Every finding on record at Seasons Healthcare and Rehabilitation

Based on observation, interview, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff wore hair restraints in the dietary department to prevent potential contamination of food and food preparation equipment. This had the potential to affect 42 of 42 residents who received meals from the dietary department. Findings included: The United States FDA 2022 Food Code, dated 01/18/2023, revealed, Chapter 2. Management and Personnel, section 2-4 Hygienic Practices, 2-402 Hair Restraints 2-402.11 Effectiveness specified, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. During a tour of the kitchen on 07/15/2024 beginning at 9:08 AM, the Dietary Supervisor (DS) was observed not wearing a hairnet while working with food items. An observation on 07/15/2024 at 9:26 AM, revealed Certified Nurse Assistant (CNA) #11 walked into the kitchen area and did not don a hairnet. She walked past a food preparation area, dishwasher, and the three-compartment sink area. During an interview on 07/15/2024 at 9:28 AM, CNA #11 stated she just came to drop off a diet slip and did not know that she had to wear a hairnet. She said she thought she could enter the kitchen without a hairnet if she did not get close to the stoves. During an interview on 07/15/2024 at 9:34 AM, the DS stated she thought staff could enter the kitchen without a hairnet if they did not come close to the stove. During an interview on 07/17/2024 at 2:10 PM, the Administrator stated he expected staff to wear hairnets when in the food preparation area and when serving food.

Based on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that addressed all triggered care areas from the Minimum Data Set (MDS) for 1 (Resident #4) of 13 sampled residents. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. An Admission Record revealed the facility admitted Resident #4 on 10/24/2023. According to the Admission Record, the resident had a medical history that included diagnoses of major depressive disorder, protein-calorie malnutrition, hemiplegia affecting unspecified side, hypertension, overactive bladder, pain, and osteoarthritis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2023, revealed Resident # 4 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #4 required supervision from staff for eating, was dependent on staff for oral hygiene, toileting, showering/bathing, putting on and taking off footwear, and personal hygiene, and required substantial maximal assistance from staff for upper and lower body dressing. The MDS also indicated Resident #4 was frequently incontinent of bladder and was at risk for developing pressure ulcers/injuries. The MDS also indicated Resident #4 received an antidepressant medication during the assessment look-back period. The MDS Care Area Assessment (CAA) Summary revealed the areas of cognitive loss/dementia, communication, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer, and psychotropic drug use had triggered and would be addressed in the care plan. Resident #4's care plan for their admission on 10/24/2023 included Focus areas that indicated the resident would live at the facility long term, was dependent on staff for activities/recreation therapy, and had potential for nutritional problems. The areas of cognitive loss/dementia, communication, urinary incontinence, falls, pressure ulcer, and psychotropic drug use were not included on the care plan. During an interview on 07/15/2024 at 11:16 AM, Certified Nurse Assistant (CNA) #9 stated she reviewed care plans to know how to take care of the residents. During an interview on 07/17/2024 at 3:41 PM, the MDS Coordinator stated the admission MDS for Resident #4 indicated the areas would be care planned but they had not been care planned. During a follow-up interview on 07/17/2024 at 12:41 PM, the MDS Coordinator stated he was behind on care plans. During an interview on 07/17/2024 at 1:54 PM, the Director of Nursing (DON) stated she was aware of the issue with care plans not being done. The DON said care plans were very important, because they gave staff a sense of what to do for each resident. During an interview on 07/17/2024 at 2:10 PM, the Administrator stated he expected care plans to be completed timely.

Based on interview, record review, and facility document and policy review, the facility failed to ensure as-needed (PRN) orders for psychotropic medications specified the duration of use and the residents' records reflected documentation of the rationale for use beyond 14 days for 2 (Resident #11 and Resident #23) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, revised in July 2022, indicated, 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. An Admission Record revealed the facility admitted Resident #11 on 09/27/2022 and readmitted the resident on 06/26/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident had active diagnoses of anxiety disorder and depression and had not received an anti-anxiety medication during the seven days prior to assessment. Resident #11's Order Summary Report, listing active orders as of 07/16/2024, contained an order started on 03/05/2024 for lorazepam intensol oral concentrate (antianxiety medication) 2 milligrams per milliliter (mg/mL), give 0.25 mL by mouth every four hours PRN for anxiety/agitation related to generalized anxiety disorder. The order did not specify the duration of use or a stop date. The Scheduling Details for Resident #11's lorazepam intensol oral concentrate 2 mg/mL revealed a start date of 03/05/2024 and an end date of Indefinite. Resident #11's Psychoactive Medication Therapy Informed Consent Form, dated 03/05/2024, indicated Ativan (lorazepam) was being used to treat agitation and anxiety with a proposed course of therapy as prolonged treatment/unknown. Resident #11's Medication Administration Record (MAR) for the timeframe from 07/01/2024 through 07/17/2024 revealed staff had documented the administration of the lorazepam once on 07/01/2024. During a telephone interview on 07/17/2024 at 12:15 PM, Pharmacist #5 stated they followed the Centers for Medicare and Medicaid (CMS) guidelines for extending PRN psychotropic use past the allotted 14 days with the physician's documented rationale on a form the facility used. Resident #11's Psychotropic Committee Medication Review form, dated 06/27/2024, for the resident's PRN Ativan revealed the physician signed and dated the form on 07/16/2024 and agreed to continue the PRN medication; however, there was no documented rationale for extending the use beyond 14 days. During an interview on 07/17/2024 at 11:54 AM, the Assistant Director of Nursing (ADON) stated the facility followed the physician's orders for PRN psychotropic medications and that PRN psychotropic medications should only be used 14 days, unless specified differently by the physician. During an interview on 07/17/2024 at 1:58 PM, the Director of Nursing (DON) stated the facility discussed PRN psychotropic use at their monthly psychotropic medication review meetings. The DON stated Pharmacist #5, the facility's physician, herself, and the ADON attended the meetings, discussed the medications, and made recommendations. The recommendations were then sent to the primary physician to agree or disagree. The DON stated the facility tried to limit PRN psychotropic use to 14 days per the guidelines, but the physicians did not like having to re-order a PRN medication every 14 days. 46659 2. An Admission Record revealed the facility admitted Resident #23 on 10/06/2023. According to the Admission Record, the resident had a medical history that included a diagnosis of generalized anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/14/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident received antianxiety medication during the seven-day assessment look-back period. Resident #23's care plan included a Focus area, initiated on 01/16/2024, that indicated the resident used anti-anxiety medications related to anxiety. Resident #23's Order Summary Report, listing active orders as of 07/17/2024, contained an order started on 05/13/2024 for lorazepam oral concentrate (antianxiety medication) 2 milligrams per milliliter (mg/mL), give 0.5 mL by mouth every four hours as needed for agitation or restlessness related to generalized anxiety disorder. The order did not specify the duration of use or a stop date. The Scheduling Details for Resident #23's lorazepam oral concentrate 2 mg/mL revealed a start date of 05/13/2024 and an end date of Indefinite. Resident #23's Medication Administration Record (MAR) for the timeframe from 07/01/2024 through 07/17/2024 revealed staff had documented administration of the lorazepam once on 07/10/2024. During a telephone interview on 07/17/2024 at 12:15 PM, Pharmacist #5 stated they followed the Centers for Medicare and Medicaid (CMS) guidelines for extending PRN psychotropic use past the allotted 14 days with the physician's documented rationale on a form the facility used. Resident #23's Psychotropic Committee Medication Review form, dated 06/27/2024, for the resident's PRN lorazepam revealed the physician signed and dated the form on 07/09/2024 and agreed to continue the PRN medication; however, there was no documented rationale for extending the use beyond 14 days.

Based on interview, record review, and facility policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 (Resident #143) of 1 newly admitted resident reviewed. Findings included: A facility policy titled, Care Plans - Baseline, copyright 2001, indicated, 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. An Admission Record revealed the facility admitted Resident #143 on 07/11/2024. According to the Admission Record, the resident had a medical history that included diagnoses of a left femur fracture, type two diabetes mellitus, and stage four chronic kidney disease. As of the time of the survey, Resident #143's admission Minimum Data Set (MDS) assessment was still In Progress. Resident #143's electronic health record (EHR), reviewed on 07/16/2024, revealed the resident's Baseline Care Plan had a status of Errors. The Baseline Care Plan, dated 07/11/2024, was incomplete with no signatures or date and no Lock Date. Resident #143's EHR indicated the resident's Baseline Care Plan was created by Licensed Practical Nurse (LPN) #3 and revised by the MDS Coordinator. During an interview on 07/17/2024 at 10:46 AM, LPN #3 stated she was not sure who was responsible for completing the baseline care plan for new admissions and did not know the time frame for completing the baseline care plan. LPN #3 stated Resident #143 was admitted the week prior, and she initiated the baseline care plan but did not complete it because she was waiting on the Assistant Director of Nursing (ADON) to verify a few things. During an interview on 07/17/2024 at 11:53 AM, the ADON stated the nurse working at the time of a resident's admission was responsible for initiating the baseline care plan, and each department completed their respective sections. The ADON further stated the baseline care plan was to be completed within 48 hours of admission, and the MDS Coordinator was responsible for locking a resident's baseline care plan once it was completed. The ADON stated when a baseline care plan indicated the status was Errors, it either meant the base line care plan was incomplete or it was not yet locked to indicate it was completed. During an interview on 07/17/2024 at 12:41 PM, the MDS Coordinator stated a resident's baseline care plan should be completed within 48 hours of admission, and he was responsible for ensuring they were complete. The MDS Coordinator stated he was behind on completing care plans and indicated the Director of Nursing (DON) was aware. During an interview on 07/17/2024 at 1:53 PM, the DON stated she expected baseline care plans to be completed. The DON stated the admitting nurse started the baseline care plan, and the MDS Coordinator completed it. During an interview on 07/17/2024 at 2:10 PM, the Administrator stated he did not know the required timeframe for baseline care plan completion but expected them to be completed on time.

