Every finding on record at Rocky Mountain Care - Maple Dell

Based on interview and record review, the facility failed to ensure one resident (Resident #2) was free from significant medication errors for one of 12 residents sampled for medication administration. Specifically, Resident #2 was inadvertently administered 13 medications intended for their roommate, including high-risk antihypertensives and antidiabetics, resulting in hypoglycemia, hypotension, and the need for acute hospitalization.The facility's noncompliance was determined to be Past Noncompliance. The facility developed and implemented a corrective action plan which was completed and verified by March 28, 2026.Resident #2 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Dementia, and Hypertension.A review of a Nurses Note dated March 16, 2026, at 1:31 PM, revealed that at approximately 9:00 AM, Resident #2 was administered a complete medication pass intended for their roommate. The medications administered in error included, but were not limited to:Amlodipine 5 mg (Antihypertensive)Furosemide 40 mg (Diuretic/Antihypertensive)Clonidine 0.2 mg (Antihypertensive)Metformin 1000 mg (Antidiabetic)Glimepiride 4 mg (Antidiabetic)Saxagliptin 5 mg (Antidiabetic)Apixaban 5 mg (Anticoagulant)Lyrica 300 mg (Neuropathic/Anticonvulsant)A Nurses Note dated March 16, 2026, at 1:03 PM, documented that following the error, Resident #2's blood glucose dropped from 138 mg/dL to 87 mg/dL. The resident's blood pressure dropped to a critical level of 67/48 mmHg. The resident was documented as sleepy but arousable only with painful stimuli.Review of Hospital Discharge Summaries dated March 18, 2026, indicated Resident #2 required a three-day hospitalization (March 16-18) for Toxic Encephalopathy and Hypotension due to accidental drug overdose and hypoglycemia.During an interview on May 4, 2026, at 2:51 PM, the Assistant Director of Nursing (ADON) confirmed that Resident #2 received the roommate's medications because the room assignments listed on the nursing report sheet were incorrect. The ADON confirmed that an agency nurse performed the administration without verifying the resident's identity against the Medication Administration Record (MAR).Past Noncompliance (PNC) Justification:The facility's failure to ensure a resident was free from significant medication errors resulted in Actual Harm (Scope/Severity: G). However, the facility met the criteria for Past Noncompliance as the following corrective actions were implemented and validated by March 28, 2026:Immediate Protection: The agency nurse involved was removed from the facility schedule and is no longer permitted to provide care at the location.Root Cause Analysis/Systemic Correction: The facility identified that the Nurse Report Sheets contained inaccurate room numbers. All report sheets were audited and corrected to ensure accurate resident location identification.Education: All licensed nursing staff (including internal and agency) received re-education on the Six Rights of Medication Administration, specifically emphasizing resident identification.Monitoring/Auditing: * The facility conducted an internal medication administration audit for all current nursing staff.An external pharmacy consultant was contracted to perform a secondary independent audit of medication passes to ensure systemic compliance.Because the facility identified the deficiency, implemented a plan to prevent recurrence, and internal monitoring showed the plan was effective prior to the start of the survey, this citation is documented as Past Noncompliance.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were not labeled and were open to air, personal items of kitchen staff were observed to be in the food preparation area, kitchen staff were handling food with bare hands, and the dish machine was not operating with water temperatures necessary to ensure the dishware was properly sanitized. Findings Include: On 8/25/24 at 9:25 AM, an initial walk-through was conducted in the kitchen. In the walk-in refrigerator, 4 packages of a green substance were found with no label and no date. In the walk-in freezer, a box of beef patties was open to air, and a box of cookie dough was open to air. An observation was made of the dish machine wash cycle during clean up from the breakfast meal. During the first observation, the wash temperature was 158 degrees Fahrenheit and the rinse temperature was 130 degrees Fahrenheit. In a second observation, the wash temperature was 154 degrees Fahrenheit and the rinse temperature was 130 degrees Fahrenheit. In a third observation, the was temperature was 150 degrees Fahrenheit and the rinse temperature was 130 degrees Fahrenheit. In a fourth observation, the wash temperature was 150 degrees Fahrenheit and the rinse temperature was 130 degrees Fahrenheit. An observation was made of the required temperatures posted on the dish machine. The wash temperature was required to be 160 degrees Fahrenheit or higher, and the rinse temperature was required to be 180 degrees Fahrenheit or higher. An observation was made of the dish machine temperature log. For the month of August, there were multiple days when the water temperature was not meeting the required temperature. The documentation was as follows, with all temperatures being in degrees Fahrenheit: a. On 8/1/24, for the lunch meal, the rinse temperature was 175. b. On 8/3/24, for the dinner meal, the wash temperature was 158 and the rinse temperature was 139. c. On 8/5/24, there were no temperatures documented for the dinner meal. d. On 8/7/24, for the breakfast meal, the rinse temperature was 177. For the dinner meal, the rinse temperature was 120. e. On 8/8/24, for the breakfast meal, the rinse temperature was 177. For the dinner meal, the rinse temperature was 174. f. On 8/9/24, for the breakfast meal, the rinse temperature was 160. For the lunch meal, the rinse temperature was 165. For the dinner meal, the wash temperature was 155 and the rinse temperature was 150. g. On 8/10/24, for the breakfast meal, the wash temperature was 135 and the rinse temperature was 150. For the dinner meal, the wash temperature was 151 and the rinse temperature was 135. h. On 8/11/24, for the breakfast meal, the wash temperature was 155 and the rinse temperature was 165. For the lunch meal, the rinse temperature was 155. For the dinner meal, the rinse temperature was 165. i. On 8/12/24, for the breakfast meal, the rinse temperature was 171 degrees. For the lunch meal, the rinse temperature was 177 degrees. For the dinner meal, the wash temperature was 150 and the rinse temperature was 130. j. On 8/13/24, for the breakfast meal, the rinse temperature was 170. For the lunch meal, the rinse temperature was 175. For the dinner meal, the rinse temperature was 150. k. On 8/14/24, for the breakfast meal, the rinse temperature was 155. For the lunch meal, the rinse temperature was 155. For the dinner meal, the wash temperature was 149 and the rinse temperature was 130. l. On 8/15/24, for the breakfast meal, the rinse temperature was 173. For the dinner meal, the wash temperature was 155 and the rinse temperature was 163. m. On 8/16/24, for the breakfast meal, the rinse temperature was 155. For the lunch meal, the rinse temperature was 160 degrees. For the dinner meal, the rinse temperature was 160. n. On 8/17/24, for the breakfast meal, the rinse temperature was 170. There were not temperatures taken during the lunch meal. For the dinner meal, the wash temperature was 148 and the rinse temperature was 128. o. On 8/18/24, for the breakfast meal, the rinse temperature was 170. For the lunch meal, the rinse temperature was 170. For the dinner meal, the wash temperature was 155 and the rinse temperature was 129. p. On 8/19/24, for the breakfast meal, the rinse temperature was 175. For the dinner meal, the wash temperature was 156 and the rinse temperature was 143. q. On 8/20/24, for the breakfast meal, the rinse temperature was 177. For the dinner meal, the wash temperature was 155 and the rinse temperature was 165. r. On 8/21/24, for the breakfast meal, the rinse temperature was 176. s. On 8/22/24, for the breakfast meal, the rinse temperature was 175. t. On 8/23/24, for the breakfast meal, the rinse temperature was 170. For the dinner meal, the wash temperature was 140 and the rinse temperature was 158. u. On 8/24/24, there were no temperature taken for the breakfast and lunch meals. For the dinner meal, the wash temperature was 156 and the rinse temperature was 133. v. On 8/25/24, for the breakfast meal, the rinse temperature was 165. There were no temperatures taken for the lunch and dinner meals. It should be noted that while making the first observations of the dish machine temperatures, Dietary Aide (DA) 1 was observed to take the plate covers as they came out of the dish machine and put them on the shelf in preparation for the next meal. On 8/25/24 at 10:01 AM, an observation was made of a soda can and a small clutch bag sitting on the surface next to the griddle. A small office caddy was also on that surface with a pad of sticky notes in it. On 8/27/24 at 11:16 AM, an observation was made of the morning/afternoon cook (CK) 1 who was pulling apart dinner rolls for the lunch meal with her bare hands. CK 1 placed some of the dinner rolls into a bag, went to the sink to wash her hands, and then took the bag to the meal cart and placed a dinner roll on each tray within the dinner cart. CK 1 then returned to the tray of rolls and began pulling them apart with her bare hands. On 8/27/24 at 11:29 AM, an observation was made of the dish machine while cleaning dishes. The wash temperature was 145 degrees Fahrenheit, and the rinse temperature was 175 degrees Fahrenheit. On 8/27/24 at 11:34 AM, an observation was made of 2 large drinking cups sitting on the area right next to the griddle. Also on that surface was an office cup with large clips, an office tray with sticky notes, kitchen gloves, a clip board and a dietary form. On 8/27/24 at 11:37 AM, an observation was made of the stove in the kitchen which had food splatter on it. The griddle had crumbs on the area under the knobs and where the griddle was turned on and off. On 8/27/24 at 12:09 PM, an observation was made of CK 1 who was filling small cups with brown sugar. CK 1 was observed with a small cup of brown sugar in her hand and with a bare finger, smoothed off and patted down the brown sugar in the cup before putting a lid on it and obtaining another small cup of brown sugar. On 8/28/24 at 1:19 PM, a second walk-through of the kitchen was conducted. In the walk-in freezer, a box of Salisbury steak patties was open to air, a box of meat patties was open to air, a box with chocolate chip cookie dough was open to air, a box of sugar cookies was open to air. There were 7 individual pot pies stacked on a shelf that were not dated. In the walk-in refrigerator, a box of bacon was open to air. A container of lime juice with a best by date of 4/7/24. Additionally, a 5 gallon bucket of dill pickle spears had a lid on top, but it was not sealed and was open to air. On the surface next to the griddle, a bag of candy was observed, a drinking cup was observed as well as a box of gloves, an office tray with sticky notes, a cup containing highlighters, pens and pencils, and a labeling gun. On a shelf above the stove, a box of creamy wheat cereal was observed to be open to air. In the dry storage room, a container of long grain rice was open to air. A white substance was observed to have dripped into a large mixing bowl and was hardened. The ovens were observed to have crumbs outside the doors on the flat surfaces. The stove had dried food around the burners and the grill was greasy on top. On 8/25/24 at 9:56 AM, an interview was conducted with DA 1 who stated if there was a problem with dish machine temperatures, she would notify the dietary manager who would then call and have it repaired. DA 1 stated the temperatures were checked before running the dishes through the dish machine and were not checked again until the next meal. The DA stated she did not monitor the temperatures on the machine while the dishes were being cleaned. On 8/26/24 at 8:40 AM, an interview was conducted with the DM who stated the dish machine was a high temperature machine. The DM stated temperatures were taken before each set of dishes started. The DM stated she was unsure what the temperatures were supposed to be. The DM looked on her computer and was unable to find what the temperatures should be. The DM stated if the temperatures were not meeting the required temperatures, she would call (company name) to fix it. During the interview an observation was made of the dishwasher during a cycle. The wash temperature was observed to be 160 degrees Fahrenheit, and the rinse temperature was 142 degrees Fahrenheit. On 8/27/24 at 11:41 AM, an interview was conducted with DA 2 who stated she checked the temperature of the dish machine right after the breakfast meal. DA 2 stated the dish machine had to be run a few times before running the dishes so it would get to the proper temperature. DA 2 showed the surveyor the thermometer on the dish machine where the temperatures were taken. DA 2 stated the wash cycle was supposed to be above 160 degrees Fahrenheit, DA 2 stated the temperature required for the rinse cycle was 180-185 degrees Fahrenheit. DA 2 stated if the temperatures were not meeting required levels, the maintenance manager was supposed to be called to fix the machine. DA 2 stated it was her opinion that the staff running the machine at night were just turning the machine on and running the dishes. DA 2 stated she thought the DM checked the temperature logs. DA 2 stated the reason for having temperature controls was to ensure the dishes were being sanitized and to prevent food bourne bacteria. DA 2 stated the temperatures documented at the dinner meal the night before were not adequate to sanitize the dishes. The temperatures for the dinner meal on 8/26/24 were 140 degrees Fahrenheit for the wash cycle and 130 degrees Fahrenheit for the rinse cycle. On 8/28/24 at 12:17 PM, an interview was conducted with the RD. The RD stated she completed a monthly kitchen audit, and completed a more in-depth quarterly audit of the kitchen that included sanitation, budget and meal service. The RD stated she looked at the dish machine and other temperature logs monthly and had been checking weekly while they did not have a DM. The RD stated she had noticed, last year, that the dish machine temperatures were not meeting the requirements, and was told by kitchen staff that the machine had been fixed. The DM stated she was told the machine was fixed in April 2024. The RD stated she did not keep copies of the temperature logs, but that they should be kept in a binder in the kitchen. The RD stated previously when the temperatures were not meeting requirements, she and the administrator were notified and the repair company came and fixed the machine. The RD stated she did not believe the facility maintenance manager did any maintenance on the machine. On 8/28/24 at 1:46 PM, an interview was conducted with CK 2 who stated the new DM had not yet made up cleaning schedules yet, so the kitchen staff were just cleaning up after themselves and when they saw something that needed to be done. On 8/28/24 at 1:52 PM, an interview was conducted with the DM who stated she had been notified about the dish machine temperatures. The DM stated (company name) should have come on 8/27/24 and fixed the dish machine. The DM stated she would call the repair man to see what was found. The DM stated food items in the freezer should have a date when it was opened and used within the next week. The DM stated the food in the freezer and the refrigerator should be sealed. The DM stated food open to air can result in residents becoming sick, and affects the quality of food. The DM stated she would have to get back to the surveyor regarding a cleaning schedule.

Based on interview, record review, and observation, the facility did not establish and implement written policies and procedures for feedback, data collections systems and monitoring to include adverse event monitoring. Specifically, on the previous recertification survey conducted on 10/3/22, F609, F697, F755, F761, F804, F812, F867, and F880 were cited. These deficiencies were cited again during the current recertification survey. Resident identifiers: 4, 5, 8, 9, 12, 14, 15, 16, 19, 21, 23, 28, 29, 30, 32, 34, 36, 38, 39, 45, 48, 53, 156, 158, 161, 166, and 206. Findings include: a. Based on observation, interview, and record review, for 2 of 42 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, a resident had a fall while in a mechanical lift and was not reported to the State Survey Agency and a resident had a fall which resulted in a fracture and the State Survey Agency was not notified within 2 hours after the allegation was identified. Resident identifiers: 28 and 156. Reference [609] b. Based on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals preferences. Specifically, for 1 out of 42 sampled residents, a resident was observed to complain about pain and pain medications were not available. Resident identifier: 16. Reference [697] c. Based on interview and record review it was determined, for 1 of 42 sampled residents, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, a resident was not administered medications as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 16 Reference [755] d. Based on observation and interview it was determined that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, medication carts were left unlocked and unattended, insulin pens were open and available for use past the expiration date. In addition, narcotics were repackaged into the narcotic cards. Resident Identifiers: 4, 5, 15, 21, 23, 34, 38, 39 and 48. Reference [761] e. Based on observation, interview and record review, the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that is palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of the food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 4, 8, 9, 12, 19, 29, 30, 32, 34, 36, 39, 45, 166 and 206. Reference [804] f. Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were not labeled and were open to air, personal items of kitchen staff were observed to be in the food preparation area, kitchen staff were handling food with bare hands, and the dish machine was not operating with water temperatures necessary to ensure the dishware was properly sanitized. Reference [812] g. Based on interview, record review, and observation, the facility did not establish and implement written policies and procedures for feedback, data collections systems and monitoring to include adverse event monitoring. Reference [867] h. Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 42 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Reference [880] On 8/28/24 at 3:54 PM, an interview was conducted with the Administrator (ADM). The ADM stated the medical director, leadership personnel, administration, medical records, the MDS [minimum data set] coordinator, the Dietary Manager (DM), therapy staff, activities director, and maintenance attended the Quality Assessment and Performance Improvement {QAPI) meetings. The ADM stated the committee met on Wednesday of every month. The ADM stated documentation of the meetings were on signature pages that were placed in the QAPI binder and meeting notes that were kept in the computer. The ADM stated during a meeting an agenda was followed to cover areas of importance. The ADM stated a quick base program was being used to look for trends, and the reporting system was used to keep track of issues. The ADM stated action plans or PIPs (performance improvement plans) were established for issues that needed to be addressed at the time. The ADM stated that audit tools and check systems were reviewed at every QAPI meeting. The ADM stated that between QAPI meetings administrative staff followed up on things. The ADM stated staff education was provided on the third Tuesday of every month. The ADM stated in the previous month a lot of time was spent on abuse and reporting. The ADM stated actions that were currently being taken to ensure quality care for the residents were addressing staffing issues and training of staff. The ADM stated the PIP that was currently being worked on was abuse and reporting, specifically identifying the causes, asking questions, and obtaining statements from staff and other residents during the investigations. The ADM stated falls, care plans, charting and communications were also being worked on. The ADM also stated better management of labs, being consistent on getting results and reviewing them, cleaning resident rooms, obtaining POLST (Provider Order for Life-Sustaining Treatment) forms and advanced directives, decreasing Urinary Tract Infections (UTIs), and better infection control measures. The ADM stated nothing specific had been done to address medication administration.

Based on interview and record review, it was determined, for 5 of 42 sampled residents, that the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to provide evidence that all alleged violations were thoroughly investigated. Specifically, allegations of neglect resulted in emergency department visits and hospitalization s, two of which resulted with surgical intervention, and one allegation of abuse by a staff member were not thoroughly investigated. Resident identifiers: 15, 53, 156, 158, and 161. Findings include: 1. Resident 156 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of right femur neck, acute respiratory disease, atrial fibrillation, metabolic encephalopathy, rhabdomyolysis, hypertension, and major depressive disorder. Resident 156's medical record was reviewed on 8/25/24 through 8/28/24. An Event Report Safety Events Fall Event dated 1/10/24 at 9:40 AM indicated resident had an unwitnessed fall in his room. It further indicated, Nursing Description Patient found on the floor. He fell trying to get his catheter back through his pant leg. Resident Description He said he fell trying to balance on left leg and thread his Foley through his pant leg and lost balance and landed on his right hip. It further indicated, Injury Type: Other: - unable to move r(right). leg. Location Of Injury Right Hip. Range of Motion [ROM] Unable to Complete ROM (If unable- why?) - 10/10 pain right hip. Describe, if necessary. Possible fx [fracture] right hip. X-ray to rule out. It further indicated that the resident was, Sent to ED [emergency department] for evaluation. A Progress Note dated 1/16/24 at 4:03 PM indicated, While at the facility, he had a fall in which he landed on his right hip. He was transported to the hospital for further evaluation. He was found to have a subcapital right hip fracture with mild displacement and rotation of the proximal femur. He was taken to the operating room on one/11/24 [sic] by [physician name] for a right hip cemented bipolar hemi arthroplasty . On 8/28/24 at 3:24 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that any unwitnessed fall should have been investigated for possible neglect. On 8/28/24 at 4:42 PM, an email was provided by the Administrator (ADM). Exhibit 359 was attached. The email indicated, .Not knowing the case number prevented the completion of the 359. No other documentation was provided regarding an investigation. 43212 2. Resident 158 was admitted on [DATE] and was readmitted on [DATE] with diagnoses that included acute respiratory distress syndrome, pulmonary embolism, sepsis, laceration without foreign body, lower left leg, and polyneuropathy. Resident 158's medical record was reviewed between 8/25/24 and 8/28/24. An entity 358 revealed that on 9/5/23 at 12:19 PM, resident 158 sustained a laceration to his shin from an unknown origin. The resident was assessed and a pressure bandage was applied. Resident 158 was transported via EMS (emergency medical services) to the hospital. The 358 entity report revealed resident 158 appeared to be shaking, pale, and had pinpoint pupils. Police were notified. An entity 359 was received on 9/12/23 at 11:45 AM, and revealed resident 158 had cut his leg on the side of his bed while using a power wheel chair. The 359 report stated, Injury was of known source from scraping against the bed frame. The investigation portion of the 359 report revealed, Interviews were done with staff working that hall. The summary of the interviews included, Nurse assisted resident who was stuck against the bed by the night stand. She applied pressure and called ems. The other interview summaries contained N/A [not applicable]. The conclusion included, Not verified this was injury of known source. It should be noted that no additional investigation documents were provided that included interviews, evaluations or education that was provided after the incident. It should also be noted that the 359 entity report was submitted after 7 days. 44640 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which included myasthenia gravis, pain, essential hypertension, opiod use, acute kidney failure, seizures, herpesviral vulvovaginits, muscle spasm, constipation, anxiety disorder, hypothyroidism, edema, muscle weakness, major depressive disorder, and major depressive disorder. Resident 15's medical record was reviewed 8/25/24 through 8/28/24. The exhibit 358 revealed that staff became aware of the incident on 8/24/23 at an 3:00 PM. The exhibit revealed that resident 15 alleged, The CNA did not deliver meals, not answer call lights, and left the resident. Immediate action to protect resident was documented as, Alleged perpetrator was immediately asked to leave facility on leave until investigation is completed. Exhibit 359 was not located in the abuse log provided by the facility. For the allegation no investigation was provided by the facility. On 8/26/24 at 9:41 AM, an interview was conducted with resident 15. Resident 15 stated the incident did take place but she could not remember all the details since it happened so long ago. Resident 15 stated there was a lot of neglect that went on in the facility back then. Resident 15 stated the facility had gotten better with the new management team and if she had problems she would let the administration know. Resident 15 stated that they take good care of her. On 8/27/24 at 2:25 PM, an interview was conducted with the ADM. The ADM stated the incident with resident 15 occurred before his time at the facility and he was unable to find an investigation or 359 for the incident. 4. Resident 53 was admitted to the facility on [DATE] with diagnoses with included atherosclerotic heart disease of native coronary artery, fracture of superior rim o fright pubis, wedge compression fracture of T(thoracic)11-T12 vertebra, fall on same level, chronic viral hepatitis C, altered mental status, hepatic failure, weakness, anxiety disorder type II diabetes and hyperlipidemia. Resident 53's medical record was reviewed 8/25/24 through 8/28/24. The exhibit 358 revealed that staff became aware of the incident on 8/1/24 at 4:30 PM. The exhibit revealed that resident 11 alleged, Staff responded to [resident 53's]room to find pt. (patient) on the mat again with further injury. and Immediate action to protect resident was documented as, [Resident 53] was sent to hospital again for further evaluation in the day with arm in sling and information indicated of a potential ' current or former ' injury. The exhibit 359 revealed that Determined that [resident 53's] fall was an unfortunate event and while staff checked on her frequently, she became mobile and appeared to have fallen while in a stare of confusion. A summary on interviews with alleged perpetrator revealed, Staff indicated that resident received frequent checks and appeared at current baseline. And no concerns noted. A summary of information from the investigation revealed, n/a. The allegation was not verified and marked as inconclusive, Determined that [resident 53's] fall was an unfortunate event and while staff checked on her frequently, she became mobile and appeared to have fallen while in a stare of confusion. Progress notes dated 8/1/24 revealed, Patient was found on floor by CNA. CNA went in to check on patient and found patient on the floor in extreme pain. CNA ran to get nurse to assess patient. Upon assessment Nurse noticed that left arm was limp and looked to be dislocated. Nurse looked for any other injuries and no other injuries were noted. Patient was helped back into bed and vitals taken. Nurse notified family and Hospice of the fall, family did not want patient to get sent out to the hospital since patient was on hospice. Nurse gave patient PRN morphine to help with the pain. Hospice nurse is coming to evaluated patient. For the allegation no investigation was provided by the facility 5. Resident 161 was admitted to the facility on [DATE] with diagnoses which included osteomyelitis, pressure ulcer of sacral region, stage 4, enterocolitis due to Clostridium difficile, paraplegia, autoimmune hepatitis, cirrhosis of liver, acute metabolic acidosis, bradycardia, bacteremia, thrombocytopenia, pain, disorder of kidney and ureter, neuromuscular dysfunction of bladder, obstructive sleep apnea, hypertension, and gastro-esophageal reflux disease. Resident 161's medical record was reviewed 8/25/24 through 8/28/24. The exhibit 358 revealed that staff became aware of the incident on 3/22/24 at 3:00 PM. The exhibit revealed that the local hospital staff alleged, Adult Protective Services (APS) contacted the Resident Advocate (RA) to inquire further regarding a case called in to their office. RA alerted the facility Administrator of the report. The administrator and staff investigated the incident further to determine that [local hospital] staff contacted APS with an allegation of neglect for [resident 161]. The claim alleges that [resident 161] was sent to [local hospital] following concerns with heart-rate and respiratory issues. [Resident 161] had been at [facility] for a couple of months for variety of care needs. [Local hospital] Emergency Department alleges that [resident 161] arrived and presented disheveled and rough appearance. Upon being contacted from APS and further contact with [local hospital], it was determined than an allegation was made and the facility is now reporting the alleged event per the facility's reporting steps and measures. Immediate action to protect resident was documented as, Resident [161] was admitted to [local hospital] for further cares. Resident was transferred to [specialty hospital] for further treatment with plans to return to [facility] and Rehabilitation following his stay there. The facility will continue its investigation process and review to determine the details of the allegation, review the findings, make any necessary recommendations or changes, report to the facility's QAPI [Quality Assurance and Performance Improvement] Committee for analysis and necessary action steps. The exhibit 359 revealed that on 3/14/24 at an unknown time, [Resident 161] was interviewed following his transfer to [local hospital]. He reported that he did not remember much about the transfer and admission to the ER [emergency room ] and [local hospital] and indicated he was told afterwards about the details and transfer. A summary on interviews of the staff revealed, Interview Wound Nurse (WN) and the DON regarding the event and they provided further information regarding attempts made to send [resident 161] to the hospital that he denied, but did admit to the hospital for the low O2 [oxygen] levels and explained that the there may have been a leak in his colostomy and. may have caused further alarm and issues upon review. The allegation was not verified, [Facility] continues to work and improve our clinical care practices, systems, and review processes. While there is a lot to learn from this situation and additional review and corrective actions have been reported to the operations QAPI committee for further evaluation, implementation of corrective actions, and necessary review and oversight processes. On 8/27/24 at 11:25 AM, an interview was conducted with the ADM. The ADM stated there was no other investigative notes for the incidents. The ADM stated they had talked to the staff involved with resident 53 and 161 but did not have the documentation. The ADM stating improving this process was part of the QAPI plan that was in place. The ADM stated they started the new process in April of this year and they were still working on it. The ADM stated he was the abuse coordinator and it was his responsibility to ensure the investigations were completed appropriately.

Based on interview and record review it was determined, for 1 of 42 sampled residents, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, a resident was not administered medications as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 16 Findings Included: Resident 16 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, protein calorie malnutrition, morbid obesity with alveolar hypoventilation, vascular dementia, mood disorder, opiod dependence, anxiety disorder, obstructive sleep apnea, Bell's palsy, chronic pain, muscle weakness, unsteadiness on feet and lack of coordination. On 8/27/24 at 8:15 AM, an observation was made as resident 16 received his morning medications. Resident 16 was observed to ask RN (Registered Nurse) 3, Do you have my fentanyl patch because it has been out for a week? RN 3 informed resident 16 he did have his fentanyl patch but it was now 2 patches instead of just one because the dosage had changed. Resident 16 stated, They told me it was because if my insurance? RN 3 was observed to put the 2 fentanyl patches on the upper left side of resident 16's back and tell resident 16 he would check into it. Resident 16's medical record was reviewed 8/25/24 through 8/28/24. On 8/21/24, an order administration note documented, Fentanyl patch 72 hour; 25 mcg [microgram]/hr [hour] . Administer: 1 patch transdermal. Not Administered: Drug/Item Unavailable. On 8/22/24, an order administration note documented, Fentanyl patch 72 hour; 25 mcg/hr . Administer: 1 patch transdermal. Not Administered: Drug/Item Unavailable. On 8/23/24, an order administration note documented, Fentanyl patch 72 hour; 25 mcg/hr . Administer: 1 patch transdermal. Not Administered: Other Comment: Waiting to get the 12 mcg patch. On 8/24/24, an order administration note documented, Fentanyl patch 72 hour; 25 mcg/hr . Administer: 1 patch transdermal. Not Administered: Other Comment: Waiting to get the 12 mcg patch. On 8/25/24, an order administration note documented, Fentanyl patch 72 hour; 25 mcg/hr . Administer: 1 patch transdermal. Not Administered: Other Comment: Waiting for the 12 mcg patch to use together. On 8/26/24, an order administration note documented, Fentanyl patch 72 hour; 25 mcg/hr . Administer: 1 patch transdermal. Not Administered: On Hold Comment: Waiting for the 12 mcg patch to use together. On 8/27/24 at 8:25 AM, an interview was conducted with RN 3. RN 3 stated he was unsure why the resident was changed from the 37.5 mcg Fentanyl patch to the 2 other patches that equaled 37 mcg. RN 3 was observed to look at the August MAR (Medication Administration Record) with this surveyor and was unable to determine why the resident had not received his patches from 8/20/24 through 8/26/24. RN 3 stated the process for getting medications that were needed was to call the pharmacy and they would deliver them. RN 3 stated the pharmacy came to the facility multiple times a day to deliver needed medications. RN 3 stated they did keep a supply of medications in a locked machine in the medication room but he was unsure if Fentanyl patches were in that supply. On 8/28/24 at 1:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a error with the pharmacy and that was the reason resident 16 had not received his medication. The DON stated resident 16 was originally getting 37.5 mcg of Fentanyl and then the pharmacy stated they could no longer provide that dose but could provide 37.0 mcg in 2 separate patches, so the provider changed the order to equal this amount. The DON stated the pharmacy had not sent the medication, and the nurses kept ordering it so the pharmacy thought they had already sent it. But no one was checking to see where the medication actually was. The DON stated the nurses had one of the Fentanyl patches, either the 25 mcg or the 12 mcg the DON was unsure, but the nurses were waiting to have both of them before they administered anything to the resident. The DON stated the resident should not have gone without his pain medication and that he was aware the process needed some clarification and follow through to ensure the residents did not go without the medications they needed.

