Every finding on record at Royse City Medical Lodge

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that:The facility failed to ensure food items in the facility walk-in refrigerator were dated and labeled on 2/10/2026.These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination.Finding included:Observation on 2/10/2026 at 9:13 AM of the walk-in refrigerator revealed one block of cheese wrapped in plastic and one pack of lunch meat not dated or labeled.In an interview on 2/11/2026 at 10:30 AM with the Consultant Dietitian revealed her expectation was that all food items in the kitchen should be appropriately labeled and dated. She stated that if the deli meat and cheese block was taken out of the original packaging, it should be labeled and dated with received date. She stated that the risk to residents of not appropriately dating and labeling food items was potential food borne illness.During an interview on 02/11/2026 at 1:09 PM with the Dietary Manager revealed that cooks were typically responsible for labeling and dating food items with received date or open date when they were stored in the refrigerator. She stated she expected all kitchen staff to date and label food items. She stated that risk of not labeling food items was food contamination and could make the residents sick. She stated that she provided frequent in-services to all kitchen staff on appropriate food storage. In an interview on 02/11/2026 at 1:17 PM with [NAME] B revealed she had been working as a cook in the facility for the last 6 years. She stated that everyone working in the kitchen were responsible for dating and labeling food items in the kitchen. She stated that they typically write used by date on all open items and received date on food items that were not opened. She stated that not labeling and dating food items could cause cross contamination and potentially cause illness in residents.Record Review of the facility policy titled Food Storage revised June 1, 2019, reflected, .2. Refrigerator.Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.Review of the Food and Drug Administration Food Code, dated 2022, reflected, 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review, the facility to all the residents the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. 2 (Resident #2 and Resident#59) of 8 residents reviewed advanced directives. 1- The facility failed to obtain a physician order for a DNR in a timely manner after Resident #2 signed a DNR on [DATE]. 2- The facility failed to obtain a physician order for a DNR in a timely manner after Resident#59 signed a DNR on [DATE]. The care plan did not reflect the correct code status.These failures could place residents at risk of not having a physician order followed and could affect the rights of residents that elected a DNR and could result in the facility not honoring the resident's wishes. 1- Record review of Resident #2's Face Sheet dated [DATE] reflected resident was a [AGE] year-old male with an original admission date of [DATE] and re-admission date on [DATE]. Relevant diagnoses included unspecified Dementia (cognitive decline affecting daily life), Cognitive Communication Deficit, Type 2 Diabetes, Atherosclerotic heart disease (a heart condition caused by plaque buildup arterial walls) and Neurocognitive Disorder (a condition involving significant decline in mental functions). Record review of Resident #2's MDS assessment dated [DATE] reflected Resident #2 was unable to complete cognitive testing. Review of Resident #2's Out of Hospital Do Not Resuscitate Order reflected a completed form with a signature dated [DATE]. Review of Resident #2's physician orders dated [DATE] reflected an order for DNR dated [DATE]. During an interview with the MDS Nurse on [DATE] at 10:46am revealed the process for DNRs was the Social Worker completed the DNRs with the residents or their representatives, then the DNRs were provided to the ADONs and they obtained an order from the residents' physicians and entered it in the medical record. Once the order was entered into the system, the DNR warning for the residents would be visible in their record. She stated there could be a risk to the resident if an order by the physician was not entered timely after the resident signed their DNR because they (staff) could perform code against residents' wishes. The MDS Nurse stated when a resident had an emergency, staff would look at the physician orders to determine if they could perform CPR. During an interview with the DON on [DATE] at 10:58am revealed Resident #2 had signed the DNR on [DATE] but the physician order was not signed until [DATE]. She stated her ADONs oversaw orders after a DNR was signed. The DON stated it was an oversight that Resident #2 did not have an order immediately following the signed DNR. She stated she was made aware of Resident #2 not having had an order during an audit and it was corrected on [DATE]. The risk to the resident of not having had a DNR order in the medical record timely was, the resident could have gotten CPR against their wishes. During an interview with ADON E on [DATE] at 1:49 PM revealed it was the responsibility of the social worker to make sure that residents' wishes regarding a DNR were granted. ADON E stated DNRs were discussed with residents during care planning. The DRNs were then handed to the ADONs so they could obtain the physician orders. The DNR paperwork should have been given by the social worker to the ADONs the same day. ADON E stated when she received the DNR paperwork she would put the order in the system on the same day it was signed. ADON E stated she did not know why there was a delay in obtaining the DNR from the social worker for Resident #2. She did not recall receiving Resident #2's DNR but obtained the order for his DNR during a random audit in [DATE]. The risk to the Resident of not having had the order for the DNR entered timely was the resident could have stopped breathing and the staff could have done CPR, which would have been against the families wishes. ADON E stated the residents face sheet changed in their medical record once the order for the DNR was entered into the system. 2- Record review of Resident #59's Quarterly MDS assessment dated [DATE] reflected Resident #59 was a [AGE] year-old female admitted to the facility on [DATE], and readmitted [DATE] with diagnoses included hypertension (elevated blood pressure), cerebrovascular accident (a medical emergency occurring when blood flow to the brain is interrupted or reduced, causing brain cells to die), Hemiplegia or Hemiparesis (both neurological conditions causing one-sided body weakness, typically due to stroke, brain injury, or tumor), non-Alzheimer's dementia (distinct brain disorders (e.g., Vascular, Lewy Body, Frontotemporal) that often present with early personality changes, hallucinations, or motor issues rather than memory loss), and seizer disorder (a chronic neurological condition characterized by recurrent, unprovoked seizures caused by sudden, abnormal electrical activity in the brain). Resident #59's had a BIMS score of 08/15, which indicated moderate cognitive impairment. Record review of Resident#59's care plan with revision date [DATE] revealed Focus: Resident#59 has elected a FULL CODE status. Goal: Resident/RP wishes will be respected x90 days. Intervention: Honor wishes Inform care givers of Full code Notify MD and family as soon as possible start of CPR and call 911. Record review of Resident #59's advance directive revealed Resident#59 signed Do not resuscitate form on [DATE], and the form was scanned to the PCC the same day ([DATE]). Record review of Resident#59's primary provider orders revealed summary order DNR (Do Not Resuscitate) dated [DATE]. Interview on [DATE] at 1:25 PM MDS nurse, she stated she did the care plan review quarterly. She stated the SW worker was responsible for getting the advance directive form signed by the Resident/ Resident representative and passed the form to the ADON to transcribe the order in the PCC. She stated the care plan not been updated with the correct advance directive will not affect the Resident because the nurses check the face sheet in case of emergency and the face sheet reflected the correct advance directive once the order was transcribed to PCC. She stated Resident#59's advance directive order not been transcribed to the PCC from [DATE] to [DATE] could lead to Resident#59 been resuscitated against her wishes. Interview on [DATE] at 1:49 PM ADON E stated if Resident#59 wishes were not followed properly and after the signature of the DNR form if the order was not in the system, the Resident could be resuscitated against her wish. She stated it was her responsibility to transcribe the DNR form order to the PCC once it was signed by the Resident or her representative. She stated the SW was responsible for getting the DNR form signed by the Resident or his/her representative and hand it to her to transcribe it to PCC. ADON E further stated she did not know how the order was not placed in PCC for one month and half. She further stated the Resident's face sheet changed once the order was in the PCC. Attempted to call Social Worker regarding Resident #2's signed DNR on [DATE] at 2pm and received no response. Requested Social Worker call Surveyor back but did not receive a call back. Interview on [DATE] at 2:04 PM the Medical Record staff stated the SW worker would give her or put in the basket (Basket for form/papers to be scanned) the DNR form signed, and she will scan it to PCC. The Medical Record staff stated her responsibility was just to scan the forms/papers staff member put in the basket for her to scan. She further stated it was not her responsibility to notify anyone about the scanned papers, because all the staff members that had access to PCC could see the scanned documents. Record review of the facility's policy Advance Directives revised [DATE] reflected .20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices, which enabled residents to transfer independently, for one (Resident #7) of three residents reviewed for assistive devices.The facility failed to obtain physician's order prior to installing Resident #7's Trapeze bar used for mobility and transfers (trapeze bar is an overhead assistive device designed for residents, with limited mobility to safely lift, reposition, or transfer themselves in and out of bed)This failure could affect residents by placing them at risk for not having their physician orders followed and decline in resident's mobility. Findings include:Record review of Resident #7's Quarterly MDS assessment dated [DATE] revealed Resident # 7 was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included: Peripheral vascular disease (narrowed blood vessels usually in the legs), Stroke (interruption of blood flow to the brain), Cerebral Palsy (permanent, non-progressive neurological disorders appearing in infancy that affect movement, muscle tone, and posture due to abnormal brain development or injury), Diabetes (high blood sugar), Hyperlipidemia (high blood lipids), generalized muscle weakness. Her BIMS score was 15 which indicated Resident #7 was cognitively intact. Resident #7 needed supervision or touching assistance for transferring from chair /bed to chair.Record Review of Resident #7's care plan revised on 12/12/25 reflected, Focus: [Resident #7] has an ADL self-care performance deficit [for Bilateral Above Knee Amputation], Developmental Disability, Reduced mobility. Intervention: Trapeze bar to assist with positioning.Record review of Resident #7's physician orders with the DON on 2/12/2026 revealed Resident #7 did not have a physician order for trapeze bar for mobility.In an observation and interview on 02/10/2026 at 12:38 PM with Resident #7 revealed she was in her wheelchair that was placed next to her bed. Resident #7 had bilateral above knee amputation. There was a free-standing trapeze bar above the bed. Resident #7 stated that she used trapeze bar for mobility from bed to wheelchair and back. She stated that the trapeze bar was put in about 5-6 months ago on her request. She stated she had a Trapeze bar at home and wanted one in the facility for easier transfers.In an interview on 02/11/2026 at 11:42 AM with ADON A stated that therapy department mostly provides recommendation for mobility devices. The charge nurses were then responsible for obtaining orders, discussing with the physician and transcribing them to physician orders. She stated that she did not remember if Resident #7 had physician orders for the trapeze bar. She stated that the risk of not having a physician order was residents would not get the care they need.In an interview on 02/11/26 at 11:55 AM with LVN C stated that she was not aware that there was no order for Trapeze bar. She stated that therapy sends recommendations and nurses would put in the physician order on behalf of the physician. She stated that having a physician order was important, so the resident receives the care. She stated that she did not know when the resident got the trapeze bar but stated she had seen the resident using the bar while transferring. In an interview on 02/11/2026 at 2:19 PM, the Director of Rehab (DOR) stated that Resident #7 received physical therapy services in the facility. The DOR reported that Resident #7 got out of bed independently, transferred herself to a wheelchair, and brought herself to the therapy room. The DOR stated that the trapeze bar was not recommended by therapy but acknowledged that it assisted with resident mobility due to the resident's bilateral above knee amputation. She stated that therapy department had observed Resident #7 transferring herself using the trapeze bar safely. She further stated that therapy provides recommendations for mobility devices and then handed them to the nursing department to be transcribed into physician orders. The DOR emphasized that physician orders were required for all mobility devices. In an interview on 2/11/26 at 2:30 PM with the DON stated that the trapeze bar was considered adaptive equipment and was therefore included in the resident's care plan. She reported that the physician was aware of and in agreement with the use of the trapeze bar and had approved it verbally. She acknowledged that the trapeze bar should have had a corresponding physician order in the medical record. The DON explained the risk associated with not having a written physician order, emphasizing that staff must follow physician orders for all mobility and adaptive devices to ensure resident safety and accurate documentation. The DON confirmed that maintenance installed the trapeze bar per Resident #7's request. In a phone interview on 02/11/2026 at 2:48 PM with the MDS Nurse stated that usually MDS and care plans were developed based on active physician orders. She stated that she observed Resident #7 transferring herself while holding the trapeze bar during a transfer in December 2025 and added it to her care plan. She reported that she did not check for a physician order for the trapeze bar at that time. She stated that having a physician order was important for accurate documentation.In an interview on 02/12/2026 at 9:59 AM with the Maintenance Director stated that for installing any mobility device, the process typically involved the ADON obtaining a physician order before equipment was put into place. The Maintenance Director stated that the trapeze bar for Resident #7 had been in place for approximately 5-6 months and he did not recall whether he checked with Nursing regarding Physician order for the same.In a follow-up interview on 02/12/2026 at 12:33 PM with the DON she stated that facility did not have specific policy for obtaining physician orders for mobility devices, however her expectation was staff followed nursing standards of practice which required obtaining a physician order for all resident care needs.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 (Resident #4) of 6 residents observed for infection control. The facility failed to ensure LVN D and CNA F wore appropriate PPE when transferring Resident #4 on EBP isolation from shower chair to bed on 02/10/26.This failure could place residents at risk for infection and cross contamination of pathogens and illness. Record review of Resident #4's Quarterly MDS assessment dated [DATE] reflected Resident #4 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included hypertension (elevated blood pressure), type 2 diabetes (elevated blood sugar), cerebrovascular accident (a medical emergency occurring when blood flow to the brain is interrupted or reduced, causing brain cells to die), Hemiplegia or Hemiparesis (both neurological conditions causing one-sided body weakness, typically due to stroke, brain injury, or tumor), non-Alzheimer's dementia (distinct brain disorders that often present with early personality changes, hallucinations, or motor issues rather than memory loss), and cognitive communication deficit. Resident #4 had a BIMS score of 09/15, which indicated moderate cognitive impairment. The MDS assessment indicated Resident #4 was coded 09 for Tub/shower transfer indicating: Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. Record review of Resident #4's Care Plan dated 12/10/25, reflected the following: Focus: [Resident #4] has an ADL self-care performance and require staff assistance for all ADL's . Goal: The resident will maintain current level of function through the review date. Interventions: . Hoyer lift for transfers . Staff to assist with all ADL's as required .Review of Resident#4 Doctor order summary dated 02/10/26 and active revealed Nursing intervention: implement and maintain enhanced barrier precautions when performing high contact care activities. Diagnosis wound Observation on 02/10/26 at 10:31 AM, revealed there was signage on the right side of Resident #4's door that read: Enhanced barrier precautions everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also: wear gloves and gown for the following high-contact Resident care activities. Inside Resident #4 room, there was PPE supplies (gloves, gowns.) stored on a supplies storage plastic drawers sitting on the top of the Resident's nightstand. CNA F was observed exiting Resident #4's room with gloved hands. CNA F removed her gloves, put them in the housekeeper trash humper, sanitized her hands with hands sanitized dispenser in the Hallway, and went looking for someone to help her transfer Resident#4 from shower chair to bed. CNA F and LVN D entered Resident #4's room. Both CNA F and LVN D washed their hands, put on clean gloves and did not put on gowns. Resident #4 was seen sitting in the shower chair covered with a blanket with the Mechanical lift sling under her. A Mechanical lift was observed next to Resident #4's bed. LVN D and CNA F attached the lift sling to the Mechanical lift and transferred Resident #4 from chair to bed. Once the transfer was completed, both staff turned Resident #4 side to side and removed the sling. LVN D removed her gloves, washed her hands, and exited the room. CNA F removed her gloves, took the Mechanical lift outside the room, and sanitized hands. In an interview and observation on 02/10/26 at 10:47 AM, LVN D stated she did not put the gown on, because she did not notice the signage at the entrance of the room, was not familiar with the resident, and it was her first day on the job. LVN D looked at the signage by the door, and reentered the room, and located the supplies at Resident#4 room, and stated yes the EBP was for Resident#4. LVN D stated that residents' transfer was a form of high contact with the Resident on EBP that required wearing a gown and gloves. She said the risk of not wearing appropriate PPE was increased risk of infection and possible cross contamination to the residents. In an interview on 02/10/26 at 10:52 AM, CNA F revealed she was a hospice Aide, that had been coming to the facility to render hospice service to Resident #4. She stated she did not know that Resident #4 was in EBP, and she did not notice the signage by the room entrance. She stated when she stepped outside the room with gloved hands, she was looking for help with Resident #4's Mechanical transfer. She said the risk of not wearing appropriate PPE was increased chance of infection and possible cross contamination to the residents. Interview with the DON on 02/12/26 at 10:26 AM, she stated for the EBP they had signage outside the resident's room, and for any high contact activity with the resident on EBP including transfer, peri care .staff should be gowning and gloving. She stated she and the staffing coordinator were responsible for training staff on infection control. The DON further stated training for EBP was done on hire, on monthly staff meeting, and as needed. The DON stated training for hospice agency staff was done by their agency, and sometimes she incorporated them with her staff training. The DON stated they used EBP to prevent infection to high-risk residents. Review of the facility policy titled Implementation of Standard and Transmission-Based Precautions dated 03/2024 revealed .3. Enhanced Barrier Precautions (EBP) - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities.I. Enhanced-Based Precautions are indicated during: . Bathing/showering in a shared/common shower room. Transferring .

