Every finding on record at Sadie G. Mays Health & Rehabilitation Center

Based on observation, interview, record review, and a review of the policy titled Food Preparation Guidelines, the facility failed to prevent avoidable accidents for two of three sampled residents (R) (R41 and R56) related to (1) hot chocolate burn and (2) fall risk. Harm was identified to have occurred on 3/18/2025 when R41 spilled hot chocolate on her left arm, causing a burn, blisters, and requiring transport to an acute care setting and wound treatment. Findings included:1. A review of a facility policy titled Food Preparation Guidelines dated 11/11/2025 indicated that proper (safe and appetizing) temperature means both appetizing to the resident and minimizing the risk for scalding and burns.A review of R41's electronic medical record (EMR) titled admission Record indicated the facility admitted the resident on 4/18/2025.A review of R41's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/2/2025 indicated the staff could not determine a Brief Interview for Mental Status (BIMS) score. The assessment indicated the resident had an impairment on one side of her upper extremity. A review of R41's Progress Notes dated 3/18/2025 indicated the resident sustained a burn when an Activity Assistant (AA)1, a former staff member, gave the resident a cup of hot chocolate. R41 had a private sitter next to her during this incident. Licensed Practical Nurse (LPN) 2 applied a cool cloth to the resident's left arm and contacted the physician, who ordered the resident to be sent to the emergency room for evaluation and treatment. The resident returned to the facility on the same day with an ace bandage wrapped around her arm.A review of R41's hospital records provided by the facility titled After Visit Summary, dated 3/18/2025, failed to identify the type of burn the resident sustained.A review of R41's Progress Notes dated 3/20/2025 indicated the resident was evaluated by the wound team, and the burn had some drainage. A review of R41's Weekly-Wound Observation Tool dated 3/20/2025 revealed the resident sustained a burn on her left arm. The assessment indicated the resident had a small amount of serous fluid, and the wound measured nine centimeters (cm) by 20 cm by 0.1 cm. A review of R41's Orders dated 3/21/2025 indicated the physician ordered Silvadene External Cream 1 percent to be applied to the resident's left arm on Monday, Wednesday, and Friday. During an interview conducted on 12/18/2025 at 9:01 am, the Activities Director (AD) stated the facility provides an activity called Coffee Club and this activity was held Monday through Friday. The AD stated that coffee, hot chocolate, and cappuccino were served to the residents who attended this activity. The AD stated the kitchen staff brought coffee and hot water for the instant hot chocolate and cappuccino to the main dining room for this activity program. The AD stated she was not present when R41 spilled hot chocolate on her left arm. The AD stated she provided training to the activity staff on allowing the hot chocolate to cool off completely before serving it to R41. During an interview conducted on 12/18/2025 at 9:15 am, LPN 1, who was also the facility's wound nurse, stated R41 did have some weakness in her left hand. Also present during this interview was Restorative Aide (RA) 1, who confirmed R41 had weakness in her left hand and could not hold anything in that hand. RA1 confirmed that R41 wore a splint on her left hand. During an observation on 12/18/25 at 9:19 am, R41 was observed sleeping in her wheelchair and had a splint on her left hand.During an interview on 12/18/2025 at 9:30 am, [NAME] 1 stated that she typically would take the temperature of the coffee and hot water served to the residents during activities. During this interview, a dual coffee maker was observed in the kitchen. Bunn was the title of the coffee maker. Both coffee pots sat on dual burners. [NAME] 1 verified that when the coffee was brewed, and the hot water ran through the coffee maker, the temperature reached 200 degrees Fahrenheit (F). The digital temperature could be observed on the outside of the coffee maker. Cook1 poured coffee from the coffee maker into a large plastic pitcher. Cook1 took the temperature from the freshly poured coffee, and the temperature read 176.80 degrees F. Cook1 then took the pitcher of coffee and poured it into the coffee urn. The lid remained off. The coffee urn was on top of a three-shelf wheeled cart, and steam was observed coming from the coffee urn. At 9:42 am, [NAME] 1 brought a coffee urn for the hot water. [NAME] 1 turned on the coffee maker to create hot water. Cook1 took the temperature from the freshly poured hot water, and the temperature read 176.8 degrees F. [NAME] 1 poured the hot water into a second coffee urn. At 9:50 am, [NAME] 1 left the kitchen with hot coffee and hot water and walked to the main dining room. The activity staff were preparing the Coffee Club activity. The cook stated that hot coffee and water should have a temperature of 165 degrees F. At 10:04 am, [NAME] 1 poured out three separate cups of hot liquid, which included coffee, hot chocolate, and hot water. [NAME] 1 took the temperature of the hot chocolate, and it was 148.8 degrees F. [NAME] 1 took the temperature of the hot water, and it was 155 degrees F. [NAME] 1 took the temperature of the coffee, and it was 155.6. All three cups of hot liquid sat until the Activities Assistant (AA) 2 began to serve the residents at 10:15 am, hot coffee and hot chocolate. [NAME] 1 then took the temperature of the hot chocolate, and it was 133.4 degrees F; the hot water was 133.20 degrees F; and the hot coffee was 133.7 degrees F. During an interview on 12/18/2025 at 10:32 am, the Director of Nursing (DON) stated she was unsure whether there were hot liquid assessments for residents. During an interview on 12/18/2025 at 11:38 am, the former private sitter (Sitter) for R41 stated she was present during the hot chocolate spill and confirmed that the resident could not open her entire left hand. The former Sitter stated she was with the resident when the resident was sent to the local emergency room. The former Sitter stated she observed the resident's left arm, and the resident sustained several blisters from the hot chocolate burn. A telephone call was placed on 12/18/2025 at 11:50 am to AA1, and no return call was received. During an interview on 12/18/2025 at 2:13 pm, the Maintenance Director stated he was unable to locate the coffee temperature logs for the month of March 2025. 2. A review of R56's Record of admission revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, peripheral vascular disease, and muscle weakness A review of R56's Care Plan Report dated 8/26/2024 revealed that R56 was at risk for falls due to limited mobility and was unaware of safety needs. An intervention was for R56 to have floor mats on both sides of the bed. An additional focus included that R56 had limited physical mobility due to Alzheimer's disease and weakness. A review of R56's annual MDS assessment, with an ARD of 10/13/2025, revealed a BIMS score of two out of 15, which indicated severe cognitive impairment. The MDS also indicated R56 was dependent on staff to complete toileting hygiene, bathing, dressing, personal hygiene, and transfers. A review of R56's Visual/Bedside Kardex Report revealed that staff were to ensure R56 had floor mats on both sides of the bed. During an observation on 12/16/2025 at 10:09 am, R56 had a fall mat on the floor on the right side of the bed. During an observation on 12/18/2025 at 11:13 am, R56 had one fall mat on the floor on the right side of the bed. During an interview on 12/18/2025 at 11:14 am with LPN 5, she confirmed there was only one mat on R56's floor. She added that there should be mats on both sides of the bed. During an interview on 12/19/2025 at 11:07 am, the DON stated that all interventions should be carried out. The mats are in place for safety. During an interview on 12/19/2025 at 12:37 pm, the Administrator stated that both mats should have been on the floor. If a staff member comes into the room and sees a mat leaning against the wall, the expectation is for them to determine whether it needs to be on the floor for the resident and if so, they need to place the mat or mats on the floor.

Based on record review, staff interviews, and a review of the policy titled Management of Beneficiary Funds, the facility failed to ensure that the surety bond was sufficient to cover the resident trust fund deposits. This deficient practice had the potential to adversely affect 129 of 129 residents in the facility.Findings included:A review of the undated facility's policy titled Management of Beneficiary Funds describes the process of managing beneficiary funds, but does not address the Surety [NAME] review of the facility's Surety Bond Document dated 3/26/2025 through 5/26/2025, indicated the amount of the bond was $190,000.00.A review of six months of the facility's Bank Statements from May 2025 to November 2025 revealed that five out of six bank statements had daily balances that were greater than the surety bond: The May 2025 beginning balance was $224,998.91 and ending balance was $229,239.06 The July 2025 beginning balance $229,239.06 and the ending balance was $228,566.62 The August 2025 beginning balance was $228,566.62 and the ending balance was $233,366.33 The October 2025 beginning balance was $187,220.09 and the ending balance was $197,124.53 The November 2025 beginning balance was $197,124.53 and the ending balance was $199,028.62The total amount of the 123 Resident Accounts as of 12/19/2025 was $205,144.77.During an interview with the Business Office Manager on 12/19/2025 at 12:30 pm, she confirmed the amount shown on the Resident Trust Fund bank statements and acknowledged the balance amount listed on the Trust Account Reconciliation document.

Based on observations, staff interviews, and record review, the facility failed to have an adequate water management program for 129 of 129 residents in the facility. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) Guidelines, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. Findings included:A review of the website for ASHRAE titled Successfully Managing the Risk of Legionellosis, dated 4/7/2021, indicated that Legionellae, the biological classification name for a [NAME] of bacteria, is the plural, referring to more than one Legionella bacterium. Legionellosis is any illness (disease) caused by exposure to Legionella. Legionnaires' disease (LD) and Pontiac fever (PF) are the two known types of legionellosis and are potentially fatal. These multisystem respiratory illnesses are accompanied by pneumonia. Symptoms include high fever, chills, muscle pain, headache, dry cough, diarrhea, vomiting, confusion, and delirium. Describe the building water systems using flow diagrams and a written description. Include details such as where the building connects to the (municipal) water supply, how water is distributed and used (processed), and where hot tubs, water heaters, cooling towers, etc., are located. A review was conducted of a facility document titled Water Management Program, dated 11/28/2025. The document failed to show a risk assessment and a diagram of the facility's water system or text that would describe the facility's water system, which would include areas indicated as high-risk areas in which water pathogens might develop.During an interview on 12/18/2025 at 10:32 am, the Maintenance Director stated that he only had blueprints of the building and no diagram of the facility's water system. A request was made to the Administrator for the total number of residents over the age of 65. No information was provided by the end of the survey.

Based on observations, staff interviews, record review, and review of the facility's policy titled Call Lights: Accessibility and Timely Response, the facility failed to ensure the call button was accessible for one of 27 sampled residents (R) (R56). This failure had the potential to place R56 at risk for accidents, injuries, or unmet needs related to an inability to call for staff assistance.Findings included:A review of the policy titled Call Lights: Accessibility and Timely Response dated 12/2/2025 revealed, The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.A review of R56's Record of admission revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, peripheral vascular disease, and muscle weakness.A review of R56's Care Plan Report dated 8/26/2024 revealed that R56 was at risk for falls due to limited mobility and was unaware of safety needs. An additional focus included [R56] had limited physical mobility due to Alzheimer's disease and weakness. A review of R56's annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/13/2025, revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment. The MDS also indicated R56 was dependent on staff to complete toileting hygiene, bathing, dressing, personal hygiene, and transfers. During an observation on 12/16/2025 at 10:09 am, R56's call button was observed under the bed, out of reach of the resident. During an observation on 12/17/2025 at 1:06 pm, R56's call button was observed under the bed, out of reach of the resident. During an observation and interview on 12/17/2025 at 1:07 pm with Licensed Practical Nurse (LPN) 6, she confirmed R56's call button was not within reach; she added that it should be at all times. She confirmed that R56 uses her call button. During an interview on 12/18/2025 at 3:04 pm, Certified Nurse Aide (CNA) 1 confirmed that R56 used her call button, and it should always be within her reach.

Based on record review, resident family member and staff interviews, and a review of the policies titled Medication Administration and Notification of Changes, the facility failed to ensure the physician was notified of a change of condition for one of 27 residents (R) (R93) related to a refusal of bedtime medications for four days in a row. This failure had the potential to result in clinical complications and potentially hospitalization.Findings included:A review of the policy titled Medication Administration dated 11/11/2025 revealed, Report and document any adverse side effects or refusals. A review of the policy titled Notification of Changes dated 12/2/2025 revealed, The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 3. Significant change in the resident's physical, mental, or psychosocial condition, such as a deterioration in health, mental, or psychosocial status. This may include.b. Clinical complications.A review of R93's Record of admission revealed she was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, dementia, type two diabetes mellitus, chronic obstruct pulmonary disease (lung condition causing airflow blockage and breathing difficulties), chronic kidney disease, and encephalopathy. A review of R93's Care Plan Report dated 4/29/2025 revealed that R93 refused all medications and times and refused care. A care plan dated 4/29/2025 revealed R93 had the potential for behaviors related to a diagnosis of paranoid schizophrenia. An intervention for staff was to discuss with the physician and family regarding the ongoing need for use of the medication. A care plan dated 4/29/2025 revealed R93 had impaired cognitive function and decision-making due to dementia. An intervention is for staff to administer medication as ordered.A review of R93's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/14/2025, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment. The MDS also indicated R93 rejected care one to three days in the seven-day look-back period.A review of R93's Order Summary Report revealed an order date 4/17/2025, for insulin glargine-yfgn subcutaneous solution pen injector, 100 units/ml (milliliter), inject 10 units at bedtime. A review of R93's Medication Administration Record dated 12/1/2025 to 12/31/2025 revealed R93 refused insulin glargine-yfgn during the 9:00 pm medication administration time on 12/3/2025, 12/6/2025, 12/7/2025, 12/8/2025, 12/9/2025, and 12/13/2025.A review of R93's Order Summary Report revealed an order dated 4/17/2025, for mirtazapine (antidepressant), 7.5 mg (milligrams), one tablet at bedtime. A review of R93's Order Summary Report revealed an order dated 4/17/2025, for Seroquel (antipsychotic), 100 mg, one tablet at bedtime. A review of R93's Order Summary Report revealed an order dated 4/17/2025, for simvastatin (helps lower bad cholesterol), 20 mg, one tablet at bedtime for cholesterol. A review of R93's Order Summary Report revealed an order dated 4/17/2025 for tamsulosin hcl (hydrochloride); treat symptoms of an enlarged prostate; 0.4 mg, one capsule at bedtime. A review of R93's Order Summary Report revealed an order dated 9/30/2025 for trazodone HCL (anti-depressant), 100 mg, one tablet at bedtime. A review of R93's Medication Administration Record dated 12/1/2025 to 12/31/2025 revealed R93 refused mirtazapine, Seroquel, simvastatin, tamsulosin HCl, and trazodone during the 9:00 pm medication administration time on 12/3/2025, 12/6/2025, 12/7/2025, 12/8/2025, and 12/9/2025. A review of R93's clinical records revealed no indication that the physician was notified of the medication refusals. During an interview on 12/16/2025 at 3:06 pm with R93's Family Member (FM), she stated she was not sure if the physician was notified if R93 refused his medication. Adding that he had refused medications multiple days in a row. She stated she thought the physician needed to know the information. During an interview on 12/18/2025 at 12:05 pm, the Administrator confirmed there was no documentation that the physician was notified of R93's medication refusals. During an interview on 12/18/2025 at 9:17 am, Licensed Practical Nurse (LPN) 4 stated that if a resident refused to take their medication, the physician was notified. She added that this notification was documented in progress notes. During an interview on 12/18/2025 at 9:23 am, LPN 3 stated that if a resident refused their medication, s/he would notify the physician and document this in the progress notes. During an interview on 12/18/2025 at 11:07 am, the Director of Nursing (DON) stated that if a resident refused their medications three consecutive times, the family and the physician needed to be notified. During an interview on 12/18/2025 at 12:37 pm, the Administrator stated that if a resident refused their medications at any time, the family and the physician needed to be notified. She added that there could be adverse effects if their medications were not taken. Additionally, the facility needed to determine why R93 refused their medications. She stated this should be documented in progress notes.

Based on staff interview, record review, and review of the facility's policy titled, Administering Medications, the facility failed to ensure the provider and the resident representative were notified when seven out of 21 sampled Residents (R1, R2, R3, R4, R5, R6, and R7) were not administered their medications, as ordered by the provider. This failure placed the provider and the resident's representatives of potential complications from not receiving their medications.Findings include:Review of the facility's policy titled, Administering Medications, dated 2001 revealed, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility with diagnoses that included stroke, diabetes, end-stage renal disease (ESRD) and was dependent on dialysis.Review of the December 2024 Medication Administration Record (MAR) located in the Orders tab of the EMR revealed the following prescribed medications were not documented as administered on 12/26/2025, as ordered:Phenytoin Sodium Extended Capsule 100mg [milligrams] Give 2 capsules by mouth every 12 hours for seizures.Atorvastatin 40 mg. Give 1 tablet by mouth in the evening for hypercholesterolemia [high cholesterol].Buspirone 10mg. Give 1 tablet by mouth two times a day for anxiety.Carvedilol 2025mg. Give 1 tablet by mouth two times a day for hypertension [elevated blood pressure].Clonidine 0.2mg. Give 1 tablet by mouth two times a day for hypertension.Divalproex 500mg. Give 1 tablet by mouth two times a day for behaviors.Eliquis 5mg. Give 1 tablet by mouth every 12 hours for deep vein thrombosis [blood clot prevention].Trazadone 50mg. Give 1 tablet by mouth at bedtime for insomnia.Spironolactone 25mg. Give 1 tablet by mouth at bedtime for hypertension.Hydralazine 100mg. Give 1 capsule by mouth every 8 hours for hypertension.There was no documentation to show that R1's provider and resident representative were notified of the medications that were not administered.2. Review of the admission Record located in the Profile tab of the EMR revealed R2 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and chronic pain syndrome.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medication that was not administered on 12/26/2024, as ordered:Gabapentin 100mg. Give 1 capsule by mouth three times a day for chronic pain syndrome.There was no documentation to show that R2's provider and resident representative were notified of the medication that was not administered.3. Review of the admission Record located in the Profile tab of the EMR revealed R3 was admitted to the facility with diagnoses that included COPD, and arthritis.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered:Famotidine 40mg. Give 1 tablet by mouth at bedtime for acid indigestion.Pravastatin 40mg. Give 1 tablet by mouth at bedtime for increased lipids.There was no documentation to show that R3's provider and resident representative were notified of the medications that were not administered.4. Review of the admission Record located in the Profile tab of the EMR revealed, R4 was admitted to the facility with diagnoses that included cancer, a stroke, and diabetes.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered:Atorvastatin 80mg. Give 1 tablet by mouth at bedtime for high cholesterol.Carvedilol 12.5mg. Give 1 tablet by mouth every 12 hours for high blood pressure.Tamsulosin 0.4mg. Give 1 capsule by mouth at bedtime for prostate.There was no documentation to show that R4's provider and resident representative were notified of the medications that were not administered.5. Review of the admission Record located in the Profile tab of the EMR revealed R5 was admitted to the facility with diagnoses that included a stroke and depression.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered.Atorvastatin 10mg. Give 1 tablet by mouth at bedtime for hyperlipidemia [increased lipids].Duloxetine 60mg. Give 1 capsule by mouth at bedtime for depression.There was no documentation to show that R5's provider and resident representative were notified of the medications that were not administered.6. Review of the admission Record located in the Profile tab of the EMR revealed R6 was admitted to the facility with a diagnosis of Alzheimer's dementia.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medication that was not administered on 12/26/2024:Levetiracetam 750 mg. Give 1 tablet twice daily for seizures.There was no documentation to show that R6's provider and resident representative were notified of the medication that was not administered.7. Review of the admission Record located in the Profile tab of the EMR revealed R7 was admitted to the facility with a diagnosis of Alzheimer's dementia.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered:Memantine 5mg. Give 1 tablet by mouth two times a day related to dementia.Metformin ER 500 mg. Give 1 tablet by mouth two times a day related to diabetes.There was no documentation to show that R7's provider and resident representative were notified of the medications that were not administered.Review of the 12/30/2024 facility investigation revealed the date and time that the medications that were not administered to the residents was 12/26/2025 at 5:00 pm and 9:00 pm. The investigation further stated that the resident representatives and the provider were notified.During an interview on 6/30/2025 at 1:06 pm, the Administrator stated, We did not find any documentation in the previous Director of Nursing's office to show that the resident representative and the provider were notified of the missing medications even though it stated that they were notified on the investigation.