Based on observation, interview and record review, for 4 of 42 sampled residents, the facility did not have menus that met the nutrition needs of residents in accordance with established nutrition guidelines. In addition, the menus were not followed. Specifically, residents complained about the portion sizes being too small. Resident identifiers: 8, 12, 34, and 167. Findings include: On 8/25/24 at 12:00 PM lunch service was observed on the 100 and 200 hallways and the following was observed: Resident 8 was observed to be sitting in the dining room eating his lunch. A piece of chicken was observed to be on resident 8's plate. The chicken was observed to be the size of a silver dollar. Resident 8 stated the amount of chicken was small and he would have liked it to be bigger. Resident 12 was observed to be in bed with his bedside table in front of him. Resident 12 was observed to have a piece of chicken on his plate that was the size of silver dollar. Resident 12 stated the food was no good, and the meat was too small. Resident 167 was observed to be sitting in bed with his bedside table in front of him. Resident 12 was observed to be holding a knife and fork and attempted to cut the piece of chicken. Resident 12 said he could cut it but stated the piece was small. 43212 Resident 34 was admitted on initially on 6/3/21 and readmitted on [DATE] with diagnoses that included cerebral palsy, diabetes mellitus, hyponatremia, malnutrition and depression. On 8/25/24 at 2:53 PM, an interview was conducted with resident 34 who stated the meals received the day before were garbage. Resident 34 stated the lunch meal on the day before were broccoli and rice casserole for lunch and beef stroganoff for dinner that consisted of noodles with watery brown gravy and very little meat. Resident 34 stated the cook apologized for the meal yesterday evening and provided doughnuts to the residents to make up for it. The Daily Spreadsheet was reviewed prior to the lunch meal. The meal consisted of pork medallions, herbed buttered pasta, broccoli florets, a dinner roll with butter, choice of beverage, and a piece of pumpkin cake with cream cheese frosting. Portion sizes were as follows: a. Pork Medallions: Regular portion was 3 oz (ounces) of meat with 1 oz of gravy; large portion was 4 oz of meat with 1 oz of gravy; small portion was 2 oz of meat with 1 oz of gravy. Mechanical soft (3 and 2) was a # (number) 8 scoop (1/2 cup) of ground meat with 1 oz and 2 oz of gravy respectively. b. Herbed buttered pasta: Regular portion was a #8 scoop of pasta; large portion was #6 scoop (2/3 cup); small portion was a #16 scoop (1/4 cup); Mechanical soft 3 was a #8 scoop of pasta; Mechanical soft 2 was to receive soft and chopped pasta with 2 oz of gravy or sauce of choice. c. Broccoli florets: Regular portion was #8 scoop of broccoli; Large portion was #6 scoop of broccoli; Small portion was a #12 scoop (1/3 cup) of broccoli; Mechanical soft 3 was a #8 scoop of broccoli, soft and chopped into smaller pieces; Mechanical soft 2 was #12 scoop of broccoli pureed. d. Dinner roll with butter: Regular portion was 1 roll with 1 serving of butter; Large portion was 2 rolls with 2 servings of butter; Small portion was 1 roll with 1 serving of butter; Mechanical soft 3 was a soft roll with 1 serving of butter; Mechanical 2 was #16 scoop of pureed roll. e. Choice of beverage: Regular, large, small, and mechanical 3 and 2 diet were to receive 1 cup. f. Pumpkin cake with cream cheese frosting: Regular, large, small and mechanical 3 and 2 diets were to receive a 3 x 2 inch piece. On 8/27/24 at 11:50 AM, an observation was made of the tray line. The cook (CK) 1 was interviewed and stated she was using a #8 scoop for the noodles, a 1oz ladle for the gravy, a #10 scoop for the chopped meat, and a #8 scoop for the broccoli. The pork medallions were roughly 3 x 2.5 inches and 1/2 inch thick. During tray line, Dietary Aide (DA) 2 was observed to call out the diet order and CK 1 plated the meal. For a regular portion, the resident received 1 piece of meat with 1 oz of gravy, 1 #8 scoop of pasta, 1 #8 scoop of broccoli florets, 1 dinner roll with 1 serving of butter, and a 3 x 2 piece of cake. For a large portion meal, the resident received 2 pieces of meat with 1 oz of gravy, 1 #8 scoop of pasta, 1 #8 scoop of broccoli florets, 1 dinner roll with 1 serving of butter and a 3 x 2 piece of cake. No small portions were observed to be served. For the mechanical 3 meal, residents received a #10 scoop (3/8 cup) of ground meat with 1 oz of gravy, a #8 scoop of chopped broccoli, and 1 dinner roll with a serving of butter and a 3 x 2 piece of cake. No puree meals were observed to be served. It should be noted that the portion size of the meat did not appear to be 3 oz. It should so be noted that for residents that disliked green vegetables or broccoli, steamed carrot cubes were served. On 8/28/24 at 12:17 PM, an interview was conducted with the Registered Dietitian (RD) who stated she conducted food quality audits on a weekly basis when she was in the building. The RD stated she did not know if she had a record of the test trays. On 8/28/24 at 1:52 PM an interview was conducted with the Dietary Manager (DM) who stated that one of the cooks needed a lot more training, and especially with food presentation, following the menus and spreadsheets. The DM stated she had complaints from residents about the portion sizes of the food.

Based on observation, interview and record review, the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that is palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of the food, and when surveyors pulled a test tray during the lunch meal, the food was found to be lacking in flavor and appearance. Resident identifiers: 4, 8, 9, 12, 19, 29, 30, 32, 34, 36, 39, 45, 166 and 206. Findings include: On 8/25/24 at 11:19 AM, an interview was conducted with resident 8. Resident 8 stated he did not like the food and that he wouldn't feed this food to his dogs. On 8/25/24 at 11:25 AM, an interview was conducted with resident 166. Resident 166 stated the food was usually cold when it was brought to her and that it did not taste very good. On 8/25/24 at 11:47 AM, an interview was conducted with family member (FM) of resident 19. FM stated the food was not good, the portions were for children and they did not give them what they asked for. On 8/25/24 at 11:52 AM, an interview was conducted with resident 12. Resident 12 stated the food was usually cold then it got to him. Resident 12 stated the food was worse than prison food. On 8/25/24 at 12:03 PM, an interview was conducted with resident 39. Resident 39 stated the food was inedible and that they got a new kitchen person and it was just bad. Resident 39 stated she was not sure she had ever tasted food so bad. 48709 On 8/25/24 at 11:32 AM, an interview was conducted with resident 4. Resident 4 stated the dinner last night was nasty and that he could not even tell what the food was. On 8/25/24 at 12:21 PM, an interview was conducted with resident 206. Resident 206 stated he was served 2 slices of untoasted bread with gravy on it and it was supposed to be biscuits and gravy. Resident 206 stated, It was bad. On 8/25/24 at 1:14 PM, an observation was made of the Resident Advocate (RA). The RA brought donuts out to three residents who were sitting outside in the smoking area. The RA told the residents that the new dietary manager heard how bad the food was yesterday so she had gotten the residents donuts to let them know that she was aware. An interview with resident 36 was conducted after the RA went back inside the facility. Resident 36 stated they brought them [NAME] Taco one day for the same reason. Resident 36 stated the dinner last night was called, Turkey Surprise, and that it was so bad that she did not even eat one meal yesterday. On 8/26/24 at 8:29 AM, an interview was conducted with resident 45. Resident 45 stated the food quality had gone down since the previous dietary manager left about three weeks ago. Resident 45 stated the quality was affected, the portion size had gotten smaller, what they serve did not match the menu, the food was served cold, and items would be missing from the meal and not supplemented. Resident 45 stated he was served two pieces of sliced bread with gravy on it yesterday for breakfast. 43212 On 8/25/24 at 10:38 AM, an interview was conducted with resident 9 who stated the food was not very good. On 8/25/24 at 11:05 AM, an interview was conducted with resident 29 who stated the food was terrible. Resident 29 stated residents filled out a menu for the week and the kitchen did not follow the menu. On 8/25/24 at 1:30 PM, an interview was conducted with resident 32 who stated dinner on the previous day was a casserole. Resident 32 stated the meal was cold and not good. On 8/25/24 at 2:53 PM, an interview was conducted with resident 34 who stated some of the meals were garbage. Resident 34 stated the lunch on the previous day was beef stroganoff which consisted of noodles in watery brown gravy with very little meat. Resident 34 stated dinner on the previous day was a broccoli and rice casserole. On 8/26/24 at 8:12 AM, an interview was conducted with the wife of resident 19 who stated the food quality was very poor. Resident 19's wife stated her husband ate very little of what was served because it was really bad. On 8/26/24 at 9:41 AM, an interview was conducted with resident 30 who stated the food was not always warm when it should be warm, or cold when it should be cold. On 8/27/24 at 11:53 AM, the trayline for the lunch meal was observed. At 12:17, a test tray was requested and sent out with the last meal cart. The results of the test tray included: a. Pork chop, approximately 3 inches x 2.5 inches and .5 inches thick. The temperature of the meat was 117.5 degrees Fahrenheit, slightly tough, but could be chewed. The gravy on the meat tasted like cream of chicken soup. b. Noodles were tri-colored and had no flavor. The temperature was 111.0 degrees Fahrenheit. c. Broccoli was mushy and overcooked. There was no salt or seasoning. The temperature was 124.3 degrees Fahrenheit. d. Also on the menu was a dinner roll and pumpkin cake with cream cheese frosting. These menu items were not provided to the surveyor. On 8/28/24 at 12:17 PM, an interview was conducted with the Registered Dietitian (RD) who stated she conducted food quality audits weekly while she was in the building. The RD stated she did not know if she kept a record from her food audits. The RD stated she had spoken to one of the newer cooks after her last audit because there were a lot of palatability issues. On 8/28/24 at 1:52 PM, an interview was conducted with the Dietary Manager (DM) who stated she started a food council shortly after she was hired to address resident's immediate concerns. The DM stated she wanted to make sure the residents were happy. The DM stated one of the cooks needed some better training, especially for food presentation, following the menus and following the spreadsheets. The DM stated she had received complaints about the portion sizes of the food.

Based on observation and interview it was determined the facility did not maintain an effective pest control program so that the facility was free of pests. Specifically, residents complained of and were observed to have flies around and on them. Resident identifiers: 2, 5, 6, 24, 37 and 40. Findings include: On 8/25/24 at 10:24 AM, an observation and interview was conducted with resident 24. Resident 24 was in her room sitting in a wheelchair next to her bed, a fly swatter was observed in her room. Two flies were observed in her room, one was on resident 24's knee. Resident 24 stated that staff knew about the flies and that the flies were a pain. Resident 24 stated the flies had been bad for months and that she was going to buy some bug spray. On 8/25/24 at 10:43 AM, an observation and interview was conducted with resident 2. Resident 2 was laying in bed in her room. Two flies were observed on resident 2's feet during the interview. Resident 2 stated there were a lot of flies at the facility and that they needed to spray. One fly was observed to land on resident 2's face. On 8/25/24 at 11:10 AM, an interview was conducted with resident 37. Resident 37 stated she could hear her roommate, resident 2, yell at the flies. On 8/25/24 at 11:42 AM, an interview was conducted with resident 6. A fly swatter was observed within reach of the resident and resident 6 stated there were flies everywhere and he had been trying to get rid of them. On 8/25/24 at 1:31 PM, an observation and interview was conducted with resident 5. Resident 5 was in her room. During the interview two flies were observed to fly around the resident's face and land on her arm. Resident 5 stated she had a fly swatter to help with the flies and that the facility was supposed to put stuff on the walls to attract the flies but that the flies were pretty bad. Resident 5 stated the doors are opened constantly. On 8/26/24 at 1:11 PM, an observation was made in the dining area near 400 hall. There were 3 flies observed, 2 of which landed on a dining table. On 8/26/24 at 1:40 PM, an interview was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated the flies are worse near the 400 hall because a lot of smokers go inside and outside in this area. CNA 2 stated one of the prizes for bingo was a fly swatter. CNA 2 stated he tried to keep the doors and windows closed. CNA 2 stated he would swat flies when residents asked him to. On 8/28/24 at 8:20 AM, an interview was conducted with the Maintenance Director (MD). The MD stated the residents do not like the flies and that the flies had increased because the smokers go outside and opened the doors. The MD stated a fly light had been placed over the fridge in long term and resident's had bought their own fly swatters and lights for their rooms. 43212 On 8/26/24 at 11:11 AM, an observation and interview was conducted with resident 40 who stated she hated the flies that were in her room. Resident 40 stated she thought the flies were disgusting. Resident 40 stated it was rude to not resolve the problem. Resident 40 stated , residents do not like eating with flies all over the place.

Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 42 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Findings include: On 8/27/24 at 7:45 AM, during morning medication pass the following was observed: a. At 7:48 AM, Registered Nurse (RN) 2 was observed to not use hand hygiene prior to starting medication pass. RN 2 was observed to use push a medication through the medication pack with his right hand into the palm of his left hand before he placed the medication into the medication cup using bare fingers. The medication was administered to resident 14. b. At 7:50 AM, RN 2 was observed to pour a medication out of a bottle into his left palm and use bare fingers to pick up the medication and place it into the medication cup. No hand hygiene was observed to be used. The medication was administered to resident 14. c. At 8:05 AM, RN 2 was observed to pour an over the counter medication from a bottle into the palm of his hand and pick up the medication and place it into a medication cup. No hand hygiene was observed to be used. The medication was administered to a resident. On 8/27/24 at 8:08 AM, an interview was conducted with RN 2. RN 2 stated that hand hygiene should be done before and after each medication pass. RN 2 stated touching the medications bare handed was not supposed to happen. On 8/27/24 at 8:35 AM, an interview was conducted with RN 3. RN 3 stated hand hygiene should be used all the time during medication pass. RN 3 stated touching the medications with bare hands was not ok and should not be done. On 8/27/24 at 9:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the staff are expected to use hand hygiene during medication pass. The DON stated the nurses should not touch the medications with bare hands and can wear gloves if they were clean and used only for one patient at a time.

Based on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals preferences. Specifically, for 1 out of 42 sampled residents, a resident was observed to complain about pain and pain medications were not available. Resident identifier: 16. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, protein calorie malnutrition, morbid obesity with alveolar hypoventilation, vascular dementia, mood disorder, opiod dependence, anxiety disorder, obstructive sleep apnea, Bell's palsy, chronic pain, muscle weakness, unsteadiness on feet and lack of coordination. On 8/27/24 at 8:09 AM, an observation was made of Registered Nurse (RN) 3 during morning medication pass. RN 3 stated it now looked like resident 16 had 2 Fentanyl patches and that they had decreased his dose and stated that he would not like that. RN 3 was observed to call over his ADON (Assistant Director of Nursing) to assist. The ADON was observed to look over the order and stated that is the new order for resident 16 and she did not know why it had changed but thought there was something to do with insurance. On 8/27/24 at 8:15 AM, an observation was made as resident 16 received his morning medications. Resident 16 was observed to ask RN 3, Do you have my Fentanyl patch because it has been out for a week and I have been hurting? RN 3 informed resident 16 he did have his Fentanyl patch but it was now 2 patches instead of just one because the dosage had changed. Resident 16 stated, They told me it was because if my insurance? RN 3 was observed to put the 2 Fentanyl patches on the upper left side of resident 16's back and tell resident 16 he would check into it. Resident 16's medical record was reviewed 8/25/24 through 8/28/24. A care plan dated 6/28/24 revealed, [Resident 16] has pain. [Resident 16] is at risk for pain secondary to poor bed mobility. The goal was [Resident 16] will have no unaddressed pain, through next review. The intervention included Offer non-pharmacological approaches to pain management [massage ice, reposition, etc.]. Monitor for side effects of pharmacological pain interventions and notify physician with positive signs or symptoms of side effects. Medications as prescribed. Monitor pain as prescribed. The physician's order dated 8/10/24, revealed Fentanyl patch 72 hour; 37.5 mcg (microgram)/hr (hour); amt (amount) 1 patch; quantity: 10; transdermal. Special instructions: Apply 1 patch every 72 hrs (hours). Once a day every 3 day. With a start date of 8/10/24 and an end date of 8/19/24. The same physician order for the Fentanyl 37.5 mcg was started on 8/19/24 and dc' d (discontinued) on 8/19/24 the restarted on 8/19/24 and dc' d on 8/20/24. The physician's order dated 8/20/24, revealed Fentanyl patch 72 hour; 25 mcg/hr; amt 1; quantity: 10; transdermal. Special instructions: Apply 1 patch every 72 hrs. Apply on the same day/time as the 12 mcg patch. A physician progress note revealed on 8/6/24, He has chronic low back pain that is currently being treated with fentanyl 37.5 mg patches and Gabapentin 600 mg (milligram) Q (every)6 hrs. He was on Percocet QID (four times a day) for many years but felt that it was no longer effective. He was switched to Fentanyl patches about a month ago. He is unable to determine the efficacy d/t (due to) new patches being late by a day each time. APC (Advanced Provider of Care) spoke with RN about the reason for patches not being changed on time, and we may have fixed the MAR (Medical Administration Record) issue. The August MAR revealed on 8/21/24, 8/22/24, 8/23/24, 8/24/24, 8/25/24, and 8/26/24 Fentanyl patch 72 hour; 12 mcg/hr was not administered: drug/item unavailable. The August MAR revealed on 8/21/24 and 8/22/24 Fentanyl patch 72 hour; 25 mcg/hr was not administered: drug/item unavailable. On 8/23/24 and 8/24/24 Fentanyl patch 72 hour; 25 mcg/hr was not administered: other comment: waiting to get 12 mcg patch. On 8/25/24 and 8/26/24 Fentanyl patch 72 hour; 25 mcg/hr was not administered: on hold comment: Will apply when the 12 mcg patch is available. On 8/27/24 at 8:25 AM, an interview was conducted with RN 3. RN 3 stated he was unsure why the resident was changed from the 37.5 mcg Fentanyl patch to the 2 other patches that equal 37 mcg. RN 3 was observed to look at the August MAR with this surveyor and was unable to determine why the resident had not received his patches from 8/20/24 through 8/26/24. RN 3 stated the process for getting medications that were needed was to call the pharmacy and they would deliver them. RN 3 stated the pharmacy came to the facility multiple times a day to deliver needed medications. RN 3 stated they did keep a supply of medications in a locked machine in the medication room but he was unsure if Fentanyl patches were in that supply. The pain history for resident 16 was reviewed and revealed, on a number pain scale from 0-10, with number 0 being no pain and number 10 being extreme pain, that resident 16's pain ranged from 2 to 10. No significant increased in pain was noted in the medical record for resident 16 during the time frame the Fentanyl patches were not available. On 8/27/24 at 11:17 AM, an interview was conducted with the Director of Nursing (DON). The DON stated there was an issue with resident 16's Fentanyl patch and his insurance. The DON stated the pharmacy could no longer get the original dose of 37.5 mcg so the provider was in agreeance to change the order to 37.0 mcg. The medication did not come so the nurses kept ordering it but the pharmacy thought they had already sent it, so they did not send a new supply. The DON stated the resident did not have increased pain during the time the Fentanyl patches were not available because the provider had changed resident 16's opiod to scheduled and changed another medication. The DON stated no one checked with the pharmacy to determine what was going on with the medication. The DON stated it was a process that needed correction. And that it was ultimately the responsibility of the facility to ensure each resident got the medications that they needed.

Based on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the Director of Nutrition Services. Findings include: On 8/26/24 at 8:40 AM, an interview was conducted with the DM who stated she had not completed the required certification to work as the dietary manager. The DM stated the RD came to the facility on ce per week on Thursday, and if she had questions she could call the RD at any time. On 8/28/24 at 12:17 PM, an interview was conducted with the RD who stated the DM was still going through the training plan, and that she had just started in the position 2-3 weeks ago. The RD confirmed that the DM did not have the required certification yet. The RD stated the goal was to provide DM with a list of who offered approved training. The RD stated the DM could call her any time if she had questions or concerns.

Based on observation and interview it was determined that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, medication carts were left unlocked and unattended, insulin pens were open and available for use past the expiration date. In addition, narcotics were repackaged into the narcotic cards. Resident Identifiers: 4, 5, 15, 21, 23, 34, 38, 39 and 48. Findings included: During morning medication pass the following was observed: 1. On 8/27/24 at 7:45 AM, an observation was made of the 300 hallway. Registered Nurse (RN) 2 was observed with a medication cart. RN 2 was observed to walk away from the unlocked medication cart and enter a resident's room. The medication cart was observed to be unlocked, have a drawer open and the computer screen was open to a resident's identifying information. Two residents were observed to be in the dayroom and within viewing distance of the medication cart computer. 2. On 8/27/24 at 8:00 AM, an observation was made of the 300 hallway. RN 2 was observed to leave the unlocked medication cart unattended and the computer screen was open with resident's identifying information in view of other residents. 3. On 8/27/24 at 8:10 AM, an observation was made of the 100 hallway. RN 3 was observed to leave the medication cart unlocked and go into the medication storage room. 4. On 8/27/24 at 7:15 AM, an observation was made of the 400 hallway medication cart with Registered Nurse (RN) 1, the following medications were located inside: a. A pre-filled pen of Lispro Injection Kwikpen 100 unit/ml (milliliters). Medication was opened and available for use and labeled with an open date of 7/26/24 and resident 48's name. b. A pre-filled pen of Admelog Injection 100 unit/ml. Medication was opened and available for use and labeled with an open date of 7/26/24 and resident 5's name. 5. On 8/27/24 at 7:45 AM, an observation was made of the 300 hallway medication cart with Registered Nurse (RN) 2, the following medications were located inside: c. A pre-filled pen of Lispro Injection Kwikpen 100 unit/ml. Medication was opened and available for use and labeled with an open date of 7/26/24 and resident 34's name. On 8/27/24 at 7:30 AM, an interview was conducted with RN 1. RN 1 stated she was unsure how long insulin was good for after it was opened. RN 1 stated when a new insulin pen was removed from the fridge the residents name should be on the pen and an open date was written on the pen. RN 1 stated the insulin's in the medication cart for the 400 hallway were the ones that they were currently using for the residents. On 8/27/24 at 7:50 AM, an interview was conducted with RN 2. RN 2 stated insulin was good for 30 days. RN 2 stated the insulin's in the medication cart for the 300 hallway were the insulin's that were currently being used for the residents. 6. On 8/27/24 at 7:18 AM, an observation was made of the 400 hallway medication cart with RN 1, the following medications were located inside: d. A medication card which held Oxycodone 10 mg (milligram) for resident 4 had the back of pocket number 27, 36 and 37 taped, no medication was located inside the pockets. e. A medication card which held Tramadol 50 mg for resident 38 had the back of pocket number 18 taped, a white tablet was observed to be taped into the pocket. 7. On 8/27/24 at 8:25 AM, an observation was made of the 100 and 200 hallways medication cart with RN 3, the following medications were located inside: f. A medication card which held Clonazepam 1 mg for resident 15 had the back of pocket number 5, 8, 11, 17, and 22 taped; a tablet was observed to be taped into pocket number 5 the other pockets were observed to have no medications in them. g. A medication card which held Tramadol 50 mg for resident 15 had the back of pocket number 15, 16, 17, 18, 19, 41 and 50 taped; 2 white tablets were observed to be taped into pocket number 15 and 1 white tablet was observed to be taped into pocket 16. The other taped pockets were observed to have no medications in them. h. A medication card which held Gabapentin 100 mg for resident 23 had the back of pocket number 39 taped; 1 capsule was observed to be taped into pocket number 39. i. A medication card which held Pregamblin 200 mg for resident 21 had the back of pocket number 9 taped, a medication was observed to be in pocket number 9. j. A medication card which held Temasepam 30 mg for resident 39 had the back of pocket number 15 taped with a Band-Aid, a medication was observed to be in the pocket. On 8/27/24 at 7:30 AM, an interview was conducted with RN 1. RN 1 stated narcotics should not be retaped into the narcotic cards. RN 1 stated it makes it difficult to see what medication is in the card and the nurse would not know if the correct medication had been put back into the card. On 8/27/4 at 7:56 AM, an interview was conducted with RN 2. RN 2 stated that is was fine to retape medications and narcotics back into the cards if they were not dirty, if the nurse knew what the medication was and if a resident refused the medication. On 8/27/24 at 8:35 AM, an interview was conducted with RN 3. RN 3 stated that is was never appropriate to retape medications back into the medication cards. RN 3 stated, There was so much wrong with that! RN 3 stated the resident could get the wrong medication or the wrong dose. RN 3 stated you just would have no way of knowing what the medication was that was put back into the card. On 8/27/24 at 10:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated insulin was good for 28 days. The DON stated the insulin in the drawers should have been discarded after the 28 days. The DON stated the staff were supposed to label and date all insulin before they were put into the medication carts. The DON stated the nurses were expected to lock the computers and medication carts if they left them. The DON stated it was unsafe to leave the medication carts unlocked and computer screens were locked to ensure resident privacy. The DON stated the nurses were supposed to waste narcotics with another nurse and never retape a medication back into a medication card, they were supposed to waste or destroy the medication.

Based on observation, interview, and record review, for 2 of 42 residents sampled, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency. Specifically, a resident had a fall while in a mechanical lift and was not reported to the State Survey Agency and a resident had a fall which resulted in a fracture and the State Survey Agency was not notified within 2 hours after the allegation was identified. Resident identifiers: 28 and 156. Findings include: 1. Resident 28 was admitted to the facility on [DATE] with diagnoses which included wedge compression fracture of lumbar vertebra, calculus of ureter, bladder neck obstruction, urinary incontinence, fall on same level, weakness, spondylosis, malignant neoplasm of prostate, type II diabetes, atherosclerotic heart disease of native coronary artery. Resident 28's medical record was reviewed 8/25/24 through 8/28/24. On 8/25/24 at 1:45 PM, an interview was conducted with resident 28. Resident 28 stated he had no complaints about the facility but that he had fallen out of the sit to stand because the band around his chest was not tight enough. Resident 28 stated there was only one CNA (certified nursing assistant) helping him when he was using the sit to stand. Resident 28 stated it had happened a few weeks ago. A Physician's Note dated 8/6/24 documented, [Resident 28] he was seen today after having a fall. He had a fall yesterday, using the lift, states he did hit his left shoulder and felt a pop but states today it is not necessarily painful . There was no additional information regarding the incident or an investigation into the incident provided. On 8/27/24 at 1:30 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was the abuse coordinator and the staff were to report all suspected abuse or neglect directly to him. The ADM stated they had been working on making this process better and was aware it was lacking. The ADM stated he was unaware of any falls that resident 28 had experienced with the sit to stand. The ADM stated he would look into it. On 8/28/24 at 12:55 PM, an interview was conducted with CNA 1. CNA 1 stated resident 28 needed a mechanical lift to help him stand because his legs were weak. CNA 1 stated resident 28 refused to use the Hoyer lift, which would have been safer. CNA 1 stated resident 28 had fallen out of the sit to stand a few times that he was aware of and 1 time that he had witnessed. CNA 1 stated he did not report the incident because he was just assisting the other worker. CNA 1 stated he was unsure how to report something like that. On 8/28/24 at 2:45 PM, a follow up interview was conducted with the ADM and the Director of Nursing (DON). The DON stated the resident did not fall out of the sit to stand, he just fell to his knees. The DON he was unaware it had happened more than one time. The ADM stated an investigation had not been done for the fall from the sit to stand. The ADM stated this is an ongoing issue the facility was working on. 48709 2. Resident 156 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of right femur neck, acute respiratory disease, atrial fibrillation, metabolic encephalopathy, rhabdomyolysis, hypertension, and major depressive disorder. Resident 156's medical record was reviewed on 8/25/24 through 8/28/24. An Event Report Safety Events Fall Event dated 1/10/24 at 9:40 AM indicated resident 156 had an unwitnessed fall in his room. It further indicated, Nursing Description: Patient found on the floor. He fell trying to get his catheter back through his pant leg. Resident Description: He said he fell trying to balance on left leg and thread his Foley through his pant leg and lost balance and landed on his right hip. It further indicated, Injury Type: Other: - unable to move r (right). leg. Location Of Injury: Right Hip. Range of Motion [ROM]: Unable to Complete ROM (If unable- why?) - 10/10 pain right hip. Describe, if necessary. Possible fx [fracture] right hip. X-ray to rule out. It further indicated that the resident was, Sent to ED [emergency department] for evaluation. A Progress Note dated 1/16/24 at 4:03 PM indicated, While at the facility, he had a fall in which he landed on his right hip. He was transported to the hospital for further evaluation. He was found to have a subcapital right hip fracture with mild displacement and rotation of the proximal femur. He was taken to the operating room on one/11/24 [sic] by [physician] for a right hip cemented bipolar hemi arthroplasty . Review of the Form 358: Facility Reported Incidents indicated the Allegation Type, Fall w (with)/fracture. It further indicated administration was notified on 1/10/24 at 5:30 PM. It should be noted that the State Agency received the Form 358 on 1/11/24 at 12:06 PM. On 8/28/24 at 3:24 PM, an interview was conducted with the DON. The DON stated that any unwitnessed fall should have been investigated for possible neglect. The DON further stated that reporting facility reported events timely was something that they could have done better.