Based on observation, interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 9 residents (Resident #61) reviewed for accuracy of assessments. The facility failed to accurately complete Resident #61's Quarterly MDS Assessment on 12/12/25 related to prescribed opioid medication use. This failure could place the resident at risk of not appropriately monitoring her medicationsFindings included: Record review of Resident #61's face sheet dated 2/12/26 reflected an [AGE] year-old female with an original admission date of 12/10/11 and readmission date of 12/22/22. Pertinent diagnoses included chronic kidney disease (long term progressive loss of kidney function, where kidneys are damaged and unable to properly filter waste), Acute and Chronic Respiratory Failure (the inability of the lungs to exchange oxygen and carbon dioxide) and Carcinoma of anus (cancer of the anus). Record review of Resident #61's Quarterly MDS assessment, dated 12/12/25 reflected resident had no cognitive impairment and had a BIMS of 15. Section N reflected resident continued antidepressant and antiplatelet medication, but Opioid medication was not checked. Record review of Resident #61's Order Summary Report as of 2/12/26, reflected a physician order dated 8/17/23 for Norco Oral Tablet 7.5-325 mg every 4 hours as needed. Record review of Resident #61's Medication Administration Record for December of 2025 reflected in the 7 days prior to the MDS completion, Norco Oral Tablet 7.5-325mg was given to Resident #61 on 12/5, 12/9 and 12/11. Interview and observation with the MDS Nurse Coordinator on 2/12/26 at 10:45am revealed she had last updated Resident #61's MDS assessment on 12/12/25 and it was her quarterly assessment. The MDS Nurse Coordinator reviewed Resident #61's assessment and noted Opioids were not checked off . She then reviewed the medical record for Resident #61 and stated the resident received opioid medication 7 days prior to when she completed the MDS assessment and therefore opioid should have been checked off on the MDS assessment. She stated she must have overlooked that the resident had received opioid medications when she completed the MDS assessment. The MDS Nurse Coordinator stated she got information to complete the quarterly MDS assessment from the MARS, CNA documentation, nurses' documentation, physician orders and progress notes. Some of the sections required a 7 day look back period and the medication section was one of those areas. The MDS Nurse Coordinator stated if something was not properly coded on the MDS assessment it could affect the care planning for the residents and managing/monitoring of their medications. The RAI manual was used to help her determine what she coded. She completed MDS training annually or as needed when CMS did updates. In an interview with the DON on 2/12/26 at 3:00pm revealed the MDS Nurse Coordinator was responsible for accurately completing the MDS Assessments of all residents. The facility did not have a policy for MDS Assessments because they used the RAI requirements set out by CMS. Record review of CMS's RAI Version 3.0 Manual effective October 2024 reflected .N0415H1. Opioid: Check if an opioid medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

49837 Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 5 (Resident#34, Resident #36, Resident #39, Resident#55, and Resident #76) of 8 residents reviewed for ADLs. The facility failed to ensure Resident#34, Resident #36's, Resident #39's, Resident#55, and Resident #76's nails were cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1. Record review of Resident # 39's Face Sheet dated, 10/17/24, reflected an [AGE] year-old woman admitted on [DATE] with diagnoses of vascular dementia (brain damage caused by multiple strokes), psychotic disturbance (a severe mental disorder that causes a person to lose touch with reality and have abnormal perceptions and thoughts), mood disturbance (a range of psychiatric conditions that affect a person's emotional state), and anxiety. Record review of Resident #39's Quarterly MDS assessment dated [DATE], reflected Resident #39 had a BIMS 6 indicated Resident #39's cognition was severely impaired. Further review of MDS assessment for Resident#39's self-care revealed she was partial to moderate assistance. Record review of Resident #39's Comprehensive Care Plan, revised 02/23/24, reflected the following: Focus: [Resident #39] has an ADL self-care performance and require staff assistance for all ADLs related to hemiplegia (partial or complete paralysis of one side of the body, usually affecting the arm, leg and face). Interventions: Staff to assist with all ADLs as required. Bathing/Showering: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. In an observation and interview on 10/15/2024 at 10:23 AM with Resident #39 revealed her nails on both hands were approximately 0.5 - 0.7 centimeter in length extending from the tip of his fingers. Resident #39 stated she had not had her nails cut in a long time. Resident #39 could not remember the last times her nails were cut. 2. Record review of Resident # 36's Face Sheet dated, 10/17/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of muscle wasting and atrophy (the decrease in size and wasting of the muscle tissue), other lack of coordination (poor muscle control that causes clumsy movements), and need for assistance with personal care. Record review of Resident #36's Quarterly MDS assessment dated [DATE] reflected Resident #36 had a BIMS of 3 which indicated Resident #36's cognition was severely impaired. Further review of MDS assessment for Resident#36's self-care revealed he was substantial to maximal assistance. Record review of Resident #36's Comprehensive Care Plan, revised 02/05/24, reflected the following: Focus: [Resident #36] has an ADL self-care performance deficit related to limited mobility. Interventions: Personal Hygiene: Resident is totally dependent in personal hygiene. An observation on 10/15/24 at 2:30 PM revealed Resident #36 was laying in his bed asleep. Resident #36 woke up upon surveyor's entry. While in the middle of speaking with Resident #36, Resident #36 closed his eyes and slept. The nails on both of his hands were approximately 0.5 - 0.7 centimeter in length extending from the tip of his fingers. The nails on the right hand had a dark brown colored residue underneath them. The nails on the left hand were clean. In an interview with CNA H on 10/15/24 at 2:35 PM, she stated CNAs and nurses were responsible for nail care. She stated if a resident was a diabetic, only nurses were allowed to cut the residents nails. CNA H stated she was not trained to trim Resident #36's nails. She stated she had not noticed Resident #36's nails. She stated the risk of not providing nailcare was the risk of infection to Resident #36. 3. Review of Resident # 76's Face Sheet dated, 10/17/24, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (a clinical syndrome that occurs when a person has dementia but it does not have a specific diagnosis), muscle weakness (a decrease in muscle strength that affects most areas of the body), psychotic disturbance (a severe mental disorder that causes a person to lose touch with reality and have abnormal perceptions and thoughts), mood disturbance (a range of psychiatric conditions that affect a person's emotional state), and anxiety. Record review of Resident #76's Quarterly MDS assessment dated [DATE], reflected Resident #76 had a BIMS of 15 which indicated Resident #76's cognition was intact. Further review of MDS assessment for Resident#76's self-care revealed he was substantial to maximal assistance. Record review of Resident #76's Comprehensive Care Plan, undated, reflected the following: Focus: [Resident #76] has an ADL self-care performance deficit related to weakness on left side. Resident has limited physical mobility related to sequelae of a cerebrovascular accident (CVA). Interventions: Staff to assist with all ADL's as required. In an observation and interview on 10/16/2024 at 10:35 AM with Resident #76 revealed nails on his left hand long and dirty. His nails on his left hand were approximately 0.5 -0.7 centimeter in length extending from the tip of his fingers. The nails on the left hand had a dark brown colored residue underneath them. Resident #76 stated his nails had never been cut. He stated a man (name unknown) came every few months to cut his toenails. In an observation and interview on 10/16/24 at 10:52 A.M. CNA I stated she provided patient care to Resident #76 but did not pay attention to his nails. She stated the expectation was to tell the charge nurse that Resident #76's nails needed to be cleaned and trimmed. She stated the risk to the resident was infection. In an interview on 10/16/24 at 1:54 PM RN B he stated he had worked at the facility for 5 years. RN B stated nurses were responsible for cutting fingernails for diabetics, after they were notified by the CNAs. He stated the nurses were responsible for cleaning and cutting resident's nails who are diabetics. He stated it was the nurse's responsibility to ensure the CNAs were cleaning and cutting the residents nails. He stated the risk was infection and would cause abrasions to the residents. In an interview on 10/16/24 at 2:08 PM CNA K she stated she had worked at the facility for 2 years. She stated cleaning and cutting nails are everyone's responsible unless the resident w ere a diabetic. The nurses are then responsible for cutting resident's nails who are diabetics. CNA K stated she provided patient care last night for Resident #76. She stated she asked Resident #76 to clean and cut his nails, but he declined. She stated Resident #76 said he did not want to be bothered or even changed. She stated she reported the refusal to LVN J, when LVN J was on the phone. She stated she was not sure if she was acknowledged by LVN J. 4. Review of Resident #34's MDS, dated [DATE], revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His BIMS score was 13 out of 15 which indicated he was cognitively intact. His diagnoses included diabetes mellitus (high sugar level in the blood), Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucination .), muscle weakness, and lack of coordination. Further review of MDS assessment for Resident#34's self-care revealed he was substantial to maximal assistance. Review of Resident #34's Care Plan, dated 10/14/24, revealed Focus: The resident has an ADL self-care performance deficit r/t impaired balance. Goal: The resident will maintain current level of function in ADLs Interventions: . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Further review revealed there was no documentation of nail care refusal. An observation/Interview on 10/15/24 at 09:45 am revealed Resident#34 setting up in the wheelchair in his room, wearing day attire, both hands fingernails approximately 0.5 centimeter in length extending from the tip of his fingers with dry matter under-net couple of them. Resident#34 stated he would like his fingernails cleaned. 5.Review of Resident #55's quarterly MDS, dated [DATE], revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score was 13 out of 15 which indicated cognitively intact. Her diagnoses included hypertension (high blood pressure), diabetes mellitus (high sugar level in the blood), cerebrovascular accident(type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain) with left side hemiplegia (paralysis of one side of the body), and Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Further review of MDS assessment for Resident#55's self-care revealed she was substantial to maximal assistance. Review of Resident #55's Care Plan, dated 10/01/24, revealed Focus: The resident has an ADL self-care performance deficit r/t CVA with left Hemiplegia. Goal: The resident will maintain current level of function through the review date Interventions: . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse Further review revealed there was no documentation of nail care refusal. An observation/Interview on 10/15/23 at 10:16 am revealed Resident #55 was laying in her bed wearing T-shirt and covered with a blanket. Right hand fingernails approximately 0.4 centimeter in length extending from the tip of her fingers with brown matter under-net. left hand severely contracted, the first, second and 3rd fingernail approximately 0.4 centimeter in length extending from the tip of her fingers, with dirty matter under net the 1st, 2nd, and the 3rd fingernail. Resident#55's 4th, and 5th finger hiding inside the contacted hand , no indentation observed on her skin, and Resident#55 did not complain of pain. Resident#55 stated she would like her fingernails trimmed and cleaned. Interview on 10/15/2024 at 11:19 am CNA N checked Resident#34 and stated the residents' nails were not trimmed, and under-net fingernails there was brown matter. CNA F checked Resident#55 and stated they needed to be trimmed and cleaned. CNA N stated residents' fingernails care was the responsibility of the CNAs to clean them during residents' shower days and let the charge nurse know if resident's fingernail needed trimming. She stated it was the responsibility of charge nurse to trim residents' fingernails. CNA N stated the risk to residents if their fingernails care were not done development of infection and scratching their skin. Interview on 10/15/24 at 12:58 pm LVN M stated Resident#34, and Resident#55 refused nail care, and it was care planed. LVN M further stated the Resident#34, and Resident#55 fingernails had been cleaned and trimmed today. LVN M stated the nails care for the resident was done by the nurses and the CNAs when it was noticed, and the risk to residents' development of infection. In an interview on 10/15/24 at 2:53 PM LVN J stated she had worked in the facility for about 4 months. She stated the CNAs were responsible for cleaning and clipping fingernails for except for residents who are diabetics. LVN J stated it was the nurses or anyone's responsibilities to cut the residents nails. She stated it was the facility's responsibly and expectation for the nurses to ensure the residents nails are cleaned and trimmed nails. She stated the risk to the residents was infection. Interview on 10/16/24 at 09:00 a.m. the DON stated residents' fingernail care should be done with shower and as needed unless the resident refuse. The DON stated it was the responsibility of the Hall charge nurse, DON and the ADON to make sure residents nails were kept cleaned and trimmed. The DON stated the risk to residents' development of infection. Review of the facility policy Titled Care of Fingernails/Toenails, dated October 2010, revealed The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guideline 1. Nail care includes cleaning and trimming 2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smouth nails prevent the resident from accidentally scratching and injuring his or her skin . Reporting 1. Notify the supervisor if the resident refuses the care.

50910 Based on observations, interviews and record review, the facility failed to store and label food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility failed to ensure food items in the facility refrigerator and freezer were covered, dated, or labeled. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: Observation in facility's kitchen walk-in refrigerator on 10/15/24 at 9:35am revealed 2 medium circular foiled covered items (about 9 inches) without a label or date used by. Observation in facility's kitchen walk-in refrigerator on 10/15/24 9:36am revealed 1 white and red square container labeled chicken with lid opened to about 1/4 inch on one corner of the container. Observation in facility's kitchen walk-in refrigerator on 10/15/24 9:37am revealed 4 fruit cups in circular plastic containers covered with plastic wrap on a tray without a date or label date used by. Observation in facility's walk-in refrigerator on 10/15/24 9:37am revealed 1 tray with approximately 20 half cut ham and cheese sandwiches with plastic wrap on the tray without a label or date used by. Observation in facility's walk-in freezer on 10/15/24 9:39am revealed an opened box, half full of cut carrots in a blue bag. The bag was open to where the carrots were visible, and the box was not securely closed with no date used by label. In an interview with Dietary Manager on 10/15/24 9:39am revealed the walk-in freezer has not been working and they were fixing it. She stated that the meat was being held in an outside trailer (Bone [NAME] Freezer) to ensure it stayed frozen. She stated the kitchen walk-in freezer had not been working since 10/5/24 and a work order to repair it was done same day. Observation in facility's Bone and [NAME] Trailer (Freezer) on 10/15/24 9:45am revealed an opened box of chicken cut in cubes, with open bag inside not closed/secured and no used by date listed on the box. There was one bag of chicken about 3lbs and it was about 80% full. The Dietary Manager removed the box of chicken and threw it in the trash. Observation in facility's Bone and [NAME] Trailer (Freezer) on 10/15/24 9:46am revealed the following: *Opened box of frozen burritos in plastic bag that was opened and exposed to the air. The box had about 25 burritos, had no used by date label. * Opened box of dinner rolls inside a plastic bag that was exposed and not closed. The box had about 50 rolls with no used by date label. * Opened box of lasagna rolls, with a bag inside that was open and exposed to the air. There were about 30 lasagna rolls and there was no used by date label. During an interview with the Dietary Manager on 10/15/24 10:01am revealed the cooks were responsible for labeling items and putting a used by date for all the food items opened in the freezer. She stated all kitchen staff were responsible for labeling any items in other areas such as refrigerators and dry storage. She stated items should be completely closed and sealed. She stated no food should be exposed to air while in the freezer and should always be closed. She stated if items are not closed then food can get contaminated, get freezer burn and make residents sick. Observation of facility's kitchen refrigerator on 10/15/24 10:09am revealed a tray of 12 white drinks in cups with plastic tops not labelled what they were or a use by date. There were also 2 cups of brown liquid covered without labels of what they were or used by date. During an interview with [NAME] Aide E on 10/16/24 02:31pm revealed that everyone was responsible for labeling items in the refrigerator and dry good storage. He clarified that the cooks were in charge labeling and dating items in the freezer outside (trailer). He stated it was very difficult to label things in that trailer because there was no light and when the door was left open too long there was a bunch of smoke from the coldness. He stated the risk to the residents of not labeling and dating items or closing them appropriately was cross contamination and sickness or even death. In an interview with [NAME] D on 10/17/24 9:27am revealed she was training to be a cook. She stated cooks were in charge of dating and labeling items in the freezer. She stated cooks needed to be cognizant of expiration dates and dates they opened an item so they were aware of how long they can use the items before they discard them. She stated not labeling and dating food items could cause them to get freezer burn, cross contaminated and potentially cause illness in residents. She stated when she opened an item she would close it tightly, wrap it with plastic or foil, label, and date when the item needed to be discarded. She stated it was also important to inspect the items by looking and smelling them before using them, to ensure they were still good regardless of the expiration date. Record Review of Food Receiving and Storage Policy, revised July 2014 reflected, .7. All food stored in the refrigerator and freezer will be covered, labeled, and dated (used by date). Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 residents (Resident #5, Resident#69, and Resident #199) of 8 residents observed for infection control. The facility failed to ensure: 1- CNA A performed hand hygiene between change of gloves during incontinent care for Resident #5. 2- CNA H donned the appropriate PPE during Resident #69 interaction who was on droplet precautions. CNA H performed hand hygiene between Resident #69 and another resident's room. 3- CNA L and CNA O donned the appropriate PPE during incontinent care for Resident #199 who was on enhanced barriers precautions. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Findings included: Resident #5 Record review of Resident #5's Quarterly MDS assessment dated [DATE] reflected Resident #5 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses included Alzheimer's disease, muscle weakness, and cognitive communication deficit. Resident #5's had a BIMS score of 15, which indicated Resident #5's cognition was intact. The MDS assessment indicated Resident #5 was frequently incontinent of bladder and bowel. Record review of Resident #5's Care Plan dated 04/16/24, reflected the following: Focus: [Resident #5] has an ADL self-care performance deficit . Interventions: . Staff to assist with all ADL's as required . Observation on 10/15/24 at 10:00 AM revealed CNA A entered Resident #5's room to provide incontinence care. CNA A sanitized his hands and donned gloves, he unfastened Resident #5's brief and cleaned the front pubic area. The resident was assisted onto her side revealing she had a small bowel movement. CNA A discarded the dirty gloves, without hand hygiene he donned clean gloves. He cleaned the resident's buttocks area using several wipes. CNA A removed and discarded the dirty gloves, without hand hygiene, he donned clean gloves. He placed a clean brief under resident buttocks, he fastened the brief, and coved the resident in the bed. CNA A gathered the dirty clothes and trash, removed his gloves, washed his hands, and left the room. In an interview on 10/15/24 at 10:25 AM, CNA A stated he supposed to perform hand hygiene between change of gloves. CNA A stated he should change his gloves and perform hand hygiene when he went from dirty to clean. CNA A stated failing to provide proper care exposed the resident to infections. Resident #69 Record review of Resident #69's face sheet, dated 10/17/2024, revealed the resident was [AGE] years old male and admitted to the facility on [DATE] and readmitted to the facility on ,d+[DATE] with the diagnosis of metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), pneumonia (a serious lung infection that occurs when the air sacs in the lungs fill with fluid or pus), and COVID-19 (an infectious disease caused by the SARS-CoV-2 virus). Record review of Resident #69's Quarterly MDS assessment dated [DATE], reflected Resident #69 had a BIMS 3 indicated Resident #69's cognition was severely impaired. Record review of Resident #69's Comprehensive Care Plan, initiated 10/11/24, reflected the following: Focus: [Resident #69] Isolation- Strict Single Room .will remain in isolation until no longer contagious to others. The resident has impaired immunity related to COVID. Intervention: .Post appropriate isolation precaution signs. Use universal precautions as appropriate. Provide proper protective equipment. Observation on 10/15/24 at 2:40 PM revealed Resident #69 was on Droplet precautions. There was signage on the right side of the door that read: visitors/staff he was on Droplet precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA H approached Resident #69 in the doorway of his room. CNA H bent down and was face to face with Resident #69 without a mask on. CNA H left Resident #69 room to answer another resident's call light. CNA H did not perform hand hygiene before she entered the resident's room. Interview with CNA H on 10/16/24 at approximately 2:40 PM revealed she did not put on a mask because all she did was talked to Resident #69 and care was not being provided. CNA H stated the facility expectation was to don and doff PPE when signage was outside door. CNA H stated the risk of not using PPE or hand sanitizing was infection to the resident and others. Resident #199 Review of Resident #199's MDS, dated [DATE], revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her BIMS score was 15 out of 15 which indicated intact cognition. Her diagnoses included hypertension (high blood pressure), diabetes mellitus (high sugar level in the blood), cerebrovascular accident, and Non-Alzheimer's Dementia (loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Resident#199 skin condition section revealed, she was admitted with one unstageable pressure ulcers to the coccygeal (the tail bone) area. Review of Resident #199's Care Plan, dated 10/14/24, revealed Focus: At risk for EBP r/t patients are indicated for the following residents who are: At increased risk of MDRO acquisition (e.g., resident has a wound) Goal: EBP care should be maintained for the residents' entire stay or until wounds have healed Interventions: . Provide patient standard precaution using gown, and gloves during .changing briefs or assisting with toileting Observation on 10/16/24 at 09:13 AM revealed Resident #199 was on Enhanced barriers precautions. There was signage on the left side of the door that informed visitors/staff she was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA L and CNA O entered Resident #199's room without any form of PPE, there was PPE cart inside the Resident#199 room on the right side of the window, and the resident bed was on the left side of the window. Both CNAs washed hands, donned gloves and procced to do incontinent care for Residnt#199 without wearing gowns. Interview with CNA O on 10/16/24 at 09:28 AM revealed she knew she supposed to wear a gown for the resident peri care, but she forgot. She stated she was nervous. She stated she was in-serviced regarding different type of infection control during orientation. She stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms was exposing herself and others to the development of infection and spreading germs from one resident to another resident. Interview with CNA L on 10/16/24 at 09:54 AM revealed he knew he supposed to wear gown for the resident peri care, but he forgot, because he was thinking the signage in front of the room was for the resident in bed A, and the resident he provided peri care to was in bed B. He could not recall the last time he had in service on infection control. He stated the risk to residents' cross contamination and development of infection. In an interview on 10/17/24 at 8:32 AM, the DON stated she expected the staff to complete hand hygiene before and after care. The DON also stated in between care CNA was to complete hand hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON stated the staff were to complete hand hygiene during care to prevent the spread of infection and cross contamination. The DON stated she would be doing quarterly skills check to monitor her staff. Interview with the DON on 10/17/24 at 08:34 AM, she stated enhanced barriers precaution (EBP) was new this year. The DON stated for the EBP they had signage outside the resident's room, and for any high contact activity with the resident on EBP including transfer, peri care .staff should be gowning and gloving. She stated she and the staffing coordinator were responsible for training staff on infection control. The DON further stated training for EBP was done on hire, on monthly staff meeting, and as needed. The DON stated They used EBP to prevent infection to high-risk residents. Record review of the facility's policy, Handwashing / Hand Hygiene, revised 12/22/23, reflected, .7. Use an alcohol-based hand rub ., or alternatively, soap and water for the following situations: . m. After removing gloves . Review of the facility provided literacy on infection control The Health and Human Services Commission of Texas Handbook on the frequently encountered infections in long-term care facilities., Version 1.0 dated 10/07/22 revealed Transmission-Based Precaution are the second tier of basic infection control and are to be used in addition to Standard Precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. 47690 49837

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 Residents (Resident #77) reviewed for respiratory care. The facility failed to ensure Oxygen (O2) in use signage was on Resident #77's room doorway. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: Review of Resident #77's face sheet dated 10/15/2024 revealed he was an [AGE] year-old-female admitted to the facility on [DATE]. Her diagnoses included: Dementia, hypertensive chronic kidney disease (kidneys are damaged and cannot filter blood adequately), Hyperlipidemia (high blood lipid levels). Record Review of Quarterly MDS assessment dated [DATE] reflected, Resident #77 was on Hospice. It also reflected, Resident #77 had BIMS of 2, which indicated that she had severe cognitive impairment. Record review of Resident #77's Hospice Orders dated 8/20/2024 reflected, Oxygen at 2-5 Liter per minute to Maintain O2 Saturation more than 90 percent. Record Review of Resident #77's Care plan, revised on 9/12/24 reflected, Focus: [Resident #77] chooses Hospice - Hope Health Care for diagnosis of Hypertensive Kidney Failure. Goal: [Resident #77] comfort will be maintained through the review date. Interventions: Work with nursing staff to provide maximum comfort for [Resident #77] including hospice therapies. In an observation on 10/15/24 at 11:10 PM revealed Resident #77 was on Oxygen therapy via nasal cannula. Observed Resident #77's room did not have signage for Oxygen in use outside the door. In an interview on 10/15/25 at 1:23 PM with resident representative stated Resident #77 was on hospice and had been on Oxygen therapy for more than a month. In an interview and observation on 10/15/24 at 11:30 AM with CNA F stated Resident #77 was on hospice and on Oxygen therapy. She stated she did not see the Oxygen in use sign on Resident #77's room door. She stated every resident on oxygen therapy should had the sign to ensure safety regarding smoking in the building and to alert staff in case of any emergency or evacuation. In an interview on 10/15/24 at 1:39 PM with LVN G stated Resident #77 was on hospice as well as on Oxygen therapy. She stated Resident #77's room should have a signage on the door for oxygen in use to alert other staff members. She stated nurses were responsible for putting up the signage. She stated that the risk of not having signage outside Resident's room was decreased quality of care by not meeting resident's care needs. In an interview on 10/16/24 03:55 PM with the DON, she stated her expectation was if the resident was on Oxygen therapy, then signage for Oxygen in use should be on the door. She stated floor nurses were responsible for putting the signage on the door. She stated the facility was a smoking facility and Oxygen in use sign was placed to warn people not to smoke or have open flames near oxygen. She stated the risk of not having appropriate signage on the door was staff may not be aware that resident was dependent on Oxygen therapy. She added the risk of inadequate signage was Resident will not receive the care they need, and quality of care will be compromised. Record review of facility policy titled Oxygen Administration revised October 2010 reflected, Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure .3. No smoking/Oxygen in Use signs .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Resident #3) of 4 residents reviewed for pharmacy services. The facility failed to ensure RN B followed physician ordered water flushes before and after medication administration given via the G-Tube for Resident #3. This failure could place residents at risk of tube obstruction and a decrease in hydration. Findings include: Record review of Resident #3's undated face sheet reflected a [AGE] year-old female with and admitted [DATE] and a re-admitted [DATE]. Diagnoses included dysphagia (difficulty swallowing), cerebral infarction (stroke), constipation, mild protein-calorie malnutrition, and seizures (convulsion). Record review of Resident #3's quarterly MDS assessment, dated 08/29/24, reflected Resident #3 had BIMS score of 7 which indicated she was severely cognitively impaired. She was totally depended on all ADL and always incontinent of bowel and bladder and she received 51 percent or more of total calories through a feeding tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach). Record review of Resident #3's care plan with a revision date of 09/07/23 reflected, . [Resident #3] requires tube feeding .Interventions .The resident needs total care with tube feeding and water flushes. See physician orders . Record review of Resident #3's Physician orders report dated October 2024 reflected, . Enteral feed order every shift enteral: Flush tube with 15 to 30 ml of water between each medication . with a start date of 12/01/23. Record review of Resident #3's Medication administration record for October 2024 reflected, .Flush tube with 15 to 30 ml of water between each medication . Record review of Resident #3's Medication administration record for October 2024 reflected: Escitalopram Oxalate Oral Tablet 10 MG (Escitalopram Oxalate) Give 1 tablet via G-Tube one time a day . with a start date of 12/01/2023. Farxiga Oral Tablet 10 MG (Dapagliflozin Propanediol) Give 1 tablet via G-Tube one time a day . with a start date of 08/22/2024. Valproic Acid Oral Solution 250 MG/5ML (Valproate Sodium) Give 5 ml via G-Tube two times a day . with a start date of 04/15/2024. Aspirin 81 Oral Tablet Chewable (Aspirin) Give 1 tablet via G-Tube one time a day . with a start date of 12/02/2023. An observation on 10/16/24 at 07:58 AM of G-Tube medication administration for Resident #3 revealed RN B prepared medication for Resident #3. RN B placed 1 tablet Escitalopram 10 mg (anti-depressant), 1 tablet of Dapagliflozin 10 mg (treat diabetes), 1 tablet of Aspirin 81 mg, and 15 ml of Valproic Acid 250 mg/5 ml in an individual cup and crushed each tablet in each cup. RN B crushed each tablet and entered the resident's room. RN B then filled a plastic cup with water from the bathroom sink and poured approximately 5-10 ml of water into each medication cup. He then retrieved a 60-ml piston syringe and placed the piston syringe into the G-tube connector and checked for residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) and flushed the G-tube with 60 ml of water. RN B then administered each medication by gravity and did not flush the tube feeding between each medication. At the completion of the medication administration RN B then flushed with 60 ml of water. RN B then reconnected the feeding tube. In an observation and interview with RN B on 10/16/24 at 08:18 AM, he stated he was not required to flush the G-tube between each medication because he did not have an order for that. When RN B looked at the medication administration record, he stated oh I have an order to flush with 15 to 30 ml of water between each medication. RN B stated he was required to review physicians' orders prior to giving any medication and had not reviewed it. He stated not flushing with the prescribed amount of water could result in tube occlusion (clogged) or a resident not getting enough water intake. In an interview with the DON on 10/17/24 at 8:32 AM, the DON stated staff were to always follow the doctors' orders on the amount of fluid to flush before and after medications. She stated failing to follow the orders could result in a clogged G-tube which would require the resident to be sent out to the hospital for replacement and it could result in a decrease in hydration. She stated all nurses are skills checked prior to G-tube medications. She stated they would also be doing follow up monitoring to ensure staff are following proper procedures. Record review of RN B's competency assessment dated [DATE] reflected he was competent in G-tube medication administration. Record review of the facility's Policy titled, Administration Medications Through an Enteral Tube, revised 07/05/2019 reflected, . 19. If administering more than one medication, flush with 15 ml (or prescribed amount) water between medication .