Based on interview and record review, it was determined, the facility did not ensure that residents who used a psychotropic medication received a gradual dose reduction (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 3 out of 27 sampled residents, residents who used a psychotropic medication did not have a GDR or a clinical contraindication to that GDR for the medication. Additionally, residents who used a psychotropic medication did not have any behavioral interventions or non-pharmacological interventions documented. Resident identifiers: 15, 27, and 40. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, dissection of aorta, abdominal aortic aneurysm, fatty liver, Alzheimer's disease, dementia, stenosis of cerebral artery, neoplasm of carotid body, hypomagnesemia, and anxiety disorder. On 1/24/23, resident 40's medical record was reviewed. Review of resident 40's physician orders revealed the following: a. Lorazepam Tablet 2 milligrams (mg), give 1 tablet by mouth two times a day for anxiety. The order was initiated on 6/2/21. b. Sertraline Tablet, give 50 mg by mouth every day shift for depression. The order was initiated on 9/16/22. Review of the December 2022 and January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of behavioral interventions or non-pharmacological interventions for the psychotropic medications Sertraline and Lorazepam. Review of the Psychotropic Committee Medication Review revealed the following: a. On 6/2/22, the medication Lorazepam 2 mg by mouth two times a day was reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented No change noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 6/8/22. On 6/2/22 at 5:31 PM, the psychotropic med review progress note documented the resident was currently taking Lorazepam 2 mg twice daily for anxiety; will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. b. On 9/8/22, the medication Lorazepam 2 mg by mouth two times a day was reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented No change noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 9/14/22. On 9/8/22 at 4:53 PM, the psychotropic med review progress note documented the resident was currently taking Lorazepam 2 mg twice daily for anxiety; will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. c. On 12/1/22, the medication Lorazepam 2 mg by mouth two times a day was reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented No change noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 12/15/22. On 12/1/22 at 10:08 AM, the psychotropic med review progress note documented the resident was currently taking Sertraline 50 mg daily and Lorazepam 2 mg twice daily for anxiety; will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. It should be noted that the Lorazepam 2 mg by mouth two times a day had not had a GDR since the medication was initiated on 6/2/21. No documentation could be found for a physician rationale for a clinical contraindication to a GDR for the Lorazepam. On 1/24/23 at 2:02 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 40's behaviors were exhibited by anxious comments about his family. RN 1 stated that resident 40 would make comments such as how long was he going to be here and when was his family visiting. RN 1 stated that resident 40 did not have any episodes of crying, tearfulness, or statements of sadness. RN 1 stated that resident 40 had scheduled Lorazepam for anxiety and it helped quite a bit. RN 1 stated that the documentation for behaviors would be located on the TAR. RN 1 stated that the Sertraline was normally ordered for depression, but resident 40 had a diagnoses of anxiety. RN 1 stated that the Sertraline was prescribed for resident 40's anxiety disorder. On 1/25/23 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 40 was taking Sertraline for anxiety. The DON stated that resident 40's as needed or PRN dose of Lorazepam was discontinued. The DON stated at the time resident 40 had a Lorazepam order for a scheduled dose two times a day and a PRN dose. The DON stated that the PRN order of Lorazepam was discontinued due to non-use. The DON stated that she would need to check with the Minimum Data Set (MDS) Coordinator to see if resident 40 had a GDR for the scheduled dose of Lorazepam as he was in charge of the psychotropic meetings. The DON stated that the staff were monitoring the resident for episodes of anxiety and how often they occurred, and for any adverse side effects of the medication. The DON stated that they did not document any non-pharmacological interventions for resident 40's episodes of anxiety I know we do it, I just don't think it's part of the documentation. On 1/25/23 at 12:57 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the physician did not specify a diagnosis for the Sertraline, but the physician did write it for depression and anxiety. The MDS Coordinator stated that the Sertraline was added because the Lorazepam two times daily was not sufficient for resident 40's increased anxiety. The MDS Coordinator stated that they did not have any physicians that documented a clinical contraindication for a GDR and resident 40 did not have a GDR for the scheduled Lorazepam. 33215 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. Resident 15's medical record was reviewed on 1/24/23. A physician's order dated 5/26/22, documented DULoxetine HCl [hydrochloride] Capsule Delayed Release Sprinkle 30 MG Give 1 capsule by mouth every day shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. The Psychotropic Committee Medication Review dated 6/2/22, documented duloxetine 30 mg daily for major depression. No target behaviors or number of episodes were documented for the past 30 days. No change noted. The interdisciplinary team recommendation was to maintain. The physician signed the form 14 days after the review and did not indicate if they agreed or disagreed with the committee recommendation. On 6/2/22 at 5:45 PM, a Psychotropic med review progress note documented that resident was currently taking duloxetine 30 mg daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. The Psychotropic Committee Medication Review dated 9/8/22, documented duloxetine 30 mg daily for major depression. No target behaviors or number of episodes were documented for the past 30 days. No change noted. The interdisciplinary team recommendation was to maintain. The physician signed the form but they did not indicate if they agreed or disagreed with the committee recommendation. On 9/8/22 at 4:31 PM, a Psychotropic med review progress note documented that resident was currently taking duloxetine 30 mg daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. The Psychotropic Committee Medication Review dated 12/1/22, documented duloxetine 30 mg daily for major depression. No target behaviors or number of episodes were documented for the past 30 days. No change noted. The interdisciplinary team recommendation was to maintain. The physician signed the form but they did not indicate if they agreed or disagreed with the committee recommendation. On 12/1/22 at 10:15 AM, a Psychotropic med review progress note documented that resident was currently taking duloxetine daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. On 12/29/22 at 9:37 AM, a Psychotropic med review progress note documented that resident was currently taking duloxetine 30 mg daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. It should be noted that the duloxetine 30 mg daily had not had a GDR since the initiation of the medication on 5/26/22. No documentation could be found for a physician rationale for a clinical contraindication to a GDR for the duloxetine. [Note: Within the first year in which a resident was admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.] The January 2023 MAR and TAR was reviewed and revealed no documentation of behavioral interventions or non-pharmacological interventions for the psychotropic medication duloxetine. On 1/25/23 at 10:00 AM, an interview was conducted with RN 1. RN 1 stated that resident 15 was scheduled to take diazepam for anxiety and resident 15 would ask about her family. RN 1 stated as far as non-pharmalogical interventions the staff were spending time with resident 15 and providing reassurance. On 1/25/23 at 12:11 PM, an interview was conducted with the DON. The DON stated if a resident was on a lower dose of a medication the pharmacist would not recommend a GDR. On 1/25/23 at 1:05 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated the facility was not meeting the regulation as far as the rationale for resident 15 not having a GDR on the duloxetine. The MDS Coordinator stated the facility did the psychotropic meetings and shared with the providers, but the providers did not send anything back. No additional information was provided. 43212 3. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes with neuropathic arthropathy, major depressive disorder, anxiety disorder, bipolar disorder, epilepsy, history of poliomyelitis, intellectual disabilities, and gastro-esophageal reflux disease. Resident 27's medical record was reviewed on 1/24/23. A review of resident 27's physician orders revealed the following: a. Effexor extended release (XR) capsule 150 MG, give 1 capsule by mouth every day shift related to major depressive disorder. The order was initiated on 6/4/21. b. Zyprexa tablet 5 MG, give 1 tablet by mouth every day shift related to bipolar disorder. The order was initiated on 2/23/22. A review of the December 2022 and January 2023 MAR and TAR revealed no documentation of behavioral or non-pharmacological interventions for the psychotropic medications Effexor XR and Zyprexa. The Psychotropic Committee Medication Review dated 4/28/22, documented the medication Effexor 150 mg and Zyprexa 5 mg were reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented no changes noted. The interdisciplinary team recommendations were to maintain the dose. They physician signed the form on 4/28/22. On 4/28/22 at 11:06 AM, the psychotropic medication review progress note documented Resident is currently taking .Effexor (150 mg, qD [daily], for depression), Zyprexa (5 mg, qD, for bipolar) .Will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. MD [Medical Director] present at review. The Psychotropic Committee Medication Review dated 8/4/22, documented the medication Effexor 150 mg and Zyprexa 5 mg were reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented no changes noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 8/4/22. On 8/4/22 at 11:11 AM, the psychotropic medication review progress note documented Resident is currently taking .Zyprexa (5 mg, qD, for bipolar disorder), Effexor (150 MG, qD, for depression) .Will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. MD present and aware of findings. On 10/6/22 at 9:43 AM, a physician progress note documented Psychological: No increase in depression, no anxiety .will continue her medical management. The Psychotropic Committee Medication Review dated 10/27/22, documented the medication Effexor 150 mg and Zyprexa 5 mg were reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented no changed noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 10/27/22. On 10/27/22 at 5:55 PM, the psychotropic medication review progress note documented Resident is currently taking .Effexor (150 mg, qD, for depression), Zyprexa (5 mg, qD, for bipolar disorder) .will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. MD present at review. On 12/1/22 at 9:35 AM, the psychotropic medication review progress note documented will continue to monitor behaviors associated with psychotropic medications. MD present at review. On 12/29/22 at 10:31 AM, the psychotropic medication review progress note documented will continue to monitor behaviors associated with psychotropic medications. MD present at review. Family informed. The psychotropic medications Effexor XR and Zyprexa were not mentioned. It should be noted that Zyprexa 5 mg once daily had not had a GDR since the medication was initiated on 2/23/22. Effexor XR 150 mg once daily had not had a GDR since the medication was initiated on 6/4/21. No documentation of contraindications to GDR's could be found. On 1/25/23 at 12:50 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that none of the physicians associated with the facility were documenting contraindications for medications that were not having a GDR.

Based on interview and record review, it was determined, the facility did not ensure that the drug regimen of each resident was reviewed monthly by a licensed pharmacist and that any identified irregularities were reported to the attending physician and documented what, if any, action had been taken to address it. In addition, the facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, for 3 out of 27 sampled residents, residents that had irregularities identified by the pharmacist were not acted upon by the attending physician in a timely manner. In addition, the Medication Regimen Review facility policy did not include time frames for the different steps in the process. Resident identifiers: 15, 27, and 40. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, dissection of aorta, abdominal aortic aneurysm, fatty liver, Alzheimer's disease, dementia, stenosis of cerebral artery, neoplasm of carotid body, hypomagnesemia, and anxiety disorder. On 1/24/23, resident 40's medical record was reviewed. Review of resident 40's physician orders revealed the following: a. Glipizide Extended Release (ER) Tablet 5 milligrams (mg), give 0.5 tablet by mouth every day. The order was initiated on 4/16/21. b. Glipizide ER Tablet 5 mg, give 1 tablet every day. The order was initiated on 7/15/22. c. Glipizide ER Tablet 10 mg, give 1 tablet by mouth every day. The order was initiated on 8/3/22. d. Lantus Solution (Insulin Glargine), Inject 1 unit subcutaneously every evening shift every 2 day(s) related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS may give 1 unit every few days until blood glucose is within optimal range. The order was initiated on 1/23/22, and discontinued on 1/17/23. e. If morning fasting glucose is over 120 for 3 consecutive days, increase long acting insulin dose by 2 units. If morning fasting glucose over 250 for 3 consecutive days, increase by 5 units. If morning fasting glucose under 70 for 2 consecutive days, decrease long acting insulin by 1 unit as needed for blood glucose management. The order was initiated on 5/7/21, and discontinued on 1/20/23. Review of the January Medication Administration Record revealed that the Lantus insulin 1 unit was documented as administered every other day, starting on 1/2/23 through 1/16/23. Resident 40's monthly Drug Regimen Reviews revealed the following: a. In May 2022, the pharmacist documented that resident 40 had fasting blood sugar levels trending high. The recommendation was please consider increasing Glipizide ER 5mg to 10 mg daily. The physician accepted the recommendation on 8/2/22. It should be noted that the new order for the increased dosage of Glipizide was initiated on 8/3/22. b. In July 2022, the pharmacist documented that resident 40's blood sugars were consistently elevated. The recommendation was to adjust the insulin. The physician accepted the recommendations with the following changes, please clarify current insulin dose and titration guidelines. The physician accepted the recommendations on 10/19/22. It should be noted that no new orders for insulin dose or titration guidelines were implemented after the recommendations were accepted on 10/19/22. On 1/25/23 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacist came to the facility at the end of the month to conduct the drug regimen review for all the residents. The DON stated that the pharmacist would then email the results to her and she would fax the recommendations to the physician. The DON stated that she would then implement the changes to the orders when the physician gave a reply. The DON stated that it depended on which physician on how long it took to get a response. The DON stated that they had a physician that they had to send the recommendations 2-3 times, or have had the transportation driver hand deliver the pharmacy recommendations to receive a response. The DON stated that resident 40's physician was who they were having a hard time obtaining a timely response to the pharmacy recommendations. The DON stated that she sent the recommendations to the physician immediately when she received them from the pharmacy. The DON stated that she did not know how to fix the problem. 43212 2. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes with neuropathic arthropathy, major depressive disorder, anxiety disorder, bipolar disorder, epilepsy, history of poliomyelitis, intellectual disabilities, and gastro-esophageal reflux disease. Resident 27's medical record was reviewed on 1/24/23. A review of resident 27's physician orders revealed the following: a. Probiotic capsule, give 1 capsule by mouth every day and night for GI (gastrointestinal) distress. The order was initiated on 7/13/21. b. Vitamin C tablet, give 1 tablet by mouth every day shift for supplement. The order was initiated on 1/31/22. c. Vitamin supplement E-1000 capsule 450 MG, give 1 capsule by mouth every day shift for supplement. The order was initiated on 1/31/22. d. Cyanocobalamin Tablet 2500 micrograms, give 1 tablet by mouth every day shift for supplement. The order was initiated on 10/9/20. e. Omeprazole Tablet delayed release 20 MG, give 1 tablet by mouth every day shift for GI distress. The order was initiated on 10/9/20. A monthly drug regimen review dated 3/7/22, revealed the pharmacist recommended to d/c (discontinue) Vitamin B 12, Vitamin C, Vitamin E and give daily MVI (multivitamin) if desired. Also evaluate if Melatonin is necessary as well as ongoing omeprazole and probiotic therapy. The physician accepted the recommendations on 4/22/22. On 1/25/23 at 11:39 AM, an interview was conducted with the DON. The DON stated the turn around time for the physician to sign orders depended on the physician. The DON stated one of the house physicians came in every Thursday, and the other one came in frequently. The DON stated they both sign orders. The DON stated that for physicians that were not in the facility, she had a terrible time getting the physicians to sign and return items. The DON stated she had spoken to the physician's offices several times and did not know what more she could do to get the physicians to review and approve or disapprove the pharmacy recommendations and sign the orders. The DON stated she kept a running list of things she was waiting for and marked them off as they came through. 33215 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. Resident 15's medical record was reviewed on 1/24/23. The December 2022 Monthly Chart Review completed by the pharmacist on 12/23/22, documented Finding(s): Patient seems to be in consistent pain based on pain assessments. Recommendation: Recommend an extended release pain medication like fentanyl patches or extended release preparations of oxycodone or morphine to provide increased pain control. The physician had not responded to the recommendation and had not signed or dated the form. On 1/3/23 at 5:15 PM, a Pharmacy Recommendation progress note documented Note Text: Received pharmacy recommendation: Patient seems to be in consistent pain based on pain assessments, recommends an extended-release pain medication like Fentanyl patches or extended-release preparations of oxycodone or morphine to provide increased pain control MD [Medical Director] notified will await further orders. On 1/25/23 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that before the pharmacy reviews were sent to the physician the DON would show the pharmacy recommendations to the floor nurses. On 1/25/23 at 12:11 PM, an interview was conducted with the DON. The DON stated the pharmacist would send her a list of all the residents that were reviewed monthly. The DON stated if there were any findings she would make a note in the resident's medical record and would fax the recommendations to the resident's provider. The DON stated she would send the recommendations to the provider the day the recommendations were received from the pharmacist. The DON stated it was a struggle to get the recommendations back from the providers. The DON stated that Transport would go out daily to the offices to pick up the recommendations and the DON stated that she would call the providers daily. The DON stated she had spoken to the providers and the facility MD in person. The DON stated if the recommendation was not an immediate order the MD wanted to wait for the resident's provider to respond. The DON stated she had gone through the MD and the MD did not want to take over everyone's orders. A review of the Medication Regimen Review policy provided by the facility documented, The consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medial director and/or the administrator. The facility policy was not dated.