Based on resident and staff interviews, record review, and review of facility policy, the facility failed to ensure medications were administered per the provider's order for seven of 21 sampled (Residents (R)1, R2, R3, R4, R5, R6, R7 reviewed. This failure placed the residents at risk of health complications and a diminished quality of life.Findings included:Review of the facility policy titled, Administering Medications, dated 2001 revealed, .Medications are administered in a safe and timely manner, and as prescribed.Medications are administered in accordance with prescriber orders, including any required time frame.Medication administration times are determined by resident need and benefit, not staff convenience.1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R1 was admitted to the facility with diagnoses that included but not limited to stroke, diabetes, end-stage renal disease (ESRD) and was dependent on dialysis.Review of the discharge-return anticipated Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 1/24/2025 revealed, R1 had a Brief Interview of Mental Status (BIMS) score that was assessed by staff of severely impaired in cognition.Review of the December 2024 Medication Administration Record (MAR) located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2025, as ordered:Phenytoin Sodium Extended Capsule 100mg [milligrams] Give 2 capsules by mouth every 12 hours for seizures. Start date: 2/20/2024.Atorvastatin 40 mg. Give 1 tablet by mouth in the evening for Hypercholesterolemia [high cholesterol]. Start dated: 2/20/2024.Buspirone 10mg. Give 1 tablet by mouth two times a day for anxiety. Start Date: 2/20/2024.Carvedilol 25mg. Give 1 tablet by mouth two times a day for Hypertension [elevated blood pressure]. Start Date: 2/20/2024.Clonidine 0.2mg. Give 1 tablet by mouth two times a day for Hypertension. Start Date: 6/7/2024.Divalproex 500mg. Give 1 tablet by mouth two times a day for behaviors. Start Date: 2/20/2024. Eliquis 5mg. Give 1 tablet by mouth every 12 hours for deep vein thrombosis [blood clot prevention]. Start Date: 2/20/2024.Trazadone 50mg. Give 1 tablet by mouth at bedtime for insomnia. Start Date: 2/20/2024.Spironolactone 25mg. Give 1 tablet by mouth at bedtime for Hypertension. Start Date: 2/20/2024.Hydralazine 100mg. Give 1 capsule by mouth every 8 hours for Hypertension. Start Date: 2/20/2024.Per the investigation, the atorvastatin, buspirone, carvedilol, clonidine, divalproex were not administered on 12/26/2025 at 5:00 PM. The hydralazine was not administered on 12/26/2024 at 10:00 PM. The Eliquis, Phenytoin, spironolactone, and Trazadone were not administered on 12/26/2024 at 9:00 PM. The Medication was discovered as not given on 12/30/2024 by the supervisor at 8:30 AM, during a cart check. The investigation further revealed that Licensed Practical Nurse (LPN)7 had signed the medications as administered.2. Review of the admission Record located in the Profile' tab of the EMR revealed R2 was admitted to the facility with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD) and chronic pain syndrome.Review of the discharge-return anticipated MDS located in the MDS tab of the EMR with an ARD of 12/29/2024 revealed R2 had a BIMS score that staff assessed to be independent in cognition.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medication that was not administered on 12/26/2024, as ordered:Gabapentin 100mg. Give 1 capsule by mouth three times a day for Chronic Pain Syndrome. Start Date: 2/9/2024.Per the facility investigation, the gabapentin was not administered on 12/26/2025 at 8:00 PM. The Medication was discovered as not given on 12/30/2024 by the supervisor at 8:30 AM, during a cart check. The investigation further revealed that LPN7 had signed the medications as administered. During an interview on 6/30/2025 at 1:30 PM, R2 stated, I don't remember anything about this. 3. Review of the admission Record located in the Profile tab of the EMR revealed R3 was admitted to the facility on [DATE] with diagnoses that included but not limited to COPD, and arthritis.Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 2/4/2024 revealed R3 had a BIMS score of 14 out of 15, which indicated R3 was cognitively intact.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered:Famotidine 40mg. Give 1 tablet by mouth at bedtime for acid indigestion. Start Date: 1/26/2024.Pravastatin 40mg. Give 1 tablet by mouth at bedtime for increased lipids. Start Date: 8/1/2023.Per the investigation, the famotidine and the pravastatin were not administered on 10/26/2024 at 9:00 PM. The medications were discovered as not given on 12/30/2024 by the supervisor at 8:30 AM, during a cart check. The investigation further revealed that LPN7 had signed the medications as administered.During an interview on 6/30/2025 at 1:37 PM, R3 stated, I don't remember anything about not getting my medications. I don't think I suffered without them.4. Review of the admission Record located in the Profile tab of the EMR revealed, R4 was admitted to the facility with diagnoses that included but not limited to cancer, a stroke, and diabetes.Review of the annual MDS located in the MDS tab of the EMR with an ARD of 10/25/2024 revealed R4 had a BIMS score of five out of 15, which indicated R5 was severely impaired in cognition.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered:Atorvastatin 80mg. Give 1 tablet by mouth at bedtime for high cholesterol. Start Date: 10/4/2023.Carvedilol 12.5mg. Give 1 tablet by mouth every 12 hours for high blood pressure. Start Date: 10/4/2023.Tamsulosin 0.4mg. Give 1 capsule by mouth at bedtime for prostate. Start Date; 10/4/2023.Per the investigation, the atorvastatin, carvedilol, and the tamsulosin were not administered on 12/26/2024 at 9:00 PM. The medications were discovered not given on 12/30/2024 by the supervisor at 8:30 AM, during a cart check. The investigation further revealed that LPN7 had signed the medications as administered.5. Review of the admission Record located in the Profile tab of the EMR revealed R5 was admitted to the facility with diagnoses that included but not limited to a stroke and depression.Review of the annual MDS located in the MDS tab of the EMR with an ARD of 1/3/2025 revealed R5 had a BIMS score of 11 out of 15, which indicated R5 was moderately impaired in cognition.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered.Atorvastatin 10mg. Give 1 tablet by mouth at bedtime for hyperlipidemia [increased lipids]. Start Date: 11/29/2023.Duloxetine 60mg. Give 1 capsule by mouth at bedtime for depression. Start Date: 4/18/2024.Per the investigation, the atorvastatin, and the duloxetine were not administered on 12/26/2024 at 9:00 PM. The medications were discovered not given on 12/30/2024 by the supervisor at 8:30 AM, during a cart check. The investigation further revealed that LPN7 had signed the medications as administered.During an interview on 6/30/2025 at 10:08 AM, R5 stated, I remember, oh yes I do. It was around 9:00 PM and I waited and waited for my medication. I thought the nurse was behind, so I ended up dozing off. I woke up around 11:00 PM and realized I did not get my medications, as she had gone home.6. Review of the admission Record located in the Profile tab of the EMR revealed R6 was admitted to the facility with a diagnosis of but not limited to Alzheimer's disease, dementia.Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 01/08/25 revealed R6 had a BIMS score of six out of 15, which indicated severe cognitive decline.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medication that was not administered on 12/26/2024:Levetiracetam 750 mg. Give 1 tablet twice daily for seizures. Start Date: 3/29/2024.Per the investigation, the levetiracetam was not administered on 12/26/2024 at 5:00 PM. The medication was discovered not given on 12/30/2024 by the supervisor at 8:30 AM, during a cart check. The investigation further revealed that LPN7 had signed the medications as administered.During an interview on 6/30/2025 at 2:10 PM, R6 stated, I don't remember if I have missed any medication, but I know I have not had a seizure since I came here.7. Review of the admission Record located in the Profile tab of the EMR revealed R7 was admitted to the facility with a diagnosis of but not limited to Alzheimer's disease, dementia.Review of the annual MDS located in the MDS tab of the EMR with an ARD of 4/1/2025 revealed R7 had a BIMS score of zero out of 15, which indicated R7 was severely impaired in cognition.Review of the December 2024 MAR located in the Orders tab of the EMR revealed the following prescribed medications that were not administered on 12/26/2024, as ordered:Memantine 5mg. Give 1 tablet by mouth two times a day related to Dementia. Start Date: 8/1/2023.Metformin ER 500mgs. Give 1 tablet by mouth two times a day related to diabetes. Start Date: 8/1/2023.Per the investigation, the memantine and the metformin were not administered on 12/26/2024 at 5:00 PM. The medications were discovered not given on 12/30/2024 by the supervisor, during a cart check. The investigation further revealed that LPN7 had signed the medications as administered.Review of the facility investigation was provided to the survey team by the Administrator revealed the incident occurred on 12/26/2024 at 5:00 PM and 9:00 PM. Assessments were completed on the residents who did not receive their ordered medication. The Resident Representatives (RPs) were in progress of being notified. LPN7 was terminated. In addition, the Unit Manager and Director of Nursing (DON) generated statements from those involved and/or around. An investigation began immediately. Residents were assessed immediately. No new findings identified or significant changes. Families notified. MD notified.During an interview on 6/30/2025 at 1:06 PM, the current Administrator stated, We did not find any more documentation in the previous DONs office regarding this investigation which included statements from those involved and/or around and documentation to show the residents were assessed immediately after identifying the situation.During an interview on06/30/2025 at 2:53 PM, Nurse Practitioner (NP) 1 stated, It's been so long, I don't remember if I was notified or not.During an interview on 6/30/2025 at 2:56 PM, NP2 stated, It's been too long, I don't remember if I was notified or not.During an interview on 6/30/2025 at 3:00 PM, the Consultant Pharmacist was asked if he was aware of any notifications from nursing that medications were not administered, as ordered. The Consultant Pharmacist stated, Actually, yes. I was aware of several patients that had not received their medications and was placed in my consultant report. I identified five but, there may have been ones I missed.

Based on observation, record review, and interview, the facility failed to maintain the dignity of one out of 21 Resident (R) (R14) reviewed in the sample. Specifically, the facility did not have any urinary drainage bags available and R14 was placed in an adult incontinence brief. This had the potential for the resident to have a diminished quality of life. Findings include:Review of R14 Medical Diagnoses located in the electronic medical record (EMR) tab titled Medical Diagnosis revealed the resident was admitted to the facility with diagnoses that included cerebral infarction (stroke) with left sided hemiplegia and hemiparesis, and chronic kidney disease stage three.Review of R14's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/10/2025 located in EMR tab titled MDS revealed the resident has a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. The resident was dependent on staff for all activities of daily living (ADLs). The resident was incontinent of the bladder and bowel and wore an external catheter.Review of R14's physician's Orders dated 6/24/2025 located in the EMR tab titled Orders revealed the resident was to wear condom catheter and change daily and monitor skin for changes.During an interview on 6/30/2025 10:18 am with R14 revealed he had complained several times about wearing the adult incontinence brief; that he did not like having that wetness next to his skin which could cause his skin to break down. R14 stated that the physician had left orders for him to wear a condom catheter with a drainage bag. R14 stated that the facility did not have any large urinary drainage bags, only the leg bags. The resident stated the leg bags were not good enough in that urine would back up and cause the condom to leak. R14 further stated that wearing the adult incontinence brief made him feel like he was a baby.During an interview on 7/1/2025 at 8:45 am Licensed Practical Nurse (LPN)4 revealed at one time the facility was out of urinary drainage bags but was unsure if there was still a shortage of drainage bags.During an observation and interview on 7/1/2025 at 11:45 am revealed Certified Nursing Assistant (CNA)4 had finished providing R14's morning care. R14 was observed wearing an adult incontinence brief. CNA4 revealed the facility was out of urinary drainage bags and she did not know when the next supply was to be delivered.During an interview on 7/1/2025 at 1:00 pm the Central Supplier and Scheduler (CSS) revealed the facility was running low urinary drainage bag in fact she only had the leg drainage bag available. CSS stated that she was just made aware of the situation with R14 and had applied a condom catheter with a leg drainage bag. CSS stated that the new delivery was due later today and she would change the leg drainage bag to a bedside drainage bag. CSS stated there was no reason why the resident had to wait that long for urinary drainage bag.

Based on record review, resident and staff interviews, and review of the facility’s policy titled, “Policy and Procedure, the facility failed to timely report allegations of abuse to the required agencies and physician within the state reporting time frame for two of 21 sampled Residents (R) (R12 and R9). This failure has the potential to increase the risk of abuse. Findings include: Review of the facility’s undated policy titled “Policy and Procedure revealed Abuse and Neglect” directs staff as follows: “…. Notify the shift supervisor immediately upon identification of actual or suspected abuse, neglect, mistreatment, injuries of unknown source, and/or misappropriation of resident property… Report the incident to the Director of Nursing and Administrator immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury… Report the incident to the State Agency and the adult protective services immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury per the guidelines established in the state reporting guidelines and any other required agency, including the Ombudsman and local law enforcement as required by law…” 1.Record review of R12’s “Medical Diagnoses” sheet located in the electronic medical record (EMR) tab titled “Medical Diagnoses” revealed the resident admitted to the facility with diagnoses that included but not limited to metabolic encephalopathy, end stage renal disease with dialysis, major depressive disorder, and anxiety disorder. Review of R12’s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/2025 located in the EMR tab titled MDS revealed the resident had Brief Interview for Mental Status (BIMS) score of 10 out of 15 points which indicated the resident had moderately impaired cognition. Review of R12’s Nurses Notes dated 2/26/2025 located in the EMR tab titled “Progress Notes” revealed the facility received a call from the Director at the dialysis center stating the resident had voiced a concern about being abused by a staff member at the nursing home. Review of the facility’s grievance form dated 2/26/2025 revealed R12 voiced concerns to the dialysis’s center staff that she was being abused at the facility by a day shift Certified Nursing Assistant (CNA) who put her hand near the resident’s vaginal area. The grievance form was forwarded to the Interim Director of Nursing (DON) for investigation. Review of the facility’s “Incident Report” dated 2/26/2025 completed by the Interim DON revealed the report was completed on 2/27/2025. R12’s responsible party was notified of the incident. However, the local law enforcement and facility’s physician were not notified. The Day One report was submitted to the State Agency 24 hours after the incident was reported to the facility. During an interview on 7/1/2025 at 1:30 pm with the Infection Control Preventionist (IP) who was the Interim DON at the time of the incident, confirmed the local law enforcement agency and facility’s physician were not notified of the incident and the incident was not reported within the two-hour time frame. The IP stated the incident was identified as staff to resident abuse when the report was filed. The IP stated the Day One report was submitted on 2/27/2025. During an interview with the current Administrator on 7/1/2025 at 10:35 am and after she reviewed the grievance investigation dated 2/26/2025 and the incident report dated 2/26/2025 completed by the Interim DON confirmed the incident was not reported timely to the appropriate agencies. 2. Review of the admission Record located in the Profile tab of the EMR revealed R9 was admitted to the facility with diagnoses that included vascular dementia, a stroke, and seizures. Review of the quarterly MDS located in the MDS tab of the EMR with ARD of 6/13/2025 revealed R9 had a BIMS score of eight out of 15 which indicated R9 was moderately impaired in cognition. During an interview on 7/2/2025 at 11:19 am, R9 was observed lying in bed awake. He was asked if anyone had abused him, physically. R9 stated, Yes. R9 was asked if he remembered when the abuse occurred. R9 stated, About six months ago. R9 was asked if he remembered who the person was who physically abused him. R9 stated, It was a lady, I did tell the nurse, I think she was let go. Review of the 12/1/2024 through 2/1/2025 Nursing Progress Notes located in the Progress Notes tab of the EMR showed no documentation of an allegation of staff to resident physical abuse. During an interview on 7/2/2025 at 1:00 pm, the Administrator stated, I reviewed the previous Administrator's records, and this allegation was on the reportable list, but there is no investigation that I can find. We don't even know if the allegation of physical abuse was actually sent to the State or not.

Based on record review, interview, and review of facility policy, the facility failed to conduct a thorough investigation of alleged abuse of two (Residents (R)12 and R9) out of 21 sampled residents. This failure had the potential to provide a safe environment for all residents against abuse. Findings include: A review of the facility’s undated policy titled “Policy and Procedure: Abuse and Neglect” revealed …An Accident/Incident Report will be initiated immediately upon identification of actual or suspected abuse, neglect, mistreatment, injuries of unknown origin, and/or misappropriation of resident property…The Administrator or designee will oversee the internal investigation…the investigative process includes but it not limited to the following: completed accident/incident report, witness statements, assessment of injuries, resident interviews, interview with the alleged perpetrator, interviews with staff, including those on duty at the time of the incident or those who may have significant information or contact with resident during the identified time frame….Abusive acts of sexual nature may warrant a thorough physical examination by the attending physician or an emergency room visit…The results of all investigations must be reported to the Administrator or his/her designee and to other officials, including state Agency, Adult Protective services (APS) and the local ombudsman, in accordance with State law within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken… 1.Record review of R12’s “Medical Diagnoses” sheet located in the electronic medical record (EMR) under the tab titled “Medical Diagnoses” revealed the resident was initially admitted to the facility with diagnoses that included but not limited to metabolic encephalopathy, end stage renal disease with dialysis, major depressive disorder, and anxiety disorder. The resident was discharged from the facility 4/29/2024 Review of R12’s annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/4/2025 located in the EMR tab titled MDS revealed the resident had Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderately impaired cognition. The resident was dependent on staff for activities of daily living (ADLs) and on dialysis. Review of R12’s Nurses Notes dated 2/26/2025 located in the EMR tab titled “Progress Notes” revealed the facility received a call from the Director at the dialysis center stating the resident had voiced a concern about being abused by a staff member at the nursing home. Review of the facility’s grievance form provided by the facility dated 2/26/2025 revealed R12 voiced concerns to the dialysis’s center staff that she was being abused by a facility day shift Certified Nursing Assistant (CNA) who put her hand near the resident’s vaginal area. The grievance form was forwarded to the Interim Director of Nursing (DON) for investigation Review of the facility’s “Incident Report” dated 2/26/2025 completed by the Interim DON revealed the report was completed on 2/27/2025. R12’s responsible party was notified of the incident. However, the local law enforcement and facility physician were not notified. The facility was unable to provide an investigation with witnesses statements and interviews with the residents regarding feeling safe and secure against abuse. During an interview on 7/1/2025 at 1:30 PM with the Infection Control Preventionist (IP) who was the Interim DON at the time of the incident, revealed the local law enforcement agency and facility were not notified of the incident. requirement. The IP stated that statements were obtained from the staff assigned to R12 the day of the alleged sexual abuse. The IP also stated that interviews were conducted with residents in the area to ensure they felt safe. The IP stated that all the documentation she had was turned over to the Interim Administrator and placed in an abuse manual that he maintained in his office. The IP identified CNA1 and CNA2 as being interviewed during the abuse investigation. During an interview on 7/1/2025 at 10:35 AM with the current Administrator on and after she reviewed the grievance investigation dated 2/26/2025 and the incident report dated 2/26/2025 completed by the Interim DON confirmed the investigation was incomplete. The Administrator stated that an Abuse Manual was maintained in the former Administrator’s office. Since the former interim Administrator suddenly resigned, the Abuse Manual had disappeared. An interview on 7/2/2025 at 10:00 AM with CNA2 revealed that she remembered R12 but was not assigned to the resident. CNA2 stated that she was not asked to provide a witness statement even though she heard about the incident. An interview on 7/2/2025 at 10:55 AM with CNA1 revealed that she was not assigned to the resident and had not been interviewed about the abuse incident. 2. Review of the admission Record located in the Profile tab of the EMR revealed R9 was admitted to the facility on [DATE]. Review of the annual MDS located in the MDS tab of the EMR with an ARD of 12/24/24 revealed R9 had a BIMS score of five out of 15, which indicated R9 was severely impaired in cognition. On 6/30/2025 at 3:25 PM, the Administrator was asked to provide the facility investigation on the alleged abuse by a staff member towards R9. During an interview on 7/2/2025 at 11:19 AM, R9 was asked if any staff member had physically abused him. He stated, Yes. R9 was asked if he remembered when the abuse occurred. R9 stated, About six months ago. R9 further stated, It was a lady, and I told the nurse, she was let go. R9 was asked if he felt safe in the facility. He stated, Yes.