Based on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #11) of one resident reviewed for catheter care. The facility failed to ensure CNA C kept Resident #11's urine catheter bag below the level of the bladder during a transfer from bed to wheelchair. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #11's Quarterly MDS assessment, dated 08/11/24, reflected an admitted [DATE]. Resident #11 had a BIMS score of 10, meaning her cognition was moderately impaired. She required moderate one-person assist with transfers from a bed to a wheelchair. Resident #11's active diagnoses included abnormal posture, unsteadiness on feet, retention of urine, and muscle weakness. Record review of Resident #11's care plan, dated 09/15/23, reflected . [Resident#11] is at risk for UTI due to use of urinary catheter related .Interventions included .Position catheter bag and tubing below the level of the bladder and away from entrance room door . Review of Resident #11's Physician Orders Report dated 10/16/24 reflected, . Change urinary catheter and accessories Q month .Ensure tubing and privacy bag is intact and secure every shift . Observation on 10/16/24 at 10:38 AM revealed CNA C completing ADL care on Resident #11 in preparation to transfer from bed to wheelchair. CNA C provided incontinent care to Resident #11 while the urinary catheter hanging to the right side of the bed. CNA C placed the Resident #11's urinary catheter bag on the bed, and she changed resident's shirt and put on a clean pants. CNA C assisted Resident #11 onto the side of the bed. Urine was observed backing up in the tubing back toward the resident's bladder. Resident #11 was transferred into her wheelchair and staff hooked the urinary catheter bag on the wheelchair. In an interview on 10/16/24 at 11:06 AM, CNA C stated the urinary drainage bag was to be always kept below the resident's bladder. CNA C stated she knew better; she stated by failing to do this it put the resident at risk for urinary tract infections. Record review of CNA C's skills verification checklist dated 06/18/24 reflected she was competent in Peri-care-Foley catheter tubing care. In an interview with the DON on 10/17/24 at 08:32 AM she stated the catheter was to be maintained below the level of the bladder. She stated placing the drainage bag on the bed was not maintaining it below the bladder. She stated by not keeping it below the bladder urine could back up into the bladder and increase the risk of urinary tract infections. She stated she would do monthly skills check on nursing staff and she would do her random checks to monitor staff. The facility's policy titled, Catheter Care, Urinary, revised January 2023, reflected, .The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one (Resident #11) of two residents observed during a transfer. The Facility failed to ensure CNA C used a gait belt when transferring Resident #11 from her bed to the wheelchair. This failure could affect the residents by placing the residents at risk for falls, discomfort, pain, and/or injury. Findings included: Record review of Resident #11's Quarterly MDS assessment, dated 08/11/24, reflected an admitted [DATE]. Resident #11 had a BIMS score of 10, meaning her cognition was moderately impaired. she required moderate one-person assist with transfers from a bed to a wheelchair. Resident #11's active diagnoses included abnormal posture, unsteadiness on feet, retention of urine, and muscle weakness. Record review of Resident #11's care plan, dated 09/15/23, reflected . [Resident#11] has an ADL self-care performance deficit related to weakness .Interventions included .Transferring: Resident requires assistance with transferring . An observation on 10/16/24 at 10:38 AM revealed CNA C assisted Resident #11 onto the side of the bed. CNA C placed the wheelchair next to the bed facing toward the head of the bed and locked the wheels. CNA C placed her feet outside of the resident legs and lifted her by her arm pits and she lifted her from the bed toward the wheelchair. Resident #11 hollered ouch. Resident stated it hurt under the breasts. In an interview with CNA C on 10/16/24 at 11:06 AM she stated she had been working at the facility since June 2024. She stated she was supposed to use a gait belt when transferring residents. She stated not using a gait belt could lead to a fall, or she could injure herself. She stated she had been in serviced on gait belt transfers when she was hired in June. In an interview with the DON on 10/17/24 at 08:32 AM she stated it was the expectation for staff to use a gait belt when providing transfers to residents to prevent the risk of injury to the resident and the staff. She stated at no time were they to lift a resident under the arms. She stated they had issued gait belts to all the CNAs, and she expected them to always have the belts with them to use it. She stated going forward she would do skills check monthly and she would do her rounds for monitoring. In an interview with the DOR on 10/17/24 at 11:45 AM she stated all transfers should utilize a gait belt to prevent injury to the employee and the resident. Record review of CNA C's orientation checklist dated 06/18/24 did not specify gait belt training. Record review of the facility's policy, Safe Lifting and Movement of Residents revised September 2024, reflected, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #1, Resident #2) of 6 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #1 had his fingernails trimmed and cleaned. 2- Resident #2 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, injuries to self or other residents, and a decreased quality of life. Findings include: 1- Review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included elevated blood pressure and schizoaffective disorder. Resident #1 had a BIMS of 5 which indicated Resident #1's cognition was severely impaired. He required extensive assistance of two-persons physical assistance with bed mobility and toilet use. He required extensive assistance of one-person physical assistance with personal hygiene. Review of Resident #1's Comprehensive Care Plan, revised 07/12/23, reflected the following: Problem: Resident may require staff assistance for ADL's related to decreased mobility at times. Goal: Resident will increase independence with ADLS. Interventions: Staff to assist with ADLs as needed. An observation on 09/17/23 at 2:22 PM revealed Resident #1 was walking in the hallway using the walker. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #1 unable to answer questions. 2- Review of Resident #2's Comprehensive MDS assessment, dated 07/26/2023, reflected Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included hemiplegia (paralysis that affects only one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left side and type 2 diabetes mellitus. Resident #2 had a BIMS of 15 which indicated Resident #2's cognition was intact. Resident #2 required extensive assistance of two-persons physical assistance with bed mobility, transfers, and personal hygiene. Review of Resident #2's Comprehensive Care Plan, revised 07/18/23, reflected the following: Problem: Resident may require staff assistance for ADL's related to hemiplegia with left sided weakness. Goal: Resident will increase independence with ADLS. Interventions: Staff to assist with ADLs as needed. Observation and interview on 09/17/23 at 2:44 PM revealed Resident #2 was laying in his bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored tan and the underside had dark brown colored residue. Resident #2 stated they told me they do nail trimming once a month . Resident#2 stated he did not like his nails long and dirty. Interview on 07/17/23 at 2:45 PM, CNA A stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA A stated she would check with the nurse, if both residents, Resident #1, and Resident #2 were not diabetic, she would clean and trim their nails. Interview on 07/17/23 at 2:50 PM, LVN B stated CNAs were responsible for cleaning and trimming residents' nails during the showers and as needed. LVN B stated only nurses cut residents' nails if they were diabetic. LVN B stated no one notified her Resident #1 and Resident #2's nails were long and dirty, and she had not noticed the nails herself. LVN B stated Resident #1 was not diabetic, but Resident#2 was diabetic, and she would clean and trim their nails. Interview on 09/17/23 3:52 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. DON stated she was responsible for routine rounds for monitoring. Record review of the facility's policy titled Care of Fingernails/Toenails, revised October 2010, reflected Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming .

Based on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in one facility (carpet throughout facility and Rooms 303, 305, 307, 309, 311, 315, and 317) of one observed for a clean and homelike environment. The facility failed to ensure that the facility carpet and resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Checklist. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life. Findings include: Observation on 09/06/23 at 10:00 AM, of the carpet throughout the facility revealed, the carpet had deep dark dirt patches throughout the entire facility. Observation of room [ROOM NUMBER] on 09/06/23 at 12:05 PM revealed, the floor under the air-conditioner unit and resident bed displayed built-up dirt stains. The air-conditioner unit was dirty on the outside. The bathroom floor was dirty and stained with some orange spots. The room door entrance was displayed heavy dirt and grime along the edges and corners. Observation of room [ROOM NUMBER] on 09/06/23 at 12:10 PM revealed, the floor under the air-conditioner unit and resident bed displayed built-up dirt stains. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained. The room door entrance was displayed heavy dirt and grime along the edges and corners. Observation of room [ROOM NUMBER] on 09/06/23 at 12:17 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained. The sink was dirty and had used paper towels thrown on it (Resident advised housekeeping was already in). Observation of room [ROOM NUMBER] on 09/06/23 at 12:20 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained on the inside. The room door entrance was displayed heavy dirt and grime along the edges and corners. Observation of room [ROOM NUMBER] on 09/06/23 at 12:24 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The room door entrance was displayed heavy dirt and grime along the edges and corners. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained on the inside. Observation of room [ROOM NUMBER] on 09/06/23 at 12:33 PM revealed, the floor under the air-conditioner unit displayed built-up dirt stains. The room door entrance was displayed heavy dirt and grime along the edges and corners. The air-conditioner unit was dirty and dusty on the outside. The bathroom floor was dirty and stained with some dark spots, the floor around the toilet was dirty, and the toilet was stained on the top seat. Interview with Housekeeping S on 09/08/23 at 1:22 PM, revealed she had been at the facility for 3 months and she cleans the rooms on the 300 hall. She stated that they showed her how to clean the rooms and then hands on training. She stated every day she cleaned the floor, handles, button, dusting, every other day and as needed. Clean bathrooms every day. She stated she does not use a checklist and when she sees it dirty, she cleans it. She stated the risk to the resident of the rooms not being cleaned thoroughly and they could get sick, and bacteria could spread. Interview with Housekeeping Manager on 09/08/23 at 1:34 PM, revealed that she had been at the facility for 1 year. She stated she trained the housekeepers by showing them the cleaning instructions for cleaning in a nursing home, and then they trained them. She stated the housekeepers did not have a cleaning list; however, she used a cleaning list and she inspected it. She stated they were trained and checked on what to and how to clean. She stated that they did not have a floor technician and they were short staffed. She stated she had met with the Administrator and advised him that the floor needed to be stripped and rewaxed and the carpet needed to be deep cleaned. She stated they had just gotten sufficiently staffed but need to train staff more. She stated the impact of a dirty room could make residents ill. Interview with Administrator on 09/08/23 at 2:30 PM, revealed he was shown the pictures of the concerns discovered in the facility's only kitchen. He advised that his Housekeeping Manager had not met with him yet to discuss the concerns, but he would be meeting with her to address. He advised that he was surprised to hear that of concerns regarding the cleanliness of the facility. He said he had already notified Corporate of the condition of the carpet throughout the facility and hoped to replace it. He advised that he expected his facility not to be in that type of condition and said if he was a resident, he would not want to be living in those conditions. He said that was not considered a clean, sanitary, and homelike environment that could make residents ill. Review of the facility's Homelike Environment dated 02/2021, revealed The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. The Characteristics include clean, sanitary, and orderly environment.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure proper discarding of expired and damaged food stored in the refrigerator and dry storage area. The facility failed to ensure the Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. The facility failed to ensure the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases once prepared. The facility failed to ensure kitchen equipment was clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations of the kitchen on [DATE] at 09:15 AM revealed the following: Ice Machine Scoop Holder was dirty on the outside and inside, with a lot of dirt particles dried up on the bottom of the Ice holder, Iced Tea dispenser filled with tea, did not have a top on it and the tea was exposed, 12 8-ounce cups of miscellaneous juices and water sitting uncovered in the refrigerator, Two large trays of bacon and breakfast sausages in the refrigerator with aluminum foil placed on top of the trays, but not sealed, Large Powdered Sugar, Sugar, and Flour bins were dirty on the outsides of the containers and along the inside openings, One unsealed bag of hamburger buns (4), Twenty Loaves of white bread with an expiration date of [DATE] was undated, One 7.3 lb. can of Baked beans with a large dent, and One Large container of Cheerios was not completely sealed. Interview with Dietary Aide P on [DATE] at 09:30 PM revealed, he made the iced Tea that morning at 06:30 AM. He stated he forgot to put the top back on the dispenser once he was done, which he normally does. He stated the risk of not covering the dispenser once the tea was done could result in something falling into the tea and contaminating it, which could make residents sick. Interview and observation with the Dietary Manager and Dietitian on [DATE] at 01:30 PM, revealed the Dietary Manager was overall responsible for ensuring the kitchen was complying to Federal and State guidelines. The Dietary Manager stated that she had the Ice machine, Ice Scooper, and Ice Scooper Holder cleaned at least once a week, but had not been checking for cleanliness recently. They were advised of the Iced Tea Container being uncovered for at least three hours and she advised that she always had to remind the kitchen aides to place the cover back on the dispenser once the tea is done preparing. They were shown the pictures of the dirty bins and she advised that all equipment in the kitchen should be cleaned weekly and there was a schedule for everyone to follow. She was shown the pictures of the concerns observed in the kitchen and the Dietary Manager advised that she needed to complete an in-service on proper food storage, and she advised that she discarded the 20 loaves of expired white bread. The Dietary Manager stated the risk of not ensuring all these concerns were addressed could result in residents getting ill because of food contamination. Interview with Administrator on [DATE] at 2:30 PM, revealed he was shown the pictures of the concerns discovered in the facility's only kitchen. He advised that the Dietary Manager had notified him of some of the concerns but not all. He advised that he definitely not want to see the concerns observed. He advised that he would meet with the Dietary Manager to address her plan to correct the concerns observed. He advised the risk of the concerns identified could result in food contamination, and residents getting ill. Record Review of the Facility's policy on Food Storage and Kitchen Sanitation dated [DATE], revealed All foods will be stored according to Federal and State guideline. All refrigerated food are labeled, dated, and tightly sealed. Scoops are stored covered in a protected area. Scoops are washed weekly or as needed. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. All equipment and utensils must be cleaned and sanitized.

Based on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for 1 of 3 residents (Resident #27) reviewed for respiratory care. The facility failed to ensure Resident #27's oxygen concentrator filter was clean. This failure placed residents at risk of not receiving safe and sufficient respiratory care. Findings include: Record review of Resident #27's Face Sheet, dated 09/08/2023, revealed he was admitted on [DATE] for long term care services. Relevant diagnoses included chronic respiratory failure, dysphagia (difficulty swallowing,) major depressive disorder, urinary tract infection, type 2 diabetes, dementia, atrial fibrillation (irregular heartbeat,) anxiety disorder, Parkinson's disease, and malignant neoplasm of the prostate. Record review of MDS dated [DATE], indicated Resident #27 was moderately cognitively impaired, and had a BIMS score of 10. Record review of Resident #27's Physician Orders revealed: Oxygen: Change Mask, O2 tubing, water bottle and clean concentrator filter . every night shift every Sun weekly . with a start date of 09/03/2023 at 10:00 PM. Oxygen: May have oxygen at 2-4 liters per minute . every shift . with a start date of 08/30/2023 at 2:00 PM. Suction PRN . every 1 hours as needed related to Dysphagia Oropharyngeal phase . with a start date of 08/16/2023 at 7:00 PM. NPO diet, NPO texture . with a start date of 08/15/2023 at 1:47 PM. An observation and interview with Resident #27 on 09/06/2023 at 1:08 PM, revealed resident was receiving approximately 3 liters of oxygen per minute via nasal cannula. The back of Resident #27's oxygen concentrator revealed the air filter had a significant accumulation of grey, brown, and black sediment. Resident #27 stated that he was not sure when or if the nurse had cleaned his oxygen concentrator filter and he was not aware it was dirty. He denied shortness of breath at this time. In observation and interview with Resident #27 on 09/07/2023 at 10:29 AM, revealed resident receiving approximately 3 liters per minute of oxygen via nasal cannula. The back of Resident #27's oxygen concentrator revealed the air filter still had a significant accumulation of grey, brown, and black sediment present. Resident #27 still denied shortness of breath at this time. In observation and interview with LVN H on 09/07/2023 at 1:40 PM, revealed her inspection of the oxygen concentrator device. She stated the air filter was dirty and it was the responsibility of the Sunday night shift nurse to ensure the oxygen concentrator filter was cleaned. She stated that nurses should be checking the oxygen concentrator and filter daily to ensure it was completed but said she did not do that for Resident #27 on 09/06/2023 or 09/07/2023. She stated if residents' oxygen concentrator filters were dirty, it affected the delivery of oxygen to the resident. In interview with the DON on 09/08/2023 at 3:12 PM, she stated she was aware of the oxygen concentrator filter concern, and she stated that it was her expectation that the shift nurses ensure that each resident oxygen concentrator filters were maintained and clean. She stated that the night shift nurse on Sundays were responsible for cleaning the filters and each shift following to inspect the filter as needed. She stated that if resident oxygen concentrator filters were not clean, respiratory and allergy related concerns could occur. She further explained that nursing leadership did rounding on Mondays to ensure compliance in multiple resident care areas, including a resident's respiratory equipment and devices. She stated ADON R was assigned to Resident #27 and it was her responsibility to have inspected his oxygen concentrator. She stated there was not a formal checklist for the areas she expected nursing leadership to inspect, but again confirmed that resident oxygen concentrators would be under that scope. In interview with ADON R on 09/08/2023 at 3:30 PM, she stated that nursing leadership was responsible for quality of care rounding each week, primarily on Mondays; but she was not assigned to Resident #27. She stated she was assigned to a different hall. She stated that she was not sure who was assigned to that room but stated resident oxygen concentrator filters need to be kept clean otherwise residents will be breathing in dirty air. In interview with the Administrator on 09/08/2023 at 4:00 PM, he stated his expectations were for the DON to ensure resident concentrators were clean and the filters maintained appropriately. He stated that if resident oxygen concentrator filters were not maintained and clean, a resident could suffer adverse effects. Review of facility policy Departmental (Respiratory Therapy) - Prevention of Infection, rev 11/2011 revealed Steps in the Procedure . Infection Control Consideration Related Oxygen Administration . 9. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry.

