15 at 9:00 a.m. found Resident #23 had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment with an assessment reference date (ARD) of 11/16/15, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The care plan for Resident #23 included a focus area which indicated the risk for potential alteration in hydration related to the use of diuretics, initiated on 04/13/12, with measurable goals and interventions. Review of the progress notes for Resident #23 found entries on 09/28/15; 10/04/15; 10/11/15; 10/18/15; 10/25/15; 11/01/15; 11/08/15; 11/15/15; 11/16/15; 11/22/15; 11/29/15, and 12/06/15, all of which indicated the resident self-propelled throughout the facility in her wheelchair. On 09/26/15, a general progress note identified resident behaviors of rummaging and hoarding. Resident #23's Medication Administration Record (MAR) and current physician's orders [REDACTED].#57's observed, unattended medications. The potential for adverse side effects were identified in the following combinations: -- Resident #23 received the antidepressant duloxetine HCL (Cymbalta), 30 mg, by mouth at 9:30 p.m. on 12/07/15 and again at 9:30 a.m. on 12/08/15. -When duloxetine and carvedilol (used to treat high blood pressure) are combined, the combination has the potential to cause adverse side effects including hypotension (low blood pressure), Atrioventricular (AV) block (partial or complete interruption of impulse transmission from the atria to the ventricles of the heart) and bradycardia (slow heart rate). -- Resident #23 received the Alzheimer's medication donepezil HCL (Aricept), 20 mg, by mouth at 9:00 p.m. on 12/07/15. -When donepezil and carvedilol are combined, the combination has the potential to cause adverse side effects including alteration in cardiac conduction, increased risk of bradycardia, and AV block. -When donepezil is combined with an additional dose of donepezil, the combination has the potential to cause adverse side effects including cholinergic overstimulation or precipitate a cholinergic crisis resulting in a drop in blood pressure. -- Resident #23 received the diuretic hydrochlorothiazide, 12.5 mg, by mouth at 9:30 p.m. on 12/07/15 and again at 9:30 a.m. on 12/08/15. -When the diuretic hydrochlorothiazide is combined with the diuretic furosemide, the combination has the potential to cause adverse side effects including a drop in blood pressure; electrolyte abnormalities, and dehydration. Resident #23 was already at risk for potential hydration concerns, as identified in the care plan. -- Resident #23 received the medication Metoprolol Succinate ER (Toprol XL), 25 mg, by mouth at 9:00 a.m. on 12/08/15, for the treatment high blood pressure (HTN) and atrial fibrillation. -The medications metoprolol and clonidine are not recommended in combination, as the combination of the medications may decrease the antihypertensive response and increase the risk of severe rebound HTN. -- Resident #23 received the antidepressant medication mirtazipine (Remeron), 30 mg, by mouth 9:00 p.m. on 12/07/15. -The antidepressant mirtazipine and clonidine are not recommended in combination, as the combination of the medications may increase the risk of central nervous system (CNS) depression (decreased rate of breathing, decreased heart rate, and loss of consciousness possible leading to coma or death). On 12/14/15 at 11:40 a.m., upon inquiry RN #52 identified Resident #23 as a resident who wandered in the facility in her wheelchair. The RN said the resident had a history of [REDACTED]. She indicated the resident could reach items unless they are located in a high position. b) Resident #60 On 12/09/15 at 11:30 a.m., Resident #2, who resided in the same room as Resident #57, was asked if other residents who did not reside in their room, wandered into the room. The resident said there were several residents that did not live in the room that wandered in and out at times. When asked if she could identify any of the residents, she said, Oh yes, (named Resident #60) comes in here a lot, day and night. At 12:35 p.m. on 12/09/15, when asked which residents had a known history of wandering in and out of other residents' rooms, RN #51 identified Resident #60, an ambulatory resident, with a known history of wandering into other resident's rooms and taking their belongings. She indicated staff had retrieved another resident's cell phone from Resident #60 on 12/08/15, and a few weeks prior, retrieved another resident's dentures from Resident #60. Resident #60 resided in a room adjoining Resident #57 ' s room, where the unattended medications were found. Medical record review on 12/10/15 at 10:25 a.m. found Resident #60 had [DIAGNOSES REDACTED]. Review of Resident #60's Admission MDS with an ARD of 10/08/15 found the resident assessed as having a BIMS score of 03, indicating severe cognitive impairment. The care plan for Resident #60 included a focus area, which indicated the risk for elopement related to attempts to leave the facility, a history of elopement, wandering, and going into other resident's rooms, initiated on 11/03/15. The goal for the focus area was for the resident to remain safe through the next review. Interventions included: a monitoring device, involving the resident in activities, and redirecting the resident from doors. Further review of the care plan found several focus areas initiated on 12/09/15, after the determination of immediate jeopardy which included: -- The focus area of behaviors indicated the resident sometimes had behaviors which included . wandering into other residents ' rooms and removing items from other resident's and hiding them in his pocket. -- A focus area which indicated the resident had impaired cardiovascular status related to cardiovascular disease. -- A focus area which indicated the risk for potential alteration in hydration related to the use of diuretics. Review of the progress notes for Resident #60 found a general progress noted dated 11/27/15, which included the resident was confused and entered other resident's rooms. Another general note entered on 11/20 15 indicated the resident had entered other residents ' rooms, rummaged through their belongings and refused to get out of their beds. Similar notes were identified for 11/18/15, 11/16/15, and 11/14/15. Observations noted Resident #60 wandering throughout the facility and exit seeking on a frequent daily basis from the start of the survey on 12/07/15 through 12/10/15. Resident #60's Medication Administration Record (MAR) and current physician's orders [REDACTED].#57's observed, unattended medications. The potential for adverse side effects were identified in the following combinations: -- Resident #60 received the Alzheimer's medication donepezil HCL (Aricept), 10 mg, by mouth at 9:00 p.m. on 12/07/15. - When donepezil and carvedilol are combined, the combination has the potential to cause adverse side effects including alteration in cardiac conduction, increased risk of bradycardia, and AV block. - When donepezil is combined with an additional dose of donepezil, the combination has the potential to cause adverse side effects including cholinergic overstimulation or precipitate a cholinergic crisis resulting in a drop in blood pressure. -- Resident #60 received the diuretic medications furosemide (Lasix) 20 mg by mouth at 9:00 a.m. on 12/08/15. - The medication furosemide contains the following black box warning: (typed as written) Fluid and electrolyte depletion - potent diuretic in excessive amounts can cause profound diuresis w/ water/electrolyte depletion; individualize dose and schedule w/ medical supervision. -- Resident #60 received the antipsychotic medication olanzapine (Seroquel) 5 mg by mouth at 9:00 p.m. on 12/07/15. -When the antipsychotic olanzapine and clonidine are combined, the combination has the potential to cause adverse side effects including an increased risk of CNS depression (decreased rate of breathing, decreased heart rate, and loss of consciousness possible leading to coma or death), psychomotor impairment, and the additive effects of hypotension. c) Resident #97 At 12:35 p.m. on 12/09/15, when asked which residents had a known history of wandering in and out of other residents' rooms, RN #51 identified Resident #97, an ambulatory resident, had a known history of wandering into other resident's rooms in search of snacks, and had also been found napping in beds other than his own. Resident #97 resided in room 137 on the West hall. Room 137 is located two (2) resident rooms away from room 133, where the unattended medications were observed, on the same side of the hall. Medical record review on 12/10/15 at 11:30 a.m. found Resident #97 had [DIAGNOSES REDACTED]. Resident #97 lacked capacity to make medical decisions, long term related to long term memory deficits, signed and dated by the physician on 05/23/15. The care plan for Resident #97 included a focus area which indicated the risk for potential alteration in hydration related to the use of diuretics, initiated on 06/06/14, with measurable goals and interventions. Other focus areas identified for Resident #97 included an impaired cardiovascular status related to coronary artery disease (CAD), HTN and a history of MI, as well as a history of falls related to weakness, impaired mobility, impaired cognition and poor safety awareness. Review of the progress notes for Resident #97 found a general progress note entered on 11/25/15 which indicated the resident had become combative with staff, when he was escorted from another resident's room, after he was found in another resident's bed. Another general note entered on 12/11/15 indicated the resident continued to have episodes of wandering in the hall and into other resident's rooms. Resident #97's Medication Administration Record (MAR) and current physician's orders [REDACTED].#57's observed, unattended medications. The potential for adverse side effects were identified in the following combinations: --Resident #97 received the medication terazosin (used to treat HTN and enlarged prostate), 5 mg, by mouth at 9:00 p.m. on 12/07/15. -When terazosin and carvedilol (used to treat high blood pressure) are combined, the combination has the potential to cause adverse side effects including an increase in first dose hypotension (low BP) and orthostatic hypotension. --Resident #97 received the diuretic hydrochlorothiazide, 25 mg, by mouth at 9:30 a.m. on 12/08/15. -When the diuretic hydrochlorothiazide is combined with the diuretic furosemide, the combination has the potential to cause adverse side effects including a drop in blood pressure; electrolyte abnormalities, and dehydration. Resident #97 was already at risk for potential hydration concerns, as identified in the care plan. d) Resident #102 At 12:35 p.m. on 12/09/15, when asked which residents had a known history of wandering in and out of other residents' rooms, RN #51 identified Resident #102, an ambulatory resident who had a known history of entering other resident's rooms to socialize, and was often unaware of other resident's personal space. Resident #102 resided in room 103 on the East hall. The resident had previously resided in room 132 on the West hall. Medical record review on 12/14/15 at 10:45 a.m. found Resident #102 had [DIAGNOSES REDACTED]. Review of Resident #102's Admission MDS with an ARD of 10/15/15 found the resident was assessed as having a BIMS score of 04, indicating severe cognitive impairment. The care plan for Resident #102 included a focus area which indicated the risk for potential alteration in hydration related to edema, diabetes mellitus and a history of urinary tract infections (UTIs). Other focus areas identified for Resident #102 included an impaired cardiovascular status related to HTN and [DIAGNOSES REDACTED], as well as a history of falls related to weakness, impaired mobility, generalized weakness and wandering. Review of the progress notes for Resident #102 found entries on 110/31/15, 11/14/15, 11/26/15, 12/03/15,and 12/09/15 which indicated the resident ambulated in the facility independently. Resident #102 was observed ambulating independently throughout the hallways of the facility, on a daily basis, during the course of the survey. Resident #102's Medication Administration Record (MAR) and current physician's orders [REDACTED].#57's observed, unattended medications. The potential for adverse side effects were identified in the following combinations: --Resident #102 received the antidepressant citalopram hydrobromide (Celexa) 20 mg, by mouth at 9:00 a.m. on 12/08/15. -When the antidepressant citalopram is combined with carvedilol (used to treat HTN), the combination has the potential to cause adverse side effects including hypotension (low blood pressure), Atrioventricular (AV) block (partial or complete interruption of impulse transmission from the atria to the ventricles of the heart) and bradycardia (slow heart rate). --Resident #102 received the Alzheimer's medication donepezil HCL (Aricept), 10 mg, by mouth at 9:00 p.m. on 12/07/15. -When donepezil and carvedilol are combined, the combination has the potential to cause adverse side effects including alteration in cardiac conduction, increased risk of bradycardia, and AV block. -When donepezil is combined with an additional dose of donepezil, the combination has the potential to cause adverse side effects including cholinergic overstimulation or precipitate a cholinergic crisis resulting in a drop in blood pressure. --Resident #102 received the antihypertensive lisinopril 5 mg, by mouth at 9:00 a.m. on 12/08/15, with a noted BP of 120/64 at the time of administration. -When lisinopril and furosemide are combined, the combination has the potential to cause adverse side effects including the risk of hypotension. --Resident #102 received the antipsychotic medication risperidone 0.5 mg, by mouth at 9:00 p.m. on 12/07/15. -When risperidone and clonidine are combined, the combination has the potential to cause adverse side effects including an increased risk of CNS depression (decreased rate of breathing, decreased heart rate, and loss of consciousness possible leading to coma or death), psychomotor impairment, and the additive effects of hypotension. e) At 11:00 a.m. on 12/18/15, the facility's consultant pharmacist, #120 was asked about the potential drug interactions and adverse side effects that could have potentially occurred if any of the wandering residents had ingested the unattended medications. The pharmacist verified the most obvious adverse effect was the potentia