Based on observation, record review, staff interview, and review of facility policy, the facility failed to revise the care plans related to falls for four (Residents (R)9, R10, and R15) from a sample of 21 residents. This failure had the potential for residents to continue to fall and possibly result in injuries. Findings include: Review of the facility policy titled Care Plans – Comprehensive Person Centered with a revision date of March 2022 revealed, …Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change…The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment… 1. Review of R10’s “Medical Diagnosis” located in the EMR tab titled Medical Diagnosis” revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included but not limited to cerebral infarct (stroke) with hemiparesis and hemiplegia, and repeated falls. Review R10’s quarterly MDS with an ARD of 5/15/2025 located in the EMR tab titled MDS revealed the resident has Brief Interview for Mental Status (BIMS) score of 15 out 15, which indicated the resident was cognitively intact. The resident had a limited range of motion of one upper extremity and limited range of motion of both lower extremities. The resident required substantial to maximum assistance with activities of daily living (ADLs); and resident has sustained a fall during the assessment period. Review of R10’s “Care Plan” with an initial date of 11/14/2024 located in the EMR tab titled “Care Plans” identified the resident had actual fall incidents on 12/1/2024 and 1/22/2025. However, the Care Plan did not reflect the incident that occurred on 5/11/2025 due to the resident’s poor balance. Review of R10’s “admission Fall Risk Assessment” dated 5/9/2025 located in the EMR tab titled Assessments” revealed the resident a had a fall risk score of 17, which indicated the resident was a high risk for falls and had not sustained any falls in the past three months. Review of the resident’s Fall Risk Assessment” dated 5/11/2025 revealed the resident had a fall risk score of five and had not sustained any falls in the past three months. Review of R10’s “Nurses Notes” dated 5/11/2025 located in the EMR tab titled Progress Notes documented the resident was found lying face down on the bed after attempting to stand up unassisted. The resident complained of left shoulder pain which was later x-rayed with negative results. The resident’s physician and responsible party were notified. 2. Review of R15’s “Medical Diagnosis” located in the EMR tab titled Medical Diagnosis revealed the resident was admitted to the facility with diagnoses that included but not limited to cerebrovascular disease (stroke) with hemiplegia and hemiparesis, unsteadiness, and difficulty walking. Review of R15’s annual MDS with an ARD of 2/3/2025 located in the EMR tab titled MDS revealed the resident had BIMS score of eight out of 15, which indicated the resident had moderately impaired cognitive function. The resident was assessed to have a limited range of motion of the lower extremities and was dependent on staff for all ADLs. The resident was assessed to have one fall without injury since admission to the facility. Review of R15’s quarterly MDS with an ARD of 5/3/2025 located in the EMR tab titled MDS revealed the resident now had a BIMS score of five out of 15, which indicated the resident’s cognition was severely impaired. During the assessment period the resident sustained one fall without injury and one fall with injury. Review of R15’s “Nurses Notes” dated 12/21/2024 located in the EMR tab titled Progress Notes revealed the resident was found on the floor in the resident’s bathroom with no visible injuries noted. Review of “Nurses Notes” dated 3/31/2025 revealed the resident was lowered to the floor by staff in his room without injury. Review of Nurses Notes dated 4/4/2025 revealed the resident experienced a coughing episode and slipped out of his wheelchair to the floor. The resident complained of some back pain but did not feel it was related to the fall and refused to be sent to the hospital for an examination. Review of R15’s “Care Plan” with an initiation date of 7/27/2023 located in the EMR tab titled Care Plans revealed the resident had an actual fall without injury related to unsteady gait and hemiparesis. However, the care plan did not identify the date of this fall; nor did the Care Plan address the falls that occurred on 3/31/2025 and 4/4/2025. During an interview on 7/2/2025 at 9:30 AM with the Director of Nursing (DON) revealed the MDS nurses were responsible for the care plan development. However, it was an expectation that any floor nurse would revise or update the resident’s care plans and changes in the resident’s condition occurred or new interventions were needed. The DON stated R10 and R15’ care plans should have been updated to reflect the falls as they occurred, and any new interventions were required. 3. Review of the admission Record located in the Profile tab of the EMR revealed R9 was admitted to the facility with a diagnosis that included but not limited to vascular dementia. Review of the quarterly MDS located in the MDS tab of the EMR with an ARD of 6/13/2025 revealed R9 had a BIMS score of eight out of 15, which indicated R9 was moderately impaired in cognition, required substantial/maximum assistance for activities of daily living (ADLs) and had two non-injury falls during the observation period. Review of the 8/13/2023 and revised on 6/9/2025 Falls Care Plan located in the Care Plan tab of the EMR revealed, The resident has had falls. Interventions included, but not limited to: Non-skid footwear (12/24/2024), Encourage resident not to get on floor and scoot to reach other areas (11/4/2024), Frequent check while in bed and provide assistance as needed (6/2/2024), Provide cue for resident to let staff assist him with obtaining foods and going into room (10/4/2023), PT (physical therapy) consult for strength and mobility (8/13/2023), Reinforce frequent checks by staff and offer rest periods as needed (2/17/2024), Reenforce with staff to observe frequently and provide rest period (1/28/2025), Staff to frequently check on resident whereabouts and provide assistance as needed (10/1/2024). During an observation and interview on 7/1/2025 at 10:54 AM, R9 was observed in the dining room during an activity and was reclined with feet up in a Geri chair (a specialized chair). During an interview on 7/2/2025 at 9:20 AM, the Director of Rehab Services (DOR) stated, We put him on Occupational therapy [OT] and Physical therapy [PT] as he was not safe in the wheelchair. We went to a Geri chair (a specialized chair designed for individuals with mobility limitations) as his trunk control was not very good, it is improving. The DOR was asked why the Geri chair was not care planned. He stated, I don't know, but it should have been. The DOR was asked how long has R9 been in the Geri chair. He stated, More than 30 days. During an interview on 7/2/2025 at 11:09 AM, Licensed Practical Nurse (LPN) 1 stated, The Geri chair was an intervention by therapy. LPN 1 was asked who was responsible for updating the care plan. LPN1 stated, Anyone can put interventions in the care plan and the Geri chair should have been in the care plan. It has been a successful intervention, and the falls have decreased.

The facility failed to ensure activities of daily living (ADLs) were provided for one of three residents (Residents (R)9) who was dependent on staff for assistance with ADLS out of a total sample of 21. This failure placed R9 at risk of a diminished quality of life.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R9 was admitted to the facility with diagnoses that include but not limited to vascular dementia, stroke, and right-sided paralysis.Review of the 6/7/2024 ADLs Care Plan located in the Care Plan tab of the EMR revealed, The resident has an ADL self-care performance deficit r/t (related to) Hemiplegia [paralysis], Limited mobility, Limited ROM [range of motion]. Interventions included, Bathing/Showering: The resident requires assistance by (2) staff with bathing/showering 3 times weekly and as necessary. Dated 6/7/2024.Review of the EMR under the Task tab revealed, a shower was documented in the EMR on 3/7/2025. 3/29/2025, 4/10/2025, and 4/15/2025 (refusal). There was no other documentation in the Task tab for May 2025. The documentation showed that for each shower, R9 was dependent on staff for the task.Review of the June 2025 Bath Book located at the C-Hall nurses station revealed R9 had documentation to show a shower had been given on 6/3/2025, 6/14/2025, and 6/19/2025 and on 6/17/2025 it was documented the resident refused. The Unit Manager (UM) was asked what the policy was regarding showers. She stated, There is a shower schedule at the desk, and the showers are to be given three times a week, either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. The Certified Nurse Aides (CNAs) are responsible for showering. The UM was shown the four shower sheets that were in the June Bath Book with only the four documented shower sheets. The UM stated, That can't be right, I will check on this. The UM was asked if the CNAs are to document the shower on the Task sheet in the EMR. The UM stated, Well, I think so.The UM did not provide any additional shower sheets for R9 by the time of the exit of the survey.During an interview on 7/2/2025 at 1:58 PM, The Director of Nursing (DON) was asked about the lack of documentation in the Task tab of the EMR and the June Shower Sheets. The DON stated, I spoke to the CNAs [on the phone] and they confirmed that they did not do any shower sheets.

Based on observation, staff interviews, record review, and review of facility policy, the facility failed to ensure adequate supervision to potentially prevent accidents for two of four residents (Residents (R)9 and R11) reviewed for accidents in a total sample of 21. These failures placed the residents at risk of injury and unmet care needs.Findings include:Review of an undated facility policy titled Falls and Injury Program revealed, .Each resident's care plan will include specific fall prevention and management strategies tailored to their individual needs and risk factors.1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R11 was admitted to the facility with diagnoses that included but not limited to Alzheimer's disease, dementia.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 1/21/2025 revealed R11 had a Brief Interview of Mental Status (BIMS) score of zero out of 15, which indicated R11 was severely impaired in cognition.Review of a 1/9/2025 Nurses Note located in the Progress Notes tab of the EMR revealed, approximately at 11:45 AM, assigned CNA [certified nurse aide] was in the process of transferring resident out of the room and the crew guy was moving the cabinets. The CNA verbally asked the crew guy to stop for a minute, and he didn't and he put the doors up against the wall, then part of the cabinets fell on the resident's chest and arms. The crew guys removed the doors and the nurse was notified. Nurse assessed the resident [R11] and the provider gave an order for an x-ray of the sternum. The resident's family was notified.Review of an 1/10/2025 Nurses Note located in the Progress Notes tab of the EMR revealed, the on-call physician was notified that the Xray of the resident's sternum was questionable for a dislocation. The physician gave an order to send the resident out for a follow up x-ray. The results revealed the resident did not have a sternum fracture.On 7/1/2025 at 8:00 AM, an attempt to contact Licensed Practical Nurse (LPN)8 regarding the incident was made. No return contact was received.On 7/1/2025 at 8:32 AM, the Administrator was asked to assist in identifying the CNA. However, the Administrator was unable to identify the CNA.During an interview on 7/1/2025 at 12:45 PM, the current Administrator was asked if there was an investigation done at the time of the incident. The Administrator stated she could not find an investigation regarding the accident.During an interview on 7/2/2025 at 11:22 AM, the Maintenance Director stated, At the time of the accident, I was not the Director, but just a maintenance employee. It was the contract company who was working in the room. The Maintenance Director denied being asked for a statement regarding the incident as well as the third party vendor.2. Review of the admission Record located in the Profile tab of the EMR revealed R9 was admitted to the facility on [DATE] with diagnoses that included but not limited to vascular dementia, stroke, and right-sided paralysis.Review of the annual MDS located in the MDS tab of the EMR with an ARD of 12/16/2024 revealed R9 had a BIMS score of five out of 15, which indicated R9 was severely impaired in cognition and had two non-injury falls since the previous assessment.Review of the 8/13/2023 and revised on 6/9/2025 Falls Care Plan located in the Care Plan tab of the EMR revealed, The resident has had falls. Interventions included, but not limited to: Non-skid footwear (12/24/2024), Encourage resident not to get on floor and scoot to reach other areas (11/4/2024), Frequent check while in bed and provide assistance as needed (6/2/2024). Provide cue for resident to let staff assist him with obtaining foods and going into room (10/4/2023), PT (physical therapy) consult for strength and mobility (8/13/2023). Reinforce frequent checks by staff and offer rest periods as needed (2/17/2024), reinforce with staff to observe frequently and provide rest period (1/28/2025), Staff to frequently check on resident whereabouts and provide assistance as needed (10/1/2024).Review of a 1/2/2025 at 3:35 PM Nurses Note located in the Progress Notes tab of the EMR revealed, at 9:00 AM resident was on the floor near his w/c [wheelchair], in his room. No injuries were noted.Review of a 1/10/2025 at 3:04 PM Nurses Note located in the Progress Notes tab of the EMR revealed that the resident was found on the floor without injury.Review of a 1/18/2025 at 6:31 PM Incident Note located in the Progress Notes tab of the EMR revealed the resident used the wall rail to intentionally put himself to the floor. No injuries noted.Review of a01/20/2025 at 3:38 PM Nurses Note located in the Progress Notes tab of the EMR revealed that the nurse was called into the resident's room by a family member. The resident was found on the floor due to falling from his chair. The Nurse notified Nurse Practitioner (NP)2 who gave an order to send the resident to the emergency room (ER) for an evaluation.Review of a 3/8/2025 at 4:20 PM, Nurses Note located in the Progress Notes tab of the EMR revealed, the resident was observed on the floor near the nursing station. He was leaning over trying to get into the shower room. After being told several times to sit down and let the rail go, he slide out of his wheelchair onto the floor. No injuries were noted.Review of a 3/17/2025 at 11:15 AM Nurses Note located in the Progress Notes tab of the EMR revealed that the resident had three witnessed falls this shift at 8:15 AM, 8:22 AM, and 9:45 AM. No visible injuries with the falls. Neuro checks started upon first incident. ROM [range of motion] remains within baseline.Review of a 3/23/2025 at 4:30 PM Incident Note located in the Progress Notes tab of the EMR revealed, the resident was up in his wheelchair at the nurses station. The resident constantly reaches for items on floor that are not there. The resident was observed slouched over with legs folded between foot pedals and forehead on floor.Review of a 3/28/2025 at 4:26 PM Incident Note located in the Progress Notes tab of the EMR revealed, the resident was in his wheelchair around 9:20 AM and was witnessed leaning forward and fell to the floor. Resident did not hit head. No injuries were noted.Review of a 3/31/2025 at 10:06 AM Behavior Note located in the Progress Notes tab of the EMR revealed that the resident was observed lying on his right side in front of the nurses' desk.Review of the 4/2/2025 at 11:10 AM Behavior Note located in the Progress Notes tab of the EMR revealed, the resident was sitting in wheelchair in hallway when he used the handrail on the wall to pull himself out of the wheelchair to the floor. The resident said he wanted to go to bed. Resident has been noted to throw himself to the floor from wheelchair on several occasions in the past.Review of a 5/10/2025 at 2:01 PM Nurses Note located in the Progress Notes tab of the EMR revealed that the resident was sitting at nurse's desk with two nurses. The resident leaned forward in his wheelchair and was redirected several times to sit up, but was unsuccessful. The resident was observed falling out of wheelchair on the right side and said he fell because he wanted to go back to bed.Review of a 5/18/2025 at 1:44 PM Incident Note located in the Progress Notes tab of the EMR revealed that the resident was found in his room on the floor next to the bed on his right side. Resident was noted on the fall mat from the waist down, from the waist up, he was on the bare floor. No apparent injuries noted on body assessment. The resident had no complaints of pain but said he hit his head. The on call NP was notified and gave an order to send the resident to the ER.During an interview on 6/30/2025 at 4:01 PM, the current Administrator confirmed that there were no fall incident reports on R9. The Administrator stated, When a resident has a fall, they are to fill out the incident report and then we will discuss this in our morning stand-up meeting for any needed interventions. The Administrator was asked if these falls were brought to QAPI and if she could provide the documentation. The Administrator stated, Since I have started at the facility, we are doing PAR [patient at risk] meetings more often. No documentation was provided regarding having had these falls brought to QAPI (quality assurance performance improvement) for review by the end of the survey.During an observation on 07/01/25 at 10:54 AM, R9 was observed reclined in a Geri chair [a specialized wheelchair] in the dining room during an activity.During an interview on 7/1/2025 at 1:20 PM the Unit Manager (UM) stated, Leaning over has been a problem for him. The falls were due to him leaning way over and a lack of coordination. He is losing his trunk control which has contributed to this. His falls were related to behaviors also and we implemented having him lay down after meals as he will fall due to getting tired.During an interview on 7/2/2025 at 11:09 AM, LPN1 stated, The Geri chair (specialized seating designed for individuals with limited mobility or specific health needs) was an intervention by therapy. It has been a successful intervention, and the falls have decreased. We do lay him down during the day. He can tell us if he is tired and we do lay him down. The resident had eight falls from his regular wheelchair from 1/2/2025 to 5/10/2025 until the Geri chair was implemented as an intervention.

Based on observation, record review, interview, and review of facility policy, the facility failed to properly position urinary drainage bags to promote adequate drainage and to potentially prevent recurring urinary tract infections (UTIs) for two residents (R)16 and R14 from four residents with urinary drainage bags out of a total sample of 21 residents. This failure has the potential for residents to develop recurring UTIs.Findings include:Review of the facility policy titled, Urinary Catheter Care Policy (undated) revealed, .Proper catheter care is essential to prevent infections, promote comfort, and maintain the dignity of residents.Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.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.Be sure the catheter tubing and drainage bag are kept off the floor. 1. Review of R16's Medical Diagnosis sheet located in the resident's electronic medical records (EMR) tab titled Medical Diagnosis revealed the resident was admitted to the facility with diagnoses that included but not limited to multiple sclerosis, hemiplegia, hemiparesis, and neuromuscular dysfunction of the bladder.Review of R16's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/4/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. The resident was dependent on staff for all activities of daily living (ADLs); incontinent of bladder and bowel and required an indwelling catheter.Review of R16's physician's Orders dated 5/3/2025 located in the resident's EMR tab titled Orders revealed an order for a Suprapubic Foley 20 French five milliliter balloon.During an observation and interview on 6/30/2025 at 11:30 AM revealed R16 was on a stretcher headed for shower. There was a urine odor present. Certified Nursing Assistant (CNA)3 uncovered the resident's urinary catheter to show the resident was wearing a leg strap. However, the resident's urinary drainage bag was flat in the stretcher with the resident; amber colored fluid was backing up in the tubing towards the resident's bladder area. CNA3 confirmed that R16's urinary drainage bag should be positioned below the resident's bladder to prevent urinary tract infections from occurring.During an observation on 7/1/2025 at 9:42 AM revealed R16 was in a low bed with the urinary drainage bag laying flat on the floor. There was a strong urine odor present in the room and the drainage bag was near a puddle of yellow colored liquid on the floor. At 10:05 AM the drainage bag remained on the floor. At 11:16 AM an observation with the Assistant Director of Nursing (ADON) and CNA3 revealed the urinary drainage bag was about an inch above the floor. There was still the strong smell of urine present in the room.During an interview on 7/1/2025 at 11:16 AM, CNA3 verified that she just repositioned the drainage bag from the floor to a higher position. CNA3 also stated that she noticed the drainage port of the drainage bag was not properly clamped off and more urine had spilled on the floor. During the interview, the ADON agreed that the resident's urinary drainage had not been positioned properly to promote drainage and would replace the drainage bag since it was leaking urine.2. Review of R14 Medical Diagnoses located in the resident's EMR tab titled Medical Diagnosis revealed the resident was admitted to the facility with diagnoses that included but not limited to cerebral infarction with left sided hemiplegia and hemiparesis, and chronic kidney disease stage three.Review of R14 quarterly MDS with an ARD of 6/10/2025 located in the resident's EMR tab titled MDS revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The resident was dependent on staff for all ADLs. The resident was incontinent of the bladder and bowel and wore an external catheter.Review of R14's physician's Orders dated 6/24/2025 located in the EMR tab titled Orders revealed the resident was to wear condom catheter and change daily and monitor skin for changes.During an observation on 7/2/2025 at 8:45 AM revealed R14 was in a low bed with the urinary drainage bag resting on the floor. At 9:15AM an observation with the Director of Nursing (DON) revealed the resident's urinary drainage remained in the same position. The DON donned (put on) a pair of gloves and repositioned the resident's drainage bag of the floor and adjusted the tubing to promote adequate urinary drainage. The DON confirmed that the resident's drainage was not positioned properly to promote drainage.

