Every finding on record at Signature Healthcare of Rockwood Rehab & Wellness

Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician's order for the administration of supplemental oxygen (O2) for 2 residents (Resident #80 and Resident #10) of 8 residents reviewed for oxygen administration and the facility failed to ensure supplemental oxygen was available on 1 of 2 crash carts (a wheeled cart which carries medical equipment and supplies to provide emergency resuscitation) observed. The findings include: Review of the facility's policy titled, Oxygen Administration Policy, dated 1/30/2026, revealed .Oxygen therapy is administered as ordered by a physician .Check the resident's medical record to confirm the presence of a complete and appropriate physician's order .Determine appropriate oxygen source and equipment needed . Review of the medical record revealed Resident #80 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #80 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and received O2 therapy. Review of the medical record revealed Resident #80 did not have a Physician's Order for O2 therapy. During an observation on 8/3/2026 at 10:08 AM, in Resident #80's room revealed the resident sitting up in wheelchair with O2 infusing at 2.5 Liters per minute (L/m). During an observation on 8/4/2026 at 8:32 AM, in Resident #80's room revealed the resident lying in bed with oxygen infusing at 2.5 L/m. During an observation and interview on 8/5/2026 at 7:50 AM, in Resident #80's room revealed the resident eating breakfast in bed with oxygen infusing at 2.5 L/m. Resident #80 stated she wore O2 at home as needed at 2 L/m. During an interview on 8/5/2026 at 9:19 AM, Registered Nurse (RN) A stated Resident #80 did not have a Physician's Order for O2 therapy and was receiving supplemental O2 therapy. During an observation and interview on 8/5/2026 at 9:21 AM, in Resident #80's room revealed the resident lying in bed with O2 infusing at 2.5 L/m. RN A confirmed O2 was infusing at 2.5 L/m. During an interview on 8/5/2026 at 2:44 PM, the Director of Nursing (DON) confirmed Resident #80 did not have a Physician's Order for O2 therapy. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Respiratory Failure, Alzheimer's Disease with Late Onset, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #10 was unable to complete the BIMS assessment which indicated the resident had severe cognitive impairment. Review of a comprehensive care plan revised 7/3/2026, for Resident #10 revealed .Administer oxygen per order . Review of the Nurse's Notes for Resident #10 dated 7/16/2026, revealed .oxygen initiated via [by] nasal cannula [NC] . During an observation on 8/4/2026 at 7:35 AM, 8/4/2026 at 1:12 PM, 8/4/2026 at 3:49 PM and 8/5/2026 at 7:32 AM, in Resident #10's room revealed the resident resting in bed with O2 infusing at 3 L/m via nasal cannula. During an interview and observation on 8/5/2026 at 7:33 AM, in Resident #10's room the DON stated she had to verify the O2 order for Resident #10. The DON confirmed the resident was receiving O2 at 3 L/m via NC. Review of the Physician's Orders for Resident #10 dated 8/5/2026 at 7:47 AM (dated after the observation), revealed .Oxygen via NC @ [at] 3 Liters per minute .hypoxia [low levels of oxygen] . During an interview on 8/5/2026 at 7:50 AM, the DON confirmed she had entered the O2 order into the electronic medical record on 8/5/2026 and there was not a physician's order for O2 administration for Resident #10 prior to 8/5/2026 in the medical record. During an observation on 8/3/2026 at 11:57 AM, 8/4/2026 at 7:56 AM, and 8/5/2026 at 7:40 AM, revealed a crash cart on the [NAME] unit with an empty small O2 tank attached to the side of the cart. During an observation on the [NAME] unit and interview with RN A on 8/5/2026 at 7:44 AM, revealed a crash cart with an empty small O2 tank attached to the side of the cart. RN A confirmed the O2 tank on the crash cart was empty and stated there were other O2 tanks readily available in the facility for emergency use. During an observation on the [NAME] unit with the DON and interview on 8/5/2026 at 8:35 AM, observation with the DON confirmed the crash cart contained an empty small O2 tank attached to the side of the cart.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop a person-centered care plan related to dementia care for 1 resident (Resident #11) of 9 residents reviewed for Dementia care.The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 1/31/2026, revealed .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs .The Comprehensive Care Plan is based on a thorough assessment that includes .the Resident Assessment Instrument and Minimum Data Set Assessments (MDS) .The Comprehensive Care Plan will be person-centered for each resident . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Generalized Anxiety Disorder, and Moderate Dementia with Mood Disturbance. Review of the Physician's Orders for Resident #11 revealed .Medication .Start Date 04/30/2026 .Aricept [medication used to treat Dementia] .10 mg [milligram] .INDICATION-DEMENTIA .Once daily .Medication .Start Date .04/30/2026 .memantine [medication used to treat Dementia] .10 mg .INDICATION-DEMENTIA .Twice daily . Review of a quarterly MDS assessment dated [DATE], revealed Resident #11 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact and had a diagnosis of Non-Alzheimer's Dementia. Review of a comprehensive care plan dated 6/11/2026, revealed Resident #11 did not have a person-centered care plan with interventions developed related to the resident's Dementia diagnosis. Review of a Psychiatric Periodic Evaluation dated 6/25/2026, revealed Resident #11 was evaluated and treated by psychiatry for diagnoses including Anxiety, Delusional Disorder, and Dementia. Further review revealed .Patient is on medication for .Dementia Related Indications . During an interview on 8/5/2026 at 2:47 PM, the Director of Nursing confirmed Resident #11 did not have a person-centered care plan related to Dementia.

Based on observation and interview the facility failed to properly store medical supplies on 2 of 2 crash carts (a wheeled cart which carries medical equipment and supplies to provide emergency resuscitation) and 1 of 2 medication rooms observed for proper storage. The findings include: During an observation on [DATE] at 11:57 AM, [DATE] at 7:56 AM, and [DATE] at 7:40 AM, revealed a crash cart on the [NAME] unit with an Ambu-Bag (artificial manual breathing unit which forces air or oxygen into a patient's lungs to provide manual breathing support during emergencies or respiratory arrest) which had an expiration date of [DATE]. During an observation on the [NAME] unit and interview with Registered Nurse (RN) A on [DATE] at 7:44 AM, revealed a crash cart with an Ambu-Bag which had an expiration date of [DATE]. RN A stated night shift nurses were responsible for checking the crash carts for expired items. RN A confirmed the Ambu-Bag had an expiration date of [DATE]. During an observation on the [NAME] unit and interview with the DON on [DATE] at 8:35 AM, revealed a crash cart with an Ambu-Bag which had an expiration date of [DATE]. Further observation revealed the integrity of the Ambu-Bag was not compromised. The DON stated night shift nurses were responsible for checking the crash carts for expired items. The DON confirmed the Ambu-Bag had an expiration date of [DATE]. During an observation on [DATE] at 12:48 PM, [DATE] at 8:23 AM and [DATE] at 7:33 AM, revealed a crash cart on the [NAME] unit with an Ambu-Bag which had an expiration date of [DATE]. During an interview and observation on the [NAME] unit on [DATE] at 7:36 AM, Licensed Practical Nurse (LPN) B stated night shift nurses were responsible for checking the crash carts for expired items. LPN B confirmed the Ambu-Bag had an expiration date of [DATE]. During an observation on the [NAME] unit and interview with the Director of Nursing (DON) on [DATE] at 8:28 AM, revealed a crash cart with an Ambu-Bag which had an expiration date of [DATE]. Further observation revealed the integrity of the Ambu-Bag was not compromised. The DON stated night shift nurses were responsible for checking the crash carts for expired items. The DON confirmed the Ambu-Bag had an expiration date of [DATE]. During an observation on the [NAME] medication room and interview with RN C on [DATE] at 3:49 PM, revealed the following: 3- 24 Gauge (GA) intravenous (IV) catheters with an expiration date of [DATE]. 3- 24 GA IV catheters with an expiration date of [DATE]. 1- 20 GA IV catheters with an expiration date of [DATE]. 2- IV start kits with an expiration date of [DATE]. 5- Bacterial culture swabs with an expiration date of [DATE]. 1 box of COVID rapid tests which contained 2 test kits with an expiration date of [DATE]. RN C confirmed the items were expired and available for resident use. During an interview on [DATE] at 4:50 PM, the DON stated she checked the above items and confirmed all the items were expired and available for resident use.

Based on the Association for Professionals in Infection Control (APIC) and Epidemiology's Guide to Hand Hygiene Programs for Infection Prevention review, facility policy review, medical record review, observation, and interviews, the facility failed to use appropriate hand hygiene practices when providing wound care to 1 resident (Resident #3) of 1 resident reviewed with an in-house pressure wound. The findings include: Review of the Association for Professionals in Infection Control [APIC] and Epidemiology's Guide to Hand Hygiene Programs for Infection Prevention, dated 6/2015, revealed .Hand hygiene is widely recognized as the most important measure to prevent the spread of infection .Hand hygiene is one of the cornerstones of reducing healthcare-associated infections and preventing occupationally acquired infections .patient care .recommendations for hand hygiene .Gather supplies .Enter .room .HH [hand hygiene] .Don [apply] gloves and remove dressing .Discard old dressing and gloves .HH .Don gloves .clean site . Review of the facility's policy titled, Hand Hygiene Policy, dated 6/27/2025, revealed .To minimize the transmission of infectious agents and reduce the risk of healthcare-associated infections in residents .staff .visitors .All stakeholders should perform hand hygiene .after removing gloves . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Diabetes Mellitus, and Heart Failure. Review of a comprehensive care plan dated 7/2/2026 for Resident #3 revealed .Skin Integrity .unstageable open area to right buttocks .Wound care as ordered . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #3 was dependent for bed mobility and had an unstageable pressure ulcer. Review of the Physician's Orders for Resident #3 dated 8/5/2026, revealed .Cleanse wound .right buttocks .pat dry .apply .moistened gauze .cover with .foam border .daily . During an observation on 8/5/2026 at 11:18 AM, revealed the Wound Care Nurse donned (applied) gloves and prepared the wound care supplies for Resident #3. Further observation revealed the Wound Care Nurse placed the supplies on Resident #3's bedside table, removed gloves and failed to wash or sanitize the hands, donned a disposable gown, and had Certified Nursing Assistant (CNA) D turn Resident #3 (CNA D had gloves on) onto the left side. CNA D removed her gloves, failed to wash or sanitize her hands, and retrieved wipes (used for peri-care) from Resident #3's dresser. CNA D re-applied gloves, provided peri-care, removed the gloves, failed to wash or sanitize her hands, and retrieved an incontinence pad from Resident #3's dresser. CNA D donned another pair of gloves and positioned the incontinence pad under Resident #3. Observation of the wound to Resident #3's right buttocks did not have any signs or symptoms of infection. During an interview on 8/5/2026 at 11:57 AM, the Wound Care Nurse confirmed she failed to follow proper infection control practices when she failed to wash/sanitize her hands between each glove changes. During an interview on 8/5/2026 at 12:01 PM, CNA D confirmed she failed to wash/sanitize her hands between glove changes. During an interview on 8/5/2026 at 1:58 PM, the Director of Nursing (DON) confirmed hands should be sanitized between glove changes. The DON confirmed the Wound Care Nurse did not follow infection control practices when she provided wound care to Resident #3 or when CNA D provided incontinence care.

