Every finding on record at Springs Village Care Center

Based on record review and interviews, the facility failed to ensure one (#1) of four residents were provided the care and services necessary to ensure a safe discharge from the facility to the community out of 11 sample residents. Specifically, the facility failed to allow Resident #1 to return to the facility after an unplanned discharge to the hospital.Findings include: I. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included dementia, respiratory failure, diabetes and asthma. The 9/11/25 minimum data set (MDS) assessment identified Resident #1 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment indicated the resident was dependent on staff for eating, personal hygiene, dressing and transferring. B. Record review A nursing progress note on 10/26/25 at 10:32 p.m. documented in pertinent part, Resident #1 was transferred to the hospital per family request . A nursing progress note on 10/27/25 at 7:34 a.m. documented Resident #1 was hospitalized with pneumonia and hyponatremia (low sodium) diagnoses. An admissions department progress note on 10/31/25 at 2:25 p.m. documented the department contacted the hospital social worker and notified the social worker that the facility would be unable to readmit Resident #1 to the facility. The note documented the nursing home administrator (NHA) would be reaching out to the hospital social worker to discuss the situation in further detail. An Expedited Notice of Transfer (With Less than 30 Days' Notice and Expedited Appeal) form for Resident #1, dated 10/31/25, was provided by the NHA on 1/6/26 at 11:00 am. The notice read in pertinent part, This notice is to inform you that (facility name) seeks to discharge you on 10/31/25. The specific reason for this transfer is as follows: The safety of the individuals in the facility would otherwise be endangered. -However, Resident #1 did not display behaviors that engaged others (see interviews below). -Review of Resident #1's electronic medical record (EMR) did not reveal the facility reassessed the resident once she returned to baseline at the hospital prior to issuing an immediate discharge notice. II. Staff interviews The admissions director was interviewed on 1/6/26 at 10:50 a.m. The admissions director said Resident #1 was not permitted to return to the facility upon discharge from the hospital and the resident's situation required an immediate discharge by the facility. The admissions director said there were family dynamics involved, but she did not know the specific reason for discharging the resident. The director of nursing (DON) was interviewed on 1/6/26 at 11:09 a.m. The DON said Resident #1 was not permitted to return to the facility after her hospitalization because there were issues with Resident #1's family. The DON said there had been no issues with Resident #1's care or the resident's behavior while at the facility. The DON said Resident #1's family member had demonstrated behaviors that were inappropriate while the resident was at the facility, including pushing a certified nurse aide (CNA). The DON said a facility could not refuse to allow a resident to return following hospitalization based upon the behavior of the resident's family. The DON said Resident #1 should have been permitted to return to the facility. The DON said the NHA contacted the hospital and did not allow Resident #1 to return to the facility. The NHA was interviewed on 1/6/26 at 11:32 a.m. The NHA said Resident #1 was a great resident and the resident treated staff well while she was at the facility. The NHA said Resident #1's family member was verbally and physically abusive to staff. The NHA said Resident #1's family never mistreated other residents while Resident #1 was at the facility. The NHA said the facility team decided not to allow the resident to return to the facility at the end of her hospital stay due to the previous behavior of the resident's family member. The NHA said he was concerned that Resident #1's family member's behavior would continue if the resident was allowed to return to the facility, and this might cause staff to resign from the facility. The NHA said Resident #1 had the right to return to the facility and the facility was able to manage Resident #1's medical needs. The NHA said the decision to not allow Resident #1 to return to the facility was made quickly and the Expedited Notice of Transfer notice was not completed or provided to the resident or family prior to discharge from the hospital. Registered nurse (RN) #1 was interviewed on 1/6/26 at 12:45 p.m. RN #1 said Resident #1 had no significant behavior issues and the resident was friendly toward staff. RN #1 said CNAs had reported one of Resident #1's family members had been directing Resident #1's care decisions and the decisions often conflicted with the resident's wishes.

