Every finding on record at Rivertown Health and Rehabilitation Center

Based on observations, interviews and a review of facility policies titled Dry Food Storage and Cold Storage Areas, the facility failed to ensure: 1) food items were dated and labeled in dry storage and;2) the freezer floor was free of ice. This had the potential to affect all residents who received meals from the kitchen. Findings Include: 1) An undated facility policy titled Dry Food Storage documented: . Procedure . 9. Opened food items should be labeled with contents, date opened and expiration or use by date . On 07/21/2025 at 2:00 PM, the surveyor toured the dry storage area with the DM, (Dietary Manager). The surveyor observed one box of light brown sugar with no open or use by date and an ant crawling on the top of the sugar box. The surveyor observed one box of powdered sugar with no open or use by date on it. On 07/23/2025 at 2:17 PM an interview was conducted with the DM. She stated that the powered and brown sugar was opened in dry storage. She could not remember the open and use by date of the items. She stated that open items should be sealed with an open and use by date. She stated that the items were not sealed properly because staff forgot to seal them and put a use by date on the items. She stated the facility's policy on labeling and dating food items when they are opened, was to be labeled with a date, expiration date and a use by date. On 07/24/2025 at 10:09 AM an interview was conducted with the Dietician. The dietician stated that it was important to label and date food items in dry storage so staff will know which item to use first. 2) An undated facility policy titled Cold Storage Areas documented: . Cold food and beverages should be stored under safe and sanitary conditions. 3. Inspect refrigerators and freezers regularly for leaks, frozen areas, . On 07/21/2025 at 2:00 PM the surveyor and the DM observed a large amount of ice on the freezer floor. There was one large chunk of ice on the left side. The surveyor observed staff take a water hose and wash the ice off the freezer floor. On 07/24/2025 at 9:04 AM, an interview was conducted with the Dietary Manager. She stated that the ice had been on the freezer floor for a few months. She stated that she reported it to maintenance. She stated that she placed several work orders to maintenance to have the freezer fixed. The last work order was placed on 07/12/2025. The DM stated that the regional manager, the administrator and maintenance knew of the ice freezing on the floor. According to the DM, maintenance was responsible for repairing the freezer. The DM described the ice on the floor like a skating ring. She stated the ice was the size of a tennis ball. The DM stated in width it was about four or five inches and in height it was about 5 inches. The DM stated that staff could injury themselves when entering the freezer with ice on the floor. On 07/24/2025 at 9:28 AM, an interview was conducted with the Cook. She stated the freezer floor had been freezing up a couple of days. She stated in width there was about six inches of ice on the floor. The cook stated that the freezer floor was cleaned off each morning for ice. She stated it was a potential harm for staff falling. On 07/24/2025 at 10:09 AM, an interview was conducted with the dietician. She stated that it was important to keep the freezer floor free of ice to prevent falls.

Based on observation, interview, and the 2017 U.S. (United States) Public Health Service Food Code the facility failed to ensure the dumpster ground was free of food debris on 07/21/2025. This had the potential to affect 98 residents who resided at the facility. Findings Include: A review of the the 2017 U.S. (United States) Public Health Service Food Code revealed: . 5-501.110 Storing Refuse, Recyclables, and Returnables.REFUSE, . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, . shall be maintained free of unnecessary items . and clean . On 07/21/2025 at 2:33 PM, the surveyor and the Dietician Manager (DM) toured the dumpster area. There was a smell at the dumpster area and the surveyor observed there was food debris around the dumpster area which included three rib bones, and one slice of bread. On 07/23/2025 at 4:19 PM, the surveyor conducted an interview with the DM. She stated that she saw a rib bone at the dumpster facing the parking lot. The DM stated that she walked around the dumpster area that morning. The DM stated that maintenance was responsible for ground keeping. According to the DM, the dumpster should be free of debris so it will not attract animals or bugs. She did not know the facility's policy on debris around the dumpster. The DM stated that the smell around the dumpster smelled like old sewage or old trash. She did not know why it smelled.

Based on an observation, record review, interviews and review of a facility policy titled, Safeguarding of Resident Identifiable Information, the facility failed to ensure the electronic Medication Administration Record (eMAR) screen was closed, while Licensed Practical Nurse (LPN) #17 was away from the medication cart, and did not reveal medical information pertaining to Resident Identifier (RI) #112.This deficient practice affected RI #112, one of 22 sampled residents, and was observed on 07/23/2025 during the evening Medication Administration observation.This deficiency was cited as a result of the investigation of complaint/report number 2563418. Findings include:Review of an undated facility policy titled, Safeguarding of Resident Identifiable Information, revealed the following: . Policy:It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information .Policy Explanation and Compliance Guidelines: .7. Computer screens showing clinical record information may not be left unattended and readily observable or accessible by other residents or visitors .RI #112 was admitted to the facility on [DATE] with diagnoses to include Type II Diabetes Mellitus, Low back Pain and Pain in Left Arm.A review of RI #112's July 2025 Order Summary Report (Physician Orders) revealed RI #112 had orders to include Finger Stick Blood Sugar (FSBS) twice a day, Fish Oil Oral Capsule 1,000 milligrams give one capsule by mouth three times a day for supplement and Gabapentin Tablet 600 milligrams one tablet by mouth three times a day for neuropathy. On 07/23/2025 at 8:24 PM the surveyor observed a medication cart on the C wing with the eMAR screen open revealing RI #112's name. FSBS, Fish Oil and the medication Gabapentin could also be observed on the eMAR screen. There was no nurse at the medication cart at the time of the observation.On 07/23/2025 at 8:27 PM LPN #17 exited RI #112's room and an interview was conducted. When asked about the the privacy of resident's information on the computer screen when the nurse was not at the medication cart, LPN #17 said, the screen should be closed. LPN #17 said when the screen was not closed it would be a privacy concern.On 07/24/2025 at 12:02 PM, the surveyor conducted an interview with the Director of Nursing (DON). When asked how should the privacy screen on the medication cart be kept when the nurse was not at the cart, the DON said, the privacy screen should be pulled up.

Based on interviews, record review, review of a Facility Reported Incident (FRI), review of the facility investigative file and a facility policy titled Abuse, Neglect and Exploitation the facility failed to protect Resident Identifier (RI) #8's right to be free from verbal abuse perpetrated by a facility employee, Certified Nursing Assistant (CNA) #21 on 07/10/2025 when Licensed Practical Nurse (LPN) #16 and the Registered Nurse (RN)/Unit Manager #15 witnessed CNA #21 verbally abuse RI #8, a cognitively impaired resident who was already upset, when CNA #21 called RI #8 an ugly [NAME] and said she would say more to RI #8 if she was not on the clock. The Administrator said, for someone to be called an ugly [NAME] would be offensive.This affected one of three residents sampled for abuse. Findings Include: Cross-reference F740.On 07/10/2025 at 3:22 PM the State Agency received a FRI alleging verbal abuse occurred when staff witnessed CNA #21 tell RI #8 he/she was an ugly [NAME] and she would say more if she was not on the clock.A facility policy titled Abuse, Neglect and Exploitation dated 06/11/2025 documented: . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: . Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. IV. B. Possible indicators of abuse include . 5. Verbal abuse of a resident overheard . RI #8 was admitted to the facility on [DATE] with diagnoses to include History of Traumatic Brain Injury and Mood Disorder. RI #8's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/13/2025 documented a Brief Interview for Mental Status (BIMS) score of eight which indicted moderate cognitive impairment. RI #8's Behavioral Care Plan initiated on, 04/21/2020, indicated RI #8 had a history of behavioral issues such as verbal abuse, loud talking, being argumentative, and easily agitated. Interventions guided staff to avoiding power struggles with RI #8, intervening when necessary to safeguard the rights and safety of others, and fostering a calm environment and approach towards the resident.The facility investigative file contained a typed, undated Investigative Summary & (and) Conclusion that documented the verbal abuse was unsubstantiated by the facility, even though witnesses heard what CNA #21 said to RI #8, as follows: . According to (Unit Manager #15) unit manager's statement she was walking up to the resident . and stated I will help (him/her) to (his/her) room. (RI#8) responded, I don't want to eat, I am upset, and I want to go home. (Unit Manager #15) ask (RI #8) who had made (him/her) upset and resident pointed back at (CNA #21) he did. that [NAME]. (CNA #21) approached resident and stated to resident (RI #8) you are the [NAME] and not a cute one she then stated, you're lucky I'm clocked in, or I would say what I really want to say. At that time (CNA #21) was removed from the facility . Investigation conclusion: . verbal abuse cannot be substantiated . CNA was terminated on (7/17/2025).The facility investigative file contained a witness statement for RI #8 dated 07/10/2025 that documented: . she said my mom don't love me . I don't like her, I don't want her to be my CNA no more. I'm mad. Who says that to someone? .Another witness statement for RI #8 dated 07/16/2025 documented . I told her she looked like a [NAME] and she told me I was a [NAME], a ugly [NAME]. On 07/23/2025, at 10:30 AM RI #8 was asked about the incident involving CNA #21. RI #8 said, CNA #21 initially upset him/her when CNA #21 said RI #8's mother did not love him/her. RI #8 said, they called each other an ugly [NAME] and CNA #21 was sarcastic. On 07/24/2025 at 4:49 PM Licensed Practical Nurse (LPN) #16 was asked about what she witnessed involving RI #8 and CNA #21. LPN #16 said, the incident occurred during lunch, RI #8 came up to her and complained of a headache, hands shaking and sounding like he/she was going to cry. LPN #16 said, RI #8 reported to her that CNA #21 had said, RI #8's mother did not love RI #8. LPN #16 said, then CNA #21 approached them, RI #8 got upset, did not want to eat, and called CNA #21 a man and CNA #21 responded by calling RI #8 a [NAME]. LPN #16 said, what she witnessed was verbal abuse and CNA #21 was immediately sent home by the charge nurse. On 07/24/2025 at 4:55PM the Registered Nurse (RN) Unit Manager (UM) was asked about the incident involving RI #8 and CNA #21. The UM stated, in the hallway when RI #8 saw CNA #21, RI #8 called CNA #21 him, and then CNA #21 said, RI #8 was a [NAME] and not a cute one and if she was not on the clock she would tell RI #8 how she really felt, then CNA #21 was advised to immediately clock out. The UM said, CNA #21 should have just walked away instead of responding to RI #8.On 07/24/2025 at 11:45 AM the Administrator asked about the verbal abuse involving RI #8 and CNA #21 and she said, on 07/10/2025 she was made aware RI #8 called CNA #21 an ugly [NAME] and CNA #21 responded by calling RI #8 an ugly [NAME]. The Administrator defined verbal abuse as the use of oral or written expressions, communications, or sounds that intentionally incorporate disparaging or derogatory terms within hearing range. The Administrator said it could have been prevented if CNA #21 had not responded back to the resident. On 07/24/2025 at 5:59 PM a follow-up interview was conducted with the Administrator, and she said, RI #8 had a BIMs score of eight, which indicated moderate cognitive impairment. The ADM said, a reasonable person would feel offended to be called an ugly [NAME] and it would potentially upset a person to be told that their mother did not love them.