Based on interviews and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease - 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 4 of the 5 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal or education of the benefits and potential risks associated with COVID-19 vaccination. Resident identifiers: 2, 3, 9, and 10. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, hypertension, pain, and urinary tract infection. Resident 2's electronic medical record (EMR) was reviewed on 1/5/23. Physician orders dated 12/31/22 included COVID-19 vaccinations, first and second doses. A review of resident 2's Medication Administration Record (MAR) revealed that no COVID-19 immunizations were administered. No consent or refusal documentation was found in resident 2's EMR. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, anemia, coronary artery disease, peripheral vascular disease, osteomyelitis, hypertension, hyperlipidemia, malnutrition, transient ischemic attack, and pain. Resident 3's EMR was reviewed on 1/5/23. Physician orders included first dose and second dose COVID-19 vaccination as needed. Resident 3's MAR revealed that no COVID-19 immunizations were administered. A document created during the complaint investigation on 1/4/23 regarding the COVID-19 vaccine revealed that the vaccine was not administered. The reason documented was resident refused with conscientious objection. The document also revealed that the resident was not provided any education regarding COVID-19 vaccination. No signed refusal was found in the resident 3's EMR. 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which included COVID-19, atrial fibrillation, frequent pain, and hypokalemia. Resident 9's EMR was reviewed on 1/5/23. A review of resident 9's MAR revealed that resident 9 was not provided the COVID-19 vaccination. Resident 9's EMR had no signed documents refusing the COVID-19 vaccination or if the resident had already received the COVID-19 vaccinations. Provided after exit: On 1/6/23 the facility obtained and provided documentation that resident 9 had received the COVID-19 vaccinations on 2/1/21, 2/22/21, and a booster on 10/7/21. 4. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hypertension, hyperlipidemia, type 2 diabetes, depression, and respiratory failure. Resident 10's EMR was reviewed on 1/5/23. Physician orders dated 8/1/22 did not include an order for the COVID-19 vaccination. A preventive health document that was created during the complaint investigation on 1/4/23 revealed that resident 10 had been administered a COVID-19 vaccination on 3/4/22. The document does not include which dose of the COVID-19 vaccine was administered, the manufacturer, the administrator of the vaccination, or if any education was provided to the resident regarding the COVID-19 vaccination. No signed consents were found in resident 10's EMR for the COVID-19 vaccination. On 1/4/23 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when a resident was admitted the form to give consent or decline immunizations was in that admit packet. RN 1 stated she had not seen a consent for the COVID-19 vaccination. RN 1 stated it was the nurse on duty's responsibility to make sure the consents were signed. On 1/4/23 at 10:55 AM, a interview was conducted with the Assistant Director of Nursing (ADON), who is also the infection preventionist. The ADON stated if a resident had been vaccinated for COVID-19 prior to admission the floor nurse would get the resident's COVID-19 vaccination information as part of the admission packet. The ADON stated the information would be found under the preventive care tab in the resident's EMR. The ADON stated if a resident was unable to provide the information a family member would be contacted for the information. The ADON stated that staff should have access to State vaccination records and that staff should document their findings from the web site in the resident's EMR. The ADON stated if the resident had a vaccination card, a copy would be taken and put into the resident's EMR. On 1/5/23 at 1:29 PM, an interview was conducted with the medical records clerk (MR). The MR stated that in the past immunization consents were obtained on paper. The MR stated when the facility switched to a different medical records program, obtaining consents were now part of the nursing admission assessment and everything was done electronically. The MR stated nurses did not get copies of the resident vaccination information. The MR stated that staff were able to download vaccination documents into the resident's chart. On 1/5/23 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that when a resident was admitted , the resident was asked if they had a card documenting their COVID-19 vaccinations. If the resident had a card, it would be copied and scanned into the resident's chart. The DON stated that if the resident knew they had received the COVID -19 vaccination, the facility would call to obtain the information. The DON stated they would also ask a family member about the COVID vaccination if the resident did not know. The DON stated if a resident did not want the COVID vaccination they would sign a refusal form, or they would sign a consent form if they did want to receive the COVID vaccine. The DON stated the consent would then be scanned into the resident's EMR. The DON stated now that the facility was moving to electronic only records, the resident would sign the consent or refusal, the nurse would sign it and it would then be scanned into the resident's chart. The DON stated if the resident was unable to consent or refuse, staff would talk with the resident's family member for consent. The DON stated sometimes if the resident refused, staff would revisit the subject with the resident to be sure the resident did not want the vaccine. The DON stated every resident had a paper file in the medical records office. The DON stated if the information was not scanned into the resident's EMR, it would be in the paper file. The DON stated education was provided verbally and no written information is provided. The DON stated staff would recommend the resident to have the vaccination, but would do what the resident prefered. The DON stated that progress notes would document that the resident was verbally educated about the vaccine. On 1/5/23 at 3:35 PM, an additional interview was conducted with the MR. The MR stated the only thing in the resident's paper chart that was not in the EMR was the narcotic records. The facility COVID-19 vaccination policy was reviewed and included the following statements: a. Prior to offering the COVID-19 vaccine, staff, residents, or the resident's representative, will be educated regarding the risks, benefits, and potential side effects associated with the vaccine in a form and manner that can be accessed and understood. b. A copy of Emergency Use Authorization (EUA) for recipients and caregivers for the specific vaccination brand will be given to staff ,residents or resident representatives prior to administration and in conjunction with education. c. Residents or their representatives and staff will sign the consent form prior to administration of the COVID-19 vaccine. The information will be retained in the resident's medical record or the staff's medical file. d. The resident's medical record will include documentation of the following: 1. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine. 2. Each dose of the vaccine administered to the resident, or; 3. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. 4. Follow-up monitoring of the resident post vaccination. 44640

Based on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized Specifically, for 5 out of 22 sampled residents, immunization information was not available in the resident's medical records. Resident Identifiers: 2, 3, 5, 9 and 10. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, hypertension, pain, and urinary tract infection. Resident 2's electronic medical record (EMR) was reviewed on 1/5/23. Resident 2 had physician orders for COVID-19 vaccinations, first and second doses. Physician orders also included providing the Influenza vaccination and the Pneumococcal vaccination on the first day of the month. A review of resident 2's Medication Administration Record (MAR) revealed that a COVID-19 or a pneumonia vaccination were not administered. Resident 2's MAR also revealed that resident 2 had already received the Influenza vaccine. A review of resident 2's progress notes revealed no consent or refusal documentation for the COVID-19, the Influenza, or the Pneumococcal vaccine. No documentation was found of COVID-19, Influenza, or Pneumococcal education that was provided to resident 2. A review of resident 2's EMR revealed no signed consents or refusals for the COVID-19 vaccine, the Influenza vaccine, or the Pneumococcal vaccine. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, anemia, coronary artery disease, peripheral vascular disease, osteomyelitis, hypertension, hyperlipidemia, malnutrition, transient ischemic attack, and pain. Resident 3's EMR was reviewed on 1/5/23. Physician orders dated 12/5/22 revealed an order to provide the Influenza vaccine and the Pneumococcal vaccine on the first day of the month. Physician orders also included providing the first and second dose of the COVID-19 vaccinations. Resident 3's MAR was reviewed and revealed that resident 3 refused the Influenza vaccine on 12/5/22. Additionally, the MAR revealed that resident 3 was not provided the Pneumococcal vaccination on the first day of the month as ordered. The MAR also revealed that no COVID-19 vaccination was administered. A document created on 1/4/23 (during the complaint investigation) regarding the COVID-19 vaccine revealed that resident 3 had been offered the COVID-19 vaccine and had refused with conscientious objection. Further, the document revealed that the resident was not provided any education regarding the COVID-19 vaccination. Resident 3's progress notes had no documentation of education provided to resident 3 about the Influenza or the Pneumococcal vaccinations. A review of resident 3's medical documentation revealed no signed refusals for the COVID-19, Influenza, or the Pneumococcal vaccinations. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, history of deep vein thrombosis, coronary artery disease, seizures, pneumonia, pain, depression, and gastroesophageal reflux disease. Resident 5's EMR was reviewed on 1/5/23. Physician orders for resident 5, dated 12/16/22, included a Pneumococcal vaccination on the first day of the month. A review of resident 5's MAR revealed that resident 5 was not provided the Pneumococcal vaccination. No education was documented in resident 5's progress notes regarding the COVID-19, Influenza, or the Pneumococcal vaccinations. A review of resident 5's medical documentation revealed no signed refusals were available for the Pneumococcal vaccination. A document obtained by the facility on 1/6/23, after the conclusion of the complaint investigation, revealed that resident 5's last Pneumococcal vaccination was on 10/13/16. 4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included COVID-19, atrial fibrillation, frequent pain, and hypokalemia. Resident 9's EMR was reviewed on 1/5/23. Physician orders dated 12/31/22 the Influenza and Pneumococcal vaccinations. The COVID-19 vaccine was not ordered as resident 9 was admitted with the COVID-19 virus. A review of resident 9's MAR revealed that resident 9 refused the Influenza vaccination on 12/31/22. The MAR also revealed that resident 9 was not provided the Pneumococcal vaccination. Resident 9's progress notes revealed no documentation that education was provided regarding the Influenza or the Pneumococcal vaccinations. A review of resident 9's medical documentation revealed no signed refusals for the Influenza or the Pneumococcal vaccinations, or if resident 9 had already received vaccination for the COVID- 19 virus. A document obtained by the facility on 1/6/23, after the conclusion of the complaint investigation, revealed that resident 9 had received the Influenza vaccination on 11/12/20, and the Pneumococcal vaccination on 9/29/15. The document also included information that resident 9 had received the COVID-19 vaccinations on 2/1/21, 2/22/21, and a booster on 10/7/21. 5. Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension, hyperlipidemia, type 2 diabetes, benign prostatic hyperplasia, dementia, gout, atrial fibrillation, frequent pain, depression, and respiratory failure. Resident 10's EMR was reviewed on 1/5/23. Physician orders for resident 10, dated 8/1/22, included the Influenza and the Pneumococcal vaccinations. In resident 10's preventive health care information, located in the EMR, documentation revealed that resident 10 received the Influenza vaccine on 10/21/22 and 11/17/22 at the facility. No information was found about the Pneumococcal vaccination. In resident 10's medical documentation, no signed refusals or consents were found for the Influenza or the Pneumococcal vaccinations. A document obtained by the facility on 1/6/23, after the completion of the complaint survey, revealed that resident 10 received an Influenza vaccination on 9/13/22 and that resident 10's last Pneumococcal vaccination was on 10/13/16. On 1/4/23 at 10:55 AM, an interview was conducted with the facility Assistant Director of Nursing (ADON), who also serves as the infection preventionist. The ADON stated the information would be found in the preventive care tab in the resident's EMR. The ADON stated if a resident was unable to provide the information a family member would be contacted for the information. The ADON stated consent forms were kept in the human resource office. The ADON stated he thought the consents or refusals were scanned into the resident's EMR. The ADON stated that if a resident could not answer about vaccinations, staff would contact a family member. The ADON also stated that staff had access to the State vaccination records and should document the information that was found on the web site. On 1/5/23 at 1:29 PM, an interview was conducted with the medical records clerk (MR). The MR stated that in the past immunization consents were obtained on paper. The MR stated when the facility switched to a different medical records program, obtaining consents were part of the nursing admission assessment and everything is done electronically. The MR stated nurses did not get copies of the resident vaccination information. The MR stated that staff were able to download vaccination documents into the resident's chart with information about vaccines. On 1/5/23 at 1:49 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated now that the facility was moving to electronic only records, the resident would sign the consent or refusal, the nurse would sign it and it would be scanned into the resident's chart. The DON stated after the consent or refusal was signed, it would be sent to medical records and scanned into the resident's EMR. The DON stated every resident had a paper file within the medical records office. The DON stated if the information was not scanned into the resident's EMR, it would be in the paper file. The DON stated education was provided verbally and no written information is provided. The facility COVID-19 vaccination policy included the following statements: a. Residents or their representatives and staff will sign the consent form prior to administration of the COVID-19 vaccine. The information will be retained in the resident's medical record or the staff's medical file. b. The resident's medical record will include documentation of the following: 1. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; 2. Each dose of the vaccine administered to the resident, or; 3. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal. 4. Follow-up monitoring of the resident post vaccination.

Based on interview and record review, for 5 of 5 sampled residents the facility did not ensure that each resident was offered an influenza and/or pneumococcal immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, residents did not have influenza and/or pneumococcal immunization documentation in their medical records. Resident identifiers: 2, 3, 5, 9, 10. Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, hypertension, pain, and urinary tract infection. Resident 2's electronic medical record (EMR) was reviewed on 1/5/23. Physician orders dated 12/31/22 revealed, an Influenza vaccination was to be administered every year between October 1 and March 31. The physician orders also revealed a Pneumonia vaccination was to be administered on the first day of the month PRN (as needed). Resident 2's Medication Administration Record (MAR) revealed that on 12/31/22, the Influenza immunization was not administered because the resident had already had the vaccination. The MAR also revealed that the Pneumonia vaccine was not provided on the first day of the month as ordered. No signed refusal documents were found in resident 2's EMR. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, anemia, coronary artery disease, peripheral vascular disease, osteomyelitis, hypertension, hyperlipidemia, malnutrition, transient ischemic attack, and pain. Resident 3's EMR was reviewed on 1/5/23. Physician orders dated 12/5/22 revealed, an Influenza vaccination was to be administered every year between October 1 and March 31. The physician orders dated 12/5/22 also revealed that the Pneumonia vaccination was to be administered on the first day of the month PRN. Resident 3's MAR revealed that resident 3 refused the Influenza vaccine on 12/5/22. No signed refusal was found in resident 3's EMR. The MAR also revealed that no Pneumonia vaccination was provided or offered on the first day of the month as ordered. 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, history of deep vein thrombosis, coronary artery disease, seizures, pneumonia, pain, depression, and gastroesophageal reflux disease. Resident 5's EMR was reviewed on 1/5/23. Physician orders for resident 5 dated 12/16/22 revealed, a Pneumonia vaccination was to be administered on the first day of the month PRN. Resident 5's MAR revealed that resident 5 did not receive the Pneumonia vaccination on the first day of the month. A document obtained and provided on 1/6/23 (after survey exit), revealed that resident 5's last Pneumonia vaccination was on 10/13/26. No information was found in resident 5's EMR indicating the resident had been offered the Pneumonia vaccination, and no refusal form was found. 4. Resident 9 was admitted to the facility on [DATE] with diagnoses that included COVID-19, atrial fibrillation, frequent pain, and hypokalemia. Resident 9's EMR was reviewed on 1/5/23. Physician orders dated 12/31/22 revealed, an Influenza vaccination and a Pneumococcal vaccination were to be administered on the first day of the month PRN. A review of resident 9's MAR revealed that resident 9 refused the Influenza vaccination on 12/31/22. The MAR also revealed that the Pneumococcal vaccination was not provided on the first day of the month as ordered. There was no documentation in resident 9's EMR indicating refusal of the Influenza vaccination or if the resident had already received the Pneumococcal vaccination. On 1/6/23, post survey, the facility obtained and provided documentation that resident 9 had received the Influenza vaccination last on 11/12/20, and the Pneumococcal vaccine was received on 9/29/15. 5. Resident 10 was admitted to the facility on [DATE] with diagnoses that included hypertension, hyperlipidemia, type 2 diabetes, dementia, benign prostatic hyperplasia, depression, and respiratory failure. Resident 10's EMR was reviewed on 1/5/23. Physician orders for resident 10 dated 8/1/22 revealed, the Influenza vaccination was to be administered every year between October 1 and March 31. The physician orders dated 12/5/22 also revealed that the Pneumonia vaccination was to be administered on the first day of the month PRN. In resident 10's preventive health care information, located in the EMR, documentation revealed that resident 10 received the Influenza vaccine on 10/21/22 and 11/17/22 at the facility. No information was found regarding the Pneumococcal vaccination. A document was obtained from the State website on 1/6/23 and provided post survey on 1/6/23, revealed that resident 10 had received an Influenza vaccination on 9/13/22. And resident 10's last Pneumococcal vaccination was on 10/13/16. No consents or refusals for Influenza or Pneumonia were found in resident 10's EMR. On 1/4/23 at 10:55 AM, an interview was conducted with the facility Assistant Director of Nursing (ADON), who also serves as the infection preventionist. The ADON stated influenza and pneumococcal vaccinations are offered September through December. The ADON stated documentation could be found in the preventative health care area of the resident's EMR. The ADON stated staff documented if a resident refused or if they had already received the vaccination. The ADON stated residents were educated about the risks and benefits of immunizations, and consent or refusal forms were signed by the resident. The ADON stated consent forms were kept in the human resource office. The ADON stated he thought the consents or refusals were scanned into the resident's EMR. The ADON stated that if a resident could not answer about vaccinations, staff would contact a family member. The ADON also stated that staff had access to the State vaccination records and should document the information that was found on the web site. On 1/5/23 at 1:29 PM, an interview was conducted with the Medical Records (MR) clerk. The MR stated in the past immunization consents were on paper. The MR stated that in August 2022 the facility switched to a new medical records program. The MR stated that now everything is done electronically. The MR stated paper copies were no longer obtained with the resident's vaccination information. The MR stated staff were able to download vaccination information into the resident's EMR. On 1/5/23 at 1:49 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident came from the hospital, they usually have had the influenza and pneumococcal vaccination. The DON stated the facility used the hospital records for information. The DON stated the hospital should include vaccination in the discharge paperwork. The DON stated if a resident refused or consented for a vaccination it should be documented. The DON stated no written education was provided to residents. The DON stated a progress note should be completed if a resident was verbally educated about vaccines. The facility Influenza vaccination policy, last reviewed on 7/1/21, stated Residents are protected from the Influenza virus by receiving the vaccine annually. The policy stated, The Infection Control and Prevention Officer maintains a file of residents and their vaccination status. Additionally, the policy stated, Residents have the right to refuse vaccination .The date and injection site is recorded on the Medication Administration Record. The facility Pneumococcal vaccination policy, last reviewed on 7/1/2021, stated All residents are provided the opportunity and encouraged to receive pneumococcal vaccinations. The policy further stated, The infection control nurse maintains a file of current residents showing status of vaccination. Additionally, the policy stated, After a new resident has been vaccinated, record vaccination date in the MAR .For new residents previously vaccinated, record vaccination date in the problem list.

Based on observation and interview, for 1 of 22 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not wear appropriate Personal Protective Equipment (PPE) when entering a resident's room with a confirmed COVID-19 infection, there was conflicting information about what PPE should be worn when entering a COVID-19 positive room, what to do with the PPE after use, and there was not adequate information posted to indicate there was a COVID-19 infection in the building. Resident Identifier: 9. Findings included: On 1/4/23 at 10:30 AM, an interview was conducted with RN 1. RN 1 stated the staff should wear full PPE when they enter a COVID-19 positive room. RN 1 stated she was unsure if there was any COVID-19 in the building at the current time. RN 1 stated full PPE meant gown, eye protection, N-95 mask and gloves. RN 1 stated staff were supposed to wear a surgical mask while in the facility and it was ok to pull the mask down under the chin or remove it while at the nurses station. RN 1 stated residents were tested for COVID-19 when they came into the facility and then, when the second test was due, it would come up in the medication administration record (MAR) so the nurses would know when to perform the test. On 1/4/23 at 11:21 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated the only resident in the facility that was COVID-19 positive was tested and confirmed to be positive before admission. CNA 1 stated that for residents that were on isolation, staff should wear a gown, gloves, and N-95 masks. CNA 1 stated when exiting the resident's room, the PPE should be doffed and placed in the containers outside the resident's room. CNA 1 stated she would sanitize her face shield and let it air dry outside the resident's room. On 1/4/23 at 11:35 AM, an observation was made of room [ROOM NUMBER]. This room had a small alcove outside of the resident's room that met up with the hallway. The door at the hallway was open and did not have signage that indicated the resident was on droplet precautions. A PPE cart stood inside the alcove and contained gloves, N-95 masks, gowns, sanitizing wipes, red biohazard bags, and a box of unused face shields. The door to the resident's room was also open. A red sign, that could not be seen from the hallway, was on the resident's door, that stated the resident was in isolation and before entering the room a visitor should check with a nurse at the nurse's station. No signage was observed that indicated what PPE should be worn when entering the room. On 1/4/23 at 11:37 AM, an observation was made of CNA 2 inside room [ROOM NUMBER] where the resident had a confirmed case of COVID-19. CNA 2 wore a gown, gloves, and a surgical mask. When CNA 2 exited the room, she was observed to doff the gown and gloves and place them in a covered container outside the resident's room. An immediate interview was conducted with CNA 2. CNA 2 stated when entering the room of a resident with the COVID-19 virus the Personal Protective Equipment (PPE) that should be worn was a gown, gloves, and a face mask. CNA 2 stated she did not think eye protection was required. CNA 2 stated she did not don any PPE when she brought in the resident's breakfast tray. On 1/5/23 at 10:55 AM, an interview was conducted with the Assistant Director of Nursing (ADON) who also serves as the infection preventionist. The ADON stated the PPE that should be worn when entering the room of a COVID-19 positive resident was an N-95 mask, a face shield, a gown and gloves. The ADON stated there was a sign on the resident's door that said to contact a nurse before entering the resident's room. The ADON stated there should be a list of what PPE should be worn in the resident's room. The ADON stated the sign that was on the door of the resident's room before he was moved to a different room did not get moved to the new room. (Note: The resident's previous room was observed not to have any signage on or around the door.) The ADON stated when staff left the COVID-19 positive room, they should doff the gown and gloves and dispose of them in the bin outside the door. The ADON stated the N-95 mask should be saved and put on a hook outside the resident's room. The ADON stated face shields should be sanitized with bleach wipes. The ADON stated the area outside the resident's room had a clean site and a dirty site and face shields should be left there. The ADON stated staff should wash and sanitize their hands. The ADON stated the resident's door should be always closed. The ADON stated staff should be donning all PPE when entering the resident's room to bring meals in. The ADON stated the service-wear was Styrofoam and should be thrown away. [Note: A clean and dirty side were not observed to be in the alcove outside the resident's room.] The facility policy regarding infection control Standard Precautions, last revised in June 2022, included the following: a. Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately to avoid transfer of microorganisms to other residents or environments. c. Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. d. Wear a gown (clean, nonsterile) to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions or cause soiling of clothing .Remove a soiled gown as promptly as possible and wash hands to avoid transfer of microorganisms to other residents or environments. The facility policy regarding Isolation Precautions, last revised in July 2022, included the following: a. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. b. The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment to be used. c. The rationale for the selected transmission-based precautions will be documented in the medical record. d. Information regarding the particular type of precaution to be utilized will be communicated through verbal reports, written in-house communication forms, and signage. Centers for Disease Control and Prevention (CDC) guidance (September 2022) included using visual alerts such as signs and posters at the entrance and in strategic places that include Infection Prevention and Control (IPC) recommendations. Personal Protective Equipment guidance for Healthcare Professionals (HCP) included: HCP who enter the room of a patient with suspected or confirmed SARS-Cov-2 infection should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e. goggles or a face shield that covers the front and sides of the face. 44640

Based on interview and record review, the facility did not ensure that a transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. Specifically for 1 out of 22 sampled residents, residents that were transferred to the hospital did not have a transfer assessment or a reason for the transfer documented in the medical record. In addition, no documentation was found in the resident's medical record to indicate the receiving provider was provided contact information of the practitioner responsible for the resident's care, resident representative contact information, advance directive information, all special instructions for care, a discharge summary and any other documentation necessary for a safe and effective transition of care. Resident identifier: 8. Findings included. Resident 8 was admitted to the facility for respite care on 11/10/22 with diagnoses which included hypertensive heart, chronic kidney disease with heart failure, anxiety, frequent pain, agitation, insomnia, and end of life care. Resident 8's Electronic Medical Record (EMR) was reviewed on 1/5/23. Resident 8's progress notes included the following entries: 11/10/22 12:56 PM ADMIT NOTE: [Resident 8] admitted to [facility] on a 5 day respite stay. She is on hospice with [hospice agency]. 11/12/22 19:42 PM Patient (pt). complained of stroke like symptoms, has a history of stroke, and described how she felt as being a stroke like with her past 6 strokes. She had a bp (blood pressure) of 215/125, and was very shaky, hands were equal grasp but weak. After finding out her blood pressure and talking with her we contacted (sig) the DON (Director of Nursing) asking what we should do, and she said to send her next door, to be checked out at the hospital. I talked with the daughter a little later, and she told me she was on hospice, and that in the past she has had a big spikes in blood pressure related to anxiety. I apologized to her for sending her when I should have contacted hospice before doing so. I posted a sign in her room that reads in case of emergency contact her hospice nurse and her number. I hope that will help if this scenario happens again. She is at the hospital now, I sent her with the required paperwork and contacted her family, I have report to oncoming nurse about what happened and about her day if she comes back tonight, she can take care of her. She knows about the history of anxiety now and we try a couple other things next time to bring that down instead of shipping her and contact the hospice nurse. 1700 we got the high blood pressure she was shipped by 1730, I contacted family after report and getting the oncoming nurse ready to take on the other patients. [Note: Resident 8's progress notes did not include information relayed to the facility from the hospice agency regarding resident 8's care needs.] The Documents file in resident 8's EMR included a Respite Stay Referral dated 11/10/22 that included a list of resident 8's medications, a list of resident 8's diagnoses, medication allergies, activity level, functional limitations, mental, psychosocial, and cognitive status, safety measures to be aware of, and a list of supplies needed for care. The documents also included notes from the Certified Nursing Assistant (CNA) caring for resident 8. A care plan created on 11/10/22 included end of life services with a goal that resident 8 would be able to express feelings about health and life as desired and will experience death with dignity and physical comfort. Intervention approaches included coordinate with ancillary partners to ensure comfort, safety, and cares are being met, PRN (as needed). A hospital discharge note dated 11/12/22 revealed that resident 8 was treated with an EKG (electrocardiogram), neurological consultation, treatment for blood pressure elevation, a CT (continuous tomography) scan, an MRI (Magnetic Resonance Imaging), and laboratory tests. The note stated After initial evaluation including CT, MRI, and hypertensive management the patient was found to be on hospice. Family and hospice did not want her admitted and requested discharge back to hospice. The patient was transported back to hospice. On 1/5/22 surveyors were provided with a Communication between [facility], [hospice organization] &[hospital]. A communication chain included the following events: a. Floor nurse called [Director of Nursing(DON)] the night of the 11/12/22 with concerns about a patient's vital signs. The DON was given an incorrect room number, to which the DON agreed to have the resident sent to the hospital thinking it was a different patient. b. The floor nurse charted the event and her communication with family and/or hospital/hospice company and realized the mistake. c. [Hospice organization] called one of the facility PCC's (Primary Care Clinicians) [name provided] to discuss what the options were. d. [PCC's name] called [Facility Administrator] and he called the [DON] to have her reach out to family and the hospital. e. [DON] spoke with both the patient's family member and the hospital to confirm the patient was NOT to be admitted to the hospital. f. The transport driver was contacted, and arrangements were made to pick resident 8 up from the hospital. The [PCC name] and the hospice team to let them know the patient was being taken back to the facility before hospital admission. g. Patient arrived back at the building around 11:00 pm the same night. On 1/4/23 at 11:32 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated if a resident had an event the nurse on duty would assess the resident, message the medical director or the nurse practitioner (NP) and report what was going on with the resident. The ADON stated the nurse would get a full set of vitals, and if needed, a urinalysis. The ADON stated nurses had a standing orders to obtain a urinalysis. The ADON stated the nurses followed the providers orders. The ADON stated if STAT (immediate) laboratory tests were ordered, they could be drawn and sent to the hospital. The ADON stated if vital signs were not stable, the physician would be notified and the resident would be sent to the hospital. The ADON stated a progress note would be completed after the resident was sent. The ADON stated that an event form should be filled out when a resident was discharged to the hospital that included why the resident was sent, the time they were sent, and who was contacted. The ADON stated a progress note should be completed when the resident returned from the hospital. The ADON stated if a resident went to the hospital and did not stay overnight, a packet would be returned to the facility with the resident. The ADON stated the nurse on duty would look through the documentation sent back with the resident to see if there were any new orders or medication changes, then the nurse would give the documents to the medical records clerk to scan into the resident's EMR. The ADON stated the process for communication between the facility staff and the hospice staff was that orders were faxed to the facility and the facility would notify the physician. The ADON stated if a resident was admitted on hospice, an order would be provided with the resident's paperwork. The ADON stated that the hospice agency staff were good about going over a verbal regimen with the nurse on duty, and that information should be documented in the progress note. The ADON stated the contact information for hospice staff was kept at the nurses station and should also be in the resident's chart. The ADON stated the hospice agency caring for the resident should be in the physician orders. On 1/5/23 at 1:49 PM, an interview was conducted with the DON. The DON stated nurses should be charting daily on each shift. The DON stated anything out of the ordinary should be charted, calls to the doctor, progress or lack thereof, or change of conditions should be included in progress notes. The DON stated if a resident had a change in condition, the nursing staff should call her (the DON), the physician, and the family and include that information in a progress notes. The DON also stated the progress notes should include what was sent to the hospital with the resident. The DON stated a lot of communication went on in the Tiger Text, the facilities communication application, that was accessible to all staff and providers. The DON stated information regarding hospice orders and communication was transmitted through the tiger text, progress notes and the EMR. The DON stated a progress note should be completed when there was any communication between hospice and the facility staff. The DON stated that baseline information, including oxygen use, normal vital signs, resident behaviors, and nutritional information, was obtained from the hospice staff. The DON stated contact numbers for hospice staff should be in the resident's EMR. The DON stated when a resident had a problem the hospice staff should be notified first, then the hospice physician, then family. The DON stated the hospice physician would make necessary changes. The DON stated nurses always refer to the hospice team.