Based on observation and interview, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #53) of five residents reviewed reasonable accommodations. The facility failed to ensure the call light system in Resident #53's room was in a position that was accessible to the resident. This failure could place residents who require reasonable accommodations at risk of being unable to obtain assistance and decreased dignity. Findings included: Review of Resident #53's Face Sheet dated 09/08/2023 reflected that Resident #53 was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified sequelae (a condition which is the consequence of a previous disease or injury) of unspecified cerebrovascular disease, fracture of unspecified parts of lumbosacral (relating to the lower back and to the large triangular bone at the bottom of the spine) spine and pelvis, nondisplaced intertrochanteric (means between the bony protrusions on the thighbone) fracture of right femur, weakness, lack of coordination, unsteadiness on feet, and unspecified dementia without behavioral disturbances. Review of Resident #53's Quarterly MDS dated [DATE] reflected Resident #53 had moderately intact cognition with a BIMS score of 9. Resident required an extensive assistance for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating, and toilet use. Resident also needed limited assistance for personal hygiene. The Quarterly MDS also indicated stroke as the primary reason for admission and hypertension as one of the primary medical conditions. The Quarterly MDS specified that the resident is incontinent for bowel and bladder. Review of Resident #53's Comprehensive Care Plan dated 08/28/2023 reflected that resident was tossing the call light onto the floor. The care plan for this was to approach in no-judgmental manner, listen to reasons for non-compliance, staff to check resident and place call light back in reach and encourage resident to use it when assistance is needed, and instruct resident on importance of safety in using call light. Review of Resident #53's Comprehensive Care Plan dated 08/28/2023 reflected that resident had a history of falling. The care plan for this was to remind the resident to ask for assistance for all ambulation, fall mat while in bed, and encourage the use of call light. Review of Resident #53's Progress Notes revealed that Resident #53 had a fall on 06/25/2023, 07/31/2023, and 08/21/2023. Observation and interview on 09/07/2023 at 1:28 PM, revealed Resident #53 was on bed with fall mat on the floor beside the resident's bed. Her call light was sitting on the nightstand where the resident could not reach it. Resident #53 said she usually pushed the call light if she needed assistance, while pointing at the call light on the nightstand which was not in reach. Observation on 09/07/2023 at 1:37 PM, revealed surveyor pushed Resident #53's call light to check if it was working, CNA L answered the call light. CNA L provided Resident #53 with incontinent care and left the room. Observation on 09/07/2023 at 1:43 PM, revealed Resident #53's call light was still sitting on the nightstand where the resident could not reach it. Interview with LVN E on 09/07/2023 at 1:56 PM, she said the call light should always be with the resident. The call light must be within reach at all times. LVN E added that if the call light is not with the resident, the resident might fall when they try to reach for something that is far from them. LVN E placed the call light that was on the nightstand within the reach of Resident #53. Interview with CNA L on 09/07/2023 at 2:01 PM, CNA L said that the policy for the call light is that the call light should be with the residents at all times. It should be positioned in a place where the resident could reach it and press the red button. CNA L acknowledged she forgot to place the call light near Resident #53. CNA L stated the call light is necessary for the residents because it is what they use to call when they need assistance. If the call light is not with them, they will not be able to call the staff. This may result to fall. Interview on 09/07/2023 at 2:13 PM, ADON R stated the call light should be within reach at all times. The call light is the resident's means of communication. This is one way the residents would let the staff know they need something. The risk of not having the call light near the resident is the resident would not be able to call in an event of an emergency. Interview on 09/07/2023 at 2:24 PM, the DON stated the call light must be within reach of the resident so that they can call the staff if assistance is needed. The DON further stated the policy of the facility is the call light should be with the residents at all times. If the resident is on the bed, the call light should be beside the resident or clipped near the resident. If the resident is on the wheelchair inside the room, the call light should be with the resident on the wheelchair. The DON stated that the expectation is that all the residents could access their call lights if assistance is needed. The expectation is the staff should follow the policy for call lights. Interview on 09/07/2023 at 2:36 PM, the Administrator stated the call light should be in a place where the resident could reach it and press when assistance is needed. Record review of facility's policy Resident Call Light System, Priority management, rev. 6/2023 revealed The purpose of this procedure is to respond to the resident's requests and needs . policy Implementation . allows individual residents to access a system that notifies nursing that the resident has a need . General Guidelines . 4. Ensure that the call light is easily reachable by the resident.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure the shelf and kitchen equipment: storage shelf, toaster, deep fryer, [NAME] chopper, steam and hold, microwave were clean. This failure could place residents at risk for food-borne illness. Findings include: An observation on 07/18/22 at 9:15 a.m. of the kitchen, with Cook B, revealed the following: -the toaster three racks had built up grease and built-up grease on the top of the toaster - The stainless-steel shelf above prep area and sink had built up grease and food particles the entire length of the shelf. - The [NAME] Chopper base had built up grease on the entire base of the chopper. - The steam and hold's entire top, was dirty with built up grease. - The deep fryer had built up grease on the top and sides, with grease running down both sides of the fryer. There was a serving tray covering the top of the deep fryer that had dried food product on it with dried grease. -The top of the microwave had built up grease on top. An interview on 07/18/22 at 9:34 a.m. with the Cook B revealed there was a weekly/monthly cleaning schedule posted on the bulletin board and on the back door. Cook B stated, we are to sign off when we clean what we are assigned to clean. Cook B stated that if we did not clean the Dietary manager will ask you why not. Cook B said if the equipment was not kept clean it could cause the residents to be sick if the food is cook there. An interview on 07/19/22 1:30 p.m. with Dietary Aide C revealed he had seen cleaning schedules posted. DA C stated, I clean up the dishes and clean up the serving carts that served the meals, weekly, but he does not clean any of the equipment in the kitchen, he said the DM would have to tell him what to do. An interview on 07/19/22 at 11:30 a.m. the Dietary manager stated the cleaning schedules for the kitchen was posted, this included each piece of the equipment, and the staff member that is supposed to clean it. The staff is supposed to sign off on the cleaning schedule. The Dietary Manager stated after observing the dirty equipment, the equipment should have been cleaned. The Dietary Manager stated she could tell since the grease was not all over the staff had cleaned the equipment, just not very well. The Dietary Manager indicated the signed cleaning schedule, posted on the door, and then stated the staff must have missed some of the areas that were assigned to clean. The Dietary Manager stated that if the equipment had not been appropriately cleaned it could cause the food that was prepared in the equipment could make the residents sick. An interview on 07/19/22 at 1:15 p.m. the Administrator stated he knew there were cleaning schedules for the equipment, in the kitchen. He was aware some of the kitchen equipment had not been appropriately cleaned, and he was assured the Dietary Manager would be cleaning the equipment herself today and the entire kitchen staff would be in-serviced on the cleaning schedule. The Administrator stated that if the kitchen was not kept clean, the residents could become ill. Record review of the facility's General Kitchen Sanitation policy and procedure r dated October 2018 revealed The food services shall be maintained in a clean and sanitary manner . keep surfaces of all cooking equipment free of encrusted grease .equipment shall be kept clean, maintained in good repair all equipment, .shall be washed to remove or completely loosen soils Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed 4-602.13 Nonfood-Contact Surfaces, Nonfood-Contact Surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interviews, and record reviews the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for one (medication aid carts) of two medication carts reviewed for medication storage. 1. -MA C failed to ensure medication supplies were secured or attended by authorized staff when the medication cart on hall 100 was left unlocked. 2. -MA D failed to ensure medication supplies were secured or attended by authorized staff when the medication cart on hall 100 was left unlocked. This failure could place residents at risk of having access to medications and/or lead to possible harm or drug diversion. Findings Included: 1. -In an observation on 07/19/22 at 7:55 AM revealed MA C entered a resident's room [ROOM NUMBER] and assisted the resident with medication administration. The medication cart was left in the hallway and was unlocked. The lock was in the out position and the drawers were able to be opened and left the medications ([MEDICATION(S)] 15 mg, [MEDICATION(S)] 20 mg, [MEDICATION(S)] hcl 5 mg, [MEDICATION(S)] 3.125 mg, [MEDICATION(S)] 20 mg and aspirin 325 mg) wiht othere medication accessible in the unlocked med cart. In an interview with MA C on 07/19/22 at 8:00 AM, she stated she does not normally leave her medication cart unlocked and had forgot to lock the medication cart when she entered the resident's room. MA C said she was supposed to lock the medication cart when not in use because a resident could take the medications. 2. -In an observation on 07/19/22 at 3:10 PM revealed a medication cart in the 100 hallway, close to room [ROOM NUMBER]. The medication cart was unlocked. The lock was in the out position and the drawers were able to be opened and left the medications ([MEDICATION(S)] 15 mg, [MEDICATION(S)] 20 mg, [MEDICATION(S)] hcl 5 mg, [MEDICATION(S)] 3.125 mg, [MEDICATION(S)] 20 mg and aspirin 325 mg) accessible. MA D observed coming from room [ROOM NUMBER]. One resident passed by the medication cart during the observation. In an interview with MA D on 07/19/22 at 3:14 PM, she stated she did not normally leave medication cart unlocked but said she went in room [ROOM NUMBER] to give medication to the resident and forgot to lock the medication cart. MA D said she was taught to lock the medication cart any time she walked away or went into a room because a resident could come and take medications that are not safe for them. In an interview with the DON on 07/20/22 at 11:45 AM, she stated it was not acceptable to leave the cart unattended or unlocked for safety reasons. The DON stated if the carts were not locked, residents could get into the cart and there would be opportunities for medication diversion. Review of the facility's policy Storage of Medication, revised April 2019, reflected, .1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended.12. Only persons authorized to prepare and administer medications have access to locked medications.

Based on interviews and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for one (Resident #58) of three residents reviewed for PASRR assessments. The facility failed to recognize Resident #58 who had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents who had a mental illness at risk of not receiving individualized specialized service to meet their needs. Findings included: Review of Resident #58's admission MDS dated [DATE] revealed, a [AGE] year-old female who admitted to the facility 05/25/22 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a BIMS score of 9, indicating her cognition was moderately impaired, and required assist of two staff for ADLs. Review of Resident #58's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . included: Sodium Valproate 250 mg/5ml liquid give 5mls by g-tube BID for [CONDITION(S)] disorder and [CONDITION(S)] disorder. Major Depressive disorder, [MEDICATION(S)]: Monitor and document any side effects related to the usage of antidepressant drugs. [MEDICATION(S)] 5mg/10ml give 10ml per G-tube daily for major depressive disorder. Review of Resident #58's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Order date 05/25/22: Sodium Valproate 250 mg/5ml liquid give 5mls by g-tube BID for [CONDITION(S)] disorder and [CONDITION(S)] disorder. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Order date 05/25/22: [MEDICATION(S)] 5mg/10ml give 10ml per G-tube daily for major depressive disorder. Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's PASRR Level 1 screen dated 05/25/22 revealed, Submitter information was the transferring facility, Referring Entity: .Nursing facility .C. 100. Mental Illness: No . This was her only PASRR Level 1 Screen found in the SIMPLE LTC system. In an interview on 07/20/22 at 1:00 p.m. with the MDS coordinator revealed she was responsible for the PASRR level 1 information when, the resident admits. The MDS coordinator stated when a resident admits to the facility, she reviews the resident's information that had been documented on the admission information on the PASRR level 1 and makes changes to the form, if required. She stated if the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS coordinator gave examples of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she had missed Resident 58's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the follow-up for the PASRR 1 was her responsibly and the Social Worker's responsibilities was the meetings. If the resident qualified for services (specialized services) it would be the responsibility of that department manager to receive the orders and initiate the services. The MDS coordinator stated that there was no follow-up with the specialized services, except the scheduled meetings. The MDS coordinator stated that if the PASRR 1 assessment was not completed correctly the resident could not receive available services. The MDS coordinator stated when she reviewed the PASRR 1 that she had not reviewed the admitting diagnose appropriately and she had missed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 07/20/22 at 1:45 p.m. with the Administrator revealed nursing services, the DON, was responsible for reviewing the information and completing the PASRR 1. The Administrator said he did not have direct involvement with the PASRR process, if the residents had qualified for specialized services, he would be made aware of that by the Social Worker or the department head, and he would assist to assure that the services were provided. In an interview on 07/20/22 at 2:00 p.m. with the DON revealed the facility would receive PASRR 1 already completed from the hospital, home, or another nursing facility. The PASRR 1 was reviewed by the MDS coordinator and if the residents required a PASRR level 2, those would be completed by the PASRR evaluator (LA), if services are needed then the facility proceeds with the services. The Social Worker is responsibility for organizing and conducting the IDT meetings. She was not involved with PASRR, she had only been working at the facility for 6 weeks. The DON stated if the assessment (PASSR 1) was not completed properly, missing a diagnosis, then the PASRR level 2 would not be completed, and the resident could miss receiving services. In an interview on 07/20/22 at 3:00 p.m. with Resident #58 revealed she did not know anything about PASRR or specialized services, no one had talked to her about that. The resident said if she was entitled to something, she wanted to able to get it. Review of the facility's policy and procedure Preadmission and Screening Resident Review (PASRR) Rules revised dated September 2021 reflected, Guideline abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) Rules .purpose .to identify residents with Mental Illness ( MI), Intellectual Disability (ID) and to ensure they receive the services they require for the MI Procedure PL1 is completed . by Social Worker or designee .in the event of a positive PL1 (PASRR 1) if PL1 that indicates the individual may have of MI ID or DD, and initiate the PE (PASRR evaluation)

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one of four residents (Resident #1) reviewed for quality of care. The facility's Nurse E failed to provide Resident #1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/16/21, Nurse E and CNA G found Resident #1 lying on a fall mat and failed to report the incident or complete a fall evaluation and monitoring. Resident #1 received an x-ray on 03/19/21 that revealed a right [CONDITION(S)] . It was determined a past non-compliance Immediate Jeopardy existed from 03/16/21 to 04/09/21. The Immediate Jeopardy was determined to have been removed on 04/09/21 due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation on 04/13/21. The facility Administrator was provided the IJ template on 04/15/21 at 1:02 PM. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization or death. Findings include: Review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. She required extensive assistance with bed mobility as well as transfers. She used a wheelchair for mobility. The MDS also revealed a fall during the month before admission. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nursing Notes dated 03/15/21 revealed resident was admitted to skilled nursing services related to a fall. Review of the Nursing Note by Nurse E dated 03/20/21 at 2:10 AM revealed 3/16: Late entry 1400 .This nurse was called to room @1415 and resident had slid out of bed onto fall mat. VS taken while on mat before placing her back to bed both legs extended out with no apparent injuries and no s/s of distress/discomfort non-verbal c/o pain. Resident very confused and combative with staff. Nursing Notes at 2:41 AM on 03/20/21 by Nurse E indicated the x-ray results showed a fracture, Nurse E notified the resident representative, DON and PA. The resident was transported to a local hospital by EMTs . Review of Resident # 1's progress note on 03/17/21 by PA O indicate d resident showed no signs of pain or distress. Review of the progress note revealed no indication that resident had experienced a fall on 03/16/21. Review of Physical Therapy Notes by PTA I for Resident # 1 dated 03/17/21 revealed precautions were to be taken for falls. Notes on 03/18/21 revealed the resident reported pain in right hip with ROM and attempt to initiate movement from the hips when asked. Notes on 03/19/21 revealed Pt made a strong indication of pain during rolling L and R, but was unable to describe or touch areas of pain when asked. After rolling R, pt touched near R hip, distal R femur, and area of R pubis. Consult with hall nurse to suggest order for an x-ray of this area. Hall nurse confirmed that nursing had the same response during rolling for changing undergarments this morning. Review of Resident #1's X-Ray exam Radiology Interpretation dated 03/19/21 revealed right [CONDITION(S)]. Interview with COTA L on 03/26/21 at 12:01 PM revealed she was taking a resident back to the therapy gym down hall 300 when she caught a glance of Resident #1's legs on the floor but could not see resident due to the bed blocking her view. COTA L did not remember whether the resident was directly on the floor or a mat. COTA L notified Nurse E and CNA G of Resident #1 and what she observed. COTA L stated Resident #1 complained about right hip pain on 03/18/21 during bed mobility. COTA L worked with Resident #1 at one point and the call light was wrapped around the resident. COTA L participated in resident's Care Plan meeting on 03/19/21 where she stated she told the Care Plan team that Resident #1 needed to not be so far down at the end of hall as she believed the resident needed 24-hour supervision. COTA L stated when a resident is found on a fall mat that counts as a fall and the nurse needs to be notified. Interview with Nurse E on 03/26/21 at 9:57 AM revealed on 03/16/21 around 2:15 PM CNA G came and told her someone had notified him that the resident had fallen onto a mattress on the floor. Nurse E went and looked at Resident #1 on the floor mat, she was waving her arms saying get me up. Nurse E first conducted an assessment and straightened Resident #1's legs out to check her legs to see if they were even. Nurse E couldn't get her blood pressure as it kept saying error but got her other vital signs of temperature and O2. When they got the resident on the bed they were able to get her blood pressure. There was a whole bed mattress next to her, not a mat. The mats are in locked storage which staff do not have access to after hours as housekeeping are the only staff with keys to access; they instead use mattresses. Nurse E stated Nurse F said she put the mattress down next to Resident #1's bed. During Nurse E's assessment Resident #1 did not show pain. Nurse E stated protocol is after a fall staff are to alert the DON, doctor, and family members. Nurse E stated at other facilities she worked at, it was not considered landing on a mat to be a fall. The DON at this facility did educate her after the incident and now knows that if someone breaks their normal plane or their legs are out of the bed it is consider a fall. Nurse E said she did not receive fall in-services or training while an employee at this facility. Nurse E stated she worked at this facility about 3 months. Nurse E stated she put a catheter in Resident #1 that same day with no issues. She said she did conduct pain assessments as was already being checked regularly due to Resident #1 pulling out her feeding tube earlier that day. Nurse E continued to check resident after the fall mat incident to see if she was showing signs of pain; checked her at least every hour. Resident was confused but would say no to pain but may not have known what she was saying at the time. Nurse E stated she did not seem to be in pain which is why she did go ahead and do the catheter and resident did it with no problem. Interview with CNA G on 03/26/21 at 12:54 PM revealed the staff were aware Resident #1 was a fall risk so they lowered her bed. CNA G was assisting another resident in the room next to Resident #1's when a therapy staff alerted him to Resident #1 had fallen. With the help of Nurse E, they got the resident up. CNA G stated Resident #1 was on a mattress; CNA G stated with the way resident was tossing and turning they knew they needed something. Resident #1 was pulling at her brief while on the mattress. Resident #1 did not appear to be in pain. CNA G stated they thought about getting the hoyer lift but because Resident #1 was close to the bed so they decided to sit her up and lift her into the bed. CNA G stated Resident #1 never showed signs of pain. After the fall, CNA G stated the resident did not complain about pain or during incontinent care. CNA G stated he never got her up out of bed. CNA G stated they do not normally use a mattress but do use fall mats and the fall mat was below the mattress. Interview with ST K on 03/26/21 at 9:10 AM revealed she, along with PT J, did the initial evaluation of Resident #1 on 3/17/21. Resident was pointing to her left hip and not making sense, so they were not able to identify if resident was in pain and where the pain was located. Interview with PT J on 03/26/2021 at 3:30 PM revealed Resident #1 said something about her leg hurting. Resident would point to left leg but during movement of right leg. It was hard to tell what she was trying to communicate so PT J left it alone. She doesn't remember specifically when resident was pointing at her leg. PT J did not know of Resident #1 sustaining a fall. PT J did not notice any difference in leg length or feet bowing in. If resident was complaining of hip pain and PT J had been told there was a fall then she would have looked further into it. PT J has seen mattresses next to beds for other residents. The facility implemented the following interventions to address the non-compliance: Review of the facility's Provider Investigation Report packet submitted on 03/26/21 involving Resident #1 included The Incident Witness Statement which revealed CNA G reported Resident # 1 was lying on a mattress in her room on the floor beside her bed. Her blood pressure was taken after she was put to bed and all others were taken before being placed back into bed. The facility's Provider Investigation Report dated 03/20/21 revealed Nurse E did not report a fall, the resident complained of hip pain on 03/19/21, and an x-ray was ordered. The facility received notice of the [CONDITION(S)] and the resident was sent to the emergency roiagnom on [DATE]. The Provider Response revealed that the resident was sent to the hospital for follow-up, the nurse was suspended, and an in-service on abuse and neglect was completed. The Investigation Summary revealed, Injury was identified as a fall that was not reported to DON or Admin. Revealed that resident fell from bed to bedside floor mat. Investigation revealed that the incident was not documented or reported. Resident received treatment at hospital. The Provider Action Taken Post-Investigation revealed that the staff member was suspended and terminated. Interview with Administrator on 03/26/21 at 3:33 PM revealed when the facility originally conducted the investigation, an Abuse and Neglect in-service was completed as an injury of unknown origin was reported. The Administrator stated