Based on interviews, record review, review of Facility Reported Incident (FRI) and the investigative file, the facility failed to ensure an allegation of physical abuse was reported to the Abuse Coordinator on 06/13/2025 when Certified Nursing Assistant (CNA) #12 witnessed Resident Identifier (RI) #94 push RI #110 on the shoulder. The facility failed to report to the State Agency until 06/16/2025.This deficient practice affected RI #110 and RI #94 two of three residents sampled for abuse.Findings include: On 06/16/2025 the State Agency received a FRI alleging physical abuse occurred on 06/13/2025 when RI #94 attempted to choke RI #110; on 06/16/2025 RI #110 reported to the Ombudsman that roommate RI #94 put his/her hands around RI #110's neck and attempted to choke him/her; no injury was noted; RI #110 had changed rooms on Friday 6/13/2025 and the residents had not been in contact.A facility policy titled Abuse, Neglect, and Exploitation, dated 06/11/2025, documented: . VII. Reporting/ResponseA.1. Reporting of all alleged violation to the Administrator, state agency, adult protective services, and to all other required agencies . within the specified timeframes: . a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . RI #94 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Chronic Kidney Disease, Hypertension and Major Depressive Disorder. RI #94's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/26/2025 documented Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. RI #110 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Fracture of First Lumbar Vertebra. RI #110's admission MDS with an ARD of 05/27/2025 documented a BIMS score of 15 which indicated intact cognition. The facility investigative file contained an undated summary of the incident that documented: . On Monday, June 16, 2025, . this writer was visited by Local Ombudsman . She stated that (RI #110) alleged to her that (his/her) roommate, (RI #94) choked (him/her) during a disagreement on Friday, June 13, 2025. An investigation was initiated on Monday June 16, 2025 as soon as we were made aware, .On Friday, 06/13/2025 Residents (RI #110) and (RI #94) were bickering in the resident room. The staff member . (CNA #14) intervened at which time the bickering stopped, and (RI #110) left the room. (RI #110) agreed to another room for a more compatible roommate. (CNA #12) came to the room due to hearing the bickering, she states she observed (RI #94) push at (RI #110). She stated (RI #110) was on the bed and (RI #94) was standing up between the beds. When asked why she did not report her observation she stated because [Assistant Director of Nursing (ADON)] was in the room so I thought she knew. (CNA #12) was asked was (ADON) present when she observed the push and she stated no. (CNA #12) was put on suspension pending outcome for not reporting. (Maintenance Assistant) came in the room . he did not witness any physical interaction/hands on the neck . (Maintenance Assistant) went out of the room with (RI #110) . (CNA #13) came to the room when she heard the bickering. She states, (RI #94) put (his/her) open hand on (RI #110's) shoulder but did not see (him/her) push . (CNA #13) was suspended pending investigation for failing to report her observation.(ADON) came into the room after she heard bickering . did not witness any physical interactions.On Monday, June 16, 2025, local state ombudsman, . came to Administrator office and reported . (RI #110) had told her that (his/her) roommate (RI #94) had choked (him/her).The investigative file contained a handwritten witness statement signed by RI #110 that documented questions and answers to include the following: . What happened with your roommate .? I told (him/her) I was going to smoke and (he/she) told me it wasn't time . (He/she) was upset . My roommate got up reached (his/her) hand through the curtain and started choking me, the nurses knocked on the door and came in the room and saw him choking me.The facility's investigative file contained a hand written witness statement dated 06/16/2025 and signed by CNA #12 which documented: . I saw them arguing, (RI #94) pushed (RI #110's) . (right) shoulder, it wasn't like a hard push, . they were still arguing . we tried to calm them down . On 07/23/2025 at 9:11 AM an interview was conducted with CNA #12 regarding the incident on 06/13/2025 between RI #110 and RI #94. CNA #12 said the morning of 06/13/2025 around 8:00 AM, she and CNA #13 were in the break room when they heard RI #110 and RI #94 across the hall cursing each other. CNA #12 said they quickly got up and went to the room. CNA #12 said RI #94 was cursing, got up, walked over and shoved RI #110 on the shoulder with one hand. CNA #12 described the push as not hard, but soft. CNA #12 said the residents were immediately separated, CNA #12 stayed in the room with RI #94 and did not report it while CNA #13 called for help; and RI #110 was escorted from the room in a wheelchair by maintenance. CNA #12 said she felt this was an abusive situation verbally and maybe physically with the shove. On 07/23/2025 at 2:34 PM an interview was conducted with Assistant Director of Nursing (ADON) regarding the incident on 06/13/2025 between RI #94 and RI #110. ADON said the CNA's reported a verbal altercation between RI #110 and RI #94 on 06/13/2025. ADON said the two residents were separated, assessed, RI #110 was given the option to move rooms and accepted. When asked if the Administrator /Abuse Coordinator was notified on 06/13/2025 of the incident, ADON said no. When asked why, ADON said she was not made aware of any physical contact between the two and felt the issue had been resolved. ADON said she was made aware of the physical allegation days later but could not recall the exact time. ADON said, had she been made aware of physical contact between RI #94 and RI #110 on 06/13/2025, she would have reported it to the Administrator/Abuse Coordinator immediately. When asked if the incident should have been reported on Friday, 06/13/2025, ADON said yes. On 07/24/2025 at 10:59 AM an interview was conducted with the Administrator regarding the incident on 06/13/2025 between RI #110 and RI #94. The Administrator said she was notified that RI #110 and RI #94 had been bickering on 06/13/2025, they were separated, and RI #110 was relocated to another room. Administrator said it was not until 06/16/2025 when she became aware of RI #110's allegation of physical abuse from RI #94 on 06/13/2025. When asked what the time frame was for reporting abuse, Administrator said two hours. When asked if the incident between RI #94 and RI #110 was reported timely, Administrator said no. Administrator said if there was any pushing between RI #94 and RI #110 on 06/13/2025, it should have been reported immediately. This citation was a result of investigation into AL00051526.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #21 was invited to and allowed to participate in his/her care plan meeting on 05/16/2025.This affected RI #21, one of two residents reviewed for care plan concerns.Findings include:RI #21 was admitted to the facility on [DATE] with Diagnoses to include: Paraplegia, Anemia, and Osteoarthritis.RI #21's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/15/2025 documented a Brief Interview of Mental Status (BIMS) of 15 which indicated cognitively intact mental status.RI #21's most recent CARE PLAN MEETING SUMMARY document dated 05/15/2025 was reviewed and revealed: . Family . was contacted no answer, left voicemail . The space on the document for Resident/Family who attended the meeting was left blank and four staff members signed as attendees. On 07/23/2025 at 9:13 AM RI #21 was interviewed regarding the care plan process. RI #21 responded, no one had told him/her about, nor invited him/her to a care plan meeting. On 7/24/2025 at 11:00 AM an interview was conducted with the Director of Social Services (DSS) and she was asked about updating residents that cannot attend the care plan meetings. The DSS responded, the Registered Nurse (RN), MDS #4 went to the residents room and gathered the information from the nursing staff and the residents. The DSS was asked the importance of inviting RI #21 to the care plan meeting. The DSS responded so he/she could advocate for his/her needs. The facility did not provide any documentation of evidence a care plan meeting was held in RI #21's room.On 07/24/2025 at 12:55 PM RN, MDS #4 was asked how she updated residents who were unable to attend care plan meetings. The RN MDS #4 responded the Wound Care Nurse, MDS Coordinator as well as the DSS, and Unit Manager all go to the bedside to attend the care plan meeting.On 07/24/2025 at 1:09 PM an interview was conducted with the RN, MDS Coordinator #5. The MDS Coordinator was asked did she provide a bedside care plan meeting for RI #21 on 05/15/2025. The MDS Coordinator responded no and it was important for residents to be included in care plan meetings for their preferences, concerns, care, treatment and involvement in their whole plan of care.

Based on interviews, observations, and record review and a facility policy titled, Activities, the facility failed to offer Resident Identifier (RI) #59 activities based on his/her comprehensive assessment.This deficient practice affected RI #59 one of one resident sampled for activity concerns. Findings Include:Review of an undated facility policy titled Activities, revealed the following: . Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. 4. Activities may be conducted in different ways: a. One-to-One Programs. b. Person Appropriate-activities relevant to the specific needs, interests, culture, background . for the resident they are developed for. c. Program of Activities- to include a combination of large and small groups, one-to-one, and self-directed as the resident desires to attend.RI #59 was admitted to the facility on [DATE] and had diagnoses to include Major Depressive Disorder and Cerebrovascular Disease.RI #59's Annual Minimal Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/23/2025 documented RI #59 had a Brief Interview for Mental Status (BIMS) score of 14 of 15 which indicated intact cognition; Section F- Preferences for Customary Routine And Activities documented it was very important for RI #59 to have books, newspapers and magazines to read, listen to music, do things with groups of people, do favorite activities, go outside to get fresh air when weather was good and participate in religious services or practices. RI #59's ONE ON ONE ACTVITY AND GROUP ACTIVITY REPORT sheet documented seven one to one room visits for activities for this year 2025 with the following dates: 1/1, 2/14, 2/27, 4/10, 5/2, 5/20, and 7/9. The sheet did not document the specific type of visit or activity that was provided, and documented verbal responses were appropriate.On 07/23/2025 at 8:56 AM RI #59 was observed lying in a supine position with Head of Bed (HOB) elevated.On 07/23/2025 at 8:57 AM RI #59 stated no one had offered him/her any activities.On 07/23/2025 at 11:28 AM RI #59 was observed lying in a supine position with the HOB elevated.On 07/24/2025 at 10:00 AM an interview was conducted with the Activities Director (AD). The AD was asked what activities were provided for the residents that were not able to attend group activities. She stated one on one activities were provided. The AD was asked if she had asked RI #59 to participate in activities. She stated RI #59 has stated he/she would like to come to activities and has participated in activities two times a week. The AD was asked where was the documentation that RI #59 was asked to participate in activities or provided one on one activities. She stated it would be documented on the activities log, but she did not have any progress notes regarding RI #59 activities.

Based on observation, record review, interviews and review of a facility policy titled Care and Treatment of Feeding Tubes, the facility failed to ensure feeding tubes were managed in a manner to ensure standard of practice and prevent complications. 1) the facility failed to start Resident Identifier (RI) #109's tube feeding as ordered by the physician at the time RI #109 was admitted to the facility on the morning of 06/26/2024; and 2) the facility failed to position RI #9's head of bed (HOB) elevated at 45 degrees as care planned while RI #9's tube feeding was infusing on 07/23/2025. These deficient practices affected RI #9 and RI #109, two of three residents sampled for tube feeding.This deficiency was cited as a result of the investigation of complaint/report number AL00048535/460742. Findings Include: Review of an undated facility policy titled, Care and Treatment of Feeding Tubes, revealed the following: . Policy:It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines:1. Feeding tubes will be utilized according to physician orders .3. The resident's plan of care will address the use of feeding tubes, including strategies to prevent complications .12. The resident's plan of care will direct staff regarding proper positioning of the resident . 1) RI #109 was admitted to the facility on [DATE]. RI #109's June 2024 Order Summary Report (Physician Orders) revealed RI #109 was to receive Diabetisource by way of a Kangaroo pump at 55 ccs (cubic centimeters) an hour. A review of RI #109's Progress Notes, dated 06/27/2024, documented: . Note Text: Late entry for 6/26/24-resident arrived to facility at 9:15AM . On review of RI #109's June 2024 Medication Administration Record (MAR) there was no evidence RI #109's Diabetisource tube feeding was started at the time RI #109 was admitted to the facility on the morning of 06/26/2024. On 07/24/2025 at 11:30 AM a telephone interview was conducted with Registered Nurse (RN) #26, the nurse assigned to care for RI #109 on the 7 AM -7 PM shift on 06/26/2024. The surveyor shared with RN #26 that RI #109 was admitted to the facility on [DATE] at 9:15 AM and had Physician Orders for Diabetisoure to infuse continuously at 55 cc an hour. When asked when was RI #109's tube feeding started, RN #26 said she did not know. RN #26 said the evidence of when a tube feeding was started would be on the MAR, and if a resident had an order for a tube feeding, it should be started as ordered by the physician. On 07/24/2025 at 12:02 PM, the surveyor conducted an interview with the Director of Nursing (DON) and she said she remembered RI #109's family member coming to her about RI #109's continuous tube feeding not being started. The DON said this was sometime in the afternoon the day RI #109 was admitted to the facility, at it was started then. The surveyor asked the DON if a resident was admitted to the facility at 9:15 AM and has an order for a continuous tube feeding, when should the feeding be started. The DON said as soon as the resident comes into the building. When asked where the evidence would be that RI #109's tube feeding was started when he/she came into the facility, the DON said on the MAR. The DON said looking at RI #109's MAR she did not see any evidence RI #109's tube feeding was started the morning RI #109 came into the facility. 2) RI #9 was admitted to facility on 01/15/2025 and readmitted on [DATE], with diagnoses to include Dysphagia and Gastrostomy. RI #9's July 2025 Physicians Orders revealed RI #9 was to receive Isosource 1.5 by way of continuous feeding pump at 60 ccs an hour. RI #9's tube feeding care plan, with an initiated date of 01/21/2025, revealed RI #9 needed to have the HOB elevated 45 degrees while the tube feeding was infusing. On 07/23/2025 at 11:55 AM RI #9 was observed in bed with the HOB down. On 07/23/2025 at 12:03 PM the surveyor escorted Employee Identifier (EI) #19 to RI #9's room. When asked what position she would describe RI #9's HOB to be in, EI # 19 said the HOB was low. EI #19 said the HOB should be elevated at least 30 degrees. EI #19 said when a resident receiving a tube feeding HOB was not elevated there was a potential for aspiration. On 07/24/2025 at 9:43 AM the surveyor conducted an interview with Certified Nursing Assistant (CNA) #20, the CNA assigned to care for RI #9 on 07/23/2025 on the 7 AM - 7 PM shift. When asked what position should the HOB of a resident receiving tube feeding be, CNA #20 said it should always be up. CNA #20 said there was a potential for the resident to choke when the HOB was flat. CNA #20 said on yesterday (07/23/2025) staff forgot to let RI #9's HOB back up. On 07/24/2025 at 12:02 PM in the continued interview with the DON, the DON said a resident on a continuous tube feeding HOB should be kept at 30 degrees or higher. The DON said there was a potential for aspiration when this was not done.

Based on interviews, resident record review, and review of a facility policy titled Behavioral Health Services, the facility failed to ensure Certified Nursing Assistant (CNA) #21 responded to resident behaviors in a manner to prevent behavior escalation and in an environment that was conducive to mental and psychosocial well-being, instead of verbally abusing Resident Identifier (RI) #8, a cognitively impaired resident. The facility further failed to ensure CNA #21 implemented interventions that were in place to address RI #8's Behavioral Symptoms to include avoiding power struggles and maintaining a calm environment and approach to the resident. This deficient practice affected RI #8 one of two residents sampled for behaviors. Findings include: Cross-reference F600. On 07/10/2025 at 3:22 PM the State Agency received a FRI alleging verbal abuse occurred when staff witnessed CNA #21 tell RI #8 he/she was an ugly [NAME] and she would say more if she was not on the clock. An undated facility policy titled Behavioral Health Services documented: . Policy Explanation and Compliance Guidelines: . 5. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 11. Facility staff will implement person-centered approaches designed to meet the individual goals and needs of each resident, . m. Focusing the resident on activities that decrease stress . q. Providing support with skills related to verbal de-escalation, coping skills and stress management. RI #8 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis to include History of Traumatic Brain Injury and Mood Disorder. RI #8's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/13/2025 documented a Brief Interview for Mental Status (BIMS) score of eight which indicted moderate cognitive impairment. RI #8's Behavioral Symptoms plan of care with initiation date of 04/21/2020 indicated RI #8 had a history of the following: . exhibits behavioral symptoms including verbal abuse, resisting ADL care, talking loudly, manipulation, argumentative . easily agitated with staff . when they don't do what (he/she) wanted within seconds, . The interventions guiding staff responses included: Avoid power struggles with (RI #8) . Approach/speak in a calm manner . Maintain a calm environment and approach to the resident . Contained within the facility's investigative file was a handwritten witness statement signed by CNA #22 dated 07/11/2025 which documented the following she observed: . I was passing lunch trays . (RI #8) was coming toward the front. CNA #21 came around the corner (and) told (RI #8) your tray is in your room, go eat (and) (RI #8) said you don't tell me what to do, then (CNA #21) said, I'm not trying to tell you what to do, I was just telling you that your tray was in the room so you go eat. (RI #8) kept saying you can't tell me what to do. That's when (RN #15 and LPN #16) came up . (RI #8) said, that [NAME] then (CNA #21) said to (RI #8) (you're) a [NAME] . The statement continued and included questions and answers: . Did you witness (CNA #21) go back to (RI #8) (and) make a statement that (he/she) was lucky she was clocked in or she would tell (him/her) what she really thinks? . yes, I heard her say that . On 07/24/2025 at 4:58 PM an interview was conducted with CNA #22 and she stated she witnessed the following: CNA #22 was on the unit as lunch trays were being passed, CNA #21 placed RI #8's tray in his/her room and told RI #8 to go eat; RI #8 responded that he/she did not want to eat and said he/she was about to cry and was pissed off; at that time, RN Unit Manager (RN) #15 and Licensed Practical Nurse (LPN) #16 were walking up the hall and RI #8 was crying and told them he/she was pissed off; CNA #22 said she heard RI #8 call CNA #21 that [NAME] . that [NAME] . then CNA #21 said how you gonna call me a [NAME] . you a [NAME]. On 07/23/2025, at 10:30 AM RI #8 was asked about the incident involving CNA #21. RI #8 said, CNA #21 initially upset him/her when CNA #21 said RI #8's mother did not love him/her. RI #8 said, they called each other an ugly [NAME] and CNA #21 was sarcastic. On 07/23/2025 at 10:59 AM, an interview was conducted with LPN #16. She stated the following was witnessed: CNAs were on the hall passing lunch trays and CNA #21 told RN #15 she already told RI #8 to come eat, RI #8 told CNA #21 you don't tell me what to do!; RI #8 told LPN #16 that he/she did not want CNA #21 to be their CNA anymore; when asked who, RI #8 pointed at CNA #21 and said him; CNA #21 walked over to RI #8 and asked RI #8, who you calling a him . (RI #8 responded) You are a him you [NAME]!; RI #8 told CNA #21, you're a [NAME], then CNA #21 said umm hum you're one too, and LPN #16 stated this would be considered verbal abuse. On 07/24/2025 at 5:39 PM the Administrator (ADM)/Abuse Coordinator was asked whether RI #8 had a behavior care plan, to which she confirmed that he/she did. Upon being asked about RI #8's behaviors, she described them as being verbally abusive, speaking loudly, and being argumentative. The ADM indicated that the interventions included approaching calmly, maintaining composure, backing off if necessary, intervening when required, and refraining from arguing back. She noted that these interventions were in effect on 07/10/2025, during the incident involving RI #8 and CNA #21. The ADM said the following: she expected that staff would address residents who exhibit verbal abuse by adhering to the care plan, remaining calm, and seeking assistance when necessary; the importance of following the care plan was to prevent escalation. The ADM stated CNA #21 did not react appropriately and the incident could have been avoided had she followed the care plan. This deficiency was cited as a result of the investigation of complaint/report number 2562064.