Based on observation, interview and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, the facility did not have a process where a missing narcotic dose could be readily detectable, the medication cart was left unlocked when unattended, and a computer was left on with resident information viewable. Resident identifiers: 5, 17, 18, 19, 20, 21, and 22. Findings included: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of olecranon process, multiple pelvis fractures, chronic kidney disease stage III, type II diabetes, and pneumonia. 2. Resident 17 was admitted to the facility on [DATE] with diagnoses which included anemia, urinary tract infection, hypertension, and thyroid disease. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses which included anemia, orthostatic hypotension, renal insufficiency, hyperlipidemia, and seizure disorder. 4. Resident 19 was admitted to the facility on [DATE] with diagnoses which included renal insufficiency, hyponatremia, and hip fracture. 5. Resident 20 was admitted to the facility on [DATE] with diagnoses which included hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, and anxiety. 6. Resident 21 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, disorder of phosphorus metabolism, heart disease, hypomagnesium and thrombocytopenia. 7. Resident 22 was admitted to the facility on [DATE] with diagnoses which included hypertension, benign prostatic hyperplasia, renal insufficiency, diabetes mellitus and depression. On 1/4/23, an observation was made of the four medications carts that were in the facility. It was observed that in each locked narcotic drawer there were narcotic cards that had sections on the backside of the card with tape over the part where a pill had been pushed through. The following narcotic cards were found with the backside taped: a. 100-hallway medication cart: For Resident 18, duct tape was observed on the back of pocket number 6 of the Hydrocodone 5/325 milligrams (mg) medication card. b. 200-hallway medication cart: For Resident 19, tape was observed on the back of pocket number 13 of the Tramadol 50 mg medication card. c. 300-hallway medication cart: For Resident 20, tape was observed on the back of pockets 55 through 60. A horizontal piece of tape across pocket number 55 and a vertical piece of tape covering numbers 55 through 60 of the Lorazepam 1mg medication card. d. 400-hallway medication cart: For Resident 21, tape was observed on the back of pocket number 52 of the Oxycodone 10mg medication card. Resident 22, tape was observed on the back of pockets number 32 through 34, 14 through 24, and pocket number 17 of the Tramadol 50 mg medication card. And tape was observed on the back of pocket number 26 of the Hydrocodone 10 mg medication card. On 1/4/23 at 10:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the narcotic count was done each change of shift with the oncoming nurse. Each medication cart had a narcotic drawer that needed to be counted. If there was a discrepancy, we look it up on the computer to see if the medication was administered and then call the Director of Nursing (DON) to see what she wanted us to do. We could not leave the building until the narcotic count was correct. But I have never had anything gone missing, so I have never had to worry about that. RN 1 stated the policy was if you remove a narcotic from the bubble pack then you need to waste it with another nurse. RN 1 was observed to make air quotes with her fingers and stated, Well that was what was supposed to happen. It doesn't always happen, that was why you are seeing the backs of the cards being taped. RN 1 stated she was unsure who was doing it, but it seemed to happen quite often. RN 1 stated it was weird how often it happened. RN 1 stated the pharmacy brings the narcotics to the facility and they are supposed to give them to a licensed nurse who puts them in the narcotic drawer in the medication cart or refrigerator. On 1/4/23 at 10:55 AM, an observation was made of Registered Nurse (RN) 1. RN 1 left the medication cart in the 300-hallway unlocked, walked away, and sat down at the nurse's desk. Resident 17 sat near the unlocked medication cart. On 1/4/23 at 10:58 AM, an interview was conducted with resident 17. Resident 17 stated she was able to move around with the assistance of her walker. Resident 17 was alert and oriented. On 1/4/23 at 11:00 AM, an interview was conducted with RN 1. RN 1 stated only the nurse had keys to the medication cart and the medication cart should be always locked when not in use for the safety of the residents. On 1/4/23 at 11:05 AM, an observation was made of the main narcotic sign out sheet for the 100-hallway titled Narcotic Count Sign Off. The Narcotic Count Sign Off sheet had columns across the top labeled with Date, Out Going Nurse, Units +/-, Total Units, Oncoming Nurse, Out Going Nurse, Units +/-, Total Units, and Oncoming Nurse. An immediate interview was conducted with RN 2. RN 2 stated when a narcotic card was added to the drawer or removed from the drawer it was written under the Units +/- column and then added or subtracted from the total. RN 2 stated the outgoing nurse would tell the oncoming nurse how many cards were added or removed and then both nurses would sign the narcotic count sheet. RN 2 stated there was no process in place to verify what happened to the narcotic cards that had been removed from the narcotic drawer when the master narcotic count was done at change of shift. RN 2 stated the nurses were supposed to put the narcotic sheet on the DON's desk when it was empty and then write minus the number of cards that were removed from the drawer on the Narcotic Count Sign Off sheet. RN 2 stated But we just trust the nurse leaving that they did what was right and put the used cards on the DON's desk. RN 2 stated that probably was not the best practice to be doing, and she could see how narcotics could go missing easily. An observation was then made of a narcotic that had been placed back into the bubble pack for resident 19. RN 2 stated she was unaware that narcotic had been taped back in and would waste it with the DON. RN 2 stated when a narcotic was not given it was supposed to be wasted, not taped back into the bubble pack. On 1/4/23 at 11:25 AM, an interview was conducted with the DON. The DON stated each nurse for the hallway will sign for the narcotics when the pharmacy brings them to the facility. The narcotic count happens at change of nurses, usually at change of shift. The DON stated the process for a narcotic that was not administered was, the medication was supposed to be wasted, a line drawn through the entry, the entry initialed by both nurses, a note entered in the margin explaining why the narcotic was wasted and the nurses are to make the DON aware of the waste. The DON stated this was not happening. The DON stated the risks associated with an incorrect narcotic count could result in missing narcotics. An observation was made as RN 2 showed the DON the taped medication in the narcotic card. The DON stated none of the medication packs should be taped, especially not the narcotic packs. Unless told to do so by management, and this would only happen if there were global dire need to save medications. The DON stated there was no secure process in place to ensure the master narcotic count was verified or correct when count was done between nurses. The DON stated the lack of this process could increase the chances of narcotics being misplaced or misused. On 1/4/23 at 2:58 PM, an observation was made of the computer on top of the medication cart in the 100-hallway. The computer was left on with resident 5's information on the screen. Paperwork with resident 5's information was left on top of the medication cart. Residents that were not in the sample were observed in the hallway near the medication cart. On 1/4/23 at 3:05 PM, an interview was conducted with RN 2. RN 2 stated the medication cart should be locked all the time unless it is being used and the computer should not have resident information on it when not being used. On 1/4/23 at 3:15 PM, an interview was conducted with the DON. The DON stated the medication carts and narcotic drawers should be locked when not in use by the nurse. The DON stated all resident information should be kept covered to protect the privacy of the residents.

Based on interview and record review it was determined, for 2 out of 34 sampled residents, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident had a urinalysis (UA) test completed with no follow up and the resident went to hospital for treatment. In addition, a resident with signs and symptoms of a urinary tract infection ([CONDITION(S)]) went to the hospital for treatment. Resident identifiers: 29 and 44. Findings included: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 29's medical record was on 9/28/22. An admission Minimum Data Set assessment dated [DATE], revealed that resident 29 was occasionally incontinent of bowel and bladder and was not on a toileting program. The MDS further revealed resident 29 required two plus person extensive assistance with toileting. A care plan dated 8/1/22, revealed Infection. [Resident 29] is at risk for infection secondary to presence in a skilled nursing facility. The goal was [Resident 29] will have no untreated s/s [signs and symptoms] of infection through next review. The approaches included Monitor labs as prescribed, Notify MD [Medical Director] of s/s of infection, Universal precautions. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Laboratory Analysis results collected on 8/19/22, were received on 8/21/22. The laboratory (lab)results revealed resident 29 had Escherichia Coli, Peptostreptococcus prevotti, and Staphylococcus aureus. The form revealed that [MEDICATION(S)] 100 milligrams (mg) twice daily for 5 to 7 days was the appropriate treatment. Resident 29's August 2022 Medical Administration Record (MAR) revealed there were no antibiotics administered. There were no progress notes from 8/16/22 until 8/21/22. The progress notes revealed the following entries: a. On 8/21/22 at 3:25 AM, PT (patient) kept complaining about pain, and requested to talk to the doctor's about her medication regimen, she feels her current regimen isn't working. Pt was extremely upset. Pt did state she was at a 9 out of 10 and was still able to sleep. On the 1800 [6:00 PM] - 0600 [6:00 AM] shift, the CNA's [Certified Nursing Assistant] went to do their rounds and the pt was wearing the same brief from the previous night, stamped 0425 [4:25 AM] and when the CNA changed her, there was evidence of a BM [bowel movement], but not actual BM present, the pt wasn't cleaned well, and she was upset about it. b. On 8/21/22 at 10:28 AM, Resident 29 complained of pain and was requesting to go to the hospital emergency room . Resident 19 was angry narcotics had been spaced further out and [MEDICATION(S)] had been discontinued. Resident 19's vital signs were taken and as needed pain medication had been administered. The Assistant Director of Nursing (ADON) was notified and resident 19 was transferred to the hospital. c. On 8/21/22 at 11:55 AM, Resident 29 was taken by ambulance to the hospital emergency room . d. On 8/21/22 at 4:16 PM, Resident 29 returned to the facility with new orders for [MEDICATION(S)] 100 mg every 6 hours. e. On 8/24/22 at 12:35 PM, Resident 29 informed the nurse of the hospital situation. Resident 29 was happy to have her pain medication back. Resident 29 was frustrated that she had not gotten any results back from the hospital. An Emergency provider report dated 8/21/22 at 11:48 AM, revealed Resident 29 was in increased pain over the last day or so and she coordinates this with increasing urination and dysuria. The patient apparently had a catheter urine specimen obtained a day or 2 ago and they do not have the results as of yet. She is worried she has a kidney infection. According to the lab results interpretation section resident 29 had trace of leukocyte esterase, 1-3 bacteria per high-power field (hpf), White Blood Cells, and a few bacteria. The Discussion/Course section revealed complaints of a possible [CONDITION(S)] and pain radiating into the right hip and knee. The lab tests were fairly unremarkable. The section revealed that she did not have evidence of a [CONDITION(S)] today. Medications administered included [MEDICATION(S)] 1 gram on 8/21/11 at 11:51 AM, through Intravenous route. [Note: There was no culture and sensitivity completed according to the lab results from the emergency department.] A Nurse Practitioner (NP) note dated 8/26/22, revealed that resident 29 was in pain over the weekend and she went to the hospital to have her [MEDICATION(S)] increased to every 6 hours. [Note: There was no information regarding resident 29's UA that was collected on 8/19/22.] On 9/29/22 at 10:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated symptoms of a [CONDITION(S)] were increased urination, frequent urination, change in vital signs, fever, and a lot more. The DON stated if a resident had symptoms the a UA would be obtained. The DON stated there should be documentation in the progress notes as to why a UA was obtained. The DON stated physician's were notified through the UA results being placed in the box for the physician when they came to the facility. The DON stated nurses also sent a tiger text to the physician with the results. The DON stated the NP was at the facility on Mondays and Thursdays and the physician on Wednesdays. The DON stated she was unable to obtain the tiger texts unless she was in on the text, so she would not be able to provide information that the physician was notified. The DON stated when the physician was notified the nurse should write a progress note. On 9/29/22 at 11:00 AM, an interview was conducted with RN 3. RN 3 stated when a lab value or UA was ordered, she would contact the NP, an order was placed in the residents electronic medical record, and the lab company was contacted. RN 3 stated that the results of the laboratory were faxed to the facility or the lab contacted the NP. RN 3 stated that sometimes the lab did not send results so the nurse had to follow up with the lab. RN 3 stated if the nurse who ordered the labs was gone for a week the nurse on shift may not be aware of what labs had been ordered and which results had been sent to the facility. RN 3 stated the lab process had resulted in missed lab results. RN 3 stated that she tried to document in the progress notes when a lab was obtained. RN 3 stated on 8/19/22, she obtained a UA for resident 29 because she was probably acting confused or had a symptom like pain or burning when urinating. RN 3 stated she did not know if the physician was notified of the UA results. RN 3 stated she did not know if there was follow up because if it was not written in the medical record it was not done. RN 3 observed the UA results from 8/19/22, and stated it was a 6 on a scale of 1 to 7 which indicated resident 29 had an infection. RN 3 stated the results revealed resident 29 had a [CONDITION(S)] that needed to be treated with [MEDICATION(S)]. RN 3 stated that things get very busy and I forget to get everything done. RN 3 stated there were not enough staff in the building. RN 3 stated there needed to be a nurse for each hallway because it's just crazy. RN 3 stated It's so stressful for me, because at the end of the day I sent the order and did not follow up on it and did not get treatment. RN 3 stated there were so many things to do and follow up on and with almost 40 residents it was impossible to get everything done. RN 3 stated that charting did not get done. On 9/29/22 at 12:38 PM, a follow up interview was conducted with the DON. The DON stated she did not have any notes about the UA. The DON stated according to the UA in the medical record, [MEDICATION(S)] was the antibiotic that should have been used to treat resident 29's [CONDITION(S)]. On 9/29/22 at 1:00 PM, an interview was conducted with resident 29. Resident 29 stated that the facility obtained a UA on 8/19/22, but she did not know the results. Resident 29 stated she got a shot at the hospital because of her [CONDITION(S)] on 8/21/22. Resident 29 stated she was in a lot of pain at the facility, so she had to go to the hospital to get treatment. Resident 29 stated she wonders if the facility ever received the results because she had asked a bunch of times and no staff knew about the results. On 10/3/22 at 12:01 PM, an interview was conducted with the ADON. The ADON stated lab results were sent to the main fax line in the facility. The ADON stated that the physician then provided medication orders and nurses had access to antibiotics in the pixus system. 2. Resident 44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 44's medical record was reviewed on 9/28/22. On 7/22/22 at 4:04 PM, a Nurses Note documented LAB - Called [name of lab removed] to pick up a urine swab for the pt [patient] who thinks that she may have a [CONDITION(S)]. Left swab and order with paperwork at the nurses station and let them know to pick it up there. They said that they will come today or tomorrow. On 7/22/22 at 11:14 PM, a Nurses Note documented Pt has been crying on and off throughout shift. Pt requests [MEDICATION(S)] frequently, nurse has contacted MD multiple times, MD has not responded, nurse told pt about communication with MD, pt seems really upset and frustrated, pt said 'I hope he gets COVID [Coronavirus Disease-2019] real bad.' Pt c/o [complains of] urinary tract pain, asked for pain med [medication], asked about results of UA. Will cont [continue] to monitor throughout shift. On 7/24/22, a urinalysis report documented that resident 44 had a [CONDITION(S)]. The common organisms detected were [MEDICATION(S)] species, Enterococcus faecium, Enterococcus faecalis, Escherichia coli, and Peptostreptococcus prevotti. The report further documented the antibiotic of choice as Amoxicillian 875/125 mg by mouth twice a day for 7 days for possible acute [CONDITION(S)]. On 7/26/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: The first dose of [MEDICATION(S)] was administered three days after the UA report was received.] A review of the August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . [Note: Resident 44 received the last dose of Amoxicillian on 8/2/22 between 6:00 PM to 10:00 PM. Resident 44 missed one dose of Amoxicillian.] On 8/5/22 at 4:08 AM, a Nursing progress note documented Pt has been tearful for most of shift. Pt c/o R [right] abd [abdomen] pain, described as 'stretching,' guarding upon assessment, reports increased pain on laying down, passing gas, last BM 8/4 [22] AM. Pt then c/o 'kidney pain,' when nurse percussed flank, pt c/o pain. DON and provider notified, tylenol given (see emAR [electronic Medication Administration Record]), will get a UA. Pt called multiple times about [MEDICATION(S)], nurse said she couldn't give d/t [due to] med d/c'd [discontinued] and provider hasn't answered yet. Pt hears screaming, staff asked pt what was wrong, pt c/o bilat [bilateral] foot pain, nurse assessed, feet looked baseline, pt c/o 'feel like they are going to explode,' pt said it was d/t increased sodium in diet, nurse explained that pt was getting renal diet so this would not be the reason. Pt requested ice packs and lotion rubbed into feet, staff applied both. Pt reported treatment effective. Pt has been tearful and c/o different pains/ailments throughout shift. Provider and DON notified. [Note: A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .] On 8/6/22 at 5:37 PM, a Nursing progress note documented Pt was found calling out for people that weren't there in her room around 4pm today. I checked her vitals [vital signs]. Her oxygen was at 60, RR [respiratory rate] 18 Temp [temperature] 98 bp [blood pressure] 122/88. I put oxygen on her and it wouldn't get to 90 until I put it to about 5 Liters. I informed NP and Dr [doctor] of the facility via tiger text. There was no response back on the matter. Kept her on oxygen because when I take it off, she dips back down to below 90. She stopped calling out to unseen others after I put the oxygen on. Its almost end of shift, she is at 93 and has oxygen on. I will give this information in report at the end of shift. Lungs sounds clear in all lobes. Pt stated that even though I was giving her, her blood sugar, that she didn't feel like taking her self administered insulin. Her bs [blood sugar] around 5pm was 497. She gave me permission to give her 10 units of fast acting insulin. On 8/8/22 at 3:01 AM, a Nursing progress note documented 8/7/22 2200 [10:00 PM]-This Nurse called non emergency transport to send Pt to [name of hospital removed] to be evaluated d/t change in condition .such as: increase in oxygen therapy, is a feeder, edematous, and change in mentation. 2220 [10:20 PM]-EMS [Emergency Medical Services] arrived to facility 2228 [10:28 PM]-Pt left facility on Stretcher Family notified and MD 8/8/22 0217 [2:17 AM]- UPDATE- admitted to ICU [Intensive Care Unit] On 8/7/22, the hospital notes documented . The patient presents by ambulance from a nursing home with acute confusion. She is unable to provide a thorough history. Her exam is concerning for diffuse anasarca with depleted intravascular volume, including dry mucous membranes. She has a history of prior urinary tract infections. She was treated with IV [intravenous] and [MEDICATION(S)] shortly after arrival. Labs are notable for severe [CONDITION(S)]. The patient also apparently has liver disease, and she has hypoalbuminemia, which could contribute to the interstitial [CONDITION(S)]. Her chemistry panel is concerning for significant elevations of the BUN [blood urea nitrogen], creatinine, and potassium. She was immediately started on treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . I spoke with the nephrologist, who states that he knows the patient has chronic renal insufficiency, she is now in acute renal failure and will likely require [CONDITION(S)]. The patient will go to the ICU for emergent management of her renal failure and [CONDITION(S)] with metabolic [CONDITION(S)]. On 8/8/22, the hospital notes documented . The patient is conversant but not oriented to year or situation. Per report, she has been having worsening confusion over the past two days. She has had a dry mouth and decreased UOP [urinary output] over this timeframe as well. She has generalized swelling. She reports nausea and vomiting over the last few days as well, and non-bloody diarrhea. She is unsure what her renal disease is from but follow with [name of doctor removed]. On 8/25/22 at 1:50 PM, a NP progress note documented . SUBJECTIVE: [Name of resident 44 removed] is seen today as a readmit. She has a medical history significant for T2DM [type 2 diabetes mellitus] on insulin, CKD [chronic kidney disease], [CONDITION(S)] [hypertension], HLD [[CONDITION(S)]], and multiple wounds. She was sent to [name of hospital removed] with nausea and decreased by mouthintake [sic] where she was found to have [CONDITION(S)] and a GFR [glomerular filtration rate]< [less than] 10. She was started on [CONDITION(S)], is followed by Nephrology. On 10/3/22 at approximately 12:40 PM, an interview was conducted with RN 1. RN 1 stated that she was an agency nurse and it was her first day working at the facility. RN 1 stated she had no knowledge regarding the circumstances of resident 44's hospitalization . On 10/3/22 at 12:58 PM, an interview was conducted with the ADON. The ADON stated that resident 44 was diagnosed at the hospital with a urinary tract infection. The ADON stated when resident 44 was readmitted to the facility resident 44 had a new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated that resident 44 was possibly sent out to the hospital due to a change in mental status. On 10/3/22 at 1:59 PM, an interview was conducted with the DON. The DON stated she had no knowledge regarding the circumstances of resident 44's hospitalization . On 10/3/22 at 3:43 PM, a follow up interview was conducted with the DON. The DON stated that she could not see that the UA was completed for resident 44 on 8/5/22.

Based on observation, interview, and record review it was determined, for 3 out of 34 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person centered care plan, and the resident's goals and preferences. Specifically, residents complained of uncontrolled pain with no interventions or physician follow up. In addition, a resident went to the hospital in pain after pain medications were adjusted. Resident identifiers: 25, 29, and 45. Findings included: 1. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 12:32 PM, an interview was conducted with resident 29. Resident 29 stated she was unable to stand her pain last night and was groaning. Resident 29 stated there was no nurse on her hallway from 12:00 AM until 6:00 AM. Resident 29 stated she needed [MEDICATION(S)] at 2:00 AM but the nurse told resident 29 it was not her problem because she would not be there. Resident 19 stated the nurse continued to tell her she would not be the nurse to administer the [MEDICATION(S)]. Resident 29 stated she had scoliosis that made a hole in her spine and she has no control over her left lower extremities. Resident 29 stated she needed her [MEDICATION(S)] regularly because her pain never quit. Resident 29 stated her [MEDICATION(S)] was not administered at 2:00 AM when she wanted it. Resident 29 stated that her pain was at a 10 and she was crying and sick to her stomach. Resident 29 stated the nurse administered three pills to her early in the morning that morning and she did not know what the medications were. Resident 29's medical record was reviewed on 9/28/22. An admission Minimum Data Set (MDS) assessemnt dated 7/14/22, revealed that resident 29 frequently experienced pain. The MDS revealed resident 29 had pain that made it hard for her to sleep at night and limited her day-to-day activities. The MDS revealed resident 29 had as needed pain medications and no scheduled pain medications. A care plan created on 9/19/22, with a problem start date of 8/1/22, revealed resident 29 was at risk for pain secondary to chronic pain. The goal was resident 29 would have no unaddressed pain, through next review. The approaches included educate resident on newly prescribed medications, monitor for side effects, medications as prescribed, monitor pain as prescribed, and other non-pharmacological approaches to pain management. A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 8/23/22, Drug/Item Unavailable: Could not find b. On 8/24/22, Drug/Item Unavailable c. On 8/25/22, Drug/Item Unavailable d. On 8/26/22, Drug/Item Unavailable: Notified DON [Director of Nursing] - DON is getting more e. On 8/27/22, Drug/Item Unavailable: Waiting for delivery f. On 8/28/22, Drug/Item Unavailable g. On 8/29/22, Drug/Item Unavailable A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The instructions were to apply to knees and ankles. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR for August 2022 revealed [MEDICATION(S)] gel was not administered on the following dates: a. On 8/9/22, No nurse b. On 8/30/22, Drug/Item unavailable c. On 8/31/22, Drug/Item unavailable A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/11/22, the [MEDICATION(S)] 5 mg was scheduled every 12 hours for low back pain. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was changed to [MEDICATION(S)] 50 mg 2 tablets scheduled every 12 hours on 8/11/22, and discontinued on 8/21/22. The [MEDICATION(S)] order was changed to 100 mg every 4 hours as needed for pain on 8/21/22, through current. Progress notes revealed the following entries: a. On 8/15/22 at 11:06 AM, the physician documented resident 29 had chronic back pain with medications listed. b. On 8/16/22 at 4:07 PM, resident 29 complained about pain and said that today was worse than normal and she kept up with pain medications and provided as needed pain medications. Resident 29 was unable to walk since she was at another nursing facility when she was walking and heard three pops. Resident 29 had since had pain radiating from her back into her legs. Pain was controlled with the medication she was on now. c. On 8/21/22 at 3:25 AM, PT [patient] kept complaining about pain, and requested to talk to the doctor's about her medication regimen, she feels her current regimen isn't working. Pt was extremely upset. Pt did state she was at a 9 out of 10 [pain scale] and was still able to sleep. On the 1800 [6:00 PM] - 0600 [6:00 AM] shift, the CNA's [Certified Nursing Assistant] went to do their rounds and the pt was wearing the same brief from the previous night, stamped 0425 [4:25 AM] and when the CNA changed her, there was evidence of a BM [bowel movement], but not actual BM present, the pt wasn't cleaned well, and she was upset about it. d. On 8/21/22 at 10:28 AM, Resident 29 complained of pain and was requesting to go to the hospital emergency room . Resident 19 was angry narcotics had been spaced further out and [MEDICATION(S)] had been discontinued. Resident 29's vital signs were taken and her as needed pain medication had been administered. The Assistant Director of Nursing (ADON) was notified and resident 19 was transferred to the hospital. e. On 8/21/22 at 11:55 AM, Resident 29 was taken by ambulance to the hospital emergency room . f. On 8/21/22 at 4:16 PM, Resident 29 returned to the facility with new orders for [MEDICATION(S)] 100 mg every 6 hours. g. On 8/24/22 at 12:35 PM, Resident 29 informed the nurse of the hospital situation. Resident 29 was happy to have her pain medication back. Resident 29 was frustrated that she had not gotten any results back from the hospital. An Emergency provider report dated 8/21/22 at 11:48 AM, revealed Resident 29 .presents with complaints of constellation of symptoms including right leg, right knee, and right hip pain that she has had for more than 3 months but has increased over the last day or so. She coordinates this with increasing urination and dysuria. In addition this week the patient's narcotic dose apparently was dropped in half and since that time the patient has had increasing pain in her back and legs. The patient tells me that the initial injury to her lower back was approximately 3 months ago and was worsened by her underlying scoliosis. The Discussion/Course section revealed no new fractures and The patient was aggressively treated upon arrival and underwent a full diagnostic workup. The patient did receive IV [intravenous] fluids and medications here in the department. The patient felt much better. The patient's primary concern was that she wanted to have her narcotics return back to where they were before. I talked with [physician from facility] and he will contact them back and readjust her medications back to where she had been. A Nurse Practitioner (NP) note dated 8/26/22, revealed that resident 29's [MEDICATION(S)] had been changed to every 12 hours and was in pain over the weekend. The NP wrote she went to the hospital to have her [MEDICATION(S)] increased to every 6 hours, she stated that worked much better for her. The MAR for September 2022 revealed the following: a. Acetaminophen 650 mg three times per day were not administered on 9/6/22, 9/7/22, and 9/8/22 because the Drug/Item was unavailable and on order. b. [MEDICATION(S)] patch adhesive patch 5% topical once per day was not administered on 9/1/22, 9/2/22, 9/26/22, and 9/27/22 because the Drug/Item was unavailable and needed to order more. The MAR for September 2022 further revealed that resident 29 was administered [MEDICATION(S)] on 9/25/22 at 10:27 PM, and was not administered the next dose until 3:45 AM. [Note: Resident 29 stated she wanted her [MEDICATION(S)] around 2:00 AM and it was not administered until 1 hour and 15 minutes after the time she was allowed to have it.] On 10/3/22 at 11:57 AM, an interview was conducted with the ADON. The ADON stated if the medication was not available then it was because the pharmacy did not have a supply. The ADON stated medications like [MEDICATION(S)] were in the Pyxus system and he was not sure why the medication was not administered on 8/9/22, because there was always a nurse at the facility. The ADON stated when a resident was in pain and the pain medications and gels were not available, then the pain would be increased. 2. Resident 25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 12:32 PM, an interview was conducted with resident 25. Resident 25 stated she saw a physician once at the facility, who came into her room and said how are you and looked at her. Resident 25 stated she had not seen one since. Resident 25 stated she was not able to tell the physician what she needed. Resident 25 stated she had asked for a referral to the pain clinic because she needed a shot in her lower back. Resident 25 stated she had pain in her lower back and the shot really helped her pain. Resident 25's medical record was reviewed on 9/29/22. An admission MDS dated [DATE], revealed resident 25 had a Brief Interview of Mental Status score of 11 which indicated moderate cognitive impairment. The MDS further revealed that resident 25 did not have scheduled pain medication but had pain medication as needed. Resident 25 did not have non-medication interventions for pain. The MDS revealed that a pain assessment interview should be conducted and there was no pain according to the resident interview. A care plan with a problem start date of 7/19/22, and created on 7/31/22, revealed resident 29 was at risk for pain secondary to limited mobility. The goal was resident 25 would not have any unaddressed pain through the next review. The approaches included education on new prescribed medications, monitor for side effects, medications as prescribes, monitor pain as prescribed, and offer non-pharmacological approaches to pain management. A physician's note dated 8/15/22 at 10:35 AM, revealed resident 25 had chronic back pain and to refer to a local pain clinic physician. Resident 25 wished to continue to be treated with her back pain at a pain clinic. Otherwise her medical conditions were well controlled at this time. An NP note dated 9/1/22 at 7:16 AM, revealed [Resident 25] is seeing today to follow up on her back and lake (sic) pain. She states that she still would like to see a physician who could do injections to her back as she states she will have weakness in her lower extremities. An NP note dated 9/21/22 at 3:52 PM, revealed, Subjective: [Resident 25] is seen today for a follow up visit. She states she continues to have pain in her back, appointment with pain specialist is pending. She denies any increased numbness or tingling to her lower extremities. The treatment plan was Chronic Pain Syndrome - Continue Tylenol - Refer to spinal interventions or similar for spinal injections. An NP note dated 9/27/22 at 8:05 AM, revealed SUBJECTIVE: [Resident 25] is in today at her request wanting to follow up on an appointment for spinal injections. Discuss this with facility staff, who have been working to make appointments. She said she has done this for many years, and reports that it helps so that she can ambulate better. She reports she would still like to pursue this. The treatment plan was Chronic Pain Syndrome - Continue Tylenol - Refer to spinal interventions or similar for spinal injections. Progress notes revealed the following entries regarding resident 25 complaining of pain: a. On 8/5/22 at 11:22 AM, resident 25 experiencing back pain from physical therapy. Administered 400 mg of ibuprofen. b. On 8/16/22 at 4:05 PM, resident 26 complaining often of back and hip pain, worried that she would not be able to go to the pain clinic. Resident 25 was counseled that the physician was working on getting her to a pain clinic. Resident 25 had chronic pain treated by another pain clinic in another city. c. On 8/24/22 at 12:55 PM, resident 25 continues to complain of back and hip pain but ointment seems to help when applied. Resident 25 was having a hard time reaching things off the floor because of her keen pain. The MAR for September 2022 revealed pain monitoring twice daily. The pain scale was 0 to 8 with non-pharmacological interventions documented. On 9/28/22 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated resident 25 had [MEDICATION(S)] Sodium for topical cream application. RN 3 stated she applied the cream to resident 25. On 9/28/22 at 10:00 AM, an interview was conducted with Restorative Nursing Assistant (RNA) 1. RNA 1 stated resident 25 complained of pain and preferred to use a walker because her knees and ankles gave out when she walked. RNA 1 stated resident 25 had pain in her knee and had complained maybe two to three times to her about pain. On 10/3/22 at 12:10 PM, an interview was conducted with the ADON. The ADON stated resident 25 complained of back pain and had a pain cream for her back. The ADON stated that resident 25 did not have other pain medications but nurses had standing orders for Tylenol that she could have every 6 hours. The ADON stated there should be information regarding standing orders in an Agency binder at the nurses station to inform agency staff. On 10/3/22 at 2:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 25 did not have an appointment with a pain clinic. The DON stated that the transportation director was trying to get an appointment at the pain clinic but had not been able to. 3. Resident 45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 10:57 AM, an interview was conducted with resident 45. Resident 45 stated that she had pain in the left foot. Resident 45 stated that she wrapped the foot herself with an ace bandage to help alleviate the pain. Resident 45 stated that the foot pain had been present since May. Resident 45 also reported chronic pain all over her body with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 45 appeared calm, no facial grimacing noted, and no outward signs and symptoms of pain were noted. Resident 45 never stated their current pain score when asked multiple times. Resident 45 stated that they were taking [MEDICATION(S)], [MEDICATION(S)] 5 mg every 6 hours, and a non-steroidal anti-[CONDITION(S)] drug for pain relief. Resident 45 stated that they had their pain managed by an outside provider at a pain clinic. Review of resident 45's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. Acetaminophen tablet 325 mg, give 2 tablets (650 mg) by mouth every 6 hours as needed (PRN) for pain - Not to Exceed 3 gram in 24 hours from all sources. The order was initiated on 8/1/22. b. [MEDICATION(S)] ([MEDICATION(S)]) - Schedule III patch, apply 20 micrograms (mcg)/hour (hr) transdermal patch once a week. Take one transdermal patch to a different site each week prn pain. Remove old patch before applying new one. Special Instructions: per pain clinic [name of provider] will be in charge of controlling and refilling all pain medication. The order was initiated on 9/2/22. c. [MEDICATION(S)] ([MEDICATION(S)]-acetaminophen) tablet 10-325 mg, give 10-325 mg by mouth every 4 hours PRN for pain. Special Instructions: per pain clinic [name of provider] will be in charge of controlling and refilling all pain medication. The order was initiated on 8/30/22. d. [MEDICATION(S)] tablet 600 mg, give one tablet by mouth three times a day. Special Instructions: per pain clinic [name of provider] will be in charge of controlling and refilling all pain medications. The order was initiated on 9/2/22. e. [MEDICATION(S)] tablet 7.5 mg, give one tablet by mouth one time a day. Special Instructions: per pain clinic [name of provider] will be in charge of controlling and refilling all pain medications. The order was initiated on 9/3/22. Review of resident 45's September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . It should be noted that the [MEDICATION(S)] patch was not available the entire month of September, and resident 45 did not have one dose administered since the medication was ordered. The [MEDICATION(S)] 10-325 mg every 4 hours was administered 147 times out of 174 opportunities during September 2022. The [MEDICATION(S)] was documented as somewhat effective for 14 of the documented administrations, and 31 of the documented administrations were for left foot pain. Review of resident 45's progress notes revealed the following: a. On 6/27/22 at 6:39 AM, the note documented, Narcotics were found in pts [patients] room. Pt states that they are the [MEDICATION(S)] that was administered by NOC [night] shift this morning. Nurse verified that they were [MEDICATION(S)]. Pt stated that she was refusing to take the [MEDICATION(S)] until she got her [MEDICATION(S)]. Administered both [MEDICATION(S)] and [MEDICATION(S)] per MD [Medical Director] orders. b. On 7/1/22 at 5:59 PM, the note documented, Pt. constantly complaining telling staff that she is upset that her MRI [magnetic resonance imaging ] on her L [left] foot was cxl [canceled] even after nurse explained twice why it was. Notified pt. that hospital was called, note was sent to physician in box and waiting for clinical note to be filled out. Pt. also asked for print out of all her meds [medications]. Was given. She requests physician to see her to change pain meds because they are not working. c. On 7/8/22 at 12:24 PM, the note documented, Walked in the room to give the patient her noon meds. Pt. stated she is upset that she is on [MEDICATION(S)] for anxiety instead of [MEDICATION(S)]. She is also upset that she has still not had her MRI. Her and her mother stated that they feel that we are not working on doing what we need to do to take care of her foot. I told her that we are doing everything we can to get an MRI approved through the insurance and scheduled. They stated that they don't believe that we are. I assured her that we are doing everything to care for her needs. d. On 7/9/22 at 2:25 PM, the note documented, I called [name of pharmacy] to follow up on the patients [MEDICATION(S)] RX [prescription]. They told me that they accidentally made a discrepancy with the amount that they put in the computer for that medication. They said that they would text the DON of the facility and explain the mistake that they made on their end. They said that they would charge the facility until they can straighten out the error with the patients insurance and then refund us for what they change (sic) us on this medication. They will send it to us asap [as soon as possible]. e. On 7/10/22 at 1:35 PM, the note documented, Pulled two [MEDICATION(S)] from the pixus while waiting on order from the pharmacy to come through. f. On 8/10/22 at 7:56 PM, the note documented, pt still refusing all meds except narcotics and [MEDICATION(S)], copies made of mri report from august 4, 2022 dx [diagnosis] of well defined 3 cm [centimeter] [CONDITION(S)] in left foot and biopsy to be scheduled, pt states another follow up end of this week g. On 8/12/22 at 1:40 PM, the note documented, Pt. returned from doctor [name omitted] for f/u [follow-up] MRI on L foot. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She has atrophy of musculature L leg. No external signs of trauma. MRI shows arthritis & [CONDITION(S)] but these do not seem to be the main cause of pain. Physician states he feels she has CRPS [complex regional pain syndrome]. New Orders: Return to [name of pain clinic omitted] for CRPS Evaluation & Treatment. h. On 8/20/22 at 7:49 AM, the note documented, Notified physician/NP on 8/18 [22] that pt. wanted to meet with her to reevaluate her meds and get [MEDICATION(S)] d/c [discontinued] and get back [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] for breakthrough pain, and to get her [MEDICATION(S)] scheduled instead of prn. Physician stated no. Notified pt. of physician answer. Pt. was verbally upset. i. On 8/24/22 at 12:48 PM, the note documented, that resident 45 had two prescriptions from the pain clinic, one for [MEDICATION(S)] 20 mcg/hr transdermal patch weekly, dispense 4 patches and [MEDICATION(S)] 10-325 mg tablet every 4 hours as needed for pain, dispense 180 tablets. The note documented that the pharmacy had reported that Medicaid would only authorize 7 tablets to be dispensed initially, then afterwards they would allow more. The pharmacy reported that the [MEDICATION(S)] needed a prior authorization. The NP was notified and replied that resident 45 needed to go through the pain clinic provider for all medication refills and prior authorizations. The nurse notified the DON that the order could not be entered into the computer due to the pain clinic provider's information not being available. The pharmacy sent a prior authorization notice to the pain clinic provider. j. On 8/25/22 at 4:59 PM, the note documented, at this time ordered with original rx from pain clinic [name of provider omitted]. [MEDICATION(S)] transdermal patch and [MEDICATION(S)] to begin after midnight with a start date of 8/26/2022 and when available from pharmacy the nurse is to DC [discontinue] [MEDICATION(S)] STAT [immediately] r/t [related to] new pain rx, no refills available and pt to f/u [follow-up] monthly with pain dr [doctor]. k. On 8/28/22 at 5:03 PM, the note documented, [MEDICATION(S)] patch that was ordered 8-25 [22] with [MEDICATION(S)] from pharmacy still has not arrived ([MEDICATION(S)] has arrived) and [MEDICATION(S)] cream ordered at this time from pharmacy r/t not on med cart but order in emar [electronic medication administration record], pt has multiple behavior r/t she wants all her old pain rxs [prescriptions] reinstated as well as the pain drs orders and educated with new orders came to dc [discontinue] old pain orders, pt unhappy and cont [continue] to have multiple behavior issues she states are r/t pain constantly and cont to refuse all other routine regular meds besides narcotivs (sic). l. On 8/29/22 at 9:45 AM, the NP note documented, . is seen today to followup on her pain. She was seen by pain management who changed her pain medication regimen. Everything previously ordered for pain from the facility was discontinued which made [resident 45's name] very upset. She has been very verbal and unkind to staff demanding her medications. Discussed with her her pain needs are to be managed by pain management. She also has continued to complain of pain to her L foot. MRI completed, [CONDITION(S)], referred to podiatry for further evaluation/biopsy. m. On 8/30/22 at 10:52 AM, the note documented, The pt's pain clinic nurse called me this morning at 0830 [8:30 AM], and told me that i needed to give the pt her [MEDICATION(S)] 3x [times] a day, and her [MEDICATION(S)] 1x a day. Went and talked to [DON name omitted], because I was unsure of what was going on, [DON name omitted], informed me, [NP name omitted] stopped all prescriptions due to the changed medication regimen. [DON name omitted], advised me to call the pain management clinic and get written orders, then let [NP name omitted] review them and decide whether or not they should be added to the pt's current medication regimen. Called [pain provider's name] clinic and asked to speak to him, or one of the nurses, and they were all in clinic and unavailable. I left a message with [receptionist name omitted], the receptionist, that I need written orders for the facilities (sic) provider to review. n. On 9/2/22 at 4:00 PM, the note documented, Spoke w/ [with] [name of pharmacy] per pt. request to see why Butran patches had not arrived, and to get [MEDICATION(S)] and [MEDICATION(S)] back. Facility physician states pt. needs to go through pain clinic. Tried calling [name of] Pain clinic about meds and they were closed . states they were supposed to get a prior auth [authorization] for Butran and instead d/c it. Notified them of the written order and put it back in computer. They stated it was reactivated on their side as well. notified pt. of status. o. On 9/8/22 at 8:38 AM, the NP note documented, . is seen today to follow up on her anxiety and depression. She is laying in bed, said she's waiting for her [MEDICATION(S)]. All of her pain management is now being completed by [name of pain provider omitted], who manages her [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and any other pain related medication. She asked me today about getting a [MEDICATION(S)] patch, again explain to her that this would have to be approved through [name of pain provider]. She states that her anxiety has been improved since she started back on her pain medication, she also states her depression is better. Resident 45's pain scores for August 2022 were reviewed. Out of 126 recorded pain scores, on a scale from 1 to 10, the resident averaged a score of 8 out of 10. No documentation could be found of a pain assessment for resident 45. On 9/26/22, a care plan for chronic pain was initiated. Interventions identified were educate the resident on newly prescribed medications; monitor for side effects of pharmacological pain interventions and notify physician; monitor pain as prescribed; and offer non-pharmacological approaches to pain management. On 9/27/22 at 10:22 AM, an interview was conducted with RN 4. RN 4 stated that she was an agency nurse. RN 4 stated that this was her first full shift at the facility and she had worked one other time for half a shift. RN 4 stated that she had noticed that all the staff today were agency. On 9/27/22 at 1:28 PM, a follow-up interview was conducted with RN 4. RN 4 stated that when she came on shift she was handed a piece of paper to write down any medications that were out of stock. RN 4 stated that she was not informed of the process for ordering medication for a resident. RN 4 stated that she thought the facility had a Pyxis machine, that is how it is at all the facilities. RN 4 stated that she did not have an access code for the Pyxis dispensary, only the facility nurses were granted access. RN 4 stated that she had not been provided any instructions at this facility. On 9/27/22 at 10:03 AM and again at 1:57 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was an agency nurse, and had worked at the facility prior to becoming an agency staff. LPN 1 stated that if medications were running low they would order them from the pharmacy. LPN 1 stated that when the blister pack had only the last row or column remaining she would pull the reorder sticker and place on the refill sheet, or check to make sure that it was not too early to refill the medication. LPN 1 stated that she had the ability to reorder some medications through the electronic medical records, but not for all residents. LPN 1 stated that she could also fax the order to the pharmacy. LPN 1 stated that she could also call the pharmacy with any orders. LPN 1 stated a Pyxis was available to pull medication from, and that she had the ability to access the Pyxis. LPN 1 stated that if medications were not available she would document in the MAR, and include a note that stated she contacted pharmacy. LPN 1 stated that medications would usually arrive at the facility the same day if it was scheduled for a refill, they will put it on the next run. LPN 1 stated sometimes if the medication was not due to be reordered then it would not be refilled. LPN 1 stated that occasionally medications were misplaced or located in another cart and she would have to locate the medication to administer it. On 9/27/22 at 2:40 PM, an interview was conducted with the DON. The DON stated that the process for reordering medication was to pull the reorder stickers from the blister pack, order through the electronic medical records, or call the pharmacy directly. The DON stated that the electronic medical records reorder was available for all residents, and that they had been training the agency staff on reordering medication for the last two weeks. The DON stated that medications were available in the Pyxis system, but not all staff had access to the medication dispensing system. The DON stated that the pharmacy was coming out this week to give access to all licensed nurses at the facility, including the agency staff. The DON stated that there was usually a nurse at the facility that had Pyxis access and the ADON lived nearby and could run over to get medication from the Pyxis for staff. The DON stated that since she had been at the facility, which was the last two weeks, she had made sure that someone was on shift who had access to the Pyxis. The DON stated that staff should contact the pharmacy to obtain a refill, and notify the provider if a medication was not administered. The DON stated that the documentation was located on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that she had worked a couple of shifts and the pharmacy had medication delivered within two hours yesterday. The DON stated that the licensed nurses should contact the pharmacy to obtain a refill or contact the provider to obtain a new prescription. On 10/3/22 at 11:04 AM, an interview was conducted with the ADON. The ADON stated that resident 45 had her own pain provider. The ADON stated that when resident 45 was first admitted , the facility provider was managing the pain medications. The ADON stated that resident 45 did not like the regimen provided by the facility physician so she went to her own pain clinic provider. The ADON stated that the pain clinic provider would send the pain medication orders to the facility for them to administer. The ADON stated that the pain clinic provider ordered [MEDICATION(S)] and [MEDICATION(S)] for resident 45. The ADON stated that he was not familiar with the [MEDICATION(S)] patch. The ADON stated that once they received the order they sent it directly to the pharmacy. The ADON stated that the coordination of care for resident 45's pain management was to call the pain clinic directly to ask questions. The ADON stated that the facility providers wanted the staff to refer to the pain clinic provider for resident 45's pain medication management. The ADON stated that if a medication needed a prior authorization, such as the [MEDICATION(S)], they should have contacted the pain clinic for the authorization. The ADON stated that documentation of the communication with the pain clinic should be in a progress note. The ADON stated that staff should have documented any