now that it is apparent the incident was related to the resident being found on the floor, the facility will be providing education to staff on what is considered a fall and the actions required to monitor and follow-up. The Administrator spoke to the DON on 03/20/21 about Resident #1 and the DON did not know how the right [CONDITION(S)] happened, so they reported it as injury of unknown origin. The DON reported the incident to the state. The Administrator stated he did not speak to Nurse E but the DON told him Nurse E denied the fall, but CNA G verified Resident #1 did fall. Administrator stated they felt like they caught Nurse E in a lie, so she was ultimately terminated. Administrator stated the expectation of nurses was to follow the fall policy and was very disappointed they hadn't been notified of the fall. Administrator stated he does not know of Resident #1 showing signs of pain prior to 03/19/21. He stated he does not know if therapy was included in the investigation report. Administrator stated a fall was anything that happens to a person who goes to the ground or fall mat or even another person. If a resident was assisted to the floor he does not regard that as a fall. Interview with DON on 03/26/21 at 3:11 PM revealed that Resident #1 began to complain of pain on 03/19/21 while working with Physical Therapy so x-rays were ordered, and DON went home. DON stated she got a message at 10:28 PM which said Resident #1 had a [CONDITION(S)]. DON stated she told them to send Resident #1 out to the hospital and asked what happened and if there had been a fall. DON stated she got ADON M on the phone and they called Nurse E together. Nurse E denied knowing of any incidents or falls. DON spoke with CNA G and CNAG stated Resident #1 did fall. DON stated CNA G had to remind Nurse E of the fall and Nurse E thought going from the bed to the fall mat was not considered a fall. DON stated to Nurse E it was a fall. DON then came to the facility to check the chart and reviewed the hospital records, which verified the fracture was not present at the time of admittance. DON stated she told Nurse E to contact Resident #1's family member; DON also notified the family member. DON stated she told Nurse E to complete a late entry charting of the incident. In further interview with DON, she stated the expectation of staff after a resident has experienced a fall is to monitor for injuries by completing a head to toe assessment, note injuries or complaints of pain. Staff are supposed to complete a pain assessment. DON stated because the resident was on the floor mat without being witnessed, they reported the incident not as a fall but injury of unknown origin. DON stated they don't usually use mattress next to resident's bed. DON stated Resident #1 did have thick fall mat but not a mattress that she saw. DON stated staff should look for moaning, grimacing, facial guarding for non-verbal residents. DON stated therapy did not report Resident #1's pain to her. DON stated when Nurse H was made of aware of Resident #1's pain, he ordered an x-ray. In further interview with DON, she stated anytime a staff member witnesses pain, the charge nurse needs to be notified. The charge nurse would notify the DON accordingly. DON stated the risk to the resident for not completing proper notification and documentation of an incident is the resident not getting proper treatment in a timely manner and then nurses would not know to follow-up. DON stated the expectation of nurses was to complete the incident report. Nurse E did not realize it was considered a fall since it was to the fall mat. The expectation was when there is a fall to notify DON, physician, and the family and to do incident report. If the fall is unwitnessed the nurse was to complete neuro checks. DON stated if there is an injury to the head then the resident was automatically sent to the hospital. DON stated it was known upon admission Resident #1 was a fall risk. DON stated therapy would had completed an evaluation even if they had known she had fallen the day prior and it was usually within 24 hours of evaluation they begin therapy. DON stated therapy would not work on a resident if they had known she had a fracture. DON stated the 24-hour report should have stated something about behaviors or confused or combative. There was a non-verbal pain assessment the nurses use. CNAs are not in-serviced on observing for non-verbal cues. DON stated she assumed that Resident #1's physician or family member were both not informed. DON stated she feels the facility did everything they could have done when they found out about what happened. In further interview with DON, she stated Nurse E was supposed to report to DON for the investigation of fall on 03/22/21 but didn't show up. Nurse E sent a message to DON on 03/23/21 that her phone wasn't working. DON stated she told Nurse E because she didn't show for the investigation she was terminated. Interview with Nurse E on 03/26/21 at 9:57 AM revealed DON told her finding someone on a fall mat does count as a fall and told Nurse E to do a late entry incident report including assessments of pain, condition, confusion, and ROM on 03/19/21. Nurse E stated she was notified of her termination on 03/22/21 and the last day she worked was 03/19/21. Interview with ADON M on 03/26/21 at 2:49 PM stated she is over the hall where Resident #1 resided. ADON M stated she believes Resident #1 had a fall on the 16th but ADON M was not at the facility at the time. ADON M stated Resident # 1 was a fall risk. ADON M stated she was not notified about the fall; staff are supposed to notify the DON, physician, and the family. ADON M stated once staff complete the fall report they are turned into her and the report then goes through ever disciplinary to check it and care plan it. ADON M stated Nurse E's documentation was not very thorough. ADON M stated a fall is if you have to pick them up off the floor; including a floor mattress or floor mat. ADON M stated they do not use mattresses. ADON M stated if she found a resident had fallen she would notify DON, physician, and family. She would also do the assessment and take vitals. ADON M would then conduct monitoring checks every 15 min for the first 2 hours. ADON M stated she would be looking for any change of condition. If the resident who had fallen is not at baseline, she would call the physician and let them know the resident was different. ADON M stated assessment for ROM includes if the person can do the same as their baseline ROM with no pain. For example, ask the resident who has fallen to flex their foot and if they can't do that, it was considered pain. ADON M stated with non-verbal residents she looks for facial expressions of pain. ADON M stated the fall report is a 72-hour follow-up but since Nurse E did not report a fall it was not completed. ADON M stated when doing the fall assessment, they were supposed to attempt to extend the resident's legs. ADON M stated they do this to see if the resident can extend their legs to the same length as when admitted . Also, to assess whether the extension of legs is shorter or if the resident was grimacing, then there is a problem. ADON M stated they do not use mattresses because they use floor mats. Interview with PA O on 03/29/21 at 8:52 AM revealed he saw Resident #1 on 03/17/21 and resident made no indication of pain. Interview with PTA I on 03/26/21 at 8:50 AM revealed that when a resident is found on the floor, or to have fallen, or to be experiencing a new kind of pain, the charge nurse is immediately notified. PTA I stated she, along with two other therapy staff, performed co-treatment on Resident #1 on 03/19/21. They performed rolling left and right and when rolled to the right she would make a sound of pain but could not verbalize whether she was in pain. When asked to show where it hurt Resident #1 couldn't point or verbalize where it hurt. PTA I stated Resident #1 grabbed her right hip, right groin, and right femur which PTA I believed was a red flag of possible [CONDITION(S)]. PTA I believed resident was showing signs of pain, so she did not want to sit resident up and instead worked only on reaching. PTA I stated she notified Nurse H of resident's pain and an x-ray was ordered. Interview with COTA L on 03/26/21 at 12:01 PM revealed when a resident is found on a fall mat that counts as a fall and the nurse needs to be notified. Interview with Nurse H on 03/26/21 at 12:15 PM revealed that when a resident is found to have broken their normal plane, it is considered a fall. Nurse H stated he would document incident, and complete fall investigation worksheet, pain assessment, and neuro checks. Nurse H stated he would notify DON, physician, and resident representative. Nurse H states Resident #1 was agitated but alert. He was not sure of resident's fall risk. Until therapy tells staff otherwise, they implement fall precautions by placing the bed low and utilizing a fall mat. To get a fall mat they ask housekeeping department and they will be the ones to provide them. Sometimes when housekeeping is not there, staff will use a mattress. Nurse H stated he was not aware of Resident #1's fall. Nurse H stated he knows therapy went to him on 03/19/21 and told him Resident #1 seemed in pain so he ordered an x-ray. Resident #1 did not show pain before that day; it was hard to tell due to her dementia. Nurse H stated he was told when therapy rolled her she seemed to be in pain, so he did a pain assessment and notified the doctor. Resident #1 did not show signs of pain with rolling from side to side prior to that day. Nurse H stated if he finds a resident on the floor he will call for assistance, do his assessment immediately to make sure nothing is broken, and conduct ROM and pain assessments. If the resident is in severe pain, he will call an ambulance. Nurse H stated he would call the doctor, supervisors, DON, and family. Nurse H stated if a resident is found on a fall mat it counts as a fall. When a resident has fallen he documents on the 24-hour report and does an incident report. He would also do neuro checks for a period of 3-4 days as well as ROM and pain assessments, and vital signs. Interview with CNA A on 03/26/21 at 1:25 PM revealed when a resident is found on a floor mat that it is considered a fall. CNA A stated she would notify the charge nurse if she found a resident on the floor and do follow-up monitoring to verify resident is not showing signs of pain or injury. CNA A stated she worked with Resident #1 the days following her fall. CNA A stated she was not told about the fall. CNA A stated she never had a problem with getting Resident #1 out of bed. CNA A stated Resident #1 never fell on her shift, but she had heard that resident had fallen on other shifts. CNA A was not sure when resident #1 fell . CNA A stated Resident #1 did not seem like she was in pain or distress and was shocked to find out she had broken her hip because even when providing incontinent care, she never showed pain and had no issue rolling. During report at shift change, CNA A was told Resident #1 was a fall risk, so they lowered her bed and put a fall mattress down. CNA A stated they don't normally use a fall mattress, but everything was locked up until staff came back the next day. CNA A stated she checked on Resident #1 every 2 hours and did not notice any bruises. Interview with Nurse F on 03/28/21 at 11:19 AM revealed when a resident is found to have fallen or is found on the floor, it is considered a fall. Nurse F stated she would report the incident, complete fall investigation worksheet, pain assessment, and provide neuro checks. Nurse F stated she would contact the DON, physician, and resident representative to notify of the incident. Nurse F stated she worked the night Resident #1 was admitted on [DATE] and was her nurse. Nurse F stated CNA N asked if a fall mat could be placed next to Resident #1's bed as she kept throwing her legs out of the bed, Nurse F stated yes. Nurse F stated it was a fall mat on the floor and not a mattress as she would not have allowed that. Nurse F stated the fall mats are locked up and she is not sure where CNA N got the fall mat but most likely from another resident's room that had discharged . Nurse F stated she did not notice Resident #1 showing signs of pain. During report the next night on 03/16/21, Nurse F stated it was not reported to her that Resident #1 had been found on the floor. Nurse F stated she did not hear anything about the resident experiencing a fall until Friday, 03/19/21, when Resident #1 was sent to the hospital. Interview with CNA N on 03/28/21 at 12:21 PM revealed if a resident is found to be on the floor, no matter how they got there, it was considered a fall. CNA N stated he would then notify his charge nurse of the resident. CNA N stated he did not see indication of Resident #1 to be in pain at any time while providing care for her. CNA N stated there was a floor mat next to Resident #1's bed but he did not see a mattress. Interview with Nurse D on 03/26/21 at 1:32 PM revealed that a fall is anytime a person breaks their plane. Nurse D stated he would document incident, and complete fall investigation worksheet, pain assessment, and neuro checks. Nurse D stated he would notify the DON, physician, and resident representative of the incident. Nurse D stated he worked with Resident #1 following her fall, and believed the floor mat next to Resident #1's bedside was green or blue but he couldn't describe what it looked like beyond that. He stated it looked to him like a regular floor mat but he could not provide any other information. Nurse D stated it was documented and communicated with him that the Resident #1 was a high fall risk. He stated according to Resident #1's son, the resident had a fall in the hospital but not in the facility. He stated the resident suffered a bleed on her head and did not fall in the facility. Nurse D stated the resident did not have any open wounds and did not appear to be in pain. He said the resident was confused and never complained of pain. Nurse D stated that Resident #1 was in bed most of the time and he could not say whether she was experiencing symptoms of a fracture. Nurse D stated he did not see any signs of a fracture while he was caring for her. He stated that he heard from someone that the doctor was talking about ordering another x-ray for the resident. Interview with Resident Representative #2 by phone on 03/26/21 at 11:40 AM revealed he was currently with Resident #1 at the hospital and stated she had somehow broken her femur at the facility. He stated she had to have surgery and now has a rod in her leg. Resident Representative #2 stated he was not notified of the fall. He stated he was told they think someone saw Resident #1 on the floor on Tuesday, 03/16/21, but was never told about an incident. Resident Representative #2 stated nobody has explained what happened but only that Resident #1 was found on the floor. Resident Representative #2 stated he visited Resident #1 on Wednesday (03/17/21) and Thursday (03/18/21). He stated on Thursday, 03/18/21, Resident #1 was confused but could answer his questions and recognized who he was. Resident Representative #2 stated he does not believe her leg was broken on Thursday because she was bending her knees and moving her legs. Resident Representative #2 stated his aunt visited Resident #1 on Friday, 03/19/21, and noticed she was not doing well. Resident Representative #2 was told she was in pain the afternoon and evening of 03/19/21 so the facility completed an x-ray. He stated he did not believe the femur break happened on 03/16/21 because when he visited on 03/18/21, she was sitting in bed with knees bent. Resident Representative #2 stated Resident #1 did not complain Thursday of pain but did complain of thirst, and she could answer basic questions. Review of Resident #1's Nurse Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of incident reports for Resident #1 03/16/21, Resident #3 dated 03/14/21, Resident #69 dated 03/06/21, and Resident #72 dated 03/02/21 revealed three out of four residents reviewed for falls met professional standards of proper and timely documentation, notification, assessment and follow-up care. Review of Nurse E's personnel file revealed her initials verifying during orientation she had received training on falls. Confidential Employee Corrective Action Form revealed Nurse E was suspended on 03/19/21 and terminated on 03/22/21. Verification of the corrective measures in place prior to the re-entry included the following interviews and record reviews: Review of a facility in-service dated 03/26/21 and titled Falls, Falls with Injury, Fall Mats, Incident Reports revealed staff were educated on the following: always document before end of shift. Incident reports must be completed same shift with notification of family and doctor. Place fall mats and receive order for the fall mat if resident is a high fall risk. Review of a facility in-service dated 03/29/21 and titled Incident Reports revealed nurses were educated on the facility's policy regarding incident reports. Review of a facility in-service dated 04/05/21 and titled Non-Verbal Pain revealed staff were educated on the following: s/s (signs/symptoms) of non-verbal pain, such as facial expressions, body language, breathing, negative vocabulary, consolability. Staff were also provided two checklists: one titled pain assessment in advanced dementia or PAINAD Scale and a checklist of nonverbal pain indicators (CNPI). Review of a facility in-service dated 04/05/21 and titled Completing Incident Reports revealed nurses were educated on the following: 24 hour reports accuracy- any falls or incidents should be documented on the 24 hour report. Review of a facility in-service dated 04/09/21 and titled Falls .Fall Risks, Fall Mats (Where are they located) Med Room, Safety of Residents, Falls and Fall Risk Managing, Abuse and Neglect revealed staff were educated on the facility's policies of each topic. In an interview on 04/13/21 at 2:48 PM with LVN H revealed he had an in-service related to falls recently and was told that any change in condition in a resident needed to be reported to the DON immediately. LVN H said he knew to complete a fall assessment and evaluation after a resident was found to have fallen or had suspicions of a fall. LVN H said after a resident had fallen he was expected to call the resident's family, physician, and the DON to inform them of the incident. LVN H said he was also expected to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN H said once a resident had been identified as a moderate or high fall risk based on their baseline care plan upon admission, he was expected to immediately get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN H provided an explanation of what a fall was which included a resident on a fall mat. In an interview on 04/13/21 at 2:59 PM with RN R revealed she had recently had an in-service related to falls a few days ago. RN R said the in-service included information about how to fill out an incident report and when to use a fall mat for a resident. RN R said if a new resident was admitted to the facility and had been identified as a fall risk she needed to immediately get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN R said that after a resident had fallen she needed to notify the resident's family, physician, and the DON immediately. RN R said she would also fill out an incident/accident report about the fall. In an interview on 04/13/21 at 3:09 PM with PTA C revealed she knew to alert the nurse when a resident was showing any signs of pain while working with them during therapy. PTA C was able to identify non-verbal pain cues. In an interview on 04/13/21 at 3:14 PM with LVN S said she was recently in-serviced related to incident reporting or falls reporting. LVN S said the in-service included what accidents/incidents to report, how to fill out an accident/incident report, what was included in an accident/incident report, and who to report accidents/incidents to. LVN S said when a resident has fallen she was expected to assess the resident, notify their family, physician, and the DON. LVN S said a fall was defined as any change of plane which included when a resident was found on a fall mat. In an interview on 04/13/21 at 3:21 PM with the DOR revealed she knew what non-verbal signs to look for that would indicate that a resident was in pain. The DOR said once she identified a resident was in pain she went to tell the nurse immediately and would document it in her notes. The DOR said she would also follow up with the nurse who she spoke with for interventions put in place to ensure the resident's pain was resolved. The DOR said that was the standard protocol she followed for any change in condition noted with a resident. In an interview on 04/13/21 at 5:42 PM with the DON revealed once she was informed about the resident's fall and finished her investigation, she began to in-service her staff. The DON said she in-serviced staff on what not to do and what to do when a resident is found to have fallen. The DON said she also in-serviced staff on the importance of a fall mat and where fall mats could be found in the facility. The DON said she had one-to-one in-services with each nurse and CNA and provided education on falls. The DON said CNA's were told to report any suspicious things to the ADON or DON immediately if they felt the nurse was not doing their part in caring for the resident. The DON said [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free from neglect, for one (Resident #1) of three residents reviewed for neglect. LVN E failed to provide the necessary care including monitoring and follow-up action to prevent and address falls for Resident #1 after she was found lying on a fall mat on 03/16/21 by LVN E. On 03/19/21, Resident #1 received an x-ray that revealed a right [CONDITION(S)]. This failure could place residents at risk for neglect, resulting in unnecessary pain and a delay in treatment. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Resident #1 required extensive assistance with bed mobility as well as transfers. Resident #1 used a wheelchair for mobility. The MDS also revealed a fall during the month before admission. Review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nursing Notes dated 03/15/21 revealed resident was admitted to skilled nursing services related to a fall. Review of the Nursing Note by LVN E dated 03/20/21 at 2:10 AM revealed 3/16: Late entry 1400 .This nurse was called to room @1415 and resident had slid out of bed onto fall mat. VS taken while on mat before placing her back to bed both legs extended out with no apparent injuries and no s/s of distress/discomfort non-verbal c/o pain. Resident very confused and combative with staff. Nursing Notes at 2:41 AM on 03/20/21 by Nurse E indicated the x-ray results showed a fracture, LVN E notified the resident representative, DON and PA. Resident #1 was transported to a local hospital by EMTs. Review of Resident # 1's progress note on 03/17/21 by PA O indicates resident showed no signs of pain or distress. Review of the progress note revealed no indication that resident had experienced a fall on 03/16/21. Review of Physical Therapy Notes by PTA I for Resident # 1 dated 03/17/21 revealed precautions were to be taken for falls. Notes on 03/18/21 revealed the resident reported pain in right hip with ROM and attempt to initiate movement form the hips when asked. Notes on 03/19/21 revealed Pt made a strong indication of pain during rolling L and R, but was unable to describe or touch areas of pain when asked. After rolling R, pt touched near R hip, distal R femur, and area of R pubis. Consult with hall nurse to suggest order for an x-ray of this area. Hall nurse confirmed that nursing had the same response during rolling for changing undergarments this morning. Review of Resident #1's X-Ray exam Radiology Interpretation dated 03/19/21 revealed right [CONDITION(S)]. Interview with COTA L on 03/26/21 at 12:01 PM revealed she was taking a resident back to the therapy gym down hall 300 when she caught a glance of Resident #1's legs on the floor but could not see resident due to the bed blocking her view. COTA L did not remember whether the resident was directly on the floor or a mat. COTA L notified LVN E and CNA G of Resident #1 and what she observed. COTA L stated Resident #1 complained about right hip pain on 03/18/21 during bed mobility. Interview with LVN E on 03/26/21 at 9:57 AM revealed on 03/16/21 around 2:15 PM CNA G came and told her someone had notified him that the resident had fallen onto a mattress on the floor. LVN E went and looked at Resident #1 on the floor mat, she was waving her arms saying get me up. LVN E first conducted an assessment and straightened Resident #1's legs out to check her legs to see if they were even. LVN E couldn't get her blood pressure as it kept saying error but got her other vital signs of temperature and O2. When they got the resident on the bed they were able to get her blood pressure. During LVN E's assessment Resident #1 did not show pain. LVN E stated protocol is after a fall staff are to alert the DON, doctor, and family members. LVN E stated at other facilities she worked at it was not considered landing on a mat to be a fall. The DON at this facility did educate her after the incident and now knows that if someone breaks their normal plane or their legs are out of the bed it is consider a fall. LVN E said she did not receive fall in-services or training while an employee at this facility. LVN E stated she worked at this facility about 3 months. LVN E stated she put a catheter in Resident #1 that same day with no issues. She said she did conduct pain assessments as was already being checked regularly due to Resident #1 pulling out her feeding tube earlier that day. LVN E continued to check resident after the fall mat incident to see if she was showing signs of pain; checked her at least every hour. Resident was confused but would say no to pain but may not have known what she was saying at the time. LVN E stated she did not seem to be in pain which is why she did go ahead and do the catheter and resident did it with no problem. Interview with CNA G on 03/26/21 at 12:54 PM revealed the staff were aware Resident #1 was a fall risk so they lowered her bed. CNA G was assisting another resident in the room next to Resident #1's when a therapy