Based on observation, interview, and review of a facility policy titled, Nurse Staffing Posting Information, the facility failed to ensure the required data was on the staff posting form, to include census, current date and the number of staff working and actual hours worked for all nursing staff.This deficient practice was observed on three of four days of the survey and had the potential to affect all 98 residents residing in the facility. Findings include: Review of an undated facility policy titled, Nurse Staffing Posting Information, revealed the following: . Policy Explanation and Compliance Guidelines:1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:a. Facility nameb. The current datec. Facility's current resident censusd. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:i. Registered Nurses [RN]ii. Licensed Practical Nurses [LPN]/Licensed Vocational Nursesiii.Certified Nurse Aides [CNA] .4. A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current.a. The information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated to reflect such . On 07/21/2025 at 1:35 PM, during the initial tour, the surveyor observed the DIRECT CARE DAILY STAFF REPORT was posted for 07/18/2025. On 07/22/2025 at 9:55 AM the Direct Care Daily Staff Report form was posted on entrance to facility. The form contained the Date: 07/22/2025, Census: 100, Shift: Day, RNs-4, LPNs-2 and CNAs-8. There were no actual hours staff worked on the form. On 07/22/2025 at 6:30 PM there still were no actual hours staff worked on the Direct Care Daily Staff form. On 07/23/2025 at 7:50 AM the Direct Care Daily Staff Report was again posted on entrance to facility. The form contained the Date: 07/23/2025, Census: 100, Shift: Day, RNs-4, LPNs-32 and CNAs-9. There were no actual hours staff worked on the form. On 07/23/2025 at 4:00 PM the Direct Care Daily Staff Report form did not have the actual hours staff worked on the form at this time either. On 07/24/2025 at 7:37 AM, an interview was conducted with the Administrator. The Administrator said, according to the facility's nurse staff posting policy, the facility name, the current date, the census, and the total actual hours worked for RNs, LPNs, CNAs, CMAs, should be on the form. The Administrator was asked who was responsible for posting the nursing staffing information on the weekend date of 07/19/2025 and 07/20/2025. The Administrator stated the Staffing Development Coordinator. The Administrator was asked if the DIRECT CARE DAILY STAFF REPORT FOR 07/21/2025, should have been dated 07/18/2025. The Administrator stated no. When asked why it would be important to have the actual hours staff worked on the staffing form, the Administrator said so residents, staff, and visitors would know the correct staffing in the building. The Administrator further replied that facility policy was not followed.

Based on interviews, record reviews, and facility document and policy reviews, the facility failed to protect 17 residents from misappropriation of resident property by the diversion of the residents' Schedule II controlled (narcotic) medications. This failure affected 17 (Residents #2, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, and #20) of 18 residents reviewed for misappropriation of resident property. Findings included: Review of a facility policy titled, Abuse, Neglect and Exploitation, implemented on 08/25/2023, indicated, . It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit . exploitation and misappropriation of resident property .Definitions .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . The policy indicated, . V. Investigation of Alleged Abuse, Neglect and Exploitation. A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The policy indicated, VII. Reporting/Response. A. The facility will have written procedures that include: 5. Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why the abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; f. Identification of staff responsible for monitoring the implementation of the plan . Review of a facility policy titled, Discarding and Destroying Medications, with a revision date of 10/2014, revealed, .1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of . The policy further indicated, .6. For unused non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA [Environmental Protection Agency] recommends destruction and disposal of the substance with other solid waste following the steps below: c. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least one witness . Further review revealed, . 11. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records . Review of a facility policy titled, Controlled Medications/Schedule II - V, with a reviewed/updated date of 04/2022, revealed, . If the facility is in possession of a signed written prescription the facility should fax a copy of the prescription to the pharmacy. [The pharmacy] will process the order based on the faxed copy from the facility. If the signed written prescription is faxed by someone who is not the prescriber or agent of the prescriber the nurse should place the original prescription inside the RED folder located on each nursing station. When the [pharmacy] driver arrives each night he will pick up the red folder and replace it with an empty folder to use until the next delivery. [The pharmacy] must then file the original prescription in accordance with the [state] State Board of Pharmacy Law . Review of a facility policy titled, Medication Delivery, with a reviewed/updated date of 04/2022, revealed, Most deliveries will occur between 8:00 PM - 3:00 AM. Once the route has been established, the delivery times should vary only slightly . Review of the facility's investigation report revealed a pharmacist reported an irregularity in a faxed prescription for Norco (hydrocodone/acetaminophen), a controlled medication, on 04/06/2023 and requested the former Director of Nursing (DON), DON #15, who had faxed the prescription, to send the original or have the delivery driver pick up the original prescription. When DON #15 stated the prescription was ruined in the fax machine, the pharmacist requested the Administrator's assistance to investigate the situation. An investigation was conducted by the facility, who determined 18 residents' Norco medications had been manipulated by DON #15. The facility terminated DON #15 on 04/18/2023 for misappropriation of resident property. 1. Review of Resident #4's Admission Record revealed the facility admitted the resident on 12/07/2021. Review of the facility investigation revealed a copy of a faxed order, dated 04/06/2023, for Norco 10/325 milligram (mg), one tablet every six hours as needed for pain. The order was faxed to the pharmacy by DON #15. Review of the facility investigation revealed an email, dated 04/14/2023, by Pharmacist #32, who reported she received a Norco order on 04/06/2023 for Resident #4 that appeared altered with white out to alter the resident's name, date of birth, date of order, and drug strength. Pharmacist #32 reported she called the facility to request the original order. A short time after that, DON #15 called to say the fax machine ate the original and she would have the physician send a new order. Pharmacist #32 informed DON #15 the order would not be filled until the pharmacy received the new order. 2. Review of Resident #2's Admission Record revealed the facility admitted the resident on 03/16/2022. Review of Resident #2's Order Summary Report revealed an order, ordered on 12/21/2022, for Norco 7.5/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #2's Medication Administration Record (MAR) revealed the Norco 7.5/325 mg order was discontinued on 02/28/2023. The MARs for January 2023 and February 2023 revealed no administration of Norco. Review of the facility investigation revealed a copy of a faxed order for Resident #2, dated 12/21/2022, for Norco 7.5/325 mg, one tablet every six hours as needed for pain. Review of a pharmacy delivery sheet revealed the medication was delivered on 12/21/2022 and DON #15 had signed the delivery form. Another pharmacy delivery sheet revealed 120 tablets of Norco 7.5/325 mg were delivered and signed for by DON #15 on 01/27/2023. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 3. Review of Resident #5's Admission Record revealed the facility admitted the resident on 12/08/2021. Review of Resident #5's Order Summary Report revealed an order for Norco 10/325 mg to be given every 24 hours as needed before wound care. The medication was ordered on 10/31/2022 and discontinued on 11/07/2022. Review of Resident #5's Medication Administration Record for October 2022 and November 2022 revealed no administration of Norco. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 4. Review of Resident #6's Admission Record revealed the facility admitted the resident on 12/10/2021. Review of Resident #6's Order Summary Report revealed an order, ordered on 03/20/2023, for Norco 10/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #6's Medication Administration Record for March 2023 revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered by DON #15 on 03/20/2023 and was discontinued by DON #15 on 03/31/2023. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not found on the medication cart or on a destruction log. 5. Review of Resident #7's Admission Record revealed the facility admitted the resident on 01/12/2020. Review of Resident #7's Order Summary Report revealed an order, ordered on 12/06/2022, for Norco 7.5/325 mg, one tablet, to be given every six hours as needed for pain. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered by DON #15 on 12/06/2022. The order was an active order on the date of the audit and was last delivered on 01/16/2023 (120 tablets). The audit indicated the medication was not found on the medication cart and the original hard copy prescription was not located. 6. Review of Resident #8's Admission Record revealed the facility admitted the resident on 10/25/2021. Review of Resident #8's Order Summary Report revealed an order, ordered on 03/07/2023, for Norco 10/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #8's March 2023 Medication Administration Record revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered by DON #15 on 03/07/2023 and discontinued by DON #15 on 03/08/2023. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not listed on a destruction log. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 7. Review of Resident #9's Admission Record revealed the facility admitted the resident on 06/25/2018. Review of Resident #9's Order Summary Report revealed an order, ordered on 01/23/2023, for Norco 10/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #9's January 2023 and February 2023 Medication Administration Record revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered by DON #15 on 01/23/2023 and discontinued on 02/01/2023. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not found on the medication cart, was not listed on a destruction log, and the original hard copy prescription was not located. 8. Review of Resident #10's Admission Record revealed the facility admitted the resident on 08/08/2022. Review of Resident #10's February 2023 Medication Administration Record (MAR) revealed an entry for Norco 5/325 mg, one tablet, to be given every six hours as needed for pain. The MAR indicated a start date of 08/08/2022 and a discontinued date of of 02/02/2023. Another entry for Norco 5/325 mg, one tablet, to be given every six hours as needed for pain was noted with a start date of 02/02/2023 and a discontinued date of 02/15/2023. Norco was documented as administered to Resident #10 on 12 occasions from 02/02/2023 to 02/09/2023. A third entry was noted for Norco 10/325 mg, one tablet, to be given every six hours as needed for pain with a start date of 02/02/2023 and a discontinued date of the same date, 02/02/2023. Review of a Pharmacy Audit, dated 04/12/2023, revealed two Norco orders were ordered by DON #15 on 02/02/2023 and two orders were discontinued by DON #15, one on 02/02/2023 and the other on 02/15/2023. Per the audit, Resident #10's Norco was not found on the medication cart, the medication was not listed on the destruction log, and the original hard copy prescription was not found. 9. Review of Resident #11's Admission Record revealed the facility admitted the resident on 09/01/2021. Review of Resident #11's Order Summary Report revealed an order, ordered on 03/14/2023, for Norco 10/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #11's Medication Administration Record (MAR) for March 2023 indicated the Norco was ordered on 03/14/2023 and discontinued on 03/20/2023. The MAR revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered on 03/14/2023 by DON #15 and discontinued on 03/20/2023 by DON #15. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not listed on the destruction log. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 10. Review of Resident #13's Admission Record revealed the facility most recently admitted the resident on 03/23/2022. Review of Resident #13's Order Summary Report revealed an order, ordered on 03/27/2023, for Norco 10/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #13's Medication Administration Record (MAR) for March 2023 indicated the Norco had a start date of 03/27/2023 and a discontinued date of 03/31/2023. The MAR revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered on 03/27/2023 by DON #15 and discontinued on 03/31/2023 by DON #15. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not listed on the destruction log, the medication was not found on the medication cart, and the original hard copy prescription was not found. 11. Review of Resident #14's record was not possible due to the turnover of electronic health record agreements between companies. The new company took over the facility on 08/01/2023, at midnight. Resident #14 had previously discharged , and the new company did not acquire access to Resident #14's record. The new company was able to provide only the resident's Medication Administration Records (MARs) for January 2023, February 2023, and March 2023. Review of Resident #14's Medication Administration Record for January 2023, February 2023, and March 2023 revealed an entry for Norco 7.5/325 mg, one tablet, to be given every six hours as needed for pain. The MARs revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered on 01/09/2023 by DON #15 and was an active order on the date of the audit, 04/12/2023. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not listed on the destruction log, the medication was not found on the medication cart, and the original hard copy prescription was not found. 12. Review of Resident #15's Admission Record revealed the facility most recently admitted the resident on 03/02/2021. Review of Resident #15's Order Summary Report revealed an order, ordered on 11/28/2022, for Norco 7.5/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #15's Medication Administration Record (MAR) for January 2023 and February 2023 revealed the Norco had a start date of 11/28/2022 and a discontinued date of 02/28/2023. The MARs revealed no administration of Norco. Review of a Pharmacy Audit, dated 04/12/2023, revealed the Norco was ordered on 11/28/2022 by DON #15 and discontinued on 02/28/2023 by DON #15. One hundred and twenty tablets had been delivered to the facility on [DATE]. The audit indicated the medication was not listed on the destruction log and the medication was not found on the medication cart. 13. Review of Resident #16's Admission Record revealed the facility admitted the resident on 12/09/2021. Review of Resident #16's Order Summary Report revealed an order, ordered on 03/20/2023, for Norco 7.5/325 mg, one tablet, to be given every eight hours as needed for pain. Review of Resident #16's Medication Administration Record (MAR) for March 2023, April 2023, May 2023, June 2023, and July 2023 revealed the Norco had a start date of 03/20/2023 and a discontinued date of 07/11/2023. The MARs revealed no administration of Norco. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 14. Review of Resident #17's Admission Record revealed the facility admitted the resident on 01/12/2020. Review of Resident #17's Order Summary revealed an order, ordered on 12/12/2022, for Norco 7.5/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #17's Medication Administration Record for December 2022 and January 2023 revealed no administration of Norco. Review of the Order Audit Report revealed the order for Norco was created on 12/12/2022 and discontinued on 01/09/2023 by DON #15. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 15. Review of Resident #18's Admission Record revealed the facility admitted the resident on 09/22/2022. Review of Resident #18's Order Summary Report revealed an order, ordered on 09/22/2022, for Norco 5/325 mg, one tablet, to be given every six hours as needed for pain. Review of Resident #18's Medication Administration Record for September 2022 and October 2022 revealed staff administered Norco twice in October 2022 to Resident #18. Review of the Order Audit Report revealed the Norco was ordered on 09/22/2022 and discontinued on 11/04/2022. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 16. Review of Resident #19's Admission Record revealed the facility admitted the resident on 12/01/2022. Review of Resident #19's Order Summary revealed an order, ordered on 12/02/2022, for Norco 5/325 mg to be given every four hours as needed for pain. Review of the Order Audit Report revealed the Norco was ordered on 12/02/2022 and discontinued on 03/07/2023. Review of Resident #19's Medication Administration Record for December 2022, January 2023, February 2023, and March 2023 revealed no administration of Norco. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. 17. Review of Resident #20's Admission Record revealed the facility admitted the resident on 10/04/2021. Review of Resident #20's Medication Administration Record for February 2023 and March 2023 revealed an entry for Norco 5/325 mg to be given every four hours as needed for pain. The entry had a start date of 02/12/2022 and a discontinued date of 03/29/2022. Staff administered Norco to Resident #20 once in February 2023 only. During an interview on 08/27/2023 at 2:02 PM, the Administrator stated the medication was not found on the medication cart, nor on the medication destruction log. The Administrator stated after DON #15 was terminated it was discovered that many of the destruction logs were missing. The Administrator stated, The Norco disappeared. During a conference call interview on 08/28/2023 at 11:39 AM with the Pharmacy Manager and Pharmacist #32, Pharmacist #32 stated she was faxed an order from DON #15 that appeared altered. She stated she requested the original order for the medication, and DON #15 stated the fax machine ate it. She stated she informed DON #15 the pharmacy could not fill the prescription without a new order from the doctor. Pharmacist #32 stated the order appeared as if someone used white out on it. She stated she informed her supervisors at the pharmacy and notified the Regional Registered Nurse (RN) Consultant and the Administrator of the irregularity. Pharmacist #32 stated the pharmacy accepted faxed written prescriptions from the doctor for controlled Schedule II narcotics, which was required to be a signed order from the doctor for it to be filled. The Pharmacy Manager stated the pharmacy audits after this event was reported were conducted by Pharmacist #33 using the facility's Electronic Medication Administration Record system and the pharmacy's system and were conducted with the Regional RN Consultant and the Administrator. He stated all additional audits were considered internal documents and they were unable to share them. The Pharmacy Manager stated the state's Attorney General's office was conducting an investigation as well. He stated the pharmacy always delivered the medications by courier when requested. During an interview on 08/28/2023 at 7:26 PM, Pharmacist #33 stated he was the consultant at the facility since April 2023. He stated he conducted the monthly medication reviews for the residents. Pharmacist #33 stated he spot checked the controlled medications to ensure the order matched the medication cards and the controlled sign-out sheets were appropriate. He stated that when he started in April, an investigation of controlled medications was done, and it was discovered many narcotics, specifically Norco, were missing. He stated once it was determined there was a drug diversion, and that it was specifically Norco. During an interview on 08/29/2023 at 1:39 PM, the Administrator stated they could not find any of the destruction logs for the missing medications. She stated that at this time, the pharmacy could only do daytime deliveries with her approval. During an interview on 08/29/2023 at 5:16 PM, the Physician stated there were 18 residents on the facility's list that they had concerns about. The Physician stated there were eight to ten residents the facility asked him about where the discontinued medications were only given a short time. He stated he did not prescribe narcotic medication for such short time frames. He stated his office now faxed orders directly to the pharmacy and bypassed the facility. The Physician stated it was safer this way because some people could commit fraud and order or discontinue a medication he did not order. During an interview on 08/29/2023 at 5:25 PM, Registered Nurse (RN) #24 stated she did not work at the facility any longer but did not remember any time the narcotic count was incorrect at shift change. She stated that when a narcotic was discontinued, the nurse took the medication card and the controlled sign-out sheet to DON #15's office, recounted with DON #15 to verify, both nurses signed the controlled sheet, and DON #15 locked up the medications. During an interview on 08/29/2023 at 5:33 PM, the previous company's Regional RN Consultant stated she assisted the Administrator in gathering information and interviews after the misappropriation was discovered and reported. She stated Pharmacist #32 from the pharmacy was not sure but was concerned of an irregularity on Resident #4's script that was faxed in from DON #15. She said the water markings were altered like white out was used, and it was a red flag. Pharmacist #32 had said she spoke with DON #15 to pick up the hard copy of the prescription because she was told by DON #15 that the original script was shredded, and they needed a new hard script. The Regional RN Consultant stated she, the Administrator, and DON #15 opened the shredder box where DON #15 said the script was and looked through the contents, but there was no prescription for Resident #4 in the shred box. She stated they looked into other residents for Norco use for any trends they could identify. The Regional RN Consultant stated all drugs were delivered on the night shift, and the facility did have an emergency kit containing Norco so there would not have been a reason to get Norco medications during the day. She stated that for many of the faxed prescriptions DON #15 sent to the pharmacy, DON #15 requested courier service, which meant the Norco would come during the day shift. The Regional RN Consultant stated all residents were checked to determine if the Norco was given, was in the medication cart, and for remaining balances of discontinued Norco. The Regional RN Consultant stated there were many Norco prescriptions they were not able to find controlled sign-out sheets for. She stated they requested that DON #15 produce the medication destruction logs, but she did not. The Regional RN Consultant stated is was the DON's responsibility to keep all discontinued controlled medications in their office, under a double lock. She stated they were not able to validate where the medications were that were delivered or if they were destroyed or missing. She stated the Administrator was the person responsible to monitor the DON, and the Administrator should have overseen DON #15. This deficient practice was cited as a result of complaint/report #AL00043932.