Based on interview and record review, it was determined, the facility did not ensure prompt efforts were taken by the facility to resolve grievances the residents may have had. In addition, the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision. Specifically, for 1 out of 27 sampled residents, the facility did not document the grievance of a resident who stated an item of her clothing went missing, and a prompt resolution to the grievance was not documented or followed up on by the facility. In addition, there were no grievances documented for the previous year. Resident identifier: 38. Findings included: Resident 38 was admitted on [DATE] with diagnoses that included chronic kidney disease, atherosclerotic heart disease, acute and chronic respiratory failure with hypoxia, hypertension, thrombocytopenia, dysphagia, spondylolysis, asthma, and pain. On 1/23/23 at 2:13 PM, an interview was conducted with resident 38. Resident 38 stated that shortly after she was admitted to the facility on e of her nightgowns went missing. Resident 38 stated she reported the item missing to the Resident Advocate (RA). Resident 38 stated she did not believe there was a name on the nightgown. A review of resident 38's inventory list that was completed on 12/31/22, included two nightgowns. No items were documented as items acquired after original entry. On 1/24/23 at 12:39 PM, an interview was conducted with the RA. The RA presented the grievance binder that had no grievances listed for the previous year. The grievance binder contained a blank grievance form. The RA stated grievances were resolved on the spot if possible. The RA stated if an item of clothing was missing she would look in the laundry, allow a whole cycle of laundry to be completed, and look in the lost and found. The RA stated if a grievance was unable to be resolved on the spot, there was a form that would be filled out, and placed in the grievance binder. The RA stated that when a resident was admitted , an inventory was taken of their personal items within the first 24 hours and placed in the resident's hard chart. The RA stated she did not know why a form was not filled out when resident 38's item was reported missing and was not found. On 1/24/23 at 12:39 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was aware of resident 38's missing item of clothing. The ADM stated staff in the facility had canvassed the rooms several times. The ADM stated that he had not spoken to a family member yet about the item. The ADM stated he had offered to replace the missing item but resident 38 had not made a decision about doing that yet. The ADM stated that he would go and speak with resident 38 about the item. On 1/24/23 at 2:35 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated if she was told about a missing item, she would try to help the resident look for it. CNA 2 stated sometimes the missing clothing could still be in the laundry. CNA 2 stated if she was unable to find what was missing, she would report it to the Director of Nursing (DON) or the ADM. CNA 2 stated sometimes a flyer would be put up about the missing item, or it would be discussed in a meeting. CNA 2 stated there should be an inventory of what the resident brought into the facility. CNA 2 stated if something came in later, there should be a record of it. CNA 2 stated other ways of communicating missing items to staff would be at shift change report or it would be written down in the CNA book at the nurses station. CNA 2 stated if the items were not found, the DON or the ADM would know what to do about it. On 1/25/23 at 8:28 AM, an interview was conducted with the Housekeeper (HK). The HK stated sometimes clothing items do not have labels. The HK stated the resident's family was responsible to label clothing that came into the facility. The HK stated if a resident was missing an item of clothing they could look for the item in the lost and found area. The HK stated there was a form that should be filled out when things were missing so there would be documentation. The HK stated if the item was not found it was usually replaced. On 1/25/23 at 3:01 PM, an interview was conducted with the ADM and the RA. The ADM stated he tried to resolve grievances within two business days. The RA stated she had reached out to resident 38's son and he was not aware of the clothing item. The RA stated it was possible that resident 38's neighbor had brought the item in and resident 38's son was checking on that. The RA stated if the resident's family did not label clothing before items were brought in, the facility would label items and put them on the inventory. The RA stated she had completed training about how to handle grievances, and had in-serviced facility staff about grievances. The RA stated, there has been nobody that has wanted to fill out a grievance. A review of the facility policy, Grievances/Complaints, Filing last reviewed on April 2017, revealed in pertinent part: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy interpretation and administration: (number 8) Upon receipt of a grievance and /or complaint, the grievance officer will review and investigate the allegation and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .(number 12) The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. (including) a. The administrator, or his or her designee, will make such reports orally within (no designation) working days of the filing of the grievance or complaint with the facility . b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office .(number 14) The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

Based on observation and interview, it was determined, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants, and the resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, the nurse staffing information was not completed and readily accessible to residents and visitors. Findings included: On 1/25/23 at 9:10 AM, an observation was made throughout the facility and the nurse staffing information could not be located. At the nurse's station, a form was observed to be pinned to a bulletin board. The form included areas for information required for the nurse staffing information, but the form had not been completed. On 1/25/23 at 9:19 AM, an interview was conducted with RN 1. RN 1 stated the staff schedule was posted on the wall behind the nurse's station. When observed, the posting RN 1 referred to was the nursing staff schedule for the month. On 1/25/23 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nighttime nurse was responsible for filling out the nurse staffing information. The DON stated she would call that nurse and see where she had put it. On 1/25/23 at 1:15 PM, an interview was conducted with LPN 1. LPN 1 stated she did not know where the nurse staffing information was. LPN 1 stated she thought the DON was the person who completed the form and posted it. On 1/25/23 at 3:01 PM, a second interview was conducted with the DON. The DON stated she was told by the nighttime nurse that she had not been completing the form. The DON stated the nighttime nurse did not have a reason for not filling out the form. The DON stated, we're going to just have to take the hit on this.

Based on interview and record review, it was determined, the facility did not ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, for 1 out of 27 sampled residents, a resident's physician visits for the first 90 days after admission were not completed timely by the facility Medical Director (MD) or the hospice physician. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. Resident 15's medical record was reviewed on 1/24/23. On 6/8/22, a Face to Face Visit was completed by the hospice Nurse Practitioner (NP). On 7/26/22, a Face to Face Visit was completed by the hospice NP. There were 50 days between the last physician visit. On 10/7/22, a Face to Face Visit was completed by the hospice physician. There were 73 days between the last physician visit. [Note:The facility MD or hospice physician should have seen resident 15 at least once every 30 days for the first 90 days after admission. A physician visit was considered timely if it occurred not later than 10 days after the date the visit was required.] On 1/25/23 at 2:43 PM, an interview was conducted with the Resident Advocate (RA). The RA stated the facility had a house physician and the residents had a choice to see their own physician. The RA stated that Transportation would set up all physician appointments. On 1/25/23 at 2:50 PM, an interview was conducted with the Transportation Manager. The Transportation Manager stated when the facility had a new resident admission, she would get the discharge orders and would schedule the appointments. The Transportation Manager stated she would schedule with the primary care physician a week to two weeks out from admission. The Transportation Manager stated the nurses would let her know if a resident needed to be seen and she would schedule the visits and transport the residents. The Transportation Manager stated that she would schedule the resident physician visits according to the regulation. The Transportation Manager stated she would get the resident scheduled out so she did not forget. The Transportation Manager stated she did not schedule the hospice physician visits. On 1/25/23 at 2:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if the resident was not on hospice services the Transportation Manager took care of getting the resident scheduled for the physician visits. The DON stated the Transportation Manager just knew that the visits were a Medicare regulation. The DON stated the Transportation Manager would put the physician visits on her calendar. The DON stated if the resident was on hospice services the hospice physician would come to the facility to see the resident. The DON stated the hospice companies knew the regulations and the frequency of visits was in the policy that the facility had the hospice companies sign. On 1/25/23 at 3:22 PM, an interview was conducted with the Administrator (ADM). The ADM stated the hospice regulations required the hospice physician to visit the resident every eight weeks. The ADM stated the hospice physician was following the hospice regulations.

Based on interview and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 27 sampled residents, a resident that had uncontrolled pain was not evaluated for increased pain medication needs by the Medical Director (MD). Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. On 1/24/23 at 9:21 AM, an interview was conducted with resident 15. Resident 15 stated that she had pain and she was starting to have some pain as we're speaking. Resident 15 stated that she was unsure when her last dose of pain medication was administered and if she was due for another pain medication she was going to request one. Resident 15's medical record was reviewed on 1/24/23. On 5/25/22, a Nursing Pain Interview was completed. The interview documented that resident 15 had frequent pain over the last five days that made it hard to sleep and had limited day to day activities. Pain intensity was documented as severe. The staff assessment for pain documented non-verbal sounds, vocal complaints of pain, and facial expressions. Resident 15 reported daily indicators of pain and a majority of pain was due to rheumatoid arthritis. [Note: No additional Nursing Pain Interviews were located.] A care plan Focus initiated on 5/25/22, documented Resident has Doctor orders for Hospice cares. A care plan Goal documented Resident will be kept comfortable. Resident will share feelings regarding end-of-life issues and diagnosis if able and as needed. The care plan Interventions included, but were not limited to, Nursing to keep resident comfortable and as pain free as medically possible. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 11. A BIMS score of 8 to 12 indicates moderately impaired cognition. In addition, the MDS assessment documented that resident 15 had been on a scheduled pain medication regimen, had received as needed (PRN) medications, and non-medication interventions for pain were not received. A pain assessment interview was completed and revealed that resident 15 had frequent pain. A care plan Focus initiated on 6/7/22, documented The resident has acute/chronic pain r/t [related to failure to thrive. A care plan Goal documented The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The care plan Interventions included: a. Initiated on 5/25/22, Per hospice - resident commonly states higher pain levels when questioned, not fully understanding pain control charting; PCP [primary care physician] is aware and does not wish to receive routine reports of increased follow-up pain levels. b. Initiated on 6/7/22, Administer analgesia, as per orders from hospice. c. Initiated on 6/7/22, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A quarterly MDS assessment dated [DATE], documented that resident 15 had a BIMS score of 14. A BIMS score of 13 to 15 indicates intact cognition. In addition, the MDS assessment documented that resident 15 had been on a scheduled pain medication regimen, had received PRN medications, and non-medication interventions for pain were not received. A pain assessment interview was not completed. The Staff Assessment for Pain documented non-verbal sounds and vocal complaints of pain. Indicators of pain or possible pain observed daily. The January 2023 Medication Administration Record and Treatment Administration Record were reviewed and the following pain medications were documented: a. On 5/25/22, morphine sulfate Solution 20 milligrams (mg)/milliliter (ml), give 0.5 ml by mouth every hour as needed for pain related to encounter for palliative care and rheumatoid arthritis with rheumatoid factor. [Note: There were no administrations documented for the month of January 2023.] b. On 5/25/22, Tylenol tablet 325 mg, give two tablets by mouth every four hours as needed for pain and or fever. [Note: There were no administrations documented for the month of January 2023.] c. On 7/21/22, methadone tablet 10 mg, give two tablets by mouth two times a day for pain related to encounter for palliative care and rheumatoid arthritis with rheumatoid factor. d. On 8/3/22, oxycodone tablet 20 mg, give one tablet by mouth every two hours as needed for pain. Give one tablet by mouth every two hours as needed for breakthrough pain. Resident 15's average pain score for the month of December 2022 was 8 out of 10. Out of 372 medication opportunities for the month of December 2022, resident 15 requested oxycodone on 206 occasions. Resident 15's average pain score for the month of January 2023 was 8 out of 10. Out of 280 medication opportunities for the month of January 2023, resident 15 requested oxycodone on 159 occasions. The hospice physician notes were reviewed and the following were documented: a. On 6/8/22, . Patient has chronic pain. Since her medications are being managed by the facility, Oxycodone was added for breakthrough pain. She takes Methadone regularly but reports it does not help her pain, oxycodone does. b. On 7/26/22, . Patient has debilitating, chronic pain. Her Methadone with [sic] recently increased from 10mg TID [three times a day] to 20mg BID [two times a day]. She take Oxycodone every 2-3 hours for breakthrough pain. A dilaudid pump was discussed but patient feared it would be too strong for her. c. On 10/7/22, . past medical history of rheumatoid arthritis, chronic pain, and malnutrition ., continues with significant pain complaints in bil [bilateral] knees, hips, and back. Bil hand deformity, ulnar deviation of 2nd - 5th fingers, swan-neck of 2nd-3rd, and interphalangeal joint swelling limits pt's [patient's] dexterity of hands. d. On 11/17/22, . States that she is always in pain, and the pain medications are not helping her pain. Her pain is in all joints, mainly feet/ankles/ and hands. Pt [Patient] is in need for further pain management, as pain is not controlled. The December 2022 Monthly Chart Review conducted by the pharmacist and completed on 12/23/22, documented Finding(s): Patient seems to be in consistent pain based on pain assessments. Recommendation: Recommend an extended release pain medication like fentanyl patches or extended release preparations of oxycodone or morphine to provide increased pain control. The physician had not responded to the recommendation and had not signed or dated the form. On 1/3/23 at 5:15 PM, a Pharmacy Recommendation progress note documented Note Text: Received pharmacy recommendation: Patient seems to be in consistent pain based on pain assessments, recommends an extended-release pain medication like Fentanyl patches or extended-release preparations of oxycodone or morphine to provide increased pain control MD notified will await further orders. On 1/24/23 at 1:36 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that resident 15 was able to toilet herself and resident 15 had a bedside commode. CNA 3 stated that mornings were the hardest for resident 15 and she would use her call light because she was weaker. CNA 3 stated resident 15 went up and down on her pain levels and there were days resident 15 really needed staff assistance. CNA 3 stated that resident 15 was really good to use the call light when she was in pain and the staff were really quick to respond because they did not want resident 15 to be in any pain. On 1/25/23 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 15 was admitted to the facility on hospice and resident 15 had chronic pain. RN 1 stated that resident 15's pain was mainly from her rheumatoid arthritis and the arthritis had exacerbated over time. RN 1 stated that resident 15 was on scheduled methadone and oxycodone every two hours. RN 1 stated that resident 15 would ask for the oxycodone every three or four hours. RN 1 stated the hospice nurse was always asking the staff about resident 15's pain when the nurse visited. RN 1 stated hospice increased the frequency of the oxycodone and he felt like resident 15's pain was better managed. RN 1 stated that resident 15 had a few evaluations with the hospice physician. RN 1 stated that before the pharmacy reviews were sent to the physician the Director of Nursing (DON) would show the pharmacy recommendations to the floor nurses. RN 1 stated the hospice nurse had mentioned a pain patch for resident 15 but the hospice nurse had not started a pain patch. RN 1 stated as far as nonpharmalogical interventions the staff were spending time with resident 15 and providing reassurance. On 1/25/23 at 12:11 PM, an interview was conducted with the DON. The DON stated the pharmacist would send her a list of all the residents that were reviewed monthly. The DON stated if there were any findings she would make a note in the resident's medical record and would fax the recommendations to the resident's provider. The DON stated she would send the recommendations to the provider the day the recommendations were received from the pharmacy. The DON stated it was a struggle to get the recommendations back from the providers. The DON stated that Transport would go out daily to the offices to pick up the recommendations and the DON stated that she would call the providers daily. The DON stated she had spoken to the providers and the facility MD in person regarding the pharmacy recommendations. The DON stated if the recommendation was not an immediate order the MD wanted to wait for the resident's provider to respond. The DON stated she had gone through the MD and the MD did not want to take over everyone's orders. The DON stated it did not matter when you go into resident 15's room, resident 15 would say her pain was a seven or a five. The DON stated that resident 15 would look at the clock and say she needed a pain pill. The DON stated the hospice nurse did not want to change resident 15's medications and they were not getting the results with resident 15's current medication regimen. The DON stated that resident 15 was getting a lot of the oxydocone. On 1/25/23 at 12:30 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that in an interdisciplinary team (IDT) meeting the hospice nurse came in and discussed resident 15's pain medications with the team. The RA stated that resident 15 had Coronavirus disease 2019 in December 2022. The RA stated the hospice nurse was afraid that resident 15 would come off of hospice and was worried what doctor would follow resident 15 if she came off. The RA stated that resident 15 tried pain patches in the past and they had not helped with her pain. [Note: The last documented IDT meeting was held on 11/15/22. No additional information was provided.] A review of the Pain Management Review Policy and Procedure provided by the facility documented, POLICY: The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. PROCEDURE: 1. Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status (e.g., after a fall, with change in behavior or mental status). 2. 3. Assessment and evaluation by the appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. b. Review of the resident's diagnoses or conditions and any additional factor that may be causing or contributing to pain. c. Identifying key characteristics of the pain (Examples: Duration, Frequency, Location, Onset, Pattern and Radiation) d. Obtaining descriptors of the pain (Examples: Aching, Burning, Throbbing, Tingling, Stabbing) e. Determining factors that make the pain better or worse f. Identifying recent exacerbations of chronic pain g. Impact of pain or quality of life h. Current prescribed pain medications, dosage and frequency i. Note all treatments the patient is receiving for pain including nonpharmalogical therapies. j. The resident's goals for pain management and his/her satisfaction with the current level of pain control k. The effectiveness of specific drugs and other treatments used in the past to treat pain. 4. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. 5. The interdisciplinary team and the resident collaborate to arrive at pertinent, realistic and measurable goals for treatment. 6. 7. Non-pharmacological pain management interventions include but are not limited to: a. Adjusting room temperature b. Smoothing linens c. Turning and repositioning to a comfortable position d. Loosen any constrictive bandage or device e. Applying splinting (e.g., pillow or folded blanket) f. Physical modalities (e.g., cold compress, warm shower or bath) g. Exercises to address stiffness h. [sic] Cognitive/behavioral interventions (e.g., music, diversions, pain education) 8. Pharmacological interventions should follow a systematic approach. 9. The interdisciplinary team is responsible for developing a pain management regimen. 10. The following are general principles for prescribing analgesics in the long-term care setting: a. Evaluate the patient's medical condition and current medication regimen to determine the most appropriate therapy for pain b. Consider whether the medical literature contains evidence based recommendations for specific regiments to treat identified causes of pain c. Use the least invasive route of administration possible d. For chronic pain, begin with a low dose and titrate carefully until comfort is achieved e. For acute pain, begin with a low or moderate dose as needed and titrate more rapidly than for chronic pain f. Reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize or manage side effects g. Some clinical conditions may require several analgesics or adjuvant medications, documentation should help clarify the rationale for a treatment regimen and to acknowledge associated risks. 11. Reassess patients with pain regularly based on the facility's established intervals. 12. If when re-evaluated, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated. 13.