Based on observation, interview, and record review, it was determined, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for 13 out of 34 sampled residents, resident's complained of not having enough staff to meet there needs, staff complained there were not enough staff to complete their job duties, residents laboratory (lab) results were not followed up with after a urinalysis (UA) was completed, showers were not completed, residents administered their own medications because there were not enough staff, there were no grievances, residents sustained falls, resident's complained of pain, and medications were not administered according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: 1. On 9/29/22 at 11:00 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated when a lab value or UA was ordered, she would contact the Nurse Practitioner (NP), an order was placed in the residents electronic medical record, and the lab company was contacted. RN 3 stated that the results of the laboratory were faxed to the facility or the lab contacted the NP. RN 3 stated that sometimes the lab did not send results so the nurse had to follow up with the lab. RN 3 stated if the nurse who ordered the labs was gone for a week the nurse on shift may not be aware of what labs had been ordered and which results had been sent to the facility. RN 3 stated the lab process had resulted in missed lab results. RN 3 stated that she tried to document in the progress notes when a lab was obtained. RN 3 stated on 8/19/22, she obtained a UA for resident 29 because she was probably acting confused or had a symptom like pain or burning when urinating. RN 3 stated she did not know if the physician was notified of the UA results. RN 3 stated she did not know if there was follow up because if it was not written in the medical record it was not done. RN 3 observed the UA results from 8/19/22, and stated it was a 6 on a scale of 1 to 7 which indicated resident 29 had an infection. RN 3 stated the results revealed resident 29 had a urinary tract infection that needed to be treated with [MEDICATION(S)]. RN 3 stated that things get very busy and I forget to get everything done. RN 3 stated there were not enough staff in the building. RN 3 stated there needed to be a nurse for each hallway because it's just crazy. RN 3 stated It's so stressful for me, because at the end of the day I sent the order and did not follow up on it and did not get treatment. RN 3 stated there were so many things to do and follow up on and with almost 40 residents it was impossible to get everything done. RN 3 stated that charting did not get done. [Cross Reference F690 and F773] 2. On 9/26/22 at 10:31 AM, an interview was conducted with resident 22. Resident 22 stated that her shower days were every Tuesday, Thursday, and Saturday. This surveyor observed a sign in resident 22's room with the posted shower days. Resident 22 stated that sometimes she did not get showered due to there not being enough staff. On 9/26/22 at 12:32 PM, an interview was conducted with resident 25. Resident 25 stated she should get a shower today, but did not get one because staff did not show up. Resident 25 stated she got a shower on 9/24/22, but did not have one for two weeks prior to that. Resident 25 stated she took showers by herself because she became very disgusted by herself. On 9/29/22 at 12:34 PM, an interview was conducted with CNA 7. CNA 7 stated that the facility was short on staff. CNA 7 stated that she had seven showers to complete today with two CNAs on the 100 and 200 hallway. CNA 7 stated that five of the seven residents were a two person extensive assistance. CNA 7 stated that the 100 and 200 hallway did not have a shower CNA and sometimes the showers got missed. CNA 7 stated that two showers had been completed today and one resident refused. CNA 7 stated that her goal was to get three showers completed each day. CNA 7 stated if a shower was missed she would pass it on in report and see if the next shift could complete the showers. CNA 7 if the next shift could not the showers completed she would try and complete the showers the next day. CNA 7 stated that resident 22 was a set up for showers. CNA 7 stated that after she set resident 22 up for a shower she would leave and give resident 22 privacy. CNA 7 stated that resident 22 needed assistance to wash her back and get dressed. CNA 7 stated that resident 22 was very involved in her care. CNA 7 stated that the shower sheets were getting missed because a lot of the staff did not know that they had to complete a shower sheet. CNA 7 further stated that the shower book did not have any shower sheets available and staff did not have a master copy to make copies. CNA 7 stated that she had a hard time answering resident call lights when there were only two CNAs staffed because most of the residents were a two person assistance. CNA 7 further stated the willingness of other staff to answer call lights was also a concern. [Cross Reference F676] 3. On 9/26/22 at 12:32 PM, an observation was made of resident 25. Resident 25 had an inhaler in a box on her over bed table. Resident 25 was interviewed. Resident 25 stated she needed the inhaler off and on. Resident 25 stated she had the inhaler in her purse and brought it out so she had it when she needed it. Resident 25 stated she could not rely on staff to provide the inhaler when she needed it because there were not enough staff. [Cross Reference F554] 4. The grievance log was reviewed. There was a grievance dated 5/2/22, regarding call lights. There were two grievances dated 9/12/22, regarding call lights not being answered and meal cards not being followed. There were no grievances between 5/3/22 through 9/12/22. The Administrator provided Resident Council Minutes dated 4/5/22, 5/3/22, 6/7/22, 7/12/22, 8/2/22, and 9/12/22. The Resident Council Minutes dated 9/12/22, revealed long call light times and there was no follow-up documented. On 10/3/22 at 9:49 AM, an observation was made of resident 16 talking to Physical Therapy Assistant (PTA) 1 and Occupational Therapist (OT) 1. Resident 16 stated the facility was so short staffed on Saturday night that a CNA came in and told him she did not have time to change him. Resident 16 stated a nurse came in later and he told the nurse that if he was not changed, he would call the police. Resident 16 stated he told staff it was their choice on what he did. Resident 16 stated the CNA came in and changed him very quickly. Resident 16 stated he hated to be that kind of a guy, but he had no other choice. Resident 16 stated he was looking at other facilities because of staffing. On 10/3/22 at 12:31 PM, an interview was conducted with PTA 1. PTA 1 stated she did not remember talking to resident 16. After being reminded of the conversation, PTA 1 stated that resident 16 stated there was one CNA and one nurse working. PTA 1 stated resident 16 was worried because he had to teach the CNA how to use the Hoyer lift to transfer him. PTA 1 stated resident 16 said when it got to the point that he did not feel safe he would call the police. PTA 1 stated resident 16 said he needed to have a brief change, and someone went in to change him but said they needed to come back. PTA 1 stated that resident 16 said the nurse came into his room and he told the nurse if he did not get changed, he would call the police. PTA 1 stated she had not reported the information to management. PTA 1 stated she was planning on talking to the Director of Nursing (DON) about it. On 10/3/22 at 12:31 PM, an interview was conducted with OT 1. OT 1 stated that resident 16 claimed that every time that he had a new CNA working with him, the CNA did not know how to transfer him. OT 1 stated if resident 16 was not in the exact right spot then he did not think the CNA knew what they were doing. OT 1 stated some of resident 16's complaints might be warranted. OT 1 stated resident 16 was very sensitive to any new staff. OT 1 stated there had been times when staffing was poor over the weekends, and it feeds into the fact that it had not been fixed and might not be going away. OT 1 stated he usually talked to the Resident Advocate (RA), DON, and Administrator and the concerns were discussed in the morning meeting throughout the day. [Cross Reference F585] 5. On 9/26/22 at 2:33 PM, an interview was conducted with resident 53. Resident 53 stated he was transferring from the wheelchair to bed and his ankle gave out and he fell to the ground. Resident 53 stated his left shoulder always hurts but it hurt more since the fall. Resident 53 stated he was waiting for staff but staff did not come. Resident 53 stated he waited for 15 to 20 minutes and was tired from returning from a doctors appointment so he transferred himself. Resident 53 stated it took 20 to 30 minutes for someone to come and he did not want to wait. On 9/28/22 at 9:45 AM, an interview with CNA 2 was conducted. CNA 2 stated that there was not enough staff at the facility to prevent residents from falling. CNA 2 stated that the facility often staffed two or three CNAs for the entire building, which was not enough to adequately supervise residents who were a fall risk. CNA 2 stated that in addition to not having enough staff, communication between nurses and CNAs was lacking, and CNA's were often not aware if resident were a fall risk. On 9/28/22 at 10:00 AM, an interview with CNA 8 was conducted. CNA 8 stated that on some shifts there were only two CNAs in the facility. CNA 8 stated that the facility needed more CNAs to supervise residents who were a fall risk because there was not enough staff to prevent residents from falling. On 10/3/22 at 11:26 AM, an interview was conducted with CNA 9. CNA 9 stated there was a CNA chart that had which residents fell and which residents were a high fall risk. CNA 9 stated the residents had signs inside their rooms and it was in the electronic charting system. CNA 9 stated she had no idea how Agency staff knew a residents transfer status or if the resident was a fall risk. CNA 9 stated Agency had a binder but she did not know what was in the binder. CNA 9 stated resident 53 required one person assistance with transfers, bed mobility, and showering. CNA 9 stated there was no reason that three people would be providing bed mobility. [Cross Reference F689] 6. On 9/26/22 at 10:47 AM, an interview was conducted with resident 45. Resident 45 stated she had a [CONDITION(S)] and was transferred to the hospital. Resident 45 stated that she was having issues with staffing, and getting assistance. Resident 45 stated that she had a stress induced [CONDITION(S)]. Resident 45 also stated that she had pain in the left foot. Resident 45 stated that she wrapped the foot herself with an ace bandage to help alleviate the pain. Resident 45 stated that the foot pain had been present since May. Resident 45 also reported chronic pain all over her body with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 12:32 PM, an interview was conducted with resident 29. Resident 29 stated she was unable to stand her pain last night and was groaning. Resident 29 stated there was no nurse on her hallway from 12:00 AM until 6:00 AM. Resident 29 stated she needed [MEDICATION(S)] at 2:00 AM but the nurse told resident 29 it was not her problem because she would not be there. Resident 19 stated the nurse continued to tell her she would not be the nurse to administer the [MEDICATION(S)]. Resident 29 stated she had scoliosis that made a hole in her spine and she has no control over her left lower extremities. Resident 29 stated she needed her [MEDICATION(S)] regularly because her pain never quit. Resident 29 stated her [MEDICATION(S)] was not administered at 2:00 AM when she wanted it. Resident 29 stated that her pain was at a 10 and she was crying and sick to her stomach. Resident 29 stated the nurse administered three pills to her early in the morning that morning and she did not know what the medications were. [Cross Reference F697] 7. On 9/26/22 at 10:32 AM, an interview was conducted with resident 22. Resident 22 stated that staff were not bringing her medications timely. Resident 22 stated that she would ask for her anxiety medication and it would take along time for the staff to bring the medication. Resident 22 stated the staff would tell her there was only one nurse. Resident 22 stated that some staff were better than others. Resident 22 stated that she did not always get her diabetic medications before meals. On 9/26/22 at 12:32 PM, an interview was conducted with resident 29. Resident 29 stated she was unable to stand her pain last night and was groaning. Resident 29 stated there was no nurse on her hallway from 12:00 AM until 6:00 AM. Resident 29 stated she needed [MEDICATION(S)] at 2:00 AM but the nurse told resident 29 it was not her problem because she would not be there and there was not a nurse to administer the medication. Resident 29 stated she had scoliosis that made a hole in her spine and she had no control over her left lower extremities. Resident 29 stated she needed her [MEDICATION(S)] regularly because her pain never quit. Resident 29 stated her [MEDICATION(S)] was not administered at 2:00 AM when she wanted it. Resident 29 stated that her pain was at a 10 and she was crying and sick to her stomach. Resident 29 stated the nurse administered three pills to her early that morning and she did not know what the medications were. [Cross Reference F755 and F757] 8. On 10/3/22 at 11:26 AM, an interview was conducted with CNA 9. CNA 9 stated there was a CNA chart that had which residents fell and which residents were a high fall risk. CNA 9 stated the residents had signs inside their rooms and it was in the electronic charting system. CNA 9 stated she had no idea how Agency staff knew a residents transfer status or if the resident was a fall risk. CNA 9 stated Agency had a binder but she did not know what was in the binder. CNA 9 stated staffing was a hit and miss. CNA 9 stated she was unable to complete showers, rounds were usually over the two hour mark, vital signs were hard to get done, sometimes she was unable to get the meal trays out of the rooms, and garbages were not taken out till the end of shift. CNA 9 stated that she talked to the old DON and Administrator about staffing and they were very aware of the problem. CNA 9 stated she was told they were working on it. CNA 9 stated she talked to the CNA coordinator, who did CNA scheduling because she left her shift and there was only one CNA for the whole building and the CNA was on the rehabilitation side. CNA 9 stated that CNA was agency and the CNA was very upset and said she was leaving also. CNA 9 stated there were complaints from residents regarding staffing and she was not sure what to do with that information. CNA 9 stated there was a nurse and four CNA's that were very upset and filed complaints with the state survey agency regarding staffing because management was not listening to them. 9. On 9/27/22 at 12:01 PM, an interview was conducted with RN 5. RN 5 stated she had worked at the facility for two years and was currently an agency nurse. RN 5 stated she thought there were three to four CNAs for the 300 and 400 hallways and one and half nurses during the day. RN 5 stated staffing was the reason she left and started working for an agency. RN 5 stated with the staffing at four CNA's on the 300 and 400 hallways she felt like they were able to give proper care, rather than just give care. RN 5 stated the 300 and 400 hallways needed four CNAs and a shower CNA to be ideal. RN 5 stated that when there were only two CNA's for the 300 and 400 hallway, she was unable to obtain vital signs or complete charting because the residents came first. 10. On 9/28/22 at 9:29 AM, an interview was conducted with RN 3. RN 3 stated that Staffing is a mess. RN 3 stated staffing had gotten better in the last few weeks. RN 3 stated the previous Administrator felt that one nurse and one CNA was enough for the full facility at night. RN 3 stated not enough staff caused a lot of issues, like resident's were not getting changed and getting butt rashes. RN 3 stated one nurse was not enough. RN 3 stated she did not have enough time to complete a full head to toe assessment on everyone, pass medications, and it was impossible to do everything each day. RN 3 stated on the 300 and 400 hallways the work load was more manageable but she still did not have enough time to adequately care for residents herself. On 9/29/22 at 11:00 AM, a follow up interview was conducted with RN 3. RN 3 stated things get very busy and she forgets to get everything done. RN 3 stated a nurse was leaving at noon and going to the other side. RN 3 stated she still had a ton of things to note. RN 3 stated there was not enough staff, and there needed to be one nurse for the 300 hallway and one nurse for the 400 hallway. RN 3 stated it's just crazy. RN 3 stated It's so stressful for me, RN 3 stated I just have so many things to note and follow up on but with almost 40 residents it's impossible to get everything done especially charting. 11. On 9/26/22 at 11:20 AM, an interview was conducted with resident 16. Resident 16 stated there were just not enough staff. Resident 16 stated when using agency it was hard for them to know the residents routine and what they need. Resident 16 stated it was hard because you have a lot of people working hard to do their job and then one to two people who were just dead weight. Resident 16 stated there have been times when he pulled the call light and it was on for two hours before he even get a response. Resident 16 stated when he has a bowel movement, he will push his call light and sometimes he had to sit in his feces for hours. Resident 16 stated usually the day crew was very good, the night crew needed a lot of help. Resident 16 stated there was absolutely no reason that someone hit their call light and wait for two hours. Resident 16 stated it made him feel unvalued, like a commodity, it was like staff were trying to do the minimum to not get fired. Resident 16 stated that the day shift staff changed resident briefs and did vital signs because night shift did not do their jobs. Resident 16 stated just sitting here for 15 months hearing it will be better by three different Administrators and it gets better for a little while and then it goes back. Resident 16 stated he did not trust management because issues were not being solved. 12. Resident 29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 12:32 PM, an interview was conducted with resident 29. Resident 29 stated the 300 and 400 hallway did not have a nurse last night from 12:00 PM until 6:00 AM. Resident 29 stated that there was only one CNA on duty one night so she was unable to get changed. Resident 29 stated she called the police one night because there were not enough staff. Resident 29 stated that the Assistant Director of Nursing would not allow the police to talk to her. Resident 29 stated that the police told him to wait outside and she talked to the police. Resident 29 stated that her stomach gets upset easily and when there were not enough staff her stomach feels worse. Resident 29's medical record was reviewed on 9/29/22. Resident 29's progress note revealed on 8/21/22 at 3:25 AM, . On the 1800-0600 [6:00 PM to 6:00 AM] shift, the CNA's went to do their rounds and the pt [patient] was wearing the same brief from the previous night, stamped 0425 am [4:25 AM] and when the CNA changed her, there was evidence of a BM [bowel movement], but not actual BM present, the pt wasn't cleaned well, and she was upset about it. 13. On 9/26/22 at 12:32 PM, an interview was conducted with resident 25. Resident 25 stated there were not enough staff to help her to the bathroom when she had to go. Resident 25 stated she has had bowel movements waiting for staff. Resident 25 stated it made her very upset. Resident 25 stated that the new Administrator had not introduced himself. Resident 25 stated Administration were the ones cutting nursing hours. Resident 25 stated she did not feel like she should have to pay since there were not enough staff to meet her needs. 14. On 9/26/22 at 11:00 AM, an interview was conducted with resident 38. Resident 38 stated there were not enough staff. Resident 38 stated she did not need help from staff very often, but other residents had bigger problems and needed help. Resident 38 stated resident 47 required more help because her mind did not work and she was going downhill. Resident 38 stated that sometimes temporary employees did not show up to work. Resident 38 stated it took a while for call lights to be answered. Resident 38 stated at night and on the weekend CNA's just sat around. Resident 38 stated there was one nurse for the 300 and 400 hallway. Resident 38 stated she should be administered medications at about 6:00 PM but did not get them till 10:00 PM because staff were not available. Resident 38 stated there was an emergency with another resident in the 300 hallway the other night and there was not a nurse around to administer her pain medications. Resident 38 stated the facility had been short staffed for a while and agency staff did not show. 15. On 9/26/22 at 2:09 PM, an interview was conducted with resident 36. Resident 36 stated that she had been told by staff that she had to wait an additional two hours for nausea medication because the facility was short staffed and a new admission came in. Resident 36 stated that she could request her nausea medication every two hours. Resident 36 stated that facility was always short staffed. On 9/29/22 at 12:34 PM, an interview was conducted with CNA 7. CNA 7 stated that most of the call lights for resident 36 were a request for a nausea shot. CNA 7 stated that she had never been on shift when resident 36 did not get a nausea shot. CNA 7 stated that sometimes resident 36 may have to wait because the nurse was with other residents. CNA 7 stated that sometimes it may be a little while before the staff were able to get to resident 36. CNA 7 stated that resident 36 has had to wait up to 45 minutes from request for a nausea shot. CNA 7 stated that the nurse may be busy or the staff put resident 36 off because she pushes the call light frequently. CNA 7 stated that there was a staffing issue. 16. On 10/3/22 at 11:58 AM, an interview was conducted with resident 1. Resident 1 stated that last night she had pressed her call light and waited for over an hour for staff to respond. Resident 1 stated while she was waiting for staff she went out to the hallway and yelled for help. Resident 1 stated when she got no response she called the facilities main telephone number to get help. Resident 1 stated that a gentlemen on the other side of the facility answered the phone and came to help her. Resident 1 stated that the staff member told her that he was the only CNA for the entire facility. 17. On 9/26/22 at 1:08 PM, an interview was conducted with resident 156. Resident 156 stated the facility was short staffed. Resident 156 stated that weekends were usually staffed with one nurse and one CNA. 18. Resident 23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/26/22 at 12:22 PM, an interview was conducted with resident 23. Resident 23 stated that the weekend staff were kind of stretched, with only one licensed nurse and two CNA's on shift. Resident 23 stated she had to wait two hours for pain medicine to be administered, and this occurred her last night. Resident 23 stated that there was just one nurse on shift. Resident 23 stated that the medication can only be administered every six hours and then she had to wait an additional two hours after that before it was administered. Resident 23 stated that her pain was located in the femur and feet. Resident 23 stated that no one could help me because they were so busy. Resident 23 stated that the pain was a 10/10, on a scale of 1 to 10. Resident 23 stated that it made her mad as hell, and no one provided help. Resident 23 stated that they have had to wait for assistance usually between 6:00 PM to 10:00 PM, and the last couple of nights it had been really bad. 19. On 09/27/22 at 10:03 AM, an interview was conducted with Restorative Nurse Assistant (RNA) 1. RNA 1 stated that she was the only RNA for the facility, and she worked Monday through Friday. RNA 1 stated that she was trying to work on getting the RNA program going. RNA 1 stated that she started providing RNA services at the beginning of September 2022, and prior to September they were working on rebuilding the program. RNA 1 stated that she began working at the facility in January 2022, and that there was not a RNA program until she began doing it. RNA 1 stated that in April or May 2022 there was one other RNA who was providing RNA services Monday through Friday. 20. On 10/3/22 at 9:06 AM, an interview was conducted with RN 6. RN 6 stated that she worked for an agency, and that this was the third shift at the facility. RN 6 clarified that this was her third shift working as an agency nurse period. RN 6 stated that she was an emergency room (ER) nurse and working agency in Long Term Care settings was new to her. RN 6 stated that when a resident had a change in condition she was not sure what the process would be, but she called the DON. RN 6 provided an example of a resident who had sustained a fall the prior day. RN 6 stated that the resident was on an anticoagulant and believed that they should be evaluated in the ER after the fall. RN 6 stated that they attempted to contact the resident's provider. RN 6 stated that they had left a voicemail for the NP, but never heard a response back. RN 6 stated that she then notified the DON and they agreed to send the resident to the hospital. RN 6 stated that the DON instructed her to document the incident in a fall report. RN 6 stated stated she would have liked to do a progress note, but that she did not know how to use the electronic medical records system. RN 6 stated that she was not provided any instructions on how to use the medical records system and she had not used it prior to coming to this facility. RN 6 stated that she had received no orientation to the facility. RN 6 stated she was provided the DON's phone number and login credentials for the electronic medical records. RN 6 stated that the previous nurse gave her the medical records website to login and access the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 6 stated that she would have liked to have had some sort of orientation. RN 6 stated that she did not know how to navigate beyond the MAR. RN 6 stated that she did not know how to access the resident's care plan until today when another nurse showed her. RN 6 stated she would have liked to know the patients diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 21. On 10/3/22 at 9:28 AM, an interview was conducted with CNA 2 and RN 8. CNA 2 stated that resident 7 was off of transmission based precautions (TBP) two days ago. CNA 2 stated that a stool sample was sent on Thursday, and they were waiting for results. CNA 2 stated that resident 7 had some stools that contained mucous. RN 8 stated that she was informed in report that resident 7 came off TBP two days ago, and that he was on precautions for Clostridioides difficile. RN 8 stated that she did not know how to look up lab reports in the electronic medical records. RN 8 stated that she worked for an agency company, just started at the facility yesterday, and was only shown how to access the MAR. RN 8 stated that this was the first time using this electronic medical records system. CNA 2 stated that none of staff were trained on the new electronic medical records system and they had been figuring out as they go. 22. Nursing and CNA schedules were provided by the facility Administrator for the previous 30 days. On 8/28/22, for the rehabilitation hallway (100 and 200 hallway) for the shift 6:00 AM to 6:00 PM, there were no CNA's scheduled. On 8/29/22, for the Long Term Care (LTC) 300 and 400 Hallway the CNA shift from 6:00 PM to 6:00 AM, was unassigned. On 8/30/22, for the LTC hallway the CNA shift from 6:00 AM to 6:00 PM, was unassigned. On 8/31/22, for the night shift for LTC hallway the CNA shift from 6:00 PM to 6:00 AM, was unassigned. On 9/2/22, for the LTC hallway there were two CNA's unassigned that day and one CNA unassigned for the rehabilitation hallway. The nursing shift from 6:00 PM to 6:00 AM, was unassigned. On 9/3/22, for the LTC hallway there were two CNA's unassigned. On 9/5/22, there was no CNA scheduled for the rehabilitation hallway from 6:00 PM until 6:00 AM. On 9/6/22, for the LTC hallway no CNA's were assigned to work from 6:00 AM to 6:00 PM. There was one CNA scheduled for the entire building from 10:00 PM to 6:00 AM. On 9/7/22, for the LTC hallway the CNA from 6:00 PM to 6:00 AM, was unassigned. There was one CNA scheduled from 10:00 PM to 12:00 AM. On 9/8/22, for the LTC hallway there was one CNA scheduled from 6:00 AM to 6:00 PM, and one CNA for the rehabilitation hallway. The shift for the 6:00 PM to 6:00 AM, the CNA was unassigned. The nursing position from 6:00 PM to 6:00 AM, was unassigned. There were no unassigned shifts from 9/18/22 through 9/30/22. On 10/1/22, there were two CNA's for the entire building scheduled from 10:00 PM to 6:00 AM. On 9/28/22 at 12:48 PM, an interview was conducted with the Administrator. The Administrator stated that he guessed an unassigned was picked up by a staff member but not written on the schedule. The Administrator stated that other staff members that filled in for CNA shifts were the RA, Housekeepers who were Nursing Assistants and other staff. The Administrator stated that he signed a contract with another agency service on 9/15/22, when he started as the Administrator. The Administrator stated there were not enough staff so that was his first thing as an Administrator to get better staffing.

