Every finding on record at Shady Oak Nursing and Rehabilitation

Based on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Residents #4, #7 and #21) reviewed for infection control, in that: 1. The facility failed to maintain correct infection control when, while providing wound care for Resident #4, LVN C failed to use proper protective equipement. 2. The facility failed to maintain correct infection control when, while observing Resident #7's room, a reusable urinal was seen hang uncovered and hanging from the resident's trash can. 3. The facility failed to maintain correct infection control when, while providing incontinent care for Resident #21, NA A did not change her gloves or wash hands after touching the resident's trash can. These deficient practices could place residents at-risk for infection due to improper care practices. The findings were: 1. Record review of Resident #4's face sheet, dated 09/04/2025, revealed an admission date of 09/11/2024, and, a readmission date of 07/16/2025, with diagnoses which included: Brief psychotic disorder ( Psychiatric condition characterized by sudden and temporary periods of psychotic behavior, such as delusions, hallucinations, and confusion), Dementia (decline in cognitive abilities), Myalgia (muscle pain), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), Epilepsy (brain condition that causes recurring seizures.), Hemiplagia (Paralysis of one side of the body), Chronic kidney disease (gradual loss of kidney function). Record review of Resident #4's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 11 indicating moderate cognitive impairment. Resident #4 required total assistance and was always incontinent of bowel and bladder. Resident #4 was coded as having a stage 4 pressure ulcer (deep wounds that may impact muscle, tendons, ligaments, and bone). Review of Resident #4's care plan, dated 07/25/2025, revealed a problem of The resident has a pressure ulcer and a goal of The resident's Pressure ulcer will show signs of healing and remain free from infection by review date. Observation on 09/04/2025 at 1:50 p.m., revealed, while providing wound care for Resident #4, LVN C did not wear a gown. Further observation revealed the resident did not have a sign indicating he was on enhanced barrier precaution. During an interview with LVN C, on 09/04/2025 at 1:59 p.m., she stated Resident #4 should be on enhanced barrier precautions because he had a wound, but he was on standard precautions. During an interview with the DON, on 09;04/2025 at 4:30 p.m., she stated Resident #4 should be on enhanced barrier precaution and LVN C should have worn a gown while providing wound care for the resident to prevent infection. The DON further stated the staff had received training on infection control and enhanced barrier precaution within the current year. Review of facility policy, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug resistant Organisms (MDROs), dated 07/12/2022, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. 2. Record review of Resident #7's face sheet, dated 09/05/2025, revealed an admission date of 07/05/2025, with diagnoses which included: Spinal stenosis (space around the spinal cord becomes too narrow causing pain and tingling), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure), Hypertension (High blood pressure), Pain. Record review of Resident #7's admission MDS, dated [DATE], revealed the resident had a BIMS score of 14 indicating no cognitive impairment. Resident #7 required limited assistance and was always continent of bladder and occasionally incontinent of bowel. Observation on 09/04/2025 at 8:25 a.m., revealed during observation of medication administration in Resident #7's room, provided by MA D,a urinal was seen hanging from the outside of the trashcan and unbagged. The urinal had Resident #7's name written on it. During an Interview with MA D on 09/04/2025 at 8:27 a.m., she stated the urinal bottle belonged to Resident #7 and was unbagged while hanging on the trash can. She stated the trash can was considered dirty and the urinal should not have been in direct contact with the trash can because it was a risk for cross contamination and infection for the resident. She stated she received infection control within the current year. During an Interview with the DON on 09/04/2025 at 4:30 p.m., she stated the urinal should not have been hanging from the trash can to prevent cross contamination for the resident. She stated infection control training was provided to the staff, at least, yearly. Review of annual skills check for MA D revealed MA D passed competency for Perineal care/incontinent care and infection control on 01/08/2025. Review of facility policy, titled Toileting, Bedpan/urinal, undated, revealed Clean and store urinal per facility policy During an interview with the Administrator on 09/05/2025 at 11:12 a.m., he stated the facility had no policy on storage of urinal. 3. Record review of Resident #21's face sheet, dated 09/04/2025, revealed an admission date of 02/25/2022, and, a readmission date of 07/08/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Mood disorder (conditions that affect a person's emotional state), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09 indicating moderate cognitive impairment. Resident #21 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #21's care plan, dated 07/09/2024, revealed a problem of Resident will be clean, dry, odor free, will have regular BM (bowel movement) patterns and will be free from S/S (sign and symptoms) of UTI (urinary tract infection) through next review. Observation on 09/04/2025 at 2:11 p.m. revealed while providing incontinent care for Resident #21, NA A, after washing her hands and putting gloves on, touched the trash can with her gloved right hand. She, then, touched the clean wipe with the same right hand without changing her glove or washing her hands. During an interview on 09/04/2025 at 2:20 p.m. with NA A, she stated, she had touched the trash can with her gloved hand and did not change gloves or wash her hands before touching the clean wipe. She stated the trash can was considered dirty and she should have changed her gloves to prevent infection for the resident. She stated receiving infection control within the current year. During an interview with the DON on 09/04/2025 at 4:20 p.m., she stated the staff should have changed gloves and wash her hands prior to start the care to prevent cross contamination and infection to the resident. She stated infection control training was provided for the staff at least yearly and their skills were checked annually. Review of annual skills check for NA A revealed NA A passed competency for Perineal care/incontinent care and infection control on 07/31/2025. Review of Facility policy, titled Hand Hygiene, undated, revealed you may use alcohol-based hand cleaner or soap/water for the following: [ .] after handling soiled equipment or utensils

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements, in that:The Dietary Supervisor did not have the appropriate certification, education, or qualification to serve as the Director of Food and Nutrition Services.This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.The findings were:During an interview with the Dietary Supervisor on 09/02/2025 at 10:30 a.m., he stated that he was not certified as a Dietary Manager, and that he was enrolled in a course scheduled to begin 09/04/2025. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator confirmed the Dietary Supervisor was not yet certified and stated he had expected to receive a citation. The Administrator further stated that the facility did not have a specific policy regarding the Dietary Supervisor's credentials but provided the Job Description. Record review of the Dietary Supervisor Job Description, undated, revealed, In this role you will.Ensure Safety and Compliance.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals.Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #21) reviewed for incontinent care, in that: The facility failed to provide appropriate treatment and services to prevent urinary tract infection by having CNA B using a back to front motion to clean Resident #21's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.The findings were: Record review of Resident #21's face sheet, dated 09/04/2025, revealed an admission date of 02/25/2022, and, a readmission date of 07/08/2025, with diagnoses which included: Dementia (decline in cognitive abilities), Mood disorder (conditions that affect a person's emotional state), Anxiety disorder (A group of mental illnesses that cause constant fear and worry), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood). Record review of Resident #21's quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 09 indicating moderate cognitive impairment. Resident #21 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #21's care plan, dated 07/09/2024, revealed a problem of Resident will be clean, dry, odor free, will have regular BM (bowel movement) patterns and will be free from S/S (sign and symptoms) of UTI through next review. Observation on 09/04/2025 at 2:11 p.m. revealed while providing incontinent care for Resident #21, CNA B wiped Resident #21's buttocks in a back to front motion. During an interview on 09/04/2025 at 2:20 p.m. with CNA B, she stated, she wiped Resident #21's buttocks in a back to front motion. She said she did not realize she had used the wrong motion, and it could cause a risk for infection for the resident. She stated she received training on incontinent care from the facility. During an interview with the DON on 09/04/2025 at 4:20 p.m., she stated the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra (tube that lets urine, a waste product, leave your body) and possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. skills were checked yearly. The DON stated she spot checked the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA B revealed CNA B passed competency for incontinent care on 03/26/2025. Review of facility policy and procedure, titled Nurse Aide Incontinence Care Proficiency Assessment , undated, revealed [ .] work from base of labia (part of the female external genitalia) toward back [ .] clean hips working toward back using one swipe technique.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff and the public in 1 of 3 (South Wing) shower rooms reviewed, in that: The toilet in the South Wing shower room was loosely affixed to the floor. This deficient practice could place residents who utilized the toilet in the South Wing shower room in danger of falling. The findings were: Observation of the South Wing shower room on 09/02/2025 at 1:42 p.m. revealed that the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. During an interview with RN E on 09/02/2025 at 1:45 p.m., RN E confirmed the toilet was loosely affixed to the floor and was able to be moved approximately three inches away from center. RN E confirmed that this could potentially cause residents who utilized the toilet to fall and stated she would alert the Maintenance Department. During an interview with the Administrator on 09/05/2025 at 1:15 p.m., the Administrator stated that he agreed the loose toilet could potentially cause residents who utilized it to fall and provided documentation of the Maintenance repair request, dated 09/02/2025. The Administrator stated the facility did not have a specific policy pertaining to the circumstance. Observation on 09/05/2025 at 1:00 p.m. revealed the toilet had been repaired.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 shower rooms reviewed, in that: 1. The South Hall shower room had a strong foul odor. 2. The temperature in the facility kitchen was 95.1 degrees Fahrenheit. These deficient practices could place residents at risk and result in an environment that is not safe, functional, sanitary, or comfortable for residents, staff, and visitors. The findings were: Observation on 08/05/2024 at 10:42 a.m. revealed a strong foul odor was emanating from the shower room in the South Hall. During an interview with CNA C on 08/05/2024 at 10:42 a.m., CNA C confirmed a strong foul odor was emanating from the shower room in the South Hall. During an interview with LVN D on 08/05/2024 at 10:44 a.m., LVN D confirmed a strong foul odor was emanating from the shower room in the South Hall. Record review of the facility policy, Deep Cleaning Process - Bathroom/Showers, undated, revealed, Follow the cleaning process in the Housekeeping Training Manual for using appropriate products can help you keep the room as sanitary as possible. 2. Observation on 08/08/2024 at 11:42 a.m., while the lunchtime meal was being prepared, revealed the temperature in the facility kitchen near the sink was 95.1 degrees Fahrenheit. During an interview with the Maintenance Director on 08/08/2024 at 11:42 a.m., the Maintenance Director confirmed the temperature in the facility kitchen near the sink was 95.1 degrees Fahrenheit. Observation on 08/08/2024 at 11:43 a.m., while the lunchtime meal was being prepared, revealed the temperature in the facility kitchen near the stove was 90.3 degrees Fahrenheit. During an interview with the Maintenance Director on 08/08/2024 at 11:43 a.m., the Maintenance Director confirmed the temperature in the facility kitchen near the stove was 90.3 degrees Fahrenheit. Observation on 08/08/2024 at 11:46 a.m., while the lunchtime meal was being prepared, revealed the temperature in the facility kitchen near the dishwasher was 83.8 degrees Fahrenheit and cans of food for resident consumption were stored within the dishwashing area. During an interview with the Maintenance Director on 08/08/2024 at 11:46 a.m., the Maintenance Director confirmed the temperature in the facility kitchen near the dishwasher was 83.8 degrees Fahrenheit and cans of food for resident consumption were stored within the dishwashing area. During an interview with the Maintenance Director on 08/08/2024 at 11:48 a.m., the Maintenance Director stated that the air conditioning unit in the facility kitchen had been in disrepair for approximately three months, a replacement unit had been chosen, and the replacement would be installed when the parent company authorized the expenditure. During an interview with the Administrator on 08/08/2024 at 3:32 p.m., the Administrator confirmed the facility strives to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Record review of the facility policy, Food Storage and Supplies, dated 2012, revealed, All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects .Storerooms are to be well lighted, ventilated, and temperature controlled.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 3 residents (Resident #23) reviewed for infection control, in that: CNA B failed to wash or sanitize her hands or change her gloves after touching the remote of Resident #23's bed before starting incontinent care. After cleaning Resident #23's genitals, CNA B let the soiled briefs get in contact with the resident's genitals. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #23's face sheet, dated 08/07/2024, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Dementia (General decline in cognitive abilities), Neutropenia (low concentration of neutrophils (white blood cell) in the blood making it harder to fight infection), Hyperlipidemia (high concentration of lipids(fats) in the blood) and, squamous cell carcinoma (skin cancer). Record review of Resident #23's Annual MDS assessment, dated 06/17/2024, revealed the resident had no BIMS score, he had memory problems and was severely cognitively impaired. Resident #23 was always incontinent of bladder and frequently incontinent of bowel and, required limited to extensive assistance with his ADLs. Record review of Resident #23's care plan, dated 11/14/2022, revealed a problem of The resident has bladder incontinence, with a goal of The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Observation on 08/07/24 at 1:36 p.m. revealed while providing incontinent care for Resident #23, CNA B after putting gloves on, touched the bed remote that was on Resident #23's bed and then without changing her gloves or sanitizing her hands, started to provide care to the resident. CNA B rolled Resident #23's soiled brief between his legs. After cleaning the resident's genitals, CNA B let the soiled brief get in contact with the resident's genitals. During an interview on 08/07/2024 at 1:50 p.m. with CNA B, she confirmed the environment around the resident was considered dirty and she should have changed her gloves and sanitized her hands prior to providing care. She confirmed the soiled briefs should not have come in contact the resident's genitals after she cleaned them. She confirmed they received infection control training within the year. During an interview with the DON on 08/07/2024 at 3 p.m., she confirmed the environment around the resident was considered dirty and the staff should change their gloves and wash. Staff should sanitize their hands after touching anything in the environment, before touching the resident and at the start of care. She confirmed soiled brief should not come in contact with the cleaned genitals to avoid cross contamination. She confirmed the staff were in-serviced in infection control and incontinent care and skills were checked annually and as needed if there were concerns with infection control. The DON revealed herself and the ADON were in charge of the training and checking of the staff's kills. Record review of the annual skills check for CNA B revealed CNA B passed competency for infection control on 06/25/2024. Record review of the facility policy, titled Fundamental of Infection control precaution , dated 2019, revealed The following is a list of some situations that require hand hygiene: [ .] after handling soiled equipment or utensils.