Based on observations, resident and staff interviews, record reviews, and review of the facility policy titled, Standard Precautions, Administering Oral Medications, and Glucometer Cleaning, the facility failed to ensure nebulizers were bagged, dated, and labeled for two of three residents (R) (R20, R68); ensure the oxygen concentrator tubing was dated and the filter in the concentrator was clean for one resident (R20); and ensure bed pans were properly bagged, labeled, and stored for one resident (R607); and (5) to properly clean and disinfect the medication cart and provide a clean barrier for accu-checks for one resident (R74). Findings included: A review of the facility policy titled, Standard Precautions revealed under the Policy Statement standard precautions are used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents under Policy Interpretation and Implementation. Standard precautions apply to the care of all residents in all situations regardless of the suspected or confirmed presence of infectious diseases. Personnel are trained in the various aspects of standard precautions to ensure appropriate decision-making in various clinical situations. Resident-Care Equipment: a. Resident-care equipment soiled with blood, body fluids, secretions, and secretions are handled to prevent skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. Single-use items are properly discarded. Environmental Control. Environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces are appropriately cleaned. A review of the facility's policy titled Administering Oral Medications dated 2001 revealed the purpose of the procedure is to provide guidelines for the safe administration of oral medications. The Policy's Steps in the Procedure revealed: 1. Wash your hands. 9 E. Prepare the correct dose of medication. For tablets or capsules from a bottle, pour the desired number into the bottle cap and transfer them to the medication cup. For unit dose tablets or capsules, place packaged medications directly into the medication cup. A review of the facility's policy titled Glucometer Cleaning revealed the Glucometers will be cleaned and disinfected according to the current Centers for Disease Control (CDC) recommendations for disinfection and the Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard. The nurse will perform hand hygiene before handling the meter and then don gloves. The nurse will use germicidal disposable wipes to wipe down the glucometer and allow wet time per the wipe manufacturer's recommendation. Place the glucometer on a barrier. 4. This cleaning will be performed after each use of a glucometer. 1. A review of the EMR revealed that R20 was admitted to the facility on [DATE] with a diagnosis that includes acute hypoxemic respiratory failure (AHRF) and pneumonia unspecified organism. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R20 had a Brief Interview for Mental Status (BIMS) score of five, indicating moderate cognitive impairments. Further review record reveals Section J in the MDS documents R20 has shortness of breath and trouble breathing while lying down. A review of the care plan dated 9/5/2023 documented R20 is at risk for respiratory complications secondary to diagnosis of chronic obstruction pulmonary disease (COPD) and history of respiratory failure, pneumonia, and influenzas. A review of the Physician's Orders dated 9/20/2024 documented Albuterol Sulfate Inhalation Nebulization Solution. One applicator inhales orally via nebulizer every 6 hours for shortness of breath (SOB), congestion, and wheezing. An observation on 10/22/2024 at 11:44 am revealed oxygen concentrator was undated, and filter had a white fuzzy substance covering it. Further, the nebulizer was at the resident's nightstand along with multiple oxygen tubing tangled that were unbagged and undated. During an observation on 10/24/24 at 09:39 am it was observed R20 nebulizer was sitting on the nightstand next to the bed unbagged and undated with tangled tubbing cords attached. 2. A review of the EMR revealed that R68 was admitted to the facility on [DATE] with a diagnosis of personal history of nicotine dependence. A review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] R20 had a Brief Interview for Mental Status (BIMS) Score of 7 indicating moderate cognitive impairments. Further review records reveal that R68 is dependent on activities of daily living (ADL). A review of the care plan documented that R68 has altered respiratory status/difficulty breathing related to complaints of productive purulent cough. A review of Physicians' orders dated 2/8/2024 documented Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliter). Inhale orally every four hours as needed for shortness of breath or wheezing via nebulizer ipratropium-albuterol solution 0.5-2.5 (3) MG/3ML. During an observation on 10/22/2024 at 11:39 am revealed Nebulizer mask was stored on top of the nightstand not inside a bag or covered at all, tubing was not dated. During an observation on an interview on 10/23/2024 at 11:40 am, R68 stated he does not have asthma or any coughing issues. He stated he does not use the nebulizer that sits on his nightstand, and it was there when he came to the facility. During an interview on 10/23/2024 at 11:38 am with Certified Nurse Assistant (CNA) LL revealed resident who uses oxygen machines or nebulizers require nurse supervision and are educated by the unit manager and director of nursing for proper use of the machines. She continued to state the oxygen machines should be clean and sterilized after use. CNA LL continued to state the machines should be kept in bags free of dust and partials. She further stated she should report any concerns with the unit manager and Director of Nursing (DON). During an interview on 10/24/2024 at 9:47 am with the Licensed Practical Nurse (LPN) MM revealed the oxygen concentrators residents should be monitored by the CNA staff and should be checking on every hour and are supervised by the nurses. She continued to state the nebulizes should be bagged, dated, and labeled for sanitation purposes. LPN MM continued to confirm all staff receive training on the use of nebulizers and h20 concentrators. During an interview on 10/24/2024 at 10:15 am with the DON revealed she expects her staff to be cleaning the nebulizer after treatment. All staff are educated on the basis of the order, they should be following the MAR and proper cleaning afterward. She continued to state the nebulizer should be stored in the nightstand with the oxygen mask bagged separately. 3. During an observation on 10/22/2024 at 11:28 am in the shared bathroom of R607, grey bedpans were found on the floor, stacked, unbagged, and not labeled. One of which is on the left side of the sink on the floor and the other two are stacked, but not directly on top of each other on the right side of the toilet. During an observation on 10/23/2024 at 3:30 pm in the shared bathroom of R607, the following was revealed: three grey bedpans on the floor in the bathroom, one of which is on the left side of the sink on the floor and the other two stacked, but not directly on top of each other on the right side of the toilet; and the bedpans were not bagged or labeled. During an observation on 10/24/2024 at 4:50 pm in the shared bathroom of R607, the following was revealed: one grey bedpan sitting on top of the left side of the sink and a grey toilet seat stacked in other bedpans on the floor in the bathroom to the right of the toilet, and the bedpans nor the toilet seat were bagged or labeled. During an interview on 10/24/2024 at 4:50 pm with Unit Manager D Hall (MM) revealed the bedpans should not be on the floor but she feels the nurses forgot to bag them properly because they had a discharge today. She further revealed they should not be on the floor, and they should be labeled with the residents' names on them. During an interview on 10/24/2024 at 5:42 pm with the DON revealed she has worked at this facility for one and a half weeks. She revealed she has stressed that the urinals and the bedpans must be off the floor in bags and labeled for whose it is. They should be discarded especially if the resident is being discharged . She stated that if it is not handled properly, it can cause a big infection control issue and spread things to other residents. 4. An observation of the medication administration on 10/23/2024 at 7:58 revealed the nurse failed to sanitize her hands and prepare a clean barrier for the resident before performing the Accu check. She placed the glucometer on the resident's bed. She did not clean the community glucometer before and after and used dry time. She did not wash her hands afterward. In addition, the nurse dropped 3 pills on top of the cart and slid them into the cup with a tongue blade that she had sitting on top of the cart. She continued to pour the rest of her solid medication and put those in the cup with the contaminated medication that she had swept from the top of the cart. No clean barrier was established for the top of the cart, and it was not witnessed that she had cleaned the cart prior to pouring the medication. However, she did say that she had cleaned the cart off before she began her med pass, but she had prepared several medications on the cart after she had previously cleaned it off. She had also placed other containers on top of the cart. An interview with the Director of Nursing (DON) on 10/23/2024 at 12:55 pm revealed her expectations for nurses passing medications is that the nurses follow the Five Rights and align the med pass with the policy. She said the skills fair with return demonstration is for all shifts. 48338 50374

Based on record review, staff interviews, and review of the facility policies titled, Antibiotic Stewardship, Antibiotic Stewardship - Orders for Antibiotics, and Antibiotic Stewardship - Review and Surveillance of Antibiotic Use the facility failed to maintain review of antibiotic prescribing practices and the documentation of the programs efforts to follow up on antibiotic usage data for all nine months (January 2024 to September 2024) that were reviewed. The deficient practice had the potential to affect any resident who was prescribed an antibiotic. Findings included: A review of the policy titled, Antibiotic Stewardship detailed the Policy Statement Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The Policy Interpretation and Implementation section details 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b. Dose c. Frequency of administration; d. Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy; e. Route of administration; and f. Indications of use. 8. When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available: a. Signs and symptoms; b. When symptoms were first observed; c. Resident's hydration status; d. Current medication list; e. Allergy information f. Infection type; g. Any orders for warfarin and results of last INR; h. Last creatinine clearance or serum creatinine, if available; and i. Time of the last antibiotic dose. A review of the policy titled, Antibiotic Stewardship - Orders for Antibiotics the policy statement details, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. The Policy Interpretation and Implementation section details, 4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: a. Drug name b. Dose c. Frequency of administration; d. Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy; e. Route of administration; and f. Indications of use. 8. When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available: a. Signs and symptoms; b. When symptoms were first observed; c. Resident's hydration status; d. Current medication list; e. Allergy information f. Infection type; g. Any orders for warfarin and results of last INR; h. Last creatinine clearance or serum creatinine, if available; and i. Time of the last antibiotic dose. A review of the policy titled, Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes. The policy statement details, Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Under Policy Interpretation and Implementation, it details 1. As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotics will undergo review by the infection prevention, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if: (1) the organism is not susceptible chosen; (2) the organism is susceptible to narrower spectrum antibiotic; (3) therapy was ordered for prolonged surgical prophylaxis, or (4) therapy was started awaiting culture, but culture results and clinical findings do not indicate the continued need for antibiotics. 4. All residents antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include the resident name and medical record number; unit and room number date symptoms appeared; name of antibiotic (see approved surveillance list); start date of antibiotic; pathogen identified (see approved surveillance list); site of infection; date of culture; stop date; total days of therapy; outcome; and adverse events. A review of the tracking and trending form for the facility revealed a document titled, Monthly Healthcare Associated Infection Summary Report. A form for each month in 2024 shows no tracking completed each month. During an interview on 10/23/2024 at 11:43 am, the Infection Control Preventionist revealed she has only worked for the facility since 10/1/2024 and her job duties include rounding the facility first thing in the morning for appropriate personal protective equipment for those residents who are on precautions. will then print the antibiotic report from the Electronic Medical Record (EMR) from what is new to the current day, do a full infection control assessment, and open a case for them in EMR along with a full assessment. She will attach the notes and pertinent assessments and close the case at the appropriate time. Infection control is a part of QAPI and they meet monthly however, this would be her first meeting which is scheduled to happen this week. Depending on the infection staff will do more monitoring such as vital signs, and wounds, documenting what they are seeing and hearing and if the antibiotics are effective. Visitors are made aware of any outbreaks by the receptionist who has been trained by a certified trainer.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the facility failed to report an alligation of sexual abuse for two of four residents (R10 and R108) reviewed for abuse. Findings included: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Reporting and Investigating with revised date of September 2022, all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility; the local/state ombudsman; the resident's representative; adult protective services (where state law provides jurisdiction in long-term care); law enforcement officials; the resident's attending physician; and the facility medical director. Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. A review of the Electronic Medical Record (EMR) revealed that R98 was admitted to this facility on 7/1/2017 with diagnoses of seizure disorder, cerebral vascular accident (CVA), chronic obstructive pulmonary disease (COPD), cognitive communication deficit, hemiplegia, vascular dementia with behavioral disturbance, and mood disorder. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R98 presented with a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. A review of the care plan dated 9/14/2024 indicated R98 has impaired cognitive function related to non-Alzheimer's vascular dementia; a mood problem related to a diagnosis of mood disorder due to known physiological condition with mixed features; and limited physical mobility related to right side hemiplegia. During a review of the nursing progress note dated 8/5/2024 at 2:39 pm documented by Licensed Practical Nurse (LPN) FF revealed that R98 was found rubbing on another resident. The other resident was not identified but noted that she was screaming 'stop'. The nurse further documented that R98 was pulled away from the female resident and told to leave her alone. R98 then went back over to the unidentified female and was pulling her shirt up. The female resident was screaming again, and the nurse separated them by standing in the middle of them with her medication cart. R98 sat there and didn't bother the female resident anymore. During a review of nursing progress note on R98 dated 8/20/2024 at 2:43 pm LPN CC documented that R98 was observed grabbing R10's breast and R10 hit R98 in the face after he grabbed her. Both residents were redirected, and the Social Services Director (SSD) was notified. During an interview via telephone on 10/23/2024 at 11:00 am, LPN FF stated that the incident on 8/5/2024 was in front of the nurse's station. There was a woman at the nurse's station, and R98 came up from behind her. She stated that she did not remember who the woman was and that she did not notify anyone in administration of the incident, but she did pass it in on during report when her shift ended. During an interview on 10/23/2024 at 2:15 pm with the Director of Nursing (DON), she confirmed she is aware of the two-hour window to report any abuse to the state agency. She stated the Abuse Coordinator for the facility is the Administrator and she or the Administrator are both responsible for submitting any abuse allegations. During an interview on 10/23/2024 at 2:45 pm with the Administrator confirmed that she is the abuse coordinator and that that they encourage timely reporting of abuse or misappropriation. We have two hours to report allegations of abuse. She stated that she reports incidents to the DON for investigation. She confirmed that she was aware of the incident documented in R98's medical chart on 8/5/2024 regarding an alleged sexual abuse. She confirmed that this was not reported. She further confirmed that she was aware of the incident on 8/20/2024 documented in R98's medical chart of an allegation of sexual abuse against R10. She was aware of this incident, and she recalled submitting the Facility Reported Incident (FRI) report, conducting the investigation with the then DON, and submitting the 5-day follow up report. She recalled attending a behavioral management meeting on 8/27/2024 wherein the incident was discussed and confirmed that the sexual abuse allegation initial report was sent seven days after the 8/20/2024 incident. During an interview on 10/24/2024 at 11:16 am, R108 stated that she recalled the incident with R98 touching her on 8/5/2024. She stated that she remembered being touched and that she did not like it. She stated that R98 touched her over her blouse once. She said that R98 has not touched her since that incident.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating the facility failed to complete a thorough investigation of abuse for three of four residents (R) (R98, R96, and R3) investigated for abuse. Findings included: A review of the facility policy entitled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating states, dated September 2022, revealed that all reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. A review of the Electronic Medical Record (EMR) revealed that R98 was admitted to this facility on 7/1/2017 with diagnoses of cognitive communication deficit, hemiplegia, vascular dementia with behavioral disturbance, and mood disorder. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that R98 presented with a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. A review of the care plan dated 9/14/2024 indicated R98 has impaired cognitive function related to non-Alzheimer's vascular dementia; a mood problem related to a diagnosis of mood disorder due to a known physiological condition with mixed features. During a review of the nursing progress note dated 8/5/2024 at 2:39 pm documented by a Licensed Practical Nurse (LPN) FF revealed that R98 was found rubbing on another resident. The other resident was not identified (later identified as R108) but noted that she was screaming 'stop'. The nurse further documented that R98 was pulled away from the female resident and told to leave her alone. R98 then went back over to the unidentified female and pulled her shirt up. The female resident was screaming again, and the nurse separated them by standing in the middle of them with her medication cart. During a review of the nursing progress note on R98 dated 8/20/2024 at 2:43 pm, LPN CC documented that R98 was observed grabbing R10's breast and R10 hit R98 in the face after he grabbed her. Both residents were redirected, and the Social Services Director (SSD) was notified. During an interview on 10/23/2024 at 2:15 pm with the Director of Nursing (DON), she stated the Abuse Coordinator for the facility is the Administrator and she or the Administrator are both responsible for investigating abuse allegations. During an interview on 10/23/2024 at 2:45 pm, the Administrator confirmed that she is the abuse coordinator, but she reports incidents to the DON for investigation. She confirmed that she was aware of the incident documented in R98's medical chart on 8/5/2024 and 8/20/2024 regarding alleged sexual abuse. She confirmed that she conducted the investigation with the then DON. She confirmed that they did not complete interviews of cognitive residents or skin assessments of noncognitive residents to identify if there were other victims. There were no written statements presented, or other investigation documentation provided when requested to show that a thorough investigation had been completed. During an interview on 10/24/2024 at 11:16 am, R108 stated that she recalled the incident with R98 touching her on 8/5/2024. She stated that she remembered being touched and that she did not like it. She stated that R98 touched her over her blouse once. She said that R98 had not touched her since that incident. 2. A review of the EMR revealed R96 was admitted on [DATE] and readmitted on [DATE]. A review of the most current MDS assessment dated [DATE] revealed that R96 presented with a BIMS score of nine, indicating moderate cognitive impairment. A review of the facility report revealed that there was a sexual abuse allegation for R96. The facility presented one written statement from staff, reporting out to the state/ police, and viewing video footage. There were no other staff-written statements, no statements from the residents, no interviews with other cognitively intact residents, and no skin assessments of cognitively impaired residents in the investigation documents provided by the facility. During an interview on 10/23/2024 at 2:15 pm, the DON confirmed that the Abuse Coordinator for the facility is the Administrator and she or the Administrator are both responsible for completing the investigation. She stated that the investigation process takes place and involves the social worker, all unit managers, herself, and the assistant director of nursing. She confirmed they interview residents with a high BIMS score as part of their investigation and will review the cameras. She stated that if the investigation is not resolved, then the investigation is handed off to the administrator. 3. A review of the EMR revealed that R3 was admitted to the facility on [DATE] with a diagnosis of mild neurocognitive disorder due to a known physiological condition with behavioral disturbance, and dementia. A review of the most recent quarterly MDS dated [DATE] documented that R3 had a BIMS score of 13 indicating the residents had intact cognition. Further record review revealed he had no behavior. A review of the care plan dated 10/4/2023 documented that R3 had the potential to be verbally and physically aggressive related to mild neurocognitive disorder due to a known physiological condition with behavioral disturbance, agitation, and dementia. A review of a facility report dated 7/19/2024 revealed that R3 reported to the Certified Nursing Assistant (CNA) that he hit his roommate (R138) on the knees with a cane. R3 stated that his roommate was saying he wanted to have sex with him. During an interview on 10/23/2024 at 1:53 pm, R3 confirmed he did hit his previous roommate (R138) with his cane after making several sexual comments to him. A review of the facility investigation revealed there was only one witness statement recorded related to this incident between R3 and R138. There was no further documentation related to the investigation. 49140 50374

Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed quarterly for two residents (R) (R33) and (R405) of 58 sampled residents. Findings included: A review of the Electronic Medical Records (EMR) revealed that R33 was admitted on [DATE]. There was no updated MDS assessment in the resident clinical record. A review of the EMR revealed that R405 was admitted on [DATE]. There was no updated MDS assessment in the resident clinical record. During an interview on 10/24/2024 at 12:20 pm, the Minimum Data Set Coordinator (MDSC) NN revealed she worked at the facility for [AGE] years and is responsible for completing the comprehensive MDS assessments. The MDSC confirmed that an updated MDS assessment was not completed for R33 as she overlooked completing it. During an interview on 10/24/2024 at 3:43 pm, MDSC OO revealed she has worked at the facility for [AGE] years. MDSC OO confirmed that R405 did not have an updated assessment. During an interview on 10/24/2024 at 4:04 pm, the Director of Nursing (DON) revealed that the MDSCs should be completing the MDS assessments quarterly, annually, and if there is a significant change in a resident's status. During an interview on 10/24/2024 at 4:04 pm, the Administrator revealed she expects the MDSCs to complete assessments timely according to federal guidelines. The policy related to MDS assessments was requested but was never provided.