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (#50) of 24 residents reviewed for abuse. The findings include: Review of facility abuse policy titled Abuse Prevention Policy & Procedure revised 9/5/2018, showed .Abuse Is the willful infliction of injury .Willful means non- accidental, Physical abuse .'abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Includes, but is not limited to, hitting, slapping, pinching, kicking, controlling behavior through corporal punishment, or any similar touching of a resident that does not have an appropriate therapeutic purpose . Resident #50 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure, Hypothyroidism, Dementia with Agitation, Anxiety Disorder, and Hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had severe cognitive impairment. Review of a comprehensive care plan revised 5/6/2023 showed Resident #50 had exhibited behaviors of wandering, aggression, and agitation. Resident #61 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, Cerebral Ischemia, Disorders of the Brain, Mood Disorder, and Dementia. Review of a quarterly MDS assessment dated [DATE] showed Resident #61 had severe cognitive impairment. Review of a comprehensive care plan revised 5/6/2023 showed Resident #61 exhibited combative behaviors during care and during episodes of confusion.May grab staff if in his personal space . Review of a nursing note dated 5/6/2023 showed .male resident [#61] .began to curse her [Resident #50] and when she got beside male resident [#61] he grabbed her arm. This nurse separated the two residents [Residents #50 and #61] .found a bruise on left forearm [of Resident #50] where male resident [#61] grabbed her [Resident #50] . Review of a facility investigation dated 5/6/2023 - 5/11/2023 showed Resident #61 grabbed Resident #50's arm resulting in a bruised forearm. Resident #61 was put on 1:1 supervision following the incident. During an interview on 5/16/2023 at 1:35 PM, the administrator stated Licensed Practical Nurse (LPN) #1 was the only witness to the altercation between Resident #50 and Resident #61. During a telephone interview on 5/16/2023 at 2:07 PM, LPN #1 stated on 5/6/2023 Resident #61 was redirected from attempting to exit to an empty section of the facility, became agitated and was directed to the other end of the hallway. LPN #1 stated a few minutes later Resident #50 walked down the hall and Resident #61 began cursing Resident #50 as she got near and grabbed her left forearm causing bruising.

Based on review of the facility policy, medical record review, review of the facility investigation and interview, the facility failed to prevent resident versus resident altercations (abuse) for 2 residents (#4 and #5) of 7 residents reviewed for abuse. The findings included: Review of the facility policy, Abuse, Neglect and Misappropriation of Property, effective 5/27/2016, last revised 10/17/2022 showed, .Physical abuse .Includes, but is not limited to, hitting, slapping, punching or kicking . Medical record review showed Resident #4 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dysphagia, Malnutrition, and Depression. Resident #4 was severely cognitively impaired with impaired thought processes, wandered daily, but had no history of aggression towards self or others. Resident #4 had no psychotic or delusional behaviors and required assistance of one person for all activities of daily living. Medical record review showed Resident #5 was admitted to the facility on [DATE], with diagnoses including Dementia with Agitation and Behaviors, Chronic Obstructive Pulmonary Disease, Malnutrition, and Major Depression. Resident #5 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 2, had impaired thought processes but no history of aggression directed towards self or others. Resident #5 required assistance of one person for all activities of daily living. Review of the facility investigation and witness statements showed on 12/23/2022 around 9:43 PM, Resident #4 wandered into the doorway of Resident #5's room. Resident #5 became agitated with Resident #4's presence and approached her yelling at her to leave. As staff in close- proximity to both residents responded to separate them, Resident #4 slapped Resident #5 across her face with an open hand. Resident #5 retaliated, pushed Resident #4, who bumped against the door frame, then fell to the floor. Resident #4 sustained a superficial 0.5 centimeter (cm), sized skin tear to her right elbow, a 3 cm bruise to her right shoulder and redness to her right hip caused by her fall. Resident #5 was not injured. Interview with the Secure Unit Charge Nurse, Registered Nurse (RN) #2 on 1/10/2023 at 2:59 PM, at the secure unit nursing station, revealed on the day of the altercation neither resident exhibited any pattern of behavioral escalation or aggression prior to the incident. RN #2 reported staff members were present on the unit in close proximity to both residents escorting another resident to bed for the evening and heard Resident #5 begin to curse and yell at Resident #4 as she approached the doorway to Resident #5's room. Resident #5 was inside the room and Resident #4 approached from the hallway. As staff attempted to intercede, Resident #5 and Resident #4 met at the doorway. Resident #5 yelled at Resident #4 and without warning, Resident #4 slapped her. Immediately, Resident #5 retaliated and pushed Resident #4 who lost her balance, bounced off the door frame, and fell to the floor before a staff member behind her could get between the two residents. The residents were immediately separated with Resident #4 taken to her room and placed on 1 to 1 supervision after she was assessed for injuries. A small skin tear less than dime-sized on her arm was covered with a band aid. Resident #5 was also monitored 1 to 1 for around 30 minutes before she retired for the evening and was then placed on every 15- minute checks. Resident #4 remained on 1 to 1 supervision for about two hours as she remained awake, but once she retired for the evening, was also changed to every 15- minute checks. Both residents had no recall of the incident by the next morning and remained on every 15- minute checks for 48 hours without further incident. RN #2 reported at time of the incident on 12/23/2022, the unit was staffed with a supervising nurse and 2 Certified Nurse Assistants (CNAs) for 4 residents present. RN #2 stated the incident was reviewed in the morning shift change report as well as the morning leadership meeting on 12/24/2022. Interview with the Director of Nursing (DON) and Administrator on 1/11/2023, at 3:30 PM in the conference room, confirmed the resident versus resident altercation had occurred, both residents exhibited willful acts of aggression as documented in the facility investigation. The Administrator confirmed the facility failed to prevent resident abuse. Facility corrective actions included: 1. 12/23/2022, Resident #4 and Resident #5 were immediately separated and placed on 1 to 1 supervision. Both were assessed for injuries by the supervising nurse. Resident #4 had a band aid applied to a superficial skin tear on her arm. Resident #4 was placed on 1 to 1 supervision until she calmed and fell asleep. Afterwards she was maintained on every 15- minute checks. Resident #5 was also placed on 1 to 1 supervision until she calmed and retired for the evening. After she was asleep, she too was placed on every 15-minute checks. Both residents remained on every 15- minute checks for 48 hours with no further behaviors or altercations. Review of facility documentation and medical record review confirmed 15-minute checks were completed. 2. Plans of care were updated for both Residents on 12/23/2022. A stop sign was added to the door for Resident #5's room to deter others from wandering into the room. Interventions to redirect and use snack items to reduce wandering in Resident #4 were added to her care planned interventions as previously identified triggers for wandering in Resident #4, included hunger. Review of the care plans confirmed the care plans were updated and interview with staff confirmed their knowledge of the care plan updates. 3. Skin Assessments for all other persons on the secure unit were performed on 12/23/2022 with no negative findings. Review of documentation confirmed skin checks were completed. 4. On 12/24/2022 Resident #5 demanded the stop sign on her door be removed. The request was honored. The care plan was updated again to reflect removal of the barrier. Review of the care plan confirmed the care plan was updated to reflect the change. 5. On 12/25/2022 every 15- minute checks for both residents were discontinued, close monitoring by secure unit staff continued. No further altercations or problem behaviors were present in either resident. 6. On 12/26/2022 the facility held an ad hoc QA (Quality Assurance) meeting related to the incident. A root cause analysis (RCA) was completed. Psychiatric services were ordered to evaluate both residents post incident. Staff training in relation to the incident was formulated and implementation of the training started. Training included review of the abuse policy and review of all updated interventions implemented for both residents on the care plans. Review of facility documentation confirmed completion of the QA meeting and review of training records confirmed completion of training. Staff interviews conducted confirmed staff's knowledge of implemented interventions. 7. On 12/28/2022 Psychiatric Evaluations of both residents were completed by the Psychiatric Nurse Practitioner with no negative findings and no changes to the psychiatric regimens of either resident. Follow-up evaluations by the medical staff were also completed with no negative findings or changes to the medical regimens for both residents. Review of the medical records confirmed psychiatric evaluations were completed. 8. On 12/29/2022 the meal tray orders for Resident #4 were adjusted to include increased portions in addition to extra evening snacks to reduce hunger. Review of facility documentation confirmed the updates to the resident's meal tray orders. 9. On 12/30/2022, all mandatory staff training implemented in response to the incident, with post testing, was completed. All staff passed testing as required. Review of facility documentation confirmed education was completed and interviews with staff confirmed staff's knowledge and understanding of received education. 10. On 12/30/2022 the Interdisciplinary Team (IDT) team and QAPI (Quality Assurance and Performance Improvement) team implemented plans for ongoing monitoring of the interventions, to be performed by nursing management as designed by the DON or Administrator, during the morning whiteboard and 24- hour report meeting, Mondays through Fridays and report any significant findings to the QAPI committee for 4 weeks. The findings will be reported to the full QAPI committee for 2 months with the first review held at the end of January 2023. The QAPI committee will evaluate the need for continued monitoring after the second report in February 2023.