Based on interview and record review, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility for 1 of 1 facility review for the surety bond, in that: The facility's surety bond was not enough to match the total residents' trust fund account balance. This failure could place residents who deposit personal funds with the facility at-risk of their personal funds not being assured. The findings were: Record review of the facility's surety bond, dated 09/01/2022, revealed the bond amount was $15,000.00. Record review of the resident trust fund as of 07/14/2023, revealed the balance was $15,717.38. During an interview with the BOM on 07/14/2023 at 12:20 p.m., the BOM confirmed the total balance of the residents' trust fund accounts was $15,717.38 which exceeded the facility's $15,000.00 surety bond. The BOM stated she had just recently completed a trust audit and didn't know how it was missed. The ABOD stated the BOM was responsible for this task and confirmed the residents' trust fund account should not have exceeded the surety bond as this could place the resident's funds at risk of not being protected. During an interview with the ABOD on 07/14/2023 at 3:07 p.m., the ABOD stated the facility did not have a policy regarding surety bonds or resident trust accounts. During an interview with the AIT and RCN on 07/14/2023 at 5:15 p.m., the AIT confirmed the residents' trust fund total balance had exceeded the amount of the surety bond and should not have done so.

Based on interview and record review, the facility failed to provide the required compliance and ethics training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received the required compliance and ethics training. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware ethics was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform and ethics would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies.

Based on interview and record review, the facility failed to provide mandatory effective behavioral health training for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received the require mandatory effective behavioral health. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware behavior health was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform where it would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies.

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 18 of 18 employees (the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator. This failure could place residents at risk for injury or improper care due to a lack of training. The findings were: Review of Facility Staff Roster, dated 07/11/2023, revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator all had a hire date of 07/01/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 11:36 a.m., the HR Coordinator revealed the AIT, ADON, SW, OT, ST, DS, AD, MA A, CNA B, CNA C, CNA D, CNA E, MA F, Cook G, Housekeeper H, LVN I, RN J and the MDS Coordinator had not received training in the QAPI program. In an interview with the AIT and RCN on 07/13/2023 at 4:36 a.m., the RCN revealed she was not aware QAPI was part of the mandatory training. She stated the facility will be transitioning to a new web-based learning platform and QAPI would be included. Record review of the facility's policy titled, Employee Education Program, dated 09/20/2019, revealed, All employees regardless of status or classification are required to complete mandatory training as defined by Federal, State and company policies.

Based on interview and record review the facility failed to develop and implement policies and procedures for screening through the employee misconduct registry to determine whether the individual is designated as unemployable for 10 of 18 staff (The DS, AD, MA A, CNA D, CNA E, MA F, Cook G, LVN I, RN J, and MDS Coordinator) reviewed for employment registry screenings, in that: The DS, AD, MA A, CNA D, CNA E, MA F, Cook G, LVN I, RN J, and MDS Coordinator did not have current employment registry screenings. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Record review of the staff roster provided on 07/11/2023 by the facility revealed a hire date of 07/01/2022 for the DS, AD, MA A, CNA D, CNA E, MA F, Cook G, LVN I, RN J, and MDS Coordinator. In an interview with the HR Coordinator on 07/13/2023 at 10:07 a.m., the HR Coordinator revealed when the current corporation acquired the facility all staff were given a new hire date as of the date of acquisition. The HR Coordinator further revealed EMRs (employee misconduct registry) were run for all staff the month prior to the acquisition. Record review of the HR background screenings file, with the HR Coordinator present revealed the last annual Employee Misconduct Registry (EMR) check for the DS was completed on 06/01/2022. Record review of the HR background screenings file, with the HR Coordinator present revealed the last annual Employee Misconduct Registry (EMR) check for LVN I was completed on 06/18/2022. In an interview and record review with the HR Coordinator on 07/13/2023 at 10:28 a.m., the HR Coordinator revealed she was unable to find an annual EMR check for MA A, CNA D, CNA E, MA F, Cook G, AD, RH J, and the MDS Coordinator, however stated they all would have had one completed in June 2022 prior to the acquisition. She further stated all EMRs are currently checked based on each employee's annual competency renewal and the check in June 2022 threw off that schedule. In an interview with the AIT and RCN on 07/13/2023 at 5:26 p.m., the AIT confirmed the HR Coordinator had revealed the EMRs had not been completed due to the HR Coordinator's scheduling process. Record review of the facility's policy titled, Employment Eligibility, revised 09/20/2019, revealed, This facility completes a comprehensive background check prior to offer of employment, annually following your hire and as needed for reported concerns that could impact the resident care or facility liability. Record review of the facility's policy titled, Abuse/Neglect, revised 3/29/18, revealed, Procedure. A. Screening: Criminal History and Background Checks. 7. Employees will be screened for abuse, neglect, and exploitation of the elderly by accessing the Employee Misconduct Registry .

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 (Resident # 12) reviewed for hospice services. 1. The facility failed to obtain Resident #12's most recent hospice plan of care, signed hospice election form, and a physician's re-certification of the terminal illness. This failure could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings were: Record review of Resident #12's face sheet, dated 07/14/23, revealed a [AGE] year old female resident admitted to the facility on [DATE] with diagnoses: [Ascites] is a buildup of fluid in your abdomen. [Malignant neoplasm]is another term for a cancerous tumor, and [Parkinson's disease] is a progressive disorder that affects the nervous system. Record review of Resident #12''s Quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated Intact cognitive response. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #12''s comprehensive care plan initiated on 02/04/23 revealed a focus area for end-of-life care with the name and number of the hospice agency. Interventions included visits from the following hospice interdisciplinary team members, RN, CNA, SW, and Spiritual support. Record review of Resident #12's electronic medical record active orders as of 07/14/2023 revealed an order on 02/04/2023, Admit to [name of facility] under [Hospice A, MD name] attending. Record review of Resident #12''s hospice binder at the nurse's station, revealed a hospice plan of care dated 04/10/2023, a hospice election form not signed by the resident/responsible party, and a physician's re-certification of the terminal illness not signed by the physician. Documentation by specific interdisciplinary hospice staff was in the hospice binder. Record review of the facility's hospice services agreement with Hospice A, with effective date, April 22, 2011, revealed, in 3.1.16 coordination of Services. Hospice shall: (c) provide facility with the following information specific to each Hospice Patient residing at Facility: (i) the most recent Plan of Care; (ii) the hospice election form and any advanced directives; (iii) the Physician certification and recertification(s) of the terminal illness; and 3.3.1 Development and implementation of Joint Plan of Care. When a facility resident is authorized by Hospice for admission to the Hospice Program, and the Facility admits a Hospice Patient to the Facility, Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care. Hospice and Facility each shall maintain a copy of each Patient's JPOC in the respective clinical records maintained by each party. Hospice and Facility each shall designate a registered nurse responsible for coordinating the implementation of the JPOC for each Patient. Record review of Resident #76's hospice binder at the nurse's station, revealed another hospice election form, dated 02/11/2023, signed by resident's family member when Resident #76 was receiving hospice services at home. Record review of the facility's hospice services agreement with Hospice Company , with effective date, February 7, 2020, revealed, in 2.4 (d) As frequently as required by the Hospice Patient's condition, but no less frequently than every fifteen (15) days, the Hospice Interdisciplinary Committee (in collaboration with the patient's Attending Physician) shall review, revise and document the Hospice Plan of Care to include information from updated patient assessments, and progress toward outcomes and goal specified in the Hospice Plan of Care. All such updates shall be communicated to Nursing Home. Further review revealed in 2.5 Hospice Services (a) Coordination of Services. (ii) Hospice shall provide Nursing Home with the following information: (a) the most recent individualized Hospice Plan of Care for each Hospice patient; (b) the Patient's election form for Hospice Services and any advance directives specific to each patient; (c) each Hospice Patient's physician certification and recertification of terminal illness. In an interview with the DON on 07/13/2023 at 10:45 a.m., the DON revealed MDS nurse was the staff person responsible for coordinating with the hospice agencies and ensuring all hospice documentation was in the resident's electronic record. In an interview with the DON on 07/13/2023 at 11:45 a.m., the DON revealed the facility must receive a hospice election form when a resident was admitted to hospice in order to bill for services. The DON further revealed the form would have to be fully completed and signed because the facility would have to know if the resident or family had chosen to elect or cancel the hospice benefit. DON stated she does not know why the needed information was not in the Hospice binder; she stated she is responsible for Auditing Hospice Binders to ensure that all needed information is included however does not know why it was missed; she stated the resident risked not having the Hospice agency and Nursing staff not communicating effectively by information needed not being in the chart. In an interview with MDS Nurse on 07/13/2023 at 11:12 a.m., MDS Nurse revealed she was assigned to coordinate with hospice agencies to ensure hospice agencies email over their documentation, and she uploads what is sent to the resident's electronic record and places necessary documentation in Hospice binder. MDS Nurse could not provide the documents needed for Resident #12 and stated she would call the agencies and ask them to bring any documentation being requested to the facility. Record review of the facility's policy titled, End of Life Hospice Type Care & Coordination, dated 2/7/2007, revealed, To provide supportive care for residents and their families during the end stages of life by enabling them to participate in interactions of their choice in a supportive environment with the assistance of compassionate caregivers and interdisciplinary teams.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 16 residents (Residents #10 and #17) for care plan revisions in that: 1. The facility failed to ensure Resident #10's care plan was revised to include hospice services. 2. The facility failed to ensure Resident #17's care plan was revised to include may sleep in another room after an altercation with their roommate (Spouse) on 7/08/23. These failures could place residents at risk of not receiving care according to their needs. These findings were: 1. Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle wasting and atrophy (loss of muscle tissue), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions). Record review of Resident #10's electronic medical record revealed as of 07/14/2023 a significant change MDS had not been completed related to Resident #10's hospice admission. Record review of Resident #10's care plan, last review date 06/06/2023, revealed no focus area for hospice care. Record review of Resident #10's electronic medical record Order Summary Report of Active Orders as of 07/13/2023, revealed an order on 06/06/2022 for: Admit to [Hospice Company]. In an interview with the MDS Coordinator on 07/12/23 at 02:12 p.m., the MDS Coordinator confirmed she was responsible for updating care plans and that Resident #10's care plan had not been updated. The MDS Coordinator stated during the time the revision was due the facility had several admissions and discharges which may have caused her to overlook the revision. 2. Record Review of Resident #17's admission record, dated 7/14/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis to include: [Major Depressive Disorder] persistently low or depressed mood, decreased interest in pleasurable activities. [Cerebral Infarction] occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts. [ Muscle Wasting] A weakening, shrinking, and muscle loss caused by disease or lack of use. Review of the progress note, dated 7/9/23, revealed that Resident #17 had an altercation with their roommate (spouse), resulting in Resident # 17 spending the night in another room per her request. Review of Resident #17's Care Plan, last revised on 01/24/23, did not reveal a focus area for Resident #17 may spend the night in another room after Altercation with a spouse if it were to occur again. Review of the facility investigation dated 7/9/2023 revealed Resident #17 had an altercation with their spouse roommate and that Resident #17 requested to spend the night in another room. Interview and observation on 07/13/2023 at 01:30 PM with Resident #17, noted no visible injuries. Resident # 17 stated she would like a spare bedroom to spend the night when her spouse has alterations as this has been his common behavior, which he has demonstrated over the last 68 + years of marriage. Resident #17 stated in the morning it's like nothing happened. Interview on 07/13/23 at 04:39 PM the MDS Coordinator confirmed she was responsible for updating care plans, and she stated she had not updated Resident #17 's care plan as no further altercations had occurred and stated Resident #17's spouse was her roommate'. The MDS coordinator stated it was a one-time occurrence and Resident #17's spouse was only in the facility for a temporary skilled stay. The MDS coordinator stated the risk of not updating the care plan was possibly risking not all team members being aware. Interview on 7/13/2023 at 515PM the DON stated she was new at her position and that the MDS coordinator would have more information regarding the care plan. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, 11. Assessments of residents are on-going and care plans are revised as information about the residents and residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: (a) when there has been a significant change in the resident's condition; (b) when the desired outcome is not met; (c) when the resident has been readmitted to the facility from a hospital stay; and (d) at least quarterly, in conjunction with the required quarterly MDS assessment. 46131