Based on staff interviews, record review, and a review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to ensure that the baseline care plan was completed for one of 11 residents (R) (R355) admitted with a catheter. Findings included: A review of the facility policy titled Care Plans, Comprehensive Person-Centered with a revised date of March 2022 revealed that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. A review of the clinical record for R355 revealed resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, cerebral a neuromuscular dysfunction of bladder, fracture of the right lower leg, subsequent encounter for closed fracture with routine healing age-related nuclear cataract, bilateral dystrophies primarily involving the retinal pigment epithelium, urinary tract infection, and retention of urine. A review of the physician orders revision dated 10/17/2024 revealed an order for Enhanced Barrier Precautions due to a supra-pubic catheter. A review of the baseline care plan dated 10/17/2024 revealed there was not a plan of care developed that included the instructions needed to provide effective and person-centered care for a resident to address the presence of a supra-pubic catheter. During an interview on 10/24/2024 at 6:40 pm, the Minimum Data Set (MDS) Coordinator/Licensed Practical Nurse (LPN) NN confirmed and verified there was no baseline for R355 related to a supra-pubic catheter. During an interview on 10/24/2024 at 6:46 pm, the Director of Nursing (DON) verified and confirmed that R355 did not have a baseline care plan for a supra-pubic catheter. She revealed that she expected the nursing staff to complete a baseline care plan within 48 hours.

Based on observation, record review, interviews, and facility policies, the facility failed to ensure two of 19 residents (R) (R6 and R15) weren't provided with nursing care and services to ensure their medical needs were met related to pain management for R6 and R15; administering medication without a physicians order for R15; and a pest infestation of gnats that were on the R6 left leg wound. Further, harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. Findings included: A review of the facility policy titled Administering Medications dated April 2019 that medications are administered in a safe and timely manner, and as prescribed; only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; the Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions; medications are administered in accordance with prescriber orders, including any required time frame; if a dosage is believed to be inappropriate or excessive for a resident, or medication has been identified as having potentially adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns; and the individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. A review of the facility policy titled Pain Assessment and Pain Management dated October 2022 revealed that the purposes of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; d. Addressing the underlying causes of the pain. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: a. musculoskeletal conditions: (1) degenerative joint disease; (2) rheumatoid arthritis. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. A review of the facility policy titled Pressure Ulcer/Skin Breakdown, with a revision date of April 2018, revealed that the physician will assist the staff in identifying the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. The physician will help identify and define any complications. A review of the facility policy titled Pest Control dated May 2008 revealed that the facility shall maintain an effective pest control program. Policy Interpretation and Implementation. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 1. A review of the Admission Record for R15 revealed she was admitted to the facility on [DATE] and diagnoses of, but not limited to major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances. A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 00 which indicated severe cognitive impairment; no mood or behavior exhibited; that R15 required supervision/touching assistance with Activities of Daily Living (ADL) care; was independent with mobility requiring no mobility device; was receiving a scheduled pain medication; and not receiving any PRN (as needed) pain medication. A review of the care plan updated 6/4/2024 revealed that R15 is care planned for pain related to left knee diagnosis of osteoarthritis and low back pain. Interventions to be implemented included administering medications for the lower back and left knee as ordered. Monitor and document effectiveness every shift. An observation on 6/18/2024 at 11:25 am revealed R15 lying in bed with the covers bunched up around her waist. The resident was gripping the covers and grimacing. The resident's bilateral knees were observed to be swollen and the resident appeared to be in pain and discomfort. During the observation, the Licensed Practical Nurse (LPN) NN and a family member entered the room. The family member stated that both of R15's knees were swollen on the previous day as well (6/17/2024) and that R15 would not allow the family to touch her knees. The family was observed to ask R15 if she could touch her knees and promised to be gentle and R15 gave permission. The family stated that R15's left knee was warm to the touch. The LPN asked R15 if she would like something for pain and the resident nodded her head up and down. The LPN stated that R15 did not have an as-needed oral pain medication and would call the Nurse Practitioner (NP) regarding R15's pain. During an interview on 6/18/2024 at 11:40 am, LPN NN stated the NP gave an order for Tylenol for R15. The LPN explained to R15 that she had something for the pain. LPN NN was observed to administer two tablets of Tylenol 325 mg (milligrams) to R15 by mouth (PO). The resident took the medication without any problems. During the reconciliation of the medication pass, there was no physician order for Tylenol 325 mg, two tablets. A phone interview on 6/18/2024 at 10:33 am with the family of R15 stated they have filed several grievances with the facility regarding R15's care and services. The family expressed that their most recent concern when they visited R15 on 6/17/2024 was that R15 looked weak, sick, and was moaning and crying. The family stated something was going on with R15 because R15 was usually up walking without any type of assistive device and was usually attending activities. The family stated that R15 had been complaining of knee pain and this was reported to the charge nurse. The family stated the nurse applied Diclofenac Sodium ointment to both knees. The family stated the ointment is routine, the pain in the knees is different and no one bothered to notify the physician asking for something else for pain. The family stated the facility is quick to notify the family when R15 is combative and refusing medication, but no one notified the family that R15 had been in the bed lethargic, with a low-grade temperature (99.0 Fahrenheit), unable to stand or walk, and not her usual self. The family stated the nurse or Certified Nursing Assistant (CNA) should have taken notes, assessed R15, and notified the physician, NP, and/or psychiatrist of R15's change. The family stated there was a meeting with the Social Worker, Unit Manager (UM), and the Psychiatrist but could not give the exact date of the meeting. She stated that the Psychiatrist explained that he would discontinue the Citalopram (Celexa) and start Escitalopram (Lexapro). The family stated he gave the UM instructions during the phone conference to have the nurses document and notify him of any adverse reactions (i.e. overly sedated). The family stated they noticed a change in R15 after the most recent medication change was made by the psychiatrist. She stated that on 6/17/2024 the family visited and R15 appeared to be overly sedated, but the psychiatrist was not notified. The family stated she understood that R15 has dementia but what was going on with her was different and not related to the diagnosis of dementia. An interview on 6/18/2024 at 11:20 am with CNA DDD stated that R15 was usually up, dressed, and attending the facility's activities. She stated that today, R15 was limping when assisted with ADL care. She stated that R15 complained of knee pain. The CNA stated that she did let the charge nurse know that R15 complained of pain but did not give a reason why she did not inform the nurse. An observation of R15's medication administration on 6/20/2024 at 10:19 am with LPN NN the following medications were administered to R15: Amlodipine Besylate (Norvasc) 5 mg 1 Aspirin 81 mg 1 over-the-counter (OTC) Depakote sprinkle 125 mg 1 (placed in water) Diclofenac Sodium External Gel (applied to the right and left knee) Escitalopram (Lexapro) 5mg/5 milliliters (ml) Fluoxetine (Prozac) 10 mg 1 Metformin 500 mg 1 Methimazole 5 mg 1 Metoprolol Succinate Extended Release (ER) 50 mg 1 Multiple Vitamins 1 OTC Omeprazole 20 mg 1 Potassium Chloride ER 10 milliequivalent 1 Prednisone 10 mg 1 The resident looked inside the medication cup before taking the medications and shook her head to the left and right. The nurse explained what was in the cup and with multiple prompts the resident took the medication and drank two 8-ounce glasses of water. During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg. A review of the care plan updated 6/4/2024 revealed that R15 is care planned for depression and insomnia with intervention to administer antidepressant medications as ordered; monitor for a decline in ADL self-care and gait changes; and to notify the physician of the findings. A review of the Physician Order dated 6/29/2023 revealed discontinuation of Fluoxetine (Prozac) 10 mg. Discontinue Order ePrescription sent successfully 6/29/2023 3:25 pm to pharmacy. Ordered signed by the Medical Director. An interview on 6/20/2024 at 2:35 pm with LPN NN confirmed that the Fluoxetine (Prozac) 10 mg capsule is a medication that is in R15's strip pack. The LPN stated on the days that she works Fluoxetine (Prozac) is administered to R15. The LPN, with the assistance of the Assistant Director of Health Services, could not locate a physician order for the medication. The LPN checked the remaining strip packs on the cart and the Fluoxetine (Prozac) is one of the medications in the individual strip packs. The LPN stated she would talk to her Director of Health Services (DHS) immediately. A phone interview on 6/20/2024 at 3:35 pm with the Psychiatrist EEE regarding R15's medication. The Psychiatrist stated it is dangerous to give a person two selective serotonin reuptake inhibitors (SSRIs) due to it causing serotonin syndrome. He stated it can cause insomnia, poor appetite, agitation, or restlessness. He stated that he was called in on consult 6/28/2023 to see R15. He stated that Prozac was discontinued due to being a potentially harmful drug in the elderly. He stated that R15 was started on Escitalopram (Lexapro) on 6/28/2023. He stated because the resident continued to have a decline, he discontinued Escitalopram (Lexapro) and started Citalopram (Celexa). He stated a few weeks ago he had a conference call with the UM and family. He stated the family expressed that R15 was continuing to decline. He stated he discontinued the Citalopram (Celexa) and restarted the Escitalopram (Lexapro). He stated the UM was instructed at that time to notify him of any changes or behaviors R15 may have. The Psychiatrist stated if the Prozac was never stopped that would explain the resident's continued decline. He stated that receiving two SSRIs (Fluoxetine (Prozac) and Escitalopram (Lexapro) is not good. An interview on 6/21/2024 at 12:36 pm with the Pharmacist stated pharmacy has been dispensing a daily dose of Fluoxetine (Prozac) 10 mg from 7/28/2023-6/20/2024. The Pharmacist stated the first time they received an order to discontinue the medicine was on 6/20/2024. The pharmacist confirmed that the Fluoxetine (Prozac) was not on the resident's profile although it is being dispensed. She stated that the pharmacy has started pulling the resident's medication profile and comparing it with the framework of the APP machine that automatically dispenses the medications. She stated that currently, the pharmacy reconciles each patient's profile in the Electronic Medical Record system. She stated the pharmacy department is willing to go to the facility and do a complete cart audit. She stated what happened was not purposely done, it was an accident. An interview on 6/25/2024 at 4:58 pm with UM JJ stated the pharmacy delivers a strip pack of medications approximately every seven days. She stated the medications arrive on the 11: 00 pm to 7:00 am shift. The UM stated it is the responsibility of the nurse to verify the medications in the strip packs with the resident's Medication Administration Record (MAR) before the strip packs of medication are placed on the cart. She stated the physician should be notified for clarification if there are any discrepancies. The UM stated if a medication is in the strip pack and not on the resident's MAR the medication should not be given. She stated the physician should be notified for clarification. An interview on 6/25/2024 with the DHS stated that she expects the nurses to administer medication safely as prescribed by the physician. She stated she has started a skills check-off on medication administration for all the nurses. She stated the nursing staff has also started a facility-wide cart audit. 2. An observation and interview on 5/2/2024 at 11:30 am of R6 who was lying flat in the bed (B), the room was dark. The resident's mood was blunted, affect was sad. An observation of R6's right hand, left hand and fingers has a deformity. The resident had a white sheet covering his waist down to the upper part of his left leg. An observation of black gnats flying around and lying on the left leg. The Resident had a dressing on the left leg from the knee to the ankle dated 5/1/2024. The dressing was covered with a large amount of reddish-brown drainage. The resident was pleasant and agreed to speak with the surveyor. The resident stated he has bad Rheumatoid Arthritis in his fingers and shoulders that are painful. The resident stated he has never been seen by therapy for any type of braces on his hands or fingers. The resident stated he must ask for his pain medication because it is not a regularly scheduled medication. The resident stated the physician or nurse practitioner had never asked if he needed his oral pain medicine scheduled. During the interview, R6 stated he has had a vascular wound on his left leg for a long time. The resident stated gnats have always been a problem in the room. An observation on 5/3/2024, 5/7/2024, and 5/8/2024 of black gnats flying around and lying on R6's left leg. The Resident had a dressing on the left leg from the knee to the ankle the dressing was saturated with a large amount of reddish-brown drainage. A review of R6 Admission Record revealed an admitted [DATE] with multiple diagnoses of, but not limited to, chronic pain, gout, and rheumatoid arthritis (RA). A review of the quarterly MDS assessment dated [DATE] revealed R6 presented with a BIMS score of fifteen, which indicated R6 was cognitively intact. The assessment further indicated the resident had a regularly scheduled pain medication and an as-needed pain medication. A review of the care plan updated 10/31/2024 revealed that R6 was care planned for rheumatoid arthritis. Interventions to be implemented included monitoring, documenting, and reporting to the physician as needed signs and symptoms or complications related to arthritis: joint pain, joint stiffness, contracture formation, and joint shape changes. A review of the Order Summary Report revealed an order for Oxycodone 10 mg every six hours as needed for pain related to chronic pain on 8/1/2023. A review of the Order Summary Report revealed an order for Tylenol 325 mg two every six hours as needed for chronic pain syndrome on 8/1/2023. A review of the Order Summary Report revealed an order for Diclofenac Sodium External Gel 1%. Apply half inch to shoulders topically four times a day, for seropositive rheumatoid arthritis on 3/27/2024. A review of the MAR for 4/1/2024 to 4/30/2024 revealed that R6 had a documented pain level of seven to nine on fifteen occasions. The resident requested and was given Oxycodone 10 mg 57 times. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. A review of the MAR for 5/1/2024 to 5/3/2024 revealed that R6 had a documented pain level of five to eight. The resident requested and was given Oxycodone 10 mg five times out of three days. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. During an interview on 5/7/2024 at 10:48 am, the Occupational Therapist (OT) stated the therapy department has never had R6 on caseload for hand braces. The OT explained that R6's right hand metacarpophalangeal (MCP) joint, also known as the knuckle, hyper flex, the proximal interphalangeal joint (PIP) that bends and extends the fingers is hyperextended, the distal interphalangeal (DIP) close to the fingernail is hyper flexed. The left-hand MCP is hyper-flexed, the PIP is flexed, and the DIP is hyper-flexed. The Therapist stated that R6 hands/fingers have a lot of inflammation that can be painful and cause discomfort. During an interview and observation on 5/8/2024 at 10:20 am of R6's wound, the Wound Care Physician confirmed the gnats on the resident's left leg dressing and the drainage. He stated the wound had a lot of moisture and that was attracting the gnats to the left leg. The Wound Care Physician stated he had seen gnats in the room on previous visits. During an interview on 5/9/2024 at 11:50 am, LPN OO stated that for the last two years, the facility had been having problems with gnats. LPN OO stated she had never reported the gnats to anyone, and she did not realize they were in R6's room that bad until the surveyor brought it to her attention. During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to the Maintenance Department. During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed. She stated that R6 was more relaxed since his pain medication had been adjusted. A review of the MAR for 4/1/2024 to 4/30/2024 revealed that R6 had a documented pain level of seven to nine on fifteen occasions. The resident requested and was given Oxycodone 10 mg 57 times. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. A review of the MAR for 5/1/2024 to 5/3/2024 revealed that R6 had a documented pain level of five to eight. The resident requested and was given Oxycodone 10 mg five times out of three days. There was no documentation that the physician was notified of the frequency of the pain and administration of the as-needed medication. During an interview on 5/7/2024 at 10:48 am, the Occupational Therapist (OT) stated the therapy department has never had R6 on caseload for hand braces. The OT explained that R6's right hand metacarpophalangeal (MCP) joint, also known as the knuckle, hyper flex, the proximal interphalangeal joint (PIP) that bends and extends the fingers is hyperextended, the distal interphalangeal (DIP) close to the fingernail is hyper flexed. The left-hand MCP is hyper-flexed, the PIP is flexed, and the DIP is hyper-flexed. The Therapist stated that R6 hands/fingers have a lot of inflammation that can be painful and cause discomfort. During an interview and observation on 5/8/2024 at 10:20 am of R6's wound, the Wound Care Physician confirmed the gnats on the resident's left leg dressing and the drainage. He stated the wound had a lot of moisture and that was attracting the gnats to the left leg. The Wound Care Physician stated he had seen gnats in the room on previous visits. During an interview on 5/9/2024 at 11:50 am, LPN OO stated that for the last two years, the facility had been having problems with gnats. LPN OO stated she had never reported the gnats to anyone, and she did not realize they were in R6's room that bad until the surveyor brought it to her attention. During an interview on 5/9/2024 at 11:54 am, UM JJ stated she was not aware of the gnat problem until the surveyor brought it to her attention on 5/2/2024 and 5/3/2024 and that she immediately reported the gnats to the Maintenance Department. During an interview on 5/15/2024, the DHS stated that she expects the nurses to assess the residents and notify the physician as needed. She stated that R6 was more relaxed since his pain medication had been adjusted.