Based on review of a facility policy, medical record review, and interview, the facility failed to convey resident information to the receiving provider during a transfer for 1 resident (#1) of 3 residents reviewed for transfer and discharge. The findings included: Review of a facility policy Transfer/Discharge Notice last reviewed 9/5/2018 showed .Documentation of transfers include .1. a. The reason for transfer or discharge .3. Information provided to the receiving facility should include a. contact information of the practitioner responsible for the care of the resident. b. representative information including contact information. c. Advanced directive information. d. Special instructions for ongoing care. e. Comprehensive care plan goals. f. any other applicable information, including discharge summary, as applicable, to ensure a safe and effective transfer . Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Nursing Progress Note dated 2/28/2022 showed .Patient found to be less responsive this AM. Patient will open eyes during stimulation only and has altered mental status. Vital Signs WNL [within normal limits] except elevated pulse. MD [Medical Doctor] notified and orders received to transport to ER [emergency room ] via EMS [Emergency Management Services]. EMS, son, and [hospital] ER notified . Review of Resident #1's EMS Ticket Authorization dated 2/28/2022 showed .Chief Complaint AMS [altered mental status] .Secondary Complaint [CONDITION(S)] [low blood pressure] hypovolemic [low blood volume] .Signs Symptoms Cognitive Functions and Awareness altered mental status .Pt. [patient] history listed in PCR [patient care record] obtained from staff but realized they had given wrong paperwork for Pt . Review of Emergency Documentation dated 2/28/2022 showed .Pt. arrived to ED [emergency department] at 8:39 AM via EMS; per EMS report they were called to the pt. facility, SNF [Skilled Nursing Facility] for altered mental status and reported to ED [Emergency Department] RN [Registered Nurse] that on arrival they were told by staff that pt. had been declining over the past 3 days; EMS states they noted pt. very lethargic and only responsive to discomfort/painful stimuli .ED RN noted pt. presenting as lethargic and responds with stimulation with a sluggish verbal response; Facility had not called ED report and when RN placed call to facility to get information was left on hold with no pickup/answer for >[greater than] 10 minutes; no paperwork sent with pt. so as MD asked for current medication list there was only from previous [hospital] visit; continuing to attempt to get a hold of staff to gain SNF records while RN cared for pt.; staff will continue to attempt communication with facility to obtain records or further information . During an interview with Resident #1's Family Member #1 on 9/28/2022 at 10:45 AM, she stated .when they [nursing home] found her unresponsive, I went to the hospital. They [hospital staff] stated she did not have a chart. They [nursing home] had not sent her chart with her . During an interview with Registered Nurse #1 on 9/28/2022 at 3:15 PM, she stated .we are required to send the resident's face sheet, a CCD [continued care document], and transfer form .I sent paperwork with her .EMS usually reviews paperwork prior to leaving the building . During an interview with the Director of Nursing on 10/5/2022 at 11:25 AM, she stated .her [Resident #1] medical record was accessed on 2/28/2022 at 7:42 AM. Her face sheet and CCD document was accessed by [Licensed Practical Nurse #5]. The paperwork was accessed; something happened to the paperwork between here and the ambulance transport and delivery. There is a nurses' progress note on 2/28/2022 that [hospital] was notified of transport to the hospital. It is our policy to send the CCD form with a transfer or discharge which includes the face sheet, MAR [Medication Administration Record], diagnoses, allergies, vital signs, vaccinations, and care plan. Per EMS documentation and hospital documentation her CCD was not received by EMS or the hospital .

Based on facility policy review, medical record review, and interview, the facility failed to follow a Physician's order to obtain a daily blood glucose level for 1 resident (Resident #1) of 3 residents reviewed for blood glucose monitoring. The findings include: Review of the facility's policy titled Physician Orders dated 11/16/2019 showed .Nurse receiving order is responsible for complete order documentation .Medications placed in Electronic Medical Record . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #1's Care Plan dated 9/11/2021 showed .Resident at risk for .Diabetes complications .monitor blood glucose as ordered . Medical record review of a Physician's Order for Resident #1 dated 9/13/2021 showed .Chemsticks [test for blood glucose levels] in AM daily .DX [diagnoses] Type 2 Diabetes mellitus without complications . Medical record review of Resident #1's Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/10/2021 at 11:38 AM, Nurse Practitioner (NP) #1 revealed Resident #1's Diabetes Mellitus II was treated with [MEDICATION(S)] (medication taken by mouth to control blood sugar levels). Continued interview revealed daily chemsticks were not routinely ordered for residents who have their blood glucose levels maintained with [MEDICATION(S)], however, chemsticks had been ordered for Resident #1 per the family's request. NP #1 stated Resident #1's blood glucose levels were monitored weekly with the resident's lab work and had been within normal limits. During an interview on 11/10/2021 at 3:29 PM, Registered Nurse (RN) #1 stated she .put the chemstick order in the wrong category .I must have done it by mistake . Continued interview confirmed the order for chemsticks was not entered into Resident #1's EMAR. During an interview on 11/10/2021 at 3:55 PM, the Director of Nursing (DON) confirmed the facility failed to follow a Physician's order to obtain daily chemsticks for Resident #1 from 9/13/2021 through 10/27/2021.

Based on policy review, medical record review, review of facility documentation, observation and interviews the facility failed to prevent resident to resident abuse for 1 resident (#1) of 3 residents reviewed. The findings include: Review of Abuse, Neglect and Misappropriation of Property policy revised 5/8/2019 showed .Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain or mental anguish . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS (Minimum Data Set) dated 8/3/2020 showed Resident #1's BIMS (Brief Interview for Mental Status) score was 12. Further review showed the resident required extensive assistance for bed mobility, dressing, toilet use and personal hygiene. Continued review showed the resident was totally dependent for transfers. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's care plan dated 8/22/2020 showed the resident was care planned for psychosocial well-being. The resident was at risk for behaviors due to current restrictions regarding visitations. Further review showed Resident #2 was care planned for behavioral symptoms. The resident had experienced paranoid delusions of people wanting to kill and steal from him. Continued review showed the resident was confused, forgetful, disoriented, poor impulse control and decreased safety awareness. The care plan approach was to show the resident his boundaries - not to go into rooms that have stop signs or doors closed. Redirect if necessary. Further review showed Resident #2 had a history of [REDACTED]. The aggressive behaviors increased during periods of increased confusion, increased paranoid delusion or with adjusting to changes in the environment. The resident had an altercation with Resident #1 on 10/31/2020. The approach to the altercation on 10/31/2020 was to provide the resident 1:1 supervision and redirect if resident noted to go into other resident's rooms. Psychiatric consult was ordered. Medical record review of Resident #2's MDS dated [DATE] showed the resident's BIMS was 00 indicating Resident #2 was severely cognitively impaired. Further review showed the resident did not show any behaviors in the prior 2 weeks. Review of documentation provided by the facility showed Resident #2 was in Resident #1's room on 10/31/2020 at 11:23 PM. Further review showed Resident #2 was attempting to steal Resident #1's purse. The CNA (Certified Nurse Assistant) went into the room and observed Resident #2 hitting Resident #1 in the head with the call light causing 2 minor raised areas. The physician and families of both residents were notified. Resident #2 was redirected from the room and placed on 1:1 supervision. Medical record review of nurse's notes dated 11/1/2020 showed Resident #1 did receive 2 minor raised areas on her head from the incident. The staff performed 15 minute neuro checks with no concerns noted. The resident denied any pain or discomfort and did not show any signs/symptoms of distress or fear. Medical record review of a social worker's note dated 11/2/2020 showed Resident #1 was able to recall the incident. She remained calm and relaxed during the social worker's visit. She stated she was fine and had no fears. She agreed to a stop strip placed at her doorway. Interview with RN (Registered Nurse) #1 on 12/15/2020 at 1:30 PM showed Resident #2 did not have any aggressive behaviors following the 10/31/2020 incident. She stated he walks throughout the hallways during the day. She also stated he liked the day room and spent a lot of time with other residents and staff. RN #1 stated he had not gone into any rooms with the stop strip at the doorway. Observation of Resident #2 on 12/15/2020 at 10:00 AM showed the resident was in another resident's room. The resident was not in the room at that time. The resident was redirected by staff (no stop strip on the door). Resident #2 had a slow gait and ambulated throughout the hallways. The resident did not make eye contact with the staff and kept his head down. Resident #2 did not attempt to communicate with the staff. Interview with the ADON (Assistant Director of Nursing) on 12/15/2020 at 11:00 AM confirmed Resident #1 was struck by a call light by Resident #2.