Based on interviews, record review, and facility policy review, the facility failed to report two injuries of unknown origin to the state survey agency for one (Resident #1) of three residents reviewed for abuse. Findings included: Review of a facility policy titled, Accidents and Incidents - Investigation and Reporting, revised 07/2017, indicated, .All accidents and incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the administrator . Review of a facility policy titled, Abuse, Neglect, and Exploitation, with an implementation date of 08/25/2023, indicated under the IV. Identification of Abuse, Neglect and Exploitation section that possible indicators of abuse included but were not limited to: 3. Physical injury of a resident, of unknown source. The policy further indicated under the VII. Reporting/Response section that A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. A review of Resident #1's Admission Record revealed the facility admitted the resident on 03/21/2023. The Admission Record indicated the resident had diagnoses that included Unspecified Sequelae of Cerebral Infarction (stroke), Severe Dementia with Behavioral Disturbance, Aphasia (inability to articulate ideas or comprehend spoken or written language), and Unspecified Osteoarthritis. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2023, revealed Resident #1 had a short- and long-term memory problem and their cognitive skills for daily decision making were severely impaired, per the Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #1 was totally dependent on staff for all activities of daily living (ADLs). A review of Resident #1's Progress Notes, dated 01/06/2023 at 2:38 PM, revealed Resident #1 had a swollen left hand. The doctor was notified and an x-ray to the left hand was ordered and completed. A review of Resident #1's EHG-Skin Observation Tool, dated 01/06/2023, revealed Resident #1's left hand was noted to be swollen/bruised and Resident #1's second finger on the left hand was puffy. There were no alterations noted to the skin. A review of Resident #1's [company name] Imaging report, dated 01/06/2023, revealed an acute oblique fracture of the shaft of the third proximal phalanx, with possible extension to the proximal interphalangeal joint, with mild displacement. A review of Resident #1's Progress Notes, dated 01/25/2023 at 4:49 AM and entered as a late entry for 2:30 AM, revealed Resident #1 had a 1-centimeter (cm) skin tear to their right eyebrow. Additionally, blood was noted on the bed rails facing the window. A review of Resident #1's EHG-Skin Observation Tool, dated 01/25/2023, revealed Resident #1 had a skin tear noted to the right eyebrow. Discolored area and puffiness were noted to the upper right lip and a scratch was noted on Resident #1's chest. An old bruise was also noted to the right arm. A review of Resident #1's Skin Injury report, dated 01/25/2023, revealed Resident #1 had a one (1) centimeter (cm) skin tear to their right eyebrow. The document revealed blood was noted on rails facing the window and noted furniture to be a predisposing environmental factor. It further revealed they were unable to get a statement from the resident about what happened. An interview with Certified Nursing Assistant (CNA) #29 on 08/30/2023 at 11:06 AM revealed she had no idea what happened to Resident #1's finger or eye. She added that Resident #1 could be combative with care and that Resident #1 would swing and curse at staff. An interview with Licensed Practical Nurse (LPN) #27 on 08/29/2023 at 10:08 AM revealed no one knew how Resident #1 got the cut on their eyebrow. However, there was blood on a plastic clip on the bed rails, and Resident #1 would lean on their bed rails at times. During an interview with Director of Nursing (DON) #15, the previous DON, on 08/29/2023 at 11:48 AM, she revealed it was not clear where Resident #1 received the finger fracture. She added that no one had any idea what happened with the cut Resident #1 had above their eye. It was thought Resident #1 cut their head on something that was attached to their bed rails. DON #15 stated that when Resident #1 was combative with care they would swing and move their head, and staff thought Resident #1 may have hit their head at one point. During an interview with the Regional Director of Operations, acting Administrator, on 08/30/2023 at 12:16 PM, he revealed he was unable to confirm if a state report was completed for either incident involving Resident #1 (the fractured finger and the skin tear to the right eyebrow). He could not find any documentation indicating reports were made to the state. A second interview with the Regional Director of Operations on 08/30/2023 at 3:34 PM revealed he was still unable to determine if the incidents were reported to the state. He was unable to locate and provide any documentation to indicate whether a state report was completed for Resident #1's injuries of unknown origin for their fractured finger or skin tear to their right eyebrow. This deficient practice was cited as a result of the investigation of complaint/report #AL00043219.

Based on interviews, record review, and facility policy review, the facility failed to thoroughly investigate two injuries of unknown origin for one (Resident #1) of three residents reviewed for abuse. Findings included: Review of a facility policy titled, Accidents and Incidents - Investigation and Reporting, revised 07/2017, indicated, .All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator . Review of a facility policy titled, Abuse, Neglect, and Exploitation, with an implementation date of 08/25/2023, indicated under the IV. Identification of Abuse, Neglect and Exploitation section that possible indicators of abuse included but were not limited to: 3. Physical injury of a resident, of unknown source. The policy further indicated, V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Part of the written procedures for investigations included, 6. Providing complete and thorough documentation of the investigation. A review of Resident #1's Admission Record revealed the facility admitted the resident on 03/21/2023. The Admission Record indicated the resident had diagnoses that included Unspecified Sequelae of Cerebral Infarction (stroke), Severe Dementia with Behavioral Disturbance, Aphasia (inability to articulate ideas or comprehend spoken or written language), and Unspecified Osteoarthritis. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/05/2023, revealed Resident #1 had a short- and long-term memory problem and their cognitive skills for daily decision making were severely impaired, per the Staff Assessment for Mental Status (SAMS). The MDS indicated Resident #1 was totally dependent on staff for all activities of daily living (ADLs). A review of Resident #1's care plan, initiated on 06/09/2020, indicated Resident #1 had a potential to exhibit behavioral problems including physical abuse, combativeness during ADL care, spitting, repositioning self in bed from top to bottom, leaning on side rails in bed, fighting with staff, and tearing their clothes off. A care plan, revised on 08/02/2022, indicated Resident #1 was totally dependent on staff for ADLs due to cerebrovascular accident. A review of Resident #1's Progress Notes, dated 01/06/2023 at 2:38 PM, revealed Resident #1 had a swollen left hand and became agitated during care and would try to push staff's hands away. The doctor was notified and an x-ray to the left hand was ordered and completed. A review of Resident #1's EHG-Skin Observation Tool, dated 01/06/2023, revealed Resident #1's left hand was noted to be swollen/bruised and Resident #1's second finger on the left hand was puffy. There were no alterations noted to the skin. A review of Resident #1's [company name] Imaging report, dated 01/06/2023, revealed an acute oblique fracture of the shaft of the third proximal phalanx, with possible extension to the proximal interphalangeal joint, with mild displacement. A review of Resident #1's Progress Notes, dated 01/25/2023 at 4:49 AM and entered as a late entry for 2:30 AM, revealed Resident #1 had a 1-centimeter (cm) skin tear to their right eyebrow. Additionally, blood was noted on the bed rails facing the window. A review of Resident #1's EHG-Skin Observation Tool, dated 01/25/2023, revealed Resident #1 had a skin tear noted to the right eyebrow. Discolored area and puffiness were noted to the upper right lip and a scratch was noted on Resident #1's chest. An old bruise was also noted to the right arm. A review of Resident #1's Skin Injury report, dated 01/25/2023, revealed Resident #1 had a 1 cm skin tear to their right eyebrow. The document revealed blood was noted on rails facing the window and noted furniture to be a predisposing environmental factor. It further revealed they were unable to get a statement from the resident about what happened. An interview with Certified Nursing Assistant (CNA) #29 on 08/30/2023 at 11:06 AM revealed she had no idea what happened to Resident #1's finger or eye. She added Resident #1 could be combative with care and that Resident #1 would swing and curse at staff. An interview with CNA #30 on 08/30/2023 at 11:11 AM revealed Resident #1 would swing and kick at staff during care. An interview with CNA #31 on 08/30/2023 at 11:21 AM revealed Resident #1 could be difficult during care; they would hit, swing at, and kick staff. An interview with Licensed Practical Nurse (LPN) #27 on 08/29/2023 at 10:08 AM revealed no one knew how Resident #1 got the cut on their eyebrow. However, there was blood on a plastic clip on the bed rails, and Resident #1 would lean on their bed rails at times. The injury was thought to have come from that. LPN #27 stated she did not think an investigation was completed for the fractured finger, but she thought the Administrator did an investigation for the skin tear above Resident #1's eye. During an interview with Director of Nursing (DON) #15, the previous DON, on 08/29/2023 at 11:48 AM, she revealed it was not clear where Resident #1 received the finger fracture. She added that no one had any idea what happened with the cut Resident #1 had above their eye. It was thought Resident #1 cut their head on something that was attached to their bed rails. DON #15 stated that when Resident #1 was combative with care they would swing and move their head, and staff thought Resident #1 may have hit their head at one point. DON #15 stated an investigation was not completed for Resident #1's fractured finger because she thought it occurred during care; however, she thought one was completed for the skin tear on Resident #1's eyebrow. During an interview with the Regional Director of Operations, the acting Administrator on 08/30/2023 at 12:16 PM, he revealed he was unable to confirm if an investigation was completed for either incident involving Resident #1 (the fractured finger and the skin tear to the right eyebrow). He could not find any documentation indicating investigations were completed. A second interview with the Regional Director of Operations on 08/30/2023 at 3:34 PM revealed he had tried to find the investigations and was still unable to provide any documentation to indicate an investigation was completed for Resident #1's injuries of unknown origin for their fractured finger or skin tear to their right eyebrow. This deficient practice was cited as a result of the investigation of complaint/report #AL00043219.