Based on record review, review of facility policy, physician interview, and staff interviews, the facility failed to provide the necessary care and services to enable all residents to maintain and/or attain the highest practicable physical well-being. Resident #107 had an order to obtain blood glucose/sugar levels two (2) times a day for a [DIAGNOSES REDACTED]. The facility failed to notify the resident's physician when the resident's blood sugar was 200 and above on 17 of 39 occasions obtained during the resident's 22 day stay at the facility. The resident was transferred to the hospital emergency roiagnom on day 21 of his nursing home stay, where he was diagnosed with [REDACTED]. Upon returning to the nursing home, the facility failed to follow the hospital's instructions for Accu-cheks (blood sugar monitoring) every 6 hours and sliding scale insulin based on the results of the Accu-cheks. Resident #107 expired at the facility on [DATE]. Further investigation of current residents at the facility with a [DIAGNOSES REDACTED].#53. On eighty-seven (87) occasions from [DATE] through [DATE], the resident's blood sugars were 401 or more. The facility administered insulin in accordance with the sliding scale orders, but failed to re-check the blood sugars within 2 hours as directed by the physician's orders [REDACTED]. The immediate jeopardy began on [DATE] at 11:30 a.m., when Resident #53's blood sugar was 493 and the facility failed to re-check the blood sugar after 2 hours. The facility was notified of the immediate jeopardy at 11:53 a.m. on [DATE]. The facility provided a plan of correction at 2:45 p.m. on [DATE], which self-identified three (3) additional residents whose blood sugars were not re-checked within 2 hours when blood sugars were above 401. The immediacy of this deficient practice was abated at 3:15 p.m. on [DATE]; however deficient practices still remained at a scope and severity of E for Residents #130, #57, #60, and #139. Resident #130 was not assessed or provided pain management after a fall in which she sustained a hematoma to the back of her head. For Resident #57, the facility failed to administer medications according to physician's orders [REDACTED]. Resident #60 did not receive a monthly finger stick as ordered by the physician, related to the resident's use of a anti-psychotic medication. The facility failed to arrange transportation for Resident #139, who was scheduled an orthopedic appointment according to hospital discharge instructions. The identified deficient practices had the potential to affect more than a limited number of residents. Resident identifiers: #107, #53, #130, #57, #60, and #139. Facility census: 91. Findings include: a) Resident #107 Medical record review on [DATE] at 9:00 a.m., found Resident #107 was admitted to the facility on [DATE] at 11:50 a.m. The resident expired at the facility on [DATE] at 4:00 p.m., 22 days after his admission. The resident's admitting [DIAGNOSES REDACTED]. On [DATE], the date of admission, the physician wrote an order for [REDACTED]. According to the Medication Administration Record [REDACTED]. Review of Resident #107's Medication Administration Record [REDACTED]. -- [DATE] at 4:30 p.m. - blood sugar was 318 -- [DATE] at 6:30 a.m. - blood sugar was 354, at 4:30 p.m. - blood sugar was 354. -- [DATE] at 6:30 a.m. - blood sugar was 307, at 4:30 p.m. - blood sugar was 337. -- [DATE] at 6:30 a.m. - blood sugar was 375, at 6:30 p.m. - blood sugar was 212 -- [DATE] at 6:30 a.m. - blood sugar was 222. -- [DATE] at 6:30 a.m. - the blood sugar was 214. -- [DATE] at 6:30 a.m. - blood sugar was 245. In [DATE], the resident blood sugar was over 200 on five (5) days of seven (7) days obtained. -- [DATE] at 4:30 p.m. blood sugar was 359. -- [DATE] at 4:30 p.m. blood sugar was 486. -- [DATE] at 6:30 a.m. blood sugar was 396. -- [DATE] at 6:30 a.m. blood sugar was 289. -- [DATE] at 6:30 a.m. blood sugar was 241. Review of the nursing notes found no evidence the physician was notified when the resident's blood sugars were over 200. The facility obtained the blood sugars and recorded the results on the Medication Administration Record [REDACTED]. At 3:44 p.m. on [DATE], the resident's physician was interviewed by telephone. The physician stated he would have expected to have been notified when the resident's blood sugars were over 200 as a blood sugar of over 200 is, . typically when sliding scale insulin starts. On [DATE], the resident was transferred to a local hospital. The only nurse's note written before the transfer was on [DATE] at 6:03 p.m., Resident up in chair returned from lunch, ate a few bites. Awake but not responding verbally to nurses requests/question. CNA (certified nursing assistant) instructed to place resident in bed for further assessment. Resident cachectic (general physical wasting and malnutrition usually associated with chronic disease), poor po (by mouth) intake. Resident does not respond to verbal commands, bp (blood pressure) ,[DATE], p (pulse) 110, r (respirations) 12, O2 sats (oxygen saturation) 80, 911 called for transport to (name of hospital) for evaluation On [DATE], Resident #107 returned to the facility from the hospital at 12:15 a.m. The hospital discharge information noted the resident had a urinary tract infection and [MEDICAL CONDITION]. The resident's blood sugar/glucose level, obtained with a BMP (basic metabolic panel), was 530 at the hospital. The discharge instructions sent to the facility from the hospital included: -- [MEDICATION NAME] (antibiotic) 1 gram IV daily x 2 days ([DATE] and [DATE]), -- Accuchecks every (6) six hours and sliding scale coverage use sliding scale provided or facility equivalent. The local hospital provided the following example of sliding scale coverage: 81 - 150 give zero (0) units. 151 - 200 give two (2) units. 201 - 250 give 4 units. 251 - 300 give six (6) units. 301 - 350 give eight (8) units. 351 - 400 give ten (10) units. Greater than or equal to notify the physician. -- [MEDICATION NAME] DS (antibiotic) 800 mg/160 mg:take 1 tablet orally every 12 hours for 7 days. -- Medications given in the emergency room included: 4:40 p.m. on [DATE], Normal saline bolus 500 milliliters wide open IV (intravenous) fluids in site #1, left wrist. 5:27 p.m. on [DATE], Insulin, regular, 6 units, in IV port in site #1, left wrist. 5:34 p.m. on [DATE], IV of saline at 250 ml/hr (milliliters per hour) in site #1 left wrist. 7:10 p.m. on [DATE], Insulin, regular, 10 units in site #1 left wrist. 7:12 p.m. on [DATE], [MEDICATION NAME] IV, 1 gram in IVPB (intravenous piggyback) in site #1 left wrist. 7:34 p.m. on [DATE], [MEDICATION NAME] 30 grams by mouth. Review of the nurses' notes after the resident's return from the hospital found: -- [DATE] 12:15 a.m. - Resident returned to facility via (name of ambulance service) and accompanied by daughter from (Name of hospital). Resident diagnosed with [REDACTED]. Resident has new order for antibiotics, will need verified with (Name of physician). -- [DATE] at 7:51 p.m. - Up in w/c for meals this shift. All meds called and verified. Fluids and ABT (antibiotic). Resident alert, skin w/d (warm/dry), resps' (respirations) even and unlabored. In dining room for lunch and dinner Pleasant and cooperative. B/P ,[DATE], T-98, P-78, R-20. Resident was layed down in bed with HOB (head of bed) elevated at 3:30 p.m. Summoned to room at 4pm (4:00 p.m.), vital signs ceased. [DATE] 7:56 p.m., Summoned to room at 4pm. Vital signs ceased (The resident expired at 4:00 p.m. on [DATE] according to the nursing note. Dinner was not served until 5:00 p.m. The resident would not have eaten dinner as the nurse's note stated). The resident was in the facility for over 15 hours from the time of arrival from the hospital until he expired. The facility failed to address the recommendations from the hospital which included: starting the antibiotic, [MEDICATION NAME], providing intravenous fluids, increasing Accu-cheks to every 6 hours and providing sliding scale coverage, and [MEDICATION NAME] DS (antibiotic) 800 milligrams/160 milligrams: take one table orally every 12 hours for 7 days. Review of the MAR, for the time after the resident's return from the hospital, found the resident's blood sugar was 241 at 6:30 a.m. on [DATE]. At 4:30 p.m. on [DATE], the MAR indicated [REDACTED]. The nurse's note stated the resident expired at 4:00 p.m. on [DATE]. It was unknown as to how the blood sugar was obtained at 4:30 p.m. on [DATE] when the resident expired at 4:00 p.m. on [DATE]. Sliding scale coverage was not initiated when the resident's blood sugar was 241 at 6:30 a.m. There was no indication the facility obtained the resident's blood sugar every 6 hours as indicated in the hospital discharge orders. An interview with Registered Nurse (RN) #12, a charge nurse, at 8:45 a.m. on [DATE] revealed she thought she should only call the physician when the resident's blood sugars were over 400. She said the physician came weekly and he should have been looking at the blood sugars during his visits. (It should be noted the physician is required to see a resident every 30 days for the first 90 days of admission, then at least once every 60 days thereafter. Unless there was a concern brought to the attention of the physician by the resident, or nursing staff on behalf of the resident, the physician would not have had occasion to examine the resident or the resident's record. By virtue of the physician ordering blood sugars to be checked on this resident, the expectation would be for nursing staff to monitor the blood sugars and alert the physician of abnormal findings. When Resident #107's blood sugars were high repeatedly, especially as he was not receiving any medications to control his blood sugars, nursing staff should have alerted the physician, just as would be expected if a resident had a fever or high blood pressure readings.) RN #12 was also the nurse on duty when the resident expired at the facility on [DATE]. She did not know why the resident's medications were not started based on the hospital recommendations. She said she did not remember the resident. She stated she must have made a mistake when she wrote the resident ate his lunch and supper in the dining room on [DATE], because if he expired at 4:00 p.m., he could not have eaten his supper in the dining room. Review of the facility's policy, entitled, Diabetes management Guideline, version #4, found the following: --All residents will have appropriate treatment and services to manage their Diabetes. The American Diabetes Association states that the ideal goal for adults with diabetes is to achieve glucose levels between ,[DATE] mg/dl before meals and less than 180 two hours after the start of the meals. [MEDICAL CONDITION] is common cause of illness and is the cause of secondary complications of the disease. Common Signs and Symptoms: More frequent urination, incontinence Increased fatigue Unexplained weight loss New vision problems Decreased mental function, confusion At 10:38 a.m. on [DATE], the director of nursing (DON) confirmed she had no further information to provide to dispute these findings. She said she would have called the doctor if the resident's blood sugars were 200 or over because that is, The typical scale of when someone would start sliding scale insulin. At 1:20 p.m. on [DATE], the resident's physician reviewed the hospital discharge instructions. The physician confirmed if he would have known about the resident's blood sugars early on, he would have started sliding scale insulin after the resident's admission to the facility. He said, That would have been the way to go because he had failure to thrive so I would not have ordered regular insulin. When the physician reviewed the hospital emergency room documents and noted the blood sugar was 530 he stated, The UTI (urinary tract infection) could have been caused by the glucose spilling over into the urine causing the infection. He said he could not remember if he was called after the resident's return from the hospital. b) Resident #53 Review of the resident's medical record on [DATE] found the resident had a [DIAGNOSES REDACTED]. Review of the resident's current Medication Administration Record [REDACTED] [MEDICATION NAME] Solution, inject as per sliding scale: - ,[DATE] = 0 units - ,[DATE] = 2 units - ,[DATE] =4 units - ,[DATE] = 6 units - ,[DATE] = 8 units - ,[DATE] = 10 units - 401+ = 12 units. Recheck in 2 hours and call MD if still over 400., subcutaneous before meals related to diabetes with unspecified complications type II unspecified not stated uncontrolled. This order was also in effect during the months of June, July, August, September, October, November, and [DATE]. On 9 occasions in [DATE], the resident's blood sugar was over 401, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] at 11:30 a.m. - blood sugar was 493. -- [DATE] at 4:30 p.m. - blood sugar was 448. -- [DATE] at 4:30 p.m. - blood sugar was 419. -- [DATE] at 11:30 a.m. - blood sugar was 431. -- [DATE] at 11:30 a.m. - blood sugar was 415. -- [DATE] at 11:30 a.m. - blood sugar was 408. -- [DATE] at 4:30 p.m. - blood sugar was 483. -- [DATE] at 6:30 a.m. - blood sugar was 442. -- [DATE] at 11:30 a.m. - blood sugar was 409. On 7 occasions in [DATE], the resident's blood sugar was over 401, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] the resident's blood sugar was 417 at 11:30 a.m. and 410 at 4:30 p.m. -- [DATE] at 11:30 a.m. - blood sugar was 497. -- [DATE] at 11:30 a.m. - blood sugar was 416. -- [DATE] at 