Based on facility policy review, medical record review, personnel file review, facility investigation review, and interview, the facility failed to prevent misappropriation of property through failure to immediately remove staff suspected of abuse for 1 (#3) resident of 5 residents reviewed. The findings include: Review of the Facility Policy, Abuse, Neglect and Misappropriation of Property, revision date 5/8/2019, revealed, .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated . Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Coaching & (and) Counseling Session, dated 11/19/2019, for Registered Nurse (RN) #2, revealed a written warning for .results of narcotic audit in findings of 1 narcotic discrepancy/missing narcotic .unable to produce the documentation of the narcotic sign out sheet .the MAR (Medication Administration Record) showed less documentation for narcotic administration than present in the copy of the narcotic sheet . Review of the Physician's Order, dated 3/20/2020, revealed Resident #3 was ordered [MEDICATION NAME] HCL (narcotic pain medication) 10 milligram (mg) tablet, 1 tablet orally every 6 hours as needed for pain. The discontinuation date was 4/3/2020. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], for Resident #3 revealed a Brief Interview of Mental Status (BIMS) of '1', indicating severe cognitive deficit. Further review revealed Resident #3 had occasional pain with moderate intensity. Review of the Staffing Time Sheets, dated 4/1/2020 - 4/6/2020 showed, RN #2 worked 12 hour shifts on 4/1/2020, 4/2/2020, 4/3/2020, 4/4/2020, and 4/5/2020 for a total of 5 twelve hour shifts from approximately 7:00 PM to 7:00 AM and left the facility after 7:00 AM on 4/6/2020. Review of the facility investigation dated 4/1/2020 revealed the facility received 120 tablets of [MEDICATION NAME] HCL 10 mg for Resident #3 at 2:10 PM on 4/2/2020 at 8:50 PM. Review of a police report dated 4/2/2020 at 7:10 PM, revealed a complaint of theft of medication .120 [MEDICATION NAME] 10 mg were taken from the facility sometime between 7:00 PM 4/1/2020 and 7:00 AM 4/2/2020 .medication as being present at shift change 7:00 PM 4/1/2020. The employee that come on shift at 7:00 PM (RN#2) and she worked until 7:00 AM 4/2/2020 when the medication was discovered missing. Also missing were the sheet and card that are kept with the meds . Review of the facility investigation, initiated 4/2/2020, revealed Licensed Practical Nurse (LPN) #1, attempted to give Resident #3 an [MEDICATION NAME] 10 mg tablet at approximately 5:00 PM, but none were in the locked narcotic box located within the assigned medication cart. He called the pharmacy for an authorization to remove an [MEDICATION NAME] from the Emergency Drug Box. At that time, pharmacy refused his request based on delivery of 120 tablets of [MEDICATION NAME] 10 mg on 4/1/2020 for Resident #3. LPN #1 notified the Unit Manager LPN #2 who notified the Director of Nursing (DON). Continued documentation revealed .(RN #2) was suspended pending investigation . Further review revealed RN #2 signed out 7 tablets of [MEDICATION NAME] 10 mg tablets on the control count sheet from 4/4/2020 - 4/6/2020, but did not document the administration to Resident #3. This was after an automatic discontinue date of 4/3/2020. On 4/6/2020 the facility unsuccessfully attempted to notify RN #2 by telephone of suspension pending results of the investigation. On 4/9/2020 RN #2 was terminated for .not following policy and procedure .had history of related incident and prior disciplinary action involving controlled medication .the facility is unable to account for the medication or count . Review of the Controlled Drug Record dated 4/3/2020 - 4/6/2020, revealed the following [MEDICATION NAME] 10 mg tablets signed out by RN #2: 2 doses on 4/3/2020, 2 doses on 4/4/2020, 3 doses on 4/5/2020, and 2 doses on 4/6/2020. The medications were not documented on the MAR. Review of the Medication Administration History revealed Resident #3 received 2 doses of the [MEDICATION NAME] on 4/3/2020 signed off by RN #2. There was no further documentation of [MEDICATION NAME] administered to Resident #3. Review of the Stakeholder Suspension Form - Investigation, dated 4/6/2020, revealed RN #2 was placed on suspension for the misappropriation of property dated 4/2/2020. Review of the Coaching Counseling Session, dated 4/9/2020, revealed RN #2 was terminated, .consistently failed to ensure accuracy of controlled medications, additionally signed out narcotics .(without) an order or documentation . During an interview with the DON and the Corporate RN, on 10/19/2020 at 2:25 PM, in the Conference Room, the DON revealed the Unit Manager/LPN #2 signed for the 120 tablets of [MEDICATION NAME] on 4/1/2020, at shift change (7 PM) she counted narcotics with RN #2 and the count was correct. LPN #3 counted with RN #2 at 7 AM, on 4/2/2020 and with LPN #1 at 3:00 PM, the same day .they counted the narcotics, but the [MEDICATION NAME] wasn't added into the card count because they weren't added to the reconciliation sheet. RN #2 returned to work on 4/2/2020 for the 7:00 PM shift and was assigned the same medication cart. On 4/2/2020 at 8:50 PM, RN #2 signed for an additional 12 tablets of [MEDICATION NAME] 10 mg tablets for Resident #3. During the interview the DON confirmed she entered the facility on 4/2/2020 at 6:45 PM, to investigate the misappropriation of property. The DON confirmed RN #2 was working the medication cart in question with the missing [MEDICATION NAME]. The DON notified the police department. The DON confirmed RN #2 worked the 7:00 PM to 7:00 AM shift the evening of 4/2/2020 .I hadn't finished the investigation . She was aware both the [MEDICATION NAME] and the sign out sheet were missing. During a telephone interview with LPN #2 on 10/19/2020 at 2:00 PM, she stated she accepted the 120 tablets of [MEDICATION NAME] 10 mg from the pharmacy on 4/1/2020 at 2:10 PM. She stated she counted the narcotics with RN #2, the count was correct at the shift change, and confirmed nursing typically worked 12-hour shifts. On 4/2/2020 LPN #1 called her at home to report there were no [MEDICATION NAME] for Resident #3. She stated she came into the facility. At that time, she saw RN #2 working the same area with the medication cart in question, for the 7:00 PM shift. During an interview with the DON and the Regional Corporate RN, on 10/21/2020 at 11:25 PM, in the Conference Room, the DON stated .(RN#2) had signed the manifest for the [MEDICATION NAME], when (LPN#3) came in, she didn't know they ([MEDICATION NAME]) existed, when (LPN#1) came in, they ([MEDICATION NAME]) weren't there .pharmacy denied his request to get more . The DON confirmed she was aware of the missing [MEDICATION NAME] on 4/2/2020 at 6:45 PM; started the investigation at that time; and the facility failed to suspend RN #2 until 4/6/2020. The DON stated the facility determined RN #2 diverted the medication. The DON also confirmed from 4/2/2020 to 4/6/2020 RN #2 worked 5 additional 12-hour shifts; RN #2 signed the Controlled Drug Record after 4/3/2020 to indicate she gave 7 tablets of [MEDICATION NAME] to Resident #3 without a physician's order and no documentation the resident received the medication. The facility confirmed they were unable to account for 7 additional doses of [MEDICATION NAME] for Resident #3.

Based on facility policy review, medical record review, personnel file review, facility investigation review, and interview, the facility failed to prevent misappropriation of property evidenced with failure to immediately remove staff suspected of abuse for 1 (#3) resident of 5 residents reviewed. The findings include: Review of the Facility Policy, Abuse, Neglect and Misappropriation of Property, revision date 5/8/2019, revealed, .if the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated . Record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Coaching & (and) Counseling Session, dated 11/19/2019, for Registered Nurse (RN) #2, revealed a written warning for .results of narcotic audit in findings of 1 narcotic discrepancy/missing narcotic .unable to produce the documentation of the narcotic sign out sheet .the MAR (Medication Administration Record) showed less documentation for narcotic administration than present in the copy of the narcotic sheet . Review of the Physician's Order, dated 3/20/2020, revealed Resident #3 was ordered [MEDICATION NAME] HCL (narcotic pain medication) 10 milligram (mg) tablet, 1 tablet orally every 6 hours as needed for pain. The discontinuation date was 4/3/2020. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], for Resident #3 revealed a Brief Interview of Mental Status (BIMS) of '1', indicating severe cognitive deficit. Further review revealed Resident #3 had occasional pain with moderate intensity. Review of the Staffing Time Sheets, dated 4/1/2020 - 4/6/2020 showed, RN #2 worked 12 hour shifts on 4/1/2020, 4/2/2020, 4/3/2020, 4/4/2020, and 4/5/2020 for a total of 5 twelve hour shifts from approximately 7:00 PM to 7:00 AM and left the facility after 7:00 AM on 4/6/2020. Review of the facility investigation dated 4/1/2020 revealed the facility received 120 tablets of [MEDICATION NAME] HCL 10 mg for Resident #3 at 2:10 PM on 4/2/2020 at 8:50 PM. Review of a police report dated 4/2/2020 at 7:10 PM, revealed a complaint of theft of medication .120 [MEDICATION NAME] 10 mg were taken from the facility sometime between 7:00 PM 4/1/2020 and 7:00 AM 4/2/2020 .medication as being present at shift change 7:00 PM 4/1/2020. The employee that come on shift at 7:00 PM (RN#2) and she worked until 7:00 AM 4/2/2020 when the medication was discovered missing. Also missing were the sheet and card that are kept with the meds . Review of the facility investigation, initiated 4/2/2020, revealed Licensed Practical Nurse (LPN) #1, attempted to give Resident #3 an [MEDICATION NAME] 10 mg tablet at approximately 5:00 PM, but none were in the locked narcotic box located within the assigned medication cart. He called the pharmacy for an authorization to remove an [MEDICATION NAME] from the Emergency Drug Box. At that time, pharmacy refused his request based on delivery of 120 tablets of [MEDICATION NAME] 10 mg on 4/1/2020 for Resident #3. LPN #1 notified the Unit Manager LPN #2 who notified the Director of Nursing (DON). Continued documentation revealed .(RN #2) was suspended pending investigation . Further review revealed RN #2 signed out 7 tablets of [MEDICATION NAME] 10 mg tablets on the control count sheet from 4/4/2020 - 4/6/2020, but did not document the administration to Resident #3. This was after an automatic discontinue date of 4/3/2020. On 4/6/2020 the facility unsuccessfully attempted to notify RN #2 by telephone of suspension pending results of the investigation. On 4/9/2020 RN #2 was terminated for .not following policy and procedure .had history of related incident and prior disciplinary action involving controlled medication .the facility is unable to account for the medication or count . Review of the Controlled Drug Record dated 4/3/2020 - 4/6/2020, revealed the following [MEDICATION NAME] 10 mg tablets signed out by RN #2: 2 doses on 4/3/2020, 2 doses on 4/4/2020, 3 doses on 4/5/2020, and 2 doses on 4/6/2020. The medications were not documented on the MAR. Review of the Medication Administration History revealed Resident #3 received 2 doses of the [MEDICATION NAME] on 4/3/2020 signed off by RN #2. There was no further documentation of [MEDICATION NAME] administered to Resident #3. Review of the Stakeholder Suspension Form - Investigation, dated 4/6/2020, revealed RN #2 was placed on suspension for the misappropriation of property dated 4/2/2020. Review of the Coaching Counseling Session, dated 4/9/2020, revealed RN #2 was terminated, .consistently failed to ensure accuracy of controlled medications, additionally signed out narcotics .(without) an order or documentation . During an interview with the DON and the Corporate RN, on 10/19/2020 at 2:25 PM, in the Conference Room, the DON revealed the Unit Manager/LPN #2 signed for the 120 tablets of [MEDICATION NAME] on 4/1/2020, at shift change (7 PM) she counted narcotics with RN #2 and the count was correct. LPN #3 counted with RN #2 at 7 AM, on 4/2/2020 and with LPN #1 at 3:00 PM, the same day .they counted the narcotics, but the [MEDICATION NAME] wasn't added into the card count because they weren't added to the reconciliation sheet. RN #2 returned to work on 4/2/2020 for the 7:00 PM shift and was assigned the same medication cart. On 4/2/2020 at 8:50 PM, RN #2 signed for an additional 12 tablets of [MEDICATION NAME] 10 mg tablets for Resident #3. During the interview the DON confirmed she entered the facility on 4/2/2020 at 6:45 PM, to investigate the misappropriation of property. The DON confirmed RN #2 was working the medication cart in question with the missing [MEDICATION NAME]. The DON notified the police department. The DON confirmed RN #2 worked the 7:00 PM to 7:00 AM shift the evening of 4/2/2020 .I hadn't finished the investigation . She was aware both the [MEDICATION NAME] and the sign out sheet were missing. During a telephone interview with LPN #2 on 10/19/2020 at 2:00 PM, she stated she accepted the 120 tablets of [MEDICATION NAME] 10 mg from the pharmacy on 4/1/2020 at 2:10 PM. She stated she counted the narcotics with RN #2, the count was correct at the shift change, and confirmed nursing typically worked 12-hour shifts. On 4/2/2020 LPN #1 called her at home to report there were no [MEDICATION NAME] for Resident #3. She stated she came into the facility. At that time, she saw RN #2 working the same area with the medication cart in question, for the 7:00 PM shift. During an interview with the DON and the Regional Corporate RN, on 10/21/2020 at 11:25 PM, in the Conference Room, the DON stated .(RN#2) had signed the manifest for the [MEDICATION NAME], when (LPN#3) came in, she didn't know they ([MEDICATION NAME]) existed, when (LPN#1) came in, they ([MEDICATION NAME]) weren't there .pharmacy denied his request to get more . The DON confirmed she was aware of the missing [MEDICATION NAME] on 4/2/2020 at 6:45 PM; started the investigation at that time; and the facility failed to suspend RN #2 until 4/6/2020. The DON stated the facility determined RN #2 diverted the medication. The DON also confirmed from 4/2/2020 to 4/6/2020 RN #2 worked 5 additional 12-hour shifts; RN #2 signed the Controlled Drug Record after 4/3/2020 to indicate she gave 7 tablets of [MEDICATION NAME] to Resident #3 without a physician's order and no documentation the resident received the medication. The facility confirmed they were unable to account for 7 additional doses of [MEDICATION NAME] for Resident #3.

Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to prevent abuse for 1 resident (Resident #3) of 6 residents reviewed for abuse, resulting in Resident #3 being hit by another resident. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, dated 5/8/2019, showed .It is the organization's intention to prevent the occurrence of abuse . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . No injuries were noted. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #3 dated 8/30/2019 and reviewed on 11/13/2019 revealed the resident had an intermittent [MEDICAL CONDITION] and would cuss at staff and make threats toward roommates. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #3 scored an 8 (moderate cognitive impairment) on the Brief Interview for Mental Status. The resident had no behaviors during the look back period. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Care Plan dated 1/24/2020 showed Resident #1 was assessed for behaviors including verbal aggression toward others, including yelling and threatening others, and physical aggression toward others. Review of an admission MDS dated [DATE] showed the Resident #1 had short and long term memory problems and had exhibited verbal behaviors towards others 1-3 days during the look back period. During an interview on 2/19/2020 at 2:02 PM, Certified Nursing Assistant (CNA) #1 stated .(Resident #3) was upset .(Resident #1) was punching (Resident #3) on his head . During an interview on 2/19/2020 at 2:55 PM, CNA #2 stated .heard (Resident #3) hollering .went to check on him .(Resident #1) was hitting (Resident #3) .told him we can't hit other people . During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to prevent abuse to Resident #3.

Based on review of facility policy, review of a facility investigation, medical record review, and interview, the facility failed to report an allegation of abuse to the State Survey Agency within 2 hours for 1 resident (Resident #3) of 6 residents reviewed for abuse. The findings include: Review of the facility's policy Abuse, Neglect and Misappropriation of Property, dated 5/8/2019, revealed .all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made . Review of a facility investigation dated 2/5/2020 showed .(Resident #1) in (Resident #3's) room standing over him and (Resident #1) was observed hitting the resident (Resident #3) in the forehead with his fist . The incident was reported to the State Survey Agency on 2/6/2020 at 4:14 PM (the next day). Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 2/19/2020 at 3:00 PM, the Administrator confirmed the facility failed to report the incident to the State Survey Agency within 2 hours after the incident occurred. Refer to F-600

Based on review of facility policy, medical record review, observation, and interview, the facility failed to revise the care plan to include the use of the back and collar brace for 1 resident (#35) of 25 residents reviewed for care plans. The findings include: Review of the facility policy, Comprehensive Care Plans, revised 7/19/18, revealed .Each resident's Comprehensive Care Plan is designed to .incorporate identified problem areas; incorporate risk factors associated with identified problems . Medical record review revealed Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #35's Current Comprehensive Care Plan, dated 6/28/19, revealed no documentation of the back and collar brace. Medical record review of the Admission Minimum (MDS) data set [DATE] revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment, and was unable to complete the interview. Medical record review of Physician Order Report revealed .7/11/19 .Back and collar brace .Special Instructions: Resident needs to wear her back and collar brace . Observation of Resident #35 on 10/14/19 at 2:46 PM, in the main dining room revealed Resident #35 was smiling and engaged in a group bingo activity. Interview with the Unit Manager (UM) #1 on 10/15/19 at 2:42 PM, confirmed she was unaware of the brace. Further interview confirmed it was UM #1's responsibility to apply the brace. Interview with Corporate Nurse #1 on 10/16/19 at 9:13 AM, in the conference room, confirmed it was her expectation that the brace intervention be care planned. Further interview confirmed the brace was not included on Resident #35's Current Comprehensive Care Plan .it's not on there .

Based on facility policy review, medical record review, review of the facility's falls documentation, observation, and interview, the facility failed to implement appropriate interventions to prevent falls, failed to complete a fall risk assessment, and failed to complete a fall investigation for 1 resident (#70) of 3 residents reviewed for accidents. The findings include: Review of the facility Falls Policy, dated 7/16/19, revealed .All residents will have a comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition .Appropriate care plan interventions will be implemented and evaluated as indicated by assessment .If a fall occurs the following actions will be taken .Evaluate resident .Document the evaluation, pertinent facts and incident . Medical record review revealed Resident #70 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #70's Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had severe cognitive impairment. Continued review revealed the resident required extensive assist of 1 staff member for bed, transfer, and dressing. Medical record review of Resident #70's Fall Risk Assessment, dated 3/21/19, revealed a score of 24, a score of 10 or greater, indicated the resident was at high risk for falls. Review of the facility Falls Investigation, dated 4/18/19, revealed Resident #70 had a fall without injury. Review of a facility Falls Investigation, dated 6/20/19, revealed .Fall without injury . Continued review revealed the fall investigation had not been completed. Medical record review of Resident #70's Fall Risk Assessment, dated 7/18/19, revealed a score of 18, a score of 10 or greater, indicated the resident was at high risk for falls. Review of a facility Falls Investigation, dated 8/20/19, revealed the resident had an unwitnessed fall without injury. Medical record review of the Comprehensive Care Plan dated 9/19/19, revealed a new fall intervention had not been implemented after the falls on 6/20/19 and 8/20/19. Medical record review of the Fall Risk Assessment revealed a quarterly falls risk assessment had not been completed for 9/24/19. Observation of Resident #70 on 10/15/19 at 7:40 AM, in the residents room, sleeping in bed. Interview with the Interim Director of Nursing on 10/16/19 at 12:05 PM, in the conference room, confirmed the facility failed to follow their falls policy, failed to complete a falls investigation, failed to complete falls risk assessments and failed to implement appropriate falls interventions to prevent falls for Resident #70.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with undated, unlabeled foods, expired foods, opened to air food items, and dirt and/or debris in 1 of 3 food storage bins, and improper cleaning of 1 of 3 food storage bins in the kitchen. The facility failed to maintain sanitary resident nourishment refrigerators with undated, unlabeled foods and expired foods, in 3 of 3 food nourishment refrigerators affecting 75 of 76 residents. The findings include: Review of facility policy Food Storage with a revised date of [DATE] revealed . Food items should be stored .with good sanitary practice .Any expired or outdated food products should be discarded .Use use-by-dates on all food stored in refrigerators .Remember to cover, label, and date .Dry storage .Clean and sanitize outside of food bins daily . Review of the facility policy Foods Brought by Family/Visitors with a review date of [DATE], revealed, .Perishable foods will be stored in re-sealable containers with tight fitting lids in the refrigerator .Containers will be labeled with the resident's name .Staff will discard perishable foods on or before the use by date . Observation and interview with the Dietary Manager (DM) on [DATE] at 9:,[DATE]:55 AM, in the kitchen, of the 2nd milk cooler, revealed: Seven 6 fluid ounce cartons of apple cranberry nutritional juice drinks, undated and available for resident use. Nine 6 fluid ounce cartons of orange nutritional juice drinks, undated, and available for resident use. Interview at this time with the DM confirmed the nutritional drinks were not dated, and the DM was unsure how long the nutritional drinks had been in the milk cooler, and was unaware of how to read the code (expiration date) on the nutritional drinks. Further interview confirmed the nutritional drinks were expired. Observation and interview with the DM on [DATE] at 9:42 AM, in the kitchen, revealed dark black and brown debris around the top of the sugar, flour, and cornmeal storage bins. Continued observation revealed dark brown and black debris in the cornmeal storage bin. Interview confirmed the facility failed to maintain the sugar, flour, and cornmeal storage bins in a sanitary manner. Observation and interview with the DM on [DATE] from 9:,[DATE]:02 AM, at the walk-in refrigerator, in the kitchen revealed: 3 pound bag of shredded cheddar cheese undated, open to air, and available for resident use. 1 half pound bag of shredded mozzarella cheese open to air, undated and available for resident use. 1 pound of sliced provolone cheese open to air, undated, and available for resident use. 8 pancakes in a plastic bag open to air, undated, and available for resident use. Interview with the DM at this time confirmed all items identified in the refrigerator were undated and open to air. Observation and interview with the DM, on [DATE] from 10:,[DATE]:06 AM, in the kitchen, revealed 2 slices of bread in a partially closed plastic bag open to air and available for resident use on the bread rack. Interview confirmed the facility failed to secure the open bread. Observation and interview with the DM on [DATE] at 9:,[DATE]:58 AM, of the secure unit nourishment refrigerator in the nursing station, revealed: Three, 4 ounce, low fat strawberry/banana yogurt cups with an expiration date of [DATE] and available for resident use. Interview with the DM at this time confirmed the yogurt cups were expired and available for resident use. Observation and interview with the DM on [DATE] at 10:,[DATE]:08 AM, of the 200 hall, nursing station, nourishment refrigerator revealed: Half a gallon carton of whole cultured buttermilk approximately ,[DATE]th full labeled with a resident's name and expired date of [DATE] available for resident use. Two opened, 24-ounce favored yellow sodas, ,[DATE] full, unlabeled without the resident's name, undated when opened, and available for resident use. Interview with the DM at this time confirmed the cultured milk had expired and the facility failed to discard the expired milk. Further interview confirmed the facility failed to label, and date sodas available for resident use. Observation and interview with the DM on [DATE] at 10:,[DATE]:16 AM, of the 300 hall, resident nourishment refrigerator, revealed: One, 20 ounce bottle of fruit punch electrolyte replacement drink, approximately ,[DATE] full, undated and unlabeled with a resident's name. Interview with the DM at this time confirmed the facility failed to label and date the fruit punch electrolyte replacement drink.