Based on observation, interview, and record review, it was determined, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, for 1 out of 27 sampled residents, a resident with a hand contracture was not being provided the ordered device to hold in the contracted hand during the day for comfort and prevention. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility initially on 6/5/15 and readmitted on [DATE] with diagnoses that included hemiplegia affecting right nondominant side, cerebrovascular disease, acute kidney failure, bipolar disorder, hypertension, major depressive disorder, history of pulmonary embolism, hypokalemia, and neuromuscular dysfunction of the bladder. On 1/24/23 at 9:58 AM, an interview was conducted with resident 10. Resident 10 was noted to have a contracture of the right hand such that her fingernails were not visible and the hand made a fist. Resident 10 was asked if she used a splint or other device to relieve the contracture to which she replied, I just don't have it. A physician's order dated 1/7/22, included cleanse right hand with ns [normal saline] between fingers and palm, dry thoroughly, dust with baby powder, and place a rolled up wash cloth in hand for comfort. The frequency included every day shift for prevention. A review of the Point of Care documentation revealed that, for the care area related to the restorative splint/brace program, each day was documented not applicable. On 1/24/23 at 1:59 PM, a request was made for any physical therapy notes for resident 10. The Minimum Data Set Coordinator revealed that resident 10 had not received any physical therapy in the past year. On 1/25/23 at 8:33 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1 who served as the CNA Coordinator. CNA 1 stated the facility did not currently have a restorative nursing program. CNA 1 stated that CNAs were helping with the duties of the restorative nursing aide. CNA 1 stated if a CNA noticed a need for a resident, they would suggest therapy or help from a restorative nursing aide. CNA 1 also stated that the physical therapist would sometimes recommend a resident have restorative therapy. CNA 1 stated when restorative therapy was recommended, the task was added in the Point of Care system. CNA 1 stated when not applicable was marked it meant that the task was not completed. CNA 1 also stated that it could also mean that the service was not offered that day. CNA 1 stated that for resident 10, she encouraged other CNAs to ensure the resident's hand was washed and to help with range of motion in that hand. CNA 1 stated if a splint or brace was being utilized, it would be charted. CNA 1 stated resident 10 did not have a brace, but did have a posy. CNA 1 stated staff offered it to the resident for a minimum of one hour per day. When shown resident 10's Point of Care for restorative splint/brace program, CNA 1 stated she needed to educate some of the CNAs about restorative stuff. CNA 1 stated the CNA's needed more training on the charting in Point of Care. On 1/25/23 at 9:30 AM, an interview and observation was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 was observed to be able to open resident 10's right hand enough to view the palm of the hand. The palm of resident 10's hand was pink, and the skin was intact. Resident 10's long fingernails were observed to be pushing into the palm of the hand. LPN 1 stated resident 10 needed her nails to be trimmed, and resident 10 stated she would like to have her nails trimmed. LPN 1 asked resident 10 why she did not have her gray thing in her hand. Resident 10 stated she did not know where it was. LPN 1 stated she would try to find it and looked in the drawers in resident 10's room but was unable to find it. LPN 1 stated there was a restorative nursing aide at the facility who weighed the residents and provided passive range of motion to those residents who needed it. Upon exiting resident 10's room, LPN 1 asked CNA 4 to obtain a washcloth to roll up and place in resident 10's hand. On 1/25/23 at 9:35 AM, CNA 4 notified LPN 1 that he had found the device for resident 10's hand and had placed it appropriately. On 1/25/23 at 3:08 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNAs were supposed to make sure the palm posy was in place for residents who used them. The DON stated the facility had to pull back on the restorative program because of short staffing. The DON stated the nurses on the unit should monitor the residents and do weekly skin assessments to ensure there was no skin breakdown.

Based on interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 1 out of 27 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with an antibiotic that was based off of a urinalysis (UA) and culture and sensitivity (C&S) that was collected three months prior. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, mental disorders due to known physiological condition, bipolar disorder, mood disorder due to known physiological condition, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. Resident 1's medical record was reviewed on 1/25/23. On 10/7/22 at 3:24 AM, a LABS AND DIAGNOSTICS progress note documented Note Text: Collected UA [urinalysis] per [name of doctor removed], urologist, d/t [due to] increased confusion, aggravation, and agitation. On 10/7/22 at 11:24 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Received UA results from lab: WBC [white blood cells] > [greater than] 30, and RBC [red blood cells] >30. Called urologist, talked with [name removed] who is on-call this weekend who stated they wanted to wait to give orders until the C&S results came back. Results were faxed to Urologist as well. On 10/9/22 at 8:43 PM, a Nurses Note documented Note Text: UA culture results sent to PCP [primary care physician]. Requested for pain medication refills sent to PCP. On 10/10/22 at 4:00 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Urinary culture and sensitivity faxed to resident's urologist, [name of doctor removed]. No orders at this time. On 10/10/22 at 10:17 PM, a Nurses Note documented Note Text: [Name of doctor removed] nurse called and said that he does not want resident on an antibiotic. Abnormality in UA culture is d/t having a suprapubic catheter. Watch for s/s [signs and symptoms] of UTI, encourage oral fluids, if any changes to contact his office. On 10/11/22 at 10:58 AM, an Infection Note documented Late Entry: Note Text: Contacted [name of doctor removed] office in regard to UA culture and having 50000 Pseudomonas noted on culture. MD [Medical Doctor] aware and stated does not want to treat with ATB [antibiotic] and to inform him of S/S of UTI. Family notified. On 1/6/23 at 12:59 PM, a Nurses Note documented Note Text: Resident had increased confusion this morning, with speaking with resident's daughter, [name removed], she reports her mom has been more confused the past couple evenings when she has spoken with her. [Name removed] is requesting we do a prn [as needed] IV [intravenous] fluid infusion today. On 1/6/23 at 3:27 PM, a Nurses Note documented Note Text: UA dip D/T increased confusion. 3+ for Leukocytes; 3+ Protein; 3+ Blood. pcp notified via backline, awaiting response. Requested to also do IV fluids per family request. On 1/6/23 at 9:14 PM, an Order Note documented Note Text: The order you have entered Cipro Tablet 500 MG [milligrams] (Ciprofloxacin HCl [hydrochloride]) Give 500 mg by mouth two times a day related to UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION. A review of the January 2023 Medication Administration Record documented that resident 1 received the Cipro on 1/7/23 through 1/9/23. On 1/9/23 at 10:56 AM, an Order Note documented Note Text: The order you have entered Cipro Tablet 500 MG (Ciprofloxacin HCl) Give 500 mg by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until 01/13/2023 13:00 [1:00 PM]. On 1/10/23 at 1:06 PM, a UA and C&S was faxed to the facility from the laboratory. The report was initialed by facility nursing staff and was noted that the PCP was notified on 1/10/23. It was documented on the UA results that the lab was collected on 10/7/22. [Note: There was no documentation indicating that resident 1 had a UA collected for the signs and symptoms of a UTI on 1/6/23.] On 1/10/23 at 2:37 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Resident's urinary culture and sensitivity received today. Culture shows the presence of several organisms. PCP, [name removed], notified of results. Awaiting response from PCP if there will be any changes to antibiotic orders. On 1/10/23 at 4:26 PM, a Nurses Note documented Note Text: New antibiotic order to start tonight as per [name of doctor removed]: Macrobid Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . for 14 Administrations Start Date:1/10/2023 End Date: 1/17/2023 Resident is now taking two antibiotics for UTI d/t urinary culture showing the presence of several different infectious organisms in urine. Resident's family already notified regarding antibiotic orders. [Note: The antibiotic treatment initiated on 1/10/23, was based off of the UA collected on 10/7/22.] On 1/10/23 at 4:40 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Reached out to PCP to see if resident needs to be put on contact precautions d/t resident had 5000 pseudomonas as one of the organisms that urine culture came back with. PCP stated he wouldn't recommend putting on contact precautions. On 1/17/23 at 10:33 AM, an Infection Note documented Note Text: Resident took her last antibiotic for UTI this morning, no adverse reactions noted. Vital signs stable, level of consciousness at her baseline. Resident does not complain of any pain at lower abdomen area; urine appears yellow and clear; Resident given sips of water throughout shift to increase hydration; will monitor this shift. On 1/25/23 at 11:06 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated labs would be collected if the resident made a visit to their PCP and returned with orders. RN 1 stated if a resident had a change of condition the nursing staff would contact the Medical Director and would receive orders to collect labs. RN 1 stated the PCP or other specialist would also fax orders for up and coming resident appointments that required labs. RN 1 stated that facility staff would collect the labs. RN 1 stated a complete blood count would be returned within one to two days after collection. RN 1 stated a urine sample for a UA would be returned within a day and a C&S could take three to four days to be returned. RN 1 stated that he would document in a progress note that the lab was received and would fax the results to the Medical Director and would follow up with a phone call to the Medical Directors office. On 1/25/23 at 1:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if the nursing staff received a physician's order to collect labs the nurse would put the order in the resident's medical record. The DON stated if the lab was to be collected immediately (STAT) the staff would collect the lab, if the lab was not STAT it would be put off a day or two. The DON stated the nursing staff had a book that stated what labs were out. The DON stated when the lab results were received by the facility the nursing staff would review the lab and send the lab results to the Medical Director for review. On 1/25/23 at 3:33 PM, a follow up interview was conducted with RN 1. RN 1 stated he was not the nurse that originally collected the UA for resident 1. RN 1 stated he had received the lab results and started resident 1 on the antibiotic per the PCP and was waiting on the culture. On 1/25/23 at 3:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the Interim Report date on the lab report indicated when the lab results were requested from the lab. LPN 1 stated that someone had requested resident 1's UA from 10/7/22, be faxed to the facility. On 1/25/23 at 3:57 PM, an interview was conducted with Infection Preventionist (IP). The IP stated the nursing staff were expecting a urine culture back for resident 1 and a urine culture was faxed to the facility on [DATE]. [Note: The urine culture that was faxed to the facility on [DATE], was from the UA collected on 10/7/22.] On 1/25/23 at 4:06 PM, a follow up interview was conducted with the DON. The DON stated that resident 1's urine was dipped on 1/6/23. The DON stated that a UA was not collected for resident 1 in January 2023 and a UA was not sent to the lab.