Based on observations, interview, and record review, it was determined the facility failed to develop and implement care plan interventions to address a resident removing their wander monitoring bracelet for one (Resident #2) of three sampled residents reviewed for elopement risk. Findings included: A review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . A review of Resident #2's Admission Record revealed the facility admitted the resident on 03/16/2022 with diagnoses that included Paranoid Schizophrenia, Dementia, Mood Disorder, and Metabolic Encephalopathy (a condition in which the brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). Family Member (FM) #46 was identified as Resident #2's responsible party. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/15/2022, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Per the MDS, the resident did not exhibit any indicators of psychosis or wandering and was independent with bed mobility, transfers, walking, and locomotion. The MDS indicated Resident #2 was not steady but able to stabilize without staff assistance when walking. A review of Resident #2's comprehensive care plans revealed a Focus, initiated on 04/19/2022, that indicated the resident was at risk for elopement/wandering without purpose due to cognitive deficit. The comprehensive care plans did not address a history of the resident removing their wander monitoring bracelet. A review of a EHG-Wandering Risk Assessment, dated 03/11/2023, revealed Resident #2 was a moderate risk for wandering. A review of Resident #2's physician's orders revealed an order, dated 03/13/2023, for a wander monitoring bracelet. The order directed staff to check for placement and functionality every shift for elopement risk. A review of Resident #2's Progress Notes revealed the following entries: - A note, dated 03/22/2023 at 10:33 AM, that indicated Resident #2 had removed the wander monitoring bracelet and it was in the resident's drawer. - A note, dated 03/22/2023 at 2:11 PM, that indicated the wander monitoring bracelet had to be reapplied to Resident #2's wrist. - A note, dated 04/16/2023 at 3:03 PM, that indicated Resident #2 refused the check for the wander monitoring bracelet. - A note, dated 04/24/2023 at 9:28 AM, that indicated Resident #2 removed the wander monitoring bracelet. - A note, dated 04/24/2023 at 10:34 AM, that indicated the wander monitoring bracelet was placed on Resident #2's right arm. - A note, dated 05/02/2023 at 4:23 AM, that indicated Resident #2's wander monitoring bracelet was not observed. - A note, dated 05/08/2023 at 12:03 AM, that indicated Resident #2's wander monitoring bracelet was not in place. - A note, dated 05/10/2023 at 9:00 AM, that indicated Resident #2's wander monitoring bracelet was not in place. A review of a quarterly EHG-Wandering Risk Assessment, dated 07/17/2023, revealed Resident #2 was a high risk for wandering. On 08/27/2023 at 12:02 PM, Resident #2 was observed with no wander monitoring bracelet on. The resident stated they had a tracker and took it off. The resident looked in the closet and drawer but was unable to locate the wander monitoring bracelet. The resident then looked in a bag packed with their personal belongings, located the wander monitoring bracelet, and slid it back onto their wrist. During an interview on 08/28/2023 at 12:47 PM, FM #46, Resident #2's responsible party, stated the resident would take their wander monitoring bracelet off and was not sure what the facility was doing to address that. During an interview on 08/28/2023 at 1:37 PM, the Director of Nursing (DON) indicated it was brought to her attention the previous day that Resident #2 was taking off their wander monitoring bracelet. The DON told staff they could not rope off the resident's wrist, but they should tighten the wander monitoring bracelet. The DON stated the resident taking the wander monitoring bracelet off should be addressed in the resident's care plans. On 08/28/2023 at 1:38 PM, Resident #2 was observed without the wander monitoring bracelet on. When asked where the wander monitoring bracelet was, the resident pulled it from their pants pocket. When asked how they were able to get the wander monitoring bracelet off, Resident #2 chuckled and stated they knew how to take it off. During an interview on 08/28/2023 at 1:40 PM, LPN #14 indicated the wander monitoring bracelet was on Resident #2 that morning because she checked it and charted it. During an interview on 08/28/2023 at 1:40 PM, CNA #19 indicated the wander monitoring bracelet was on Resident #2's wrist between 1:00 and 1:15 PM when she took a bottle of lotion and deodorant to the resident. On 08/28/2023 at 1:44 PM, the surveyor observed LPN #14 put the wander monitoring bracelet back on Resident #2. LPN #14 indicated if the resident kept taking it off, she would ask the DON what to do. During an interview on 08/28/2023 at 5:09 PM, Registered Nurse (RN) #24 indicated she remembered Resident #2 was often seen in the hallways or sitting up front. RN #24 indicated the resident did have a wander monitoring bracelet placed on them, but they would find a way to take it off. RN #24 said when the resident took it off, she charted it and indicated if the resident continued to take it off, RN #24 would have gone to the DON. RN #24 indicated the resident's care plan should be updated to reflect the resident's behavior of removing the wander monitoring bracelet. This deficient practice was cited as a result of the investigation of complaint/report #AL00043666.

Based on record reviews, interviews, and facility document review, the facility failed to ensure medical records were readily available and retained for two (Resident #3 and Resident #14) of six residents sampled as closed records. Findings included: During an interview on [DATE] at 9:35 AM, the [NAME] President (VP) of Clinical Operations stated the facility's new owner was on the way to the facility, and she would have him reach out to the previous owners for resident records. During a follow-up interview on [DATE] at 10:10 AM, the VP of Clinical Operations provided a copy of a contract with the facility's electronic health record (EHR) company indicating the current owners would only be able to access records for residents that were on the census as of [DATE]. A review of a Data Copy Authorization for Acquisitions and Transfers of Data between Entities, signed by the facility's previous owner on [DATE], confirmed the previous owner instructed the EHR company to only provide resident records to the current owners for residents that were on the current census as of [DATE]. A review of a discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #3 was discharged from the facility on [DATE], indicating Resident #3's records were not available from the EHR company. A review of a death in facility MDS, with an ARD of [DATE], revealed Resident #14 expired in the facility on [DATE], indicating Resident #14's records were not available from the EHR company. During an interview on [DATE] at 2:08 PM, the Regional Director of Clinical Services indicated the previous owners would not provide access to the residents' records. This deficient practice was cited as a result of the investigation of complaint/report #AL00043666.

Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to prevent the potential for cross-contamination by: 1.) storing a 50-pound bag of sugar directly on the floor, 2.) running ceiling fans with heavy dust build-up on the blades in the dishwashing area, and 3.) allowing the drain from the dishmachine to extend down into the floor drain. This had the potential to affect 95 of 95 residents receiving meals from the kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. During the initial tour of the kitchen on 01/08/2023 at 11:20 AM, an unopened, 50-pound bag of sugar was observed sitting directly on the floor of the Dry Storage Room. A delivery label attached to the bag indicated it had been delivered on 01/05/2023. On 01/08/2023 at 4:47 PM, Employee Identifier (EI) #3, the Dietary Manager, was interviewed. When asked what was the problem with a 50-pound bag of sugar being stored directly on the floor, EI #3 said the potential for cross-contamination. 2.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. . (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4-903.11 Equipment, Utensils, Linens, . and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS, . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . During the initial tour of the kitchen on 01/08/2023 at 11:30 AM, the Dishwashing Room was observed to be divided into two sections, a dirty side and a clean side. Each side had a ceiling fan, which started running when the light switch was turned on. Both ceiling fans had dust build-up upon the fan blades. On 01/08/2023 at 4:47 PM, EI #3, the Dietary Manager, was shown the black build-up of dust on the edges of the fan blades in the dishroom. When asked what was the problem with this, EI #3 said bacteria from the dust can get on the clean plates. 3.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During the initial tour of the kitchen on 01/08/2023 at 11:30 AM, the Dishwashing Room was observed. There was no air gap between the floor drain and the dishwashing machine drain pipe. The drain from the dishmachine tank extended down into the floor drain. On 01/09/2023 at 4:35 PM, EI #4, the Maintenance Director PRN (pro re nata - Latin for as the circumstance arises) was interviewed in the Dishwashing Room. EI #4 said the drain from the dishmachine was actually in the floor drain and it could cause contamination if the floor drain backed up.

Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure the dumpsters were kept closed and there was not discarded equipment and food-related litter around the dumpsters to attract vermin on 01/08/2023 and 01/09/2023. This had the potential to affect 98 of 98 residents residing in the facility. Findings Include: A review of the 2017 Food Code of the U.S. Public Health Service and the FDA revealed the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE . shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area . for REFUSE . shall be maintained free of unnecessary items . and clean. On 01/08/2023 at 11:45 AM, after exiting the back door of the kitchen to view the dumpster area, a broken down shell of a deep fat fryer was observed laid on its side by the emergency generator. Grass clippings and an empty potato chip bag were seen lodged inside the fryer shell. On 01/08/2023 at 11:50 AM, an observation was made of the dumpster area. There were two garbage dumpsters. One dumpster was uncovered due to one of the two lid flaps being left pulled open. The open dumpster had bags of garbage inside. The ground around the dumpsters was littered with the following: seven plastic gloves, a package of saltine crackers, three straws, five opened individual condiment packets, an opened metal drink can, twelve metal dinner knives, two plastic spoons, and an opened plastic drink bottle. There was also a cart loaded with a mattress parked behind one of the dumpsters. On 01/08/2023 at 4:47 PM, Employee Identifier (EI) #3, the Dietary Manager, was interviewed. EI #3 said the deep fat fryer by the emergency generator was previously used in the kitchen and it had been out there about six months. Upon being asked what was the problem with discarded equipment, such as the deep fat fryer and the mattress, accumulating outside; EI #3 said it could lead to potential cross-contamination by attracting flies and rodents and, in addition, provide shelter for vermin. On 01/09/2023 at 3:55 PM, the dumpster area was observed with EI #3. The side door of one of two garbage dumpsters was observed to be open with a bag of trash sticking out. There were six metal dinner knives, a metal drink can, four open condiment packets, and a packet of saltine crackers on the ground by the dumpsters. When asked what was the problem with food litter around the dumpster, EI #3 said rodents.

Based on interview, record review, and review of facility Quality Assurance and Performance Improvement Process (QAPI) meeting attendance records, the facility failed to ensure the QAPI committee was composed of the required committee members. Specifically, the facility failed to provide evidence that the Infection Preventionist (IP) participated as a required QAPI committee member. This deficient practice had the potential to affect all 98 residents residing in the facility. Findings Include: Review of the facility's QAPI Meeting sign-in sheets dated 05/2022, 6/2022, 7/2022, 8/2022, 9/2022, 11/2022, and 12/2022 revealed an IP had not signed as present during the meetings. In an interview on 01/11/2023 at 4:17 PM, Employee Identifier (EI #1), Administrator, stated the facility's Infection Preventionist left in April 2022. EI #1 stated EI #8, Registered Nurse (RN)/ Regional Infection Control has been the facility's interim IP. EI #1 said, the members of the QAPI committee were herself, the DON, the medical director, the social worker, the MDS Coordinator, Dietary, and the Business Office Manager. EI #1 stated EI #8 did not attend QAPI meetings. A second review of the sign in sheets revealed EI #8's name was not found.