Based on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 12 residents (Resident #10) reviewed for MDS assessments, in that: The facility failed to complete a Significant Change MDS for Resident #10 within 14 days after the resident was admitted to hospice services. This failure could place residents admitted to hospice services at-risk of not having their individual needs met. The findings were: Record review of Resident #10's face sheet, dated 07/13/2023, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: hypertensive heart disease without heart failure (includes a number of complications of high blood pressure that affect the heart), dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), muscle weakness, difficulty in walking and cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions). Record review of Resident #10's Care Plan, revised on 06/06/2023, did not reveal a focus for hospice services. Record review of Resident #10's electronic MDS record revealed the resident did not have a Significant Change MDS initiated or completed. Record review of Resident #10's electronic medical record Order Summary Report of Active Orders as of 07/13/2023, revealed an order Admit to Hospice B with a start date of 06/06/2023. During an interview with MDS Coordinator on 07/12/2023 at 2:12 p.m., the MDS Coordinator confirmed the significant change MDS should have been completed withing the 14 days and stated, We had several admissions and discharges and payor changes during that time. I will get it scheduled now. During an interview with the Regional Compliance Nurse on 07/12/2023 at 4:25 p.m., the RCN confirmed the significant change MDS should have been completed and stated the facility follows the RAI manual as policy for completing resident assessments. Record review of CMS's RAI Version 3.0 Manual, dated 10/2019, page 2-23 and 2-24 revealed a Significant Change in Status Assessment is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on a resident.

Based on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for five (Resident #3, Resident #4, Resident #9, Resident #11, and Resident #15) of twelve residents reviewed for advance directives, in that: 1. Resident #3's OOH-DNR was invalid because the attending physician's medical license number was missing from the form. 2. Resident #4's OOH-DNR was invalid because the executor failed to sign in the bottom section of the form. 3. Resident #9's OOH-DNR was invalid because the attending physician's medical license number was missing from the form. 4. Resident #11's OOH-DNR was invalid because the attending physician's signature was present in two incorrect sections of the form, and not present in the section for the attending physician. 5. Resident #15's OOH-DNR form was invalid because the attending physician's signature, date signed, and medical license number were missing from the form. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: 1. Record review of Resident #3's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 12 which revealed moderate cognitive impairment. Record review of Resident #3's care plan, revised [DATE], revealed a focus: Resident is a DNR, a goal, Resident's wishes will be honored X 90 days, and interventions, Ensure appropriate documentation is present . Record review of Resident #3's order summary, dated [DATE], revealed a physician's order, DNR dated [DATE]. Record review of Resident #3's OOH-DNR, revealed the physician's medical license number was missing from the form. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.002, revealed, Definitions. In this chapter: (12) Physician means: (A) a physician licensed by the Texas Medical Board . Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form . Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. During an interview with the ADON on [DATE] at 1:58 p.m., the ADON confirmed the physician's medical license number was missing from Resident #3's OOH-DNR form. 2. Record review of Resident #4's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's quarterly MDS, dated [DATE], revealed a BIMS score of 05 which revealed severe cognitive impairment. Record review of Resident #4's care plan, revised [DATE], revealed a focus: Resident is a DNR, a goal, Resident's wishes will be honored X 90 days, and interventions, Ensure appropriate documentation is present . Record review of Resident #4's order summary, dated [DATE], revealed a physician's order, DNR dated [DATE]. Record review of Resident #4's OOH-DNR, revealed the executor of Resident #4's OOH-DNR failed to sign in the bottom section of the form. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form . Signatures: The statute requires that everyone who signed the form MUST sign the form again in the bottom section to acknowledge that the form has been completed. During an interview with the ADON on [DATE] at 1:58 p.m., the ADON confirmed the executor of Resident #4's OOH-DNR failed to sign in the bottom section of the form. 3. Record review of Resident #9's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's quarterly MDS, dated [DATE], revealed a BIMS score of 05 which revealed severe cognitive impairment. Record review of Resident #9's care plan, revised [DATE], revealed a focus: Resident is a DNR, a goal, Resident's wishes will be honored X 90 days, and interventions, Ensure appropriate documentation is present . Record review of Resident #9's order summary, dated [DATE], revealed a physician's order, DNR dated [DATE]. Record review of Resident #9's OOH-DNR, revealed the physician's medical license number was missing from the form. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.002, revealed, Definitions. In this chapter: (12) Physician means: (A) a physician licensed by the Texas Medical Board . Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form . Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. During an interview with the ADON on [DATE] at 1:58 p.m., the ADON confirmed the physician's medical license number was missing from Resident #9's OOH-DNR form. 4. Record review of Resident #11's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's quarterly MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further review revealed Resident #11 did not use a hearing aid, had clear speech, was able to express ideas and wants, and was about to understand verbal content. Record review of Resident #11's care plan, revised [DATE], revealed a focus: Resident is a DNR, a goal, Resident's wishes will be honored X 90 days, and interventions, Ensure appropriate documentation is present . Record review of Resident #11's order summary dated [DATE], revealed a physician's order, DNR dated [DATE]. Record review of Resident #11's OOH-DNR, revealed the physician signed Section D, attesting Declaration by physician based on directive to physicians by a person now incompetent or nonwritten communication to the physician by a competent person, and signed Section F, attesting Directive by two physicians on behalf of the adult, who is incompetent or unable to communicate and without guardian, agent, proxy or relative: The person's specific wishes are unknown ., but did not sign in the correct section, Physician's Statement: I am the attending physician of the above-noted person and have noted the existence of this order in the person's medical records. Record review of Resident #11's facility clinical record from admission to [DATE], revealed a directive to physicians was not present, the resident had not been declared incompetent, the resident was able to make her own wishes known, and the resident had a Medical Power of Attorney in case she did become unable to make her own decision, and the resident had two additional relatives listed in her contacts list. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Sec. 166.083. Form of Out-Of-Hospital DNR Order. (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (4) a statement that the physician signing the document is the attending physician of the person . 6) places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physician . During an interview with the ADON on [DATE] at 1:58 p.m., the ADON confirmed Resident #11's attending physician signed twice in incorrect sections of the form, and not at all in the section for the attending physician. 5. Record review of Resident #15's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's quarterly MDS, dated [DATE], revealed a BIMS score of 06 which indicated severe cognitive impairment. Record review of Resident #15's care plan, revised [DATE], revealed a focus: Resident is a DNR, a goal, Resident's wishes will be honored X 90 days, and interventions, Ensure appropriate documentation is present . Record review of Resident #15's order summary dated [DATE], revealed a physician's order, DNR dated [DATE]. Record review of Resident #15's OOH-DNR, revealed the physician's signature, date signed, and medical license number were missing from the form in Physician's Statement section. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], accessed [DATE], revealed, Filling out the Out-of-Hospital Do-Not-Resuscitate Form . Physician's Statement: The patient's attending physician must sign and date the form, print or type his/her name and give his/her license number. During an interview with the ADON on [DATE] at 1:58 p.m., the ADON confirmed the physician's signature, date signed, and medical license number were missing from Physician's Statement section of Resident #15's OOH-DNR form. Further interview with the ADON on [DATE] at 1:58 p.m. revealed it was the responsibility of the Social Worker to ensure each resident's advance directive was correct. The Social Worker was not available for interview during the investigation. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility policy, Resident Rights: Request/Refuse/Discontinue Treatment; Advance Directive, effective [DATE], revealed, Policy: The right to request, refuse, and/or discontinue treatment .and to formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 residents (Resident#1) reviewed for care plans, in that: Resident #1's comprehensive care plan did not reflect the resident's use of a pacemaker, the risk for bruising and/or bleeding associated with anticoagulant use, and signs, symptoms, or treatment related to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices could place residents at risk for not receiving the appropriate care and services needed to maintain optimal health. The findings were: Record review of Resident #1's face sheet, dated 09/15/2021, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the face sheet did not indicate Resident #1 had a cardiac pacemaker or a history of [CONDITION(S)] (blood clot). Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated moderate impaired cognition, required extensive assistance of two persons for ADLs, and required supervision of one person for eating. Further review revealed the resident had received 6 days of anticoagulant medications. Record review of Resident #1's care plan, dated 08/13/2021, revealed the resident care plan did not have a care plan in place to address the presence of a cardiac pacemaker, the use of [MEDICATION(S)] ([MEDICATION(S)]-an anticoagulant, which is used to reduce blood clotting)related to her history of DVT ([CONDITION(S)], known as a blood clot). Further review of Resident #1's care plan did not reveal a care plan to observe for signs, symptoms, or treatment related to [CONDITION(S)] or myasthenic crisis. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of paperwork from the hospital, dated 08/06/2021, revealed Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's history and physical dated 8/3/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #1 received IVIG in the hospital setting for [CONDITION(S)]. Record review of Resident #1's progress notes titled, COMS-Skilled Evaluation, dated: 9/4/2021 at 11:12 AM; 9/5/2021 at 9:36 AM, 9/6/2021 at 9:54 AM, 9/7/2021 at 8:35 AM, 9/8/2021 at 12:53 PM, 9/9/2021 at 12:42 PM, 9/10/2021 at 9:47 AM, 9/11/2021 at 2:32 PM, 9/12/2021 at 11:05 AM, and 9/13/2021 at 1:29 PM, revealed that Resident #1 had a pacemaker and included a Special Care Note: left lower extremity reports blood clot may have permanently [CONDITION(S)] [CONDITION(S)] storm hx (history). Record review of the facility's 24-hour report, dated 08/07/2021, revealed Resident #1 had a pacemaker. Observation on 09/15/2021 at 9:00 AM revealed Resident #1 was laying in bed with glasses on and covered, call light was within reach, visible discoloration to both arms. During an interview with LVN C on 09/15/2021 at 2:50 PM, LVN C confirmed Resident #1 was prescribed [MEDICATION(S)] ([MEDICATION(S)]), and further confirmed side effects for the medication should be monitored. LVN C confirmed Resident #1 should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 did not have at this time. LVN C stated labs would not be ordered for [MEDICATION(S)] use. LVN C confirmed she was responsible for care plans and completion of the MDS. LVN C confirmed in the resident's electric medical record under the assessment tab, under Skilled eval form dated 8/6/2021 section CV: Cardiovascular CV8, indicated Resident #1 had a pacemaker. LVN C further confirmed Resident #1 received 6 days of anticoagulants as documented on the resident's Admission MDS. LVN C indicated she would review a residents' chart during their MDS review look back period, complete the MDS, and for any areas triggered on the MDS, she would formulate a plan of care based on the care the resident needed. LVN C further confirmed that she would review the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN C indicated nurses were responsible for obtaining physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the Administrator on 09/15/2021 at 4:00 PM, the Administrator confirmed LVN B maintained the facility medical records, confirmed LVN C completed the MDS/Care plans for the facility. The Administrator further confirmed Resident #1 should have a care plan and physicians' orders for her pacemaker and the use of anticoagulant ([MEDICATION(S)]/[MEDICATION(S)]). The Administrator confirmed the ADON's and DON were responsible for checking residents' charts for completion. The Administrator indicated that a daily clinical meeting was held with the nurses in charge of the residents along with the ADON's and DON to discuss any changes in condition, changes in physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the facility's policy titled, Comprehensive Resident Centered Care Plans: Comprehensive Care Plan, dated 11/28/2017, revealed, to provide the appropriate care and services for each resident according to his/her functional capacity and health status. Further review revealed, the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 5 resident's (Resident #1) reviewed for admission physician orders: The facility did not have physician orders for Resident #1's pacemaker, to monitor for side effects of the anticoagulant [MEDICATION(S)] ([MEDICATION(S)]), and to monitor for signs and symptoms of [CONDITION(S)] or myasthenic crisis. This deficient practice could place residents at risk of staff being unaware of the care ordered by the physician. The findings were: Record review of Resident #1's face sheet, dated 09/15/2021, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the face sheet did not indicate Resident #1 had a cardiac pacemaker or a history of [CONDITION(S)] (blood clot). Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated moderate impaired cognition, required extensive assistance of two persons for ADLs, and required supervision of one person for eating. Further review revealed the resident had received 6 days of anticoagulant medications. Record review of Resident #1's care plan, dated 08/13/2021, revealed the resident had an ADL self-care performance deficit related to [CONDITION(S)], [CONDITION(S)], and Lower extremity weakness and included an intervention to provide extensive assistance with ADL's. Further review revealed on 08/13/2021 Resident #1 had a physical mobility deficit related to [CONDITION(S)], [CONDITION(S)], Lower extremity weakness. Physical Therapy and Occupational Therapy to evaluate and treat. Resident #1's care plan for physical mobility deficit was initiated on 08/13/2021 and revised on 09/15/2021 to include Speech Therapy to evaluate and treat. The interventions listed for the physical mobility deficit on 08/13/2021 stated: Appropriate assistive device to be used for mobility and locomotion. Resident #1 requires wheelchair. She requires extensive assistance X 2 staff. Resident #1 is mobile using wheelchair. She requires extensive assist X 1 staff on and off unit. Physical Therapy to evaluate and treat as ordered/indicated. Refer to therapy evaluations, progress notes. Record review of Resident #1's physician's order summary for September 2021 revealed Resident #1 did not have orders for a cardiac pacemaker such as: settings, next pacemaker check date, date of last pacemaker check, name of cardiologist. Further review of Resident #1's physician's orders revealed the resident received [MEDICATION(S)] ([MEDICATION(S)]) daily related to [CONDITION(S)]. The physician orders for Resident #1 did not reveal an order to monitor for side effects of [MEDICATION(S)] ([MEDICATION(S)]). The physician's orders did not reveal an order to monitor for signs and symptoms of [CONDITION(S)] or myasthenic crisis for Resident #1. Record review of paperwork from the hospital, dated 08/06/2021, revealed Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's history and physical dated 8/3/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Resident #1 received IVIG (intravenous immunoglobulin) in the hospital setting for [CONDITION(S)]. Record review of Resident #1's progress notes titled, COMS-Skilled Evaluation (skilled nursing progress note), dated: 9/4/2021 at 11:12 AM; 9/5/2021 at 9:36 AM, 9/6/2021 at 9:54 AM, 9/7/2021 at 8:35 AM, 9/8/2021 at 12:53 PM, 9/9/2021 at 12:42 PM, 9/10/2021 at 9:47 AM, 9/11/2021 at 2:32 PM, 9/12/2021 at 11:05 AM, and 9/13/2021 at 1:29 PM, revealed that Resident #1 had a pacemaker, and included a Special Care Note: left lower extremity reports blood clot may have permanently [CONDITION(S)] [CONDITION(S)] storm hx. Record review of the facility's 24-hour report, dated 08/07/2021, revealed Resident #1 had a pacemaker. During an interview with LVN C on 09/15/2021 at 2:50 PM, LVN C confirmed Resident #1 was prescribed [MEDICATION(S)] ([MEDICATION(S)]), and further confirmed side effects for the medication should be monitored. LVN C confirmed Resident #1 should have a physician's order to monitor for medication side effects such as: bruising and/or bleeding for [MEDICATION(S)] ([MEDICATION(S)]), which Resident #1 did not have at this time. LVN C stated labs would not be ordered for [MEDICATION(S)] use. LVN C confirmed she was responsible for care plans and completion of the MDS. LVN C confirmed in the resident's electric medical record under the assessment tab, under Skilled eval form dated 8/6/2021 section CV: Cardiovascular CV8, indicated Resident #1 had a pacemaker. LVN C further confirmed Resident #1 received 6 days of anticoagulants as documented on the resident's Admission MDS. LVN C confirmed she did not have the pacemaker information for Resident #1, and she had not assessed Resident #1 for the presence of a cardiac pacemaker. LVN C confirmed that the nurses involved in Resident #1's care would be capable and responsible for obtaining an order to monitor for side effects related to the anticoagulant use. LVN C confirmed monitoring of the pacemaker was needed to monitor the battery life of the pacemaker, and to monitor the proper function that sends signals to the heart for irregular heart rhythm or low heart rate. During an interview with Resident #1 and LVN C on 09/15/2021 at 3:00 PM, Resident #1 confirmed she had a pacemaker and she could not remember the last time it was checked. Resident #1 stated she had the pacemaker information card in her purse and provided LVN C the information card to copy for the medical record which included the serial number, model number, and cardiologist name and phone number. During an interview with the Administrator on 09/15/2021 at 4:00 PM, the Administrator confirmed LVN B maintained facility medical records, confirmed LVN C completed the MDS/Care plans for the facility. The Administrator further confirmed Resident #1 should have a care plan and physicians' orders for her pacemaker, use of anticoagulants, and the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator further confirmed the nurses obtain any physicians orders regarding care and enter the physician's order in the electronic record. On 09/15/2021 at 5:58 PM a policy and procedure were requested for pacemakers and care of a resident with a cardiac pacemaker and physicians' orders. On 09/15/2021 at 7:00 PM upon facility exit, a policy for cardiac pacemakers and physician's orders were not provided to the surveyors as requested.

Based on observation, interview, and record review, the facility failed to maintain clinical records that were complete and accurate in accordance with accepted professional standards and practices for 1 of 5 residents (Resident #1) reviewed for accuracy of records, in that: Resident #1's clinical record did not contain: - Copies of her medical power of attorney available in the facility. - Records related to the presence of a cardiac pacemaker. - Inappropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . - Inaccurate nursing progress notes stated she was not participating in Speech Therapy as ordered. - There were not History and Physical's or progress notes from facility physician available on the chart. This failure could place residents at risk for errors in care and treatment. The findings were: Record review of Resident #1's face sheet, dated 09/15/2021, revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the face sheet did not indicate Resident #1 had a cardiac pacemaker or a history of [CONDITION(S)] (blood clot). Further review revealed Resident #1's family member was listed as: Responsible Party, POA (power of attorney) - Financial, POA (power of attorney)- Care, Guardian, Care Conference Person, and Emergency Contact # 1. Record review of Resident #1's Admission MDS, dated [DATE], revealed the resident had a BIMS score of 12, which indicated moderate impaired cognition, required extensive assistance of two persons for ADLs, and required supervision of one person for eating. Record review of Resident #1's care plan, dated 08/13/2021, revealed Resident #1 did not have a care plan in place to address the presence of a Power of Attorney, which would indicate who she chose to make decisions for her should she be unable to make her own decisions. Record review of Resident #1's clinical record revealed there were no copies of Resident #1's paperwork regarding her power of attorney for financial or power of attorney. Record review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed there was no order for Speech Therapy. Record review of paperwork from the hospital, dated 08/06/2021, revealed Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's history and physical dated 8/3/2021 revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's progress notes titled, COMS-Skilled Evaluation, dated: 9/4/2021 at 11:12 AM; 9/5/2021 at 9:36 AM, 9/6/2021 at 9:54 AM, 9/7/2021 at 8:35 AM, 9/8/2021 at 12:53 PM, 9/9/2021 at 12:42 PM, 9/10/2021 at 9:47 AM, 9/11/2021 at 2:32 PM, 9/12/2021 at 11:05 AM, and 9/13/2021 at 1:29 PM, revealed that Resident #1 had a pacemaker and included a Special Care Note: left lower extremity reports blood clot may have permanently [CONDITION(S)] [CONDITION(S)] storm hx (history). Record review of the facility's 24-hour report, dated 08/07/2021, revealed Resident #1 had a pacemaker. Record review of Resident #1's progress note, dated 09/13/2021 at 11:59 PM, revealed Resident #1's, family member is POA. Observation on 09/15/2021 at 3:00 PM revealed LVN C assessed and confirmed that she could feel a pacemaker under Resident #1's skin on the upper left chest wall. During an interview with the Administrator and BOM on 09/15/2021 at 10:49 AM, the Administrator and BOM stated Resident #1 was admitted to the facility on [DATE] from the hospital for rehabilitation. The Administrator stated Resident #1 was sent to theER on [DATE] due to complaints of right facial drooping and difficulty swallowing. The Administrator stated she was told Resident #1 refused care and to be treated in the ER and was sent back to the facility. The Administrator stated they were not sure why Speech Therapist was not seeing Resident #1. The Administrator indicated that the nurse who received physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the DOR on 09/15/2021 at 11:15 AM, the DOR stated there were no orders for Speech Therapy to treat Resident #1 and they were providing PT/OT services at present. The DOR stated she had not been informed Resident #1 needed Speech Therapy services. During an interview with LVN C on 09/15/2021 at 2:50 PM, LVN C confirmed she was responsible for care plans and completion of the MDS. LVN C confirmed that in the electric medical record under the assessment tab, under Skilled eval form dated 8/6/2021 section CV: Cardiovascular CV8, indicated that Resident #1 had a pacemaker. LVN C confirmed she did not have the pacemaker information for Resident #1, and she had not assessed Resident #1 for the presence of a cardiac pacemaker. LVN C further stated [MEDICATION(S)] was used to treat [CONDITION(S)] or blood clots not [CONDITION(S)]. LVN C confirmed monitoring of the pacemaker was needed to monitor the battery life and to monitor the proper function to send signals to the heart for irregular heart rhythm or low heart rate. During an interview with Resident #1 and LVN C on 09/15/2021 at 3:00 PM, Resident #1 confirmed she had a pacemaker and she could not remember the last time it was checked. Resident #1 stated she had the pacemaker information card in her purse and provided LVN C the information card to copy for the medical record. During an interview with the Administrator on 09/15/2021 at 4:00 PM, the Administrator confirmed LVN B maintained facility medical records, confirmed LVN C completed the MDS/Care plans for the facility. The Administrator confirmed Resident #1 should have a care plan and physicians' orders for her pacemaker. The Administrator confirmed she could not locate a copy of Resident #1's power of attorney information in the electronic chart. During an interview with LVN B on 09/15/2021 at 4:30 PM, a copy of Resident #1's physician visits, progress notes and history and physical for Resident #1 while a resident in the facility was requested from LVN B. LVN B stated she did not have them, confirmed they were not in the electronic record, and stated she would have to call the physician and request them. Records were not provided at the time of exit. During an interview with the BOM on 09/15/2021 at 5:30 PM, the BOM confirmed she did not have a copy of Resident #1's power of attorney. On 09/15/2021 at 5:58 PM a policy and procedure were requested from the Administrator regarding: documentation, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/15/2021 at 7:00 PM upon facility exit, the policies regarding: documentation, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 12 residents (Residents #16, #26, and #34) reviewed for comprehensive care plans, in that: 1. The facility failed to indicate the parameters for Resident #16's pacemaker in the care plan. 2. The facility failed to indicate the parameters for Resident #26's pacemaker in the care plan. 3. The facility failed to indicate Resident #34's code status in the care plan. These deficient practices could place residents at risk of not receiving the appropriate care and services needed to maintain optimal physical and psychosocial well-being. 