Based on observation, record review, staff interviews, and the facility policy Administering Medications the facility failed to ensure one of forty-three sampled residents (R) (R15) was receiving medications as prescribed by the psychiatrist. The pharmacy continued to dispense Fluoxetine (Prozac) to R15 after it was discontinued on 6/29/2023 by the psychiatrist. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. Findings included: A review of the facility policy titled Administering Medications dated April 2019 revealed that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services (DNS) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During an observation of R15's medication administration on 6/20/2024 at 10:19 am with a Licensed Practical Nurse (LPN) NN, the following medications were observed to be administered to R15: Amlodipine Besylate (Norvasc) 5 milligrams (mg) 1 Aspirin 81 mg 1 over-the-counter (OTC) Depakote sprinkle 125 mg 1 (placed in water) Diclofenac Sodium External Gel (applied to the right and left knee) Escitalopram (Lexapro) 5mg/5 milliliters (ml) Fluoxetine (Prozac) 10 mg 1 Metformin 500 mg 1 Methimazole 5 mg 1 Metoprolol Succinate Extended Release (ER) 50 mg 1 Multiple Vitamins 1 (OTC) Omeprazole 20 mg 1 Potassium Chloride ER 10 milliequivalent 1 Prednisone 10 mg 1 During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg. A review of the Admission Record for R15 revealed she was admitted to the facility on [DATE] with diagnoses of, but not limited to, major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances. A review of the Psychiatrist Progress Note dated 6/28/2023 revealed that R15 was seen for initial psych evaluation and ongoing management of symptoms related to cognitive impairment/behaviors. Coordination of Care: Discussed with nursing, discussed with social services, reviewed medications, reviewed chart, discussion of medication side effects. Psychotropic medication (include dosage, frequency): Prozac 10mg by mouth (PO) every am for depression, Trazodone 50mg PO every night for sleep, Melatonin 3 mg PO every night for sleep, Depakote DR 125mg PO twice a day for mood/agitation. Recommendations for Primary Care Physician/Facility Staff: will stop Prozac and start R15 on Lexapro solution 10 mg PO every morning for agitated dysphoria. A review of the Physician Order dated 6/29/2023 revealed discontinuation of Fluoxetine (Prozac) 10 mg. Discontinue Order ePrescription Sent Successfully 6/29/2023 3:25 pm to the pharmacy. The order was signed by the Medical Director. A review of the Pharmacy Medication Regimen Review for July 2023 through May 2024 revealed the pharmacist conducted monthly reviews. There were no pharmacy recommendations for R15 and/or Fluoxetine (Prozac). A review of the Pharmacy Med Room, Med Cart & Nursing Station Inspection Report conducted by the Pharmacy Nurse Consultant from 9/8/2023 to 6/3/2024 revealed the nurse consultant conducted monthly medication cart audits twice a month. There was no documentation of a medication cart audit for R15. During an interview on 6/25/2024 at 1:00 pm, the Executive Director stated in August 2023 the facility was transitioning from one pharmacy to the current pharmacy. She stated that the current pharmacy physically picked up all the resident physician orders on or around 6/23/2023. She stated that the nursing staff were educated to fax all orders after 6/23/2023 to both pharmacies. She stated that R15 order to discontinue the Fluoxetine (Prozac) was on 6/29/2024 and should have been faxed to both pharmacies. The Executive Director stated the pharmacy did not reconcile R15's medication orders. She stated that the facility has started a medication cart audit, and the pharmacy is in the process of also completing a facility-wide medication cart audit. The medication cart audit is to ensure that residents are getting the medications as ordered by the physician. A post-survey telephone interview on 6/27/2024 at 1:00 pm with the Pharmacy Nurse Consultant stated onsite visits to the facility are conducted twice a month. She stated she is responsible for medication cart audits. The Nurse Consultant stated during her visits to the facility she does not audit every resident medication cart. She stated the medication cart audit is randomly selected. She is aware that the pharmacy continued to dispense a medication for R15 that had been discontinued. The Nurse Consultant stated she has not completed a medication cart audit on R15. She stated that the pharmacy has planned to come in on Friday 6/28/2024 and complete a facility-wide medication cart audit on the residents that are currently in the facility. Cross-refer to F-Tag 684 and 757

Based on interviews, record review, and review of facility policy titled Administering Medications, the facility failed to ensure one of two residents (R) (R15) was free from unnecessary psychotropic medications. Resident (R15) was administered Fluoxetine (Prozac) during a medication observation. Harm was identified to have occurred when R15 was administered Fluoxetine (Prozac) for forty-eight weeks after it was discontinued on 6/29/2023, resulting in increasing unusual behavior, a low-grade temperature, swelling in bilateral knees, and going from ambulating independently to not being able to ambulate. Findings included: A review of the Admission Record for R15 revealed she was admitted to the facility on [DATE] with diagnoses of, but not limited to, major depressive disorder, osteoarthritis, thyrotoxicosis, and unspecified dementia, severe, with other behavioral disturbances. A review of the resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 00 which indicated severe cognitive impairment. Section N R15 was assessed as receiving antidepressants in this assessment period. An observation of R15's medication administration on 6/20/2024 at 10:19 am with Licensed Practical Nurse (LPN) NN the following medications were administered to R15: Amlodipine Besylate (Norvasc) 5 milligrams (mg) 1 Aspirin 81 mg 1 (over the counter OTC) Depakote sprinkle 125 mg 1 (placed in water) Diclofenac Sodium External Gel (applied to the right and left knee) Escitalopram (Lexapro) 5mg/5 milliliters (ml) Fluoxetine (Prozac) 10 mg 1 Metformin 500 mg 1 Methimazole 5 mg 1 Metoprolol Succinate Extended Release (ER) 50 mg 1 Multiple Vitamins 1 (OTC) Omeprazole 20 mg 1 Potassium Chloride ER 10 milliequivalent 1 Prednisone 10 mg 1 During the reconciliation of the medication pass, there was no physician order for Fluoxetine (Prozac) 10 mg. A review of the Order Summary Report revealed a physician order dated 1/17/2024 Observe closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings. An interview on 6/20/2024 at 2:35 pm with LPN NN confirmed that the Fluoxetine (Prozac) 10 mg capsule is a medication that is in R15's strip pack. The LPN stated on the days that she works Fluoxetine (Prozac) is administered to R15. She confirmed that the Fluoxetine (Prozac) was not listed on R15's Medication Administration Record (MAR). An interview on 6/25/2024 at 10:40 am with LPN NN stated she just started in the role as a nurse in February 2024. The LPN stated all her education/in-services have been provided by the staff in the facility. The LPN stated the facility does provide resources (i.e. Drug Handbooks) on each medication cart. She stated in the future she will make sure she is checking the MAR and the medication in the strip packs for accuracy. She stated if it is a question about the residents medication, she will notify the physician or Nurse Practitioner. The LPN expressed she is open and willing to learn. An interview on 6/25/2024 at 11:00 am with the Director of Health Services (DHS) stated that LPN NN was hired in 2/2024 and has not had a Medication Pass completed. She stated she would schedule a medication pass with the Pharmacy Nurse Consultant for LPN NN. She stated she would also do random medication passes with the nurses in the facility. She stated the staff will be in-service on medication passes and assess residents who are administered psychotropic medication. She stated the facility is in does not have a Staff Educator and is in the process of hiring someone. A post-survey telephone interview on 6/27/2024 at 1:00 pm with the Pharmacy Nurse Consultant stated onsite visits to the facility are conducted twice a month. She stated she is responsible for medication passes with the nursing staff. She stated She will conduct a medication pass with the nursing staff that are working during the time she is in the facility. The Pharmacy Nurse Consultant stated she has not done a medication pass with LPN NN. She stated she and the DHS would arrange to conduct a medication pass with LPN NN. A review of the facility policy titled Administering Medications dated April 2019 revealed that medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Cross Refer to F-tag 684 and 755

Based on interview and record review, the facility failed to follow the care plan for 1 of 9 sampled residents (R4) related to bowel management, which resulted in R4 having a stool impaction. After R4's hospitalization , the facility failed to monitor R4's bowel movements (BMs) and initiate bowel medications timely per the care plan, which increased the likelihood for further impaction, and causing actual harm. Findings include: The Admission Record indicated R4's [DIAGNOSES REDACTED]. The 2/4/16 plan of care related to bowel incontinence with a risk of constipation, included: Document episodes of incontinence each shift; observe for bowel movement (BM) each shift; report if no BM for 2-3 days, and administer medications as ordered. The Quarterly Change in Status Minimum Data Set (MDS), with an assessment reference date of 4/14/16, indicated R4 had severely impaired cognition, was dependent on staff for toilet use, and was always incontinent of bowel function. The 4/8/16 BM Report indicated R4 had a small, soft BM. The BM Report dated 4/9/16 to 4/21/16 (13 days) indicated R4 did not have any BMs. The 4/22/16 BM Report indicated R4 had a small BM. During an interview with Licensed Practical Nurse (LPN) 3 on 8/18/16 at 10:45 a.m., she said the Nurse Aides (NAs) were to report to the nurses when a resident did not have a BM for 2 to 3 days. LPN3 said between 4/8/16 and 4/22/16, the NAs did not report that R4 had any bowel issues. The 4/22/16 Situation, Background, Assessment, Recommendation (SBAR) Communication Form indicated R4 had an elevated heart rate of 102, and elevated temperature of 102 degrees Fahrenheit, an elevated blood sugar of 170, and a decreased oxygen saturation level of 89 %. The SBAR Communication Form indicated R4 was not responding as usual and refused to eat, drink, or take his medications. During an interview with Registered Nurse (RN) 14 on 8/19/16 at 11:10 a.m., RN14 said on 4/22/16, R4 had a decline in his medical status and the staff transferred R4 to the Emergency Department for an evaluation. The 4/29/16 Hospital Physician Discharge Summary indicated R4 complained of abdominal pain and had abdominal tenderness to palpation, likely due to stool impaction. The Physician Discharge Summary indicated a CT (computerized tomography) scan of the abdomen revealed marked distention of the rectum with a large fecal ball extending into the sigmoid colon with upstream dilatation of multiple loops of colon which were filled with air and stool. The 4/30/16 Nurse's Note indicated the staff admitted R4 back to the facility and his [DIAGNOSES REDACTED]. During an interview with the Director of Health Services (DHS) on 8/19/16 at 9:30 a.m., the DHS said although there was no facility Bowel Policy, the nurses were to follow the physician's orders [REDACTED]. The DHS said the NAs did not notify the nurses that R4 did not have a BM for greater than 3 days. The DHS said the nurses did not administer bowel medication to R4 per the Physician Order. The DHS said the staff did not follow R4's plan of care related to bowel management. The BM Report dated 5/29/16 to 6/4/16 (7 days), indicated R4 did not have any BMs. The day shift 6/4/16 Nurse's Note indicated the NA reported R4 did not have a BM for 3 days and a laxative was given as ordered for constipation. The DHS said the NAs did not notify the nurse of R4's lack of BMs; the nurse did not give R4 timely bowel medication, and the staff did not follow R4's plan of care related to bowel management. The BM Report dated 6/10/16, 6/12/16, 6/16/16, 6/17/16, and 6/18/16 did not indicate R4 had any BMs. There was no documentation on the BM record dated 6/11/16, 6/13/16 to 6/15/16 to indicate if R4 had any BMs. During interviews with CNA13 on 8/18/16 at 3:00 p.m., CNA13 said some of the NAs did not have access to enter a resident's BMs in the computer and the nurses were to enter that information in the computer. During an interview with the Corporate Nurse on 8/18/16 at 2:00 p.m., she said there was inconsistent documentation regarding R4's bowel history. The Corporate Nurse said the NAs and/or the nurses did not always document whether R4 had a BM, therefore the nurses were not able to determine if R4 needed bowel medication due to the staff not following R4's plan of care. Refer to F309 The facility failed to ensure that R4 received the appropriate care and services to maintain the highest practicable well-being. The facility failed to assess and follow R4's plan of care related to bowel management, which resulted in R4 having a stool impaction.

Based on record review and interview, the facility failed to ensure 1 of 9 sampled residents (R4) received the appropriate care and services to maintain the highest practicable well-being. The facility failed to assess and follow R4's plan of care and Physician order [REDACTED]. Findings include: The Admission Record indicated R4's [DIAGNOSES REDACTED]. Review of the 2/4/16 plan of care related to bowel incontinence with a risk of constipation, included, Document episodes of incontinence each shift; observe for bowel movement (BM) each shift; report if no BM for 2-3 days, and administer medications as ordered. The 4/1/16 Physician Orders included: [MEDICATION NAME] 325 milligrams (mg) daily (side effect can be constipation), [MEDICATION NAME]/Tylenol ([MEDICATION NAME]) 10-325 mg one tablet every 6 hours for pain (side effect can be constipation), [MEDICATION NAME] 1 cap daily for constipation, [MEDICATION NAME] 5-325 mg one tablet by mouth 30 to 45 minutes prior to wound care, Milk of Magnesia (MOM) 30 milliliters (ml) by mouth daily as needed (prn) for constipation and if constipation not relieved by MOM in 6 hours, may give enema of choice rectally prn. The Quarterly Change in Status Minimum Data Set (MDS), with an assessment reference date of 4/14/16, indicated R4 had severely impaired cognition, was dependent on staff for toilet use, and was always incontinent of bowel function. During interviews with Certified Nurse Aide (CNA) 11 on 8/18/16 at 3:15 p.m., CNA12 on 8/18/16 at 3:08 p.m., and CNA13 on 8/18/16 at 3:00 p.m., they said they reported to the nurse when a resident did not have a BM for 3 days. The 4/8/16 BM Report indicated R4 had a small, soft BM. The BM Report dated 4/9/16 to 4/21/16 (13 days) indicated R4 did not have any BMs. The 4/22/16 BM Report indicated R4 had a small BM. During an interview with licensed practical nurse (LPN) 3 on 8/18/16 at 10:45 a.m., she said the CNAs were to report to the nurses when a resident did not have a BM for 2 to 3 days. LPN3 said between 4/8/16 and 4/22/16, the CNAs did not report that R4 had any bowel issues. The 4/21/16 Nurse's Note indicated R4 was lethargic and ate 50% of his dinner. The 4/22/16 Situation, Background, Assessment, Recommendation (SBAR) Communication Form indicated R4 had an elevated heart rate of 102, and elevated temperature of 102 degrees Fahrenheit, an elevated blood sugar of 170, and a decreased oxygen saturation level of 89%. The SBAR Communication Form indicated R4 was not responding as usual and refused to eat, drink, or take his medications. During an interview with Registered Nurse (RN) 14 on 8/19/16 at 11:10 a.m., RN14 said on 4/22/16, R4 had a decline in his medical status and the staff transferred R4 to the Emergency Department for an evaluation. The 4/29/16 Hospital Physician Discharge Summary indicated R4 complained of abdominal pain and had abdominal tenderness to palpation, likely due to stool impaction. The Physician Discharge Summary indicated a CT (computerized tomography) scan of the abdomen revealed marked distention of the rectum with a large fecal ball extending into the sigmoid colon with upstream dilatation of multiple loops of colon which were filled with air and stool. The 4/30/16 Nurse's Note indicated the staff admitted R4 back to the facility and his [DIAGNOSES REDACTED]. During an interview with the Director of Health Services (DHS) on 8/19/16 at 9:30 a.m., the DHS said the NAs were to report to the nurse if a resident did not have a BM for 2 to 3 days and the nurse was to assess the resident and administer medications as ordered. The DHS said although there was no facility Bowel Policy, the nurses were to follow the physician's orders [REDACTED]. The DHS said the nurses did not follow R4's plan of care related to bowel management. During an interview with LPN16, she said although she was assigned to R4 after his April 2016 hospitalization , she was not aware R4 had bowel issues at the hospital. The BM Report dated 5/29/16 to 6/4/16 (7 days), indicated R4 did not have any BMs. The day shift 6/4/16 Nurse's Note indicated the CNA reported R4 did not have a BM for 3 days and a laxative was given as ordered for constipation. The BM Report dated 6/10/16, 6/12/16, 6/16/16, 6/17/16, and 6/18/16 did not indicate R4 had any BMs. There was no documentation on the BM record dated 6/11/16, 6/13/16 to 6/15/16 to indicate if R4 had any BMs. on 8/18/16 at 3:00 p.m., CNA13 said some of the CNAs did not have access to enter BMs in the computer and the nurse was to enter that information for them in the computer. During an interview with the Corporate Nurse on 8/18/16 at 2:00 p.m., she said there was inconsistent documentation regarding R4's bowel history, which made assessing R4 for constipation difficult. During an interview with Nurse Practitioner (NP) 1 on 8/19/16 at 11:35 a.m., NP1 said sometimes when she discussed a resident's BMs with a nurse and/or CNA assigned to a resident, they told her they did not know when the resident last had a BM, which was an issue.