staff alerted him to Resident #1 had fallen. With the help of LVN E, they got the resident up. CNA G stated Resident #1 was on a mattress; CNA G stated with the way resident was tossing and turning they knew they needed something. Resident #1 was pulling at her brief while on the mattress. Resident #1 did not appear to be in pain. CNA G stated they thought about getting the hoyer lift but because Resident #1 was close to the bed so they decided to sit her up and lift her into the bed. CNA G stated Resident #1 never showed signs of pain. After the fall, CNA G stated the resident did not complain about pain or during incontinent care. CNA G stated he never got her up out of bed. Interview with ST K on 03/26/21 at 9:10 AM revealed she, along with PT J, did the initial evaluation of Resident #1 on 3/17/21. Resident was pointing to her left hip and not making sense, so they were not able to identify if resident was in pain and where the pain was located. Interview with PT J on 03/26/2021 at 3:30 PM revealed Resident #1 said something about her leg hurting. Resident would point to left leg but during movement of right leg. It was hard to tell what she was trying to communicate so PT J left it alone. She doesn't remember specifically when resident was pointing at her leg. If resident was complaining of hip pain and PT J had been told there was a fall then she would have looked further into it. Review of the facility's Provider Investigation Report packet submitted on 03/26/21 involving Resident #1 included s Provider Investigation Report dated 03/20/21 revealed Nurse E did not report a fall, the resident complained of hip pain on 03/19/21, and an x-ray was ordered. The facility received notice of the [CONDITION(S)] and the resident was sent to the emergency roiagnom on [DATE]. The Provider Response revealed that the resident was sent to the hospital for follow-up, the nurse was suspended, and an in-service on abuse and neglect was completed. The Investigation Summary revealed, Injury was identified as a fall that was not reported to DON or Admin. Revealed that resident fell from bed to bedside floor mat. Investigation revealed that the incident was not documented or reported. Resident received treatment at hospital. The Provider Action Taken Post-Investigation revealed that the staff member was suspended and terminated. Interview with Administrator on 03/26/21 at 3:33 PM revealed he did not speak to LVN E but the DON told him LVN E denied the fall, but CNA G verified Resident #1 did fall. Administrator stated they felt like they caught LVN E in a lie, so she was ultimately terminated. Administrator stated the expectation of nurses was to follow the fall policy and was very disappointed they hadn't been notified of the fall. Administrator stated he does not know of Resident #1 showing signs of pain prior to 03/19/21. Interview with DON on 03/26/21 at 3:11 PM revealed that Resident #1 began to complain of pain on 03/19/21 while working with Physical Therapy so x-rays were ordered, and DON went home. DON stated she got a message at 10:28 PM which said Resident #1 had a [CONDITION(S)]. DON stated she told them to send Resident #1 out to the hospital and asked what happened and if there had been a fall. DON stated she got ADON M on the phone and they called LVN E together. LVN E denied knowing of any incidents or falls. DON spoke with CNA G stated Resident #1 did fall. DON stated CNA G had to remind LVN E of the fall and LVN E thought going from the bed to the fall mat was not considered a fall. DON stated to LVN E it was a fall. DON then came to the facility to check the chart and reviewed the hospital records, which verified the fracture was not present at the time of admittance. DON stated she told LVN E to contact Resident #1's family member; DON also notified the family member. DON stated she told LVN E to complete a late entry charting of the incident. In further interview with DON, she stated the expectation of staff after a resident had experienced a fall was to monitor for injuries by completing a head to toe assessment, note injuries or complaints of pain. Staff were supposed to complete a pain assessment. DON stated because the resident was on the floor mat without being witnessed, they reported the incident not as a fall but injury of unknown origin. DON stated staff should look for moaning, grimacing, facial guarding for non-verbal residents. DON stated therapy did not report Resident #1's pain to her. DON stated when Nurse H was made of aware of Resident #1's pain, he ordered an x-ray. In further interview with DON, she stated anytime a staff member witnesses pain, the charge nurse needs to be notified. The charge nurse would notify the DON accordingly. DON stated the risk to the resident for not completing proper notification and documentation of an incident was the resident not getting proper treatment in a timely manner and then nurses would not know to follow-up. DON stated the expectation of nurses was to complete the incident report. Nurse E did not realize it was considered a fall since it was to the fall mat. The expectation was when there is a fall to notify the DON, physician, and the family and to do incident report. If the fall was unwitnessed the nurse was to complete neuro checks. DON stated if there was an injury to the head then the resident was automatically sent to the hospital. DON stated it was known upon admission Resident #1 was a fall risk. Interview with LVN E on 03/26/21 at 9:57 AM revealed the DON told her finding someone on a fall mat does count as a fall and told LVN E to do a late entry incident report including assessments of pain, condition, confusion, and ROM on 03/19/21. Nurse E stated she was notified of her termination on 03/22/21 and the last day she worked was 03/19/21. Interview with ADON M on 03/26/21 at 2:49 PM stated she was over the hall where Resident #1 resided. ADON M stated she believed Resident #1 had a fall on the 16th but ADON M was not at the facility at the time. ADON M stated Resident # 1 was a fall risk. ADON M stated she was not notified about the fall; staff were supposed to notify the DON, physician, and the family. ADON M stated once staff complete the fall report they were turned into her and the report then goes through every discipline to check it and care plan it. ADON M stated Nurse E's documentation was not very thorough. ADON M stated a fall was if you have to pick a resident up off the floor; including a floor mattress or floor mat. Interview with PTA I on 03/26/21 at 8:50 AM revealed that she, along with two other therapy staff, performed co-treatment on Resident #1 on 03/19/21. They performed rolling left and right and when rolled to the right she would make a sound of pain but could not verbalize whether she was in pain. When asked to show where it hurt Resident #1 couldn't point or verbalize where it hurt. PTA I stated Resident #1 grabbed her right hip, right groin, and right femur which PTA I believed was a red flag of possible [CONDITION(S)]. PTA I believed resident was showing signs of pain, so she notified Nurse H of resident's pain and an x-ray was ordered. Interview with Nurse H on 03/26/21 at 12:15 PM revealed he was not aware of Resident #1's fall on 03/16/21. Nurse H stated he knew therapy went to him on 03/19/21 and told him Resident #1 seemed in pain so he ordered an x-ray. Nurse H said Resident #1 did not show pain before that day, but it was hard to tell due to her dementia. Nurse H stated he was told when therapy rolled her she seemed to be in pain, so he did a pain assessment and notified the doctor. In an interview on 04/15/21 at 9:55 AM with ADON M revealed had the incident been reported by LVN E like it should have been, the facility would have been able to track the fall better and respond appropriately. ADON M said she was not sure if LVN E's actions were neglectful. In an interview on 04/15/21 at 10:08 AM with the DON revealed LVN E did not do her due diligence to report the incident. The DON said not reporting the incident was neglectful because an assessment and follow up was not completed per the facility's procedures. The DON said not providing necessary resident care was neglectful. In an interview on 04/15/21 at 10:32 AM with the Administrator revealed LVN E neglected Resident #1 by not reporting the incident. The Administrator explained that LVN E neglected to follow the process and procedure of the facility when an incident or fall occurred which resulted in Resident #1 not receiving the necessary care. Review of LVN E's personnel file revealed her initials verifying during orientation she had received training on falls. Confidential Employee Corrective Action Form revealed LVN E was suspended on 03/19/21 and terminated on 03/22/21. Review of the facility's policy dated July 2017 and titled Abuse Investigating and Reporting revealed the following: 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of residents property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury .5. If the investigation reveals that the allegations of abuse are founded, the employee(s) will be terminated with no pay . Review of the facility's policy dated March 2018, and titled Falls and Fall Risk, revealed According to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level .unlesss there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occured. Review of the facility's policy dated July 2017, and titled Accidents and Incidents - Investigating and Reporting revealed, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. As well as, The following data, as applicable shall be included on the Incident Report form: a. The date and time the accident or incident took place; b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.); c. The circumstances surrounding the accident or incident; d. Where the accident or incident took place; e. The name(s) of witnesses and their accounts of the accident or incident as indicated; f. The injured person's account of the accident or incident; g. The time the injured person's Attending Physician was notified, as well as the time the physician responded and his or her instructions; h. The time the injured person's family was notified and by whom; i. The condition of the injured person, including his/her vitals; j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, retired to work, etc.); k. Any corrective action taken; l. Follow-up information; m. Other pertinent data as necessary or required; and n. The signature and title of the person completing the report. 3. The Charge Nurse or designee shall complete a Incident Report form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of five residents requiring assistance with toileting in the bathroom. CNA E failed to properly monitor Resident #1 while toileting, and the resident fell from the toilet and sustained a laceration on her head and a fractured hip. This failure could place 24 residents who require assistance with toileting in the bathroom at risk for falls and injury. Findings included: Review of Resident #1's face sheet, undated, revealed the resident was an [AGE] year old female admitted [DATE] and discharged [DATE]. Review of Resident #1's MDS assessment, dated 09/29/17, reflected the resident was moderately impaired cognitively. Resident #1 required extensive assistance of one staff with transfer and toileting. Review of Resident #1's electronic clinical chart under diagnoses, Resident #1's [DIAGNOSES REDACTED]. Review of the Care Plan, dated 09/28/17, for Resident #1 reflected the resident had short and long term memory problems, impaired cognitive skills for daily decision making, difficulty making decisions in new situations and/or severely impaired, never or rarely making decisions. The Care Plan, dated 09/15/17 reflected Resident #1 had a recent fall related to vertigo. Review of the incident report for Resident #1, dated 10/02/17, reflected Resident #1 fell while toileting. According to the report, Resident #1 fell on her right side and had a deep laceration on the side of her head. Resident was sent to the emergency room . Interview with the DON on 10/19/17 at 12:25 p.m. said she was not changing the policy, but the handwritten addition to the policy was what she wants them to do, and was used with the in-service following the incident with Resident #1. She said Resident #1 was going to the bathroom when the CNA observed her. She said the resident was pushing her wheelchair toward the bathroom as Resident #1 had diarrhea, and it was running down the resident's leg. The DON reported CNA E placed the resident on the toilet, and left the room to get some towels to clean the resident. The resident was found in the floor with a laceration on her head, and later it was discovered the resident had a fractured hip. Two attempts were made to contact CNA E with no success. Messages were left for return call on both attempts. CNA was the staff providing care for Resident #1 on the night of the incident, 10/02/17, according to the DON. Interview with CNA C on 10/19/17 at 1:45 p.m. revealed Resident #1 could stand by herself, but she always stood next to her because the resident at times was dizzy. Review of the Fall Prevention form for management only, no date, revealed Resident #1 was admitted to the hospital on [DATE] with a laceration on the right side of her head, concussion, and fractured right hip. Review of the fall risk assessment, dated 10/02/17 reflected the resident was a fall risk. According to the assessment, Resident #1 was chair bound requiring restraints and assist with elimination. The previous fall risk assessment, dated 09/15/17, reflected the resident had a score of nine with ten being a fall risk. This previous fall risk had documented the same as the later with the resident being chair bound requiring restraints or assist with elimination. Interview with Family Member on 10/19/17 at 2:19 p.m. revealed Resident #1 was on the toilet, and suddenly, she was on the floor. The resident told the Family Member that she did not know what happened. The Family Member confirmed the resident was at the facility for rehabilitation due to a fall with vertigo which occurred at the resident's home. The Family Member also reported Resident #1 had a laceration on her head, and at the hospital, it was discovered she had a fracture. She said the resident would not be returning to the facility as she was admitted to a different facility after exiting the hospital. Review of the policy, Assisting a Resident to Walk to the Bathroom, dated October 2010, revealed a handwritten note if a resident has need for supervision, stay with the resident and use call light for assistance or additional supplies needed. Review of a list provided by the DON on 10/19/17, revealed there were 24 residents requiring assistance with toileting in the bathroom.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #2) of 21 residents reviewed for neglect. Resident #2 was assessed as requiring extensive assistance of two or more staff utilizing the mechanical (sling-type) lift. Resident #2 sustained a severe leg laceration when only one staff member (CNA B) transferred the resident using a mechanical lift. Resident #2 was sent to the hospital on [DATE] where the laceration required sutures to close and returned on [DATE]. Failure to provide care and services in accordance with the facility's policies to prevent neglect resulted in injury for Resident #2 and could result in injuries affecting all eight residents who required two-person, mechanical-assisted transfers. Findings included: Resident #2 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS further reflected she required extensive assistance of two or more people for transfers. Resident #2 was observed in her room on [DATE] at 12:37 p.m. receiving care by two CNAs. A dressing was observed to her left lower leg. When asked about her wound, Resident #2 stated the pain had decreased and she would feel better when the sutures were removed. Observation on [DATE] at 10:25 AM revealed Resident #2 received wound care from LVN A. Resident #2 had a crescent-shaped wound to her left lower leg approximately 12 centimeters long. There were steri-strips in various locations along the wound and a dime-size open area at the bottom of the wound. Wound treatment was given as ordered and Resident #2 tolerated the procedure well, only complaining of discomfort at the open portion of the wound. An observation of a Hoyer lift transfer of Resident #2 by CNA C and CNA D on [DATE] at 9:45 AM revealed she was safely transferred using good technique. Review of Resident #2's consolidated Physician order [REDACTED]. During an interview on [DATE] at 1:20 PM, Resident #2 was asked about the time of the incident involving her leg injury. Resident #2 stated she remembered her leg hitting the wheelchair twice during the Hoyer transfer. She stated there was only one staff member transferring her, and there were usually two. She identified CNA B. When asked whether she told CNA B she was hitting her leg, Resident #2 replied, "Yeah I did." Resident #2 went on to say when CNA B finally got her into bed and removed her pants, there was "blood everywhere" and she and CNA B were frightened. She said the CNA went for help right away and they sent her out to the hospital for treatment. When asked if it was painful for her, Resident #2 replied, "Oh yes." She stated the stitches she received at the hospital were painful, as well, but it was not as bad after a day or so. During an interview on [DATE] at 2:44 PM, CNA B was asked about the events leading up to Resident #2's leg injury. CNA B stated she was transferring Resident #2 using a Hoyer lift. She stated while the resident was in the air she complained of pain. CNA B stated she thought the Hoyer straps were too tight and that was causing her complaints. She said when she had Resident #2 suspended over her bed, the battery in the lift died and so she lowered her using the emergency release. CNA B stated when she was removing Resident #2's pants, "...that's when I saw all the blood and her skin hanging off." When asked why she transferred Resident #2 alone, CNA B stated the resident had previously been identified on the CNA care tracker as able to pivot and so she thought she could handle her alone with a Hoyer lift. When asked how Resident #2 was currently identified on their care tracker, CNA B showed the surveyor Resident #2's kiosk entry identifying her as needing, "Two Person Physical Assist." CNA B stated, "I now know Hoyers are always two person, they in-serviced everyone on that." Review of in-service records for CNA B revealed she had received transfer training on [DATE] given by the Therapy Tech. The in-service record reflected a Transfer Check List dated [DATE] that included: "1. One Man Pivot. 2. One Man Assist. 3. Two Man Total Assist. 4. Hoyer Lift." During an interview on [DATE] at 12:45 PM, the Director of Rehab Services was asked about the training her department provided the facility staff related to transfers. The Director of Rehab Services identified the Therapy Tech as responsible for doing the training and provided the survey team with a "Skills Checklist for Transferring with Hoyer Lift" and stated they were working on a more extensive program. The undated Skills Checklist for Transferring with Hoyer Lift reflected the following: "...3. Check lift device to make sure it is in good working order, is clean and battery charged ...14. Two staff are available to guide the resident to the bed/chair, lifting legs over the bed mattress as needed." During an interview on [DATE] at 2:10 PM, the Therapy Tech was asked about the training she provided the staff regarding Hoyer Lift transfers. The Therapy Tech explained she had the staff transfer herself or another staff member, and she explained all the procedures as she went. She stated she taught the staff there always had to be at least two staff with them at all times, one working the Hoyer, and one guiding the resident toward the destination. During another interview on [DATE] at 6:05 PM, when CNA B was asked whether she had received transfer training from the Therapy Tech, she stated she had. When asked whether she had been taught how many staff were to perform Hoyer transfers, she stated there should be two. When asked whether she could describe different types of neglect, CNA B replied, "Not caring for residents, not answering call lights, I guess the Hoyer thing could have been neglect." When asked why she moved her alone, CNA B replied, "We were short, I knew the resident had been up a long time, I just wanted to get her to bed." Review of Resident #2's Care Plans revealed an entry dated [DATE]: "Self Care Deficit" and "Requires 2 staff assistance with mobility and transfers." Approaches included: "Requires ,[DATE] person total assistance with bed mobility...May use Hoyer lift, requires 2 person extensive assistance with bed mobility." The Provider Investigation Report dated [DATE] and signed by the DON reflected the following: Description of Allegation: "Resident was being lifted per employee by Hoyer lift. Hoyer lift battery malfunctioned. Employee pulled manual release and placed her on the bed. When employee pulled down resident's pants to perform peri-care, she noted the skin tear." Assessment Date: [DATE] Time: 6:00 PM. Description of Assessment: "Complete head to toe..." Provider response: "Pressure applied. Loose bandage applied. Transferred to ER (emergency room )." Investigation Summary: "the employee reported the incident immediately. We cannot conclude that the Hoyer transfer caused the skin tear, but have concluded that this was the incident that preceded immediately before skin tear was found. The resident stated that she is not scared of employee, and that this employee has transferred her many times without any issues. The resident does not feel like this incident was on purpose or out of malice or neglect." Investigation findings; "Confirmed." Provider Action Taken Post-Investigation: "Employee received a corrective action plan regarding improper use of hoyer lift. Employee went through extensive hoyer lift training with therapy department." Resident #2's Nurse's Notes dated [DATE] at 7:30 PM reflected: "6:00 PM...Nurse was called into room by CNA. Upon entering room noted resident in bed with copius (sic) amount of blood on the floor and in bed coming from left leg. CNA stated that while transferring resident from w/c (wheelchair) to bed after dinner with hoyer lift, hoyer lift malfunctioned and froze in mid air (battery died ) and CNA had to use emergency release because electric release would not work. CNA stated that sling then cut into resident's leg causing large laceration. Laceration noted from anterior part of left lower leg to inner lateral area. Laceration measures 13 cm L (length) x 8 cm W (width) and about 1 cm in depth with fatty tissue exposed. Pressure applied to wound. Resident was on [MEDICATION NAME] (blood thinner) 6.75 mg but has been on hold x 1 day due increased INR. Notified (physician) and received order to send resident to (hospital name)...Called 911. DON made aware." Entry on [DATE] at 4:49 AM: "...resident returned from ER with multiple sutures to laceration to L (left) lower leg...dressing to L leg soaked, continues bleeding to wound, scupious (sic) amount; DON notified; SN (skilled nurse) change pressure dressing to wound; decrease bleeding noted at this time...." Entry on [DATE] at 9:30 PM: "...6 AM Serous drainage seeping through bandage to left lower leg measures 6.0 x 5.0 cm. 730 AM sized increased to 6.5.[MEDICAL CONDITION] cm. Notified treatment nurse. Treatment nurse and this nurse changed bandage to site, Noted soaked (sic) serous drainage 3 old ABD pads (abdominal pads-large thick pads). Placed three new ABD pads, roll gauze and Ace wrap to site. Noted sutures to site 1 inch apart. Noted dishesence (sic) to site at several places. 1030 AM noted bandage to site with 8 cm x 10 cm serous drainage to site. Called (physician). New orders: Clean left lower leg laceration site with NS, Reinforce site with steri-strips between sutures, apply QuickClot to site and pressure bandage. With help of treatment nurse, new orders for QuickClot pressure dressing applied. Noted all 3 old ABD pads soaked again. Called (physician). New orders: STAT (immediate) H&H (hemoglobin and hematocrit) STAT PT/INR...Elevated affected extremity above heart level. No further serous drainage noted to bandage this shift. INR=4.4 (high). HGB=10.6 (low) HCT=32.6(low). Called (physician). New orders: Continue to hold [MEDICATION NAME]. Keep current dressing on x 2 days; then, change dressing on 3rd day, use QuickClot for bleeding...." Note: Wound dehiscence is the bursting or splitting open of a suture line. QuickClot is a product used in a wound to stop bleeding. Review of the facility's policy and procedure entitled "Two Person Hoyer (Mechanical) Lift," undated and identified as current by the Corporate RN revealed, "Purpose: To safely get resident from one surface to another when the resident is unable/unwilling to bear weight on his or her lower extremities and cannot be safely transferred using the 2 person total lift." "Equipment: 1. Hoyer Lift 2. Hoyer Sling 3. Chains with 'S' Hooks 4. Two Staff Members." "Procedure: ...10. Turn knob on lift clockwise until firm and pump handle back and forth until the resident is suspended over the bed. 11. Slowly guide the lift away from the chair and position lift above the chair. 12. Turn knob counterclockwise not more than one revolution to slowly lower resident into chair. One staff member holds the sling to help keep the resident's hips back in the chair as the lift is lowered. 13. When lowering the lift, monitor the location of the resident's feet and arms to prevent injury...." Review of the facility's undated policy and procedure entitled SCC Abuse Prohibition Policy and Procedure, provided by the Administrator and identified as current revealed, "Senior Care Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property...Each resident has the right to be free from mistreatment, neglect and misappropriation of property..." "Prevention: The facility has in place policies and procedures to aid in the prevention of abuse, neglect, mistreatment, and misappropriation of resident property...." Review of a Hoyer Lift List provided by ADON E on [DATE] revealed there were eight residents in the facility who required a Hoyer lift for transfers.