6:30 a.m. - blood sugar was 403. -- [DATE] at 11:30 a.m. - blood sugar 469. -- [DATE] at 4:30 a.m. - blood sugar was 498. On 12 occasions in [DATE], the resident's blood sugar was over 401, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] at 11:30 a.m. - blood sugar was 469. -- [DATE] at 11:30 a.m. - blood sugar was 411; at 4:30 p.m. - blood sugar was 459. -- [DATE] at 11:30 a.m. - blood sugar was 431; at 4:30 p.m. - blood sugar was 532. -- [DATE] at 6:30 a.m. - blood sugar was 439. -- [DATE] at 4:30 p.m. - blood sugar was 433. -- [DATE] at 11:30 a.m. - blood sugar was 428. -- [DATE] at 11:30 a.m. - blood sugar was 540. -- [DATE] at 4:30 p.m. - blood sugar was 480. -- [DATE] at 11:30 a.m. - the blood sugar was 422. -- [DATE] at 11:30 a.m. - the blood sugar was 410. On 16 occasions in [DATE], the resident's blood sugar was 401 or above, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] at 4:30 p.m. - blood sugar was 529. -- [DATE] at 11:30 a.m. - blood sugar was 437; at 4:30 p.m. - blood sugar was 422. -- [DATE] at 11:30 a.m. - blood sugar was 437; at 4:30 p.m. - blood sugar was 588. -- [DATE] at 4:30 p.m. - blood sugar was 475. -- [DATE] at 11:30 a.m. - blood sugar was 450; at 4:30 p.m. - blood sugar as 401. -- [DATE] at 11:30 a.m. - blood sugar was 458. -- [DATE] at 11:30 a.m. - blood sugar was 503, at 4:30 p.m. the blood sugar was 499. -- [DATE] at 4:30 p.m. - blood sugar was 445. -- [DATE] at 4:30 p.m. - blood sugar 521. -- [DATE] at 4:30 p.m. - blood sugar was 593. -- [DATE] at 4:30 p.m. - blood sugar was 421. -- [DATE] at 4:30 p.m. - blood sugar was 459. On 20 occasions in [DATE], the resident's blood sugar was over 401, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] at 11:30 a.m. - blood sugar was 407. -- [DATE] at 11:30 a.m. - blood sugar was 438. -- [DATE] at 11:30 a.m. - blood sugar was 458; at 4:30 p.m. - blood sugar was again 458. -- [DATE] at 11:30 a.m. - blood sugar was 468; at 4:30 p.m. - blood sugar was 560. -- [DATE] at 11:30 a.m. - blood sugar 408. -- [DATE] at 4:30 p.m. - blood sugar was 414. -- [DATE] at 11:30 a.m. - blood sugar was 441; at 4:30 p.m. - blood sugar was 409. -- [DATE] at 4:30 p.m. - blood sugar was 500. -- [DATE] at 4:30 p.m. - blood sugar was 447. -- [DATE] at 4:30 p.m. - blood sugar was 450. -- [DATE] at 4:30 p.m. - blood sugar was 450. -- [DATE] at 11:30 a.m. - blood sugar was 411. -- [DATE] at 11:30 a.m. - blood sugar was 420. -- [DATE] at 11:30 a.m. - blood sugar was 471. -- [DATE] at 4:30 p.m. - blood sugar was 421. -- [DATE] at 4:30 p.m. - blood sugar was 421. -- [DATE] at 4:30 p.m. - blood sugar was 419. On 14 occasions in [DATE], the resident's blood sugar was over 401, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] at 11:30 a.m. - blood sugar was 417; at 4:30 p.m. - blood sugar was 486. -- [DATE] at 11:30 a.m. - blood sugar was 420; at 4:30 p.m. - blood sugar was 450. -- [DATE] at 4:30 p.m. - blood sugar was 450. -- [DATE] at 11:30 a.m. - blood sugar was 428. -- [DATE] at 4:30 p.m. - blood sugar was 490. -- [DATE] at 6:30 a.m. - blood sugar was 408. -- [DATE] at 11:30 a.m. - blood sugar was 455; at 4:30 p.m. - blood sugar was 458. -- [DATE] at 11:30 a.m. - blood sugar was 419. -- [DATE] at 11:30 a.m. - blood sugar was 550; at 4:30 p.m. - blood sugar was 435. -- [DATE] at 11:30 a.m. - blood sugar was 516. On 9 nine occasions in [DATE], the resident's blood sugar was over 401, insulin was administered according to the sliding scale coverage order, but there was no evidence the resident's blood sugar was re-checked after 2 hours: -- [DATE] at 11:30 a.m. - blood sugar 500 -- [DATE] at 11:30 a.m. - blood sugar was 450 -- [DATE] at 4:30 p.m. - blood sugar was 511. -- [DATE] at 11:30 a.m. - blood sugar was 505, at 4:30 p.m. the blood sugar was 525. -- [DATE] at 4:30 p.m. - blood sugar was 482. -- [DATE] at 4:30 p.m. - blood sugar was 414 -- [DATE] at 11:30 a.m. - blood sugar was 433; at 4:30 p.m. - blood sugar was 437. Review of the nursing notes for these months found no indication the resident's blood sugars were rechecked after 2 hours. By failing to recheck the resident's blood sugars 2 hours after administration of sliding scale insulin as ordered by the physician, the facility failed to ensure the resident's blood sugars were controlled. At 10:30 a.m. on [DATE], the director of nursing confirmed she could find no evidence the resident's blood sugars were rechecked after 2 hours when the blood sugars were 401 or above. c) Based on the findings regarding elevated blood sugars for deceased Resident #107 and for Resident #53, who was still at risk for health problems resulting from elevated blood sugars, an immediate jeopardy to the resident was identified. The facility was notified of the immediate jeopardy on [DATE] at 11:53 a.m. At 2:45 p.m. on [DATE], the facility administrator provided the immediate plan of correction, as follows: In response to the alleged deficient practice on [DATE], the facility plan of correction is as follows: Resident #107 no longer resides in facility. Resident #53's [DATE] blood sugars were sent to the physician for review. Resident #53's current blood sugar order was reviewed and is now being followed as ordered. All residents with sliding scale insulin orders and all residents with orders for glucometer checks have the potential to be affected. All residents with sliding scale insulin orders were audited and any issues were sent to the physician for review. All residents with active orders for glucometer checks will be reviewed to ensure proper parameters are in place. All licensed nurses will be reeducated beginning on [DATE] and prior to their next scheduled shift on Diabetic Management Guideline and specifically proper procedure for following sliding scale insulin coverage according to physician order [REDACTED]. The education will be completed by the Director of Nursing, RN Clinical Educator, Assistant Director of Nursing, or Unit Managers. All residents that have orders for accuchecks and or sliding scale insulin will have their MAR's audited daily 5 days a week 1 time a day for 4 weeks to ensure sliding scale insulin coverage orders are being followed. Then all residents will be monitored 3 times a week 1 time a day for 4 weeks. Then all residents will be monitored 1 time a week for 4 weeks. Monitoring will continue randomly there after to ensure compliance. The audit will be completed by Administrative Nurses. The results will be reported to the quality assurance committee monthly with further action completed as necessary. d) Resident #130 Record review at 2:30 p.m. on [DATE], found the resident was admitted to the facility on [DATE]. Review of the resident's admission paperwork from the hospital found the resident was a passenger in a motor vehicle accident on [DATE]. The resident was found to have multiple fractures including rib fractures, left ankle fracture, left tibial plateau fracture, nondisplaced metacarpal fractures of the right hand digits 2 and 3, [MEDICATION NAME] process fracture of T1 (first [MEDICATION NAME] vertebra), C6, and C7 (6th and 7th cervical vertebrae), cardiac contusion, a left eye hematoma, and a [MEDICAL CONDITION] with a noted scalp hematoma with a minimal amount of subarachnoid hemorrhage (bleeding into the space between the brain and tissue covering the brain). On [DATE] at 7:10 p.m., the resident fell at the facility while ambulating without assistance. The accident report noted the resident fell in her room and was found between the bed and the wheelchair. She had a hematoma to the back of her head. The incident report, completed on [DATE], noted the resident said she had a headache. The summary and outcome of the investigation on the incident report were: Resident was put back in bed and assessed by the nurse. A small hematoma was found on the back of her head. The physician was notified. Pain management and neuro (neurological) checks started and call light was placed in reach. Further review of the nurses' notes and the Medication Administration Record [REDACTED]. Her pain was not rated after the fall, although she reported a headache. Review of the [DATE] MAR found the resident was already prescribed a PRN (as needed) pain medication before the fall occurred. There was an existing order for [MEDICATION NAME] HCI ([MEDICATION NAME]) tablet mg (milligrams), give 5 mg by mouth every 8 hours as needed for pain. According to the MAR, the resident did not receive this medication on [DATE] There was no evidence in the resident's electronic medical record, or the resident's paper medical record, of any neurological checks being implemented. At 3:22 p.m. on [DATE], the director of nursing (DON) was unable to provide any evidence of care provided to the resident after her fall on [DATE], such as rating the resident's pain, providing medication for her headache, or providing neurological checks for 72 hours after the fall. At 3:35 p.m. on [DATE], Registered Nurse (RN) #51, the unit manager, said the neurological checks should be the resident's paper medical record. However, she was unable to find any evidence neurological checks were started after the fall. She provided a blank copy of a paper form entitled, Neurological Assessment which directed staff to provide 15 minute checks x 4, 1 hour checks x 2, then every 4 hours x 4, then every shift for 72 hours. On [DATE] at 4:42 p.m., the DON verified she was unable to provide any verification of neurological checks completed on the resident for 72 hours after her fall. The DON provided a copy of the facility's policy entitled, Neurological Checks. The policy directed: It is the policy of Golden Living to conduct neurological checks on residents as clinically appropriate (whenever there is a question of a head injury or a change in neurological status or level of consciousness) . Neurological checks should be performed periodically for at least 72 hours At 1:19 p.m. on [DATE], the resident's physician, Physician #118, stated staff did call him regarding residents' falls, but he could not recall this particular fall. He stated the resident could have had a Tylenol if needed as it was a standing order. e) Resident #57 An observation on [DATE] at 9:35 a.m., found a medication cup containing six (6) pills sitting on Resident #57's over-bed table. Registered Nurse (RN) #51 verified Resident #57 did not have an order for [REDACTED].#51 further verified the medications were from an evening medication administration pass, scheduled to be administered at 8:30 p.m. and 9:00 p.m. The medications found on the resident's over-bed table were verified with RN #51, by visual comparison of the medications found in the room, to the medications contained on the medication cart. The medications were labeled with the name of the medication as well as the dosage. The comparison confirmed the following medications, observed in the medication cup on Resident #57's over-bed table were: 1. [MEDICATION NAME] 10 mg ([MEDICATION NAME]) - a medication used to treat [MEDICAL CONDITION] (high cholesterol and lipids) 2. Carvedilol 25 mg ([MEDICATION NAME]) - a medication used to treat Hypertension (high blood pressure) 3. Donepezil 10 mg ([MEDICATION NAME]) - a medication used to treat [MEDICAL CONDITION] 4. [MEDICATION NAME] 20 mg three (3) tablets for a total of 60 mg ([MEDICATION NAME]) - a diuretic medication Review of the Medication Administration Record [REDACTED].) All seven (7) medications were initialed as administered on [DATE]. RN #51 said she could not speculate as to why the [MEDICATION NAME] was not in the medication cup. RN #51 agreed the medications should not have been on the resident's over-bed table, and were not administered as ordered by the physician. On [DATE] at 11:30 a.m., review of the facility's policy for Medication Administration, identified the following medication administration step, which was not followed during the administration of Resident #57's medications: [REDACTED] -- B. Administration, 17) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. At 11:40 a.m. on [DATE], findings of the observed, unattended medications found on Resident #57's over-bed table, were discussed with the Director of Nursing (DON). The DON agreed the unattended medications had not been administered to the resident as ordered by the physician, or as indicated in the facility's policy for Medication Administration. f) Resident #60 A review of Resident #60's medical record at 10:12 a.m. on [DATE], found a physician's orders [REDACTED]. This finger stick was scheduled to be obtained on the last day of the month every month. Review of the [DATE] Medication Administration Record [REDACTED]. There were no documented blood sugars in the medical record for Resident #60. An interview with the West Wing Unit Manager Registered Nurse (RN) #51 at 12:43 p.m. on [DATE], confirmed the resident's blood sugar was never obtained as ordered by the physician. She reviewed the medical record and confirmed there were no blood sugars obtained for Resident #60. g) Resident #139 Review of Resident #139's medical record at 12:57 p.m. on [DATE], found she was admitted to the facility on [DATE] after having a surgical repair of a [MEDICAL CONDITION] at a local hospital. A review of the hospital discharge paperwork, which was received by the facility on [DATE], found the resident had a follow up appointment scheduled with her orthopedic surgeon on [DATE] at 8:30 a.m. This appointment had been circled as to draw attention to it. Further review of the record found a handwritten page which was later confirmed as notes written by the nurse who had received a verbal report from the hospital prior to Resident #139's arrival on [DATE]. Written on this sheet was the following text (typed as written), (name of orthopedic doctor) drsg (dressing) ,[DATE] - DO NOT CHANGE! appt (appointment) /c (with) Nov (November) 6 (six) 8:30 (a.m.). Additional review of the record found a handwritten physician's progress note written by Resident #139's attending physician on [DATE]. The physician wrote, (typed as written) Pt. (patient) was suppose to have appt (appointment) with Dr. (name of orthopedic surgeon) on [DATE] & (and) pt was not sent to appt by us. Pt still has staples we need to call (name of orthopedic surgeon) office and reschedule the appt for this week & also see if we can remove staples. Review of Resident #139's nursing progress notes found the following notes (all typed as written): [DATE] at 2:54 a.m. new order to f/u (follow up) on appt (appointment) with (name of orthopedic surgeon) that was missed on [DATE] to reschedule and check on staple removal [DATE] at 9:13 a.m. (Name of Orthopedic Surgeon),[DATE] @ (at) 1:45 (p.m.) (name of office) DOES NOT WANT STAPLES TAKEN OUT