Based on medical record review and interview, the facility failed to complete an annual Minimum Data Set (MDS) for 1 resident (#1) of 25 residents reviewed. The findings include: Medical record review revealed Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS history, revealed Resident #1 had an entry MDS assessment completed on 3/26/18, a quarterly assessment was completed on 4/13/18, and no further assessments were noted in the system. Telephone interview with the Clinical Reimbursement Consultant on 9/19/18 at 5:10 PM, confirmed an annual MDS with an assessment reference date of 7/14/18, was initiated and not completed, and no further assessments have been completed for Resident #1.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to revise the Comprehensive Care Plan to address post fall interventions for 1 resident (#22) of 25 residents reviewed. The findings include: Review of the facility's Falls Policy Statement, undated, revealed .If a fall occurs the following actions will be taken: Update care plan . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed the resident was severely cognitively impaired, required maximum to total assistance with all activities of daily living, and had previously fallen. Medical record review of the Nursing Assessment for description of falls and the post fall interventions initiated dated: on 4/12/18 revealed the resident fell out of bed, and the post fall intervention was to assess the resident's normal routines; 4/30/18 the resident fell from the wheel chair, and the post fall intervention was to offer to assist the resident to bed after the evening meal; 5/14/18 the resident fell from the bed, and the post fall intervention was to monitor pain, place fall mats next to bed; 5/18/18 the resident fell from the bed, and the post fall intervention was to place fall mats to both sides of the bed; 6/12/18 the resident fell from the wheel chair, and the post fall intervention was to remove the wheel chair foot rests; 6/29/18 the resident fell from the bed, and the post fall intervention was to place fall mats next to the bed; 7/31/18 the resident fell from the bed, and the post fall intervention was to keep the resident close to the nurse's station; and on 8/5/18 the resident fell from the wheel chair, and the post fall intervention was to keep the resident close to the nurse's station and to assess the resident's routines. Medical record review of the Comprehensive Care Plan dated 4/17/18 revealed .At risk for fall related injury .assist resident with transfers as needed .anticipate resident needs .monitor for pain . with no further interventions to prevent further falls. Observation of Resident #22 on 9/17/18 to 9/19/18 at various times from 8:00 AM to 5:00 PM, revealed the resident was in the bed with a curved mattress, was very restless, but made no attempts to climb out of the bed. Interview with the Interim Director of Nursing on 9/19/18 at 7:25 PM, in the conference room, confirmed Resident #22's Comprehensive Care Plan had not been revised to address the post fall interventions.

Based on medical record review, observation, and interview, the facility failed to attempt a Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications for 1 resident (#38) of 5 residents reviewed for unnecessary medications of 25 residents sampled. The findings include: Medical record review revealed Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum (MDS) data set [DATE] revealed Resident #38 was easily annoyed and rummages through items, received antipsychotic, antidepressant, and antianxiety medications 7 days each week, and no GDR had been attempted. Medical record review of the physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED]. Medical record review of the monthly pharmacist reviews, revealed the pharmacist initialed each month the resident's medications were reviewed, with no recommendations for GDR of [MEDICAL CONDITION] medications. Observation on 9/19/18 at 2:30 PM, on the secure unit revealed Resident #38 was seated at the table in the day area with a busy cloth (promotes self-directed activity). Continued observation revealed the resident was calm and observed the activity taking place. Interview with the Corporate Regional Nurse on 9/19/18 at 5:30 PM, in the conference room confirmed no GDRs of Resident #38's [MEDICATION NAME], and [MEDICATION NAME] had been attempted since the resident's admission to the facility on [DATE].

Based on review of facility policy, observation, and interview, the facility failed to distribute and serve food under sanitary conditions for 1 unit of 3 units observed for dining, and failed to perform proper hand hygiene after providing peri-care for 1 resident of 2 residents observed for peri-care. The findings include: Review of the facility policy, Handwashing/Hand Hygiene, revised 8/2015 revealed .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations .Before and after assisting a resident with meals .After contact with objects (e.g., (for example) medical equipment} in the immediate vicinity of the resident .After removing gloves . Observation on 9/17/18 from 1:00 PM-1:07 PM, on the Harriman Unit revealed Certified Nursing Assistant (CNA) #2 delivered a lunch tray to Resident #29 in the resident's room, moved the resident's bedside table and exited the room without performing hand hygiene; CNA #2 then delivered a lunch tray to Resident #62, moved the resident's bedside table, touched the resident's bed and the privacy curtain, and exited the room without performing hand hygiene; CNA #2 proceeded to deliver a lunch tray and pour coffee for Resident #42, and exited the room without performing hand hygiene. Further observation revealed CNA #2 delivered a lunch tray to Resident #58, moved a soiled shirt from the bedside table, touched the linen on the resident's bed, moved the resident's bedside table, touched the call light which was laying on the bedside commode, placed the soiled clothes in a plastic bag, and carried the soiled clothes to the soiled utility room. Continued observation revealed CNA #2 did not perform hand hygiene and proceeded to the cart to retrieve another tray. Interview with CNA #2 on 9/17/18 at 1:07 PM, on the Harriman hallway, confirmed CNA #2 had failed to perform hand hygiene between residents and after contact with objects in the resident's rooms during the lunch meal tray pass. Interview with the Interim Director of Nursing (DON) on 9/17/18 at 3:00 PM, in the hall outside of the DON's office, confirmed staff was expected to perform hand hygiene between residents during the meal tray pass and after touching objects in the resident's room. Observation on 9/19/18 at 3:48 PM, in a resident's room of Certified Nursing Assistant (CNA) #1 providing peri-care for a resident revealed after CNA #1 completed the peri-care, the CNA touched the resident's blanket to place the blanket over the resident, repositioned the call light, and washed the bedpan, and then removed the contaminated gloves. Continued observation revealed CNA #1 did not perform hand hygiene after she removed the contaminated gloves, donned one new glove, and adjusted the resident's head of the bed. Interview with CNA #1 on 9/19/18 at 3:55 PM, on the Harriman hallway, confirmed she had not removed the contaminated gloves and performed hand hygiene after providing resident care prior to donning one new glove. Interview with the Interim Director of Nursing on 9/19/18 at 5:10 PM, in the conference room confirmed the facility failed to follow their facility policy regarding hand hygiene after resident care and before donning new gloves

Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to notify the physician of unrelieved pain for 1 resident (#186) of 3 residents reviewed for notification, of 40 residents reviewed. The facility's failure resulted in actual harm (unrelieved pain) to resident (#186). The findings included: Review of the facility's policy, Pain Management, undated, revealed .Whenever the results of pain assessments reveal that the resident's pain is not under control, the attending MD (medical doctor) should be notified . Medical record review revealed Resident #186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] (medication for pain) 5-325 MG (milligram) tablet .take one tablet by mouth every 6 hours as needed DX (diagnosis) pain . Medical record review of the Medication Administration Record [REDACTED]. Review of a facility investigation revealed Resident #186 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 (highest score for intact cognition). Continued review of a facility investigation witness statement dated 8/29/16 at approximately 8:00 AM, authored by Registered Nurse (RN) #3, revealed, .(Resident #186) stated, I was in pain all night long and I asked the nurse during the night to call the Doctor because the pain medicine was not working. The nurse did nothing as the night went along .I wish I could have just had my leg cut off at that time . Review of a facility investigation witness statement dated 8/29/16, authored by Certified Nurses Aide (CNA) #1, revealed CNA #1 came on shift at 11:45 PM on 8/28/16, and Resident #186 turned her call light on stating she was in a lot of pain. CNA #1 placed ice on Resident #186's leg and about an hour later Resident #186 turned her call light on again and asked for a pain pill. Further review of the witness statement revealed at 3:45 AM, Resident #186 turned her call light on needing to go to the restroom and almost fell coming out of the restroom because she said she was in so much pain. Review of a facility investigation witness statement dated 8/29/16, authored by CNA #2, revealed CNA #2 took over shift at 4:00 AM on 8/29/16 and CNA #1 was in Resident #186's room. The resident was in a great deal of pain and CNA #2 asked Licensed Practical Nurse (LPN) #1 if the resident could have her pain medication. LPN #1 stated it was too soon. Interview with RN #3 on 9/6/16 at 2:05 PM, confirmed she came in at 8:00 AM on 8/29/16 and was made aware by a CNA Resident #186 was in pain. Continued interview confirmed RN #3 talked with the resident, who said she was in severe pain and the night shift nurse was aware. LPN #1 came in with a pill at approximately 1:00 AM. Further interview confirmed the resident still had no pain relief 2 hours after the pain pill. Resident #186 told LPN #1 the pain was not relieved and the nurse said she couldn't get any more pain medication until 5:00 AM. Interview with Resident #186 on 9/6/16 at 2:55 PM, in the resident's room, confirmed the resident .had a spell Monday morning (8/29/16) and thought I was going to die .wasn't getting my pain medication . Telephone interview with LPN #1 on 9/7/16 at 7:34 PM confirmed she gave Resident #186 pain medication on 8/29/16 around 1:15 AM and 2 hours later the resident asked for more medication due to unrelieved pain. Continued interview confirmed LPN #1 did not give Resident #186 any medication at that time because it was too early, and she did not notify the physician of the continued pain. Interview with the Director of Nursing (DON) on 9/8/16 at 9:13 AM, in the DON's office, confirmed Resident #186 experienced unrelieved pain. Refer to F-309