Based on observation, record review, hospital CT scan report review, review of the facility's Fall Risk Assessment Policy and Procedures, and staff interview, it was determined that the facility failed to adequately review and review the Care Plans of four (4) residents who had been identified to be at a high risk for falls, on the survey sample of thirty (30) residents (Resident #s 9, 10, 19, and 25). Specifically, the facility failed to reassess and revise the Care Plan of Resident #9 to develop effective fall interventions, even after Resident #9 experienced three (3) subsequent falls, one of which resulted in a large hematoma to the head. The facility failed to reevaluate and revise the Care Plan of Resident #10 to develop effective interventions, even after the resident had sustained a fall and struck his face, causing bleeding and resulting in hospital transfer. The facility failed to reevaluate and revise the Care Plan of Resident #19 to develop an effective intervention to address the resident's fall potential from the wheelchair, even after the resident had fallen and hit his head and nose while using the planned intervention of a non-slip mat in the wheelchair. And, the facility also failed to revise the Care Plan of Resident #19 to reflect the use of a Stand Lift, even after the resident hit his mouth during transfer utilizing a Hoyer Lift and the use of the Hoyer Lift was discontinued. Additionally, the facility failed to reevaluate and revise the Care Plan of Resident #25 to develop interventions to address the resident's potential for falling from the wheelchair, even after the resident had fallen from the wheelchair and sustained a laceration to the temple requiring hospital transfer, resulting in the resident experiencing an additional fall from the wheelchair. It was therefore determined that the facility's noncompliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents, and Immediate Jeopardy was identified to have existed as of March 18, 2012, and continued. On 04/16/2012 at 8:45 a.m., the facility Administrator was notified that Immediate Jeopardy existed. The findings include: Review of the facility's Fall Risk Assessment Policy and Procedures revealed that the Care Plan Coordinator/Care Plan Nurse would conduct the fall risk assessment on each resident on a quarterly basis and with significant changes, and that updated interventions would be developed based on the resident's condition and quarterly assessment, with significant changes, or as needed. 1. Cross refer to F323, example 1, for more information regarding Resident # 9. Record review for Resident # 9 revealed a Care Plan of 03/12/2012 which identified Resident # 9 as being at risk for falls, and identified Approaches to address this risk. A Nurse's Note dated 03/18/2012 at 8:30 p.m. documented the resident climbed out of bed, fell to the floor, and sustained three (3) small skin tears to the right arm below the elbow. A later Nurse's Note of 03/18/2012 at 9:15 p.m. documented that Resident # 9 was found on the floor at the nurse's station lying on his side holding his head, with a pool of blood next to his head. This Note documented that the resident sustained [REDACTED]. This Note documented that the nurse practitioner was notified and ordered a hospital transfer, and a 03/19/2012 hospital CT head without contrast final report for Resident # 9 documented the reason for the exam was a loss of consciousness. However, during observations on 03/21/2012 at 3:15 p.m., 03/22/2012 at 12:47 p.m., and 03/22/2012 at 6:00 p.m., Resident # 9 was observed sitting in a wheelchair, with no additional interventions in place to address the fall-potential. Review of Resident #9's Care Plan revealed no evidence to indicate that the Care Plan had been revised as necessary, after the Care Plan entry of 03/12/2012 identifying the fall-risk, to identify interventions to address the resident's falls, even though the resident experienced two (2) subsequent falls on 03/18/2012. During an interview conducted on 03/22/2012 at 5: 45 p.m., the Director of Nursing (DON) acknowledged that the resident's Care Plan should have been updated. The following additional information regarding Resident #9 was obtained during the extended survey of 04/16-18/2012: Record review for Resident #9 revealed a Nurse's Note dated 04/13/2012 at 10:10 p.m. which documented that Resident # 9 was observed sitting on the floor with his back against the heating/air conditioning unit. During an interview conducted on 04/18/2012 at 9:25 a.m., Nurse "CC" stated that because Resident #9 had gotten out of bed and had fallen to the floor, a new intervention would have been to get an order for [REDACTED]. However, review of the current Care Plan for Resident #9 revealed no reference to the use of a bed alarm, and further record review revealed no evidence to indicate physician follow-up regarding bed alarm use. 2. Cross refer to F323, example 2, for more information regarding Resident #25. Review of Resident #25's medical record revealed an admission sheet which documented that the resident was admitted on [DATE]. A Fall Risk Evaluation of 03/12/2012 documented a score of fifteen (15), indicating a high-risk for falls. An Initial/Admission Care Plan was created on 03/12/2012 that identified falls as a problem but failed to identify or document any interventions to address this fall-risk. A Comprehensive Care Plan was developed on 03/20/2012 with Interventions which included placing the bed in the lowest position, keeping the room clutter free and well illuminated, and staff checking frequently and rendering incontinent care as needed. A Nurse's Note of 03/20/2012 at 5:20 p.m. documented that Resident #25 was found lying on the floor and that she had sustained an approximate 1/2 inch laceration to right temple, and a Physician's Interim Order of 03/20/2012 at 5:15 p.m. specified to transfer the resident to the hospital to be treated post-fall. The Incident Report for this fall documented that the fall had occurred from the wheelchair. However, further record review, to include review of the 03/20/2012 Care Plan referenced above, revealed no evidence to indicate that the facility had reviewed and revised the Care Plan, upon the resident's return from the hospital (on 03/26/2012), to develop new interventions to address the resident's potential for falling from the wheelchair. A Nurse's Note of 04/04/2012 of 11:30 a.m. documented that at approximately at 10:45 a.m., the resident was observed sitting on the floor in the hallway with the wheelchair by her side. The resident's Care Plan then documented a 04/04/2012 Approach to use an activity tray for safety and positioning while up. This reflected a nine (9) day delay after the resident's post-hospital readmission to the facility on [DATE] and the implementation of an intervention to address the resident's fall risk from the wheelchair. 3. Cross refer to F323, example 3, for more information regarding Resident # 10. Record review for Resident #10 revealed a Nurse's Note dated 01/18/2012 at 5:00 a.m. which documented that Resident # 10 was found on the floor in his room, having fallen from the wheelchair. A Nurse's Note dated 01/25/2012 at 1:15 p.m. documented that around 12:40 p.m., the resident had been observed sitting on the floor in the hallway, and a Nurse's Note of 01/25/2012 at 4:30 p.m. documented the resident was found sitting on the floor by his bed. An additional Nurse's Note of 01/25/2012 at 5;15 p.m. documented that upon staff's entering the resident's room, the resident was observed to be sitting on the floor. The Comprehensive Care Plan for Resident #10 contained a 02/17/2012 entry which identified the resident's risk for falls, and identified Approaches to address this risk. A Nurse's Note of 03/02/2012 at 6:15 p.m. documented that Resident # 10 had been found on the floor in his room at approximately 5:15 p.m., with bright red blood observed on the floor, a hospital Documents Review Report documented a small abrasion on the face. . However, further record review revealed no evidence to indicate that the 02/17/2012 Care Plan for Resident #10, which identified the resident to be at risk for falls, had been revised as necessary to identify additional interventions, even though the resident fell on [DATE] and sustained an injury to the face. During an interview conducted on 03/22/2012 at 4: 45 p.m., the DON acknowledged that resident's Care Plan should have been updated. 4. Cross refer to F323, example 5, for more information regarding Resident #19. Review of the clinical record for Resident #19 revealed the Care Plan documented a 01/27/2012 entry which identified Resident #19 to be at a high risk for falls and referenced Approaches which included the use of a Hoyer Lift for transfers, and a 02/17/2012 addition of a Dyson non-slip mat to the wheelchair. A Nurse's Notes entry dated 02/22/2012 at 10:45 a.m. documented that Resident #19 was being assisted to bed when he apparently hit his mouth on the Hoyer Lift, and that when the blood that was initially noted was removed, there were no signs of injury. The Incident/Accident report for this 02/22/2012 incident documented that the resident experienced [MEDICAL CONDITION] while being transferred with a Hoyer Lift and the bar of the lift hit the resident's mouth. During an interview on 04/18/2012 at 12:40 p.m., the DON stated that at the current time, the resident was not to have the Hoyer Lift used for transfers, and that a Stand Lift was to be used. During observation conducted on 04/17/2012 at 11:30 a.m., two (2) CNAs used a Stand Lift to transfer the resident out of bed. However, further review of the resident's current Care Plan revealed no reference to the use of the Stand Lift, and the Care Plan still specified the use of the Hoyer Lift for transfers. There was no evidence to indicate that this Care Plan had been reviewed and revised to ensure the reference to the correct type of lift to be used for transferring Resident #19. Additionally, a Nurse's Notes entry dated 03/12/2012 documented that Resident #19 had slid out of the wheelchair while being wheeled to the room, and interview with the DON on 04/18/2012 at 12:40 p.m. revealed that at the time of this fall, the resident slid out of the wheelchair despite the intervention of the non-skid mat referenced on the Care Plan. However, review of the current Care Plan revealed the continued reference to the Dyson non-slip mat to the wheelchair, with no evidence to indicate that this Care Plan had been reviewed and revised to identify an any additional interventions post this 03/12/2012 fall from the wheelchair.

Based on record review, staff interview, and Allegation of Compliance review, it was determined that the Immediate Jeopardy identified during the abbreviated survey which concluded on 04/18/2012 had been removed related to resident care plan review and revision. However, non-compliance continued to exist at a S/S of "E" as the facility had not completed Quality Assurance assessment and assurance initiatives related to resident falls and the facility's process of care plan review and revision, the analysis of results of facility resident care plan audits, and the development and implementation of the falls/care plan process as related to the review and revision of care plans. Findings include: Review of the facility's acceptable Allegation of Compliance dated 04/27/2012 revealed that the facility revised the policy and procedure related to care plans, and the facility's Fall Program. The facility's policy related to the Fall Program requires that each time a resident falls, the charge nurse will implement a different intervention. Documentation of the fall incident with the implemented intervention will be placed on the resident's care plan by the charge nurse. The Interdisciplinary Team/Care Plan Team will be made aware in morning briefings of each new intervention developed in response to each resident fall to allow for the review and re-evaluation of care plan interventions for effectiveness, and to allow for needed revisions. The facility's new care plan process also indicates that resident care plans will be checked daily in the morning by the unit manager/charge nurse to assure accuracy. The facility conducted a full house audit of all resident care plans to determine the accuracy of approaches and interventions, and to determine the need for updating and revision. Care plans were updated as needed and appropriate to ensure that they reflected each resident's current interventions related to fall-prevention. All nursing staff were in-serviced by the Administrator, the Staff Development Coordinator, and facility administrative nursing staff regarding the facility's new, revised policies and procedures as they related to the care plan process and the updating and revision of care plans. All newly hired licensed nurses and certified nursing assistants will receive education on the facility's care plan process during orientation. Comprehensive care plans have been incorporated into the Quality Assurance Committee meetings, and will be reviewed weekly for three months, then monthly thereafter for the purpose of assessing the proficiency of interventions and measures utilized for residents with a history of falls and/or who are at risk for falls. Interview with the Administrator and Director of Nursing on 05/03/2012 at 8:50 a.m. revealed that the Quality Assurance Committee had met on 04/25/2012 and will continue to monitor the facility's care plan process and fall prevention program during subsequent scheduled meetings. During this interview, it was acknowledged that during the 04/25/2012 meeting, the Quality Assurance Committee had conducted an initial review of the policies and new care plan process, but had not at this point made any specific recommendations for changes or corrective measures in the facility's process of care plan review and revision, and that this process was ongoing. As of 05/03/2012, the facility had not had the opportunity to submit an acceptable Plan of Correction.

Based on observation, record review, Fall Risk Evaluation review, hospital CT scan report review, Fall/Near Fall Incident Form review, Incident Report review, hospital Documents Review Report review, hospital Health Report review, In-Service Sign In sheet review, and staff interview, it was determined that the facility failed to ensure adequate supervision and monitoring for six (6) residents who had been identified to be at a high risk for falls, on the survey sample of thirty (30) residents (Resident #s 9, 10, 11, 19, 20 and 25). Resident #9 subsequently fell and sustained a large hematoma to the head, and with a CT scan report indicating the reason for the exam as being a loss of consciousness. Resident #25 subsequently fell and sustained a laceration to the temple requiring transport to the hospital for evaluation. Resident #10 subsequently fell and struck his head, causing bleeding. And, Resident #19 subsequently fell , hit his head and nose, and complained of a headache. It was therefore determined that the facility's non-compliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents, and Immediate Jeopardy was identified to have existed as of March 18, 2012, and continued. On 04/16/2012 at 8:45 a.m., the facility Administrator was notified that Immediate Jeopardy existed. Findings include: 1. Record review for Resident #9 revealed a Nurses Notes entry of 02/28/2012 indicating that the resident had been admitted to the facility on that date. The resident had [DIAGNOSES REDACTED]. A Fall Risk Evaluation completed on 02/28/2012 identified the resident to be at high risk for falls, with contributing factors which included intermittent confusion, having a recent history of falls, being ambulatory and incontinent, having a balance problem while walking, and having poor vision. The resident's Care Plan 03/12/2012 also identified Resident #9 as being at risk for falls related to an unsteady gait, dementia, wondering behavior and impaired cognition, and included Approaches of keeping the bed in a low position and assessing information on past falls. A Nurse's Note dated 03/18/2012 at 8:30 p.m. documented the resident climbed out of bed and fell to the floor as he was trying to walk out. This Note documented the resident was confused and that he had sustained three (3) small skin tears to the right arm below the elbow. This Note further documented that the resident was placed in a wheelchair and placed near the nurse's station. However, a later Nurse's Note of 03/18/2012 at 9:15 p.m. documented that after the nurse left the nurse's station to obtain something out of the medication room for another resident, a different resident called for the nurse as the nurse left the other resident's room, and when the nurse returned to the nurse's station, Resident #9 was found on the floor lying on his side holding his head, with a pool of blood next to his head. This Note documented that the resident sustained [REDACTED]. This Note documented that the nurse practitioner was notified and ordered to transfer the resident to the emergency room for evaluation. A Nurse's Note of 03/18/2012 at 10:15 p.m. documented that Resident #9 was transferred to an acute care hospital. A 03/19/2012 hospital CT head without contrast final report for Resident #9 documented the reason for the exam was a loss of consciousness. The same report also indicated the resident had a frontal scalp contusion. A Nurse's Note of 03/19/2012 at 7:15 a.m. documented that Resident #9 returned to the facility from the hospital, and staff assessed the resident to have a small open area to the top of the head, and a purple left eye. During observation on 03/21/2012 at 3:15 p.m., Resident #9 was observed sitting in a wheelchair with a dark brown bruise around his left eye. During this same observation, the resident got out of the wheelchair and walked to the door next to him. As he was trying to open the door, the nurse ran to him and instructed the resident not to get up by himself. At the time of this observation, there were no observed interventions in place to address the resident's fall-potential. During an additional observation on 03/22/2012 at 12:47 p.m., Resident #9 was in a wheelchair at the nurse's station, but with no observed interventions in place, and observation on 03/22/2012 at 6:00 p.m. also revealed the resident in a wheelchair with no observed interventions in place to address the resident's fall-potential. Further record review revealed no evidence to indicate that the resident had been reevaluated, after the initial Fall Risk Evaluation of 02/28/2012 and Care Plan entry of 03/12/2012, to identify interventions to address the resident's continued falls, even though the resident had experienced two (2) subsequent falls on 03/18/2012. The second fall of 03/18/2012 resulted in the resident sustaining a large hematoma on the right side of the head, requiring hospital transfer. During an interview conducted on 03/22/2012 at 5: 45 p.m., the Director of Nursing (DON) stated Resident #9 was confused with dementia and was not able to see well. She acknowledged the resident had experienced multiple falls since admission to the facility, and further acknowledged that the resident should have been evaluated after these falls to develop additional interventions, such as bed and wheelchair alarms, to allow for monitoring. The following additional information regarding Resident #9 was obtained during the extended survey of 04/16-18/2012: Record review for Resident #9 revealed a Nurse's Note dated 04/13/2012 at 10:10 p.m. which documented that Resident # 9 was observed sitting on the floor upright with his back against the heating/air conditioning unit, with no injury. A Nurse's Note dated 04/15/2012 at 1:45 a.m. documented the day number two follow-up from the 04/13/0212 fall, and documented the resident was resting quietly in bed with a bed alarm in place. However, observations on 04/16/2012 at 9:45 a.m., and on 04/17/2012 at 8:45 a.m. and 9:45 a.m. revealed Resident # 9 was lying in bed with no bed alarm in place. Additional observation on 04/18/2012 at 09:20 a.m. with Nurse "CC" in attendance revealed that the resident was lying in bed with no bed alarm in place. During an interview conducted on 04/18/2012 at 9:25 a.m., Nurse "CC" stated that about two weeks prior, Resident #9 had gotten out of bed and had fallen to the floor. This nurse further stated that since the resident had fallen from the bed, a new intervention would have been to call the physician and get an order for [REDACTED]. However, this nurse acknowledged that during the 04/18/2012, 9:20 a.m. observation referenced above, the resident was in bed with no bed alarm in place, and additional record review revealed no evidence of physician contact regarding the use of a bed alarm for this resident. 2. Review of Resident #25's medical record revealed an admission sheet which documented that the resident was admitted on [DATE] post hospital stay with [DIAGNOSES REDACTED]. A hospital Physical Therapy Medical/Surgical Evaluation and Clearance of 03/09/2012 documented a social history of multiple ground-level falls. A Fall Risk Evaluation was performed on 03/12/2012 by the admitting nurse in which Resident #25 scored fifteen (15), which placed her as high-risk for falls. An Initial/Admission Care Plan was created on 03/12/2012 that identified falls as a problem but failed to identify or document any interventions to address this fall-risk. A Nurse's Note written on 03/20/2012 at 1:00 a.m. documented that Resident #25 was found on the floor of her room, alert but confused, stating she did not know how she fell and that she was looking for the president. No injury was noted, and this Note further indicated to continue to monitor. Further record review for Resident #25 revealed that a Comprehensive Care Plan was developed on 03/20/2012 with Interventions which included the following: - place bed in lowest position - CNA to assist with all cares and mobility - Keep room clutter free and well illuminated - Staff to check frequently and offer to use bathroom/bed pan, render incontinent care as needed. - Encourage all therapies A Nurse's Note of 03/20/2012 at 5:10 p.m. documented that Resident #25 was sitting in the wheelchair in her room, and a subsequent Nurse's Note of that date at 5:20 p.m. documented that Resident #25 was found lying on the floor with her head next to the bedside table, and that she had sustained an approximate 1/2 inch laceration to right temple. Neurological checks were initiated, and the resident was described as being restless and unable to follow commands. A Physician's Interim Order of 03/20/2012 at 5:15 p.m. specified to transfer the resident to the hospital to be treated post-fall. A Nurse's Note of 03/20/2012 at 5:45 p.m. documented that the resident had been transported by ambulance to the hospital for evaluation. Review of the Incident Report for the 03/20/2012, 5:20 p.m. fall referenced above documented the un-witnessed fall which occurred from the wheelchair in which Resident #25 was sitting. A hospital Health Report documented Resident #25's 03/20/2012 admission to the hospital with an Admission [DIAGNOSES REDACTED]. A 03/26/2012 Fall Risk Assessment in the resident's clinical record documented that upon her return to the facility on that date post her hospital stay related to the fall, the resident scored 15, indicating a continued high risk for falls. However, further record review, to include review of the 03/20/2012 Care Plan referenced above, revealed no evidence to indicate any interventions were put in placed at the time of the resident's 03/26/2012 readmission to the facility to address the resident's potential for falling from the wheelchair, even though the resident had fallen from the wheelchair on 03/20/2012 and sustained a laceration to right side of the head. A Nurse's Note of 04/03/2012 (time not designated) documented that Resident #25 was alert but very confused and attempting to get out of the chair on several occasions. However, despite the resident's previous fall from the wheelchair on 03/20/2012 and continued efforts to get out of the chair on 04/03/2012, further record review still revealed no evidence to indicate that the facility had put interventions in place to address the resident's risk of falls from the wheelchair. A Nurse's Note of 04/04/2012 of 11:30 a.m. documented that at approximately at 10:45 a.m., the resident was observed sitting on the floor in the hallway with the wheelchair by her side. An assessment at that time revealed no apparent injuries and documented that the nurse practitioner, when notified, recommended that an activity tray to be placed on the wheelchair. Review of the resident's Care Plan revealed that a 04/04/2012 Approach was added to use an activity tray for safety and positioning while up. This resulted in a nine (9) day delay between Resident #25's readmission to the facility on [DATE] (from a hospital transfer resulting from a 03/20/2012 fall with injury from the wheelchair) and the implementation of an intervention to address the resident's fall risk from the wheelchair on 04/04/2012, with this intervention being implemented only after the resident had experienced another fall from the wheelchair on 04/04/2012. 3. Record review for Resident #10 revealed the resident had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Fall Risk Evaluations completed on 01/17/2012 and 02/09/2012 identified the resident as being at a high risk for falls, having intermittent confusion, being ambulatory and incontinent, having a balance problem while walking, and having gait problems. An initial care plan of 01/17/2012 identified Resident #10's fall potential, with Interventions put into place including staff assistance with transfers and keeping the call bell in reach. A Nurse's Note dated 01/18/2012 at 5:00 a.m. documented that Resident # 10 was found on the floor in his room, having fallen from the wheelchair. The resident was assessed to have no injury. An initial care plan entry of 01/18/2012 documented this fall, with an intervention of reminding the resident to call for assistance. However, further review of the Fall Risk Evaluation of 01/17/2012 revealed that this Evaluation, which had been completed on the day before this resident's 01/18/2012 fall, had assessed the resident to have intermittent confusion. A Nurse's Note dated 01/25/2012 at 1:15 p.m. documented that around 12:40 p.m., the resident had been observed sitting on the floor in the hallway, and was assessed to have no injury. A Nurse's Note of 01/25/2012 at 4:30 p.m. documented the resident was found sitting on the floor by his bed, and was assessed to be confused but to have no visible injury. An additional Nurse's Note of 01/25/2012 at 5:15 p.m. documented that upon staff's entering the resident's room, the resident was observed to be sitting on the floor. The physician, who was in attendance at that time, gave an order for [REDACTED]. The Comprehensive Care Plan for Resident #10 contained a 02/17/2012 entry identifying the resident's risk for falls, and identified Approaches to address this risk. A Nurse's Note of 03/02/2012 at 6:15 p.m. documented that Resident # 10 had been found found face down on the floor in his room at approximately 5:15 p.m., with bright red blood observed on the floor. This Note documented the resident stated "I fell on the floor and broke my nose". A Fall/Near Fall Incident Form which referenced this fall specifically documented that Resident #10 stated he had fallen from the bed. The 03/02/2012, 6:16 p.m. Nurse's Note referenced above documented the physician was notified of the resident's fall and ordered to transfer Resident # 10 to the emergency room for further evaluation. The acute hospital Documents Review Report documented that Resident #10 had a small abrasion on the face. However, further record review revealed no evidence to indicate that the resident had been reevaluated after the development of the Comprehensive Care Plan of 02/17/2012 to identify additional interventions to address the resident continued fall-potential, even though the resident had subsequently fallen from the bed on 03/02/2012 and struck his head. Observations conducted on 03/20/2012 at 11:00 a.m., 2:00 p.m., and 4:15 p.m., on 03/21/2012 at 10:45 a.m., 2:45 p.m., and 5:55 p.m., and on 03/22/2012 at 10:00 a.m., 1:55 p.m., and 6:00 p.m. revealed no fall-prevention interventions in place, other than those referenced in the 02/17/2012 Comprehensive Care Plan entry which identified the resident's fall-potential, even though the resident had experienced a 03/02/2012 fall from the bed, hit his head, and sustained an injury. During an interview conducted on 03/22/2012 at 4: 45 p.m., the DON acknowledged that new interventions should have been developed, such as a mat on the floor, after the resident's 03/02/2011 fall. 4. Record review for Resident #11 revealed a Care Plan entry of 10/13/2011, and dated as having been reviewed on 01/11/2012, which identified the resident to be at a high risk for falls related to impaired mobility, a decline in functional status, and a history of falls. Approaches to address this resident's fall-risk specified to utilize floor mats at bedtime or as ordered, and to use a bed sensor/alarm as ordered. Further record review revealed the March 2012 physician's orders [REDACTED].#11 specified that the resident receive an 81 milligram dose of the anticoagulant Aspirin daily. Fall Risk Assessments of 02/29/2012 and 03/01/2012 continued to identify Resident #11 to be at a high risk for falls. A Nurse's Note dated 03/01/2012 at 10:30 a.m. documented that Resident #11 was found in his room lying on the left side with the wheelchair tilted up, and assessment revealed a small hematoma to the posterior side of the resident's upper left leg. A Nurse's Note of 03/01/2012 at 10:45 a.m. documented that the nurse practitioner was notified of the fall. Further review of the resident's Care Plan referenced above revealed a 03/01/2012 notation which documented this fall, and which also specified an Approach of utilizing a wheelchair alarm. However, during observations of Resident # 11 conducted on 03/21/2012 at 1:30 p.m. and 5:00 p.m., the resident was up in the wheelchair with no chair alarm in place. Additional observations in the resident's rooms on that date at those times revealed no mat on the floor by the resident's bed. During additional observation conducted on 03/22/2012 at 6:00 p.m., Resident # 11 was observed lying on the bed, but with no mat on the floor. During an interview conducted on 03/22/2012 at 6:05 p.m., the DON acknowledged that Resident # 11 had a experienced falls, and that the wheelchair alarm and floor mat should have been in place. 5. Review of the clinical record for Resident #19 revealed the Care Plan documented an admission date of [DATE]. The resident was also documented to have [DIAGNOSES REDACTED]. This Care Plan documented a 01/27/2012 entry which identified Resident #19 to be at a high risk for falls related to impaired mobility, a decline in functional status, and a history of falls, and multiple Approaches were noted to address this fall-risk, including bolsters to the bed to prevent the resident from rolling out of the bed and Dyson non-slip mat to the wheelchair. A Nurse's Notes entry dated 02/21/2012 at 5:55 a.m. documented that Resident #19 had been in the wheelchair in his room and had fallen to the floor, with a witness being present at the time of the fall. This Note documented that the resident stated he had hit his head and nose and complained of pain and a headache. This Note documented that the nurse practitioner was called and gave an order to transfer the resident to the hospital for evaluation and treatment. A Nurse's Note of 02/21/2012 at 6:55 a.m. documented that the resident remained conscious, and that ambulance attendants had arrived and transported the resident to the hospital. A Nurse's Note entry of 02/21/2012 at 2:00 p.m. documented that the resident had returned to the facility, and a 3:00 p.m. entry documented the hospital had reported that a CT scan had yielded negative results. Review of the Fall/Near Fall Incident Form for this 02/21/2012 fall involving Resident #19 revealed the resident was being pushed out of the room by a Certified Nursing Assistant who said the resident learned forward, fell out of the wheelchair and hit his head and nose. During an interview conducted on 04/18/2012 at 12:40 p.m., the DON revealed that at the time of the resident's 02/21/2012 fall, as the CNA rolled the resident out of the room in the wheelchair, a metal plate on the floor in front of the resident's room had become loose and needed repair, and had caused the fall. A Nurse's Notes entry dated 03/12/2012 (no time indicated) documented that Resident #19 had slid out of the wheelchair while being wheeled to the room, with no injury noted. During an interview on 04/18/2012 at 12:40 p.m., the DON revealed that at the time of this fall, staff was pushing the wheelchair and the resident slid out of the wheelchair, despite the existing intervention (implemented 02/17/2012) of the non-skid mat to the chair. However, further record review revealed no evidence to indicate that any additional interventions had been developed and implemented since this resident's 03/12/2012 fall from the wheelchair to ensure the resident's safety while seated or being transported in the wheelchair, despite the existing intervention of the non-skid mat to the chair having proven ineffective. A Nurse's Notes entry dated 03/25/2012 at 10:30 a.m. documented that Resident #19 was observed on the mat beside the bed, stating that he rolled out of bed. No injury was noted. The resident's Care Plan, which referenced the application of bolsters to the bed to prevent the resident from rolling out of bed, documented this 03/25/2012 fall and also documented an intervention to re-educate staff on the placement of bolsters. However, review of the In-Service Sign-in Sheet of 03/25/2012 revealed that only five (5) staff were educated on the application of the bolsters. During interview on 04/18/2012 at 9:15 a.m., the DON acknowledged that the entire staff should have been re-educated on application of the bolsters for this resident. 6. Review of the clinical record for Resident #20 revealed an admission date of [DATE] listed on the resident's Care Plan. Resident #20 also had listed [DIAGNOSES REDACTED]. An 11/27/2011 entry on the Care Plan, also dated as having been reviewed on 02/25/2012, identified that Resident #20 was at high risk for falls related to bilateral amputations and a history of falls, and included as an Approach to utilize a seat belt when out of bed in the wheelchair for poor sitting balance. A Fall Risk assessment dated [DATE] assessed Resident #20 with a score of 10, indicating that the resident continued to be at high risk for falls at that time. However, observation of Resident #20 conducted on 04/16/2012 at 3:45 p.m. revealed the resident to be out of bed in the wheelchair, sitting in the hallway near the courtyard, with no evidence of a seat belt in use for the resident. During an interview conducted on 04/18/2012 at 9:10 a.m. with the DON, the DON acknowledged the resident's use of a seat belt while in the wheelchair.