1. Record review of Resident #16's face sheet, dated [DATE] revealed an admitted [DATE] with a readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #16's Consolidated Physicians Orders for [DATE] revealed that resident #16 has a pacemaker implanted and has right bundle-branch block with combined systolic and diastolic congestive heart failure. Record review of Resident #16's care plan with a last review date of [DATE] reveals a focus of the resident has a pacemaker related to symptomatic [CONDITION(S)] with right bundle branch block and congestive heart failure, the interventions state monitors vital signs as ordered/as needed and record. Notify MD of significant abnormalities . monitor/document/ report to MD PRN signs or symptoms of altered cardiac output or pacemaker malfunction: dizziness, [CONDITION(S)], difficulty breathing, pulse rate lower than programmed rate, lower than baseline B/P. During an interview on [DATE] at 2:00 p.m. with LVN A she was unable to verbalize the programmed rate for the pacemaker or a baseline blood pressure for Resident #16. She stated that she would contact the Physician if she felt it was out of the normal vital signs parameters. During an interview on [DATE] at 2:00 p.m. the MDS coordinator confirmed the current care plan for Resident #16 did not indicate the programmed rate for the resident's pacemaker or a baseline blood pressure. She was unable to verbalize what the baselines would be and stated that she would have to get that information from the cardiologist. During an interview on [DATE] at 2:30 p.m. the DON confirmed that the care plan for Resident #16's care plan should have included the baseline parameters for physician notification. 2. Record review of Resident #26's face sheet, dated [DATE] revealed an admitted [DATE] with a readmission on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #16's Consolidated Physicians Orders for [DATE] reveal that resident #26 has a pacemaker implanted and is a full code [has Record review of Resident #26's care plan with a last review date of [DATE] has a focus that the resident has a pacemaker related to [CONDITION(S)] with a goal that the resident will maintain heart rate within acceptable limits as determined by MD/pacemaker setting through review date. The interventions direct nursing to monitor vital signs as orders/as needed and record. Notify MD of significant abnormalities. Record review of Resident #26's care plan with a last review date of [DATE] has a focus that resident is a full code with interventions of have c rash cart ready . Initiate CPR should resident be found without pulse, respiration. During an interview on [DATE] at 2:00 p.m. with LVN H she was unable to verbalize the programmed rate for the pacemaker or a baseline blood pressure for Resident #26. During an interview on [DATE] at 2:00 p.m. the MDS coordinator confirmed the current care plan for Resident #26 did not indicate the programmed rate for the resident's pacemaker or a baseline blood pressure. She was unable to verbalize what the baselines would be and stated that she should have obtained that information from the cardiologist. During an interview on [DATE] at 2:30 p.m. the DON confirmed that the care plan for Resident # 26's care plan should have included the baseline parameters for physician notification. 3. Record review of Resident #34's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's comprehensive MDS, dated [DATE], revealed a BIMS score of 14 which indicated intact cognition. Record review of Resident #34's clinical record revealed a physician's order, dated [DATE], Full Code. Record review of Resident #34's care plan, revised [DATE], revealed the care plan did not reflect the resident's choice of code status (choice of whether or not to receive cardiopulmonary resuscitation and/or other heroic measures should the need arise). During an interview with Resident #34 on [DATE] at 4:02 p.m., Resident #34 stated he would like to be considered a full code and thus receive cardiopulmonary resuscitation and/or other heroic measures should the need arise. During an interview with the MDS/Care Plan Coordinator on [DATE] at 2:00 p.m., the MDS/Care Plan Coordinator confirmed Resident #34's choice of code status was not reflected on his current care plan. Record review of the facility policy, Comprehensive Care Plans, dated [DATE], revealed, Objective: To provide the appropriate care and services for each resident according to his/her functional capacity and health status Policy: The facility must develop and implement a comprehensive person-centered care plan for each resident .

Based on interview and record review the facility failed to review and revise the person-centered care plan for 2 of 12 residents (#13 and #14) reviewed for care plans, in that: 1. The facility did not revise Resident #13's care plan to indicate the discontinuation of nightly splinting devices for right wrist contracture. 2. The facility failed to include that Resident #14 was on Hospice care in his care plan. These deficient practices could place residents at risk for not having their care plan revised to address needs in a timely manner. The findings were: 1. Record review on 04/04/2021 of Resident #13's face sheet, dated 04/04/2021, revealed an original admitted [DATE] with current admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 04/04/2021 of Resident #13's MDS, significant change dated 01/06/2021 indicated that Resident #13 has a BIMS score of 10, moderately impaired cognitively. The MDS indicated that Resident #13 has functional limitation in range of motion on one side of the body. Record review on 04/04/2021 of Resident #13's Consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed it does not address splints or right-hand contracture. Further review of Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on April 4, 2021 of Resident #13's care plan with a last review date of 01/18/2021, revealed a focus area that read,The resident has an ADL Self Care Performance Deficit . due to cerebral infarction with right side [CONDITION(S)] and contracture to right wrist. Interventions: Patient to wear right splint nightly as tolerated. During an interview on 4/7/2021 at 2:00 p.m. the MDS coordinator confirmed the current care plan, reviewed on 1/18/2021, should have been updated after Resident #13's MDS completion for a significant change completed on 1/06/2021. She stated it was an oversight and she should have removed the intervention of right wrist splints during her review since the splints were discontinued on 12/16/2020. During an interview on 04/07/2021 at 2:30 p.m. the DON confirmed that the intervention for right wrist splint should have been removed from the current care plan during the care plan review conducted on 1/18/2021. 2. Record review of Resident #14's face sheet, dated 04/04/2021 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's Consolidated Physicians Orders for April 2021 reveal an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's quarterly MDS review dated 10/01/2020 reflected a BIMS score of 6, severe cognitive impairment. Record review of Resident #14's care plan with a last review date of 02/25/2021, did not reflect that the resident was admitted to hospice care on 01/15/2021. During an interview on 4/7/2021 at 2:00 p.m. the MDS coordinator confirmed the current care plan should have been updated during the care plan review conducted on 2/25/2021 to indicate that Resident #14 was placed under hospice care on 01/15/2021. During an interview on 04/07/2021 at 2:30 p.m. the DON confirmed that the care plan for Resident #14 should have included that he was receiving hospice care in the current care plan. The DON stated that she is responsible for care plans and that the development is a team effort. Review of a facility policy dated 11/28/2017: Comprehensive Resident Centered Care Plans; Care Plan Timing and Revision revealed, The comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview, and record review, the facility failed to provide effective pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #29) reviewed for pain management. The facility failed to consult with Resident #29's doctor to address the severe pain Resident #29 had been experiencing for 3 days following a fall, failed to monitor and treat the resident's pain after the resident was diagnosed with [REDACTED].#29. This failure could affect 3 residents who had orders for prn pain medication and put them at risk for further decline in their mental or physical functioning. The findings include: Record review of Resident #29's electronic face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #29's electronic notes, copied and pasted from the resident's electronic chart revealed: -Nurse's Note, dated and timed 6/23/2018 17:30, revealed Late Entry: Note Text: LATE ENTRY: Upon (CNA C) and nurse entering resident's room resident noted to be kneeling in front of chair with arms on chair. Blood noted on floor. Resident assessed and assisted into wheelchair. (RN D) also present now and cleansed skin tear to forehead and applied steri strips. Small skin tear also noted to the left arm, site cleansed by treatment nurse (Jan) and steri strips applied. Resident is A/O X4 and reports having fallen upon ambulating back from restroom. Resident complains of bilateral knee soreness but denies pain otherwise. Denies the need for PRN pain medication for knees. Will continue NVS as directed. -eMar - Medication Administration Note, dated and timed 6/23/2018 18:12, reveald Note Text:[MEDICATION NAME][MEDICATION NAME] Formula Tablet Give 1 tablet by mouth two times a day related to [MEDICATION NAME] DEGENERATION OF RETINA UNSPECIFIED (362.50) . Tablet Oral [MEDICATION NAME] DEGENERATION OF RETINA UNSPECIFIED (362.50) TAB 1 PO BID -eMar - Medication Administration Note, dated and timed 6/23/2018 20:00, revealed, Note Text: Tylenol Extra Strength Tablet Give 2 tablet orally every 4 hours as needed for Pain; Elevated Temperature 1000 MG Tablet Oral Pain; Elevated Temperature (500 MG TAB 2) PO Q4H PRN;**NOT TOO EXCEED 4 DOSES/24H** C/O pain to Lt side rib area post fall -eMar - Medication Administration Note, dated and timed 6/23/2018 21:02, revealed Note Text: PRN Administration was: Effective -One-on-One Activity Note, dated and timed 6/25/2018 12:51, revealed Late Entry: Note Text: One-on-one/in room activity assessment completed for (Resident #29). The resident scored a 0.0 which places them in the Active Participation category. -eMar - Medication Administration Note , dated and timed 6/26/2018 08:05, revealed Note Text: Aspirin Low Dose Tablet 81 MG Give 1 tablet by mouth one time a day related to COR ATHEROSLERO UNSPEC TYPE VESSEL NATIVE/GRAFT (414.00) 81 MG Tablet Delayed Release Oral COR ATHEROSLERO UNSPEC TYPE VESSEL NATIVE/GRAFT (414.00) TAB 1 PO Q DAY DO NOT CRUSH fell ING SICK -eMar - Medication Administration Note, dated and timed 6/26/2018 08:05, revealed Note Text: FEELING SICK -Nurse's Note, dated and timed 6/26/2018 08:06, reveald Note Text: resident refused bkft stated having chest pain and hurt when he moves v/s 97.8, 83, 18, 134/69, 92 @ room air -Nurse's Note, dated and timed 6/26/2018 08:31, revealed Note Text: Moulton Clinic was called about resident C/O of chest pains and not wanting to move due to pain spoke with (A nurse) at clinic and stated that (PA) could come seen him around 9:30, but if RP wanted sent to ER for evaluation,(RP's daughter) is here and talked with resident and he would wait and the PA check him. -Nurse's Note, dated and timed 6/26/2018 08:45, revealed Note Text: MF CN asked me to check on resident as he wasn't feeling well. Upon entering room res was sitting on side of bed eating a banana with shallow breaths and wincing when he swallowed. Res stated he hurts real bad when he swallows from (pointing) here (left lateral side under breast) to here and he pointed to his left side of abdomen. Res stated his rib hurts and he thinks it needs checked out because it is getting worse. I asked if he wanted to go to ER for eval and he stated yes please. Informed MF CN she called clinic for orders to send to ER was told PA on the way. -Nurse's Note, dated and timed 6/26/2018 09:40, revealed Note Text: (PA) here see resident new orders written for lab and portable chest xray and EKG. RP (and daughter) was told of new orders. -Nurse's Note, dated and timed 6/26/2018 09:45, revealed Note Text: CMMS was notified of orders for Stat Chest x ray and EKG. and Blood was drawn and send to Yoakum lab. -Nurse's Note, dated and timed 6/26/2018 11:45, revealed Note Text: (Staff) from Moulton Clinic called back after reviewing lab results and order a CT scan of chest with contrast. -Nurse's Note, dated and timed 6/26/2018 12:25, revealed Note Text: CMMS here to perform EKG and Chest X ray. -eMar - Medication Administration Note, dated and timed 6/26/2018 13:07, revealed Note Text: Weak - will be admitted to hospit -Nurse's Note, dated and timed 6/27/2018 16:02, revealed Note Text: KM PA delivered script and gave verbal order for res to have APAP#3. Record review of Resident #29's MDS (Annual 6/14/2018) revealed the resident had a BIMS Score of 12, indicating moderate cognitive impairment. Record review of Resident #29's MDS (significant change 7/3/2018) revealed he had a BIMS Score of 5, indicating severe cognitive impairment. Record review of Resident #29's consolidated orders, dated 1/14/2017, revealed orders for Tylenol Extra Strength Tablet ([MEDICATION NAME]) Give 2 tablet orally every 4 hours as needed for pain. Record review of a Diagnostic Imaging report date, 6/26/2018, revealed Resident #29 had an, Acute nondisplaced fractures of the left lateral seventh through ninth ribs. Record review of a Facility Investigation Report, Investigation Date 6/28/2018, revealed Resident #29 had an unwitnessed fall on 6/23/2018 at around 5:25 pm and presented with, . blood on the forehead & floor and a skin tear to left wrist area . Further review revealed on 6/26/2018 at approximately 8:00 AM, Resident #29 complained that he felt ill and had pain in his chest. Further review revealed the resident was seen by the PA at 9:30 AM, received orders for labs, a chest x-ray, and an EKG, and was then sent to a hospital for a CT scan and returned to the facility at 3:30 PM on the same day. Furthermore, the facility was notified on 6/27/2018 that the resident had a non-displaced fracture of left ribs 7-9 and stated the facility received an order for [REDACTED].