Based on facility policy review, medical record review, review of facility investigation, and interview, the facility failed to provide adequate pain management for 1 resident (#186) of 3 residents reviewed for pain management, of 40 residents reviewed. The facility's failure to treat pain resulted in actual harm (unrelieved pain) to Resident #186. The findings included: Review of the facility's policy, Pain Management, undated, revealed .Whenever the results of pain assessments reveal that the resident's pain is not under control, the attending Medical Doctor (MD) should be notified . Medical record review revealed Resident #186 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].[MEDICATION NAME] (medication for pain) 5-325 MG (milligram) tablet .take one tablet by mouth every 6 hours as needed DX (diagnosis) pain . Medical record review of the Medication Administration Record [REDACTED]. Review of a facility investigation revealed Resident #186 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 (highest score for intact cognition). Continued review of a facility investigation witness statement dated 8/29/16 at approximately 8:00 AM, authored by Registered Nurse (RN) #3, revealed, .(Resident #186) stated, I was in pain all night long and I asked the nurse during the night to call the Doctor because the pain medicine was not working. The nurse did nothing as the night went along .I wish I could have just had my leg cut off at that time . Review of a facility investigation witness statement dated 8/29/16, authored by Certified Nurses Aide (CNA) #1, revealed CNA #1 came on shift at 11:45 PM on 8/28/16, and Resident #186 turned her call light on, stating she was in a lot of pain. CNA #1 placed ice on her leg and about an hour later the resident turned her call light on again and asked for a pain pill. Further review of the witness statement revealed at 3:45 AM, Resident #186 turned her call light on, needing to go to the restroom, and almost fell coming out of the restroom because she said she was in so much pain. Review of a facility investigation witness statement dated 8/29/16, authored by CNA #2, revealed CNA #2 took over shift at 4:00 AM on 8/29/16, and CNA #1 was in Resident #186's room. The resident was in a great deal of pain and CNA #2 asked Licensed Practical Nurse (LPN) #1 if the resident could have her pain medication. LPN #1 stated it was too soon. Review of a facility investigation witness statement dated 8/29/16, authored by LPN #4, revealed Resident #186 told LPN #4 she was awake every 2 hours the night before in excruciating pain. The resident stated she asked the nurse for pain medication, she brought something in, but it did not relieve the pain. Interview with RN #3 on 9/6/16 at 2:05 PM, confirmed she came in at 8:00 AM on 8/29/16 and was made aware by a CNA Resident #186 was in pain. Continued interview confirmed RN #3 talked with the resident, who said she was in severe pain and the night shift nurse was aware. LPN #1 came in with a pill at approximately 1:00 AM. Further interview confirmed the resident had no pain relief after 2 hours. Resident #186 told LPN #1 her pain was not relieved and the nurse said she couldn't get any more pain medication until 5:00 AM. Interview with Resident #186 on 9/6/16 at 2:55 PM, in the resident's room, confirmed .(Resident #186) had a spell Monday morning (8/29/16) and thought I was going to die . Telephone interview with LPN #1 on 9/7/16 at 7:34 PM, confirmed she gave Resident #186 pain medication on 8/29/16 around 1:15 AM and 2 hours later the resident asked for more medication due to unrelieved pain. Continued interview confirmed LPN #1 did not give Resident #186 any medication at that time because it was too early and she did not notify the physician of the continued pain. Interview with CNA #1 on 9/8/16 at 7:26 AM, in the Chapel on the skilled unit, confirmed she worked 11:00 PM to 4:00 AM on 8/28/16-8/29/16, and at approximately 11:30 PM or 12:00 AM had answered a call light for Resident #186 asking for ice for pain. Continued interview confirmed at approximately 3:30 AM, the resident was assisted to the bathroom and almost fell coming out due to pain. Interview with CNA #2 on 9/8/16 at 7:38 AM, in the Chapel on the skilled unit, confirmed she came to work at approximately 3:45 AM on 8/29/16 and was told by CNA #1, Resident #186 almost fell . Continued interview confirmed Resident #186 said the pain was worse than usual and the LPN #1 said it was too soon to receive additional pain medication. Further interview confirmed CNA #2 took the resident to the restroom at approximately 5:45 AM and then asked LPN #1 to give medication for pain to Resident #186. Continued interview confirmed CNA #2 saw LPN #1 carry a medicine cup toward the resident's room and Resident #186 fell asleep approximately 45 minutes later. Interview with the Director of Nursing (DON) on 9/8/16 at 9:13 AM, in the DON's office confirmed Resident #186 experienced unrelieved pain. The facility staff did not follow the policy for pain management.

Based on facility policy review, record review, and interview, the facility failed to ensure anticoagulant therapy monitoring for 2 residents (#11, #12) of 4 residents reviewed receiving anticoagulant therapy, for a total sample of 15 residents who received laboratory monitoring of the [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) as ordered by the Physician. This failure was cited as past non-compliance which was determined to exist on [DATE] until [DATE]. The findings included: Review of the facility policy, Laboratory Protocol-Diagnostic Testing, revealed To provide uniform procedures for obtaining necessary diagnostic services when ordered by the Attending Physician/NP. Guideline: 1. Provide laboratory, radiological and diagnostic services as necessary and appropriate. 2. Assure that the residents receive laboratory, radiological and diagnostic services as ordered by the Attending Physician/NP. 3. Assure that the results of all diagnostic services are reported to the resident's Attending Physician/NP as necessary. Closed record review revealed Resident #11 was admitted to the facility on [DATE] and expired on [DATE]. Resident #11's anticoagulant treatment was managed by the orthopedic [MEDICATION NAME] service-anticoagulation pharmacist. Review of the hospital discharge information revealed the orthopedic [MEDICATION NAME] service would manage Resident #11's [MEDICATION NAME] therapy until [DATE]. Continued medical record review revealed the normal INR (International Normalized Ratio) range was 1.7 to 2.5. Review of the hospital Interagency Discharge Orders dated [DATE] indicated follow-up Labs: PT ([MEDICATION NAME])/INR twice weekly on every Monday and Thursday. Review of the Physician's Order Sheet dated [DATE] at 12:00 AM revealed [MEDICATION NAME] Sodium 2.5 milligram (mg) tablet one by mouth (po) at hour of sleep (HS) for femur fracture. PT/INR draw every Monday-anticoagulant therapy. Review revealed the facility failed to transcribe the Physician's Orders for PT/INR twice weekly on Mondays and Thursdays for Resident #11. This failure resulted in a delay in anticoagulant therapy monitoring. Review of the first Coagulation [MEDICATION NAME] Time Laboratory Report for Resident #11 dated [DATE] revealed PT 49.30 H (high), INR 5.30 (C) critical. Result was called to the facility at 10:10 PM on [DATE]. Review revealed an untimed order to send resident to the emergency room (ER) on [DATE] and and included and order to hold [MEDICATION NAME] written on [DATE]. Interview with RN D on [DATE] at 10:00 AM revealed there were no prior PT/INR's drawn by the facility for Resident #11. RN D stated the facility identified the situation regarding PT/INR's and [MEDICATION NAME] therapy and had a performance improvement plan (PIP) in place. Review of the PIP for following INR Orders indicated the overall goal was to ensure all PT/INR orders are followed as ordered and not missed. The target end date was [DATE]. Review of the Analysis revealed the admission orders [REDACTED]. Orders were not transcribed correctly. The Nurse Supervisor failed to notice this when checking the Physician's Order Sheet. Record review of the June Medication Administration Record [REDACTED]. Review revealed the Nurse initialed the MAR indicated [REDACTED] Interview with the laboratory, revealed no INRs were drawn until [DATE]. Closed record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired [DATE]. Medical record review of the Physician's Order Sheet dated [DATE] - [DATE] for Resident #12 revealed [MEDICATION NAME] 60 mg/0.6 milliliter syringe inject 0.6 ml subcutaneous daily for A Fib continue until INR is therapeutic on [MEDICATION NAME], Aspirin 81 mg one by mouth daily, and [MEDICATION NAME] 5 mg one po daily for A Fib. Medical record review of the Physician's Order Sheet dated [DATE] - [DATE] for Resident #12 revealed [MEDICATION NAME] 5 mg one po daily for A Fib, [MEDICATION NAME] 60 mg/0.6 ml syringe inject 0.6 ml subcutaneous daily for A Fib, continue until INR is therapeutic on [MEDICATION NAME], ASA 81 mg one po daily. Medical record review of the Coagulation Report dated [DATE] for Resident #12 revealed [MEDICATION NAME] time 85.10 INR 10.76. Further review of the closed record for Resident #12 revealed no other PT/INR reports. Review of the closed record for Resident #12 revealed no orders for PT/INR until Friday [DATE]. Continued review revealed on [DATE] the PT/INR results were critically high with PT 85.10 and INR 10.76. Vitamin K was ordered on [DATE] after Resident #12's INR results had increased to 12.5. Interview with RN H on [DATE] at 11:56 AM revealed .normally if a resident is admitted into the facility on a blood thinner the nurse asks the doctor if they want to order an INR. Interview with RN D on [DATE] at 10:00 AM revealed the facility identified the situation regarding PT/INR's and [MEDICATION NAME] therapy and had a performance improvement plan (PIP) in place. Interview with RN D on [DATE] at 11:25 AM revealed .normally the nurse that admits the resident calls the doctor and lets them know the resident is on [MEDICATION NAME] and gets an order for [REDACTED]. Interventions: 1. [MEDICATION NAME] nurse to oversee [MEDICATION NAME] residents (new nurse role). 2. Admission/Readmission chart check: All new admissions and readmission charts will be brought to the first daily clinical meeting following admission/readmission. a. One staff member will read the admission orders [REDACTED] b. A second staff member will check those orders against the Physician Order Sheet. c. A third staff member will check the lab books to ensure all the labs are logged to be drawn. d. A fourth staff member will update the white board as needed based on the orders. Conclusion: PIP is ongoing. Interview with Administrative Staff Member Q on [DATE] at 1:55 PM revealed he/she attends all clinical meetings held in the mornings on Monday through Friday. Administrative Staff Member Q stated that attendees of the clinical meeting include: a. chaplain b. quality of life director (activity director) c. behavior health manager d. rehabilitation staff e. maintenance (plant ops) f. director of nursing g. assistant directors of nursing h. medical records i. staff development j. dietitian. Administrative Staff Member Q added the Assistant Director of Nursing's (ADON) read the Physician Orders for their units. A second ADON checks the admission orders [REDACTED]. The Administrative Staff Member Q stated when there is no order and the resident is on [MEDICATION NAME] it would be noted. Continued interview with the Administrative Staff Member Q stated .the White Board was revamped in August or September of 2015. It was revised before [DATE] .the facility's Medical Director prefers to follow residents individually and monitor them closely . Both RN D and Administrative Staff Member Q stated on [DATE] at 1:55 PM .PT/INRs are recorded/tracked on a flow sheet now. Re-education of the white boards has kept everything in check. The Performance Improvement Plan (PIP) is ongoing. For [MEDICATION NAME] the resident's name is put on the White Board. Anything that needs to be followed up on is put on the White Board. In Stand Down meetings staff follow up on those things. Stand down meetings are held Monday through Friday at 3:30 PM . Telephone interview with the Medical Director on [DATE] at 3:50 PM revealed .the decision whether to order PT/INR on residents on anticoagulant therapy varied from person to person. The decision was multifactorial. When notified of a critical INR value normally would immediately write an order for [REDACTED]. The facility implemented a performance improvement plan and is evaluated by the Quality Assurance Quality Improvement Committee process to prevent any further laboratory monitoring errors of this type, for this reason and the above interventions F-309 was cited as a past non-compliance [DATE] through [DATE].