Based on record review and staff interview the facility failed to ensure Resident #69 who entered the nursing home without a pressure sore did not develop pressure sores unless unavoidable. The facility failed to implement preventative measures for Resident, who was assessed as being at risk to develop pressure sores. The resident developed pressure sores on her heels, which were identified as necrotic when discovered. The resident's pressure ulcers could not be determined to be unavoidable due to the facility's failure to provide appropriate and timely interventions. The right heel wound required debridement and became infected, necessitating treatment with antibiotics. The facility's failure to provide needed care and services to Resident #69 resulted in actual harm to the resident. This was true for one (1) of four (4) residents reviewed for the care area of pressure ulcers during Stage 2 of the Quality Indicator Survey. Resident Identifier: #69. Facility Census: 91. Findings Include: a) Resident #69 A review of Resident #69's medical record at 12:35 p.m. on 12/15/15, found this [AGE] year-old female, originally admitted to the facility on [DATE], returned from an acute care hospital on [DATE]. The Clinical Health Status form completed upon her readmission on 06/15/15, identified Resident #69 had no skin concerns upon her readmission. The form specifically asked if Resident #69 had a history of [REDACTED]. The form also directed staff to complete a Braden Scale for Predicting Pressure Sore Risk. Upon completion of this scale, Resident #69's score was 15, indicating she was at risk for developing a pressure ulcer. Resident #69's [DIAGNOSES REDACTED]. The record also contained a Quarterly Clinical Health Status assessment completed by Registered Nurse (RN) #58 and another staff member, whose signature was illegible. The assessment, completed on 07/15/15, indicated Resident #69's skin was intact, and there were no concerns noted to the resident's feet. The Braden Scale for Predicting Pressure Ulcers completed at that time scored the resident as 16, indicating she was at risk for developing pressure ulcers. On 07/16/15 at 5:50 p.m., the Assistant Director of Nursing Services (ADNS) RN #33 wrote a progress note, Suspected Deep Tissue Injury (SDTI) to the left heel measuring 1.8 X 1.1 centimeters (cm) and a SDTI to the right heel measuring 7.2 X 8 cm. She indicated both areas were soft and the areas around the wounds were blanchable. The ADNS noted the resident's history of toe amputations to the resident's left foot, and that the attending physician was aware of the new areas. The note indicated they would offload (keep pressure off) the heels with pillows. She also noted new orders for Prevalon boots when out of bed and Sureprep (skin protectant) to the areas every shift. The Clinical Health Status assessment, completed the day before, did not identify these wounds. The nursing staff assessing the resident at that time noted no skin irregularities, indicating they looked at the resident's skin and found no concerns. The National Pressure Ulcer Advisory Panel (NPUAP) defines a Suspected Deep Tissue Injury (SDTI) - depth unknown as a, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. NPUAP definitions also include, Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown - Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV Based on these definitions, it was difficult to determine whether the resident actually had SDTI or unstageable pressure ulcers at the time the wounds were discovered on 07/16/15. The ADNS initiated a Wound evaluation Flow Sheet for each wound. Review of these flow sheets found the following: 1. Left Heel wound - a. Left heel evaluations completed by the ADNS: -- 07/16/15: Measured: 1.8 X 1.1 X 0 cm Identified: on 07/16/15 as in-house acquired Wound bed: 100% necrotic Wound margins: defined. Current treatment: Sureprep initiated on 07/16/15. Current preventative measures: wheelchair cushion and heel protectors. -- 07/22/15: Measured: 1.8 X 1.0 X 0 cm Wound bed: 100% necrotic Wound margins: defined. Current treatment: Sureprep initiated on 07/16/15. Current preventative measures: wheelchair cushion, protein supplement, and heel protectors. -- 07/28/15: Measured: 1.1 X 1.9 X 0 cm Wound bed: 100% necrotic. Wound margins: defined Current treatment: Sureprep initiated on 07/16/15 Current preventative measures: wheelchair cushion and heel protectors. b. Left heel evaluations by Wound Care Nurse RN #47 -- 08/03/15: Measured: 1.1 X 1.9 X 0 cm Wound bed: 100% skin Wound margins: undefined Current treatment: Sureprep initiated on 08/03/15 Current preventative measures: pressure redistribution mattress, float heels in bed, and heel boots. -- 08/19/15: Measured: 1.1 X 1.9 X 0 cm Wound bed: 100% skin Wound margins: undefined. Current treatment: Sureprep, Prevalon boots, Float Heels, pressure reducing mattress MA65 (with no date as to when these treatments were initiated) Current preventative measures: pressure redistribution mattress, and nutritional supplements. 08/24/15: Measured: 1.1 X 1.9 X 0 cm Wound bed: 100% skin Wound margins: described as not assessed Current treatment: Sureprep initiated on 08/24/15. Current preventative measures: nutritional supplements and heel boots. 09/01/15: The wound was described as healed on this date. Wound Care Nurse RN #47 began completing the wound assessments on 08/03/15 at which time she began describing the wound bed as 100% skin. Prior to 08/03/15, the ADNS was describing the wound as 100% necrotic. The physician also described the wounds as necrotic in his note dated 08/10/15. 2. Wound to right heel: a. Right heel evaluations completed by the ADNS: -- 07/16/15: Measured: 7.2 X 8 X 0 cm Identified on 07/16/15 , staged as a SDTI, identified as in-house acquired pressure ulcer. Wound bed: 100% necrotic. Wound color: black. Wound margins: defined. Current treatment: None listed on the wound evaluation. Current preventative measures: wheelchair cushion and heel protectors. -- 07/22/15: Measured: 7.2 X 8 X 0 cm Wound bed: 100% necrotic Current treatment: Sureprep initiated on 07/16/15 Current preventative measures: wheelchair cushion, protein supplements, and heel boots. -- 07/28/15: Measured: 6.8 X 9.1 X 0 cm Wound bed: 100% necrotic Wound margins: defined Current treatment: Sureprep initiated on 07/16/15 Current preventative measures: Pressure redistribution mattress, wheelchair cushion, and heel boots b. Wounds evaluation was completed by the Wound Care Nurse RN #47 -- 08/03/15: Measured 6.8 X 9.1 X 0 cm Wound bed: 100% skin Wound Margins: undefined. Current treatment: Sureprep initiated on 08/03/15 Current preventative measures: pressure redistribution mattress, float heels while in bed, and heel boots 08/19/15: Measured: 6.8 X 9.1 X 0 cm Wound bed: 100% skin. Wound margins: were not assessed Current treatmen: Hydrogel with no initiation date listed Current preventative measures: included a pressure redistribution mattress, and vitamin supplements 08/24/15: Measured 6.8 X 9.1 X 0 cm Exudate: This was the first assessment in which the wound had exudate which was described as sanguineous in color, consistency thin and watery, amount small/minimal Odor: none present. Wound bed: 50% slough and 50 % skin. Wound margins: were not assessed. Current treatment: Santyl with alginate and refer to wound care clinic. Current preventative measures: heel boots. 09/02/15: Measured: 6.8 X 9.1 X 0 cm Wound bed: 30% slough and 70% skin Color: brown Wound margins: undefined Exudate: seroanguineous in color, consistency thin and watery, amount moderate Odor: foul. Current treatment: Santyl with alginate, wound care clinic referral with a start date of 09/01/15 Current preventative measures: pressure redistribution mattress, wheelchair cushion, and heel boots. 09/10/15: Measured: 6.8 X 9.1 X 0 cm Wound bed: 30% slough and 70% skin Color: brown Wound margins: were not assessed Exudate: seroanguineous in color, consistency thin and watery, amount moderate Odor: foul Current treatment: Santyl with alginate started on 09/01/15 Current preventative measures: pressure redistribution mattress, wheelchair cushion, nutritional supplement, vitamin supplement, and heel boots. 09/23/15: Measured: 4.2 X 5.9 X 2.5 cm Wound bed: 100% granulation. Wound margins: undefined. Exudate: [MEDICAL CONDITION] in color, thick and tenacious consistency, amount small, minimal Odor: foul Current treatment: [MEDICATION NAME] Alginate with a start date of 09/09/15 Current preventative measures: pressure redistribution mattress, nutritional supplement, vitamin supplement and heel boots. Evaluation: noted the wound had been debrided. 10/01/15: Measured: 4 X 4.6 X 2.5 cm Wound bed: 100% granulation. Wound margins: were not assessed Exudate: [MEDICAL CONDITION] in color, thick and tenacious consistency, amount moderate Odor: foul Current treatment: Aqualcel alginate ordered by the wound care clinic with a start date of 09/25/15 Current preventative measures: pressure redistribution mattress, wheelchair cushion, nutritional supplement, protein supplements, and heel boots 10/07/15: Measured: 3.8 X 4.5 X 2.2 cm Wound bed: 100% granulation Wound margins: undefined Exudate: [MEDICAL CONDITION] in color, consistency thin and watery, amount moderate Odor: foul Current treatment: Aqualcel Alginate with a start date of 10/02/15 Current preventative measures: pressure redistribution mattress, nutritional supplement 10/14/15: Measured: 3.5 X 4.3 X 2 cm Wound bed: 100% granulation Wound margins: undefined Exudate: [MEDICAL CONDITION] in color, consistency thick and tenacious, amount moderate Odor: foul Current treatment: Aqualcel Alginate with a start date of 09/09/15. Current preventative measures: nutritional supplement, vitamin supplement, and heel boots, CAM (Controlled Ankle Movement) Boot. Stage: RN #47 noted the wounds appeared as a Stage III (3) wound at that time. 10/20/15: Measured: 3.5 X 4.1 X 2 cm Wound bed: 100% granulation Wound margins: undefined Exudate: [MEDICAL CONDITION] in color, consistency thick and tenacious, amount small, minimal Odor: musty Current treatment: Aqualcel Alginate - start date of 10/20/15. Current Preventative measures: pressure redistribution mattress, w/c (wheelchair) cushion, nutritional supplement, vitamin supplement, and heel boots. 10/27/15: Measured: 3.5 X 4.1 X 2 cm Wound margins: undefined Exudate: [MEDICAL CONDITION] in color, consistency thick and tenacious, amount small/minimal Odor: musty Wound bed: 100% granulation Current treatment: Aqualcel Alginate - start date of 10/20/15 Current preventative measures: pressure redistribution mattress, vitamin supplement, and CAM Boot Stage: Stage III 11/04/15: Measured 3.5 X 4.1 X 2 cm Wound bed: 100% granulation. Wound margins: undefined Exudate: purulent drainage Current treatment: Aqualcel Alginate - start date of 10/20/15 Current preventative measures: pressure redistribution mattress, nutritional supplement, and heel boots Stage: Stage III 11/11/15: Measured: 3 X 4.1 X 1.6 cm Wound bed: 100% granulation Wound margins: undefined Exudate: purulent, [MEDICAL CONDITION] in color, consistency thick and tenacious, amount small/minimal Odor: musty Current treatment: Aqualcel Alginate - start date of 11/10/15 Current preventative measures: pressure redistribution mattress, nutritional supplement, and heel boots. Stage: Stage III. Late Entry for 11/16/15 entered on 11/23/15: Measured: 3 X 4.1 X 1.6 cm Wound bed: 100% granulation Wound margins: undefined Exudate: purulent, [MEDICAL CONDITION] in color, consistency thick and tenacious, amount small/minimal Odor: musty Current treatment: Aqualcel Alginate - start date of 11/17/15 Current preventative measures: pressure redistribution mattress Stage: Stage III. 11/23/15: Measured: 3 X 4.1 X 1.6 cm Wound bed: 100% granulation Wound margins: undefined Wound exudate: serosanguinous in color, consistency thin and watery, amount was small/minimal Odor: no odor Current treatment - Aqualcel Alginate - start date was 11/18/15 No preventative measures identified Stage: Stage III 12/01/15: Measured: 2.3 X 4 X 1.3 cm Wound bed: 100% granulation Color: Pink Wound margins: undefined Exudate: serosanguineous, consistency thin and watery, amount scant Odor: no odor Current treatment: [MEDICATION NAME] Alginate - start date of 11/24/15 Current preventative measures: pressure redistribution mattress Stage: Stage III 12/07/15: Measured: 2 X 3.8 X 0.8 cm Wound bed: 100% granulation Color: pink Wound margins: undefined. Exudate: serosanguineous, consistency thin and watery, amount scant Odor: no odor Current treatment: [MEDICATION NAME] Alginate - start date of 12/02/15 Current preventative measures: heel boots Stage: Stage III 12/14/15: Measured: 2 X 3.5 X 0.5 cm Wound bed: 100% granulation Color: pink Wound margins: undefined. Exudate: serosanguineous, consistency thin and watery, amount was scant Odor: no odor Current treatment: [MEDICATION NAME] alginate - start date 12/08/15 No preventative measures listed Stage: Stage III Again, on 08/03/15 the Wound Care Nurse RN #47 began describing the wound as 100% skin as opposed to the ADNS's and physician's description of the wound as being 100% necrotic. An interview with the wound care nurse, RN #47, at 4:39 p.m. on 12/16/15, found she described the wounds as 100% skin because the wounds were not open. She then reviewed the physician's progress note dated 08/10/15, which indicated the wounds were necrotic. She said that whatever he said was what it was, because he out ruled her, because he was the doctor. Further review of the medical record found laboratory (lab) results measuring the resident's total protein and her [MEDICATION NAME] (low [MEDICATION NAME] has been linked to increased risk of pressure sores, protein is needed for healing). (Normal ranges should be between 6.2 and 8.5 for total protein, and the [MEDICATION NAME] level should fall between 3.2 and 5.5.) The resident's lab results prior to the pressure sores developing were: -- 12/23/14: Total Protein 6.3 - within normal range -- 12/23/14: [MEDICATION NAME] 2.9 - low -- 06/22/15: Total Protein 5.4 - low -- 06/22/15: [MEDICATION NAME] 2.1 - low -- 06/29/15: Total Protein 5.9 - low -- 06/29/15: [MEDICATION NAME] 2.3 - low The resident's lab results after the pressure sores developed were: -- 09/11/15: Total Protein 6.0 - low -- 09/11/15: [MEDICATION NAME] - 2.3 - low A progress note dated, 08/18/15 at 2:07p.m., by the former Director of Nursing Services (DNS), noted the resident was at her targeted weight of 188 pounds for her planned weight loss and that she has continued to lose weight. The former DNS went on to note Resident #69 would be started on 2 Cal (a high calorie) protein supplement to aide in wound healing. This intervention was not added until 08/18/15 even though the resident had low protein and [MEDICATION NAME] levels on 06/22/15 and 06/29/15. This was a month after the pressure ulcers were identified on 07/16/15. On 09/11/15 Resident #69's protein and [MEDICATION NAME] levels remained low and were not addressed by the facility until 10/02/15, when the Licensed Dietitian (LD) recommended double portions of proteins with meals. Review of the physician progress notes [REDACTED].