>Record review of Resident #29's consolidated orders, dated 6/27/2018, revealed orders for: Tylenol with [MEDICATION NAME] #3 Tablet 300-30 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for Moderate Pain. Record review of a written prescription for Resident #29, dated 6/27/2018, and signed by PA E, revealed an order for [REDACTED].>Review of a typed letter, dated 7/27/2018 addressed to the facility by it's pharmaceutical provider revealed the provider had no record of a request to fill Resident #29's Tylenol with [MEDICATION NAME] #3. Record review of Resident #29's (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Resident #29 was not administered any other medication to treat his pain despite staff being aware the resident was indicating a pain level of 10 on a 1-10 scale, indicating the worst pain experienced, on the day of 6/26/2018. Record review of a word document sent via email from Resident #29's PA, stated, . The CT report was reviewed 6/27/18, which indicated acute left rib fractures, otherwise negative. At that time, I (Physician on Duty) who was present in the (the facility) clinic that day to ensure appropriate treatment steps were taken. We agreed beginning Tylenol #3 as needed for pain was appropriate. If pain not tolerated well with regimen, a change would be made at the appropriate time. A Tylenol #3 prescription was written and hand delivered to (facility nurse, LVN B), at the nurse's station by me. She replied thank you upon receiving the prescription with no concerns noted as I left or that same day . During an interview on 7/26/2018 at 8:48 AM, the DON revealed Resident #29 fell on a Saturday evening (6/23/2018, at 5:30 PM). The nurse and an aide were making rounds and found the resident kneeling on the floor and had his elbow on a chair. The resident initially denied pain and did not present with shortness of breath. The staff helped the resident up onto his bed and continued to check on the resident every 15 minutes for neuro checks. She said the resident did not have any complaints other than being sore for several days but then on Tuesday (6/26/2018) the resident mentioned he was having pain when breathing and referred to it as chest pain. An X-Ray taken on 6/26/2018 revealed the resident had non-displaced fractures on ribs 7-9. The DON further stated the physician's assistant came to the facility with the x ray results and an order for [REDACTED]. During an interview on 7/26/2018 at 8:56 AM, Charge Nurse, LVN A, revealed Resident #29 was discovered on his knees. She said blood was seen on the floor and discovered it was from a skin tear on his scalp and indicated the resident reported that he was trying to ambulate to the restroom and claimed that he had lost his balance. The nurse indicated that neuro checks were started after the fall. LNV A said that at the time of the fall, the resident was only complaining of pain to his knees but said several days later he complained of pain to his ribs. The nurse said she called the resident's emergency contact and his physician as well. LVN A said the idea of the resident receiving an X-ray never came up with the physician. LVN A was asked about the resident's pain levels but said she could not recall. LVN A was asked what could have been done differently and replied that the resident's chair could have been placed closer to the restroom where he normally keeps it as his vision was poor. The nurse was asked if the resident was considered to be blind and said that he likely was and tends to move around by feel. The nurse said staff were prompted to order an X-ray for the resident 3 days later because he was complaining of pain. During an interview on 7/26/2018 at 9:14 AM, CNA C, revealed she and the other nurse found Resident #29 on the floor and were told by the resident that he was coming from the restroom. She said she observed some blood on the floor and on the resident. After the resident was assisted up, she said the nurse assessed the resident. The CNA said she returned several days later and found out the resident was in pain. During an interview on 7/26/2018 at 9:35 AM, LVN B, revealed she came to the facility on [DATE] and had heard the resident would not get up. She said the resident was complaining of chest pain and pain to his side so she called the resident's responsible party and were making preparation to send the resident to the ER. LVN B indicated the resident did not want to go to the ER and elected to wait for the PA and had X-rays done at the facility. A CT Scan was performed at the hospital and discovered the resident had a fracture to his ribs. LVN B said on the morning of 6/26/2018, the resident was .screaming and hollering in pain, beyond anything she had ever witnessed with him before. During an observation and interview on 7/26/2018 at 9:45 AM, Resident #29 was observed in his bed, lying on his side and listening to the radio. The resident reported that he was still experiencing some pain in his ribs but said it was, nothing like before. The resident expressed that he would like a bed rail on the side of his bed to prevent him from falling from his bed but said staff have told him that he does not need one. The resident was asked and said he had fallen from bed quite some time ago. The resident was asked if he had been given medication for his pain but seemed confused and could not provide a coherent answer. During an interview on 7/26/2018 at 3:15 PM, with the Administrator, DON, Regional Nurse, LVN A, and LVN B, this investigator asked if it was true that this resident was not issued any pain medication other than the extra strength Tylenol on 6/23/2018 following his fall. It was confirmed after reviewing the resident's MAR indicated [REDACTED]. The DON replied that the resident was a tough man and did not usually ask for medications. This investigator asked how the resident was being assessed for pain and was told by the DON that the resident would only have been assessed for pain had he been administered pain medication and also the resident was able to ask for pain medication and stated he was able to speak and answer questions. The DON added that the facility only, documents by exception, indicating that a pain assessment would have only been documented if the resident was experiencing pain and had been administered medication as a result. The DON agreed there was no documentation showing this resident was being assed for pain following the [DIAGNOSES REDACTED]. During an interview on 7/26/2018 at 3:50 PM, the DON was asked to show this investigator the resident's medications. The DON went to the resident's hall and opened the medication cart that contained the resident's medications but was unable to locate the resident's Tylenol #3. During an interview on 7/26/2018 at 4:15 PM, the DON said she recalled the resident's Tylenol #3 was pulled off the cart yesterday, because it was a PRN Narcotic, which according to policy, had to be discarded after 14 days from the order date. The DON was asked where this policy was and explained that it was, New State Policy. The DON was asked to reveal the order date for the resident's Tylenol #3. She logged onto her computer and then indicated that she forgot to input a drop off date, and took responsibility for the error. The DON and Regional Nurse were then asked to go to the drug destruction room and show this investigator the resident's Tylenol #3 medication. Upon arrival to the drug destruction room, the DON removed a large plastic bag from a locked drawer but was unable to locate the resident's medication. The DON then opined that the medication must not have been filled. The Regional Nurse said, No, that wouldn't happen. The DON then opined the drug must have already been destroyed, to which this investigator asked to see the drug destruction log and asked when the last destruction occurred, to which the DON said, .that would have been in June, before this resident's Tylenol #3 was filled, so she then agreed that Tylenol #3 would not yet have been destroyed. During an interview on 7/26/2018 at 5:15 PM with the Administrator, DON, Regional Nurse, and LVN A, the DON indicated the facility's doctor did not allow the facility's Physician Assistant to be a designee for orders, therefore the prescription was never filled and said she contacted the pharmacy and was told this prescription was never filled. This investigator then requested the DON supply written confirmation from the pharmacy that the order for Tylenol #3 was never filled and never arrived to the facility. It was further explained that there was concern as the resident was sent out for evaluation on 6/27/2018 after complaining of pain to his chest at a level 10 and subsequently being diagnosed with [REDACTED]. The DON explained once again that this resident was a tough man and opined that just getting out of the facility that day may have been, . all he needed. The DON was also reminded that this resident's BIMs Score went from a 12 in (MONTH) (YEAR) to a 5 in (MONTH) (YEAR) (post incident) and was unable to clearly explain or recall the pain he was experiencing post fracture diagnosis. During an interview on 7/27/2018 at 8:45 AM, the Administrator was asked if the facility had received the written confirmation from the pharmacy confirming the resident's Tylenol #3 was never filled or received by the facility. She explained the DON was still working on receiving this confirmation. The Administrator was asked if the pharmacy was located near this facility and responded that it was not. The Administrator was asked the location of the pharmacy and she explained that it was located in Bryan College Station, Texas. During an interview on 7/27/2018 at 9:50 AM, the Administrator and Regional Nurse, revealed they were in contact with the resident's pharmacy but said the pharmacy was unable to locate the fax that was sent by the facility confirming a request to fill the prescription. A request for written confirmation from the pharmacy was made but the pharmacy was in agreement that they could not locate a request made by the facility to fill the resident's Tylenol #3. During a telephone interview on 7/27/2018 at 1:30 PM, the PA revealed she assessed the resident on 6/26/2018 and discovered he was in a great deal of pain and was told by the resident that he had been experiencing pain throughout the weekend since he had his fall. She said facility staff were concerned the resident may be having heart related problems, however, that concern was ruled out following lab work. The PA indicated that she believed the resident's symptoms were more indicative of a muscular-skeletal problem. The PA said after she received the report on the resident following his imaging and [DIAGNOSES REDACTED]. The PA was asked if she had any problems getting prescriptions filled for residents who were under care of Dr. F to which she responded that she had not. The PA said that there were some medications that she could not write orders for but said Tylenol #3 was a medication she could prescribe without Physician authorization. Additionally, the PA said she discussed this prescription with a Dr. H who was said to have been overseeing the resident's care at the time and said this doctor was in agreement with this prescription and relayed that he could prescribe something more powerful if needed. The PA revealed that a rib fracture was a slow-healing type of injury that would involve a significant amount of pain throughout recovery. The PA agreed that a reasonable person would be expected to be in pain following this type of injury and would require pain medication which was why she wrote the prescription for Resident #29 During an interview on 7/27/2018 at 2:00 PM, LVN B said that PA E told her, I know you are going to need this script, and delivered the script around 4 or 5 pm that evening (6/27/2018). LVN B said she gave the DON the order just before leaving for the day. LVN B said staff make a copy of the prescription for the chart and send it to Med Chest and said the courier picks up the original later in the evening. When asked why the prescription was never filled, she opined that it was possible Medicine Chest may have forgotten to fill the prescription. During an interview on 7/27/2018 at 3:55 PM, the DON, acknowledged receiving the order for Tylenol #3 from LVN, B, and said she then sent the order to the pharmacy via fax and courier but was unable to provide confirmation. Record review of the facility's Pain Management Policy, effective date 1/1/2010, stated: OBJECTIVE: To provide pain management to maximize comfort and enhance the quality of life for residents.' PR[NAME]EDURE: 1. Pain shall be assessed on admission, quarterly, and on an as-needed basis. 2. Practice guidelines: Assess description of pain. Assess intensity and severity using resident appropriate pain scale. Identify the location of the pain. Assess aggravating and relieving factors. 3. Pharmacological interventions will be initiated according to Physicians orders. 4. Non-pharmacological interventions may be utilized as deemed necessary. Record review of the facility documentation received from the facility, revealed 3 residents with orders for Tylenol #3 for pain management.