Based on observation, interview, and record review, it was determined the facility failed to consult with the physician or notify the family of significant physical changes in status or a need to alter treatment significantly for two (Residents #5 and #8) of 20 sampled residents. 1. On 02/27/11, when facility staff still failed to intervene, Resident #8, who stated he was in excruciating pain, called his family member, who brought Tylenol #3 to the facility and gave it to the nurse, who then consulted with Resident #8's physician, who gave an order for [REDACTED]. The only medication Resident #8 had ordered prior to this was plain Tylenol as needed, despite the resident's repeated requests to address his concerns regarding his pain since his admission on 02/18/11 and his referral to a medication regimen he had previously been using. 2. Resident #5 lost 22 pounds from his admission on 11/22/10 through 02/15/11, which resulted in a 13.7% severe weight loss. The family and/or responsible party was not notified of the weight loss. These failures could affect the facility's 115 residents in the facility, including Residents #5 and #8, placing them at risk for a lack of optimal involvement of the residents' physicians and/or family members, which could have a negative impact on the resident and contribute to the decline of the physical well-being of the resident due to a lack of continuity of care. Findings included: 1. According to the 03/01/11 Face Sheet, Resident #8 was admitted to the facility on [DATE]. The Face Sheet reflected [DIAGNOSES REDACTED]. Review of Resident #8's facility admission orders [REDACTED]. This order also included staff were to document the level of pain on a scale of 0 to 10 when the Tylenol was administered for pain. In addition, a pain assessment was to be conducted every shift. Review of Resident #8's Admission Care Plan dated 02/18/11 revealed under the heading of Pain: "Goal: Resident will be as comfortable as possible." The approaches listed were: "Monitor Pain; Administer pain medications as ordered; and Establish causative factors and ways to alleviate them." Resident #8 was observed during the initial tour of the facility on 03/01/11 at 10:31 AM, by the surveyor while accompanied by LVN H. Prior to entering Resident #8's room, LVN H stated Resident #8 occasionally complained of pain, and the resident had a list of medications he took. Upon entering the room, Resident #8 was observed sitting up on the side of his bed. Resident #8 stated he wanted to talk to the surveyor about his concerns. Resident #8 removed a list of medications from his bedside drawer and stated nobody at the facility listened to him about the medications he was supposed to be taking, especially his [MEDICATION NAME] (narcotic [MEDICATION NAME]). Resident #8 stated he had pain, but it was not being controlled. A review of a hospital History and Physical dated 02/13/11, revealed Resident #8 was admitted to the hospital with [REDACTED]. The History and Physical reflected a computerized tomography scan of the abdomen revealed proximal ureter stones (kidney stones), and he was diagnosed with [REDACTED]. The History and Physical also reflected a cystoscopy with stent placement was performed secondary to the [MEDICAL CONDITION] obstruction. Review of his hospital medication regimen revealed he received [MEDICATION NAME] (narcotic [MEDICATION NAME]) while hospitalized to control his pain. The History and Physical also reflected Resident #8 had a [DIAGNOSES REDACTED]. During an interview with Resident #8 on 03/01/11 at 7:30 PM, he again pulled out the list of medications he had been taking at home. Resident #8 stated it took the concerted effort of three physicians to develop the list, and the medications, if taken as written, best controlled his disease processes and pain. One of the entries was for [MEDICATION NAME] 30-300 mg (Tylenol #3) at 1:00 AM and 1:00 PM. On 03/02/11 at 11:08 AM, a further interview with Resident #8 regarding his list of medications revealed he continued to state he had shown the list to the facility nurses and anyone who would listen. Resident #8 placed special emphasis on the Tylenol #3 and stated the staff would not intervene and call the physician to discuss the need for the medication. Resident #8 stated the plain Tylenol ordered by the physician would decrease the pain level from a 9 to a 7 on a scale of 1 to 10, 10 being the worst. Resident #8 stated he was never pain-free, even at home, but the Tylenol #3 kept the pain level at a 4 to 5 or even lower level. Resident #8 stated with the pain controlled at that level, he was able to do more for himself. During the same interview, Resident #8 also stated, since being admitted to the facility, his pain would wake him up during the night, several times a week. Resident #8 stated "it hurt," causing him to twist around in bed to find the most comfortable position. Resident #8 stated he had arthritis in his back, legs, knees and arms, which caused pain, until his family member intervened. Resident #8 stated one evening when he was in excruciating pain, he finally called his family member and told him/her nothing was being done to control his pain. Resident #8 stated his family member immediately came to the facility with his Tylenol #3 from home. Resident #8 stated he received his first dose that night and within an hour, felt much better. Resident #8 continued that even with the Tylenol #3 twice daily, he still usually had pain early in the morning between 4 AM and 5 AM, at an 8 or 9 level. When asked what the night nurse would do when he told her his pain was at an 8 or 9 level, Resident #8 responded, "She would say, 'Someone will come along with medication,' but no one does. So I sit from 4 or 5 AM to 8 or 9 AM, waiting for my next Tylenol #3." Resident #8 stated sometimes he "felt like crying," and would get up and move around. Resident #8 stated it did not help his pain, but it took his mind off the pain and decreased his suffering of thinking about it. Review of Resident #8's March 2011 consolidated physician orders [REDACTED]. No telephone order for this medication dated 02/27/11 or any other date was found. When requested, the facility was unable to produce the telephone order. Resident #8's nurses notes were reviewed and on 02/27/11, an entry at 4:39 PM by LVN I reflected: "...____ (Resident #8's family member) brought Tylenol #3 from home for pt. (patient) to take called Dr. ___ (doctor's name) ok to take tylenol #3 1 po (orally) bid (twice daily) for arthritis pain will Id (initial dose) tonight...." Review of the February 2011 Medication Aide MAR indicated [REDACTED]. Interview with Resident #8's family member was conducted by phone on 03/02/11 at 3:26 PM. Resident #8's family member stated when the resident called him/her on the evening he/she took in his Tylenol with [MEDICATION NAME], he complained about his arthritis pain. Resident #8's family member stated the resident had called on other nights and said he was in pain, but this night it was different. He/She stated, "The pain was real bad." Resident #8's family member stated the resident called and told him/her he was not receiving the pain medication on his medication list. Resident #8's family member stated he/she also had a copy of the resident's medication list and determined the pain medication he wanted was the [MEDICATION NAME]. Resident #8's family member stated he/she immediately took Resident #8's [MEDICATION NAME] pills and the medication list into the facility and gave them to LVN I, who immediately called the doctor. At that point, the doctor approved the [MEDICATION NAME] pill be given twice daily. Resident #8's family member stated he/she did not know why the facility had not listened to the resident and had called the doctor before the pain got to the level it did. He/She added Resident #8 had severe arthritis of his knees, back, joints, and hips, and that night, it was so bad, he could hardly move. Resident #8's family member added, he was taking Tylenol Arthritis and Tylenol #3 at home. Review of Resident #8's initial MDS assessment dated [DATE], revealed the resident was not on a scheduled pain medication regimen but had received prn (as needed) pain medications. The Pain Assessment Interview portion of the MDS assessment was conducted with Resident #8 and reflected he had occasional pain in the last five days, which made it hard to sleep at night and limited his day-to-day activities. This interview portion reflected Resident #8 stated his worst pain over the last five days had been a 9 with zero being no pain, and 10 being the worst pain imaginable. 2. Resident #5's Face Sheet dated 11/26/10 reflected he was admitted to the facility on [DATE]. Review of Resident #5's consolidated Physician order [REDACTED]. Resident #5's MDS Admission assessment dated [DATE] reflected he was sometimes understood and sometimes understands, had unclear speech, had short and long term memory problems, and was severely impaired cognitively. The MDS assessment did not identify weight loss at the time of the assessment. A list entitled "Weight Change History," which included weights from 09/01/10 through 03/01/11, was provided by Corporate RN O to the surveyors on 03/01/11 at 4:45 PM. Resident #5's Weight Change History reflected he weighed 160 pounds at admission on 11/22/10, and on 02/15/11 weighed 138 pounds, a 22-pound severe weight loss in approximately 3 months. His first weight loss occurred on 12/01/10 of two pounds. On 12/06/10, the resident had lost a total of 17 pounds. He remained stable until 12/13/10, when he lost three pounds. He gained weight and reached 146 pounds on 01/04/11. He was stable but had a gradual loss of weight until 02/15/11 and weighed 138 pounds. Review of Resident #5's Nutritional assessment dated [DATE] revealed the resident was at IBW. On 01/24/11 the Nutritional Assessment identified the resident had lost 13 pounds, an 8% weight loss. At that time, the Dietitian recommended a Mechanical Soft, Fortified Diet for an additional 1288 caloiries and 54 grams of protein. On 02/25/11, the Nutritional Assessment reflected, "a progressive loss of 19 pounds/90 days, a 12% weight loss." At that time the Dietitian continued the Fortified Food Plan for additional calories, and the assessment reflected his [MEDICATION NAME] level was within normal limits, but had dropped from 4.1 g/dL to 3.1 g/dL (normal range 3.5 g/dL - 5.2 g/dL). Review of the "Nutritional Recommendations by the R.D. Consultant," dated 01/24/11 and provided by Corporate RN O on 03/03/11 at 6:15 PM, revealed Resident #5 had weight loss and the "Recommendation," was a Fortified Mechanical Soft Diet. Resident #5's Care Plan dated 11/29/10 reflected the resident needed one to two staff to assist with bed mobility, transfers, locomotion on/off unit, dressing, toileting, bathing, personal hygiene, and eating related to decreased mobility and [MEDICAL CONDITION]. Another Care Plan dated 11/29/10 reflected the problem of "Potential for weight loss related to unstable health condition." One of the goals was, "Follow supplemental diet as ordered by 90 days." Resident #5 also had a Care Plan dated 01/01/11 with the problem he was to receive assistance at the table due to decreased appetite with gradual weight loss. An Acute Care Plan dated 01/24/11 reflected a Care Plan for "Weight Loss of 6% or Greater." Approaches included: "1. Administer therapeutic diet as ordered. ...9. Fortified diet plan...." None of the previous Care Plans identified the need to notify the family that Resident #5 was losing weight. An interview was conducted with family members of Resident #5 on 03/03/11 at 4:10 PM, one of whom was the responsible party. During the meeting the family members stated they had noticed the resident had been losing weight, but none of the staff at the facility had discussed it with them. Review of Resident #5's Nurses' Notes revealed there was no documentation regarding notification of the family in reagrd to Resident #5's weight loss. The failure to notify Resident #5's family members of his weight loss was shared with the facility staff, which included the Administrator, DON, and ADONs on 03/03/11 at 5:47 PM. No information was provided to the surveyor the family had been informed about the weight loss. 3. Review of the current, undated facility policy and procedures provided by Corporate RN O on 03/04/11 revealed the following procedures for "Change of Condition - Notification: 1. The charge nurse will notify the resident, his/her physician, his/her legal representative, and his/her family member when there is: ...b. A change in the resident's condition in either life-threatening conditions or clinical complications; c. A need to alter treatment significantly; ...." "Documentation: 1. Nurses notes will include: a. Notification of resident ' s physician b. Notification of family/legal representative c. What the condition is d. Date and time of each event " 4. Review of the facility Resident Census and Conditions of Residents Report (CMS-672) signed on 03/01/11 by ADON F revealed there were 115 residents in the facility.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one (Resident #8) of 17 sampled residents residents reviewed for pain, when he experienced high levels of pain; and for two (Residents #4 and #7) of three sampled residents with indwelling urinary catheters to avoid possible dislodgement and prevent the potential for infection: 1. Resident #8 complained of pain at levels of 8 and 9 (on a scale of 1-10) without receiving pain relief. Facility staff knew about Resident #8's list of medications, but did not follow-up when the resident requested Tylenol #3, which had previously provided pain relief. The MAs gave Resident #8 plain Tylenol without notifying the nurses and without reassessing the resident's pain. The LVNs did not reassess Resident #8's pain after administering Tylenol. Resident #8 went 10 days without pain relief until a family member brought Tyelnol #3 to the facility and an order was finally obtained from the physician. This failure could affect the facility's 89 residents who were on a pain mangement program, placing them at risk for having unnecessary pain, resulting in difficulty sleeping, decreased mobility, decreased socialization, decreased appetite, unplanned weight loss, and a negative impact on their quality of life. 2. Resident #7's catheter tubing: was not secured to prevent accidental dislodgement and urethral traction; was not positioned to allow for urine to flow from the bladder; and was positioned to allow for the potential of urinary tract infection to develop. 3. Resident #4's catheter tubing: was not secured to prevent accidental dislodgement and urethral traction; was left hanging onto the floor, which prevented drainage of the urine into the catheter bag and allowed for the potential of urinary tract infection to develop. These failures could affect the five residents with indwelling urinary catheters, placing them at risk for infection,[MEDICAL CONDITION], and accidental dislodgement with trauma to the urethra. Findings included: 1. Resident #8 was observed during the initial tour of the facility on 03/01/11 at 10:31 AM, by the surveyor while accompanied by LVN H. Prior to entering Resident #8's room, LVN H stated Resident #8 occasionally complained of pain, and the resident had a list of medications he took. Upon entering the room, Resident #8 was observed sitting up on the side of his bed. Resident #8 stated he wanted to talk to the surveyor about his concerns. Resident #8 removed a list of medications from his bedside drawer and stated nobody at the facility listened to him about the medications he was supposed to be taking, especially his [MEDICATION NAME] (narcotic [MEDICATION NAME]). Resident #8 stated he had pain, but it was not being controlled. A review of a hospital History and Physical dated 02/13/11, revealed Resident #8 was admitted to the hospital with [REDACTED]. The History and Physical reflected a computerized tomography scan of the abdomen revealed proximal ureter stones (kidney stones), and he was diagnosed with [REDACTED]. The History and Physical also reflected a cystoscopy with stent placement was performed secondary to the [MEDICAL CONDITION] obstruction. Review of his hospital medication regimen revealed he received [MEDICATION NAME] (narcotic [MEDICATION NAME]) while hospitalized to control his pain. The History and Physical also reflected Resident #8 had a [DIAGNOSES REDACTED]. According to the 03/01/11 Face Sheet, Resident #8 was admitted to the facility on [DATE]. The Face Sheet reflected [DIAGNOSES REDACTED]. During an interview with Resident #8 on 03/01/11 at 7:30 PM , he again pulled out the list of medications he had been taking at home. Resident #8 stated it took the concerted effort of three physicians to develop the list, and the medications, if taken as written, best controlled his disease processes and pain. One of the entries was for [MEDICATION NAME] 30-300 mg (Tylenol #3) at 1:00 AM and 1:00 PM. On 03/02/11 at 11:08 AM, a further interview with Resident #8 regarding his list of medications revealed he continued to state he had shown the list to the facility nurses and anyone who would listen. Resident #8 placed special emphasis on the Tylenol #3 and stated the staff would not intervene and call the physician to discuss the need for the medication. Resident #8 stated the plain Tylenol ordered by the physician would decrease the pain level from a 9 to a 7 on a scale of 1 to 10, 10 being the worst. Resident #8 stated he was never pain-free, even at home, but the Tylenol #3 kept the pain level at a 4 to 5 or even lower level. Resident #8 stated with the pain controlled at that level, he was able to do more for himself. During the same interview, Resident #8 also stated, since being admitted to the facility, his pain would wake him up during the night, several times a week. Resident #8 stated "it hurt," causing him to twist around in bed to find the most comfortable position. Resident #8 stated he had arthritis in his back, legs, knees and arms, which caused pain, until his family member intervened. Resident #8 stated one evening when he was in excruciating pain, he finally called his family member and told him/her nothing was being done to control his pain. Resident #8 stated his family member immediately came to the facility with his Tylenol #3 from home. Resident #8 stated he received his first dose that night and within an hour, felt much better. Resident #8 continued that even with the Tylenol #3 twice daily, he still usually had pain early in the morning between 4 AM and 5 AM, at an 8 or 9 level. When asked what the night nurse would do when he told her his pain was at an 8 or 9 level, Resident #8 responded, "She would say, 'Someone will come along with medication,' but no one does. So I sit from 4 or 5 AM to 8 or 9 AM, waiting for my next Tylenol #3." Resident #8 stated sometimes he "felt like crying," and would get up and move around. Resident #8 stated it did not help his pain, but it took his mind off the pain and decreased his suffering of thinking about it. Review of Resident #8's facility admission orders [REDACTED]. This order also included staff were to document the level of pain on a scale of 0 to 10 when the Tylenol was administered for pain. In addition, a pain assessment was to be conducted every shift. Review of Resident #8's March 2011 consolidated physician orders [REDACTED]. No telephone order for this medication dated 02/27/11 or any other date was found. When requested, the facility was unable to produce the telephone order. Resident #8's nurses notes were reviewed and on 02/27/11, an entry at 4:39 PM by LVN I reflected: "...____ (Resident #8's family member) brought Tylenol #3 from home for pt. (patient) to take called Dr. ___ (doctor's name) ok to take tylenol #3 1 po (orally) bid (twice daily) for arthritis pain will Id (initial dose) tonight...." Review of the February 2011 Medication Aide MAR indicated [REDACTED]. LVN I was interviewed on 03/02/11 at 1:57 PM. LVN I stated Resident #8 had never really complained to her of severe pain, and she never received a report from the off-going nurse Resident #8 experienced major pain. LVN I stated she just received change of shift reports, which indicated the pain Resident #8 experienced was, "nothing major, just generalized arthritis pain." LVN I added one day Resident #8 took out his medication list and showed her he had been on Tylenol #3 for arthritis pain. LVN I stated Resident #8 told her it was what controlled his arthritic pain. LVN I stated shortly after that day, Resident #8's family member called and stated he/she was going to bring up Resident #8's [MEDICATION NAME] pills. LVN I stated the family member gave her the bottle of Resident #8's Tylenol #3 and she called the physician who approved administering it twice daily. LVN I also stated she understood everyone handled pain differently, but if Resident #8 who was alert and oriented had told her he had a pain level of 9 and nothing was ordered, she would have called the physician even if it was early in the morning. Interview with Resident #8's family member was conducted by phone on 03/02/11 at 3:26 PM. Resident #8's family member stated when the resident called him/her on the evening he/she took in his Tylenol with [MEDICATION NAME], he complained about his arthritis pain. Resident #8's family member stated the resident had called on other nights and said he was in pain, but this night it was different. He/She stated, "The pain was real bad." Resident #8's family member stated the resident called and told him/her he was not receiving the pain medication on his medication list. Resident #8's family member stated he/she also had a copy of the resident's medication list and determined the pain medication he was complaining about, which he was not receiving, was the [MEDICATION NAME]. Resident #8's family member stated he/she immediately took Resident #8's [MEDICATION NAME] pills and the medication list into the facility and gave them to LVN I, who immediately called the doctor. At that point, the doctor approved the [MEDICATION NAME] pill be given twice daily. Resident #8's family member stated he/she did not know why the facility had not listened to the resident and had called the doctor before the pain got to the level it did. He/She added Resident #8 had severe arthritis of his knees, back, joints, and hips, and that night, it was so bad, he could hardly move. Resident #8's family member added, he was taking Tylenol Arthritis and Tylenol #3 at home. Review of Resident #8's February 2011 Electronic MAR under pain assessment, revealed LVN L documented pain levels of an 8 on 02/19/11, and a level of 9 on 02/22/11, 02/23/11, and 02/24/11. On 03/02/11 at 7:01 PM, LVN L was interviewed and stated Resident #8 was alert and oriented and could express his needs because, "he is in his right mind." LVN L stated Resident #8 complained of arthritis pain all the time. LVN L stated she would tell MA M to give him pain medication. When shown all the times the MAR indicated Maybe she forgot. ___ (MA M) is ___ (MA M). We have a list for the MAs to document prn (as needed) medication that is given and she probably forgot to document she gave it." LVN L continued Resident #8 was always in pain and always had high levels of pain. LVN L stated she would tell Resident #8 to call if the prn medication did not work and when he didn't complain again and did not call, "I say he is okay. He never told me the medication was not working for pain, so I assumed if he didn't call, he's okay." LVN