#69's wounds: -- 08/10/15: . Pt (patient) seen for acute visit stopped by res (resident) room & (and) noticed heels wrapped Pt has two ulcer (sic) 1 (one) each heel /c (with) necrotic, I was never notified of these wounds . Skin: (sign for right) heel large necrotic ulcer unstageable (sign for left) heel small necrotic eschar ulcer unstagable . 1) unstageable ulcer b/l (bilateral) heels - change wound orders to hydrogel & tegrafoam change once a day & prevalon boots at all times. -- 08/24/15: Pt. (patient) seen for acute visit Res (resident) has b/l (bilateral) unstageable ulcers heels. Nursing notice(d) eschar tissue opening on (sign for right) heal /c (with) odorous discharge . (sign for right) heel open ulcer with slough & (and) odorous drainage large ulcer. (Sign for left) small necrotic ulcer. Unstageable ulcers b/l heals - start levequin (an antibiotic) 500 mg po (by mouth) q (every) day X (times) 7 days order given to nurse on phone for Santyl & Alginate dressing refer to (name of local hospital) wound center. -- 09/18/15: The physician saw the resident in regards to the wound to her right heel. The physician noted the resident was seen at the wound clinic at (name of local hospital) and had a debridement and was put on [MEDICATION NAME] (antibiotic) and had a large amount of odorous drainage from wound bed on that date. He noted slough being present deep in the wound. He ordered [MEDICATION NAME] (antibiotic) 1 gram intravenous or intramuscularly for 10 days. -- 10/26/15: The physician saw the resident in regards to the wound to the right heel. He noted the wound was doing better and had decreased in size. He noted she had continued to go to the wound center and the wound was improving on [MEDICATION NAME] (antibiotic). A review of Resident #69's care plan found a goal of Skin will remain intact thru (through) next review. The goal was initiated on 07/03/14 with a revision date of 08/21/15 and a target date of 01/01/16. This goal did not address the wound to the right heel, which was ongoing since 07/16/15. The care plan contained no interventions for the prevention of pressure ulcers to the heels. The rest of the medical record also contained no indication any interventions were ever put in place to prevent the resident from developing pressure ulcers to her heels. She was readmitted to the facility on [DATE] after an acute illness. She experienced a decline in mobility and the staff failed to recognize interventions were necessary to prevent the development of pressure ulcers to the heels. The facility identified the resident was at risk by using a Braden Scale as the care plan instructed, but failed to follow up with interventions to prevent the development of avoidable pressure ulcers. An interview with the ADNS at 7:32 p.m. on 12/16/15, confirmed she identified the wounds to the left and right heels on 07/16/15. She stated she had telephoned the attending physician when the wounds were discovered, and he must have forgotten she had called him when he evaluated the resident on 08/10/15. She stated both heels were dark in color and were calloused when she evaluated them on 07/16/15. She indicated she felt the wound bed was necrotic. She said she only marked 100% skin on healed wounds. She stated that meant the skin was 100% healthy. She indicated she would have to speak with the wound care nurse as to why she was marking 100% skin on the assessments. The ADNS commented when the resident returned from the hospital on [DATE], she was very sick and she was just not getting up and moving around as she once did. She added that they encouraged the resident to get out of bed, but due to her recent illness, she just would not. When asked how they evaluated for risk of pressure ulcers, the ADNS stated that upon admission, quarterly, or if there was a change of condition, they would complete an assessment which included a Braden scale. She stated if the Braden Scale indicated the resident was at risk, they would implement preventative measures to ensure the resident did not develop a pressure ulcer. When asked what preventative measures were in place for Resident #69, the ADNS reviewed the record and stated she would have to look some more and provide the information later. At the time of exit on 12/18/15 at 3:30 p.m., no further information was provided as to what, if any, preventative measures were put into place for Resident #69 to help avoid the development of the pressure ulcers to her heels. The ADNS reported the wound to the left heel healed with no problems. She stated they have had trouble getting the wound to the right heel to heal. She confirmed the resident went to the wound care clinic on a weekly basis, where she has had the wound debrided. The resident was also treated with antibiotics for an infection in the wound to the right heel. After the ADNS reviewed the Clinical Health Status assessment completed on 07/15/15, she confirmed the wounds to the resident's right and left heel were not identified on the assessment. When asked if the staff completing this form should have looked at the resident's heels, she stated they should have. She was unable to answer whether it was possible for the wounds to the right and left heels developed in less than 24 hours. An interview with Resident #69's attending physician at 12:23 p.m. on 12/16/15, confirmed he was likely notified of the wounds by nursing prior to him seeing Resident #69 on 08/10/15. He stated that sometimes he forgot they had called him about things. He reviewed the note written by the ADNS on 07/16/15 and stated, I gave orders so they must have called me and I forgot. When asked about Resident #69's weight loss (The resident weighed 220.3 pounds on 06/03/15 and 177 pounds on 12/08/15, a loss of 43.3 pounds) as it would relate to her wounds, he commented, You have to watch the protein levels when a resident has wounds. He said he recently ordered protein powder for her due to her low protein levels. During an interview with the DNS at 11:00 a.m. on 12/18/15, these findings were reviewed. She was asked to provide any information the facility might have to indicate they attempted interventions and/or treatments to prevent the development of Resident #69's SDTIs to her right and left heels. At the time of exit on 12/18/15 at 3:30 p.m., no further information was provided to show these wounds were unavoidable.

Based on record review and staff interview, the facility failed to ensure Resident #69 maintained acceptable parameters of nutritional status such as body weight and protein levels. This was true for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey. Resident #69 experienced a severe weight loss in a 180 day time period. The facility noted her weight losses were planned because she was on a physician prescribed weight loss plan, but the resident's medical record contained no evidence of a physician's order for a weight loss plan or that a plan was ever developed and implemented. During this time Resident #69's protein levels also fell below the normal range for multiple months during which time she developed pressure ulcers. This constituted actual harm for Resident #69. Resident Identifier: #69. Facility Census: 91. Findings Include: a) Resident #69 A review of Resident #69's medical record at 12:35 p.m. on 12/15/15, found this [AGE] year-old female, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. 1. The electronic medical record contained the following weights for Resident #69: - 06/03/15 220.3 pounds - 08/26/15 192.3 pounds - 09/01/15 194 pounds - 09/08/15 193.1 pounds - 09/14/15 192.9 pounds - 09/21/15 190.7 pounds - 09/28/15 189.5 pounds - 10/17/15 190 pounds - 10/27/15 187.0 pounds - 11/09/15 181.7 pounds - 11/21/15 182.6 pounds - 11/27/15 180.5 pounds - 12/08/15 177 pounds Using the percentage of weight loss formula, percent of body weight loss = (usual weight - actual weight) / (usual weight) x 100, the resident had severe weight losses: - 06/03/15 to 12/08/15: 19.65% in 180 days, a severe weight loss. - 09/01/15 to 12/08/15: 8.7% in 90 days, a severe weight loss 2. Additional review of the record found on 07/16/15 the facility identified two (2) suspected deep tissue injuries (SDTI) one to each heel of Resident #69. The wound to the left heel was resolved on 09/01/15. The right heel wound remained and the resident was sent to a wound care center for treatment, including debridement of the wound. 3. Medical record review found the following laboratory (lab) results measuring the resident's total protein and her [MEDICATION NAME]. --12/23/14: Total Protein - 6.3 - low normal (normal range of 6.2 to 8.5). --12/23/14: [MEDICATION NAME] - 2.9 - low (normal range 3.2 to 5.5). -- 06/22/15: Total Protein - 5.4 - low. -- 06/22/15: [MEDICATION NAME] was 2.1 - low. -- 06/29/15: Total Protein - 5.9 - low. -- 06/29/15: [MEDICATION NAME] - 2.3 - low. -- 09/11/15: Total Protein - 6.0 - low. -- 09/11/15: [MEDICATION NAME] - 2.3 - low. 4. Further review of the medical record found the following nutritional assessments and/or notes: -- 03/31/15 at 4:38 p.m.: A nutritional note by the Certified Dietary Manager (CDM) identified Resident #69's current weight was 225 pounds and her usual body weight was within the 220 range. The CDM indicated the resident had no weight changes, was not on a physician prescribed weight loss program, was on a controlled carbohydrate diet, and chose her meals. He noted her average intake was 96% for the previous week. He further noted the resident came to the dietary department frequently for sodas and other items on each shift. -- 05/19/15 at 2:25 p.m.: A change of condition nutritional assessment, completed by the Licensed Dietitian (LD), identified the resident's total calorie needs were 2651 calories per day and her protein needs were 106 grams per day. The LD noted the resident's intake met her estimated needs and her diet was a controlled carbohydrate diet. The LD made no recommendations to change the resident's diet. -- 05/21/15 at 1:35 p.m.: In this nutritional note, entered into the medical record by the CDM, listed no current weight. (There was no weight entered into the record for Resident #69 during the month of May 2015 because Resident #69 refused to have her weight obtained). The CDM indicated the resident had no change in weight, was on a controlled carbohydrate die,t and had an average meal intake for the previous week of 61%. He recommended no new dietary interventions. There was no mention a physician prescribed weight loss plan -- 06/23/15 3:18 p.m.: This readmission nutritional assessment by the LD, noted the resident's calorie needs were 2503 per day and her protein needs were 100 grams per day. She indicated the resident's intake of the controlled carbohydrate diet met the her daily needs. The note also identified the resident was on contact precautions related [MEDICAL CONDITIONS] and was receiving intravenous antibiotics. The LD made no recommendations. -- 07/27/15 at 1:04 p.m.: This change of condition nutritional assessment by the LD, noted the resident needed to consume 2306 calories and needed 92 grams of protein per day. The LD indicated the resident's nutritional intake met her needs. She again noted the resident [MEDICAL CONDITION] and was receiving antibiotics to treat this. She indicated that dietary would begin offering prune juice or prunes for bowel management. Further review of Resident #69's progress notes found the following in which her nutritional status was addressed: -- 07/16/15 at 10:52 a.m., a change of condition note written by the Assistant Director of Nursing (ADNS), indicated Resident #69 had lost 6.72 % in the last 30 days. She noted the resident had been hospitalized and was wanting to lose weight. She indicated that the attending physician was aware of the resident's desire to lose weight and was supportive of that goal. The ADNS indicated no new orders were given by the physician at this time. -- 07/23/15 at 1:56 p.m., the ADNS noted the resident continued with intended weight loss which was okay with the resident's attending physician. She noted the resident's weight was down to 201.9 pounds