Based on interview and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #29) reviewed for Tylenol #3 (opiate pain medication). The facility failed to ensure nursing staff filled Resident #29's prescribed Tylenol #3. This failure placed the 3 residents who were receiving who were prescribed medication for pain management and had physician's orders [REDACTED]. The findings include: Record review of Resident #29's electronic face sheet revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #29's electronic notes, copied and pasted from the resident's electronic chart revealed: -Nurse's Note, dated and timed 6/23/2018 17:30, revealed Late Entry: Note Text: LATE ENTRY: Upon (CNA C) and nurse entering resident's room resident noted to be kneeling in front of chair with arms on chair. Blood noted on floor. Resident assessed and assisted into wheelchair. (RN D) also present now and cleansed skin tear to forehead and applied steri strips. Small skin tear also noted to the left arm, site cleansed by treatment nurse (Jan) and steri strips applied. Resident is A/O X4 and reports having fallen upon ambulating back from restroom. Resident complains of bilateral knee soreness but denies pain otherwise. Denies the need for PRN pain medication for knees. Will continue NVS as directed. -eMar - Medication Administration Note, dated and timed 6/23/2018 18:12, reveald Note Text:[MEDICATION NAME][MEDICATION NAME] Formula Tablet Give 1 tablet by mouth two times a day related to [MEDICATION NAME] DEGENERATION OF RETINA UNSPECIFIED (362.50) . Tablet Oral [MEDICATION NAME] DEGENERATION OF RETINA UNSPECIFIED (362.50) TAB 1 PO BID -eMar - Medication Administration Note, dated and timed 6/23/2018 20:00, revealed, Note Text: Tylenol Extra Strength Tablet Give 2 tablet orally every 4 hours as needed for Pain; Elevated Temperature 1000 MG Tablet Oral Pain; Elevated Temperature (500 MG TAB 2) PO Q4H PRN;**NOT TOO EXCEED 4 DOSES/24H** C/O pain to Lt side rib area post fall -eMar - Medication Administration Note, dated and timed 6/23/2018 21:02, revealed Note Text: PRN Administration was: Effective -One-on-One Activity Note, dated and timed 6/25/2018 12:51, revealed Late Entry: Note Text: One-on-one/in room activity assessment completed for (Resident #29). The resident scored a 0.0 which places them in the Active Participation category. -eMar - Medication Administration Note , dated and timed 6/26/2018 08:05, revealed Note Text: Aspirin Low Dose Tablet 81 MG Give 1 tablet by mouth one time a day related to COR ATHEROSLERO UNSPEC TYPE VESSEL NATIVE/GRAFT (414.00) 81 MG Tablet Delayed Release Oral COR ATHEROSLERO UNSPEC TYPE VESSEL NATIVE/GRAFT (414.00) TAB 1 PO Q DAY DO NOT CRUSH fell ING SICK -eMar - Medication Administration Note, dated and timed 6/26/2018 08:05, revealed Note Text: FEELING SICK -Nurse's Note, dated and timed 6/26/2018 08:06, reveald Note Text: resident refused bkft stated having chest pain and hurt when he moves v/s 97.8, 83, 18, 134/69, 92 @ room air -Nurse's Note, dated and timed 6/26/2018 08:31, revealed Note Text: Moulton Clinic was called about resident C/O of chest pains and not wanting to move due to pain spoke with (A nurse) at clinic and stated that (PA) could come seen him around 9:30, but if RP wanted sent to ER for evaluation,(RP's daughter) is here and talked with resident and he would wait and the PA check him. -Nurse's Note, dated and timed 6/26/2018 08:45, revealed Note Text: MF CN asked me to check on resident as he wasn't feeling well. Upon entering room res was sitting on side of bed eating a banana with shallow breaths and wincing when he swallowed. Res stated he hurts real bad when he swallows from (pointing) here (left lateral side under breast) to here and he pointed to his left side of abdomen. Res stated his rib hurts and he thinks it needs checked out because it is getting worse. I asked if he wanted to go to ER for eval and he stated yes please. Informed MF CN she called clinic for orders to send to ER was told PA on the way. -Nurse's Note, dated and timed 6/26/2018 09:40, revealed Note Text: (PA) here see resident new orders written for lab and portable chest xray and EKG. RP (and daughter) was told of new orders. -Nurse's Note, dated and timed 6/26/2018 09:45, revealed Note Text: CMMS was notified of orders for Stat Chest x ray and EKG. and Blood was drawn and send to Yoakum lab. -Nurse's Note, dated and timed 6/26/2018 11:45, revealed Note Text: (Staff) from Moulton Clinic called back after reviewing lab results and order a CT scan of chest with contrast. -Nurse's Note, dated and timed 6/26/2018 12:25, revealed Note Text: CMMS here to perform EKG and Chest X ray. -eMar - Medication Administration Note, dated and timed 6/26/2018 13:07, revealed Note Text: Weak - will be admitted to hospit -Nurse's Note, dated and timed 6/27/2018 16:02, revealed Note Text: KM PA delivered script and gave verbal order for res to have APAP#3. Record review of Resident #29's MDS (Annual 6/14/2018) revealed the resident had a BIMS Score of 12, indicating moderate cognitive impairment. Record review of Resident #29's MDS (significant change 7/3/2018) revealed he had a BIMS Score of 5, indicating severe cognitive impairment. Record review of a Diagnostic Imaging report date, 6/26/2018, revealed Resident #29 had an, Acute nondisplaced fractures of the left lateral seventh through ninth ribs. Record review of a Facility Investigation Report, Investigation Date 6/28/2018, revealed Resident #29 had an unwitnessed fall on 6/23/2018 at around 5:25 pm and presented with, . blood on the forehead & floor and a skin tear to left wrist area . Further review revealed on 6/26/2018 at approximately 8:00 AM, Resident #29 complained that he felt ill and had pain in his chest. Further review revealed the resident was seen by the PA at 9:30 AM, received orders for labs, a chest x-ray, and an EKG, and was then sent to a hospital for a CT scan and returned to the facility at 3:30 PM on the same day. Furthermore, the facility was notified on 6/27/2018 that the resident had a non-displaced fracture of left ribs 7-9 and stated the facility received an order for [REDACTED].>Record review of Resident #29's consolidated orders, dated 6/27/2018, revealed orders for: Tylenol with [MEDICATION NAME] #3 Tablet 300-30 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 1 tablet by mouth every 6 hours as needed for Moderate Pain. Record review of a written prescription for Resident #29, dated 6/27/2018, and signed by PA E, revealed an order for [REDACTED].>Review of a typed letter, dated 7/27/2018 addressed to the facility by it's pharmaceutical provider revealed the provider had no record of a request to fill Resident #29's Tylenol with [MEDICATION NAME] #3. Record review of Resident #29's (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. Further review revealed Resident #29 was not administered any other medication to treat his pain despite staff being aware the resident was indicating a pain level of 10 on a 1-10 scale, indicating the worst pain experienced, on the day of 6/26/2018. Record review of a word document sent via email from Resident #29's PA, stated, . The CT report was reviewed 6/27/18, which indicated acute left rib fractures, otherwise negative. At that time, I (Physician on Duty) who was present in the (the facility) clinic that day to ensure appropriate treatment steps were taken. We agreed beginning Tylenol #3 as needed for pain was appropriate. If pain not tolerated well with regimen, a change would be made at the appropriate time. A Tylenol #3 prescription was written and hand delivered to (facility nurse, LVN B), at the nurse's station by me. She replied thank you upon receiving the prescription with no concerns noted as I left or that same day . During an interview on 7/26/2018 at 8:48 AM, the DON revealed Resident #29 fell on a Saturday evening (6/23/2018, at 5:30 PM). The nurse and an aide were making rounds and found the resident kneeling on the floor and had his elbow on a chair. The resident initially denied pain and did not present with shortness of breath. The staff helped the resident up onto his bed and continued to check on the resident every 15 minutes for neuro checks. She said the resident did not have any complaints other than being sore for several days but then on Tuesday (6/26/2018) the resident mentioned he was having pain when breathing and referred to it as chest pain. An X-Ray taken on 6/26/2018 revealed the resident had non-displaced fractures on ribs 7-9. The DON further stated the physician's assistant came to the facility with the x ray results and an order for [REDACTED]. During an interview on 7/26/2018 at 8:56 AM, Charge Nurse, LVN A, revealed Resident #29 was discovered on his knees. She said blood was seen on the floor and discovered it was from a skin tear on his scalp and indicated the resident reported that he was trying to ambulate to the restroom and claimed that he had lost his balance. The nurse indicated that neuro checks were started after the fall. LNV A said that at the time of the fall, the resident was only complaining of pain to his knees but said several days later he complained of pain to his ribs. The nurse said she called the resident's emergency contact and his physician as well. LVN A said the idea of the resident receiving an X-ray never came up with the physician. LVN A was asked about the resident's pain levels but said she could not recall. LVN A was asked what could have been done differently and replied that the resident's chair could have been placed closer to the restroom where he normally keeps it as his vision was poor. The nurse was asked if the resident was considered to be blind and said that he likely was and tends to move around by feel. The nurse said staff were prompted to order an X-ray for the resident 3 days later because he was complaining of pain. During an interview on 7/26/2018 at 9:14 AM, CNA C, revealed she and the other nurse found Resident #29 on the floor and were told by the resident that he was coming from the restroom. She said she observed some blood on the floor and on the resident. After the resident was assisted up, she said the nurse assessed the resident. The CNA said she returned several days later and found out the resident was in pain. During an interview on 7/26/2018 at 9:35 AM, LVN B, revealed she came to the facility on [DATE] and had heard the resident would not get up. She said the resident was complaining of chest pain and pain to his side so she called the resident's responsible party and were making preparation to send the resident to the ER. LVN B indicated the resident did not want to go to the ER and elected to wait for the PA and had X-rays done at the facility. A CT Scan was performed at the hospital and discovered the resident had a fracture to his ribs. LVN B said on the morning of 6/26/2018, the resident was .screaming and hollering in pain, beyond anything she had ever witnessed with him before. During an observation and interview on 7/26/2018 at 9:45 AM, Resident #29 was observed in his bed, lying on his side and listening to the radio. The resident reported that he was still experiencing some pain in his ribs but said it was, nothing like before. The resident expressed that he would like a bed rail on the side of his bed to prevent him from falling from his bed but said staff have told him that he does not need one. The resident was asked and said he had fallen from bed quite some time ago. The resident was asked if he had been given medication for his pain but seemed confused and could not provide a coherent answer. During an interview on 7/26/2018 at 3:15 PM, with the Administrator, DON, Regional Nurse, LVN A, and LVN B, this investigator asked if it was true that this resident was not issued any pain medication other than the extra strength Tylenol on 6/23/2018 following his fall. It was confirmed after reviewing the resident's MAR indicated [REDACTED]. The DON replied that the resident was a tough man and did not usually ask for medications. This investigator asked how the resident was being assessed for pain and was told by the DON that the resident would only have been assessed for pain had he been administered pain medication and also the resident was able to ask for pain medication and stated he was able to speak and answer questions. The DON added that the facility only, documents by exception, indicating that a pain assessment would have only beEN documented if the resident was experiencing pain and had been administered medication as a result. The DON agreed there was no documentation showing this resident was being assed for pain following the [DIAGNOSES REDACTED]. During an interview on 7/26/2018 at 3:50 PM, the DON was asked to show this investigator the resident's medications. The DON went to the resident's hall and opened the medication cart that contained the resident's medications but was unable to locate the resident's Tylenol #3. During an interview on 7/26/2018 at 