Based on record review, staff interview, and Allegation of Compliance review, it was determined that the Immediate Jeopardy identified during the abbreviated survey which concluded on 04/18/2012 had been removed related to the implementation of the facility's plan to review and revise the falls prevention process. This plan included updating policies and procedures related to the Fall Program, auditing current resident care plans to ensure they were updated and accurate regarding the fall-risk of residents and interventions to minimize falls, implementing procedures to ensure that resident care plans remain updated and accurate regarding fall-risk and interventions to address this risk, implementing a log to track and document fall-prevention measures for each resident, utilizing the Situation-Background-Assessment-Recommendations Process to facilitate communication between staff, revising the Incident Reports process, ensuring that all nursing staff were trained regarding the new policies and processes as related to the falls prevention program, and including the routine review and assessment of the falls prevention program as part of future Quality Assurance Committee meetings. However, non-compliance continued to exist at a S/S of "E" as the facility had not completed Quality Assurance assessment and assurance initiatives related to resident falls, the analysis of results of facility audits which track the implementation of interventions intended to minimize resident falls, and the development and implementation of the facility's fall protocol. Findings include: Review of the facility's acceptable Allegation of Compliance dated 04/27/2012 revealed that the facility reviewed and revised the policies and procedures related to the Fall Program and fall prevention. Residents #9, #10, #11, #19 and #25 were reassessed related to their fall history and fall potential, and their care plans were updated with the appropriate interventions to address their risk for falls. A subsequent full house audit of all residents was conducted to ensure a current assessment of their fall risk, to ensure that current fall interventions which were in place were appropriate. The facility developed and initiated the use of a check-off log which is utilized for the tracking of, and to ensure adherence with, implemented care plan interventions related to fall-prevention. These logs identify planned fall-prevention interventions for residents, including chair alarms, bed alarms, bedside mats, self-release belts, self-release belts with alarms, bed bolsters, non-skid footwear, and also identify the staff assistance necessary for care and safe transfer (1-2 person assist) and if the person is a frequent faller. This process of monitoring also includes when residents are taken to activities, exercises, and the dining room, to ensure the ongoing monitoring of residents and the utilization of interventions intended to address their fall-potential. Designated staff members utilize this check-off log during walking rounds, observing for care plan-implemented interventions on each unit. These rounds are conducted each shift each day to monitor for, and to document the presence of, the appropriate devices/interventions, as specified by resident care plans. The fall monitors carry a current list of the devices for each resident and the fall monitor check-off log. This routine monitoring is intended ensure that interventions which have been planned to minimize resident falls have been implemented and are being utilized as intended. In addition, Certified Nursing Assistant Care Plan Flow-Sheets have been audited to ensure they reflect the current care plan interventions and physicians' orders for each resident, to include those related to fall-prevention. This is to ensure that certified nursing assistants providing direct care to residents are aware of the current interventions of each resident's care plan to allow for consistent implementation. The Situation-Background-Assessment-Recommendations Program is also used to facilitate communication between staff about the status and care needs of residents, including information related to fall-risk. The facility has revised the policy and procedure related to the process by which Incident Reports are completed. The input of Incident Reports will be done by shift supervisors, and on off-hours to include the 3:00 p.m.-11:00 p.m. and 11:00 p.m.-7:00 a.m. shifts Monday through Friday, and the 7:00 a.m.-7:00 p.m. and 7:00 p.m.-7:00 a.m. shifts on Saturday and Sunday. This is to ensure that the Incident Log remains current at all times regarding resident incidents, including falls. Shift supervisors were trained on this process. All nursing staff have been in-serviced by the Administrator, the Assistant Administrator, the Staff Development Coordinator, and facility administrative nursing staff regarding the facility's fall prevention process, the policies and procedures related to this process, and the changes and modifications to this process, as indicated above. In addition, due to identified problems with the application of bed bolsters, special in-service training was done with nursing staff regarding the application of bolsters, with the application to be done around the clock, 7 days per week by the maintenance department, supervisors, nurse management and charge nurses. All newly hired licensed nurses and certified nursing assistants will receive education on the facility's fall prevention process during orientation. The facility has also incorporated the monitoring of the fall prevention program, its implementation and assessment of its effectiveness into the Quality Assurance Committee meetings, and will be reviewed weekly for three months, then monthly thereafter. Interview with the Administrator and Director of Nursing on 05/03/2012 at 8:50 a.m. revealed that the Quality Assurance Committee had met on 04/25/2012 and will continue to monitor the facility's fall prevention program, including the process of ensuring the provision of care to each resident in accordance with planned interventions intended to minimize fall-potential. During this interview, it was acknowledged that during the 04/25/2012 meeting, the Quality Assurance Committee had conducted an initial review of the fall prevention policies and procedures, but had not at this point made any specific recommendations for changes or corrective actions related to these new fall prevention protocols, and that this process is ongoing. As of 05/03/2012, the facility had not had the opportunity to submit an acceptable Plan of Correction.

Based on observation, record review, review of the facility's Fall Risk Assessment Policy and Procedures, and staff interview, the facility failed to have an effective Quality Assurance Committee that implemented a process to investigate the occurrence of falls, to analyze the root cause of falls, and to implement and monitor interventions to prevent falls. Six (6) residents who had been identified to be at a high risk for falls, on the survey sample of thirty (30) residents (Resident #s 9, 10, 11, 19, 20 and 25), did not receive monitoring and/or reassessment to address repeated falls. This failure to provide a process for fall prevention resulted in a situation in which the facility's non-compliance with requirements of participation caused, or was likely to cause, serious injury, harm, impairment or death to residents. On 04/16/2012 at 8:45 a.m., the facility Administrator was notified that Immediate Jeopardy existed. It was identified to have existed as of March 18, 2012, and continued. Observation, record review, fall evaluation review, facility incident form review, hospital document review, and staff interview revealed that the facility failed to ensure adequate supervision, monitoring, and the development and/or implementation of effective interventions for Resident #s 9, 10, 11, 19, 20 and 25, despite these residents' known histories of falls. This resulted in Resident #9 falling and sustained a large hematoma to the head, Resident #25 falling and sustaining a laceration to the temple, Resident #10 falling and striking his head, and Resident #19 falling, hitting his head and nose, and complaining of a headache. 1. Cross refer to F323. Based on observation, record review, Fall Risk Evaluation review, hospital CT scan report review, Fall/Near Fall Incident Form review, Incident Report review, hospital Documents Review Report review, hospital Health Report review, In-Service Sign In sheet review, and staff interview, the facility failed to ensure that six (6) residents who had been identified to be at a high risk for falls, on the survey sample of thirty (30) residents (Resident #s 9, 10, 11, 19, 20 and 25), were provided supervision to prevent and/or reduce falls, and had adequate interventions put into place to prevent subsequent falls. This resulted in a situation in which the facility's noncompliance with requirements of participation caused, or was likely to cause, serious injury, harm, impairment or death to residents. 2. The Quality Assurance (QA) interview was conducted with the Medical Director on 04/18/2012 at 2:45 p.m.. During the interview, the Medical Director, who was part of the facility's QA Committee, the Medical Director stated that the facility did have a falls program, and that during the quarterly QA Committee meetings, resident falls data was discussed. The Medical Director stated he was aware of the survey findings. However, when asked about the survey findings regarding resident falls in the facility, the Medical Director expressed surprise. The Medical Director further stated that what was lacking in the facility was the process of monitoring and supervision of residents to address and minimize resident falls. 3. The QA Committee did not identify that there was no effective system in place to ensure that residents who had repeated falls were reevaluated for the development and implementation of additional interventions to minimize subsequent falls. The QA Committee also did not identify the need to implement corrective action plans to address residents who were known to have a history of falls and known to be at risk for falls, and who then experienced repeated falls.

Based on record review, staff interview, and Allegation of Compliance review, it was determined that the Immediate Jeopardy identified during the abbreviated survey which concluded on 04/18/2012 had been removed. However, non-compliance continued to exist at a S/S of "E", as the facility's Quality Assurance Committee had not fully implemented Quality Assurance initiatives related to the ongoing collection and analysis of information to prevent reoccurrence of the deficient practice, related to the failure to ensure the Quality Assurance Committee was effective in identifying and correcting quality deficiencies related to falls. Findings include: Review of the facility's acceptable Allegation of Compliance dated 04/27/2012 revealed that the facility revised the review process of the Fall Program, as it pertained to the Quality Assurance Committee. During each meeting, the Quality Assurance Committee will review the fall prevention program, and the care plan process, and will make any needed revisions. The purpose of this review will be to assess the proficiency of the preventative measures utilized for residents who have sustained falls, the residents who have a history of falls, and/or residents who had scored as having a high risk for falls on assessment. The Quality Assurance Committee will also review the interventions which have been put into place for residents who have sustained falls, in order to assess their effectiveness. The Committee will discuss any equipment that might be needed to prevent injury or harm to residents, and will also evaluate the need for further staff training as related to the facility's fall prevention program. After the re-evaluating of interventions in the Quality Assurance Committee meetings, any revisions or changes in the interventions will be relayed to, and care planned by, the unit managers and charge nurses, and will be placed on the assistive device monitoring log. Changes and modifications will then be tracked daily, along with all other assistive devices. Per this newly implemented process, the Quality Assurance Committee meetings were to start the week of April 23, 2012, for the month of April, are to occur weekly for the months of April, May, June and July, 2012, and then monthly thereafter, to review on an ongoing basis the facility's falls prevention program, to identify needed revisions and corrections, and to ensure the implementation of these revisions and corrections. Interview with the Administrator and Director of Nursing on 05/03/2012 at 8:50 a.m. revealed that the Quality Assurance Committee had met on 04/25/2012 and will continue to monitor the facility's fall prevention program during subsequent scheduled meetings. During this interview, it was acknowledged that during the 04/25/2012 meeting, the Quality Assurance Committee had conducted a review of the new protocols regarding the falls program, and that the Committee would continue analyzing the protocols in future meetings to ensure implementation. As of 05/03/2012, the facility had not had the opportunity to submit an acceptable Plan of Correction.

Based on observation, record review, and staff interview, the facility failed to provide care, related to fall-prevention, in accordance with the Care Plans of two (2) residents who had been identified to be at a high risk for falls, on the survey sample of thirty (30) residents (Resident #s 11 and 20). Specifically, the facility failed to ensure the use of a wheelchair alarm for Resident #11, per the Care Plan, even after the resident had fallen from the wheelchair and sustained a hematoma to the leg. The facility also failed to ensure the use of a seat belt, per the Care Plan, for Resident #20 when the resident was out of bed in the wheelchair, even though the resident had bilateral leg amputations. It was therefore determined that the facility's non-compliance with one or more requirements had caused, or was likely to cause, serious injury, harm, impairment or death to residents, and Immediate Jeopardy was identified to have existed as of March 18, 2012, and continued. On 04/16/2012 at 8:45 a.m., the facility Administrator was notified that Immediate Jeopardy existed. The findings include: 1. Cross refer to F323, example 4, for more information regarding Resident # 11. Record review for Resident #11 revealed a Care Plan entry of 10/13/2011, dated as having been reviewed on 01/11/2012, which identified the resident to be at a high risk for falls, with Approaches to address this fall-risk including floor mats at bedtime, or as ordered, and a bed sensor/alarm as ordered. A 03/01/2012 notation on this Care Plan documented a fall and specified an Approach of utilizing a wheelchair alarm. A Nurse's Notes entry of 03/01/2012 at 10:30 a.m. documented that Resident #11 had been found in the room lying on his left side, with the wheelchair tilted up and with a hematoma to the upper left leg. However, during observations of Resident #11 conducted on 03/21/2012 at 1:30 p.m. and 5:00 p.m., the resident was up in the wheelchair with no chair alarm in place, per the Care Plan, and observations in the resident's room at those times revealed no mat on the floor by the bed, per the Care Plan. Additional observation on 03/22/2012 at 6:00 p.m. revealed Resident # 11 to be lying on the bed, but with no mat on the floor, per the Care Plan. During an interview conducted on 03/22/2012 at 6:05 p.m., the Director of Nursing acknowledged that the wheelchair alarm and floor mat should have been in place. 2. Cross refer to F323, example 6, for more information regarding Resident #20. Record review for Resident #20, who had bilateral amputations of the legs, revealed an 11/27/2011 entry on the Care Plan which identified that Resident #20 was at high risk for falls, and included as an Approach to utilize a seat belt when out of bed in the wheelchair. However, observation of Resident #20 conducted on 04/16/2012 at 3:45 p.m. revealed the resident to be out of bed in the wheelchair with no evidence of a seat belt in use, per the Care Plan.