Based on interview and record review it was determined, for 1 out of 34 sampled residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, a resident had expressed desires to die by refusal of treatment for diabetes and was not evaluated and seen by social services. Resident identifier: 20. Findings included: Resident 20 was admitted to the facility on [DATE] with diagnoses which included tinea cruris, repeated falls, [CONDITION(S)], hypertension, type 2 diabetes mellitus, [CONDITION(S)], multiple rib fractures, and [CONDITION(S)]. On [DATE], resident 20's medical record was reviewed. Review of resident 20's physician's orders revealed: a. [MEDICATION(S)] (insulin [MEDICATION(S)]) insulin pen; 100 unit/milliliter (mL); inject 35 units subcutaneously two times a day. The order was initiated on [DATE]. b. Blood Glucose Checks two times a day. The order was initiated on [DATE]. c. A regular diet was ordered on [DATE]. d. [MEDICATION(S)] capsule, delayed release 60 milligram by mouth one time a day for nerve pain. The order was initiated on [DATE]. On [DATE], a Pre-Admission Screening Applicant/Resident Review (PASRR) documented that resident 20 had medical diagnoses only and no psychiatric or intellectual disability diagnoses. On [DATE], a Provider Order for Life-Sustaining Treatment (POLST) order documented that resident 20's advance directives were do not attempt or continue any resuscitation. The medical interventions documented were Limited Additional Interventions: Treating medical conditions while avoiding burdensome measures. Medical care may include treatment of airway obstruction, bag/valve/mask ventilation, monitoring of cardiac rhythm, Intravenous (IV) fluids, IV antibiotics and other medications as indicated. On [DATE], the resident signed a Risk verses (vs.) Benefit form for a diabetic diet. The form listed the benefits of following the diet were controlled blood sugar, controlled weight, glycated hemoglobin (A1C) lab values within normal range, and increased energy. The risks of not following the diet were possible increased blood sugar and A1C, possible weight gain, complications such as retinopathy, [CONDITION(S)], and [CONDITION(S)], stroke, and lethargy. On [DATE], the resident signed a Risk vs. Benefit for a treatment refusal of a diabetic diet. It should be noted that no documentation could be found for a risk vs. benefit for the refusal of treatment of [CONDITION(S)]. Review of resident 20's progress notes revealed the following: a. On [DATE] at 10:50 PM, the nurse documented, At 2130 [9:30 PM] [resident 20] BG [blood glucose] level was high, we check it twice, I gave him 12 units of insulin and asked him if I could check it in 15 minutes. Twenty minutes later, a CNA [Certified Nurse Assistant] went to check him and he was rude to her. I was going to check on him, heard him and offered to check his BG. I pocked (sic) him but he did not bleed enough and he refused to get him blood glucose check. I educated him on the risks, he stated that he didn't care. b. On [DATE] at 10:35 AM, the nurse documented, . he yelled at me and refused to let me take his blood sugar. I explained the importance of taking insulin and he still declined and yelled at me to get out of his room. c. On [DATE] at 3:17 AM, the nurse documented, Pt [patient] refused insulin. Educated about the importance of diabetic management and still refused insulin. d. On [DATE] at 4:16 AM, the nurse documented, Pt has been refusing all medication and care regimens throughout the shift. Educated about the importance of regulating blood sugar levels with the use of insulin and antibiotic therapy. Pt has been presenting anger towards the staff. e. On [DATE] at 12:54 AM, the nurse documented, Patient stated that he is not taking any antibiotic or accepting any txs [treatments] today. He stated that the doctor were treating him as a [NAME] pig> he has refused to get his blood glucose checked, refused to take any insulin but he stated that he would the (sic) some long acting insulin in the morning. f. On [DATE] at 10:18 AM, the nurse documented that the wound physician educated resident 20 about his diabetes and the importance of keeping his blood sugars down, taking his medication, and eating a well balanced diet. g. On [DATE] at 2:36 PM, the nurse documented, Pt is noted refusing all medications besides IV abx [antibiotics]. Pt refused for BGL [blood glucose level] to be checked and is also refusing insulin. Notified MD [Medical Doctor]. h. On [DATE] at 5:01 PM, the nurse documented, Pts BGLs have been low these last couple of mornings. Yesterday it was 60 and today it was 52. Notified MD. Pt refused [MEDICATION(S)] this morning and refuses to lower the dose, says he wants to give it a couple of days. Notified MD. i. On [DATE] at 9:26 PM, the nurse documented, PT HAD LOW BG THIS AM. IT WAS REPORTED TO ME THAT PT HAD RECENT INCREASE OF [MEDICATION(S)] DOSE GIVEN BID [two times a day]. PT REFUSED TO LET ME CHECK BG BEFORE GIVIN (sic) HS DOSE OF [MEDICATION(S)]. IT WAS REPORTED TO ME THAT HE DID NOT EACH MUCH OF HIS DINNER. I ATTEMPTED TO EDUCATE THE PATIENT ABOUT WHY I WOULD LIKE TO CHECK HIS BLOOD SUGAR BEFORE GIVING THE HS [bedtime] DOSE. PT REFUSED THE GLUCOSE CHECK AND REFUSED HIS OTHER HS MEDICATIONS INCLUDING A PAIN MEDICATION WHICH HE REQUESTED STATING 'IF HE HAS TO BEG FOR HIS [MEDICATION(S)] HE WANTS NOTHING' I AGAIN ATTEMPTED TO EDUCATE HIM ON THE REASON FOR CHECKING HIS BLOOD SUGAR BEFORE GIVING A HIGH RISK MEDICATION. I ALSO ATTEMPTED TO HAVE HIM SIGN A RISK V BENEFIT DOCUMENT. HE ALSO REFUSED TO SIGN. j. On [DATE] at 10:09 PM, the nurse documented, Pt refused glucose check, stating 'I only get that twice a day and I already got it the second time today.' Nurse told pt that he didn't get his glucose checked twice today, just once, pt still refused. k. On [DATE] 9:15 PM, the nurse documented, Patient was rude and refused all his medications and treatments for the night. Nurse charted his refusal. 10 minutes later he came out and apologized to the nurse. He accepted his long [MEDICATION(S)] insulin, [MEDICATION(S)]. 35 unites (sic) was administered to thigh. His blood glucose was 153. l. On [DATE] at 2:29 PM, the nurse documented Pt would not wake up this morning for breakfast, tried to wake pt vigorously. Pt was drenched in sweat, whole bed was wet. Took pts BS [blood sugar] and BS was 42. Immediately gave pt spoonful's of honey until [MEDICATION(S)] shot was found. Administered [MEDICATION(S)], notified NP [Nurse Practitioner] who was in building. Was able to get pt to wake up a bit- able to put small amount of Orange Juice in mouth so he could swallow it down. Continues to check BS- went up to 54, 109, 132 and 160. As the day went on pt continued to sleep in bed. Pt refused to eat breakfast and lunch. Staff including Nurse, CNA, and NP went to check on patient every 30 minutes to ensure pt was still okay. After 1100 pt would not allow Nurse (me) or CNA to take blood sugar or do ANY cares. Pt was offered food, drink, and any snacks he wanted but pt yelled at staff to get out of room and leave him alone. Was unable to take blood sugar again due to pt refusal. m. On [DATE] at 4:40 PM, the nurse documented Today around noon I was called to help inject the patient with [MEDICATION(S)] because his blood sugar was 64 and he was unconsious (sic). I injected him in the left deltoid muscle and he came too, two minutes later. He got mad and told me that hes (sic) upset that he was brought back and wants to die. Around 1600 [4:00 PM] I was called over again because his blood sugar was 69 and he wasn't responding or waking up. I tried glucagon15 gel and he couldn't swallow. I gave him a second injection of [MEDICATION(S)] after notifying NP and DON [Director of Nursing] of facility. He came back and refused to eat. He said he will eat later. I explained that he needs to eat or his blood sugar can go too low and he could die. He yelled at me and said that he doesn't care. n. On [DATE] at 9:00 PM, the nurse documented, Pt alert and oriented x4 [person, place, time, and situation.]. Currently resting quietly in room. Has been refusing all medications and BS checks. Has not eaten anything tonight. o. On [DATE] at 1:45 PM, the NP documented, . seen today after he walked over to the hospital to get some lunch. He states that the food at the facility he does not enjoy, so he walked to the hospital to get some better food. Facility staff reports he continues to be fairly noncompliant with his antibiotics and wound changes, then will demand it when it is convenient for him. He hasn't had any further [CONDITION(S)] after his episode on Monday, staff to discuss hospice with him, he states that he does not want to do that, he just did not feel good that day. He states he continues to have pain to his foot, refuses further amputation. He is cantankerous and defiant, in all aspects. Reports he can't wait to discharge. No needs today, he is making little progress. p. On [DATE] at 9:55 AM, the NP documented, He had another episode of [CONDITION(S)], which required with a gun. He continues to state that he wants to be a DNR [Do Note Resuscitate], is resistant to treatments and cares. He states he does not decline treatment, facility staff report he will refuse his wound care. Diet is very irregular, he states the food is not good so he will not eat often. It should be noted that no documentation was found of the episode of [CONDITION(S)] that was reported by the NP. q. On [DATE] at 9:10 AM, the nurse documented, i worked Sunday 022 and pt stated next nurse who gave him [MEDICATION(S)] was being sued by him and that he is purposely not eating causing his blood sugar to go low so he can die, at this time myslef (sic) and [nurse name omitted] noticed accucheck 48 and pt refusing [MEDICATION(S)] and gel and he shakes his head no and mumbles no to medicine, he is now at 38 with same response, pt is a dnr and able to make his own decisions, adament (sic) about not getting [MEDICATION(S)], will cont [continue] to monitor. r. On [DATE] at 9:15 AM, the nurse documented BS was 46 at 0730 [7:30 AM] . is now 38 at 0900 [9:00 AM]. Will barely respond to me/sternal rub but mumbles when I ask if he wants glucose gel or not. Is breathing heavy, [nurse name omitted] LPN [Licensed Practical Nurse] notified me that he said to not give glucose again this past Sunday after the nurse administered. Will not take meds [medications], drink anything, or swallow applesauce. Will continue to monitor. s. On [DATE] at 9:31 AM, the nurse documented that the NP was notified of resident 20's [CONDITION(S)] and refusal of [MEDICATION(S)]. t. On [DATE] at 12:40 PM, the nurse documented, called [name of hospital emergency room ] and spoke with charge nurse [name omitted] who stated if pt is making his own decisions and refusing [MEDICATION(S)], he has his right to refuse, at this time pt is breathing and laying down in bed with employees checking on him multiple times per hour. u. On [DATE] at 1:09 PM, the nurse documented, pt has been educated multiple times on nutrition and hypogylcemia (sic) and ase [adverse side effects] over his stay here including this morning when he refused [MEDICATION(S)] from other nurse and on Sunday [DATE] by myself,care team also notified of pts status today. v. On [DATE] at 1:56 PM, the nurse documented, pt talking and awake with blood sugar at 52 and states he wants to smoke and still refusing [MEDICATION(S)] but is also eating a brownie for lunch. w. On [DATE] at 2:30 PM, the nurse documented, pt given glass of pepsi and also wound arnp [Advanced Registered Nurse Practitioner] here and pt gave her permission for glucose injection which she gave in luq [left upper quadrant] without ase, glucose cont at 58 and still eating brownie and able to make needs known. x. On [DATE] at 2:47 PM, the nurse documented, pts arnp and nurse here to see his foot wound and have discussed with him his options again and they report he wants to go by ambulance to [name of hospital omitted], medics called and transporting him and current blood sugar is now 70, have not heard the pt say he has changed his mind and asked him but he doesn't answer that question and arnp states he gave her permission and is cooperating with ems [emergency medical services], face sheet, dnr polst and med list given to ems y. On [DATE] at 5:13 PM, the nurse documented, after ems responded to arnp wound dr [doctor] calling them, pt refused transport and refused any further treatment for [CONDITION(S)] and states he will sign risks and benefits for not being treated in the future for [CONDITION(S)] and also signed new post form for NO treatment including diabetes tx [treatment] with interim DON, blood sugar wnl [within normal limits] rest of this shift and will pass on report. z. On [DATE] at 3:41 PM, the nurse documented, Called and spoke with [name omitted] (resident's podiatrist) to inquire about Vanco and give him status update on resident request to decline [MEDICATION(S)] and non-compliance with treatments and assistance with cares in general. Discussion also completed with resident regarding wishes as it pertains to POLST status. Resident continues to request to be changed from limited DNR to DNR comfort measures, but does not wish to sign updated POLST to reflect this and won't state rationale for not wanting to sign it. Resident continues to be alert and oriented and able to make his decisions and was educated upon the risks of not signing updated POLST that show his current wishes and that he would have to be treated with his previous limited DNR if we don't get a signed update version. He stated, 'No, I won't take [MEDICATION(S)] ever again.' Resident has been approached regarding possible benefits to hospice. Resident refuses hospice assessment at this time. Social work is aware of resident status. Resident denies any thoughts or plans of self-harm Nurse practitioner notified of all of the above and resident made aware of new orders. aa. On [DATE] at 10:21 PM, the nurse documented, Resident requested to have [MEDICATION(S)] discontinued after refusing it. States that he doesn't need to take those psycho meds. Discussed with NP, order given to discontinue medication. Resident aware. bb. On [DATE] at 941 AM, the NP documented, He is adamant on his insulin dose, and refuses any changes. He did sign a risk versus benefit regarding this. He is quite particular about his diet, and will often not eat if he does not like the food, which will then cause him to be hypoglycemic. He also frequently refuses his blood sugar checks and other cares from staff. Antibiotics have been completed, he is anxious to be able to discharge, unable to do so until wounds heal. cc. On [DATE] at 835 PM, the nurse documented, Nurse entered resident's room to administer morning medications. Nurse found resident with labored and increased respirations, extremely diaphoretic and using accessory muscles to breathe. Also noted a congested sound in resident's chest. Nurse assessed blood glucose level which was 42. Also assessed oxygen saturations which were 72% on room air. Nurse attempted to wake resident, who was only responsive with grunts and slight groaning. Nurse and CNAs pulled resident up in his bed and elevated the HOB [head of bed] to 45 degrees. Per conversations with previous nurses and management team, resident has adamantly stated that he is DNR and absolutely does not want [MEDICATION(S)] IM [intramuscular] administered. This nurse was informed that he would accept oral glucose gel. Nurse pulled oral gel from pixis [sic] and administered the tube to resident's [MEDICATION(S)] pouch a small amount at a time. At one point, resident swallowed the gel, and more was administered. Entire contents of tube were given. Oxygen sats were again assessed and found to be fluctuating between 88 and 93% on room air. Approx. 15 minutes after oral glucose gel was administered, resident is still unresponsive. dd. On [DATE] at 8:48 AM, 15 minutes after glucose gel administration, blood glucose reassessed and remains at 42. Resident continues to be unresponsive but is loudly moaning with breathing. ee. On [DATE] at 8:53 AM, the nurse documented resident 20's vital signs as: blood pressure ,d+[DATE], respiratory rate 32, oxygen saturation 91% on room air, heart rate 111, and temperature was 97.4 degrees Fahrenheit. ff. On [DATE] at 9:09 AM, the nurse documented, Blood glucose is now 36 and resident continues with moaning while breathing. Respirations have come down to 12 per minute with periods of apnea. Oxygen continues to fluctuate from high ,d+[DATE]% on room air. gg. On [DATE] at 9:45 AM, the nurse documented, MD and management have been notified of resident's status via tiger text. hh. On [DATE] at 10:05 AM, the nurse documented, Blood glucose is now 38. Resident continues to be unresponsive when nurse speaks to him, also unresponsive with sternal rub. Moaning with breathing remains. No next of kin contacts listed to call and update. ii. On [DATE] at 10:13 AM, the nurse documented, Nurse heard louder moaning coming from resident's room. Nurse entered to find resident with is (sic) eyes wide open and looking around his room. Nurse said , 'Hi, [resident 20's name omitted]!' Nurse asked him if he was comfortable. [Resident 20's name omitted] looked at nurse and shook his head no. Nurse asked if he wanted her to reposition him. He looked at her and he shook his head no again. Nurse told him his blood sugar was low and asked if he would like [MEDICATION(S)]. [Resident 20's name omitted] looked at nurse, furrowed his eyebrows and shook his head very hard no again. Nurse told him that his oxygen had been getting low and asked if he would like oxygen. He again looked at nurse with furrowed eyebrows and shook his head with a hard no. Nurse told him that she would respect his wishes and would not do anything he didn't want done. He then closed his eyes and started moaning again. Nurse updated management. jj. On [DATE] at 10:50 AM, the nurse documented, Nurse entered resident's room to reassess. Noted no breathing. Nurse auscultated for heart sounds-none present. Management notified of resident's passing. Review of resident 20's Care Plans revealed no focus areas that addressed diabetes, insulin, nutrition, or refusal of cares. On [DATE] at 10:03 AM, an interview was conducted with LPN 1. LPN 1 stated that she was an agency nurse, had worked at the facility prior, and was familiar with the residents. LPN 1 stated that if she had a resident with a low BS, she would give them juice or sugar if they were able to have oral intake. LPN 1 stated if the resident was not able to take anything by mouth then they should have standing orders for [MEDICATION(S)] or glucagel. LPN 1 stated that all sliding scale orders for insulin also stated to contact the physician if the BS was less than 80. LPN 1 stated that there was usually an order for [MEDICATION(S)] as needed or the physician would order it when they were contacted. LPN 1 stated that if a resident refused the [MEDICATION(S)] then she would contact the physician to see what should be done next. LPN 1 stated that it would also depend on if the resident was coherent and able to refuse the medication. LPN 1 stated that if they were unable to get a hold of the provider they would transfer the resident to the hospital for further evaluation and treatment. LPN 1 then stated that she would still need an order to transfer the resident, so she would wait for an order from the provider. In my experience diabetic patients have an order for [MEDICATION(S)]. LPN 1 stated that she would verify the [MEDICATION(S)] order in the Medication Administration Record. LPN 1 stated that if it was passed off in report that the resident was refusing treatment and was not able to provide that information for themselves then she would still contact the provider. LPN 1 stated that she would not direct her care and treatment based off of nurse's notes if the resident could not speak for themselves. LPN 1 stated that she would refer to a POLST form which would indicate the resident's preferred resuscitation status and preference for medical treatment. LPN 1 stated that if the resident was unresponsive and there were questions about the resident refusing treatment in the past it would be helpful to look at that document. LPN 1 stated that she was familiar with resident 20. LPN 1 stated that resident 20's cognitive status was alert and oriented times 3, person, place, and time. LPN 1 stated that resident 20 was able to make his own decisions. LPN 1 stated she recalled caring for him and having him refuse BS checks in the morning. LPN 1 stated she was informed that resident 20's BS dipped a lot. LPN 1 stated that she was careful with resident 20's insulin administration and would not administer if he did not allow a BS check. LPN 1 stated that resident 20 thought the BS should be checked before breakfast but he would not wake until lunch. LPN 1 stated that she would obtain the BS check before lunch to accommodate the resident. LPN 1 stated that resident 20 did not eat well, and he did not like what was being served. That was a compliant of his. LPN 1 stated she knew he liked oatmeal so she would make him oatmeal so he had something to eat. LPN 1 stated that the insulin was scheduled for morning administration, but they would not administer the medication until they had a BS check. LPN 1 stated that a lot of time resident 20 was upset with her for not administering the medication. LPN 1 stated that resident 20 refused a lot of care and medication, and was opinionated on what he should and should not have. LPN 1 stated that resident 20 always refused his [MEDICATION(S)] for depression, saying I'm not taking that crap. LPN 1 stated that the one time resident 20 was hypoglycemic she could not recall if she notified the physician. LPN 1 stated she recalled being told in report that resident 20's BS was low the previous day, that he was administered [MEDICATION(S)] on a previous shift, and that he refused going to the hospital for [CONDITION(S)]. LPN 1 stated that she was never informed that resident 20 had refused treatment with [MEDICATION(S)]. On [DATE] at 12:31 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that the resident would refuse wound care, most of his medication and his psych pills. RN 5 stated that resident 20 would take his blood pressure medication and the long acting insulin. RN 5 stated that resident 20's BS typically ran high. RN 5 stated she would educate resident 20 on his BS, and he would say I know, but didn't care. RN 5 stated that if resident 20's BS was 500 she would ask if she could administer the short acting insulin. RN 5 stated resident 20 wanted the long acting insulin and refused the short acting insulin. RN 5 stated that when resident 20's BS was low it was not that bad, and she would give the resident milk and a peanut butter and jelly sandwich. RN 5 stated that the low BS that she recalled for resident 20 were 60 or 70, and maybe 55 one day. RN 5 stated that resident 20 was alert and oriented times 4 and could communicate his needs. RN 5 stated that resident 20 was able to make decisions about his care. RN 5 stated that after she provided the milk and peanut butter sandwich she would recheck the BS in an hour. RN 5 stated sometimes resident 20 would tell her to come back in 30 minutes if he was sleeping. He wanted to run his own show. RN 5 stated the process for a resident who was hypoglycemic was to first notify the NP, treat the resident with milk and a peanut butter and jelly sandwich, applesauce or juice, then monitor the BS. RN 5 stated that if the BS did not increase she would give more of the listed foods. RN 5 stated that if the resident was unresponsive and the BS was low she would administer [MEDICATION(S)] intramuscular or administer the glucose gel. RN 5 stated that she never had to administer [MEDICATION(S)] or glucose gel to resident 20, but thinks that it was administered by another nurse. RN 5 stated that resident 20 never refused cares with her. RN 5 stated, sometimes if he didn't like a person he wouldn't do what they asked. RN 5 stated that resident 20 was not on hospice services, but he did have a DNR order to not perform compressions. RN 5 stated that she would continue to provide resident 20 with care and treatments until he no longer had a pulse. RN 5 stated that if resident 20 no longer wanted treatment for diabetes then it should have been documented on the POLST form in the notes. RN 5 stated that resident 20 had the short acting insulin discontinued, but that he had standing orders for [MEDICATION(S)]. RN 5 stated that [MEDICATION(S)] was automatically in the orders on the previous medical records system. RN 5 stated that if she found resident 20 unresponsive with a low BS she would have administered [MEDICATION(S)]. RN 5 stated that there should have been a care plan that addressed resident 20's diabetes. RN 5 stated that for any refusals of care she was not sure if that was documented in a care plan. RN 5 stated that for refusals of care they usually completed a risk vs. benefits. RN 5 stated she was not sure if this was done for resident 20, but that it was discussed. RN 5 stated that she was aware that the NP gave orders in a tiger text communication that a Risk vs. Benefit needed to be completed for the discontinuation of the short acting insulin. RN 5 stated that resident 20's mood depended on the day and who you were. RN 5 stated that resident 20 was good with her, and if she asked him to please do something he would. RN 5 stated that if resident 20 did not like a staff member he would tell them no to everything. RN 5 stated that resident 20 had signs and symptoms of depression and would isolate himself in his room and have everything dark. RN 5 stated that resident 20 refused his medication for depression. RN 5 stated she was not aware if resident 20 saw anyone with behavior health or a Social Service Worker (SSW) about his depression. RN 5 stated that she believed that the resident advocate (RA) took over for the SSW. RN 5 stated that they had a SSW from behavioral health that came to the facility 1 to 2 times a month, but she was not sure if resident 20 was seen by them. On [DATE] at 2:02 PM, a follow-up interview was conducted with LPN 1. LPN 1 stated that resident 20 was on [MEDICATION(S)] for depression. LPN 1 stated that resident 20's signs and symptoms of depression were that he slept all the time. He wasn't happy about being here. LPN 1 stated she was not sure if resident 20 saw the SSW at the facility or any contracted behavioral health services. LPN 1 stated that the RA was the SSW. On [DATE] at 9:58 AM, an interview was conducted with RN 3. RN 3 stated that she recalled resident 20, and he was a DNR with limited interventions. RN 3 stated that resident 20 has since passed but recalled that the resident did not want the medication [MEDICATION(S)]. RN 3 stated that for residents who were DNR, she would verify on the POLST for if it was limited interventions or comfort measures. RN 3 stated that she administered [MEDICATION(S)] to resident 20 in the past and recalled looking at the POLST and it said DNR with limited interventions. RN 3 stated that she recalled working with an agency nurse that day who was resident 20's nurse. RN 3 stated that the agency nurse told her that the POLST documented DNR, but she was confused on if she should resuscitate resident 20 because it said limited interventions. RN 3 stated that she educated the other nurse that limited interventions meant that they should still provide treatment. RN 3 stated that if the BS was low they could give [MEDICATION(S)] or any other interventions to keep resident 20 stable. RN 3 stated that after this incident she believed that resident 20 signed a new POLST form for DNR with comfort measures only. RN 3 stated that resident 20 had an episode of [CONDITION(S)] and they honored his wishes and did not administer [MEDICATION(S)] and he passed. RN 3 stated that on the day of resident 20's passing she called the DON. RN 3 stated that she did not see the updated POLST form with comfort measures only. RN 3 stated that on the day that resident 20 died , they administered the [MEDICATION(S)] gel, but not the [MEDICATION(S)] IM. RN 3 stated that she did not administer the gel, but that she pulled it from the Pyxis and gave it to the other nurse. RN 3 stated that the other nurse was an agency nurse and she wanted to give the [MEDICATION(S)] gel. RN 3 stated that she was the only nurse who had access to the Pyxis and she pulled the gel. On [DATE] at 10:18 AM, and interview was conducted with the RA and the Corporate Social Service Worker (CSSW). The RA stated that her duties included the following: scheduling resident appointments; conducting a Brief Interview for Mental Status (BIMS) exam; conducting Patient Health Questionnaire-9 (PHQ-9) screening to assess for depression; obtaining a social history; conducting Interdisciplinary Team conferences; discharge planning; arranging home health services; assisting with New Choice Waiver paperwork; and referrals to mental health if needed. The RA stated that the PHQ-9 were based off the Minimum Data Set (MDS) assessment and she completed them for all the MDS assessments. The RA stated that she had been doing them for the past 8 weeks. The RA stated that she was transitioning from the business office to the RA. The RA stated that they had a contracted mental health service that the facility referred residents to. The CSSW stated that the facility had a Licensed Clinical Social Worker available, but that she was at the facility more often. The CSSW stated that the RA would initially talk to the residents and would ask if they wanted to see someone from mental health services. The CSSW also stated that if the RA did not know how to handle a situation she would refer the resident to the CSSW. The CSSW stated at that point she would have a discussion with the resident and make any necessary referrals. The RA stated that she had talked to resident 20. The RA stated that resident 20 had refused a lot of his cares. The RA stated that resident 20 had wanted to go out on a New Choice waiver, the paperwork had been submitted, and was being reviewed at the time of his passing. The RA stated that she obtained a PHQ-9 score on resident 20. The RA stated that the score would give indicators for the resident's mood. The CSSW stated that the most recent assessment on [DATE], had a PHQ-9 score of 1 out of 30, which indicated minimal depression. The RA stated that she did not have any indicators of depression for resident 20 and was never notified of depressive symptoms from the nurses. The CSSW stated that resident 20's [MEDICATION(S)] was prescribed for nerve pain. The CSSW stated that if resident 20 was having any signs and symptoms of depression or suicidal ideation (SI) she would expect the nurses to report that to her. The RA stated that if this information was communicated to her she would have had a conversation with resident 20 she would have consulted with the CSSW. The CSSW stated that if resident 20 had expressed wishes to harm himself they would have sent him to the hospital for evaluation. The CSSW stated that resident 20 had refused to go to the hospital for treatment in the past, but there was no indication that he was suicidal. The RA stated that as far as she was aware resident 20 wanted to live in assisted living or independent living, had toured a couple of facilities, and was looking forward to that. The CSSW stated that according to resident 20's PHQ-9 score and expressed desire to discharge they were not aware of any indications of SI or wanting to die. The CSSW stated that had they been made aware of these statements they would have had a discussion about options for resident 20. The CSSW and the RA stated that resident 20 did not have any referrals made to mental health services. On [DATE] at 11:30 AM, an interview was conducted with the DON. The DON stated that resident 20 was a very self directed man, meaning he refused cares, refused dressing changes, decided what medicat

Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically,with regard to residents who were on Transmission Based Precautions (TBP), staff were observed to not fully don gowns, wear soiled gowns throughout the facility, not wear appropriate eye protection, not clean face shields after exiting the room, not store face shields appropriately, not clean vital signs equipment between resident use, contaminate isolation carts, contaminate syringes by placing them on top of isolation carts, clean and store syringes inappropriately, not clean glucometers between residents, not perform appropriate hand hygiene, not wear masks appropriately, not don gowns or gloves to deliver meal trays, not have isolation carts that were adequately supplied, and not isolate unvaccinated residents for 14 days. Resident identifiers: 85, 86, 185, 186 and 187. On 7/15/21 at 11:30 AM, an Immediate Jeopardy (IJ) was identified when the the facility failed to implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. Specifically, with regard to residents who were on Transmission Based Precautions (TBP), staff were observed to not fully don gowns, wear soiled gowns throughout the facility, not wear appropriate eye protection, not clean face shields after exiting the room, not store face shields appropriately, not clean vital signs equipment between resident use, contaminate isolation carts, contaminate syringes by placing them on top of isolation carts, clean and store syringes inappropriately, not clean glucometers between residents, not perform appropriate hand hygiene, not wear masks appropriately, not don gowns or gloves to deliver meal trays, not have isolation carts that were adequately supplied, and not isolate unvaccinated residents for 14 days. Notice of IJ was given verbally to the Administrator (ADM) and Director of Nursing (DON), and they were informed of the findings of IJ pertaining to F880. On 7/17/21, the ADM provided the following plan for the removal of the Immediate Jeopardy: Dear [Name of Long Term Care Survey Manager]: On July 15, 2021 at 11:30 AM, you, as the Long Term Care Survey Manager, with the Utah State Survey Agency, and a team of Long Term Care Surveyors informed me and my Director of Nursing that conditions existing at Parkway Health and Rehabilitation represent an Immediate Jeopardy to residents health and safety represents non-compliance with 42 Code of Federal Regulation 483.80; F-880. As the Administrator of Parkway Health and Rehabilitation, and after consultation, and input from professionals within [Name of Company], a non-profit quality improvement organization, as well as input from infection preventionists within our organization, I understand that the full implementation of this plan will serve only to remove immediate jeopardy, and that Parkway Health and Rehabilitation will need to continue efforts and develop a more extensive plan of correction upon receipt of the form CMS 2567 to achieve substantial compliance. I am now satisfied that Parkway Health and Rehabilitation has fully implemented the plan submitted July 17, 2021 to remove Immediate Jeopardy, as well as any other measure deemed necessary. This letter constitutes allegation that Immediate Jeopardy has been removed as of July 19, 2021 at 3:00 pm. As a follow up to our action plan on July 17, 2021, to remedy the Immediate Jeopardy to our resident's (sic) health and safety, we have completed the following action items and implemented training to remedy the non-compliance identified as immediate jeopardy. Friday July 16, 2021, I contacted [Name of Company], who has agreed to provide technical consultation services with Parkway Health and Rehabilitation. Specifically two professionals; one with a Masters in Public Health Administration (MPH) who is a Certified Health Education Specialist, and the other a clinical care practitioner and Senior Infection Preventionist with [Name of Company]. This practitioner's credentials include a PhD, Board Certification as a Family Nurse Practitioner, and Board Certification as a Psychiatric Mental Health Nurse Practitioner. To date the consultation with [Name of Company], has been remotely. [Name of Company] has provided training that has been reviewed by the Infection Preventionist and CMS Certified Infection Preventioist (sic). We continue to have ongoing education with the identified experts from [Name of Company]. [Name of Management Company], the management company at Parkway Health and Rehabilitation, has brought a Registered Nurse, who is a CMS Certified Infection Preventionist (IP), from a sister facility to Parkway to provide onsite consultation. This consultant IP continues working onsite training and educating the facility Infection Preventionist and facility personnel. Facility personnel were trained specific to the identified areas of Immediate Jeopardy, by the Director of Nursing, and repeat training has been done by the consultant IP and facility IP at 83% of staff, the remaining 17% will be trained prior to working a shift. The consultant IP has assessed the attitudes and culture of the staff. The consultant IP has determined that staff are willing to comply with regulations and that the non-compliance was related to miseducation of staff. Staff have expressed willingness to abide by policies and procedures to comply with Infection Prevention. The supply chain was also evaluated and determined that sufficient supplies are on hand to provide TBP patients. The supply carts are stocked and have been stocked daily, since implementation of new protocols on July 15, 2021. Members of the QAPI (Quality Assurance Performance Improvement) team have reviewed each identified issue of non-compliance daily since July 15, 2021. The full QAPI team has met on July 19, 2021 and has assessed the plan and implementation thus far and agree that Immediate Jeopardy has been removed, the consultant IP has also participated in this process and agrees. The consultant IP will continue as we move forward to obtain substantial compliance. The consultant IP, the Director of Nursing and facility IP have reviewed the Policies and Procedures in conjunction with the CDC (Centers for Disease Control) guidelines and State of Utah protocols and guidelines to assure that they are consistent in relation to following standard Precautions and Transmission Based Precautions. The Policy and Procedures will continue to be evaluated and updated as guidelines change. The consultant IP has assessed the availability of hand washing locations, hand-sanitizing stations, and appropriate disinfecting of reusable supplies. The consultant IP and facility IP with Director of Nursing and Administrator have placed PPE stations outside of each TBP room. Each TBP resident room also has patient specific vital signs equipment to illuminate the potential for cross contamination. This equipment remains in the resident room. The consultant IP continues, with the facility IP to provide direct and directed training with all staff. Directed education includes hard copy handouts, youtube videos suggested by [Name of Company], consultants. The consultant IP and administrator are working with [Name of Electronic Health Record Company] to use the [Name of Training software Company], training system to continue to educate and stay current with updated standard precautions for Infection Prevention. The consultant IP and facility IP have followed up with staff to evaluate staff understanding with and competencies in relation to hand hygiene, PPE usage and contact and airborne precautions related to TBP. The consultant IP will reported (sic) to the Administrator completed (sic) preliminary education of all staff and individual training and assessment is ongoing. This training was provided to all available staff. Those staff on vacation or who have not worked in the building since July 15, 2021 will be giving (sic) necessary training prior to working the next shift. The HAI (Healthcare Acquired Infection Team) has provided [name of tool] and the consultant IP is working with the facility IP to complete a more thorough assessment/evaluation of where we are as a facility and will report to the administrator and QAPI team as soon as it is completed. The consultant IP worked with the QAPI team to develop more frequent observation and reporting of staff screening upon arrival, the Administrator or Director of Nursing have reviewed the self-screening tool. The designated employee has been trained on reviewing the screening process for employees and visitors to assure compliance with current guidelines. The QAPI team members are also trained and can provide training when needed in relation to Infection Prevention, as it related to people entering the building. The QAPI team met on July 19, 2021 at 11:00 am and determined that the Immediate Jeopardy action plan has worked to remove the Immediate Jeopardy and remedies thus far are effective. The QAPI will continue to provide immediate intervention, when identified, including training and education as needed on a continual basis. Sincerely, [Name of ADM]. On 7/19/21, while completing the Recertification Survey, surveyors were onsite to verify Immediate Jeopardy had been removed. The surveyors determined the Immediate Jeopardy was removed, as alleged, on 7/19/21 at 3:00 PM. Findings include: It should be noted that upon entrance to the facility on [DATE], the facility provided a census sheet that indicated there were three unvaccinated residents on isolation precautions: Resident 187 who was admitted on [DATE], resident 185 who was admitted on [DATE], and resident 186 who was admitted on [DATE]. All of the residents resided on the 100 hall. 1. On 7/14/21 at approximately 2:00 PM, Registered Nurse (RN) 2 was observed entering a resident's room. The resident was on isolation precautions. RN 2 was observed to enter the room while carrying a plastic syringe, without a gown. RN 2 was then observed to exit the resident's room, place the medication syringe down on the isolation cart, perform hand hygiene, and then walk to the dining area sink. At that point, RN 2 was observed to rinse the contaminated medication syringe in the sink. RN 2 then walked into a medication room. RN 2 was immediately interviewed. RN 2 stated that she had returned the syringe to the medication room's medication refrigerator so she could use the syringe the next time she needed to administer medications to the resident. 2. On 7/14/21, RN 2 was followed and observed during afternoon medication pass. The following observations were made: a. At 3:13 PM, RN 2 took a cup of medication into a resident room without hand sanitizing prior to entering. RN 2 administered the medication, exited the resident room without hand sanitizing, and then returned to the medication cart and began typing on the computer keyboard. b. At 3:39 PM, RN 2 withdrew medication for a resident from the medication cart without first hand sanitizing. RN 2 took the medication in a small cup to the resident while he was sitting in the dining room, then went back to medication cart and started typing on the computer keyboard without hand sanitizing. c. At 3:54 PM, RN 2 checked a resident's blood glucose. RN 2 donned clean gloves, then proceeded to get a small blood sample from the resident's finger by pricking it with a lancet and squeezing the finger to get a drop of blood for the glucometer to test. After getting the reading from the glucometer, RN 2 discarded the used test strip, exited the resident room, and placed the unclean glucometer on top of a clean box of gloves, directly over the box's opening. RN 2 then doffed the dirty gloves and donned clean gloves without hand sanitizing or cleaning the glucometer. RN 2 then entered another resident room and checked that resident's blood sugar using the same, uncleaned glucometer. After getting a blood sugar reading, RN 2 doffed the dirty gloves and exited the resident room without hand sanitizing. RN 2 then proceeded directly to the medication cart where she placed the uncleaned glucometer in a drawer. RN 2 then began to type on the computer keyboard without hand sanitizing. Constant observation was made of the medication cart where RN 2 placed the glucometer. It was never removed and cleaned. d. At 4:44 PM, RN 2 removed the still uncleaned glucometer and checked two residents' blood sugar. RN 2 doffed the dirty gloves and donned clean gloves between each resident, however, RN 2 did not hand sanitize between each resident nor was the glucometer cleaned between residents. At 5:55 PM, RN 2 was interviewed and asked if the glucometer was cleaned between any of the residents. RN 2 stated, No, I didn't clean it. I check blood sugars again at eight (8:00 PM) and I'll clean it then because I didn't clean it this time. Per review of the CDC guidance at https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, the guidance indicated that Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. 3. On 7/12/21 at 11:55 AM, an observation was made of Dietary Aide (DA) 1 delivering lunch trays on the 100 hallway, which was the hallway designated for residents in isolation. DA 1 did not put on a gown or gloves to enter multiple resident rooms on the isolation hall. DA 1 was wearing a face mask and eye protection. DA 1 did not clean her eye protection upon exiting the resident rooms. An interview was immediately conducted with DA 1. DA 1 stated staff were only required to wear gowns and gloves when they anticipated coming in contact with residents. Per review of the CDC guidance at https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html, appropriate PPE donning steps for staff were to: identify and gather the proper PPE to don, perform hand hygiene using hand sanitizer, put on isolation gown, put on NIOSH-approved N95 filtering face respirator or higher, put on face shield or goggles, and put on gloves. The guidance also stated that appropriate doffing steps for staff were to: remove gloves, remove gown, exit patient room, perform hand hygiene, remove face shield or goggles, remove mask, and perform hand hygiene after removing the mask and before putting it on again if the workplace was practicing reuse. 4. On 7/13/21 at approximately 12:00 PM, an observation was made on the 100 hallway outside of room [ROOM NUMBER]. A disposable gown was observed draped over the Personal Protective Equipment (PPE) cart and on top of a box of clean gloves. There was a glove on the floor next to the PPE cart. No disinfectant or alcohol based hand rub (ABHR) was observed to be on the PPE cart. There were 2 face shields tucked in the hand railing behind the PPE cart. There were no additional disposable gowns in the PPE cart, and no extra face masks. Another PPE cart in the same hallway had extra PPE in the cart. On 7/13/21 at approximately 12:15 PM an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated the gown on the cart was for donning before entering the resident's room. CNA 6 stated the gown outside the resident room was used by any staff that went into the resident's room. CNA 6 stated the visors were shared by staff. CNA 6 stated staff were not required to change their mask when going into the resident room. CNA 6 stated resident meal trays were delivered by kitchen staff and CNAs. CNA 6 stated whoever does the 100 hallway has to put on the gown. CNA 6 stated after delivering the meal trays the staff member would have to reach inside the resident's room for hand sanitizer. CNA 6 stated one disposable gown was used for the whole shift. CNA 6 stated clean gowns were kept in the storage room and either the CNAs or the nurses stocked the PPE carts. CNA 6 stated extra masks were kept in the medication room or the stock room. CNA 6 stated she cleaned her goggles with wipes after leaving an isolation room. CNA 6 stated she had worked at the facility for 3 months and was trained by another CNA. CNA 6 stated the Infection Preventionist did a little bit of the training on the floor. CNA also stated she received some training from the Director of Nursing (DON). CNA 6 stated she would go ask a nurse if she didn't know what to do. On 7/13/21 at 1:08 PM, an observation was made of CNA 6 donning the gown outside of room [ROOM NUMBER] that was draped over the PPE cart. CNA 6 entered the resident's room to answer the call light. Soon after she exited the resident's room. CNA 6 doffed the disposable gown and placed it back over the clean gloves on the PPE cart. CNA 6 did not change her mask, and was not observed sanitizing her hands after doffing the used gown. Review of Centers for Disease Control and Prevention (CDC) guidance on Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes documented under Personal Protective Equipment that Facilities should have policies and procedures addressing: Which PPE is required in which situations (e.g., residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection, residents placed in quarantine) and Recommended sequence for safely donning and doffing PPE. Additionally, Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. The guidance further recommended under Implement Universal Use of Personal Protective Equipment that HCP (Health Care Personnel) working in areas with minimal to no community transmission should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other PPE. The guidance also recommended under New Admissions and Residents who Leave the Facility documented, In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. The guidance was last updated on March 29, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe Review of the CDC guidance on Strategies for Optimizing the Supply of Isolation Gowns, documented under Crisis Capacity Strategies that The risks to HCP and patient safety must be carefully considered before implementing a gown reuse strategy. Disposable gowns generally should NOT be re-used, and reusable gowns should NOT be reused before laundering, because reuse poses risks for possible transmission among HCP and patients that likely outweigh any potential benefits. Similar to extended gown use, gown reuse has the potential to facilitate transmission of organisms (e.g., C. auris) among patients. However, unlike extended use, repeatedly donning and doffing a contaminated gown may increase risk for HCP self-contamination. If reuse is considered, gowns should be dedicated to care of individual patients. Any gown that becomes visibly soiled during patient care should be disposed of or, if reusable, laundered. The guidance further stated, Once gown availability returns to normal, healthcare facilities should promptly resume conventional practices. The guidance was last updated on January 21, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html# Review of the United States Food and Drug Administration (FDA) guidance on Personal Protective Equipment documented on questions about PPE, In general, most PPE cleared by the FDA is intended to be used only one time and by one person. Sharing PPE is not advised. The protective capabilities of single use PPE cannot be assured when it is reused by the same person or used by more than one person. Sharing PPE that is intended for single use may expose another person to infectious materials. PPE should be removed promptly after use and disposed of properly. The content was current as of March 11, 2020. https://www.fda.gov/medical-devices/personal-protective-equipment-infection-control/questions-about-personal-protective-equipment-ppe 5. On 7/13/21 at 1:18 PM, therapy staff were observed to be in room [ROOM NUMBER]. The therapist was heard asking the resident if he wanted to get dressed, brush his teeth and comb his hair. The therapy staff member said he would get the resident a comb, a razor and a tooth brush. The therapy staff member doffed the gown he was wearing and put it on top of the used disposable gown on the PPE cart. When the staff member returned with the care items, he re-donned the disposable gown and re-entered the resident's room. The therapy staff was wearing a surgical mask and eye protection. Soon after, the same therapy staff member was observed exiting the resident's room again, this time without doffing his gown, and walked down the hall to the storage closet to get the resident some towels. The therapy staff member then re-entered the resident's room and closed the door. 6. On 7/13/21 at approximately 1:25 PM, an observation was made outside of another resident's room on the 100 hallway. There was a used disposable gown laying across the PPE cart outside of room [ROOM NUMBER], and on top of the clean gloves. 7. On 7/13/21 at 3:00 PM, an observation was made of CNA 5 going into room [ROOM NUMBER]. CNA 5 got a clean disposable gown out of the PPE cart. CNA 5 put on clean gloves and then donned the gown up to her elbows and entered the resident's room. The gown was observed not to be donned appropriately, as it only covered the staff member's elbows and part of her lower torso. The gown was not covering the upper rib and chest area of the CNA. 8. On 7/14/21 at 7:30 AM, an observation was made of Registered Nurse (RN) 3 entering the building. RN 3 walked past the front desk in the lobby area where screening was done, without screening in. An interview was conducted with RN 3 at the nursing station on the 300/400 hallway. RN 3 stated she usually waited a few minutes before taking her temperature so it normalized. RN 3 stated staff took their temperatures 3 times per day. RN 3 stated staff do one to two COVID tests weekly depending on the county infection rate. RN 3 stated all staff were supposed to screen at the front desk upon arriving to work. RN 3 stated everyone coming into the building fills out the screening sheet, every day. RN 3 stated if staff left the building for any reason, they were required to re-screen before going to their work stations. RN 3 stated she had been at the facility for 1 year and 9 months. RN 3 stated the screening protocol had changed so much depending on the state requirements. RN 3 stated currently surgical masks and eye protection were required for all staff. RN 3 stated full PPE is required on the 100 hallway. Review of the CDC's guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic documented under Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19 stated .symptom screening remains an important strategy to identify those who could have COVID-19 so appropriate precautions can be implemented. The guidance further stated to Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19 and Properly manage anyone with suspected or confirmed [CONDITION(S)]-CoV-2 infection or who has had contact with someone suspected or confirmed with [CONDITION(S)]-CoV-2 infection: Healthcare personnel (HCP) should be excluded from work The guidance was last updated on February 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html 9. On 7/14/21 at 2:37 PM an observation was made of a used disposable gown laying on a chair outside of room [ROOM NUMBER]. A disposable gown was also hanging inside the doorway at room [ROOM NUMBER], where there were no residents residing. Observations were made of the three PPE carts in the 100 hallway. The cart outside of room [ROOM NUMBER] had masks, gowns, and gloves. There was no hand sanitizer and no disinfectant wipes. There was no garbage receptacle near the cart in which staff could dispose of their used PPE or used disinfectant wipes. A pair of goggles was observed on the floor next to the PPE cart. The cart outside of room [ROOM NUMBER] had no gowns and masks. There was a box of clean gloves sitting on top. No ABHR or disinfectant wipes were observed. The PPE cart outside of room [ROOM NUMBER] had no masks and no gowns. Clean gloves were observed to be on top of the cart, and visors were tucked into the hand railing behind the cart. No garbage receptacle was observed for used PPE. 10. On 7/14/21 at 2:44 PM, an interview with CNA 5 was conducted about donning PPE. CNA 5 stated she first put on gloves, then a gown and stated she already had on a mask and eye protection. When asked if she needed additional eye protection or face shield she stated I already have eye protection on (pointing to her glasses). CNA 5 stated she had hand sanitizer in her pocket and she would put the used gown in the red bin in the resident's bathroom before exiting the room. An observation was then made of CNA 5 donning PPE to enter a resident room. CNA 5 put a gown on, then put gloves on and entered the resident room. Upon exiting the resident's room, she had already taken off her gown and gloves. CNA 5 was not observed sanitizing her hands. CNA 5 left the gown that was lying across the PPE cart where it was and did not throw it away. Review of the CDC guidance regarding eye protection indicated that Workers should understand that regular prescription eyeglasses and contact lenses are not considered eye protection https://www.cdc.gov/niosh/topics/eye/eye-infectious.html Review of the current county positivity rates at https://data.cms.gov/covid-19/covid-19-nursing-home-data, the county positivity rate for the week of 7/6/21 was 9.3 percent in Utah county. Per https://coronavirus.utah.gov/recommendations-for-providers/, in communities with moderate to high transmission, universal eye protection and additional precautions are advised. 11. On 7/14/21 at 2:52 PM, an observation was made of the facility Infection Preventionist (IP) exiting room [ROOM NUMBER] with a container of vitals equipment. When exiting the resident room the IP put his [NAME] on the hand railing with the other visors outside the resident's room, without cleaning it. The IP then walked over the nurse's station, removed his mask, put the vitals container on the counter and went to the sink to wash his hands. The IP was not observed to clean the vitals equipment that had just been used in room [ROOM NUMBER]. It should also be noted that the PPE cart outside of the resident's room had no cleaning supplies on it, nor did it have ABHR on the cart. 12. On 7/14/21 at 3:08 PM, an observation was made of CNA 5 walking through the 200 hallway to the nurse's desk with her mask below her chin. Review of the CDC guidance on Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic under Implement Universal Source Control Measures stated that Source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility. The guidance was last updated on February 23, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html 13. On 7/14/21 at 3:14 PM, an observation was made of RN 2 with her eye protection on top of her head. 14. On 7/14/21 at 3:16 PM, an interview was conducted with RN 2. RN 2 stated when she worked on the 100 hallway she used her eye protection, put on a gown and gloves and entered the room. RN 2 stated when she doffed her gown, she would hang it on the door to use again. RN 2 stated she did not put her name on the gown to know which gown was hers. After exiting the resident's room, RN 2 stated she would put her eye protection back on top of her head because of having poor eyesight. RN 2 stated she put her gloves in the garbage in the hallway. She was asked to show what garbage she was referring to, and she walked over to the 100 hallway and there was no garbage. RN 2 stated there was usually a garbage in the 100 hallway. RN 2 stated residents on the 100 hallway were not allowed to leave their rooms during isolation. 15. On 7/14/21 at 3:46 PM, an interview was conducted with CNA 5. CNA 5 stated she had been in an automobile accident and had been out of the facility for some time. CNA 5 stated upon her return to the facility she was not tested prior to starting work again. CNA 5 stated she was not tested because she did not ask to be tested so it's on me, not the facility. I did not ask to be tested when I came back. 16. On 7/15/21 at 7:49 AM, an observation was made of Dietary Aide (DA) 1 serving breakfast in the 200 hallway. She was observed sanitizing her hands upon exiting each room. DA 1 then pushed the food cart to the 100 hallway. Before entering room [ROOM NUMBER], DA 1 put on a gown and gloves. She had a mask and eye protection on. She brought the meal into the resident room. Upon exiting, DA 1 put the disposable gown she was wearing on the chair outside of the room, where 2 other gowns were already lying across the chair. An interview was immediately conducted with DA 1. DA 1 stated the gown she put on the chair with the other gowns was one that she was going to use later. DA 1 was asked if anyone else would use her gown and she stated no, we know which ones are ours. DA 1 did not change her mask or eye protection, nor did she clean her eye protection upon exiting the room. DA 1 then proceeded to room [ROOM NUMBER] to deliver a meal tray. DA 1 put on a new gown and entered the room. Upon exiting room [ROOM NUMBER] she put her used gown over the PPE cart and went to get the resident a banana from the kitchen. When DA 1 returned, she put the used gown on again, donned new gloves and entered the room. When DA 1 exited the room again, she put her used gown over the PPE cart and rearranged the face shields by the door, then left. The PPE cart was observed to have no ABHR or disinfectant wipes. 17, On 7/15/21 at 8:10 AM, an observation was made of the PPE carts on the 100 hallway. The PPE cart next to room [ROOM NUMBER] still did not have any gowns or masks, nor was there any ABHR or disinfectant wipes on the cart. There was no garbage by the door. The PPE cart next to room [ROOM NUMBER] had masks and some gowns, but no ABHR and no disinfectant wipes, and no garbage can. 18. On 7/17/21 at 5:56 AM, an observation was made of RN 6 reporting to her work station. RN 6 was not wearing a mask. 19. On 7/17/21 at 6:05 AM, an observation was made of CNA 8 performing hand hygiene incorrectly. CNA 8 rinsed her hands in the sink without using soap, then she dried her hands and turned the water off. On 7/17/21 at 6:13 AM, another observation was made of CNA 8 performing hand hygiene incorrectly. CNA 8 rinsed her hands off under the water and dried them before turning off the water. 20. On 7/18/21 at 8:35 PM, an observation of RN 2 was made going into a resident room. RN 2 came out soon after and got some gloves off of the wall inside the door and re-entered the room. Upon exiting the room again, RN 2 took off the gloves and tucked them under her arm while she used ABHR. She then took the gloves back into her hands and walked toward the nurse's cart while rolling the used gloves in her hands. When she reached the nurse's cart she threw the gloves into the garbage by the cart. RN 2 then went

Based on observation, interview and record review, it was determined, for 1 of 25 sample residents, that the facility did not ensure that pain management was provided for residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, one resident did not receive consistent and ongoing pain monitoring and treatment after having a fall and fracturing her femur and the ineffectiveness of the pain medications were not called into her physician. Resident identifier: 35. Findings include: Resident 35 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing progress notes in resident 35's online medical record revealed the following entries: a. 11/13/17 at 10:20 AM, Had fall this morning trying to get out of bed on her own. C/O (complains of) left knee pain. X-ray ordered. Helped back into bed. Bed in low position. Patient education on need to use call light. Frequent checks. Vitals BP (blood pressure) 157/75, P (pulse) 67, 02 (oxygen) 97% (percent), (Resident 35's physician) notified and family called. b. 11/13/17 at 4:37 PM, Results of x-ray taken as a result of fall. There is a prosthetic left femoral condyle in proper alignment with respect to the tibia plateau prostheses. There is acute distal femur fx (fracture) with slight lateral displacement. The prosthesis is properly situated without any loosening. No joint effusion is seen. c. 11/13/17 at 4:40 PM, After x-ray results shown (sic) a left femur fx, the ambulance was called and transported (Resident 35) to the ER (emergency room ) for Tx (treatment). The incident report for resident 35, dated 11/13/17 at 6:30 AM, revealed that resident 35 had a fall in her room. A description of the event revealed that (Resident 35) was attempting to get out of bed to go dancing. She slid to the floor and called for help. The resident disposition after the incident revealed that resident 35 C/O pain in L (left) knee . The interventions included bed in low position, frequent checks, educated patient to use call light, and allow CNAs (Certified Nursing Assistants) to help, full body check, vitals taken, x-ray order on knee. (Note: The incident report shows that resident 35's physician was not notified of the fall until 10:37 AM and the x-ray order had not been written on a telephone order, so the exact time of the x-ray order or who ordered the x-ray was unknown.) The completed radiology report for resident 35, dated 11/13/17 and electronically signed by the radiologist at 4:14 PM, revealed Results: There is a prosthetic left femoral condyle in proper alignment with respect to the tibia plateau prostheses. There is acute distal femur fx with slight lateral displacement. The prosthesis is properly situated without any loosening. No joint effusion is seen. (Note: No radiology report could be located in the medical record to show what time the x-ray report had been called or faxed into the facility. No documentation could be located in the medical record to show why the x-ray was not completed and reported to facility staff for nearly 10 hours after documentation that the x-ray had been ordered.) Resident 35's (MONTH) (YEAR) physician's orders [REDACTED]. a. 11/16/15, Tylenol 1000 milligrams (mg) orally every six hours as needed for pain. b. 11/5/17, [MEDICATION NAME] 5 mg twice daily for pain management. c. 11/13/17, [MEDICATION NAME] 5 mg orally once daily as needed, one time dose. Resident 35's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. 11/13/17 at 6:40 AM, Tylenol 1000 mg administered for pain in leg and knee; pain: 6. The follow up documentation at 4:12 PM, revealed that the Tylenol 1000 mg was ineffective. b. 11/13/17 at 11:54 PM, [MEDICATION NAME] 5 mg administered for One time dose for pain. The follow up documentation at 4:11 PM, revealed that the [MEDICATION NAME] 5 mg was Not effective. (Note: No documentation could be located in the medical record at the time of administration of [MEDICATION NAME] 5 mg to show what resident 35's pain rating was. No other documentation could be located in the medical record after the administration of the [MEDICATION NAME] 5 mg to indicate that resident 35's pain level had been reduced.) The facility Narcotic Record revealed that resident 35 received her scheduled dose of [MEDICATION NAME] 5 mg on 11/13/17 at 9:10 AM. (Note: According to resident 35's MAR, the scheduled dose of [MEDICATION NAME] was due at 8:00 AM but was not administered until 9:10 AM. There was no documentation in resident 35's medical record of a pain level when the [MEDICATION NAME] was administered.) A Pain Management care plan dated 4/19/17, for resident 35 revealed the following: Problems: Pt (Patient) has episodes of pain related to history of falls and chronic pain. Goals: Pt will suffer no unrelieved episodes of pain during facility stay. Pt will express comfort and management of chronic pain every day. Pt will express comfort and management of acute pain every day. Episodes of increased pain will be relieved within one hour of intervention. Plan of Approach: Assess location, type, duration and frequency of pain. Assess intensity of pain using pain scale .Monitor for s/s (signs/symptoms) of increased pain: verbal c/o pain, guarding, grimacing, moaning, etc .Monitor for med effectiveness .Notify MD (Medical Doctor) of unrelieved pain and medication ineffectiveness. According to facility documentation, resident 35's pain level was not reassessed for approximately 10 hours after the initial pain level of 6 at 6:40 AM was assessed. In addition, resident 35's physician was not notified of resident 35's ineffective pain level that was documented at approximately 4:10 PM. The hospital History and Physical (H&P) dated 11/13/17 at 5:57 PM, revealed that resident 35 Reports extremity pain and swelling, and Consultation requested with (physician) from Orthopedics. Recommends 5-10 pounds of Buck's traction and with long leg posterior splint placement. The patient will receive surgery in 2 days following suspensions of Xarelto. The hospital H&P further revealed Left distal closed oblique femur fracture. The patient has IV (intravenous) fluid replacement with oral [MEDICATION NAME], and IV [MEDICATION NAME] for pain control. On 2/22/17 at 12:19 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated I know it looks bad on paper, the charting could have been much better. The facility DON stated that this looked concerning enough to her that she had a quality assessment meeting to improve the way that the resident's would receive care. When asked for a copy of the Quality Assessment meeting that had been completed, the facility DON stated Well, it was really more of a nursing meeting on the floor with the nurses that were working, regarding pain score documentation rather than documenting effective or ineffective. The facility DON stated that she did not have any documentation regarding the nursing meeting. The facility DON further stated that she knew that her staff monitored resident 35 for pain throughout the day and that it was just a documentation error rather than a care issue. The facility DON stated that she had called (physician's name) on 11/13/17 at 2:00 PM, at the hospital and that he had instructed her not to give resident 35 any more pain medications. The facility DON stated that there was no documentation of the phone call nor an order written [REDACTED].>On 2/26/18 at 8:10 AM, a follow up interview was conducted with the facility DON. The facility DON stated that she did not have a copy of the ambulance report to show what time resident 35 was sent to the hospital. On 2/26/18 at 8:30 AM, an interview was conducted with resident 35. Resident 35 was unable to answer questions regarding the incident. Resident 35 was observed to close her eyes. On 2/26/18 at 4:14 PM, a telephone interview was conducted with the diagnostic company that performed resident 35's x-ray. The diagnostic company employee did not have a time that the x-ray had been called or faxed to the company. The diagnostic company employee stated that the x-ray report was electronically signed by the radiologist at 4:14 PM.