L stated she did not always go and assess if the prn medication worked, because she relied on Resident #8 to call if still in pain. LVN L also stated MA M administered prn pain medication without informing her first, and sometimes failed to chart all prn medications. LVN L stated she was going to suggest to ADON N nurses give all prn medication, because the MAs have the key to the medication carts until 10:00 PM. LVN L stated, "I think having control of prn meds, we will know when residents are in pain, so we can assess because sometimes MAs give prn pain meds without telling us, and we can't assess properly." When asked why she never called the doctor when Resident #8 complained of high levels of pain, LVN L stated she never thought to, because Resident #8 was in his right mind and could call if he needed something. LVN L stated she always made sure he had his call light within reach. Review of Resident #8's February 2011 Medication Aide MAR indicated [REDACTED]. In addition, MA M documented a pain level of an 8 on 02/24/11 at 9:23 AM. MA M documented these pain levels when she administered two tablets of Tylenol 325 mg to Resident #8. MA M was interviewed on 03/02/11 at 12:40 PM regarding how she became aware of Resident #8's pain levels she documented on the February 2011 Medication Aide MAR. MA M stated the nurses told her to always ask about pain when in a resident's room. MA M stated Resident #8 complained of a pain level of 9, "lots of times." MA M stated when Resident #8 complained of pain, she would ask him if he wanted a Tylenol. MA M stated Resident #8 would ask if she had "anything stronger but I told him that was all he had." When asked if she ever gave prn pain medication without first informing the nurse, MA M stated she had because, "the nurses trust my judgement." MA M stated when she told LVN L or LVN H about Resident #8's pain, they told her to go ahead and give the Tylenol. MA M stated she has given prn pain medication to Resident #8 and other residents without the nurses first assessing the resident. When asked if she followed up with Resident #8 after administering a prn pain medication, MA M stated she would check a box on the computer electronic MAR indicated I don't usually get down to re-assess the effectiveness. I just rely on the fact that they have not asked for anything more or I ask the aides how he is doing. We don't have the time to do it because we have such a full house." An interview was conducted with LVN A who worked on Hall 200 on 03/04/11 at 10:45 AM. During the interview, the LVN stated there were times the medications aides administered prn pain medication without bringing it to her attention, but she would assess the residents later. Review of Resident #8's initial MDS assessment dated [DATE], revealed the resident was not on a scheduled pain medication regimen but had received prn (as needed) pain medications. The Pain Assessment Interview portion of the MDS assessment was conducted with Resident #8 and reflected he had occasional pain in the last five days, which made it hard to sleep at night and limited his day-to-day activities. This interview portion reflected Resident #8 stated his worst pain over the last five days had been a 9 with zero being no pain, and 10 being the worst pain imaginable. Review of Resident #8's Admission Care Plan dated 02/18/11 revealed under the heading of Pain: "Goal: Resident will be as comfortable as possible." The approaches listed were: "Monitor Pain; Administer pain medications as ordered; and Establish causative factors and ways to alleviate them." 2. According to the Face Sheet dated 02/16/11, Resident #7 was admitted to the facility on the same date with a Surgical Repair of a Fractured Femur. The 02/28/11 MDS assessment also reflected Resident #7 had [MEDICAL CONDITION], Hypertension, Wound Infection, Altered Mental State, Pressure Ulcer to the Lower Back, [MEDICAL CONDITION], Senile Dementia, [MEDICAL CONDITION] Fibrillation, Depression, [MEDICAL CONDITION], and Insulin-Dependent Diabetes Mellitus. During initial tour of the facility with LVN H at 10:24 AM on 03/01/11, LVN H stated Resident #7 had a Stage IV Pressure Ulcer with visible bone, and she was admitted with a Urinary Tract Infection. LVN H also stated Resident #7 was alert and oriented with periods of confusion. During the initial tour with LVN H, Resident #7 was observed in the therapy room. Her indwelling urinary catheter tubing was positioned on the floor and and looped upwards to the urine collection bag which disallowed for the flow of urine by gravity. There was urine in the catheter tubing. Resident #7's indwelling urinary catheter was observed on other dates, times and locations with her catheter positioned in the same manner: 03/02/11 at 9:15 AM, Resident #7 was observed up in a chair in her room 03/02/11 at 11:05 AM, Resident #7 was observed in her wheelchair in the television lounge. 03/03/11 at 9:30 AM, Resident #7 was observed in her wheelchair in her room. During this observation, her urinary catheter tubing was positioned under the left front wheel of her wheelchair. 03/03/11 at 2:11 PM, Resident #7 was observed in her room in a wheelchair. During an interview with Resident #7 on 03/02/11 at 9:15 AM, Resident #7 was asked if she had a strap on her leg or any other device attached to her body which secured her catheter. Resident #7 stated, "No, it just hangs there all by itself." Resident #7 allowed the surveyor to feel along her pant legs to determine if a device was present. None was felt. During incontinent care observations on 03/03/11 at 3:01 PM, with CNA R, Resident #7's indwelling urinary catheter was not secured to her body or bed linen. This was confirmed by CNA R, who stated Resident #7 did not have any device to secure the catheter to her body or bed linen. A hospital History and Physical dated 02/10/11, reflected Resident #7 had an Acute Urinary Tract Infection. No orders for a urinalysis had been given since her admission to the facility. 3. Resident #4 was first observed on 03/01/11 at 10:50 AM during initial rounds in her room by the surveyor while accompanied by LVN A. At the time of the observation, LVN A stated Resident #4 was not interviewable, was bedfast, required total care for ADLs, utilized a Foley catheter, was incontinent of bowel, and had a contracture of the right hand. At the time of the observation, the resident's Foley catheter was not secured in any manner to the resident or to the bed. The tubing was pulled up and curled up into the resident's rectal area, which prevented the free flow of the urine. Resident #4's Face Sheet dated 12/23/10 reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the consolidated Physician order [REDACTED]. Review of Resident #4's MDS Admission assessment dated [DATE] revealed she was usually understood and usually understood, was severely impaired cognitively, did not exhibit behavior symptoms, required extensive to total assistance for all ADLs; she was not able to walk, and was not steady, was only able to stabilize with human assistance when moving from seated to standing position and surface-to-surface transfer. The MDS assessment also reflected she had functional range of motion impairment on one side to her arm and leg. On 03/02/11 at 9:03 AM, LVN KK accompanied the surveyor into Resident #4's room. The resident's catheter tubing was again observed as not being secured to the bed or to the resident in any manner. The catheter tubing was dragging on the floor from the bag, which was hanging on the side of the bed. On 03/02/11 at 10:30 AM, Resident #4 was again observed while accompanied by LVN KK. At that time, LVN KK was at the side of Resident #4's bed, and the tubing was on the floor. When LVN KK walked toward the bed to see the resident, LVN KK's shoes were touching the catheter tubing. This occurred two times during the observation. On 03/02/11 at 12:30 PM, Resident #4 was observed to receive incontinent care. Again, the catheter was not secured and observed to be dragging on the floor for most of the procedure. The resident had been incontinent of feces, and the tubing was not cleaned during the procedure. 4. The CDC's (Centers for Disease Control and Protection) Guidelines for Prevention of Catheter-Associated Urinary Tract Infections dated 03/25/03 reflected: "With indwelling catheters, infecting microorganisms can migrate to the bladder along the outside of the catheter in the periurethral mucous sheath." "d. Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction." According to the article entitled, Preventing Catheter-Associated Urinary Tract Infections (CAUTI), posted on Medscape on 02/03/09: The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) developed guidelines for the prevention of CAUTI: Under the section entitled Risk Factors for CAUTI: "Duration of catheter use is the most important risk factor for the development of infection. The risk of CAUTI increases by an estimated 5% to 10% each day that the catheter remains in place....The urine collection bag is a reservoir for microorganisms and handling it properly can reduce the risk of infection." Under the section entitled Follow Proper Insertion and Management Techniques: "Appropriate management begins with correctly securing the catheter to prevent movement of the catheter and traction forces on the catheter... The collection bag is positioned below the level of the patient's bladder, but not resting on the floor." Under the section entitled Proper Techniques for Urinary Catheter maintenance: "Maintain unobstructed urine flow." 5. Review of the Resident Census and Conditions of Residents, Form CMS-672, completed by ADON F on 03/01/11, revealed 89 residents were on a pain management program and five residents had indwelling catheters.

Based on observation, interview, and record review, the facility failed to ensure Charge Nurse LVN managed the facility's resources effectively and efficiently to attain or maintain the highest practicable physical well-being for one (Resident #8) of 17 residents reviewed for pain. Charge Nurse LVN L failed to manage Resident #8's pain control: Reports of Resident #8's pain did not match administration of pain medication. Charge Nurse LVN L did not follow-up with Resident #8 to assess if his pain was relieved. Charge Nurse LVN L was aware residents were being medicated with prn medications by MAs without being assessed before and after by LVNs and did nothing. Charge Nurse LVN L never reported Resident #8's high levels of pain to his doctor. Resident #8 complained of pain at levels of 8 and 9 (on a scale of 1-10) without receiving pain relief. Facility staff knew about Resident #8's list of medications, but did not follow-up when the resident requested Tylenol #3, which had previously provided pain relief. The MAs gave Resident #8 plain Tylenol without notifying the nurses and without reassessing the resident's pain. The LVNs did not reassess Resident #8' pain after administering Tylenol. Resident #8 went 10 days without pain relief until a family member brought Tyelnol #3 to the facility and an order was finally obtained from the physician. This failure could affect the facility's 89 residents, placing them at risk for having unrelieved pain, resulting in difficulty sleeping, decreased mobility, decreased socialization, decreased appetite, unplanned weight loss, and a negative impact on their quality of life. Findings included: Resident #8 was observed during the initial tour of the facility on 03/01/11 at 10:31 AM, by the surveyor while accompanied by LVN H. Prior to entering Resident #8's room, LVN H stated Resident #8 occasionally complained of pain, and the resident had a list of medications he took. Upon entering the room, Resident #8 was observed sitting up on the side of his bed. Resident #8 stated he wanted to talk to the surveyor about his concerns. Resident #8 removed a list of medications from his bedside drawer and stated nobody at the facility listened to him about the medications he was supposed to be taking, especially his [MEDICATION NAME] (narcotic [MEDICATION NAME]). Resident #8 stated he had pain, but it was not being controlled. A review of a hospital History and Physical dated 02/13/11, revealed Resident #8 was admitted to the hospital with [REDACTED]. The History and Physical reflected a computerized tomography scan of the abdomen revealed proximal ureter stones (kidney stones), and he was diagnosed with [REDACTED]. The History and Physical also reflected a cystoscopy with stent placement was performed secondary to the [MEDICAL CONDITION] obstruction. Review of his hospital medication regimen revealed he received [MEDICATION NAME] (narcotic [MEDICATION NAME]) while hospitalized to control his pain. The History and Physical also reflected Resident #8 had a [DIAGNOSES REDACTED]. According to the 03/01/11 Face Sheet, Resident #8 was admitted to the facility on [DATE]. The Face Sheet reflected [DIAGNOSES REDACTED]. During an interview with Resident #8 on 03/01/11 at 7:30 PM , he again pulled out the list of medications he had been taking at home. Resident #8 stated it took the concerted effort of three physicians to develop the list, and the medications, if taken as written, best controlled his disease processes and pain. One of the entries was for [MEDICATION NAME] 30-300 mg (Tylenol #3) at 1:00 AM and 1:00 PM. On 03/02/11 at 11:08 AM, a further interview with Resident #8 regarding his list of medications revealed he continued to state he had shown the list to the facility nurses and anyone who would listen. Resident #8 placed special emphasis on the Tylenol #3 and stated the staff would not intervene and call the physician to discuss the need for the medication. Resident #8 stated the plain Tylenol ordered by the physician would decrease the pain level from a 9 to a 7 on a scale of 1 to 10, 10 being the worst. Resident #8 stated he was never pain-free, even at home, but the Tylenol #3 kept the pain level at a 4 to 5 or even lower level. Resident #8 stated with the pain controlled at that level, he was able to do more for himself. During the same interview, Resident #8 also stated, since being admitted to the facility, his pain would wake him up during the night, several times a week. Resident #8 stated "it hurt," causing him to twist around in bed to find the most comfortable position. Resident #8 stated he had arthritis in his back, legs, knees and arms, which caused pain, until his family member intervened. Resident #8 stated one evening when he was in excruciating pain, he finally called his family member and told him/her nothing was being done to control his pain. Resident #8 stated his family member immediately came to the facility with his Tylenol #3 from home. Resident #8 stated he received his first dose that night and within an hour, felt much better. Resident #8 continued that even with the Tylenol #3 twice daily, he still usually had pain early in the morning between 4 AM and 5 AM, at an 8 or 9 level. When asked what the night nurse would do when he told her his pain was at an 8 or 9 level, Resident #8 responded, she would say, "Someone will come along with medication, but no one does. So I sit from 4 or 5 AM to 8 or 9 AM, waiting for my next Tylenol #3." Resident #8 stated sometimes he "felt like crying," and would get up and move around. Resident #8 stated it did not help his pain, but it took his mind off the pain and decreased his suffering of thinking about it. Review of Resident #8's facility admission orders [REDACTED]. This order also included staff were to document the level of pain on a scale of 0 to 10 when the Tylenol was administered for pain. In addition, a pain assessment was to be conducted every shift. Review of Resident #8's March 2011 consolidated physician orders [REDACTED]. No telephone order for this medication dated 02/27/11 or any other date was found. When requested, the facility was unable to produce the telephone order. Resident #8's nurses notes were reviewed and on 02/27/11, an entry at 4:39 PM by LVN I reflected: "...____ (Resident #8's family member) brought Tylenol #3 from home for pt. (patient) to take called Dr. ___ (doctor's name) ok to take tylenol #3 1 po (orally) bid (twice daily) for arthritis pain will Id (initial dose) tonight...." Review of the February 2011 Medication Aide MAR indicated [REDACTED]. LVN I was interviewed on 03/02/11 at 1:57 PM. LVN I stated Resident #8 had never really complained to her of severe pain, and she never received a report from the off-going nurse Resident #8 experienced major pain. LVN I stated she just received change of shift reports, which indicated the pain Resident #8 experienced was, "nothing major, just generalized arthritis pain." LVN I added one day Resident #8 took out his medication list and showed her he had been on Tylenol #3 for arthritis pain. LVN I stated Resident #8 told her it was what controlled his arthritic pain. LVN I stated shortly after that day, Resident #8's family member called and stated he/she was going to bring up Resident #8's [MEDICATION NAME] pills. LVN I stated the family member gave her the bottle of Resident #8's Tylenol #3 and she called the physician who approved administering it twice daily. LVN I also stated she understood everyone handled pain differently, but if Resident #8 who was alert and oriented had told her he had a pain level of 9 and nothing was ordered, she would have called the physician even if it was early in the morning. Interview with Resident #8's family member was conducted by phone on 03/02/11 at 3:26 PM. Resident #8's family member stated when the resident called him/her on the evening he/she took in his Tylenol with [MEDICATION NAME], he complained about his arthritis pain. Resident #8's family member stated the resident had called on other nights and said he was in pain, but this night it was different. He/She stated, "The pain was real bad." Resident #8's family member stated the resident called and told him/her he was not receiving the pain medication on his medication list. Resident #8's family member stated he/she also had a copy of the resident's medication list and determined the pain medication he not receiving was [MEDICATION NAME]. Resident #8's family member stated he/she immediately took Resident #8's [MEDICATION NAME] pills and the medication list into the facility and gave them to LVN I, who immediately called the doctor. At that point, the doctor approved the [MEDICATION NAME] pill be given twice daily. Resident #8's family member stated he/she did not know why the facility had not listened to the resident and had called the doctor before the pain got to the level it did. He/She added Resident #8 had severe arthritis of his knees, back, joints, and hips, and that night, it was so bad, he could hardly move. Resident #8's family member added, he was taking Tylenol Arthritis and Tylenol #3 at home. Review of Resident #8's February 2011 Electronic MAR under pain assessment, revealed LVN L documented pain levels of an 8 on 02/19/11, and a level of 9 on 02/22/11, 02/23/11, and 02/24/11. On 03/02/11 at 7:01 PM, LVN L was interviewed and stated Resident #8 was alert and oriented and could express his needs because, "he is in his right mind." LVN L stated Resident #8 complained of arthritis pain all the time. LVN L stated she would tell MA M to give him pain medication. When shown all the times the MAR indicated Maybe she forgot. ___ (MA M) is ___ (MA M). We have a list for the MAs to document prn (as needed) medication that is given and she probably forgot to document she gave it." LVN L continued Resident #8 was always in pain and always had high levels of pain. LVN L stated she would tell Resident #8 to call if the prn medication didn't work and when he didn't complain again and did not call, "I say he is okay. He never told me the medication was not working for pain, so I assumed if he didn't call, he's okay." LVN L stated she did not always go and assess if the prn medication worked, because she relied on Resident #8 to call if still in pain. LVN L also stated MA M administered prn pain medication without informing her first, and sometimes failed to chart all prn medications. LVN L stated she was going to suggest to ADON N nurses give all prn medication, because the MAs have the key to the medication carts until 10 PM. LVN L stated, "I think having control of prn meds, we will know when residents are in pain, so we can assess because sometimes MAs give prn pain meds without telling us, and we can't assess properly." When asked why she never called the doctor when Resident #8 complained of high levels of pain, LVN L stated she never thought to, because Resident #8 was in his right mind and could call if he needed something. LVN L stated she always made sure he had his call light within reach. Review of Resident #8's February 2011 Medication Aide MAR indicated [REDACTED]. In addition, MA M documented a pain level of an 8 on 02/24/11 at 9:23 AM. MA M documented these pain levels when she administered two tablets of Tylenol 325 mg to Resident #8. MA M was interviewed on 03/02/11 at 12:40 PM regarding how she became aware of Resident #8's pain levels she documented on the February 2011 Medication Aide MAR. MA M stated the nurses told her to always ask about pain when in a resident's room. MA M stated Resident #8 complained of a pain level of 9, "lots of times." MA M stated when Resident #8 complained of pain, she would ask him if he wanted a Tylenol. MA M stated Resident #8 would ask if she had "anything stronger but I told him that was all he had." When asked if she ever gave prn pain medication without first informing the nurse, MA M stated she had because, "the nurses trust my judgement." MA M stated when she told LVN L or LVN H about Resident #8's pain, they told her to go ahead and give the Tylenol. MA M stated she has given prn pain medication to Resident #8 and other residents without the nurses first assessing the resident. When asked if she followed up with Resident #8 after administering a prn pain medication, MA M stated she would check a box on the computer electronic MAR indicated I don't usually get down to re-assess the effectiveness. I just rely on the fact that they have not asked for anything more or I ask the aides how he is doing. We don't have the time to do it because we have such a full house." An interview was conducted with LVN A who worked on Hall 200 on 03/04/11 at 10:45 AM. During the interview, the LVN stated there were times the medications aides administered prn pain medication without bringing it to her attention, but she would assess the residents later. Review of Resident #8's initial MDS assessment dated [DATE], revealed the resident was not on a scheduled pain medication regimen but had received prn (as needed) pain medications. The Pain Assessment Interview portion of the MDS assessment was conducted with Resident #8 and reflected he had occasional pain in the last five days, which made it hard to sleep at night and limited his day-to-day activities. This interview portion reflected Resident #8 stated his worst pain over the last five days had been a 9 with zero being no pain, and 10 being the worst pain imaginable. Review of Resident #8's Admission Care Plan dated 02/18/11 revealed under the heading of Pain: "Goal: Resident will be as comfortable as possible." The approaches listed were: "Monitor Pain; Administer pain medications as ordered; and Establish causative factors and ways to alleviate them." Review of the Resident Census and Conditions of Residents, Form CMS-672, completed by ADON F on 03/01/11, revealed 89 residents were on a pain management program.