Based on medical record review, observation, and interview, the facility failed to perform Range of Motion (ROM) and apply orthotics resulting in a decrease in ROM (Harm) for one resident (#13) of four residents reviewed for ROM. The findings included: Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed moderately impaired for daily decision making, extensive assistance of two for bed mobility and transfers, ambulation did not occur, and no functional limitations in Range of Motion. Medical record review of the Care Plan dated November 13, 2013, revealed "...ADL (Activity of Daily Living) self-care deficit as evidenced by extensive to total...Range of Motion...at risk for developing an impairment in functional joint mobility...D/C (discharged ) (no date)(from restorative)...Lower extremities Trunk, Bil (bilateral) hips, knees...report and document any declines in ability..." Medical record review of the Physical Therapy Recertification & Updated Plan of Treatment dated August 9, 2013, revealed "...Contracture Management...bilateral...dorsiflexion of (less than)...15 degrees...orthotic management...design and fitting...Reason for Skilled Services...increase LE (lower extremity) ROM...enhance patient's quality of life...Orthotic Management and Training..." Medical record review of a Physical Therapy Discharge Summary dated September 23, 2013, revealed "...Discharge Status and Recommendations...Splint/Orthotic Recommendations...to continue wearing...prescribed ankle splint on B (bilateral) LE to prevent deformity and contracture formation..." Medical record review of Restorative Nursing Notes dated September 24, 2013 through November 5, 2013, revealed ROM to trunk, hips, and knees. Continued medical record review of the Restorative Nurse's Notes revealed no documentation of ROM to lower extremities. Further medical record review revealed Restorative Nursing was discontinued on November 5, 2013. Medical record review of a PT (Physical Therapy) Evaluation & Plan of Treatment dated February 5, 2014, revealed "...Contracture of Joint; Lower Leg...Short Term Goals...nursing staff will be 100% competent in bilateral ankle orthotic schedule and maintain...AROM of bilateral LE (lower extremity)...Patient demonstrates good rehab potential...Reason for referral...Patient exhibits decrease in ROM...the pt (patient) will benefit from skilled PT to reduce bilateral plantar flexion contractures...establishment of splinting schedule, orthotics...upon D/c (discharge) from skilled on 9/23/13...goal for multi-podus boot (splint) tolerance of six hours...the last known bilateral dorsiflexion...were on 9/5/13 with bilateral ankle dorsiflexion at approximately 15 degrees...2/5/14...Range of Motion Goniometric Measurements...AROM (active range of motion)...R (right) ankle...Plantar Flexion = 40-45...AROM...L ankle...Plantar Flexion = 40-40..." Observation on February 5, 2014, at 11:12 a.m., in the resident's room revealed the resident lying in the bed and the resident's splints in the wheelchair. Interview with the resident's daughter on January 30, 2014, at 8:00 a.m., by telephone revealed the resident was supposed to wear "corrective boots" for contractures in the resident's feet. Continued interview revealed "...the facility never uses the boots...I visited last night and put the special shoes on..." Interview with Licensed Practical Nurse (LPN) #4 (assigned to the resident) on February 5, 2014, at 11:15 a.m., in the resident's room revealed the LPN was unaware if the resident had contractures or if the resident wore splints. Interview with Certified Nurse Technician (CNA) #2 (assigned to the resident) on February 5, 2014, at 11:17 a.m., in the resident's room revealed the CNA never performed ROM or applied the splints. Continued interview revealed the CNA thought the Restorative Nurse performed ROM and applied the splints. Interview with LPN #4 on February 5, 2014, at 11:18 a.m., at the Nurse's Station confirmed the resident had contractures of the bilateral lower extremities. Interview with CNA #3 (assigned to the resident) on February 5, 2014, at 11:20 a.m., in the 200 Hall revealed the CNA was unaware of a schedule for splints. Continued interview revealed the CNA does not perform ROM for resident #13's bilateral lower extremities (BLE) and does not apply the splints. Further interview revealed restorative applied splints. Interview with the Rehabilitation Director on February 5, 2014, at 11:24 p.m., in the Conference Room confirmed the resident had bilateral contractures to the ankles. Interview with LPN #5 (Restorative Nurse) on February 5, 2014, at 11:27 a.m., in the Conference Room revealed the resident was not currently on restorative case load. Continued interview revealed the resident was on restorative from September 24, 2013 through November 5, 2013. Further interview revealed Restorative provided AROM (active range of motion) to the resident's trunk, hips, and knees and confirmed the resident had not received AROM to the lower extremities. Interview with the Rehabilitation Director on February 5, 2014, at 11:30 a.m., in the Conference Room revealed Physical Therapy discharged the resident to nursing on September 23, 2013, for ROM and application of the splints. Continued interview revealed no documentation nursing was educated on the application of the splints or ROM to BLE for resident #13. Interview with the Director of Nursing (DON) on February 5, 2014, at 11:35 a.m., in the Conference Room revealed the ROM and the application schedule of the splints were not on the Nurse Aide Flow Record and had not been care planned. Continued interview revealed the ROM was on the Care Plan for Restorative, to provide however, the splints were not on the care plan and ROM or Splints were not on the Nurse Aide Flow Record. Interview with Physical Therapist (PT) #1 on February 5, 2014, at 2:20 p.m., in the conference Room confirmed the resident has bilateral Plantar Flexion Contractures of the ankles. Continued interview confirmed the resident received PT in September 2013, was fitted with orthotics to improve ROM, and decrease the Plantar Flexion Contractures. Interview confirmed the resident's degree of dorsiflexion of the BLE on September 5, 2013, was 15 degrees. Continued interview confirmed the resident's dorsiflexion on February 5, 2014, as right 40 degrees and left 39 degrees. Interview with the PT confirmed the contractures had increased since September 5, 2013, and confirmed "the resident could have maintained some or part of the dorsiflexion with ROM and application of the orthotics." Interview with the Physician Assistant (PA) on February 5, 2014, at 3:32 p.m., by telephone confirmed with ROM exercises and the use of the splints the contracture could have been at a lower degree and would not be at the current level. Interview with the DON on February 5, 2014, at 5:15 p.m., in the Conference Room confirmed the facility had failed to perform ROM to BLE; had failed to apply the splints provided by the Physical Therapy Department for contracture management; and had failed to provide any preventive measures to prevent a further decline of the resident's contractures of the bilateral ankles, since the resident was discharged from PT on September 23, 2013. C/O #

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to provide a two person transfer resulting in a fall with fracture (Harm) for one resident (#2), failed to apply proper foot wear for one resident (#4), and failed to apply a pressure alarm for one resident (#3) of seven residents reviewed for falls. The findings included: Resident #2 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired for daily decision making, required extensive assistance of two plus persons for transfers and bed mobility, and did not ambulate. Medical record review of the Care Plan dated May 17, 2013, revealed "...ADL (Activity of Daily Living) self-care deficit ext (extensive) to total...assistance with...transfers...non amb (ambulatory)..." Medical record review of a Weekly Summary dated June 7, 2013, revealed the residnet required total dependence for transfers. Medical record review of a Fall/Change in Status dated June 9, 2013, revealed "...CNA (Certified Nurse Assistant) took res (resident) in to do shower I was walking by and heard my name went in and observed res lying on L (left) side in floor. CNA explained that...couldn't hold...resident)...and sat...(resident)...in floor..." Medical record review of a Physician's Telephone Order dated June 9, 2013, revealed "...X-ray left leg from knee to ankle...Indication-DX (diagnosis) fall..." Medical record review of a Radiology Report dated June 9, 2013, revealed "Exam: Knee...right...Fractures of the proximal tibia and fibula..." Review of a facility investigation and a Witness Statement hand written by the CNA dated June 9, 2013, revealed "...lifting the resident from W/C (wheelchair) to shower chair...started to slide out of my hands...sat...in the floor...not sure what caused skin tear..." Review of the facility investigation (no date) revealed "...Post Intervention: Instructed CNA to ask for help with transfers...Conclusion: CNA stated couldn't transfer res from w/c to shower chair and sat (resident) in the floor..." Medical record review of a Physician's Progress Note dated June 21, 2013, revealed "...Pt had incident where...(resident)...fell during a transfer...Fall resulted in L shin skin tear...suffered an R (right) proximal Tib (tibia)/Fib (fibula) fx (fracture)...ecchymosis (bruising) down R leg and slight swelling and edema at knee..." Medical record review of the Physician's Recapitulation Orders dated January 2014 revealed "...Sensor alarm on bed..." Observation on January 30, 2014, at 10:50 a.m., in the resident's room revealed the resident lying on the bed with one-quarter side rails up bilaterally, body alarm, and the sensor alarm turned off. Interview with CNA #1 on January 30, 2014, at 10:52 a.m., in the resident's room confirmed the CNA had turned the sensor alarm off. Interview with the Director of Nursing (DON) on January 30, 2014, at 4:07 p.m., in the Conference Room confirmed the sensor alarm is to be on at all times. Interview with the DON on February 3, 2014, at 12:23 p.m., in the Conference Room confirmed the facility had failed to ensure a two person transfer was performed for a resident assessed as a two person transfer resulting in a fall with a right tibia fibula fracture (Harm). Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was moderately impaired for daily decision making and required extensive assistance of two for transfers. Medical record review of the Care Plan dated April 18, 2013, revealed "...Resident has edema...knee high compression stockings (ted hose)...At risk for falls...Related to...poor safety awareness...Goal...will not sustain a fall related injury by utilizing fall precautions...appropriate footwear..." Medical record review of the Physician's Recapitulation Orders dated July 2013 revealed "...compression hose on in morning off at bedtime..." Review of a Fall Incident Questionnaire dated July 1, 2013, revealed "...What did the resident have on their feet? Ted Hose...What interventions were in place and were they functioning? (fall mat, alarm, footwear)...alarms..." Medical record review of a Fall/Change in Functional Status dated July 2, 2013, at 3:00 a.m., revealed "...CNA went in room and observed res in floor beside bed..." Review of Stakeholders Termination Notice dated July 2, 2013, revealed "...Stakeholder failed to follow tx (treatment) orders to remove res ted hose res had fall d/t (due to) improper foot wear..." Observation on January 30, 2014, at 10:10 a.m., in the main dining room revealed the resident sitting in a wheelchair, with anti tippers and pull alarm in place. Interview with the DON on February 3, 2014, at 5:34 p.m., in the Conference Room confirmed the facility had failed to remove the compression stockings and follow a fall intervention to apply proper foot wear resulting in a fall for resident #4. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly MDS dated [DATE], revealed the resident was cognitively impaired and required extensive assistance of two for transfers. Medical record review of the Care Plan dated February 5, 2013, revealed "...At risk for falls...poor safety awareness...resident will not sustain a fall related injury by utilizing fall precautions...pressure alarm in bed..." Medical record review of a Physician's Telephone Order dated June 24, 2013, revealed "...Pressure alarm to bed at all times...Indication...safety..." Review of facility investigation dated July 2, 2013, at 7:00 a.m., revealed "...res (resident) had fallen...observed res lying in the floor at the foot of the bed..." Observation on January 30, 2014, at 10:12 a.m., in the main dining room, revealed the resident sitting in a Geri-chair with a pull alarm in place secured by a pin. Interview with LPN #1 on February 3, 2014, at 2:30 p.m., by telephone revealed the alarm had not sounded when the resident was observed in the floor on July 2, 2013. Interview with the DON on February 3, 3014, at 5:31 p.m., in the conference Room confirmed the facility had failed to apply a pressure alarm to resident #3. C/O #