4:15 PM, the DON said she recalled the resident's Tylenol #3 was pulled off the cart yesterday, because it was a PRN Narcotic, which according to policy, had to be discarded after 14 days from the order date. The DON was asked where this policy was and explained that it was, New State Policy. The DON was asked to reveal the order date for the resident's Tylenol #3. She logged onto her computer and then indicated that she forgot to input a drop off date, and took responsibility for the error. The DON and Regional Nurse were then asked to go to the drug destruction room and show this investigator the resident's Tylenol #3 medication. Upon arrival to the drug destruction room, the DON removed a large plastic bag from a locked drawer but was unable to locate the resident's medication. The DON then opined that the medication must not have been filled. The Regional Nurse said, No, that wouldn't happen. The DON then opined the drug must have already been destroyed, to which this investigator asked to see the drug destruction log and asked when the last destruction occurred, to which the DON said, .that would have been in June, before this resident's Tylenol #3 was filled, so she then agreed that Tylenol #3 would not yet have been destroyed. During an interview on 7/26/2018 at 5:15 PM with the Administrator, DON, Regional Nurse, and LVN A, the DON indicated the facility's doctor did not allow the facility's Physician Assistant to be a designee for orders, therefore the prescription was never filled and said she contacted the pharmacy and was told this prescription was never filled. This investigator then requested the DON supply written confirmation from the pharmacy that the order for Tylenol #3 was never filled and never arrived to the facility. It was further explained that there was concern as the resident was sent out for evaluation on 6/27/2018 after complaining of pain to his chest at a level 10 and subsequently being diagnosed with [REDACTED]. The DON explained once again that this resident was a tough man and opined that just getting out of the facility that day may have been, . all he needed. The DON was also reminded that this resident's BIMs Score went from a 12 in (MONTH) (YEAR) to a 5 in (MONTH) (YEAR) (post incident) and was unable to clearly explain or recall the pain he was experiencing post fracture diagnosis. During an interview on 7/27/2018 at 8:45 AM, the Administrator was asked if the facility had received the written confirmation from the pharmacy confirming the resident's Tylenol #3 was never filled or received by the facility. She explained the DON was still working on receiving this confirmation. The Administrator was asked if the pharmacy was located near this facility and responded that it was not. The Administrator was asked the location of the pharmacy and she explained that it was located in Bryan College Station, Texas. During an interview on 7/27/2018 at 9:50 AM, the Administrator and Regional Nurse, revealed they were in contact with the resident's pharmacy but said the pharmacy was unable to locate the fax that was sent by the facility confirming a request to fill the prescription. A request for written confirmation from the pharmacy was made but the pharmacy was in agreement that they could not locate a request made by the facility to fill the resident's Tylenol #3. During a telephone interview on 7/27/2018 at 1:30 PM, the PA revealed she assessed the resident on 6/26/2018 and discovered he was in a great deal of pain and was told by the resident that he had been experiencing pain throughout the weekend since he had his fall. She said facility staff were concerned the resident may be having heart related problems, however, that concern was ruled out following lab work. The PA indicated that she believed the resident's symptoms were more indicative of a muscular-skeletal problem. The PA said after she received the report on the resident following his imaging and [DIAGNOSES REDACTED]. The PA was asked if she had any problems getting prescriptions filled for residents who were under care of Dr. F to which she responded that she had not. The PA said that there were some medications that she could not write orders for but said Tylenol #3 was a medication she could prescribe without Physician authorization. Additionally, the PA said she discussed this prescription with a Dr. H who was said to have been overseeing the resident's care at the time and said this doctor was in agreement with this prescription and relayed that he could prescribe something more powerful if needed. The PA revealed that a rib fracture was a slow-healing type of injury that would involve a significant amount of pain throughout recovery. The PA agreed that a reasonable person would be expected to be in pain following this type of injury and would require pain medication which was why she wrote the prescription for Resident #29 During an interview on 7/27/2018 at 2:00 PM, LVN B said that PA E told her, I know you are going to need this script, and delivered the script around 4 or 5 pm that evening (6/27/2018). LVN B said she gave the DON the order just before leaving for the day. LVN B said staff make a copy of the prescription for the chart and send it to Med Chest and said the courier picks up the original later in the evening. When asked why the prescription was never filled, she opined that it was possible Medicine Chest may have forgotten to fill the prescription. During an interview on 7/27/2018 at 3:55 PM, the DON, acknowledged receiving the order for Tylenol #3 from LVN, B, and said she then sent the order to the pharmacy via fax and courier but was unable to provide confirmation. During an interview on 7/26/2018 at 4:15 PM, the DON said she recalled the resident's Tylenol #3 was pulled off the cart yesterday, because it was a PRN Narcotic, which according to policy, had to be discarded after 14 days from the order date. The DON was asked where this policy was and explained that it was, New State Policy. The DON was asked to reveal the order date for the resident's Tylenol #3. She logged onto her computer and then indicated that she forgot to input a drop off date, and took responsibility for the error. The DON and Regional Nurse were then asked to go to the drug destruction room and show this investigator the resident's Tylenol #3 medication. Upon arrival to the drug destruction room, the DON removed a large plastic bag from a locked drawer but was unable to locate the resident's medication once again. The DON then opined that the medication must not have been filled but then the Regional Nurse said, No, that wouldn't happen. The DON then opined the drug must have already been destroyed, to which this investigator asked to see the drug destruction log and asked when the last destruction occurred, to which the DON said would have been in June, before this resident's Tylenol #3 was filled, so she then agreed that it would not yet have been destroyed. The DON proceeded to walk with this investigator and the Regional Nurse to check all the facility's medication carts once more, again, unable to locate the resident's Tylenol #3. This investigator then asked the DON to call the pharmacy to see if this medication was ever filled. During an interview on 7/26/2018 at 5:15 PM with the Administrator, DON, Regional Nurse, and LVN A, the DON indicated the facility's doctor didn't allow the facility's Physician Assistant to be a designee for orders, therefore the prescription was never filled and said she contacted the pharmacy and was told this prescription was never filled. This investigator then requested the DON supply written confirmation from the pharmacy that the order for Tylenol #3 was never filled and never arrived to the facility. It was further explained that there was concern as the resident was sent out of evaluation on 6/27/2018 after complaining of pain to his chest at a level 10 and subsequently being diagnosed with [REDACTED]. The DON indicated that she understood this concern but explained once again that this resident was a tough man and opined that just getting out of the facility that day may have been, . all he needed. The DON was also reminded that this resident's BIMs Score went from a 12 in (MONTH) (YEAR) to a 5 in (MONTH) (YEAR) (post incident) and was unable to clearly explain or recall the pain he was experiencing post fracture diagnosis. During an interview on 7/27/2018 at 8:45 AM, the Administrator was asked if the facility had received the written confirmation from the pharmacy confirming the resident's Tylenol #3 was never filled or received by the facility. She explained the DON was still currently working on receiving this confirmation. The Administrator was asked if the pharmacy was located near this facility and responded that it was not. The Administrator was asked the location of the pharmacy and she explained that it was located in Bryan College Station, Texas. During an interview o 7/27/2018 at 9:50 AM, the Administrator and Regional Nurse, revealed they were in contact with the resident's pharmacy but said the pharmacy was unable to locate the fax that was sent by the facility confirming a request to fill the prescription was made. A request for written confirmation from the pharmacy was made so this investigator could confirm the pharmacy was in agreement that they could not locate a request to fill the medication by the facility. During a telephone interview on 7/27/2018 at 1:30 PM, A E revealed she assessed the resident on 6/26/2018 and discovered he was in a great deal of pain and was told by the resident that he had been experiencing pain throughout the weekend since he had his fall. She said facility staff were concerned the resident may be having heart related problems, however, that concern was ruled out following some labs. The PA indicated that she believed the resident's symptoms were more indicative of a muscular-skeletal problem. The PA said after she received the report on the resident following his imaging and [DIAGNOSES REDACTED]. The PA was asked if she had any problems getting prescriptions filled for residents who were under care of Dr. F to which she responded that she had not. The PA said she there were some medications that she could not write orders for but said Tylenol #3 was a medication she could prescribe without Physician authorization. Additionally, the PA said she discussed this prescription with a Dr. H who was said to have been overseeing the resident's care at the time and said this doctor was in agreement with this prescription and relayed that he could prescribe something more powerful if needed. The PA revealed that a rib fracture was a slow-healing type of injury that would involve a significant amount of pain throughout recovery. The PA agreed that a reasonable person would be expected to be in pain following this type of injury and would require pain medication which was why she wrote the prescription for Resident #29 During an interview on 7/27/2018 at 2:00 PM, LVN B said that PA E told her, I know you are going to need this script, and delivered the script around 4 or 5 pm that evening (6/27/2018). The LVN said she gave the DON the order just before leaving for the day and said DON likely put it in as an order and left it for the med chest courier. The nurse said staff make a copy of the prescription for the chart and send it to Med Chest and said the courier would pick up the original later in that evening. When asked why the prescription was never filled, she opined that it was possible Medicine Chest may have forgotten to fill the prescription. LVN B was asked to request a copy of treatment information from the hospital where the resident was sent on 6/26/2018. During an interview on 7/27/2018 at 3:55 PM, the DON, acknowledged receiving the order for Tylenol #3 from LVN, B, but could not adequately explain why this order was either not filled nor received by the facility. Record review of the facility's Controlled Substances Policy, effective date, 1/1/2010, stated: 2. Controlled medications are obtained from the locked cabinet or safe, or medication cart. 3. Current controlled medication accountability records and audit records are kept by the nursing facility. When completed, audit and accountability records are kept on file according to state and federal regulations. Record review of the facility documentation received from the facility, revealed 3 residents with orders for Tylenol #3 for pain management. Record review of the facility's Pharrmacy Services Policy, effective date, 11/28/2017, stated: . The facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility must employ or obtain the services of a licensed pharmacist who- Provides consultation on all aspects of the provision of pharmacy services in the facility. Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled . Record review of the facility documentation received from the facility, revealed 3 residents with orders for Tylenol #3 for pain management.