Based on observation and interview it was determined, for 4 of 37 sample residents, that the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained that the food was not palatable and the test tray was not visibly attractive or palatable. Resident identifiers: 8, 33, 35 and 41. Findings include: On 6/13/21 at 4:43 PM, an interview was conducted with resident 8. Resident 8 stated that the food was not very good. Resident 8 that the eggs at breakfast were too hard. On 6/14/21 at 8:20 AM, an interview was conducted with resident 35. Resident 35 stated that the chicken sandwich was not good. Resident 35 stated that the facility served beets a lot and the same vegetables. Resident 35 stated that the food did not taste good all the time. Resident 35 stated that the food was very bland and was sometimes served cold. On 6/14/21 at 8:43 AM, and interview was conducted with resident 33. Resident 33 stated the food was just OK. Resident 33 stated that When you're used to home cooked food, nothing tastes that good. On 6/13/21 at 4:32 PM, an interview was conducted with resident 41. Resident 41 stated that the food was not very good. Resident 41 stated that the eggs are very hard, need a little milk or cream. Resident 41 stated that the food was comparable to army food. On 6/15/21 at 11:58 PM, the lunch meal was brought out to the serving cart and three hall carts were prepared. At 12:02 PM cart 1 went out of the kitchen to the hallway for residents eating in their rooms. At 12:08 PM cart 2 went out of the kitchen, and at 12:16 PM cart 3 was taken to the last resident hallway. On 6/15/21 at approximately 12:20 PM, a test tray was taken off of hall cart 3 after all residents were served. Temperatures were taken on each item on the meal tray and the food was sampled. Results were as follows: [Note: All temperatures were in degrees Fahrenheit.] a. Water in a small cup was 60.0 degrees. The water was warm to the taste. b. Milk in a small cup was 50.0 degrees. c. Orange punch in a small cup was 49.2 degrees. d. Fried chicken was 78.7 degrees. The chicken was cold to the taste. e. Mashed potatoes with chicken gravy was 78.7 degrees. The mashed potatoes were cold to the taste, bland, gravy was thick with a strong taste of corn starch. f. Broccoli was 75.2 degrees. The broccoli was dull in color with a mushy texture. The broccoli was also cold to the taste. g. Green salad was 61.7 degrees. The lettuce had a brown tint. h. Dinner roll with butter was cold to the taste. I. Vanilla ice cream was 31 degrees. The tray was observed to be all brown and yellowish foods with a pale green from the broccoli.

Based on observation, interview and record review it was determined that the facility did not post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Specifically, the full survey results were not available to residents. Findings include: On 6/13/21, an observation was made of a binder at the front of the building. The binder was labeled Survey results. The binder was observed to be missing pages for each deficiency cited for the survey dated 4/11/2019. On 6/15/21 at 10:29 AM, resident council was conducted. The members of resident council meeting stated that the survey results were not available. On 6/14/21, an interview was conducted with the Administrator. The Administrator stated that he would have to get a bigger binder for all the pages of the survey results for the recertification survey for 2019. The Administrator stated that he placed the pages of the survey results that contained the plan of correct because I felt that was the most important part. The Administrator stated that there was more than half of the survey results missing from the binder.

Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility the director of food services was did not meet the requirements to serve as the director of food and nutrition services. Findings include: On [DATE] at 7:55 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that she was taking the courses to become a Certified Dietary Manager(CDM). The DM stated that she had been taking the courses for 2 months. The DM stated that she was previously certified by another certifying body, but the certification expired about a year ago. The DM stated that the RD came to the facility twice per month. The DM stated that the RD was available by phone if she had any problems.

Based on interview and record review it was determined, for 1 of 37 sample residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 36. Findings include: Resident 36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 36's medical record was reviewed on 6/14/2021. A review of resident 36's Pre-admission screening Application/Resident Review (PASRR) dated 7/9/2019 revealed there was no serious mental illness diagnoses. According to the form if any diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . One of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The box was not checked. On 6/14/21 at 4:35 PM, an interview was conducted with the Resident Advocate (RA). The RA stated when the doctor diagnosed resident 36 with anxiety 2/23/21. The RA stated that the PASARR was filled out prior to admission and the nurses filled in the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RA stated that she had not provided the information to the PASARR so that resident 36 was re-evaluated.

Based on interview and record review it was determined, for 1 of 37 sample residents, that the facility did not implement written policies and procedures that prohibited and prevented abuse. Specifically, staff did not investigate or follow up after a resident was yelled at by another resident in the dining room. In addition, the resident hit the table while yelling at the resident. Resident identifier: 30. Findings include: A nursing progress note dated 5/30/2021 at 3:05 PM revealed, During lunch, she yelled at another resident, pounding and hitting the table, telling the other resident to hurry up and eat his food. Resident was asked to leave the dining hall and return to her bedroom to finish her meal. Resident was cooperative and redirected easily. Will continue to monitor this shift. The note was written by Registered Nurse (RN) 1. Resident 30 did not have any care plans regarding behaviors. On 6/14/21 at 5:02 PM, an interview was conducted with RN 1. RN 1 stated that if there was a resident to resident altercation he separated the residents, determined what was going on, de-escalated the situation and reported it to the Director of Nursing (DON). RN 1 stated if it was something that caused injury then would notify DON. RN 1 stated depending on the yelling then might not report the altercation to the DON. RN 1 state that if someone was upset and de-escalated the situation then he reported the situation to the DON. RN 1 stated that resident 30 had yelled out during dining when she had to wait for her food. RN 1 stated that he did not know who the other resident was that resident 30 yelled at on 5/30/21. RN 1 stated he was could not remember the incident. RN 1 stated that he notified the DON. RN 1 stated that the DON developed new interventions for resident 30 after the incident when she yelled at the other resident. RN 1 stated that staff wait to bring resident 30 to the dining room until her food is ready. RN 1 stated I think if there was threatening of safety or harm or danger then it would be abuse. RN 1 stated determining abuse depended on who the other resident was and if they felt threatened. RN 1 stated he should have asked the other resident about how they felt. RN 1 stated that the Resident Advocate (RA) was the abuse coordinator. RN 1 stated that he Feels like (the situation) might need to be looked into more, but it was an instance where she was cooperative and it didn't go past yelling. On 6/14/21 at 5:22 PM, an interview was conducted with the RA. The RA stated that the Director of Nursing, the Administrator and her were the abuse coordinators. The RA stated that any type of abuse needed to be reported including verbal. The RA stated that abuse was reported to the Administrator and he completed an investigation. The RA stated that staff have reported resident to resident allegations. The RA stated that if a resident to resident altercation happened it was reported to the State Survey Agency and the Ombudsman. The RA stated there had not been any resident to resident altercations to report to the State Survey Agency. The RA stated that when there was an resident to resident altercation at the facility there was no abuse. The RA stated that if a resident was really upset and yelled that would be considered verbal abuse. The RA stated that if the staff can calm the situation between the residents then it was not considered abuse. The RA stated that Adult Protective Services (APS) had told the facility staff that, if facility staff can handle the situation on their own, then don't call APS. The RA stated if there was physical or sexual abuse she reported that to APS. The RA stated that if a resident had a threatening manor and was yelling, then that would be reported. The RA stated if a resident was acting differently and not going to activities or not eating then she would report abuse. The RA stated that the facility used the STOP technic. The RA stated it meant Separate, Tell the nurse, Obtain information, P. The RA could not remember what the P was for. The RA stated that the facility staff worked with a lot of dementia and brain injury residents that yelled out and required redirection. The RA stated residents yelled out in the dining room. The RA stated that if a resident was yelled at another resident she asked them if they felt safe, offered hot chocolate or something else to comfort the resident. The RA stated she had not heard of resident 30 yelling directly at another resident and hitting the table. The RA stated that resident 30 yelled out while in the dining room but it was not abuse. The RA stated she had not talked to the other resident about how that resident felt because she did not know about it. On 6/14/21 at 5:41 PM, an interview was conducted with the DON. The DON stated that the RA was the abuse coordinator. The DON stated that any type of abuse would be investigated. The DON stated that she expected staff to contact management with any type of abuse. The DON stated she would find out who the residents were and look into things. The DON stated that resident 30 came to the dining room and scream out if she did not get food right away. The DON stated that resident 30 was asked to calm down. The DON stated that staff were to bring her to the dining room when her food was ready. The DON stated that she looked for physical abuse rather than verbal with dementia residents. The DON stated If (staff were) unable to re-direct, a resident was attacking another resident, then I would expect to be notified. On 06/15/21 at 11:26 AM, a follow up interview was conducted with the RA. The RA stated resident 30 hollered out when she was hungry. The RA stated that resident 30's brain and personality was what was causing her to yell out. The RA stated that resident 30 was becoming more demanding with her personality. The RA stated she remembered that In a case like this, with another resident being yelled at. A text was sent to her and she called RN 1 back. The RA further stated RN 1 told her that resident 30 was yelling in the dining room, re-directed her and had her go to her room to finish her meal. The RA stated that RN 1 did not tell her who the other resident was. The RA stated she would expect staff to talk with other resident. The RA stated that if resident 30 repeatedly yelled at the same resident, then she would look into it. The RA stated that if it was a willful act then would have gotten more information and more would have been done at that moment. The RA stated I would have made the decision to come in and contacted the DON and Administrator, if I felt there was a threat of some kind. The RA stated that she was sure RN 1 would have done more if there was more of a willful attack than an outburst. The RA stated she did not document or investigate to determine if the act was willful. On 6/15/21 at 12:20 PM, an interview was conducted with the DON. The DON stated resident 30 came to her office and asked for food regularly and did not feel abused by resident 30. The DON stated that resident 30 did not direct her yelling at anyone. The DON stated that her nurse should have documented the incident differently. The DON stated that if it was abuse it would be a personal attack. The DON stated she did not investigate to determine if it was a personal attack on the other resident. The facility Abuse policy and procedures titled Recognizing Signs and Symptoms of Abuse/Neglect revealed the definition of abuse was .a willful infliction of injury,.intimidation, or punishment with resulting physical harm, pain or mental anguish. Another section of the Abuse policy and procedure was titled Abuse Investigations. The Policy stated was All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. An additional section titled Reporting Abuse to Facility Management revealed It is the responsibility of our employees, .to promptly report an incident or suspected incident of neglect or resident abuse.to facility management. The Policy Interpretation and Implementation revealed that 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: a. b. 'Verbal abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents.or within hearing distance, to describe residents, regardless of their, age, ability to comprehend or disability. 3. All personnel.are encourage to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing Services.