Based on observations, interviews, review of the Maintenance Supervisor's Job Description and review of a facility document titled, Quality of Life - Homelike Environment, the facility failed to ensure Room Locators (RL) #1-9, were not found in need of repair. This affected nine RLs out of 78 RLs observed. Findings Include: An undated and unsigned facility Job Description for the Maintenance Supervisor documented: . SUMMARY Responsible and accountable for maintaining physical plant and essential mechanical, electrical, and resident care equipment in safe operating condition. ESSENTIAL DUTIES AND RESPONSIBILITIES . Maintenance and beautification of facility and grounds. Review of a facility policy with a revised date of May 2017, titled Quality of Life - Homelike Environment revealed: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment . On 01/08/2023 at 11:44 AM, RL #3 was observed with paint scraped from the wall. On 01/09/2023 at 8:29 AM, RL #2 was observed with paint scraped from the wall behind the bed. On 01/09/2023 at 12:08 PM, RL #4 was observed with five spots on the ceiling, brown in color, approximately fist size, and located over the wardrobe. On 01/10/2023 at 9:33 AM, RL #9 was observed with the right hand side doorway noted with an electrical box for unknown wiring with no cover, leaving 12 plus exposed wires hanging out of the box. Employee Identifier (EI) #4, Maintenance Director from a sister facility, was walking through the dining room and when asked, stated it was an old keypad entry with no power to it. EI #4 stated it needed a blank cover on it and he could take care of that. There was also a discolored rectangular space where there was a light fixture previously mounted in the dining room. The space had five holes from where the old light fixture was installed. EI #4 said it needed a new fixture and did not look good. Five water stains were noted in the dining room ranging from approximately three to 12 inches in diameter. The largest brown discoloration also had paint peeling from it and dangling from the ceiling. A door labeled exit on the left side of the dining room was noted with horizontal scuffs and scrapes from the bottom to almost the top of the door. A vertical crack from the middle of the top of the door frame ran to the ceiling approximately two and a half feet long and a similar crack was noted above the door on the right side of the dining room and above the door going into the kitchen. Four square vents in the ceiling had brown discolorations and peeling paint with two of the vents pulled away from the ceiling with an approximate one half inch separation. Seams between the sheet rock ceiling were separated throughout the dining room with spackling and paint chipped off. A crack was in the linoleum approximately five feet long located in the middle of the dining room. A light switch cover to the left of the dietary entrance door was crooked and exposed a hole between it and the three switch light cover. A Muzak metal volume switch located in between the dietary entrance door and the light switches was loose and away from the wall. On 01/10/2023 at 11:27 AM an observation was made of a bedside table in RL #7 with rusty chrome. An observation was made of a broken handle on the third drawer of the night stand and cable for the television coming out of the wall. On 01/10/2023 at 3:53 PM, RL #5 was observed with a mattress with a dent in the middle. The Resident stated when he/she laid down, he/she touched the frame. The Resident stated it was uncomfortable and hard to get up. The Resident stated he/she only slept in the bed about three hours each night and then slept the rest of the night in the recliner. On 01/10/2023 at 4:19 PM, RL #6 was observed with a smoke detector not mounted on the wall but was placed on a table in the room. An observation was made of the cover of a resident's mattress ripped in pieces and a vast majority of foam exposed and shedding on the sheets. The resident reported the mattress was uncomfortable but was covered up by bedding. A bed side table had very rusty chrome. On 01/10/2023 at 4:35 PM, RL #8 was observed with bed B's closet with no door on it, exposing the clothing hanging. In an interview on 01/11/2023 at 10:34 AM, EI #4 was asked about his position. EI #4 stated he was at the facility helping out from a sister facility due to the facility not having a current maintenance man. When asked how would environmental issues and rooms in disrepair make the residents feel, he replied, residents would be uncomfortable with the situation. On 01/11/2023 at 10:48 AM, the surveyor made rounds with EI #4 and EI #4 observed and described the following: RL #1 was observed and the walls behind the bed were scraped up, wall paper was coming lose, chair rails were gone from behind the beds, and the room needed painting all the way around. RL #2 had broken blinds, an over bed table with rust on it and walls behind the bed were scraped. EI #4 stated over bed tables were supposed to be stainless and not rusted. RL #3 was observed with a wall scratched to the right side of bed A, the room needed painting, and the left door on the wardrobe would not close all the way. RL #4 was observed with stain on the ceiling. RL #5 was observed with a mattress with a concave indention in the middle. RL #6 was observed with scrapes on the walls, a smoke detector unmounted, a mattress had a big tear in it, an over bed table top wobbled back and forth and an over bed table was rusty. RL #7 had the wall scraped behind bed A and bed B, an over bed table was rusty, a handle on the dresser was broken on the bottom drawer, and a cable plate cover was loose. RL #8 was observed with no door on the wardrobe for bed B, a door on the wardrobe for bed A did not close all the way, walls were scratched, and an over bed table needed to be replaced. RL #9 was observed and EI #4 stated the walls needed to be painted, doors needed to be replaced, ceiling stain needed to be spackled and sprayed, and needed to replace the cover on the key entry and wires. EI #4 stated ceilings and door frames needed to be painted. EI #4 stated the vent grills were loose. Observed a stress crack in the floor and above doors. Observed wires hanging from the old fire alarm relay but EI #4 stated there was no power going to those wires. EI #4 stated the room did not currently look very good. EI #4 when asked how do you think the state of this room feels to the resident, replied, he was sure the residents would like it to look better. In an interview on 01/11/2023 at 12:30 PM, EI #1, Administrator, when asked how the residents were impacted when environmental concerns and repairs were not addressed as they occurred, EI #1 stated it depended on what the concern was. EI #1 stated she wanted the environment to be aesthetically pleasing for the residents but agreed there were environmental problems.

Based on observation, interviews, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #88's Minimum Data Set (MDS) assessments dated 12/21/2021, 05/31/2022, and 06/25/2022 were accurately coded to reflect RI #88 as a current tobacco user. This deficient practice had the potential to affect RI #88, one of 24 sampled residents for whom MDS assessments were reviewed. Findings Include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed: . SECTION J: HEALTH CONDITIONS . J1300: Current Tobacco Use . RI #88 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #88's comprehensive care plans included a care plan, initiated 12/24/2021, identifying RI #88 as a smoker. On 01/10/2023 at 7:48 AM, the surveyor reviewed RI #88's comprehensive MDS assessments. Section J1300 of RI #88's 12/21/2021 Admission MDS, 05/31/2022 Significant Change MDS, and 06/25/2022 Significant Change MDS were all coded as NO, indicating RI #88 was not a current tobacco user. On 01/09/2023 at 3:58 PM, RI #88 was observed smoking two cigarettes in the covered smoking area during the designated smoking break. On 01/10/2023 at 8:45 AM, Employee Identifier (EI) #16, Certified Nursing Assistant (CNA), stated RI #88 has smoked ever since his/her admission to the facility. In an interview on 01/10/2023 at 12:13 PM, EI #7, MDS Coordinator, stated RI #88 does smoke cigarettes. EI #7 said, RI #88's MDS assessments should be coded to reflect current tobacco use.

Based on interviews, review of the manufacturer's information, the facility's policies titled Vehicle Safety Program and Abuse Prevention Program, a complaint received by the Alabama State Survey Agency, Resident Identifier (RI) #1's medical record, the facility's investigation file, RI #1's Emergency Medical Service (EMS) run report and the local hospital's medical record, the facility failed to ensure Employee Identifier (EI) #3, the Activity Director, who transported RI #1 on 8/1/2019, properly secured the resident in the facility's van prior to transport. On 8/1/2019, EI #3 failed to secure RI #1's lap/seat belt before she proceeded to transport the resident to [MEDICAL TREATMENT]. When the vehicle made an abrupt stop, RI #1, who was not wearing a lap/seat belt, fell from the wheelchair and hit his/her head. EMS was called, and they transported RI #1 to the local hospital, where the resident was diagnosed as having a medial distal femur fracture. This deficient practice placed RI #1, one of three sampled residents reviewed for transport needs, in immediate jeopardy, as it was likely to result in serious injury, harm, impairment or death. On 8/22/2019 at 5:30 PM, the facility's Administrator and the Corporate Clinical Consultant were provided the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation, F600. On 9/12/2019, at the direction of the CMS Atlanta Regional Office, the Statement of Deficiencies (FORM CMS-2567) was amended to reflect deficient practice at F689 instead of F600. Findings include: Pages 13 and 14 of the undated manufacturer's information titled Doing It Right A Guide to the Proper Use of Sure-Lok Wheelchair Securement and Occupant Restraint Systems documented . Section 5: Securing the Occupant Once the wheelchair is secured, you're ready to secure the occupant . Lap Belts Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down through the opening between the side panel or the seat back and the seat cushion. Remember to position the lap belt around the occupant's pelvic zone near the hip, with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall . Shoulder Belts The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone, and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly attached . The facility's Vehicle Safety Program dated (YEAR), revealed the following: . X. SAFE DRIVER RULES [NAME] Rules Our organization has developed some key driver safety rules that all employees who drive for company business need to comply with . 1. Safety belts: a) The driver and all occupants are required to wear safety belts when the vehicle is in operation or while riding in a vehicle. The driver is responsible for ensuring passengers wear their safety belts and are properly secured in the event that resident is transported in a mobily (mobility) assistive device, e.g. (for example) wheelchair . On 8/16/2019 the Alabama State Survey Agency received a complaint alleging RI #1, a bilateral, paraplegic [MEDICAL CONDITION], was being transported to [MEDICAL TREATMENT] by a facility staff member in the facility's van. The facility's staff member failed to secure the resident's lap/seat belt. When the driver had to brake quickly to avoid hitting a car, the resident was thrown out of the wheelchair. The resident was transported to a local hospital and diagnosed as having a hairline fracture to the right knee and a hematoma to the head. RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include [DIAGNOSES REDACTED]. RI #1's Resident Progress Notes written by EI #19, the Social Worker and dated 8/1/2019 8:01 AM, documented Writer received a call from (transportation company) on yesterday about inability to transport resident to [MEDICAL TREATMENT] due to van being in shop. Arrangements then made with Activity Director (EI #3) to transport resident . The facility's Investigation summary for (EI #3) written by EI #7, the Regional Marketing and Admissions Coordinator and dated 8/1/2019 1:45 PM, documented The following is a summary of events that occurred during the investigation of an incident that occurred on 08/01/2019 during the transport of (RI #1) by (EI #3). The facility was notified that (RI #1) had fallen out of (his/her) chair while transporting (him/her) to (his/her) [MEDICAL TREATMENT] appointment. The driver, (EI #3), stated that (RI #1) had fallen out of (his/her) wheelchair and she had called 911 for paramedics to come to them. They then transferred (him/her) to (a local hospital). When (EI #3) returned to the facility, statements were gotten from her, (EI #4), Activities Assistant, who was with her during transport. Upon returning to the facility, (EI #3) reported to (EI #11, EI #16, EI #17, and EI #18) that she had secured the wheelchair, but did not use the lap belt because it was too small for (RI #1) . In addition to the statements, a review was done of the training (EI #3) had completed on safe transportation methods. Upon review that she had completed the safety training, admitted in her own statement that the patient wasn't secured for transport, corroborated by the statements of (EI #4) and four other witnesses, (EI #3) was terminated from employment from Blue Ridge Healthcare [MEDICATION NAME] due to a violation of safety rules . In an interview on 8/19/2019 at 3:10 PM, RI #1 stated he/she goes to [MEDICAL TREATMENT] on Tuesday, Thursday, and Saturday. When asked about the incident, RI #1 stated it happened about two weeks ago. RI #1 said his/her wheelchair was strapped in but there was no lap/seat belt around the resident. RI #1 said when the driver (EI #3) stopped, he/she fell out of the chair and hit his/her head. When asked what injuries were sustained, RI #1 said he/she had a knee fracture, two places on the head, and a scratch on his/her arm. In a follow-up interview on 8/21/2019 at 3:00 PM, RI #1 stated after the accident, Emergency Medical Service (EMS) was called and he/she was loaded onto a stretcher and taken to the local hospital. The EMS Patient Care Report indicated on 8/1/2019 at 9:27 AM dispatch was notified and arrived on scene at 9:37 AM. The report documented . NARRATIVE dispatched to location on a mva (motor vehicle accident), arrived with no incident. u/a (upon arrival) pt (patient) laying on right side inside wheelchair transport vehicle from blue ridge [MEDICATION NAME]. pt was in wheelchair, unrestrained, and fell out of it hitting head on pole when coming to a stop. pt c/o (complained of) head and neck pain. no obvious deformities. no loc (loss of consciousness). no vomiting. pt is paralyzed from waist down with a right leg below knee amputation. pt was being transported to (his/her) [MEDICAL TREATMENT] appt. (appointment), . RI #1's local hospital records indicated . Patient Narrative: The reports being transported to [MEDICAL TREATMENT] clinic for scheduled [MEDICAL TREATMENT] when the wheelchair van stopped and (RI #1) fell out of (his/her) wheelchair striking (his/her) head on the metal bar in the van. The patient denies L[NAME], c/o neck and head pain . The Computed [NAME]ography (CT) of the brain dated 8/1/2019 revealed No acute intracranial findings. The CT of the cervical region dated 8/1/2019 revealed No acute fracture . The x-ray of the right knee dated 8/1/2019 revealed Medial distal femur fracture . On 8/20/2019 at 11:22 AM, a telephone interview was conducted with EI #3, the Activity Director and facility staff member who transported RI #1 on 8/1/2019. EI #3 said once a resident is loaded into the van, their wheelchair should be strapped (secured) to the floor, the wheelchair brake applied, and the seatbelt secured around the resident. EI #3 acknowledged that RI #1 did not have a seat belt on during the transport on 8/1/2019. When asked if the resident was properly secured, EI #3 said obviously not. EI #3 stated when the lap/seat belt would not fit around RI #1, she should have gone back into the facility and informed the staff, but she did not. Contained within the facility's investigation was a written statement from EI #4, the Activity Assistant dated 8/1/2019, which read On the date of (MONTH) 1, 2019, (EI #3) and I were transporting (RI #1) to (his/her) appointment, via (by way of) company bus (van). Upon loading (RI #1) on the bus, we applied 4 straps on (his/her) chair to lock (him/her) down. Going down [NAME] Road, I did notice (EI #3) looking at her phone. Don't know if she was still looking at her phone when this happened. I turned my head to look out the window, shortly after I heard (RI #1) screaming. I looked over towards (him/her) to find (RI #1) falling head first . Never have I seen (EI #3) apply them (cross chest seatbelt). When she (EI #3) asked me if I think it was her fault, I replied, Yes. Reason why is because she hit the brakes too fast . (RI #1) started crying . (RI #1) complained of (his/her) neck hurting . On 8/20/2019 at 10:00 AM, EI #4, the Activity Assistant, who was a passenger in the van during RI #1's transport on 8/1/2019 was interviewed. EI #4 said the straps that secure the wheelchair to the floor were in place, but RI #1 did not have a seatbelt on. When asked why not, EI #4 said she did not know. EI #4 said after they left the facility, the driver (EI #3) hit the brakes, and she heard RI #1 yell and fall. When asked if EI #3 should have left the facility without having RI #1 properly secured, EI #4 said no. On 8/21/2019 at 11:50 AM an interview was conducted with EI #7, the Regional Marketing and Admissions Coordinator. EI #7 acknowledged that he completed the investigation into the transport of RI #1 on 8/1/2019 by EI #3, because the Administrator (EI #1) was on vacation. EI #7 said through his investigation, it was determined EI #3 had violated the facility's safety policy, so she was terminated. When asked how EI #3 had violated the safety policy, EI #7 said she (EI #3) did not properly secure RI #1 in the van during the transport on 8/1/2019. During an interview on 8/21/2019 at 8:00 AM, EI #1, the Administrator was asked, what caused the incident of RI #1 getting injured on 8/1/2019. EI #1 replied, the employee (EI #3) did not buckle the seat belt around the resident. When asked what he was told about the incident, EI #1 replied, EI #3 put RI #1 on the bus (van), secured the resident's wheelchair, that she did not think the seat belt would go around RI #1, but she drove the bus regardless. When asked if RI #1 was properly secured in the van, EI #1 replied no. EI #1 said RI #1 should have been strapped in and since the resident was not, EI #3 was terminated. ************************* On 8/23/2019 at 11:15 AM, the facility submitted an acceptable Removal Plan which documented: Blue Ridge Healthcare [MEDICATION NAME] Immediacy Removal Plan, (MONTH) 22, 2019 F 600 1. Employee involved was terminated immediately on 8/1/19 for failure to meet policy standards and expectations regarding resident safety. 2. Since 8/1/19, no other residents have been transported utilizing the facility van. No resident transports will occur until after the full implementation of this plan. This will be accomplished by all keys being kept in administrator's office and needing to be signed out prior to van use. Steering column will also be locked out to deter the likelihood of unauthorized use of the van. 3. Activities Assistant has been trained, on 8/6/19 in accordance with manufacturer's specifications by maintenance staff. Activities assistant will receive additional training, from maintenance staff, regarding facility transportation safety protocols including accommodating all residents in seat belts and complete with maintenance staff the Driver's Skill Validation tool with return demonstration prior to her first resident transport and no later than Friday (MONTH) 23, 2019. Activities assistant will receive re-training on abuse prevention, identification and reporting requirements, and this training will include identification of signs and symptoms of neglect. This education will be completed on (MONTH) 23, 2019 by Human Resources Director. All future and current drivers, including maintenance staff and activities staff, prior to transporting a resident, will be trained on manufacturer's specifications including accommodating all residents in seat belts and facility transportation safety protocols. This training shall be completed for maintenance staff by the Vice President of Plant Operations. Maintenance will be responsible for training the activities staff. Each driver shall also prior to transporting a resident receiving training, from the administrator or designee, regarding abuse prevention, abuse identification, abuse reporting requirements, and neglect identification. Each driver prior to transporting a resident shall also complete with maintenance staff Driver's Skills Validation tool with a return demonstration prior to transporting a resident. This system will begin (MONTH) 23, 2019. Beginning Friday (MONTH) 23, 2019 maintenance staff will complete with the driver weekly Driver's Skill Validation tool with return demonstration to verify for continual understanding and compliance with all safety protocols. No transports are currently scheduled utilizing the facility van. Upon the first resident transport in the facility van, maintenance will accompany activities assistant and resident on transport, to verify staff member has adhered to and followed safety training. All drivers prior to transporting a resident will be required to review Safe Driver Rules document prior to obtaining the keys to the van with driver's signature acknowledging that they know the safety protocols. This acknowledgement will be validated by the signature of the administrator or designee. The signed documents will be maintained in a binder located in the administrator's office. This system will begin prior to the first resident transport and remain ongoing. All staff, including all departments, nursing, maintenance, housekeeping, laundry, dietary, rehabilitation, and administrative services, will receive re-training, from administrator or thoroughly trained designee, on abuse prevention, identification and reporting requirements, and will include identification of signs and symptoms of neglect. This education will begin on (MONTH) 22, 2019 and all currently on-shift staff will be completed on Friday (MONTH) 23, 2019. After Friday (MONTH) 23, 2019 no employee shall be permitted to provide goods or services to a resident without receiving training from administrator or thoroughly trained designee regarding abuse prevention, identification, and reporting requirements and including identification of signs and symptoms of neglect. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F600 was lowered to a D level on 8/23/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 433.