and that she received Vitamin C and Zinc for wound healing. She made no mention of what the resident's weight loss plan entailed or what her targeted weight was. -- 07/24/15 at 3:45 p.m., the Minimum Data Set Coordinator wrote a general progress note indicating the resident had lost 15 pounds in one month and continued to lose. She made no mention of the resident's desire to lose weight or of any physician ordered weight loss plan for Resident #69. -- 07/31/15 at 2:34 p.m., the ADNS noted the resident's weight was 200.9 pounds and resident had a recommended intentional weight loss approved by the resident's attending physician. She again made no mention of the resident's target weight or what the weight loss plan consisted of. -- 08/05/15 at 12:29 p.m., the former Director of Nursing Services (DNS) (no longer employed at the facility), noted Resident #69's weight was 196.9 and she had some continued weight loss. The former DNS indicated the resident was glad she was losing weight and the doctor suggested a planned weight loss. The former DNS indicated that the dietitian was aware and was going to work with the resident to set weight loss goals. She noted the resident was not on any snacks at that time related to being on a planned weight loss. The former DNS made no mention of what the physician ordered as a weight loss plan or what the resident's target weight was. -- 08/10/15 at 10:52 a.m., the ADNS noted the resident's potassium level was low at 3.2 and that she had a history of [REDACTED]. -- 08/14/15 at 4:40 p.m., the former DNS noted the resident had a significant weight loss and the resident had voiced a desire to lose weight. The former DNS noted the Dietitian had the resident on a planned weight loss program with a goal weight of 188 pounds. The former DNS indicated she had spoken with Resident #69 and advised her she had reached her target weight of 188 pounds. She noted the resident voiced understanding. There was no indication the resident had voiced a desire to lose further weight, nor was there any mention that any further weight loss was expected or desired by the resident, physician, or dietitian. -- 08/18/15 at 2:07 p.m., the former DNS noted the resident was at her targeted weight of 188 pounds for her planned weight loss and had continued to lose weight. The former DNS went on to note Resident #69 would be started on 2 Cal (a high calorie protein supplement) protein supplement to aide in wound healing. This intervention was not added until 08/18/15, even though the resident had low protein and [MEDICATION NAME] levels on 06/22/15 and 06/29/15. There was no mention of a planned weight loss being acceptable to the physician, dietitian, or the resident. -- 08/26/15 at 2:11 p.m., the ADNS noted Resident #69's average meal intakes were at 45% for the week. She noted the resident was slightly above her optimal weight of 188 pounds, was receiving a 2 Cal supplement and a controlled carbohydrate diet. The ADNS made no mention of a continued weight loss plan. -- 09/09/15 at 3:17 p.m., the Wound Care Nurse Registered Nurse (RN) #47 noted the resident's weight was down a pound at 193.1 pounds. She noted the resident received a 2 Cal supplement. She made no mention of a continued weight loss plan. -- 09/17/15 at 12:31 p.m., the ADNS noted Resident #79's current weight was 194 pounds, and that the previous month she was at 185.2 pounds, which represented an 8.8 pound weight gain. The ADNS further noted the resident's weight two months prior was 205.5 pounds. She noted the resident continued on supplements and weight loss plan, and the resident's meal intakes for the week were 68%. There was no mention of what the weight loss plan was, what the resident's target weight was, or that the said weight loss plan was not effective since the resident was gaining weight. -- 09/23/15 at 2:02 p.m., the ADNS noted the resident's weight was stable and there were no dietary recommendations. Again there was no mention of a planned weight loss, nor was a target weight identified. -- 10/02/15 at 2:43 p.m., the LD noted in a nutritional review, the resident was receiving 2 Cal, a controlled carbohydrate diet, and weighed 189.5 pounds. The LD made a recommendation for for large portions of protein foods for all meals. She made no mention of a planned weight loss for Resident #69. -- 10/08/15 at 12:29 p.m., the ADNS noted Resident #69's average meal intake for the previous week was 59%. She noted the resident's weight was 189.5 pounds and that she enjoyed snacking. The ADNS noted the resident was on a weight loss plan and that some loss was expected to reach her goal. The ADNS did not mention what the weight loss plan was, nor did she indicate what the resident's weight loss goals were. -- 10/15/15 at 12:25 p.m., Wound Care Nurse RN #47 noted the resident enjoyed snacking, was on a weight loss plan, and some loss was expected in order for her to reach goal. Again there was no indication of what the weight loss plan was, nor of a target weight. -- 10/15/15 at 2:45 p.m., in a nutritional review, the LD noted the resident's weight decrease from 180 days was acceptable. She noted the resident was on a controlled carbohydrate diet with large portions of protein for skin health. The LD noted the resident was receiving 2 Cal for her skin health and to help reduce excessive weight changes. The LD made no recommendations, nor did she mention a plan for weight loss or weight loss goal for Resident #69. -- 11/04/15 at 3:49 p.m., the ADNS noted Resident #69's current weight was 187 pounds and was stable. She noted the resident's weekly meal percentage average for the previous week was 49%, the resident was receiving 2 Cal for wound healing, remained on a weight loss plan, and gradual weight loss was expected toward her goal. The actual weight loss plan was not noted nor was the target goal identified. -- 11/11/15 at 2:00 p.m., the ADNS noted Resident #69 weighed 181.7 pounds and had an expected weight loss due to a weight loss plan. She noted the resident's average meal consumption for the previous week was 69 %, the resident was on a controlled carbohydrate diet, and received a 2 Cal supplement. -- 11/19/15 at 11:02 a.m., the ADNS noted the resident's average meal intake for the previous week was 75%, the resident weighed 181.7 pounds, enjoyed snacks, and remained on an ongoing diet plan for wanted weight loss. Again the plan was not discussed, nor was a target weight identified. -- 11/25/15 at 11:59 a.m., the ADNS noted Resident #69's average meal percentages for the previous week were 63%, the resident's weight was 182.6 pounds and was stable with an on going weight loss plan. Again the plan was not discussed, nor was her target weight identified. -- 12/02/15 at 4:01 p.m., the ADNS noted Resident #69 remained on a current weight loss plan and her current weight was 180.5 pounds. She noted the resident's average meal percentage for the previous week was 85%. The weight loss plan, nor a target weight, were identified. -- 12/03/15 at 12:54 p.m., the LD noted the resident weighed 180.5 pounds, received large portion protein, and 2 Cal. She made no mention of a planned weight loss, nor did she identify the resident's progress toward an established target weight. 5. Review of the Minimum Data Sets (MDS) for Resident #69 found the following: -- A significant change MDS with an assessment reference date (ARD) of 06/22/15, indicated Resident #69 had no significant weight loss. -- A significant change MDS with an ARD of 07/24/15, indicated Resident #69 had a significant weight loss and was not on a physician prescribed weight loss plan. -- A quarterly MDS with an ARD of 10/13/15, indicated Resident #69 had a significant weight loss and was on a physician prescribed weight loss plan. An interview with MDS Coordinator Registered Nurse (RN) #35, at 9:30 a.m. on 12/18/15, confirmed Item K0300 of this quarterly MDS did not accurately reflect Resident #69's status. She stated there was no physician's order for a planned weight loss and the assessment should indicate the resident had lost weight, but was not on a physician prescribed weight loss plan. 6. Review of Resident #69's care plan found a focus statement of, Obesity as related to: Obese with a BMI (Body Mass Index) greater than 30. Weight may fluctuate r/t (related to) fluid changes d/t (due to) dx (diagnosis) of [MEDICAL CONDITIONS] weight loss acceptable and encouraged This focus had an initiation date of 02/27/14. The goals were as follows: - Current Goal revised on 12/15/15 with a target date of 01/01/15, Maintain at Goal weight 180# (pounds) plus or minus 5# through next review. (This intervention was revised to 180# after surveyor intervention on 12/15/15). - Previous goal revised on 08/21/15, Maintain at Goal weight 188# plus or minus 5#. - Another previous goal, revised on 08/18/15 with target date of 11/12/15, Maintain at Goal weight 188# plus or minus 5#. Interventions included: - 2 cal as ordered. Initiated on 12/15/15. - Diet as ordered large portion protein as ordered. Initiated on 02/27/14 revised on 12/10/15 - Educate patient on risks of not following diet restrictions. Initiated on 02/27/14. - Invite and encourage to attend exercise related activities. Initiated on 02/27/14. - Medication as ordered. Initiated on 02/27/14. - Monthly weights. Initiated on 02/27/14. - Observe Meal Consumption daily. Initiated on 02/27/14 revised on 07/03/14. - Supplements as ordered if ordered. Initiated on 08/18/15. The resident's care plan did establish a target weight, but still failed to describe and/or direct what physician ordered planned weight loss this resident was to follow. The care plan mentioned nothing that would indicate she was on a planned weight loss except the statement that the weight loss was acceptable and encouraged, and the target was established. No actual plan was established in the resident's care plan. 7. A review of the physician's orders and progress notes found no mention of a planned weight loss 8. At 1:30 p.m. on 12/15/15, the ADNS and DNS were asked to print all of Resident #69's nutritional notes and assessments, as well as the resident's weights for the previous six months. After this request by the surveyor, the following progress notes were entered into Resident #69's medical record: -- 12/15/15 at 1:52 p.m., the LD noted Resident #69's significant weight loss was acceptable and had been a plan for the resident. She noted the resident remained at the [MEDICAL CONDITION] range, but was approaching a more normal ideal body weight. She noted the resident received large portion protein and 2 Cal for skin health. The note included an excessive/rapid weight change was not desired. She noted the resident's weight at 177.2 pounds. -- 12/16/15 at 2:41 p.m. the ADNS noted there were new dietary recommendations to increase the resident's 2 Cal to three (3) times a day and for protein powder one (1) scoop three (3) times a day for weight management and wound healing. Even though nursing noted on multiple occasions Resident #69 had a plan for weight loss the LD never noted the plan existed, nor did she ever define the plan, share the plan with nursing, nor get it approved by the physician to make it a physician ordered planned weight loss. There was no evidence an actual plan to encourage and achieve weight loss in a way to maintain Resident #69's nutritional parameters was developed. 9. Resident #69 had a severe weight loss in 180 days which was identified by the facility, but was never addressed to ensure she did not become nutritionally compromised. The facility failed to ensure Resident #69's health and well-being were maintained during the weight loss process and she continued to lose weight. At the time of this review, the resident weighed 177.2 pounds, which was 10.8 pounds less than her initial targeted weight loss contained in her care plan. After surveyor intervention, the care plan was changed to reflect the resident's target weight was 180 pounds which was still more than the resident weighed at the time of this review. Additionally, Resident #69's 2 Cal was increased to three (3) times daily for weight management after surveyor intervention. Additionally, Resident #69's protein levels were low on multiple occasions in June 2015 and were not addressed until 08/18/15, when the attending physician ordered 2 Cal twice daily. During this time, Resident #69 developed pressure sores on her heels - identified on 07/16/15. On 09/11/15, Resident #69's protein and [MEDICATION NAME] levels remained low and were not addressed by the facility until 10/02/15, when the LD recommended double portions of proteins with meals. After surveyor intervention on 12/15/15 the following dietary interventions were put into place: -- On 12/16/15 at 2:30 p.m., an order for [REDACTED]. -- On the same date and time, an order to increase Resident #69's 2 Cal to three (3) times a day was written. 10. An interview with Resident #69's attending physician at 12:23 p.m. on 12/16/15, confirmed the resident had voiced a desire to lose weight. When asked what Resident #69's weight loss plan was the physician stated, I think we just restricted her calories. He did not elaborate. There was never any mention in the medical record that Resident #69's calories were restricted to promote weight loss. In fact, she was ordered and given a high calorie supplement two (2) times daily beginning in August of 2015. She was also ordered double portions of protein, which again increased her amount of calories beginning in October of 2015. This did not support the facility's claim Resident #69 was on a physician prescribed weight loss plan. 11. These findings were reviewed with the DNS at 11:00 a.m. on 12/17/15. She was asked to provide any further information that would indicate Resident #69 was on a physician prescribed weight loss plan. She reviewed the information and indicated she would look, but was doubtful she could find anything. At the time of exit on 12/18/15 at 3:30 p.m., no further information was provided.