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. Specifically, staff were not performing hand hygiene or changing gloves between resident rooms, and were not cleaning the glucometer or vital sign equipment per manufacturer recommendations. Findings include: 1. On 2/9/21 at 1:21 PM, an observation was made of Certified Nurse Assistant (CNA) 1 picking up finished lunch trays from resident rooms. CNA 1 was observed to enter room [ROOM NUMBER], took room [ROOM NUMBER]'s lunch tray out and placed it on the meal cart. CNA 1 did not perform hand hygiene before she entered, or after she left room [ROOM NUMBER]. CNA 1 then entered room [ROOM NUMBER], took room [ROOM NUMBER]'s lunch tray out and placed it on the meal cart. CNA 1 did not perform hand hygiene before she entered, or after she left room [ROOM NUMBER]. CNA 1 then entered room [ROOM NUMBER], took room [ROOM NUMBER]'s lunch tray out and placed it on the meal cart. CNA 1 did not perform hand hygiene before she entered, or after she left room [ROOM NUMBER]. On 2/9/21 at 1:23 PM, an interview was conducted with CNA 1. CNA 1 stated that she had been educated about performing hand hygiene between each resident. CNA 1 stated that she did not use hand hygiene while picking up the meal trays because she was not touching the residents; stated she was only touching their dirty lunch trays. On 2/9/21 at 1:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the staff were supposed to perform hand hygiene before and after resident cares and as needed. The DON stated that staff should use hand sanitizer after leaving a resident room, even if the staff member was not performing cares on the resident. A review of the Centers for Disease Control and Prevention (CDC) website found at https://www.cdc.gov/handhygiene/providers/index.html provided requirements on When and How to Perform Hand Hygiene for healthcare providers. The CDC stated to Use and Alcohol-Based Hand Sanitizer. After contact with blood, body fluids or contaminated surfaces. (Note: per Centers for Medicare and Medicaid Services (CMS) regulations in appendix PP, soiled meal trays are considered contaminated surfaces.) 2. On 2/9/21 at 11:37 AM, an observation was made of Registered Nurse (RN) 2 disinfecting the glucometer. RN 2 was observed to use an alcohol prep pad, which was 70% [MEDICATION NAME] alcohol, to wipe the surface glucometer once and then lay it down on the nurses' cart. The glucometer was observed to be dry in 10 seconds. On 2/9/21 at 11:37 AM, an interview was conducted with RN 2. RN 2 stated that each nurse had one glucometer per nurses' cart that was used on all of the residents. RN 2 stated that the nurses used alcohol swabs to wipe off the glucometer in between residents. RN 1 stated that the glucometer would be dry and ready to use for the next resident within 30 seconds. RN 1 stated that he was not familiar with disinfectant wet-times. (Note: wet-time refers to the time that a disinfectant needs to stay wet on a surface in order to efficiently kill bacteria [MEDICAL CONDITION] on the surface.) On 2/9/21 at 11:53 AM, an interview was conducted with RN 1. RN 1 stated that the nurses' carts each had one glucometer to use for all the residents. RN 1 stated that the nurses used alcohol prep pads to wipe down the glucometers in between each resident. RN 1 stated that the alcohol on the glucometer was usually dry within 8 seconds and ready to use for the next resident. On 2/9/21 at 11:54 AM, an observation was made of RN 1 cleaning the glucometers. RN 1 was observed to wipe the surface of the glucometer with an alcohol prep pad, RN 1 then laid the glucometer down on the nurses' cart to dry. On 2/9/21 at 12:05 PM, RN 2 was observed performing glucose checks on a resident. After testing the residents' glucose level, RN 2 returned to the med cart with the soiled glucometer. RN 2 placed the soiled glucometer on top of the med cart and retrieved a 70% [MEDICATION NAME] Prep Pad from the top drawer. RN 2 wiped down the glucometer then immediately placed it in the top drawer of the cart. When asked about their glucometer cleaning procedure, RN 2 stated they use the alcohol prep pads. On 2/9/21 at 12:12 PM, an interview was conducted with the DON. The DON stated that shared medical equipment, such as glucometers, should have been wiped down with alcohol wipes. The DON stated that she had talked to the pharmacist who told the DON that alcohol would kill whatever. The DON stated that she was not advised about wet-times, but that the alcohol dried pretty fast. The DON stated that the staff wiped down the equipment and it would be dry and ready to use for the next resident right away. A review of appendix PP, CMS federal regulations stated on page 652: Blood glucose meters, can become contaminated with blood and, if used for multiple residents, must be cleaned and disinfected after each use according to manufacturer's instructions for multi-patient use. The FDA (food and drug administration) has released guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters. This guidance can be found at the FDA's website: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm 5.htm. An excerpt from this guidance reads: 'The disinfection solvent you choose should be effective [MEDICAL CONDITION](human immunodeficiency virus), [MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device.' On 2/9/21 the facility's glucometer owner's manual was reviewed and documented on page 36: To Clean and Disinfect the Meter. With ONLY Super Sani-Cloth Wipes (or any disinfectant product with the EPA (environmental protection agency) reg. no. of 9480-4) . make sure that all outside surfaces of the meter remain wet for 2 minutes. (Note: 70% [MEDICATION NAME] alcohol's EPA number is 1677-249.) A record review revealed two residents that were currently in the facility and were both diagnosed as [MEDICAL CONDITION] positive, although they were not diagnosed with [REDACTED]. On 2/9/21 at 12:49 PM, a follow-up interview was conducted with RN 1. RN 1 stated that she had 2 diabetic residents on her hall that shared the glucometer, but that if a resident had a change in condition then she would for sure check their blood sugar, even if they aren't diabetic. On 2/9/21 at 12:53 PM, a follow-up interview was conducted with RN 2. RN 2 stated that if a resident had a change in condition then he would definitely check the resident's blood sugar, even if the resident was not diabetic. A review of the EPA registration list found at https://cfpub.epa.gov/giwiz/disinfectants/index.cfm documented that [MEDICATION NAME] alcohol has a wet time of at least 5 minutes on a surface in order to kill Covid-19 and other blood borne pathogens. 3. On 2/9/21 at 11:56 AM, an interview was conducted with CNA 3. CNA 3 stated that they had 3 vital sign carts to share among all the residents. CNA 3 stated that the staff used alcohol prep pads to clean the vital sign equipment in between each resident. CNA 3 stated that after wiping the vital sign equipment down, the alcohol was dry within 10-15 seconds, maybe less. On 2/9/21 at 11:56 AM, CNA 3 was observed to clean the vital sign equipment with alcohol prep pads which were 70% [MEDICATION NAME] alcohol. CNA 3 quickly wiped down all surfaces, which were then observed to be dry within 10 seconds. On 2/9/21 at 12:12 PM, an interview was conducted with the DON. The DON stated that shared medical equipment, such as lifts and vital sign equipment, should have been wiped down with alcohol wipes in between each resident and wiped down with purple topped wipes once a day. The DON stated that she had talked to the pharmacist who told the DON that alcohol would kill whatever. The DON stated that she was not advised about wet times, but that the alcohol dried pretty fast. The DON stated that the staff wiped down the equipment and it would be dry and ready to use for the next resident right away. On 2/9/21 at 1:15 PM, an interview was conducted with RN 2. RN 2 stated that resident vital signs were taken at least four times a day. RN 2 stated that all of the residents had shared vital sign equipment, even the isolation rooms, unless they were on isolation for Covid at which point they had their own vital sign equipment. On 2/9/21 at 1:27 PM, an interview was conducted with CNA 5. CNA 5 stated that she took residents temperatures and oxygen saturations starting around 1:30 PM, and then another CNA came in at 4:00 PM and took a full set of vital signs on all the residents. On 2/9/21 at 1:31 PM, an observation was made of CNA 5 wipe down the vital sign cart with a paper towel that she had gotten wet with water from the sink. CNA 5 then entered room [ROOM NUMBER] with the vital sign equipment. On 2/9/21 at approximately 1:40 PM, a follow up interview was conducted with CNA 5. CNA 5 stated that she did use a grey top Sani-Wipe to wipe down the vital sign equipment prior to entering room [ROOM NUMBER]. CNA 5 was asked to show the surveyor where the Sani-Wipe container that she used was, CNA 5 was not able to produce it. On 2/9/21 at approximately 1:40 PM, RN 2 and the facility Transport Driver attempted to find Sani-Wipes in the facility. After approximately ten minutes the CNA coordinator retrieved a container of grey topped Sani-Wipes from a locked office. On 2/9/21 at 1:50 PM, a follow up interview was conducted with RN 2. RN 2 stated that there were no Super Sani-Wipes in the facility, only the regular Sani-Wipes. (Note: Super Sani-Wipe containers have a purple top, while the Sani-Wipes have a grey top.) On 2/9/21 at 1:52 PM, an interview was conducted with CNA 2. CNA 2 stated that she took residents temperatures and oxygen saturations throughout her shift. CNA 2 stated that she disinfected the thermometer and saturation monitor with alcohol prep pads in between each resident. CNA 2 stated that she quickly wiped down the equipment and that the alcohol was dry within a few seconds. CNA 2 stated that she never used any other types of wipes to clean the shared medical equipment. On 2/22/21 at 3:00 PM, a phone interview was conducted with the DON. The DON stated that the facility ran out of purple top wipes, so they were using the grey top wipes because the grey top was the same thing as the purple top. (Note: the grey top's EPA number is 9480-9 and has a manufacturer's recommended wet-time of 3 minutes. The purple top's EPA number is 9480-4 and has a manufacturer's recommended wet time of 2 minutes.) A review of the EPA registration list found at https://cfpub.epa.gov/giwiz/disinfectants/index.cfm documented that [MEDICATION NAME] alcohol has a wet time of at least 5 minutes on a surface in order to kill Covid-19 and other microbes. A review of the CDC guidelines found at https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html documented: Disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. However, multiple scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens with a contact time of at least 1 minute. By law, all applicable label instructions on EPA-registered products must be followed. If the user selects exposure conditions that differ from those on the EPA-registered product label, the user assumes liability from any injuries resulting from off-label use and is potentially subject to enforcement action under FIFRA (federal insecticide, fungicide, and rodenticide act). Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). If dedicated, disposable devices are not available, disinfect noncritical patient-care equipment after using it on a patient who is on contact precautions before using this equipment on another patient.

Based on observation, interview, and record review, it was determined the facility failed to properly implement prevention strategies related to Coronavirus (COVID-19). Specifically, the facility lacked comprehensive staff and resident screening procedures. Resident identifiers: 2, 3, 4, and 5. Findings include: 1. On 9/16/20 at 8:00 AM, survey team members were screened in accordance with facility practices. The screening process upon entrance to the facility included a temperature check and questions related to exposure to a positive case, recent travel, and presence of a cough, sore throat, or shortness of breath. The Employee Screening Tool was reviewed and documented that the facility gathered the following information during the screening process: a. Name; b. Signature; c. Date; d. Time In; e. In Temp (temperature); f. Lunch Out; g. Temp; h. Lunch back in; i. Temp; j. Time Out; k. Out Temp; l. Have a cough, sore throat, shortness of breath? m. In the last 14 days traveled in China, Japan, Italy Europe or S. (South) Korea? n. Close contact with person diag (diagnosed ) with Covid 19 or been outside the US (United States) in the past 14 days? On 9/16/20 at approximately 8:30 AM, an interview was conducted with the Director of Nursing (DON) and Infection Preventionist (IP). The DON stated staff members and visitors were screened utilizing the same process experienced by the survey team. On 9/17/20 at 10:07 AM, an exit conference was conducted with the Administrator, DON, and IP. The Administrator stated the Employee Screening Tool was the form provided to them and they will have to revisit the screening practices for staff and visitors. The Centers for Disease Control and Prevention's Preparing for COVID-19 in Nursing Homes reference, most recently updated on 6/25/20, documented that facilities should evaluate and manage healthcare personnel. The reference indicates, Screen all HCP (Healthcare Personnel) at the beginning of their shift for fever and symptoms of COVID-19 . Actively take their temperature and document absence of symptoms consistent with COVID-19 . (Reference: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) The Centers for Disease Control and Prevention's Symptoms of Coronavirus reference, most recently updated on 5/13/20, documented the following symptoms associated with COVID-19: a. Fever or chills; b. Cough; c. Shortness of breath or difficulty breathing; d. Fatigue; e. Muscle or body aches; f. Headache; g. New loss of taste or smell; h. Sore throat; i. Congestion or runny nose; j. Nausea or vomiting; k. Diarrhea (Reference: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html) 2. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 2's medical record was completed on 9/16/20. A physician's orders [REDACTED]. There was no additional documentation related to screening resident 2 for signs and symptoms associated with COVID-19. Resident 2's Assessments were reviewed. There was no documentation related to screening resident 2 for signs and symptoms associated with COVID-19. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on 9/17/20. A physician's orders [REDACTED]. There was no additional documentation related to screening resident 3 for signs and symptoms associated with COVID-19. Resident 3's Assessments were reviewed. There was no documentation related to screening resident 3 for signs and symptoms associated with COVID-19. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's medical record was reviewed on 9/16/20. A physician's orders [REDACTED]. There was no additional documentation related to screening resident 4 for signs and symptoms associated with COVID-19. Resident 4's Assessments were reviewed. There was no documentation related to screening resident 4 for signs and symptoms associated with COVID-19. Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 5's medical record was reviewed on 9/17/20. A physician's orders [REDACTED]. There was no additional documentation related to screening resident 5 for signs and symptoms associated with COVID-19. Resident 5's Assessments were reviewed. There was no documentation related to screening resident 5 for signs and symptoms associated with COVID-19. On 9/16/20 at approximately 8:30 AM, an interview was conducted with the DON and IP. The DON stated the facility's process for screening residents for COVID-19 included monitoring residents' vital signs, specifically temperature and oxygen saturations, every shift. On 9/17/20 at 9:48 AM, an interview was conducted with the IP. The IP stated that the resident COVID-19 screening consisted of a temperature check and oxygen saturation twice a day. The IP stated that staff were also expected to complete temperature checks on residents prior to entering the dining area for meals three times a day. The IP stated that if a resident presented with a cough the staff were expected to obtain a complete set of vital signs. On 9/17/20 at 10:07 AM, an exit conference was conducted with the Administrator, DON, and IP. The DON stated residents were not screened for other signs and symptoms associated with COVID-19 because they were considered changes of condition, which were monitored by the nursing staff and reported to the physician as necessary. The Centers for Disease Control and Prevention's Preparing for COVID-19 in Nursing Homes reference, most recently updated on 6/25/20, documented that facilities should evaluate and manage residents with symptoms of COVID-19. The reference indicates, Actively monitor all residents upon admission at least daily for fever . and symptoms consistent with COVID-19 . Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell . (Reference: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html) (Note: See the Centers for Disease Control and Prevention's Symptoms of Coronavirus reference above for the list of symptoms associated with COVID-19.)