Based on interview and record review, it was determined that for 3 of 33 sample residents, the facility did not ensure that each resident's drug regimen was free from unnecessary medications. An unnecessary medication is any medication when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring. Specifically, (1) The facility did not monitor laboratory results as ordered which resulted in one resident being hospitalized for [REDACTED]. Resident identifiers: 29, 48, and 82. The deficient practice for resident 48 was determined to be past noncompliance. The facility Director of Nursing (DON) implemented the following interventions as of 2/19/14: "...1. admission orders [REDACTED]. 2. Upon admission orders [REDACTED]. 3. Any conflict (with) admission or home meds (medications) will be verified (with) MD (Medical Doctor) upon review of admission orders [REDACTED]. Nurses will be reinserviced on admission orders [REDACTED]. Nurse will be added to rehab (rehabilitation) side 8 hours daily and will review all orders, coordinate home meds, new orders, CP (Care Plan) and assessments (with) family and or resident." Findings include: 1. Resident 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 48's medical record was reviewed on 6/10/14. Review of the initial admission orders [REDACTED]. Additionally, orders were given to check a [MEDICATION NAME] (PT) every Monday with a goal INR to be between 2.5 and 3.5. On 1/6/14, the facility staff developed an "Anticoagulation" care plan related to "...at risk for abnormal bleeding or hemorrhage because of anticoagulation related to [MEDICATION NAME]." The goals developed included: (1) "Resident will be free from signs and symptoms of abnormal bleeding through the next review date: 2/6/14; and (2) Resident's PT and INR values will be maintained within therapeutic range, as determined by their physician through the next review date: 2/6/14." The approaches developed to achieve the goals included: (1) "Administer anticoagulants as currently prescribed by the resident's physician... and (2) ...Schedule lab tests as ordered by the physician to monitor coagulation factors - report results to physician..." The laboratory results obtained for resident 48 were reviewed. There was no documentation that the PT and INR was drawn on 1/6/14 and 1/13/14 as ordered by the physician. The "Interdisciplinary Progress Notes (IPN)" were reviewed. The licensed nursing staff documented: a. 1/14/14 at 10:11 AM: "...Pt. (patient) has notably increases (sic) swollen firm area on L (left) upper chest, no heat or redness noted, tender to touch. (Primary Care Physician (PCP)) notified orders to get a US (Ultrasound) today. ..." b. 1/14/14 at 3:00 PM: "Ultrasound results back. ...Pt. has a hematoma to L upper chest. ..." c. 1/15/14 at 12:52 AM: "...reports pain 6/10 in LU (left upper) chest RT (related to) hematoma..." d. 1/15/14 at 6:36 PM: "PT/INR checked, results were 5%, (greater than) 8.0. (PCP) was called. He ordered to stop the [MEDICATION NAME] for 3 days and recheck." e. 1/16/14 at 6:55 AM: "Received call from pt's daughter aprox (approximately) 0430 (4:30 AM) concerned about the care of her father. Asked about why INR had not been checked before hematoma developed. ...Advised her that we will continue to monitor and treat the hematoma and dr (doctor) has been informed and involved in treatment plans with a follow up dr visit today and that we will follow through with any additional blood work and care as ordered." f. 1/16/14 at 7:30 AM: "Pts wife notified of pts firm swollen area on L upper chest, notified of plan of care to get ultrasound per (PCP) orders, wife verbalizes concern that the pt needs to go to the hospital, states 'You guys need to do something right now.'" g. 1/16/14 at 8:52 Am: "Pt assessed this morning, pt is difficult to arouse and slow to respond, pt is confused disoriented to place, time and situation, oriented to self only. Hematoma on L side of chest noted. INR checked reading (greater than) 8. VS (vital signs) (blood pressure) 108/58, P (pulse) 84, R (respirations) 20, SP02 (oxygen saturation) 84% on RA (room air), PRN (as needed) O2 (oxygen) immediately administered on 2L (liters) SP02 increased to 96%. (PCP) notified of status. Orders to send pt to ER. ...wife called immediately, verbalized upset and states 'You guys made him bleed out,' ..." On 6/10/14 at 12:15 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that the PT and INR was not completed as ordered on [DATE] and 1/13/14. On 1/16/14, resident 48 was evaluated at the Emergency Department (ED). The ED physician documented: "...developed a large lump on the left side of his left subclavicular region. ...he was found to have a hemoglobin of 6 and an INR of greater than 6. Per the family, his INR was in fact checked last evening and was found to be 8, although why the patient was not brought to the hospital at that time is not clear. The patient has subsequently been admitted to the intensive care unit to receive aggressive treatment for [REDACTED]. 2. Resident 29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Findings include: On 6/10/14, resident 29's medical record was reviewed. Resident 29's physician ordered on [DATE]: 1) [MEDICATION NAME] 25 mg orally every day for an increased pulse rate and palpitations, and on 9/19/13: 2) [MEDICATION NAME] 40 mg orally every day for hypertension. The May 2014 Medication Administration Record [REDACTED]. The licensed nurse documented that the [MEDICATION NAME] and [MEDICATION NAME] were not administered "due to resident condition." On 6/11/14 at 10:10 AM, Licensed Practical Nurse (LPN) 2 was interviewed. LPN 2 was asked how she determined when to not administer [MEDICATION NAME] and [MEDICATION NAME] medications to resident 29. LPN 2 stated that she "generally withheld blood pressure medications if the resident's blood pressure was below 110/60." LPN 2 was shown on the May 2014 MAR indicated [REDACTED]. LPN 2 stated, "I probably should have gotten a doctor's order" regarding parameters for when not to administer resident 29's blood pressure medications. 3. Resident 82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/10/14, resident 82's medical record was reviewed. Resident 82's physician ordered on [DATE]: [MEDICATION NAME] 2.5 mg one tablet every day for hypertension. The June 2014 MAR indicated [REDACTED]. The licensed nurse documented that the [MEDICATION NAME] was not administered "due to resident condition." On 6/11/14 at 10:10 AM, Licensed Practical Nurse (LPN) 2 was interviewed. LPN 2 was asked how she determined when not to administer the [MEDICATION NAME] medication to resident 82. LPN 2 stated that she "generally withheld blood pressure medications if the resident's blood pressure was below 110/60." LPN 2 was shown on the June 2014 MAR indicated [REDACTED]. On 6/1/14 resident 82's blood pressure was 109/59. The [MEDICATION NAME] medication was documented as administered. LPN 2 stated, "I probably should get a doctor's order" regarding parameters of when not to administer resident 82's blood pressure medication. On 6/11/14 at 11:40 AM, the Director of Nursing (DON) was interviewed. The DON stated, "Nurses should learn in nursing school to obtain parameters for withholding blood pressure medications." The DON stated that the nurse should have called the doctor and obtained blood pressure parameters before withholding resident 29 and resident 82's blood pressure medications.

Based on observation, interview and record review, it was determined that for 1 of 32 sample residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance to prevent accidents. Specifically, a resident sustained [REDACTED]. Resident identifier: 83. Findings include: Resident 83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/9/14 at 10:15 AM, Registered Nurse (RN) 3 was interviewed related to resident 83's fall history. RN 3 stated that resident 83 fell while being transferred by the facility staff and sustained a fibula fracture. Resident 83's medical record was reviewed on 6/11/14. On 4/30/14, the facility staff completed an admission Minimum Data Set (MDS) assessment for resident 83. The facility staff assessed resident 83 as requiring extensive assistance of two or more people for bed mobility, transfers, and toileting. A Care Area Assessment (CAA) triggered for activities of daily living and falls. The facility staff documented that the CAA areas would be addressed in a care plan. Review of the care plans that were developed for resident 83 revealed the following: a. On 5/8/14 an "Activities of Daily Living (ADL's) (related to) ADL self-care deficit as evidence by needs assistance with bed mobility, transfers, locomotion, dressing, eating, toilet use, personal hygiene and bathing..." The goal that was developed for the ADL care plan was "Resident will maintain ADL self performance levels as evidenced by no decline in stated level for the next 21 days." The interventions implemented to achieve the goal included: (1) "Report changes in ADL self performance to nurse; ...(6) Provide only the amount of assistance/supervision that is needed stand-by, cueing/prompting/ contact guard, weight bearing; and ...(10) Explain all procedures and purpose prior to performing task and encourage self-performance..." b. On 5/8/14 a "Safety" care plan was developed related to "at risk for falls" due to "weakness, injury and a fall risk score (of) 38." The goal that was developed was "Resident will not sustain injury related to falling through next review." The interventions implemented to achieve the goal included: "...(2) Place call bell within each reach; (3) Cue for safety awareness; (4) Assist for toileting (and) transfers PRN (as needed). ..." The "Interdisciplinary Progress Notes" were reviewed. The facility staff documented: a. 5/11/14 at 5:04 AM: "Pt (patient) yelling help. Nurse went into room and pt states: 'Help, Help, I don't know where I'm at' Explained to patient where she was and why she was here. Still confused. Stating 'I still don't know where I'm at.' When I told pt. that she fell and broke her ribs and hurt her back, she looked surprised and asked me if that was why they hurt. She knows she is confused, but is hard to orient. ..." b. 5/11/14 at 7:01 AM: "Pt was being helped back from the toilet to her w/c (wheelchair) by the aide. He had one arm under her arm for support, and one hand under her buttocks. As she was turning her leg gave out and she went down. He eased her to the floor, ensuring that she did not hit her heat (sic). Her right knee slightly bumped the wall. It was apparent when he yelled for the nurse, that something was wrong, she was crying in pain, and the bone on her left knee was protruding. The nurse and aide helped the patient back to bed doing a two person threshold carry (her arms around both necks and our arms under her buttocks and upper legs). Pt was placed in bed and a pillow placed under her knee. C/O (complained of) 10/10 pain, hurts to move, hurts when touched. Contacted (primary care physician), orders to send her to the ER (emergency room ) for evaluation. Called dispatch and an ambulance came at 0530 (5:30 AM) and she was out the door to the hospital at 0550 (5:50 AM). Notified her son (name removed) of the fall at 0530 and he went to met her at the hospital." c. 5/11/14 at 12:59 PM: "Resident returned from ER Hosp (hospital) visit, has left fibula fx (fracture), long leg splint in place, ice pack applied to the site, elevated, as tolerated. Percocett (sic) 10 mg (milligrams) 1 to 2 q (every) 4 (hours) given for pain. Will follow up with (orthopedic surgeon). ..." The discharge paperwork, dated 5/11/14, from the hospital revealed a [DIAGNOSES REDACTED]. Displaced fracture present. Fall." On 6/12/14 at 8:32 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that the rehabilitation side of the facility had one Certified Nurse Assistant (CNA) working on the night shift. LPN 1 stated that the CNA was "sort of cradling" resident 83 in his arms when the fall occurred. LPN 1 stated that the CNA should have asked for assistance before transferring resident 83 related to her fragile condition of vertebral and rib fractures. On 6/12/14 at approximately 8:45 AM, the facility Director of Nursing (DON) was interviewed. The DON stated that resident 83 sustained a fibula fracture after sustaining a fall related to the way the CNA was transferring resident 83. The DON stated that the CNA that was transferring resident 83 received "One-On-One" transferring training on 5/14/14 to prevent additional injuries from occurring. On 6/12/14 at 9:15 AM, the Director of Nursing Administrative Assistant (DONAA), who functioned as the CNA Supervisor, was interviewed. The DONAA stated that the CNA did not ask for assistance prior to transferring resident 83 and that resident 83 required two people to transfer her.

Based on interview and record review, it was determined the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 32 sample residents. Specifically, a resident was found to have a Cerebrospinal Fluid (CSF) leak after a surgical procedure. The resident complained of "severe" headaches for ten days before his neurosurgeon was notified. Resident identifier: 113. Findings include: Resident 113 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident 113's medical record was reviewed on 6/10/14. An Interdisciplinary Team (IDT) Care Plan Meeting note dated 3/11/14 revealed the following information, "...(Resident 113) stated he has experienced headaches since fall..." A Clinical Summary Note from resident 113's Cardiologist, dated 3/14/14 revealed the following information, "...He has a bad headache a lot too and they haven't been giving him any tylenol or anything...He can certainly get tylenol 650mg (milligrams) every 4-6 hours as needed..." The March 2014 Medication Administration Record [REDACTED] a. 3/14/14 at 1:09 PM, "FOR HA (headache)". The result of the Tylenol was documented on 3/14/14 at 2:00 PM as, "HELPFUL". b. 3/15/14 at 10:00 AM, "c/o (complains of) pain". The result of the Tylenol was documented on 3/15/14 at 10:37 AM as, "effective". c. 3/15/14 at 2:46 PM, "c/o headache". The result of the Tylenol was documented on 3/15/14 at 4:07 PM as, "effective". d. 3/15/14 at 7:29 PM, "pt (patient) request for a HA". The result of the Tylenol was documented on 3/15/14 at 11:09 PM as, "helpful with H/A". e. 3/17/14 at 8:23 AM, "for ha". The result of the Tylenol was documented on 3/17/14 at 12:13 PM as, "HELPFUL". f. 3/17/14 at 2:09 PM, "PT REQUESTED FOR HA". The result of the Tylenol was documented on 3/17/14 at 3:07 PM as, "HELPFUL". g. 3/17/14 at 7:00 PM, "pt req (request) for HA". The result of the Tylenol was documented on 3/18/14 at 12:21 AM as, "pt reports decreased HA". h. 3/18/14 at 7:29 AM, "2 tabs for HA". The result of the Tylenol was documented on 3/18/14 at 11:55 PM as, "pt reports decreased HA" i. 3/18/14 at 12:45 PM, "PER PT REQUEST". The result of the Tylenol was documented on 3/18/14 at 11:55 PM, "pt reports decreased HA". j. 3/18/14 6:35 PM, "PER PT REQUEST". The result of the Tylenol was documented on 3/18/14 at 11:55 PM as, "pt reports decreased HA". k. 3/19/14 at 9:04 AM, "c/;o (sic) headache". The result of the Tylenol was documented on 3/19/14 at 9:49 AM as, "helped a little". l. 3/19/14 at 2:09 PM, "c/o headache". The result of the Tylenol was documented on 3/19/14 at 4:33 PM as, "effect". The facility's Pain Clinical Protocol was reviewed and revealed the following information: Assessment and recognition: "...2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain." "...3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain." Cause Identification: "1. The physician will help identify causes of pain; for example, by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff." "...2. As part of the medical assessment, the physician will help identify the extent to which underlying causes of pain can be addressed or reversed." "3. The physician will perform or order appropriate tests as needed to help clarify sources (sic) pain. For example, an x-ray may help to identify the cause of joint pain." Review of the Nurse's Notes revealed the following entries: A. 3/19/14 at 2:25 PM, "...Pt has stayed in bed all shift related to passing out and c/o headache...(Facility Medical Director) in to see PT this AM. He is going to meet with (Resident 113's Primary Care Physician (PCP) and go over test results to see if they can find a reason for the orthostatic [MEDICAL CONDITION]" B. 3/20/14 at 2:39 PM, "...(Resident 113's PCP) in to see (Resident 113)..." C. 3/20/14 at 6:42 PM, "(Resident 113's PCP) TO (Telephone Order): CT (computed tomography) MYELOGRAM TOMORROW AT 9 AM AT (local hospital)... (Resident 113's PCP) STATES TO R/O (Rule Out) CSF LEAK FROM SURGERY." D. 3/21/14 at 1:35 PM, "PT WENT TO HOSPITAL AND GOT CT. (Patient 113's PCP) CALLED AND REPORTED WITH (staff) STATING PRELIMINARY REPORT SHOWED CSF LEAK. PRELIMINARY REPORT GIVEN TO FAMILY AFTER (Resident 113's PCP) SPOKE WITH (Resident 113's) daughter (name redacted), AND HE GAVE REPORT ON CSF LEAK TO HER. HE WANTED THEM TO GET TRANSPORTED TO (local hospital) ASAP (As Soon As Possible). TRANSPORTATION FOR PARKWAY WAS BUSY SO (Staff) TRANSPORTED HIM. THEY WILL CHECK IN WITH (local hospital) ER (emergency room ) TO GET ONCALL NEUROSURGEON." (Note: No documentation could be found showing that resident 113's surgeon was contacted regarding resident 113's headache's.) On 3/20/14 at 1:00 PM, resident 113's PCP wrote the following regarding resident 113 in his physician note, "... has HA with sitting upright. better with laying down. I am concerned that there could a (sic) minor CSF leak. I will order a CT myelogram of his back..." Review of the History and Physical Report written by resident 113's Neurosurgeon on 3/21/14 obtained on 6/10/14 at 1:58 PM revealed the following information regarding resident 113, "... his headaches have increased, and he does have what appear to be positional headaches. He had a CT myelogram performed today at (local hospital), which hints that there may be a leak at the L4-5 level with a pseudo[DIAGNOSES REDACTED]..." An Operative Report written by resident 113's Neurosurgeon on 3/25/14 obtained on 6/10/14 at 1:56 PM revealed the following information, "OPERATIVE FINDINGS: Right anterolateral durotomy with CSF leak at the L4-5 disk space." On 6/10/14 at 12:43 PM, an interview was conducted with Registered Nurse (RN)1. RN 1 stated that the DON (Director of Nursing) told her to chart pain on a 0-10 scale. RN 1 stated that if a resident had back surgery she would watch for signs and symptoms of infection and watch for bleeding. RN 1 also stated that if the resident had recurring headaches they could have a CSF leak and she would call the doctor. On 6/10/14 at 12:47 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she had worked with resident 113 and remembered him having dizziness, but that she could not recall the headaches. LPN 1 stated that with a back surgery resident she would watch for swelling or tenderness at the incision site and that if a resident had headaches she would call the doctor and see what he wanted her to do. (Note: LPN 1 gave 2 doses of Tylenol to resident 113 on 3/17/14 because he had a headache.) On 6/11/14 at 9:48 AM, a phone interview was conducted with resident 113. Resident 113 stated that he had, "Severe headaches and they tell me that was due to leakage of spinal fluid in my spine..." Resident 113 stated that his headaches were worse if he was sitting up or moving and better if he was lying down and not moving. Resident 113 stated that the pain he experienced from his headaches on a 0-10 scale, 0 being no pain and 10 being the worst pain he could imagine, "If I moved 9..." On 6/11/14 at 10:06 AM, an interview was conducted with RN 2. RN 2 stated that she remembered that resident 113 had headaches. RN 2 then stated, "O yeah there was definitely something going on with his back surgery." RN 2 stated that she didn't recall whether or not she had called resident 113's doctor to inform him of resident 113's recurrent headaches. When asked if she would be concerned that resident 113's headaches could indicate a CSF leak RN 2 stated that, "... I have not really had experience with that (a resident who has had back surgery) he was probably my first patient with that (back surgery) now that you say that it, it does come back to my mind that it would be a concern of CSF leak. It probably didn't dawn on me at the time that he could have had a leak. It's not an excuse that I am here one day a week but I try to catch up on what has happened..."

Based on interview and record review it was determined, for 1 of 30 sample residents, that the facility did not ensure that all residents were cared for in a manner and in an environment that promoted maintenance or enhancement of each resident's quality of life. Specifically, the facility Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator did not report or act upon a resident's complaint of mistreatment or that she was afraid of a Certified Nursing Assistant (CNA). Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/24/13, resident 21 was interviewed regarding staff abuse. Resident 21 stated that a staff member had been rough with her while providing cares. Resident 21 stated that she was afraid of the staff member and did not know if the staff member was going to hurt her. Resident 21 stated that she had reported the incident to several nurses and they had not acted upon her report of the Certified Nursing Assistant's (CNA) treatment. Resident 21 stated that the staff member was still working at the facility. Resident 21 stated, "I don't want her taking care of me, I don't want her around me, she scares me. Resident 21 stated, "I am afraid that she will hurt me." On 6/26/13 at 7:18 AM, resident 21 was re-interviewed. Resident 21 stated that CNA 1, "is rough with me, she grabs my arm to pull me up instead of gently trying to assist me in getting up" and that CNA 1, "is really strong and I'm old and weak, I'm afraid that she will come in and hurt me." Resident 21 stated that her feet were swollen from gout, she had a prior ankle fracture and that it was too painful to walk to the bathroom. Resident 21 further stated that, "CNA 1 will yell at me and tell me 'you can walk to the bathroom', instead of getting my wheelchair to take me to the bathroom." Resident 21 stated that she had reported the complaint about CNA 1 to several people in her care conference. When resident 21 was asked if anyone had come back to her to report that the problem had been resolved, resident 21 answered, "No." On 6/26/13 a medical record review was conducted for resident 21. Resident 21's Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 21's functional status for toilet use and personal hygiene was "Limited 1 person assistance." Resident 21's MDS dated [DATE] revealed that resident 21's functional status for toilet use and personal hygiene was "extensive 1 person assistance." A nurses note dated 6/13/13 at 18:18 (6:18 PM), revealed that "Pt (patient) refused to get up and walk to the bathroom throughout the morning, pt c/o (complains of) pain to her left ankle, state (sic), 'I broke a (sic) few years back and it will hurt every once in a while', pt's (patient's) ankle slightly swollen, pt agreed to get up and walk to w/c (wheelchair) to go to the bathroom when needed for a few days until her ankle started feeling better." On 6/26/13 at 9:30 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that resident 21's care conference took place on 6/13/13 at 2:00 PM. The RA further stated that she did not conduct the care conferences on 6/13/13. The RA stated that the care conferences were conducted on 6/13/13 by the DON and the MDS Coordinator. On 6/26/13 at 9:45 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that she was in the care conference for resident 21 on 6/13/13 and that resident 21 did not have any complaints. On 6/26/13 at 9:55 AM, an interview was conducted with the DON. The DON stated that she was in the care conference for resident 21 on 6/13/13 and that resident 21 did not have any complaints. On 6/26/13 at 10:55 AM, an interview was conducted with the Administrator. The Administrator stated that he and the RA took care of all of the abuse complaints in the facility. The Administrator stated that he had not received any complaints of abuse since the last survey and had no investigations to report. On 6/26/13 at 1:12 PM, a telephone interview was conducted with CNA 1. CNA 1 stated that she worked on the rehabilitation floor and the long term floor of the facility. When asked about working with resident 21, CNA 1's tone of voice appeared to raise in pitch. CNA 1 stated that resident 21 was a "hard resident" and that resident 21 "can get herself up and knows when she has to go to the bathroom and knows when she is going to the bathroom in her brief." CNA 1 stated that resident 21 "constantly gives excuses as to why she can't do things and thinks that I'm attacking her or treating her bad, she changed overnight from being independent to dependent." CNA 1 continued, "When she asked me to change her brief, she told me that her ankles were hurting and she was upset that I was treating her like a 2 year old because I wanted her to walk, I don't want her to end up dependent, you can totally tell she can do more than she does. I have done nothing wrong to hurt her, I've never transferred her to the wheelchair, just to walk with her and I don't have to assist her with her walking. You can ask the other CNAs how she is." On 6/26/13 a review of the facility CNA schedule was conducted. The CNA schedule for June 2013 revealed that CNA 1 was on the schedule throughout the month of June 2013 and was going to be scheduled prn (as needed) throughout the month of July 2013. No observations of changes were made to the June schedule to indicate that CNA 1 had been reassigned to another floor, away from resident 21. CNA 1 continued with her assigned duties including assisting other residents with daily cares. On 6/26/13 at 1:25 PM, an interview was conducted with the MDS coordinator. The MDS Coordinator was asked if resident 21 had a complaint in the care conference about any of the CNA staff. The MDS Coordinator stated, "that's right, she did report that a CNA was rough with her. I had forgotton about that." When asked who the CNA was, the MDS Coordinator stated, "I'm trying to think" but was unable to remember the name of the CNA. When asked if it was CNA 1, the MDS Coordinator stated, "possibly". When asked why that information was never reported to the Administrator, the MDS Coordinator stated, "Well, the DON was in there." On 6/26/13 at 1:30 PM, an interview was conducted with the DON. The DON was asked if resident 21 had a complaint in the care conference about any of the CNA staff. The DON stated that "(resident 21) did report that there was a CNA that had treated her roughly." When the DON was asked why she did not report that to the Administrator, the DON answered, "that CNA is no longer here." When this surveyor explained to the DON that the CNA worked throughout the month of June 2013 and was on the schedule to be prn throughout July 2013, the DON stated, "I will give (CNA 1) a call." On 6/16/13 at 1:50 PM, an interview was conducted with the RA. The RA stated that she was the one to report complaints of abuse to the Administrator when she received them. The RA stated that the facility had an inservice in February 2013 from Adult Protective Services (APS) regarding abuse. The RA stated that abuse was not tolerated but that she had not been made aware of the complaint by resident 21 regarding CNA 1. On 6/16/13 at 2:50 PM, an interview was conducted with the Administrator. The Administrator was informed of the findings regarding resident 21 and CNA 1 and was given an opportunity to find any additional information, investigation and/or documentation that the facility may have had to show that the problem had been resolved. The Administrator stated, "there isn't anything." On 6/26/13 a review of the facility Abuse Policy and Procedures was conducted and revealed the following: The Abuse Investigations Policy Statement revealed, "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management." The Abuse Investigations Policy Interpretation and Implementation revealed the following: "1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.... 9. Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator. (See policies governing employee sanctions and reporting requirements.)" No documentation could be found to show that CNA 1 was assigned to non resident care duties after resident 21 reported her concern to the DON and MDS Coordinator. The Abuse Prevention Program Policy Statement revealed, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion." The Abuse Prevention Program Policy Interpretation and Implementation revealed the following: "1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to : facility staff.... 2. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. a. Protocols for conducting employment background checks; b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse...; c. Identification of occurrences and patterns of potential mistreatment/abuse; d. The protection of residents during abuse investigations; e. The development of investigative protocols governing resident abuse, theft/misappropriation of resident property, resident-to-resident abuse and resident-to-staff abuse; f. Timely and thorough investigations of all reports and allegations of abuse; g. The reporting and filing of accurate documents relative to incidents of abuse; h. An ongoing review and analysis of abuse incidents; and i. The implementation of changes to prevent future occurrences of abuse." The Preventing Resident Abuse Policy Statement revealed that "Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse." The Preventing Resident Abuse Policy Interpretation and Implementation revealed the following: "1. The facility's goal is to achieve and maintain an abuse-free environment. 2. Our abuse prevention/intervention program includes, but is not limited to, the following: a. Training all staff and practitioners how to resolve conflicts appropriately; b. Allowing staff to express frustration with their job, or in working with difficult residents; c. Assisting or rotating staff working with difficult or abusive residents...; i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.)...; o. Identifying areas within the facility that may make abuse and/or neglect more likely to occur (e.g., secluded areas) and monitoring these areas regularly; p. Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met; and q. Encouraging all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately." The Reporting Abuse to Facility Management Policy Statement revealed "It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse...." The Reporting Abuse to Facility Management Policy Interpretation and Implementation revealed the following: "1. Our facility does not condone resident abuse by anyone, including staff members.... 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: a. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physican harm, pain or mental anguish. b. 'Verbal abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability.... e. 'Mental abuse' is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. f. 'Neglect' is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 3. All personnel, residents, fmaily members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 4. Employees, facility consultants and/or Attending Physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty.... 6. Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. 7. Staff members and persons affiliated with this facility shall not knowingly: b. ...Fail to report an incident of mistreatment or other offense...; 13. Upon receiving information concerning a report of abuse, the Director of Nursing Services will request that a representative of the Social Serives Department monitor the resident's reactions to and statements regarding the incident and his/her involvement in the investigation...." No documentation could be found to show that the Director of Nursing reported resident 21's concern to the Administrator. No documentation could be found to show that the facility investigated resident 21's concern regarding CNA 1.