Based on observation, record review and interviews, the facility failed to ensure care plans were developed for pressure ulcer prevention for RI (Resident Identifier) #1, a resident who was assessed as being at risk for developing pressure ulcers. As a result of not having a plan of care with individualized approaches for prevention of pressure ulcers, RI #1 developed a stage three pressure ulcer on 8/31/2016. This failure affected one of four sampled residents whose care plans were reviewed. Findings Include: Review of a facility policy titled Skin Management with a revision date of 8/2012 revealed the following: . NEWLY admitted RESIDENTS . 3. Appropriate preventive services .will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale - For Predicting Pressure Sore Risk), and the interventions documented on the Care Plan. 6. A Care Plan is developed upon admission, identifying the contributing risks for breakdown, . and the interventions implemented to promote healing and prevent further breakdown. The Care Plan should address, but is not limited to: .Preventive devices . Positioning requirements . Proper body alignment . 1.) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's admission Braden Scale assessment form (for predicting pressure sore risk) dated 4/21/2016, on the day of admission, was incomplete and did not have a score totaled. The back side of the Braden Scale assessment form had further guidance for additional risk factors that were checked for RI #1 that revealed, End Stage [MEDICAL CONDITION] and Diabetes Mellitus were co-morbid conditions. RI #1's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 4/27/2016, revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The MDS also revealed RI #1 required extensive assistance of two or more persons for bed mobility, had limitations in both lower extremities, was at risk for pressure ulcer development, and had two stage one pressure ulcers at the time of admission. RI #1's Braden Scale assessments dated 4/27/2016, 5/3/2016, and 5/10/2016 revealed a score of 15, a mild risk for pressure ulcer development. RI #1's Braden Scale assessment dated [DATE], revealed a score of 14, a moderate risk for pressure ulcer development. RI #1's Braden Scale assessments dated 6/6/2016 and 7/27/2016 both revealed a score of 13, a moderate risk for pressure ulcer development. On 08/31/2016 at 8:38 p.m., the Division of Health Care Facilities Complaint Unit received a call from RI #1's spouse which revealed the following: . (spouse) received a call from the facility notifying . (of) the areas on (RI #1's) legs . (spouse stated RI #1 was) not being turned . is unable to position (self) . and is at risk for pressure ulcers . A review of RI #1's care plans revealed the facility failed to develop an individualized plan of care that included interventions for pressure ulcer prevention. RI #1's care plans did not include approaches to address RI #1's risk for pressure ulcer development or actual ulcers present at the time of admission. A review of RI #1's Progress Notes revealed the following: . 8/31/2016 17:20 (5:20 p.m.) . Resident has . wounds on . left ankle. A review of RI #1's WEEKLY PRESSURE ULCER RECORD dated 9/1/2016, with Initial Evaluation checked and Plan of Care Updated checked yes, revealed a stage three wound that contained necrotic tissue on the left lateral leg measuring three by 0.9 centimeters. On 9/13/2016 at 2:10 p.m., RI #1 was observed in bed on his/her back with the head of the bed elevated. RI #1's left outer ankle was turned to the left, lying on the bed, and covered with a bandage. On 9/13/2016 at 6:00 p.m., EI (Employee Identifier) #2, RN (Registered Nurse) Treatment Nurse, was asked when the area was first noticed. EI #2 said, one night last week and she assessed it the next day. EI #2 further said, RI #1's left leg just flops that way. When asked what was done to position RI #1 to keep the ankle from lying on the bed, EI #2 said, RI #1 was provided with a bigger bed. When asked when the bed was provided, EI #2 said, 9/2/2016 (after the wound on the ankle had already been identified). When asked why RI #1 received the bed at that time, EI #2 said, RI #1's spouse was asking constantly for RI #1 to be turned every two hours or more. When asked how often RI #1 was being turned, EI #2 said, RI #1 did not have a turn schedule, and the staff turned and repositioned RI #1 as often as they could. On 9/14/2016 at 11:15 a.m., EI #9 MDS Coordinator, was asked who was responsible for developing care plans for pressure ulcer prevention. EI #9 said, MDS. When asked why RI #1 did not have a care plan to address pressure ulcer prevention, EI #9 said, RI #1 should have had one, and she would have to check the chart. When asked what the harm was in not having a care plan for pressure ulcer prevention, EI #9 said, developing a pressure ulcer. On 9/14/2016 at 3:25 p.m., EI #4 CNA (Certified Nursing Assistant) was asked how she knew what to do for RI #1. EI #4 said, the Kardex. When asked what RI #1's cardex documented for prevention of pressure ulcers, EI #4 said, to turn every two hours with two person assist. When asked what other information the cardex documented about pressure ulcer prevention, EI #4 said, preventive care was checked. EI #4 was asked what that included. EI #4 said, It doesn't tell me. When asked what her observation was of why RI #1's left leg leaned to the left side, EI #4 said, Because, (RI #1) doesn't have the wedge up under (him/her) to support it. When the pillow is used it (left leg) flops to the side. EI #4 was asked how she usually found RI #1 positioned. EI #4 replied, Mostly on (RI #1's) back with (RI #1's) left leg flopped over and the pillow is being used under (RI #1's) foot and (RI #1's) ankle and the left leg/foot is turned out to the left. When asked what she used to position RI #1. EI #4 said, two pillows or a wedge. When asked how well the pillows held up, EI #4 said, not good. When asked what happened to the pillows, EI #4 replied, When you put them behind (RI #1), (because of RI #1's) weight, they will be flat when you go back to position (RI #1). When asked if she had asked anybody about something stronger to use for a positioning device, EI #4 said, no, because she sometimes used a wedge when she could find one, but if not, she just used the pillows. On 9/14/2016 at 4:00 p.m. EI #2, RN Treatment Nurse was again interviewed and was asked why RI #1 did not have a care plan developed for the prevention of pressure ulcers. EI #9 said, she did not know why and MDS should know. When asked why RI #1 should have a care plan for being at risk for developing pressure ulcers, EI #9 said, Because we want to prevent (RI #1) from getting any breakdown. When asked what harm RI #1 suffered in not having a care plan for pressure ulcer risk, EI #9 said, RI #1 had an ulcer to develop. When asked how staff knew how to position RI #1 to best prevent wounds without a care plan, EI #9 said, they would not know. On 9/15/2016 at 9:35 a.m. EI #1 DON (Director of Nursing), was asked why individualized care plans were not developed for prevention of pressure ulcers for RI #1. EI #1 said she could not say why care plans were not there, but they should have been. When asked what harm RI #1 suffered because there were no care plans for pressure ulcer prevention and there were not any measures in place for the staff to follow, EI #9 said, RI #1 developed a wound without a care plan in place. This deficiency was cited as a result of the investigation of complaint/report number AL 641.