Based on observation, interview, and medical record review, it was determined for 4 of 43 sample residents, that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, one resident sustained [REDACTED]. A second resident had 13 falls, two of which required trips to the hospital and staples. Additionally, a cabinet of unsecured razors and chemicals was located in an area with confused resident who wandered. Resident identifiers: 5, 21, 42, and 43. Findings include: 1. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/11/19 resident 5's medical record was reviewed. Nursing progress notes revealed the following entries: a. 8/27/18 at 6:16 PM, Resident was on the toilet and stood up without assist (assistance) and sat on the ground. no apparent injury noted, will continue to monitor. MD (Medical Doctor) and family notified. b. 9/27/18 at 8:48 PM, Resident had an assisted fall with the CNAs (Certified Nursing Assistants) at approx (approximately) 1715 (5:15 PM). Per CNA report, resident was being transferred when her legs began to give out and so resident was assisted to the floor on her bottom. No injuries noted. Will continue to monitor. c. 9/30/19 at 4:12 PM, Resident was found laying in prone position on floor next to bed. LG (large) goose egg noted to Rt (right) forehead, ice pack applied. NO other injuries noted. Husband notified, Husband was grateful for call. MD faxed. Resident had just been put into bed by husband, call light was within reach, resident had bed alarm which was patient (?) and going off when CNA went into RM (room) and found resident on floor. will continue to monitor. d. 10/2/18 at 10:59 AM, Resident is scheduled for Xray of right hip today, has been refusing meals and very little to drink. Resident has been very lethargic. Will continue to encourage PO (by mouth) intake as resident will allow and tolerate. e. 10/2/18 at 1:24 PM, Right hip xray results back and no fracture noted. MD faxed a copy of results. f. 10/11/18 at 1:39 PM, Resident sitting in her w/c (wheelchair). She was with a few other residents in hall next to dining room. This (nurse?) turned and heard a thud. (Resident 5) was lying on the floor on her left side. Called for help to get her up. She had a bump on left side of forehead in her hairline. Her ear was very red. No other apparent injuries. Her pupils were sluggish, her hand grips weak, She was c/o (complaining of) her vision changed. She was unable to see. Husband notified. Notified (Director of Nursing (DON)) and she came into check on her to see if she needed to go to the ER (emergency room ). Will perform neuro (neurological) checks throughout the shift. g. 10/12/18 at 9:58 AM, Resident is incontinent of bladder and usually continent of bowels and wears briefs. No pedal [MEDICAL CONDITION] noted. Skin is intact and barrier cream is applied after peri care done. Resident usually denies pain but does c/o (complain of) headache once in a while and [MEDICATION NAME] effective in relieving headaches. Resident needs 1 person extensive assist with ADL (activities of daily living) cares and is assisted with meals in the dining room and resident usually has a good appetite. Resident had a fall last night, landed on left side, bump on left side and resident continues to have soft lump on right side of forehead from previous fall with bruising fading on right side. No med (medication) changes made this past week. Will continue to monitor. h. 10/12/18 at 10:00 AM, Meet today with Administrator, husband and daughter in regards to possible hospice. Explained to family what hospice is and what to expect from it. Family on board with hospice, they wanted to see if their doctor (Name of Physician) was a medical director of a hospice company. Talked to family also about a possible IV (intravenous fluids) to aid in hydration, family stated they were ok with IV. Contacted MD in regards to IV and hospice eval (evaluation), will await response. Facility incident reports revealed that resident 5 had two falls within days of each other, one occurring on 9/30/18 and one occurring on 10/10/18. 1. The incident report for resident 5 for the fall occurring on 9/30/18 revealed the following: a. 9/30/18 at 3:50 PM EVENT CODES: Fall. INJURY CODES: Other: goose egg R (right) side. L[NAME]ATION CODES: Resident room. CAUSE CODES: Resident health/mental status. FOLLOW UP CODES: Family education, Falls investigation worksheet, 72 hour neuro (neurological) checks. Transferred to hospital: No. Physician Notified: No documentation. Description of events: Resident was noted laying prone next to bed. Resident was noted having lg (large) goose egg to R side head. Ice pack applied. (NOTE: A facsimile transmission report revealed that resident 5's physician was sent the fax of the fall on 9/30/18 at 4:15 PM.) The Neurological Flow Sheet dated 9/30/18 revealed that resident 5's neuro checks did not last for 72 hours, they continued until 11:00 PM on 9/30/18 with vital sign monitoring occurring until 2:00 PM on 10/1/18. The Neurological Flow Sheet dated 9/30/18 revealed the following: Level of Conciousness (sic): 1. (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 was fully concious (sic) - awake, aware, oriented). Resident 5's Level of Consciousness changed at 8:00 PM when she became a 2. (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5 was Lethargic - responds slowly to verbal stimuli). Resident 5's Level of Consciousness changed again at 9:00 PM when she became a 3. (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5 was Obtund - very drowsy, responds to touch stimuli). Movement: 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 was able to move all 4 extremities). Hand Grasps: 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 had equal and strong hand grasps). Resident 5's Hand Grasps changed at 10:00 PM to a 3 (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5 had L (left) weakness in her Hand Grasp). Pupil Size: Rt. (right) 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5 pupil size was 2 mm (millimeters). Resident 5's Pupil Size on the right side changed at 7:30 PM to a 3 (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5's pupil size was 3 mm). Pupil Size: Lt. (left) 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5 pupil size was 2 mm). Resident 5's Pupil Size on the right side changed at 7:30 PM to a 3 (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5's pupil size was 3 mm). Pupil Reaction: Rt. 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 had brisk pupil reaction). Pupil Reaction: Lt. 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 had brisk pupil reaction). Speech: 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 had clear speech). Resident 5's speech changed at 9:00 PM to a 3 (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5's speech was Rambling). B/P (blood pressure) on 9/30/18 ranged from 94/44 to 167/105. Pulse: on 9/30/18 ranged from 56 to 82 BPM (Beats per Minute). Respiration: on 9/30/18 ranged from 14 to 28. At the bottom of the Neurological Flow Sheet there was a note: Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!! No documentation could be located in the medical record to show that resident 5's neurological change's were called into her physician. 2. No incident report could be located for the fall on 10/10/18 in resident 5's medical record. The Neurological Flow Sheet dated 10/10/18 revealed that resident 5's neuro checks lasted until 10:00 PM on the night of 10/11/18 and then started back up again on 10/12/18 at 8:30 AM. The Neurological Flow Sheet dated 9/30/18 revealed the following: Level of Conciousness (sic): 1. (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 was fully concious (sic) - awake, aware, oriented). Movement: 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 was able to move all 4 extremities). Resident 5's movements's changed at 8:30 AM on 10/12/18 to a 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5 was moving her arms only). Resident 5's movements changed again at 9:30 AM to a 7 (According to the key at the bottom of the Flow Sheet, a 7 meant that resident 5 had no movement at all or that she had unusual movement). Hand Grasps: 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 had equal and strong hand grasps). Resident 5's Hand Grasps changed at 8:30 AM on 10/12/18 to a 2/3 (According to the key at the bottom of the Flow Sheet, a 2/3 meant that resident 5's hand grasps had right and left weakness). Resident 5's hand grasps changed again at 10:00 AM to a 4 (According to the key at the bottom of the Flow Sheet, a 4 meant that resident 5 had none when referenced to hand grasps). Pupil Size: Rt. 3 (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5 pupil size was 3 mm). Resident 5's Pupil Size on the right side changed at 8:30 AM on 10/12/18 to a 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5's right pupil was 2 mm). Resident 5's Pupil Size changed again at 9:15 AM on 10/12/18 to a 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5's Pupil Size was 1 mm). Pupil Size: Lt. 3 (According to the key at the bottom of the Flow Sheet, a 3 meant that resident 5's pupil size was 3 mm). Resident 5's Pupil Size on the left side changed at 8:30 AM on 10/12/18 to a 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5's right pupil was 2 mm). Resident 5's Pupil Size changed again at 9:15 AM on 10/12/18 to a 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5's Pupil Size was 1 mm). Pupil Reaction: Rt. 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5's Pupil Reaction was sluggish). Pupil Reaction: Lt. 2 (According to the key at the bottom of the Flow Sheet, a 2 meant that resident 5's Pupil Reaction was sluggish). Speech: 1 (According to the key at the bottom of the Flow Sheet, a 1 meant that resident 5 had clear speech). (NOTE: Resident 5's speech was only documented on 10/12/18, no other documentation was noted for resident 5's speech within the first 48 hours after the fall.) B/P: BP on 10/10/18 ranged from 128/72 to 144/76. BP on 10/11/18 ranged from 141/70 to 147/95. BP on 10/12/18 ranged from 105/70 to 178/100. Pulse: Pulse on 10/10/18 ranged from 80 to 85 BPM. Pulse on 10/11/18 ranged from 71 to 85 BPM. Pulse on 10/12/18 ranged from 54 to 105 BPM. Respiration: Respirations on 10/10/18 ranged from 12 to 16. Respirations on 10/11/18 ranged from 16 to 18. Respirations on 10/12/18 ranged from 16 - 18, with resident's respirations mostly at the 18 mark. At the bottom of the Neurological Flow Sheet there was a note: Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!! No documentation could be located in the medical record to show that resident 5's physician had been notified of the fall, the changes in resident 5's eyesight, that her pupil reaction was sluggish, nor that her movements and hand grasps had changed. A Facsimile Transmittal Sheet dated 10/12/18 revealed that resident 5's physician had been faxed that family would like an order for [REDACTED]. Thanks. New orders on the Facsimile Transmittal sheet dated 10/12/18 revealed decline IV hydration - not c/w (consistent with) goals of care. OK for hospice eval to (Name of Hospice) or patient's family preference. 3. A facility Incident Report dated 4/9/19 with a revision date of 4/11/19 revealed that resident 5 had a fall. The nursing description of the fall revealed Resident was sitting in her wheelchair in front of the nurse's station when she suddenly fell forward out of her chair and onto the floor. The Injuries observed at the time of the incident was that resident 5 had a bruise to her face and a skin tear to her left forearm. The predisposing environmental factors included clutter with crowding (the fall occurred near the dining room in front of the nurse's station) and a fall alarm in place. The facility Incident Report revealed that resident 5's husband had been notified of the fall as well as the facility DON. No documentation could be located in the medical record to show that resident 5's physician was notified of the fall and that she had hit her face and had bruising. A Baseline Care Plan dated 5/23/18 revealed that resident 5 had a Safety Care Plan for a history of fall and a history of fall-related bruises. No goals nor interventions could be located on the Safety Care Plan. No update to the care plan after the falls on 8/27/18, 9/27/18, 9/30/18, 10/10/18 and 4/9/19 were noted on the Safety Care Plan. A Comprehensive Care Plan dated 9/30/19 revealed that resident 5 had an Actual fall: on 9/30/19. The goal for resident 5 was that Resident will remain free from injuries. The Interventions for resident 5 included Keep call light and most frequently used personal items within reach and Maintain room and pathways free of clutter. (NOTE: The Comprehensive Care Plan did not have measureable goals and interventions implemented in an attempt to prevent resident 5 from falling. Additionally, resident 5 did have injuries from the fall dated 9/30/19 with a large goose egg and bruising to her right forehead with a change in her neurological status. The Comprehensive Care Plan was not updated after resident 5 had a second fall with serious injury to the left side of her head with a change in neurological status including the loss of eyesight. No Comprehensive Care Plan was provided prior to the fall on 9/30/19.) On 4/11/18 at 10:51 AM, the facility DON was interviewed. The facility DON stated that she needed to look at resident 5's medical record before I say something because my brain is fried. The facility DON was asked why resident 5's care plan was not updated after her fall on 9/30/18 and the facility DON stated what would I add? When asked if the facility nursing staff were required to call her in to assess whether or not the resident needed to go to the hospital, the facility DON stated no. The facility DON stated that she expected her nursing staff to assess any resident accurately and to know whether or not they needed to go to the hospital and take the appropriate action and send them when they need to go. The facility DON stated that she had not come into the facility to assess resident 5 after the fall on 10/10/18. The facility DON stated that she had been informed that resident 5's physician had been notified of the fall but that there was no documentation of that. The facility DON stated that she would have sent resident 5 to the hospital after the fall on 10/10/18. The facility DON stated that she had been told that they notified resident 5's husband about the need to go to the hospital and that he had declined to send her but that there was no documentation of that. The facility DON further stated that she and the Health Unit Coordinator (HUC) reviewed falls on a prn (as needed) basis but that they did not meet weekly nor have a set time that they met. The facility DON stated that if need be she would add interventions when they met prn. The facility DON stated that absolutely there should have been new interventions put into place in an attempt to prevent resident 5 from falling. On 4/11/19 at 10:58 AM, the HUC was interviewed. The HUC