Based on observation, resident interview, family interview, staff interview, and clinical record review, the facility failed to ensure two (2) of eight (8) sampled residents received the care and services needed to maintain the highest practicable well-being. The facility failed to identify pain, failed to adequately assess and treat pain, failed to obtain labs ordered by the physician, and failed to notify the physician and the resident's Medical Power of Attorney (MPOA) when the labs were not obtained for Resident #32. The facility also failed to assess pain, failed to communicate with the [MEDICAL TREATMENT] center, and failed to assess Resident #95 on a consistent basis when returning from [MEDICAL TREATMENT]. The failure to ensure optimal pain management for these residents constituted actual harm. Resident Identifiers: #32 and #95. Facility Census: 94. Findings Include: a) Resident #32 Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. At 9:20 a.m. on 11/04/14, a review of the Minimum Data Set (MDS) assessments revealed the following: -- The significant change in status MDS assessment, with an assessment reference date (ARD) of 06/02/14, Section J, Health Conditions, J0100 Pain Management, indicated the resident had not received scheduled pain medication in the last five (5) days. It also indicated the resident had not received as needed (PRN) pain medication in the last five (5) days. It further indicated the resident had not received non-medication interventions for pain in the last five (5) days. The Pain Assessment Interview, J0300, Pain Presence, indicated the resident had pain or hurting in the last five (5) days, occasionally. Pain Intensity, J0600, A. Numeric Pain Rating, indicated the resident had rated her pain at a seven (7), on the zero (0) to ten (10) scale, with zero (0) being no pain and ten (10) being the worst possible pain imaginable. The quarterly MDS assessment, with an ARD of 09/02/14, Section J, Health Conditions, J0100 Pain Management indicated the resident had not received scheduled pain medication in the last five (5) days. It also indicated the resident had not received as needed (PRN) pain medication in the last five (5) days. It further indicated the resident had not received non-medication interventions for pain in the last five (5) days. The Pain Assessment Interview, J0300, Pain Presence, indicated the resident had pain or hurting in the last five (5) days, occasionally. Pain Intensity, J0600, A. Numeric Pain Rating, indicated the resident had rated her pain at a six (6), on the zero (0) to ten (10) scale, with zero (0) being no pain and ten (10) being the worst possible pain imaginable. On 11/04/14 at 10:10 a.m., during an observation of Resident #32, the resident reported to Employee #69, a registered nurse (RN), the wound nurse, that she was hurting. Employee #69 asked the resident where she was hurting. Resident #32 said , "Down there", and pointed to her perineal area. The resident described the pain as, "It feels like a knife." Observation of the resident revealed she had multiple contractures of her bilateral upper extremities, as well as severe contractures of her bilateral lower extremities. Both lower extremities were crossed in a fixed position, bent at the knees, and both feet tucked up near the resident's bottom. Employee #69, left the room, and returned with Employee #12, RN, the nurse providing care for the resident. Together, both nurses were observed assessing the resident's perineal area for possible causes of the pain. At 10:20 a.m. on 11/04/14, during an interview with Employee #12, she reported the resident had complained of pain in her perineal area for quite some time. The RN said a urinalysis (UA) had been completed at the end of October. Upon inquiry as to the results of the UA, the RN said she was not sure, but she assumed it was negative because the resident was not on an antibiotic. On 11/04/14 at 10:40 a.m., Employee #12, reported the last time the resident had complained of pain, her Klonopin had been changed from 0.5 milligrams (mg) every eight (8) hours to 0.5 mg every six (6) hours. She reported the resident had complained of abdominal discomfort and cramping. At 11:00 a.m. on 11/04/14, a review of the physician orders [REDACTED].#32: 1. Order date 03/15/14 for [MEDICATION NAME] HCL tablet 100 mg by mouth every six (6) hours as needed (PRN) for pain. The order was discontinued on 03/27/14. 2. Order date 03/27/14 for [MEDICATION NAME] HCL tablet 50 mg by mouth every six (6) hours PRN for pain. The order was discontinued on 05/29/14. 3. Order date 04/22/14 for Tylenol tablet 1000 mg by mouth every eight (8) hours PRN for pain related to (r/t) generalized pain. The order was discontinued on 05/29/14. 4. Order date 04/22/14 for [MEDICATION NAME] tablet 20 mg by mouth four (4) times a day (QID) r/t generalized pain. 5. Order date 04/22/14 for [MEDICATION NAME] HCL tablet 50 mg by mouth every six (6) hours PRN r/t generalized pain. The order was discontinued on 05/29/14. 6. Order date 05/02/14 for Klonopin 0.5 mg by mouth three (3) times a day (TID) r/t muscle spasms. The order was discontinued on 07/29/14. 7. Order date 06/26/14 for [MEDICATION NAME] HCL tablet 50 mg by mouth (TID) r/t acute pain until 07/10/14. 8. Order date 07/29/14 for Klonopin 0.5 mg by mouth TID r/t muscle spasms. The order was discontinued on 09/30/14. 9. Order date 09/09/14 to obtain a urinalysis with a culture and sensitivity (UA/C&S) r/t dysuria (painful urination). Order discontinued 09/23/14 10. Order date 09/30/14 for Klonopin 0.5 mg by mouth every six (6) hours r/t anxiety state, and spasm of muscles. The order was discontinued on 10/13/14. 11. Order date 10/17/14 to obtain a UA/C&S r/t dysuria. The order was discontinued on 10/28/14. 12. Order date 10/17/14 to schedule an ultrasound of the pelvis d/t pelvic pain. 13. Order date 10/17/14 for [MEDICATION NAME] XL 5 mg by mouth every six (6) hours PRN for pain r/t the urinary system. 14. Order date 11/03/14 for Klonopin 0.5 mg by mouth every six (6) hours r/t [MEDICAL CONDITION] not elsewhere classified. On 11/04 at 11:30 a.m. on 11/04/14 a review of the nurses' notes revealed the following entries related to the resident's pain status: 1. 05/05/14 at 14:49 by Employee #80, RN, "...doing better today, still states pain present but [MEDICATION NAME] seems to alleviate it...does not ask to get up in chair, states hurts her back to much..." 2. 05/08/14 at 16:47 by Employee #80, RN, "...very vocal this am, after am meds ([MEDICATION NAME] and klonopin) resident quieted down and resting with no c/o noted at this time..." 3. 05/08/14 at 17:23 by Employee #80, RN, "resident to be up in chair for two (2) hours at a time with two (2) hour break in between getting up to chair while awake every shift, unable to tolerate at this time." 4. 05/09/14 at 02:17 by Employee #84, RN, "...Crying out occasionally during beginning of shift noted, calmed down after med administered..." 5. 05/12/14 at 15:55 by Employee #80, RN, "states pain meds effective...no crying and yelling out noted today...does not ask to get out of bed at this time...states hurts back too much." 6. 05/13/14 at 06:58 by Employee #84, RN, "Remains on therapy for skilled services...crying out occasionally during beginning of shift noted, calmed down after med administered." 7. 05/19/14 at 14:53 by Employee #80, RN, "skilled for therapy services...doing okay today seems to be writhing and restless, better after klonopin and [MEDICATION NAME]" 8. 05/20/14 at 08:49 by Employee #80, RN, "...very anxious and squirmy this am (morning), states back hurts, [MEDICATION NAME] klonopin given with am meds per orders...does not want to get oob (out of bed) d/t discomfort..." 9. 09/09/14 at 11:37 by Employee #37, RN, assistant director of nursing services (ADNS), "c/o dysuria..order for UA C&S...Responsible Party (RP) aware and in agreement." 10. 10/17/14 at 23:24 by Employee #38, licensed practical nurse (LPN), "Dr. (name) in to see resident and resident c/o pain in pelvic area. Order received for [MEDICATION NAME] and to schedule S/S (unknown abbreviation) of pelvis for pelvic pain, RP to be notified." 11. 10/21/14 at 22:00 by Employee #30, RN, "(name) mobile imaging arrived to facility at this time for abd (abdominal) xray, flat and upright, on resident, dx (diagnosis): abd pain..." During the review of the nurses' notes, no evidence was found identifying the characteristics of the resident's pain, such as the intensity of the pain, descriptors of the pain, pattern, frequency, timing or duration of the pain. There was no indication that the resident not wanting to get out of bed due to discomfort or back pain, or that when she was noted to be "writhing" or "squirming," even after administration of medications, that these were identified by nurses as indicators of inadequate pain management. At 12:00 p.m. on 11/04/14, a review of the resident's clinical record found no evidence of the results, or evidence of physician and/or MPOA notification, for both of the UA/C&Ss ordered on [DATE] and 10/17/14. When no evidence could be located in the clinical record, the director of nursing services (DNS) was asked to provide the results of the ordered labs for review. The DNS said she could not, as they were not obtained. Upon inquiry as to the reason the physician's orders [REDACTED]. She said the resident had refused on 09/09/14. On 11/04/14 at 12:15 p.m., a review of the resident's care plan identified the following focus areas: 1. Focus - "Needs pain management and monitoring related to: generalized pain, contractures, chest pain, pressure wounds, reflux, muscle spasms..." Goals - "Will maintain adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress...." Interventions -"administer pain meds as ordered, evaluate characteristics and frequency/pattern of pain, evaluate need to provide medications prior to treatment or therapy, evaluate what makes patient's pain worse, utilize pain monitoring tool to evaluate effectiveness of interventions..." 2. Focus - "Impaired neurological status related to: [MEDICAL CONDITION], muscle spasms." Goals - "Will maintain current level of function thru next review." Interventions - "...observe for pain or increased stiffness and notify MD if indicated..." 3. Focus - "Urinary Tract Infection, at risk due to: Urinary Incontinence, Recurrent Urinary tract infections." Goal - "Recurring Urinary tract infection managed without complications thru next review." Interventions - "...observe and report signs and symptoms of UTI...dysuria...pain...administer medication as ordered by physician..." At 12:30 p.m. on 11/04/14, a review of the pharmacist's recommendations identified the recommendations to discontinue the PRN pain medications [MEDICATION NAME] and Tylenol. The recommendations were made by the pharmacist on 05/11/14. The recommendations stated the medications had not been requested for administration and/or not been used in over thirty (30) days. The recommendations were reviewed and signed by the physician on 05/23/14. On 11/04/14 at 12:35 p.m., upon inquiry as to how often the resident said she had pain, or gave nonverbal indicators of pain, Employee #12, RN, said the resident complained of pain on a daily basis. When asked how often the resident would ask for medication to relieve her pain, Employee #12 said the resident did not ask for pain pills, she just let the staff know she was hurting. At 2:10 p.m. on 11/04/14, upon inquiry as to the facility's policy on pain assessment and management, the DNS reported the facility did not have a policy specific to pain. She said the facility completed assessments quarterly, annually, and as needed. Upon inquiry as to how a resident's pain was assessed, she said there was not a specific tool or protocol in place to monitor a resident's pain. She expected the nursing staff to assess resident pain based on how they were taught in nursing school. Inquiry was made in regards to the facility's practice for administering PRN medications. The DNS said PRN medications were given to residents upon their request. When asked about residents who were unable to verbalize pain or ask for specific medications, the DNS said she would then expect the nurses to assess the pain and administer medications as needed. At that time, further inquiry was made regarding the two (2) UA/C&S orders that had not been obtain for Resident #32. It was brought to the attention of the DNS, no evidence had been found in the clinical record identifying the resident's refusal of straight catheterization, or evidence to indicate the resident had been provided education related to the refusal of the ordered treatment, nor was there evidence of notification of the physician or MPOA regarding the resident's refusal. The DNS said the nurses charted by exception, and that the resident's refusal to be straight cathed for the UA should have been documented. She further stated that the physician as well as the MPOA should have been notified when the facility was unable to obtain the UA. On 11/04/14 at 2:50 p.m., a review of the Medication Administration Record [REDACTED]. In an interview at t 3:05 p.m. on 11/04/14, when asked about the resident's pain, Employee #62, NA, said Resident #32 complained of pain on a regular basis. She said for quite a while now, the resident had been saying she hurt. The NA said when she had heard the resident complain of pain, she had reported it to the nurse. On 11/04/14 at 3:30 p.m., during a telephone interview with the resident's MPOA, she said she had been notified a few weeks ago, the resident had complained of urinary pain, and an order had been written to obtain a urine sample. The MPOA said she had not yet been notified as to the results of the urine specimen, and she had thought she would have heard by this time. She said when she was notified of the order for the urinalysis, she was also informed a new medication had been ordered to help with bladder spasms. The MPOA voiced concern as to the resident's level of pain control. She said the resident had been taking [MEDICATION NAME] for such a long time, she wondered if it still worked for the resident. Upon further inquiry as to how the resident made others aware of her pain, the MPOA said, the resident will say she hurts, or sometimes act out by yelling. The MPOA said the resident more than likely did not know the names of her medications, and it was not in her nature to ask for pills. At 4:30 p.m. on 11/04/14, during an interview with the administrator, she was informed of the findings regarding Resident #32. She agreed the resident had not been properly assessed and treated for [REDACTED]. of treatment and/or the failure to obtain the ordered UAs. On 11/04/14 at 5:05 p.m., Employee #24, RN, was asked to describe the procedure for obtaining an ordered specimen for UA. She said if she was unable to obtain an ordered UA, she would document and tell the next shift so they could attempt to obtain the specimen. She said if after three (3) consecutive unsuccessful attempts, the physician would be notified to see if there would be an order to straight cath for the specimen. She said the MPOA would also be notified. Upon inquiry as to obtaining the specimen via straight catheterization, she said the same steps would apply. Further inquiry as to the steps to be taken if a resident refused to be catheterized, the RN said, both the physician and the MPOA need to be notified immediately, and it should be documented. At 8:55 a.m. on 11/05/14, Upon inquiry as to UAs ordered for resident #32, the ADNS said the UA ordered on [DATE], had not been obtained because the nursing department assumed the physician did not want the UA, because he had ordered the ultrasound. There was no evidence found to indicate an attempt had been made to clarify this with the physician. An additional review of the progress notes on 11/05/14 at 9:10 a.m., found two (2) new entries, after the staff interviews had been conducted: 1. 