Based on observation, interview, and record review the facility failed to ensure RI (Resident Identifier) #1, a resident assessed to be at risk for pressure ulcer development, was turned and repositioned in bed to prevent pressure ulcer development. There was no plan of care in place to address RI #1's risk for pressure ulcer development. As a result, RI #1 developed a stage three pressure ulcer on the left lower leg. This affected one of three residents sampled for pressure ulcers. Findings included: Review of a facility policy titled Skin Management, with a revision date of 8/2012, revealed the following: . NEWLY admitted RESIDENTS . 3. Appropriate preventive surfaces of beds, . will be implemented on all residents identified at risk (score of 18 or less on the Braden Scale - For Predicting Pressure Sore Risk), and the interventions documented on the Care Plan. 6. A Care Plan is developed upon admission, identifying the contributing risks for breakdown, . and the interventions implemented to promote healing and prevent further breakdown. RI #1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's admission Braden Scale assessment form (for predicting pressure sore risk) dated 4/21/2016, on the day of admission, was incomplete and did not have a score totaled. The back side of the Braden Scale assessment form had further guidance for additional risk factors that were checked for RI #1 that revealed End Stage [MEDICAL CONDITION] and Diabetes Mellitus were co-morbid conditions. RI #1's admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 4/27/2016, revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The MDS also revealed RI #1 required extensive assistance of two or more persons for bed mobility, had limitations in both lower extremities, was at risk for pressure ulcer development, and had two stage ones present on admission. RI #1's Braden Scale assessments dated 4/27/2016, 5/3/2016, and 5/10/2016 revealed scores of 15, a mild risk for pressure ulcer development. RI #1's Braden Scale assessment dated [DATE], revealed a score of 14, a moderate risk for pressure ulcer development. RI #1's Braden Scale assessments dated 6/6/2016 and 7/27/2016, revealed scores of 13, a moderate risk for pressure ulcer development. RI #1's quarterly MDS assessment, with an Assessment Reference Date of 7/28/2016, revealed a BIMS score of 15, which indicated intact cognition. The MDS also revealed RI #1 required extensive assistance of two or more persons for bed mobility, had limitations in both lower extremities, was at risk for pressure ulcer development, and had no pressure ulcers present at the time of the assessment. On 08/31/2016 at 8:38 p.m., the Division of Health Care Facilities Complaint Unit received a call from RI #1's spouse which revealed the following: . (spouse) received a call from the facility notifying . (of) the areas on (RI #1's) legs . (spouse stated RI #1 was) not being turned . is unable to position (self) . and is at risk for pressure ulcers . (spouse) said they are located . above (RI #1's) ankle . A review of RI #1's care plans revealed the facility failed to develop an individualized plan of care that included interventions for pressure ulcer prevention. There were no approaches to address RI #1's risk for pressure ulcer development. A review of RI #1's Progress Notes revealed the following: . 8/31/2016 17:20 (5:20 p.m.) . Resident has . wounds on . left ankle. A review of RI #1's WEEKLY PRESSURE ULCER RECORD dated 9/1/2016, with Initial Evaluation checked and Plan of Care Updated checked yes, revealed a stage three wound that contained necrotic tissue that covered 40 percent of the wound bed, on the left lateral leg measuring three by 0.9 centimeters. On 9/12/2016 at 4:35 p.m., during the initial observations of the facility, RI #1 was laying on his/her back on a specialty air mattress with the head of the bed elevated. On 9/12/2016 at 5:25 p.m., during a phone interview, RI #1's spouse stated RI #1 did not receive a new bed (the current specialty air mattress) until last week even though she had been requesting one since April. On 9/13/2016 at 2:10 p.m., RI #1 was observed lying on his/her back in bed with the head of the bed elevated. RI #1's left lateral ankle was turned to the left, lying on the bed, and covered with a bandage. On 9/13/2016 at 2:50 p.m., EI (Employee Identifier) #2, RN (Registered Nurse) Treatment Nurse, changed RI #1's dressing on the left ankle. As EI #2 observed the wound with the surveyor, she described the wound as a stage three that contained white/yellow necrotic tissue that covered more than half of the wound (60 percent). On 9/13/2016 at 6:00 p.m., EI #2 was asked when the area was first noticed. EI #2 said, one night last week and she assessed it the next day. EI #2 further stated, RI #1's left leg just flops to the left side. When asked what was done to position RI #1 to keep the ankle from lying on the bed, EI #2 said, RI #1 was provided with a bigger bed. When asked when the bed was provided, EI #2 said, 9/2/2016 (after the wound on the ankle had already been identified). When asked why RI #1 received the bed at that time, EI #2 said, RI #1's spouse was asking constantly for RI #1 to be turned every two hours or more. When asked how often RI #1 was being turned, EI #2 said, RI #1 did not have a turn schedule, and the staff turned and repositioned RI #1 as often as they could. EI #2 further stated, even when the facility tried to position RI #1 with a pillow, turned to the right side, RI #1's left leg favors turning to the left onto the ankle. On 9/14/2016 at 8:00 a.m. RI #1 was asked how often he/she was turned. RI #1 said, Only when they would bathe me. RI #1 was asked if staff provided repositioning during incontinent care. RI #1 repeated that repositioning only occurred during bathing. RI #1 was asked what kind of pillows or wedges were used for repositioning. RI #1 stated, They didn't use any. I've been on my back since I've been here since April. RI #1's head of the bed was observed elevated, with RI #1 lying on his/her back, with the left leg turned to the side with a pillow under the left ankle and the foot/ankle resting directly on the pillow. RI #1's left heel was not floated (positioned with the heel elevated to eliminate pressure and prevent pressure ulcers). On 9/14/2016 at 8:05 a.m., EI #3 CNA (Certified Nursing Assistant), was asked how she knew what to do for RI #1 for prevention of pressure ulcers. EI #3 said, inservices were provided, some cream was provided to apply to the resident's back and leg, and to make sure the foot was elevated at all times. When asked what kind of care she provided for RI #1 to prevent pressure ulcers, EI #3 said, reposition, keep foot on a pillow with heel protector. When asked how often RI #1 was repositioned, EI #3 said, every two hours, and if the resident did not want to be turned, she would tell RI #1 to use the call light when ready to turn. When asked how often RI #1 would refuse to be turned, EI #1 said, not often, RI #1 cooperates pretty well. On 9/14/2016 at 8:15 a.m. EI #3 was asked to observe RI #1 and describe what she saw. EI #3 said the left foot was floated on a pillow. When asked if the left leg was floated or lying on the pillow, EI #3 said, It's lying on the pillow. When asked what area was to be floated, EI #3 said, the heel. When asked if she actually knew where RI #1's wound area was, EI #3 said, she had not seen the area. When asked about the wound on the side of the leg/ankle and how pressure was being prevented with that area lying on the pillow, EI #3 said, It's not. EI #3 was asked if she thought RI #1's wound was on the heel. EI #3 replied, yes. When asked what she would do differently knowing the wound was on the side of the leg/ankle, EI #3 stated, I would use a wedge. EI #3 pointed to a wedge on the other side of RI #1's room. On 9/14/2016 at 2:10 p.m. EI #3 was again questioned about RI #1. EI #3 was asked what she had observed as to why RI #1's left leg leaned to the left side. EI #3 said, I guess (RI #1) has no control over the left leg and that is why it leans to the left side. When asked how she usually found RI #1's left leg positioned, EI #3 stated, I don't look at the left leg until I get ready to turn (RI #1) and I find it the way you did this morning, laid over on the pillow. When asked why she thought RI #1 felt like repositioning was not being done, EI #3 replied, Maybe because we use the pillow and it is not really strong enough to turn (RI #1) and it just goes down flat. When asked if she had asked anybody for something stronger to use for a positioning device, EI #3 said, no. When asked why she had not told someone about the pillow not being strong enough, EI #3 stated, I didn't think about it until you said (RI #1) didn't feel (he/she) was being turned. On 9/14/2016 at 3:25 p.m. EI #4, a CNA, was asked how often she cared of RI #1. EI #4 said, frequently. When asked what her observation was of why RI #1's left leg leaned to the left side, EI #4 said, Because, (RI #1) doesn't have the wedge up under (him/her) to support it. When the pillow is used it (left leg) flops to the side. EI #4 was asked how she usually found RI #1 positioned. EI #4 replied, Mostly on (RI #1's) back with (RI #1's) left leg flopped over and the pillow is being used under (RI #1's) foot and (RI #1's) ankle and the left leg/foot is turned out to the left. When asked what she used to position RI #1, EI #4 said, two pillows or a wedge. When asked how the pillows held up, EI #4 said, not good. When asked what happened to the pillows, EI #4 replied, When you put them behind (RI #1), (because of RI #1's) weight, they will be flat when you go back to position (RI #1). When asked if she had asked anybody about something stronger to use for a positioning device, EI #4 said, no, because she sometimes used a wedge when she could find one, but if not, she just used the pillows. On 9/14/2016 at 4:15 p.m. EI #2, Treatment nurse, was again interviewed. EI #2 was asked what she had observed happening with RI #1's left leg/ankle. EI #2 stated, When I go in (RI #1) has a dependent area. It turns and favors the left side and the skin gets moist and with dry flaky areas it is easy to get a wound there with it pressing down. EI #2 was asked what devices she had seen used to turn and position RI #1 from side to side. EI #2 replied, they use pads to turn (RI #1) and use pillows behind his/her back and also to elevate the left leg. When asked what she observed happening to the pillows used for positioning RI #1, EI #2 stated, I see them squashed. EI #2 was asked how the pillows were effective if they were flat behind RI #1. EI #2 said, they were not effective. When asked what harm RI #1 had suffered as a result of pillows being used for turning and repositioning, EI #2 said, RI #1 had skin breakdown from the pillows being used. When asked if she had been asked by anyone about using something else to help position RI #1, EI #2 said, no. On 9/15/2016 at 10:25 a.m. EI #2 was again interviewed. EI #2 was asked if RI #1's left ankle wound was avoidable or unavoidable. EI #2 replied, I think we could have done more. We could have consulted PT (physical therapy). (RI #1) does not move at all (him/her) self. When asked what level of dependence on staff RI #1 was for turning and positioning in bed, EI #2 said, total. This deficiency was cited as a result of the investigation of complaint/report number AL 641.

Based on interviews and record review, the facility failed to provide evidence Resident Identifier (RI) #1 was assessed for pain to determine cause and severity of the pain. RI #1, an alert and oriented resident, stated in an interview that he/she complained of pain and the facility failed to assess him/her to determine the cause of the pain. RI #1 stated the facility only gave him/her medication for the pain but failed to determine why he/she was having pain in his/her stomach. A review of facility's documents revealed RI #1 was medicated for pain for six days (04/12/2016, 04/13/2016, 04/14/2016, 04/15/2016, 04/16/2016 and 04/19/2016). The facility failed to provide evidence their Pain Management policy and procedure was followed to evaluate the resident on a regular basis after pain medication was administrated, evaluate the effectiveness of the medication, and make changes if the medication or approach was not effective. RI #1 stated the facility continued to ignore him/her when he/she was sick, resulting in him/her calling his/her family member to take him/her to the hospital. According to hospital records, RI #1 was admitted to the hospital on [DATE], after being discharged from the facility. The hospital's admitting [DIAGNOSES REDACTED]. This affected RI #1, one of three residents sampled for pain management. Findings Include: A facility policy titled Pain Management with a revision date of February 2010, documented the following: OVERVIEW . Residents who experience a change in condition or have a suspected new onset of pain are evaluated for pain. Residents are also evaluated for pain regularly by inquiring if they have pain and observation of the resident for signs and symptoms of pain . STEPS FOR PAIN MANAGEMENT . Fifth Step: Re-evaluate on a Regular Basis You need to to-re-evaluate the resident on a regular basis. This will be done each time you administer a pain medication to the resident, evaluating the effectiveness of the medication and making changes if the medication or approach is not effective. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A prescription for a Controlled Drug for RI #1, dated 04/10/16, documented: [MEDICATION NAME] ([MEDICATION NAME]) 50 mg (milligrams) Take a tablet twice a day as needed for pain x (times) 10 days . An Admission Minimum Data Set assessment with an Assessment Reference Date of 04/12/16, assessed RI #1 as scoring a 15 on the Brief Interview for Mental Status indicating no impaired cognition. Under Section J - Health Conditions, RI #1 was assessed as having received both routine as well as PRN (as needed) pain medication during this assessment period. RI #1's care plan titled Pain/Discomfort Actual . Related to: . Joint Pain . Neuropathic pain Musculoskeletal . dated 04/19/16, documented the following approach: . Implement pain management flowsheet . A review of RI #1's Controlled Substance Proof of Use sheet for the [MEDICATION NAME] 50 mg revealed RI #1 received one [MEDICATION NAME] on 04/12, 04/13, 04/14, two [MEDICATION NAME]'s on 04/15, one on 04/16 and one on 04/19/16. A review of RI #1's May 2016 MAR (Medication Administration Record) revealed there was no evidence RI #1 was re-evaluated each time the [MEDICATION NAME] was administered to determine the cause of cause of the pain and the effectiveness of the medication. On 07/06/16 at 4:47 p.m., the surveyor conducted a phone interview with RI #1. RI #1 said he/she had requested to speak with the Administrator at the facility because his/her stomach was hurting really bad. RI #1 said when they gave pain medication his/her stomach still continued to hurt. The surveyor asked RI #1 was pain medication given routinely or as needed (PRN). RI #1 said the nurses gave the pain medication when he/she asked for it. The surveyor asked RI #1, before giving the pain medication, did the nurses ask him/her where the pain was, the rate of the pain on a scale of 1-10 or what caused the pain. RI #1 replied no. RI #1 said he/she asked for the medication and the nurses gave it. RI #1 said the nurses would not listen to him/her when he/she told them he/she was sick. RI #1 said the nurses would tell him/her they would tell the doctor. RI #1 said one day he/she called his/her family member to come and get him/her and was taken to the hospital. RI #1 said one of the doctors at the hospital asked him/her if his/her stomach was hurting. RI #1 said the doctor said it sounded like he/she had Pancreatitis then they said it was Pancreatitis. RI #1 said he/she was admitted to the hospital. RI #1's Nursing Daily Skilled Summary (Nurses Notes) dated 04/28/16, documented: . Sponsor asked that resident be sent to hospital . A review of RI #1's emergency room Report dated April 28. 2016, documented: . Basic Information Time seen: Date and time 04/28/16 14:45 (2:45 p.m.) History source: Patient, EMS (Emergency Medical Service) . History of Present Illness . Pt (patient) also reports experiencing abdominal pain . Review of Systems . Gastrointestinal symptoms: Abdominal pain, mild, epigastric . Physical Examination . Gastrointestinal: Soft, Non distended, Tenderness . Neurological: Alert and oriented to person, place, and time . Impression and Plan Diagnosis acute pancreatitis acute abdominal pain . On 07/06/16 at 1:05 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, one of the (Licensed Practical Nurses) LPN medication nurses administering [MEDICATION NAME] to RI #1 on the 7-3 shift. The surveyor asked EI #3 did RI #1 receive pain medication. EI #3 said she believed RI #1 received [MEDICATION NAME] and it was PRN (as needed). EI #3 said it may have been a couple of times that RI #1 complained of pain and received pain medication on her shift. The surveyor asked EI #3, when a resident complains of pain what should be done. EI #3 replied she needed to find out where the pain was, how long the resident has had the pain, if it was sharp or dull and what level the pain was. On 07/07/16 at 7:30 a.m., the surveyor conducted an interview with EI #4, a LPN caring for RI #1 on the 3-11 shift. The surveyor asked EI #4 if RI #1 had complained of pain what would she have done. EI #4 said she would have assessed RI #1's pain on a scale of 1-10, she would have checked the MAR indicated [REDACTED]. The surveyor asked EI #4 what was a pain management flow sheet. EI #4 said it was a sheet (PRN Medication Administration Record) that had the PRN pain medication listed on it and had an area where the nurse could sign when ever the pain medication was given. EI #4 said you could also rate the effectiveness on the flow sheet. EI #4 said she had seen the pain management flow sheet being used on the Long Term Care floors but not on the Rehab (Rehabilitation) floor. A review of RI #1's medical records revealed there was no evidence in RI #1's medical records that a PRN Pain Medication Record (pain management flow sheet) MAR indicated [REDACTED]. On 07/07/16 at 5:54 p.m., the surveyor conducted an interview with EI #8, one of the LPN medication nurses caring for RI #1 on the 3-11 shift. The surveyor asked EI #8 did she administer [MEDICATION NAME] to RI #1 on 4/15/16 and on 4/16/16. EI #8 said yes. The surveyor asked EI #8 why was the [MEDICATION NAME] administered. EI #8 said RI #1 was complaining of some type of pain. The surveyor asked EI #8 how do you assess a resident who is complaining of pain. EI #8 said you would ask the resident, from head to toe, what is going on with them, ask about the duration and type of pain they are having and after you have given them the pain medication, do a reassessment. The surveyor asked EI #8 where the pain assessment would be documented. EI #8 said on the back of the MAR. A review of RI #1's April 2016 MAR indicated [REDACTED]. On 07/07/16 at 3:25 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing (DON). The surveyor asked EI #1, when a resident complains of pain, how should the resident be assessed. EI #1 replied you should ask the patient where they are hurting, what does the pain feel like, on a scale of 1-10 what level is the pain and basically look at patient and see what is going on. The surveyor asked EI #1 where was this assessment documented. EI #1 replied, In the nurses notes. A review of RI #1's Nursing Daily Skilled Summary notes (Nurses notes) dated 04/07/16 through 04/28/16 revealed there was no evidence in the nurses notes that RI #1 had been assessed to determine the type, cause and severity of the pain each time RI #1 complained of pain.