stated that resident 5 had been declining, had not been eating well and that she felt it was more of a mental change. The HUC stated that resident 5 had been able to ambulate when she was first admitted , but not able to do so anymore. The HUC stated that they had put resident 5 on Part B Therapy per the kindness of the Therapy department but stated that I cannot say that there is documentation that she worked with therapy. The HUC stated that the facility had put an intervention in place, that resident 5 had an alarm on her because she tried to get up and would fall. The HUC stated that she did not know the date the intervention was put into place and did not know if the alarm was on resident 5 when she had her fall in October. The HUC stated to be honest, the family is very, very, very ready for her to be gone. On 4/11/19 at 11:43 AM, a call was placed to Licensed Practical Nurse (LPN) 3 who documented that resident 5 was unable to see after her fall on 10/10/18 and who no longer works at the facility. There was no answer but a message was left for LPN 3 to call me back. No return call was received. On 4/11/19 at 12:10 PM, resident 5's husband was interviewed. Resident 5's husband stated that he was unaware that his wife was unable to see nor of the significant change in condition after her fall on 10/10/18. Resident 5's husband stated that he had been told that resident 5 had been sent to the hospital after the fall on 9/30/18 but had come back to the facility and was okay. Resident 5's husband stated that when he was told that she had another fall in which she had hit her head, he stated I'll meet you at the hospital. Resident 5's husband stated that he had been told by the facility DON to wait a minute, we'll see if she needs to go to the hospital. Resident 5's husband stated that the DON called him back and that he was told that we think she'll be okay, we don't think she needs to go out. Resident 5's husband stated that I can't imagine that I would have told them not to send her to the hospital with those changes. Resident 5's husband stated that it was hard to watch his wife go through life this way but that it would be a hard day when she finally goes. (NOTE: Resident 5 was not sent to the hospital for the fall dated 9/30/18 nor for the fall dated 10/10/18.) On 4/11/19 at 12:36 PM, the Physical Therapist (PT) was interviewed. The PT stated that he had never seen resident 5, never worked with resident 5 for ambulation and weakness and did not have any documentation stating otherwise. The PT stated that he recalled seeing her briefly for some neck issues and soreness early last fall but did not recall the date. On 4/11/19 at 1:46 PM, this surveyor received a call back from resident 5's husband. Resident 5's husband stated that he had a chance to really think back to (MONTH) and think about what had transpired. Resident 5's husband stated that with the first serious fall in September, that he had been told that resident 5 had gone to the hospital but that she was okay and had no serious issues. Resident 5's husband stated that when the fall occurred on 10/10/18, that he had been told that his wife had fallen and hit her head and that he automatically got up and told facility staff that he would meet her at the hospital. Resident 5's husband stated that he never told them not to take her to the hospital. Resident 5's husband stated that he was frustrated with the facility as they had talked him into placing her on hospice after the fall and that now he is being asked to take her off of hospice with the current hospice company and going inpatient at the facility. Resident 5's husband stated that it would mean they needed to give up the physician that she currently has and that the facility could not give him a good reason to do so. Resident 5's husband stated that it feels financial to me. Resident 5's husband asked if there was not something that the facility could do to keep his wife from falling 2. Resident 42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/8/19 at 3:00 PM, resident 42 was observed in her wheelchair in her room working on a puzzle. Resident 42 had some bruising to the right side of her face, and a fall mat in the room. On 4/11/19, a review of resident 42's medical record was completed. A progress note on admitted d 11/7/18 at 3:24 PM documented the following history, Resident does not know how to read and write . Resident had fallen within the last 6 months. Resident will need 1 to 2 person extensive assist with transfers and 1 person extensive assist with ADL cares. Resident is unsteady on feet and has shaky legs. a. On 11/29/18 resident 42 had two falls. On 11/29/18 2:27 PM, facility nursing staff documented the following in a progress note, At (12:45 PM) Resident was being propelled back to room in wheelchair by staff as requested when resident put feet down to help by propelling with feet and got feet caught under wheelchair and went forward out of wheelchair and staff reached arm around from behind and brought arm around resident but unable to keep resident from landing on floor. Resident landed on right side and hit head. No bump noted. Resident denies pain or discomfort. Resident assist up off the floor by 3 person assist. Pupils are reactive to light, hand grasp with right sided weakness but residents right from hand grasp has been weaker since childhood from hx (history) of Polio. Teaching done for resident to keep feet up and not to put feet down while being pushed in wheelchair. Resident verbalized understanding. On 11/29/18 at 2:42 PM, facility nursing staff documented the following in a progress note, continued from note at (2:27 PM). At (1:00 PM) (resident's sister) was called and notified of what happened and she was appreciative of the phone call and states will call resident today and visit in house tomorrow. PCP (Primary Care Physician) was then notified at (1:30 PM) and spoke with (name redacted) at office. Resident resting quietly in recliner at this time with eye closed and resp (respirations). even and unlabored. Neuro (neurological) checks WNL (within normal limits), No change in L[NAME] (level of consciousness) noted. Will continue to monitor. On 11/29/18 at 5:21 PM, facility nursing staff documented the following in a progress note, Staff went to answer call light at (4:40 PM) and resident was sitting on floor next to bed. Resident had just been taken to the toilet and was assisted back into recliner as requested. Resident stated was trying to transfer self. No injuries noted. Resident denied pain or discomfort. Resident was assisted up off the floor with 3 person assist. Resident stated, I need to walk. Resident was reminded that had walked with restorative today using walker and not to walk by self d/t (due to) unsteady gait and weakness. Resident verbalized understanding and said will have staff assist with transfers and ambulation. PCP's office was called and a voice mail was left. (name redacted) Resident's sister was also called and notified of incident. Neuros continue to be WNL. No change in L[NAME] noted. On 11/30/18 at 4:42 PM, Category: Falls, IDT (interdisciplinary team) NURSING NOTE Post fall assessment noted resident had 2 falls on 11/29/18 first resident was noted being wheeled in wheelchair, resident put feet down feet got caught under wheelchair propelling resident out, Education given to resident to keep feet up while being propelled. 2nd fall resident was in room, resident was noted setting (sic) on floor next to bed. Resident stated, she was trying to transfer self. education given to use call light for assistance. Family and MD (Medical Director) notified. Resident continues to work with restorative to aid in transfers. b. On 12/3/19, resident 42 had a fall and was found on the floor. On 12/3/18 at 9:00 PM, CNA (Certified Nurse Aide) was walking by residents room and hheard (sic) a noise. She looked in her room to find her sitting on the floor next to the chair she had been sitting in. Resident was assessed for injuries and helped back into her chair. No injuries noted at this time. Denies pain. MD faxed. Family will be notified this morning. VS (Vital Signs) T (Temperature) 98 P (Pulse) 94 R (Respirations) 24 O2 (Oxygen Saturations) 94 BP (Blood Pressure) 126/82. On 12/4/18 at 4:11 PM, Falls, IDT NURSING NOTE Post fall assessment noted resident had an unwitnessed fall on 12/3/18. No injury noted, Resident was noted setting on floor in front of chair, Educated resident on importance of using call light for assistance. Family and MD notified. Will continue to monitor. It was noted the the IDT note did not address factors contributing the fall and did not identify any new interventions to prevent falls. c. On 12/12/18, resident 42 was found on the floor. On 12/12/18 at 4:44 PM, Resident was sitting in recliner and stood up attempting to walk to find her sister who had just left the room. Resident was found on the floor in front of wheelchair. Small bump noted on right side of head, resident is unable to tell us what she bumped it on. Ice applied. No other injuries noted. Sister here with resident and resident is up in dining room at this time. Neuro checks started. There was no information in the progress notes regarding an assessment of the fall and care planning of new interventions. Per review of the physician's orders [REDACTED]. It was noted that the progress note from resident 42's fall on 11/30/18 stated that she was to continue working with restorative. d. On 12/31/18, resident 42 had a fall attempting to get out of her chair. On 1/1/19 at 7:07 PM, facility nursing staff documented the following in a progress note, Patient had a fall on 12/31/18 (9:35 PM). The patient attempted to get up out of her chair without assistance and fell . No injuries occurred with the fall. On 01/01/19 their were no signs of injuries or complaints of pain. The skin was clean, dry and intact. Equal grips and pupils equal and reactive to light. Patient alert and orientated x (times) 3. Some confusion and forgetfulness present. Vital signs at (6:00 PM) were: BP: 145/77, Pulse: 86, RR: 18, Temperature: 96.3, 02: 93 on room air. Patient left the facility from (12:00 PM to 2:00 PM), neuro checked q4hrs (every four hours). Patient was educated to use her call light when needing to get up from her chair to prevent falls. The call light is within the patient's reach. Patient closely monitored to ensure safety. Per the physician's orders [REDACTED]. No other fall assessment or review was identified. e. On 1/14/19, resident 42 fell well attempting to stand unassisted. On 1/14/19 at 3:01 PM facility nursing staff documented the following in a progress note, Falls Resident attempted to stand up and sat on the floor, witnessed fall. No apparent injuries. On 1/15/18 at 3:25 PM, facility nursing staff documented the following in a progress note, Post fall assessment noted resident had a witnessed fall on 1/14/19. Resident attempted to stand up and sat on the floor, witnessed fall. No apparent injuries. MD and family notified. Educated resident on importance of using call light for assistance. Per the physician's orders [REDACTED]. On 1/26/19 at 11:18 AM facility nursing staff documented the following in a progress note, IDT NURSING NOTE, IDT S[NAME]IAL NOTE, Resident Advocate (RA) Progress Note DON, RA and resident's sister had met yesterday to review resident and her medications. Facility staff has reported an increase of mood and behaviors. Residents Dr. has ordered new medications for resident and residents sister states that she is ok with the medications. DON has also spoke to resident's family about IV fluids and resident's daughter has stated that she is giving the facility a verbal okay to IV fluids. RA and DON also talked to the sister about the possibility of moving resident to a different room. The facility has a room that has become available and is a bit bigger and has more windows so that the room will be a bit brighter for the resident. Residents sister agreed and has stated that she is excited for the changing of the room. f. On 2/4/18, resident 42 had an unwitnessed fall with an injury that required two staples while ambulating independently. On 2/4/19 at 8:15 PM, facility nursing staff documented the following in a progress note, Resident was in her recliner in her room. Resident stated she got up without assistance and to look for her dentures that were missing. Resident upon getting out of the chair slid and hit her head. Resident had copious amounts of blood coming from the right side of her head. There was blood on the floor and the wall when I came in the room. Resident was able to move all her extremities within normal limits. CNA assisted with cleaning the blood up and assisting the resident. I contacted the resident M.D. and resident family member and also the D.O.N. I then contacted 911 to have an ambulance come to transfer to (hospital) for further evaluation. On 2/5/19 at 12:56 AM, facility nursing staff documented the following in a progress note, Resident returned from (hospital) via her sister in there (sic) vehicle. Resident received 2 staples on the right side of her head. Resident had a C.T. (computed tomography) done at the hospital and it was negative. Resident has to follow up with her primary care provider within 2 to 4 day. Resident is sleeping now and neuro checks have been implemented. Will continue to monitor. A copy of the DON's fall notes dated 2/4/19 documented that the family and MD were aware and that the resident continued to be reminded to use call light for assistance and to continue to monitor. On 2/15/2019 at 1:39 PM, IDT has met to review residents care plans for accuracy . Resident at this time is doing well with living in the facility and has doing better with coping with her illness. Resident has been referred out to . counseling and will be seen in a few weeks . Resident has had a reported fall on 2/2/19 with no (sic) reported falls. Resident has been removed from the restorative program due to decreased willingness to participate but restorative aids will continue to work with resident to encourage resident to participate. Resident has changed rooms in the last 30 days and resident is very pleased with her new room and states that she enjoys it . (Note: No new interventions were implemented following a fall with serious injury; nor was there a review assessing contributing factors to the fall.) g. On 3/5/19, resident 42 had a fall while attempting to ambulate from her recliner. The DONs fall notes documented on 3/5/19, Was notified by floor nurse at (7:22 PM) resident had a fall while getting out of her recliner. Nurse staed (sic), That resident had hit her head, no injury noted. Neuros initiated. Nurse stated, all neuros WNL. Family and MD aware. Resident continues to be reminded to use call light for assistance. Will continue to monitor. will apply bed/chair alarm d/t unaware of safety needs. On 3/6/19 at 5:53 AM, facility nursing staff documented the following in a progress note, Resident continues on fall charting with no c/o (complaints of) pain or disco (TRUNCATED)