11/04/14 at 16:45 by Employee #37, RN, ADNS, "...obtained order for UA C &S at this time." 2. 11/04/14 at 16:48 by Employee #37, RN, ADNS, "Phoned RP...discussed new order for UA C & S. UA obtained at this time." On 11/05/14 at 10:00 a.m., during an interview with the Resident #32, she said she was having a lot of pain in her urinary area. She said her pain had remained almost constant for a long time, without having been alleviated. She said she had requested to be sent to the hospital. The resident said, "They got a urine sample last night." Inquiry was made as to how the specimen had been obtained, and the resident said, "They used a catheter." Upon inquiry as to what other tests she had had to determine the cause of her pain, she said she had an ultrasound and an X-ray recently. When asked if anyone had attempted to obtain a urine specimen prior to last night, she said, "No, I wished they would have." Upon inquiry as to whether she had ever refused catheterization to obtain a urine specimen, the resident denied ever having refused. At 10:30 a.m. on 11/05/14, Employee #12, RN was notified by the surveyor, of the resident's complaints of pain and her request to be sent to the hospital, and the resident was immediately assessed. Observation of the nurse's assessment revealed, the resident rated her pain at a ten (10), her worst possible pain. The RN asked the resident why she had not reported this earlier, and the resident said she had reported the pain, to the night nurse, and asked to be sent to the hospital. The RN, then asked the resident if the medication to ease the bladder spasms was effective. The resident said, "No." The RN informed the resident she would notify the doctor. Upon leaving the room, per surveyor request, the RN looked up the order for the [MEDICATION NAME] on the MAR, and found it was not a scheduled medication, but a PRN medication, that had never been administered since it was ordered on [DATE]. On 11/05/14 at 11:00 a.m., during a telephone interview with Resident #32's physician/facility medical director, he stated he had not been notified when the UAs ordered on [DATE] and 10/17/14, had not been obtained, nor was he aware the resident continued to complain of urinary pain. The physician stated he had ordered the medication [MEDICATION NAME] to aide in alleviating the resident's pain due to bladder spasms. The physician said he was not aware the medication had never been administered. Upon inquiry, the physician said, it was his expectation that PRN medications be administered by nursing, when residents had complaints of pain. Further inquiry as to the PRN pain medications, Tylenol and [MEDICATION NAME], which were discontinued in May per pharmacy recommendations for non-use, he said he had not been notified, nor was he aware nursing had documented pain or discomfort pertaining to the resident. He verified the resident's pain had not been adequately assessed. He further verified, the lack of action taken to alleviate the pain, and the failure to notify the physician, was of concern. He stated, "This is a concern, not just from the perspective of a medical director, but also in relation to patient care." At 12:20 p.m. on 11/05/14, Employee #12, RN, reported she had contacted the physician and requested pain medication for the resident. She further reported she had requested the medications to be regularly scheduled rather than PRN. On 11/05/14 at 12:55 p.m., a review of the physician orders [REDACTED]. 1. Order date 11/05/14, [MEDICATION NAME] XL 5mg, give one (1) tablet by mouth every 6 hours related to other symptoms involving urinary system. 2. Order date 11/05/14, [MEDICATION NAME] ([MEDICATION NAME]) 50 mg give one (1) tablet by mouth every 6 hours related to generalized pain. 3. Order date 11/05/14, [MEDICATION NAME] tablet 2 mg give one (1) tablet by mouth every 6 hours related to generalized pain. At 2:30 p.m. on 11/05/14, during an interview with Employee #12, RN, she reported that she had just left the room of Resident #32, where she had been checking the effectiveness of the pain medication [MEDICATION NAME], administered earlier. The RN reported the resident's pain had been alleviated. On 11/05/14 at 2:45 p.m., during an interview with Resident #32, upon inquiry, she stated she "felt better than she had felt in a good while." When asked what she thought had made the difference, the resident said, "I got some new medicine." b) Resident #94 1) A review of Resident #94's physician's orders [REDACTED]. Review of the resident's medical record found it was not consistently recorded when the resident went to [MEDICAL TREATMENT] and when the resident returned. There was no evidence the facility regularly assessed the resident's condition after she returned from having [MEDICAL TREATMENT] treatments. The Director of Nursing (Employee # 35) was interviewed 11/04/14 at 3:00 p.m. regarding the communication with the [MEDICAL TREATMENT] center and how Resident # 95's condition was monitored after she returned from [MEDICAL TREATMENT]. She stated the facility had a communication form that was to be completed by [MEDICAL TREATMENT] and then a section was completed by the facility when the resident returned. She presented eight (8) [MEDICAL TREATMENT] communication forms dated between 08/19/14 and 09/14/14. She verified this was all she could find for this resident because sometimes they had issues getting these back from the [MEDICAL TREATMENT] center. It was verified the resident had received twenty eight (28) treatments during her stay at this facility. The eight (8) communication forms reviewed had been completed by [MEDICAL TREATMENT] at the top of the form. The lower half of the forms contained the assessment that was to be completed by the facility after the resident returned from [MEDICAL TREATMENT]. This section was titled "In-Facility (Skilled Nursing Facility) post [MEDICAL TREATMENT] form." This entire section was left blank and was not completed on any of the communication forms reviewed. Column One (1) had a specific place to monitor vital signs after a resident returned from a [MEDICAL TREATMENT] treatment. There was no evidence the facility monitored the vital signs when the resident returned. Column two (2) instructed that a mark be placed in each box indicating the assessment was completed. If the area was not normal, instructions stated a more descriptive information should be documented in the interdisciplinary progress notes. This column included the assessments of the resident's access site, mental status, heart, lungs, skin, [MEDICAL CONDITION]. None of the communication forms indicated these areas were assessed. The bottom of the form indicated the fistula site observation/assessment, and signs of headache, nausea, dizziness, sweating, ringing in ears, fever, chills, hives, itching, pressure in chest, tightness, in throat, and muscle cramps. The nurse was then instructed to sign and date the assessment. These assessments were left blank on the communication forms and there was no indication this was completed. Further review of the medical record found in the nursing notes, an occasional brief assessment was recorded, but not consistently. There were no post [MEDICAL TREATMENT] assessments after the resident went to [MEDICAL TREATMENT] for thirteen (13) of twenty-eight (28) days. During the interview on 11/04/14 at 3:00 p.m., the director of nursing (Employee #35), verified there was no evidence the facility assessed this resident on [MEDICAL TREATMENT] days on a consistent basis. 2) Further review of the medical record revealed Resident #95 complained of pain frequently. The resident was receiving [MEDICATION NAME] 5-325 mg q (every) 6 hours PRN (as needed) for pain. On 07/25/14 the resident's pain medication was increased to [MEDICATION NAME] 7.5-325 PRN for pain, and on 09/02/14 the pain medication was increased to [MEDICATION NAME] 10-325 mg as needed every four (4) hours for generalized pain. During a review of the medical record, it was identified the resident's pain was not always assessed. The nurses administered the pain medication, but did not assess what kind of pain the resident was experiencing, did not always assess the severity, and there was no process to address the pain before the resident was experiencing severe pain. There was no evidence the facility had a process to consistently assess the resident's pain and to ensure each nurse followed a process to reassess and treat the pain. A nursing note, dated 09/11/14, stated this resident's responsible party was at her bedside. The nurse spoke with the resident and her husband concerning her pain medication. The nurse documented, "Explained to resident and RP (responsible party) that residents order is for every four hours PRN. Resident needed to ask for pain med and that it would not be delivered throughout the night or day without her requesting. Resident and responsible party expressed they understood what as needed meant and that resident would have to ask for pain medication when needed." There was no evidence the facility had a method to assess residents for the need to administer their pain medication unless they asked for it and the pain was not consistently monitored. The Director of Nursing was questioned on 11/05/14 regarding the facility's policy for pain. She stated the facility did not have a policy. She stated if a person got a pain medication that was ordered "PRN" they had to ask for the medication. She confirmed the nurses did not do a pain assessment daily or each shift. She was questioned about the the pain assessment and how did she know residents were getting assessed and she stated, "Nurses know to do that". .

Based on clinical record review, observations, resident interview, and staff interview, the facility failed to ensure the care plan of one (1) of eight (8) sampled residents reviewed was implemented. Resident #32 was not adequately assessed or treated for [REDACTED]. Resident Identifier: #32. Facility Census: 94. Findings Include: a) Resident #32 Review of the resident's care plan on 11/04/14 at 12:15 p.m., found the focus area, "Needs Pain management and monitoring related to: Generalized pain, contractures, chest pain, pressure wounds, reflux, Muscle spasms." The goal associated with this focus area was, "Will maintain adequate level of comfort as evidenced by no s/sx (signs and/or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort thru (through) next review." Interventions associated with this focus area were to administer pain medication as ordered, evaluate the characteristics and frequency/pattern of pain, evaluate the need to provide medications prior to treatment or therapy, evaluate what makes the patient's pain worse..., and to utilize the pain monitoring tool to evaluate the effectiveness of the interventions. On 11/04/14 at 10:10 a.m., during an observation of Resident #32, the resident reported to Employee #69, a registered nurse (RN), the wound nurse, that she was hurting. Employee #69 asked the resident where she was hurting. Resident #32 said, "Down there", and pointed to her perineal area. The resident described the pain as, "It feels like a knife." Employee #69, left the room, and returned with Employee #12, RN, the nurse providing care for the resident. At 10:20 a.m. on 11/04/14, upon exit of Resident's room with Employee #12, the RN reported the resident had complained of pain in her perineal area for quite some time. On 11/04/14 at 11:00 a.m., a review of the physician orders [REDACTED]. Also noted was an order written [REDACTED]. ([MEDICATION NAME] XL is a once-daily controlled-release tablet indicated for the treatment of [REDACTED].) At 11:30 a.m. on 11/04/14, a review of the nurses' notes revealed the following entries related to the resident's pain status: 1. 05/05/14 at 14:49 by Employee #80, Registered Nurse (RN), "...doing better today, still states pain present but [MEDICATION NAME] seems to alleviate it...does not ask to get up in chair, states hurts her back to much..." 2. 05/08/14 at 16:47 by Employee #80, RN, "...very vocal this am (morning), after am meds ([MEDICATION NAME] and klonopin) resident quieted down and resting with no c/o (complaints of) noted at this time..." 3. 05/08/14 at 17:23 by Employee #80, RN, "resident to be up in chair for two (2) hours at a time with two (2) hour break in between getting up to chair while awake every shift, unable to tolerate at this time." 4. 05/09/14 at 02:17 by Employee #84, RN, "...Crying out occasionally during beginning of shift noted, calmed down after med administered..." 5. 05/12/14 at 15:55 by Employee #80, RN, "states pain meds effective...no crying and yelling out noted today...does not ask to get out of bed at this time...states hurts back too much." 6. 05/13/14 at 06:58 by Employee #84, RN, "Remains on therapy for skilled services...crying out occasionally during beginning of shift noted, calmed down after med administered." 7. 05/19/14 at 14:53 by Employee #80, RN, "skilled for therapy services...doing okay today seems to be writhing and restless, better after klonopin and [MEDICATION NAME]" 8. 05/20/14 at 08:49 by Employee #80, RN, "...very anxious and squirmy this am, states back hurts, [MEDICATION NAME] klonopin given with am meds per orders...does not want to get oob (out of bed) d/t (due to) discomfort..." 9. 09/09/14 at 11:37 by Employee #37, RN, assistant director of nursing services (ADNS), "c/o dysuria...order for UA C&S...Responsible Party (RP) aware and in agreement." 10. 10/17/14 at 23:24 by Employee #38, licensed practical nurse (LPN), "Dr. (name) in to see resident and resident c/o pain in pelvic area. Order received for [MEDICATION NAME] and to schedule S/S of pelvis for pelvic pain, RP to be notified." 11. 10/21/14 at 22:00 by Employee #30, RN, "(Name of imaging provider) imaging arrived to facility at this time for abd (abdominal) xray, flat and upright, on resident, dx (diagnosis): abd pain..." During the review of the nurses' notes, no evidence was found identifying the characteristics of the resident's pain, such as the intensity of the pain, descriptors of the pain, pattern, frequency, timing or duration of the pain. On 11/04/14 at 12:35 p.m., upon inquiry as to how often the resident says she has pain, or gives nonverbal indicators of pain, Employee #12, RN, said the resident complains of pain on a daily basis. Further inquiry as to how often the resident will ask for medication to relieve her pain, Employee #12 said the resident does not ask for pain pills, she just lets the staff know she is hurting. At 2:10 p.m. on 11/04/14, when asked about the facility's policy on pain assessment and management, the DNS reported the facility did not have a policy specific to pain. She said the facility completed assessments quarterly, annually, and as needed. Upon inquiry as to how a resident's pain was assessed, she said there was not a specific tool or protocol in place to monitor a resident's pain. She expected the nursing staff to assess resident pain based on how they were taught in nursing school. Inquiry was made in regards to the facility's practice for administering PRN (as needed) medications. The DNS said PRN medications were given to residents upon their request. The DNS was asked about residents who were unable to verbalize pain or ask for specific medication. She said she would then expect the nurses to assess the pain and administer medications as needed. On 11/04/14 at 2:50 p.m., a review of the Medication Administration Record [REDACTED]. In an interview at 3:05 p.m. on 11/04/14, Employee #62, NA (nurse aide), said Resident #32 complained of pain on a regular basis. She said for quite a while now, the resident had been saying she hurt. The NA said when she had heard the resident complain of pain, she had reported it to the nurse. On 11/04/14 at 4:30 p.m., during an interview with the administrator, she was informed of the findings regarding Resident #32. She agreed the resident had not been properly assessed and treated for [REDACTED]. .