Based on record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to make prompt efforts to resolve resident grievances about missing clothing that were brought up by the resident council. Findings include: I. Facility policy and procedure The Grievance/Complaints Filing policy, revised July 2022, was provided by the nursing home administrator (NHA) on 5/13/25 at 12:23 p.m. It read in pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. II. Resident group interview Six alert and oriented residents (#40, #76, #51, #25, #64 and #20) who regularly attended the resident council meetings were interviewed on 5/14/25 at 10:08 a.m. The residents were identified as alert and oriented through the facility and assessment. The group of residents said the facility did not follow up on grievances brought up in the resident council meetings. Resident #3 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting. Resident #3 said if it was an individual grievance the department head would follow up with the individual resident. Resident #3 said if it was a group grievance a resolution was not brought back to the next resident council meeting by the facility. Resident #40 said the resident council had been bringing up the issue of items going to the laundry and then being delivered to the wrong residents by housekeeping for several months. He said this happened even if the residents labeled their clothes before the clothes went to the laundry. Resident #51 said when the subject of the clothes not coming back from laundry to the right rooms was brought up during resident council, the facility managers told the residents it was because residents are not labeling their own clothes and it was the resident' s responsibility to ensure their clothes were labeled. Resident #51 said the staff delivering the clothes to the residents did not take the time to read the names on the clothes. Resident #25 said the issue with the clothes going to the wrong rooms had not been resolved and the facility expected the residents to be responsible for labeling their own clothes with markers even though there was a label maker in the laundry department. Resident #25 said she asked her roommate to help her label her clothes. Resident #76, Resident #64 and Resident #20 said they were in agreement that the laundry issue had not been resolved and the facility had not advised them in resident council how or when it would be resolved. III. Record review A review of the resident council meeting minutes, dated 2/20/25, revealed the residents brought up a concern regarding clothes not being returned to the correct rooms even with the residents' names being on the clothing tag. -Review of the February 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concern regarding missing laundry. A review of the resident council meeting minutes, dated 3/20/25, revealed the residents brought up a concern regarding clothes not being returned to the correct rooms even with the residents' names being on the clothing tag. -Review of the March 2025 resident council minutes did not reveal documentation indicating the facility had addressed the residents' concerns regarding missing laundry. A review of the resident council meeting minutes, dated 4/17/25, revealed the previous months concerns brought forward by the group regarding missing clothing were not discussed. IV. Staff interviews The social services director (SSD) was interviewed on 5/14/25 at 2:07 p.m. The SSD said the facility had a process for addressing individual resident grievances but there was no process for following up on group grievances generated during resident council. She said the manager present at the meeting whose department would be responsible for the grievance, would talk about how they planned to resolve it in the meeting. The activities director (AD) was interviewed on 5/15/25 at 1:01 p.m. The AD said all the department managers attended the resident council meeting. She said when a grievance was brought up, the manager present at the meeting, whose department would be responsible for the grievance, would talk about how they planned to resolve it in the meeting. The AD said the grievance was recorded in the resident council meeting minutes but not on an actual facility grievance form. She said the wasn't a process that ensured the department manager handling the grievance returned and provided an update on the resolution of the group grievance to the resident council members.

II. Failure to ensure Resident #46 followed appropriate infection control procedures when emptying her own indwelling catheter A. Facility policy and procedure The Catheter Care, Urinary policy and procedure, revised August 2022, was received from the NHA on 5/15/25 at 2:29 p.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. B. Resident #46 1. Resident status Resident #46, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included bipolar disorder, unspecified dementia, anxiety disorder and unspecified symptoms and signs involving cognitive function and awareness. The 2/13/25 MDS assessment revealed Resident #46 was cognitively intact with a BIMS score of 15 out of 15. She was independent with mobility, dressing and eating. The MDS assessment indicated the resident had an indwelling catheter. 2. Observations and resident interview Resident #46 was interviewed on 5/13/25 at 1:18 p.m. Resident #46 said she emptied her catheter bag herself. Resident #46 said she did not remember being educated about the appropriate way to manage the care of a urinary catheter. During the interview, Resident #46 was sitting on her bed and left her catheter bag lying on the floor in front of her bed. The catheter bag was not contained inside of a privacy bag to protect it from becoming contaminated while lying on the floor. Resident #46 stood up, picked up the catheter bag from the floor, attached it to her waistband and started walking towards her bathroom. The resident went to her bathroom and began emptying the urine in her catheter bag into the toilet bowl without washing her hands. Resident #46 touched the toilet seat and the catheter bag with her bare hands. After emptying her catheter bag, Resident #46 exited the bathroom but did not perform hand hygiene. 3. Record review Review of Resident #46's urinary catheter care plan, initiated 3/20/25, revealed the resident had an impaired urinary elimination pattern due to neuromuscular dysfunction of the bladder. -The urinary care plan failed to include that Resident #46 was emptying the catheter bag by herself and the steps staff should take to ensure proper handling of the catheter, including hand hygiene. -Review of Resident #46's May 2025 CPO did not reveal a physician's order for routine catheter care maintenance by the resident. -Review of Resident #46's electronic medical record (EMR) revealed there was no documentation to indicate the resident had been assessed, educated or monitored to ensure she was adhering to appropriate infection control guidelines, including hand hygiene, when emptying her catheter. C. Staff interviews CNA #4 was interviewed on 5/13/25 at 3:25 p.m. CNA #4 said Resident #46 emptied her own catheter bag. CNA #4 said she did not know whether Resident #46 was assessed before allowing her to manage her catheter bag. Registered nurse (RN) #4 was interviewed on 5/13/25 at 3:35 p.m. RN #4 said there was no documentation in Resident #46's EMR which indicated the resident was assessed to ensure she performed appropriate hand hygiene before and after emptying her catheter bag to prevent infections. The assistant director of nursing (ADON) was interviewed on 5/13/25 at 4:15 p.m. The ADON said Resident #46 was admitted with a catheter due to her diagnosis of neuromuscular dysfunction of the bladder. The ADON said catheters could lead to infections and monitoring them was important to prevent infections. She said Resident #46 should have had an assessment completed to ensure the resident was capable of performing appropriate hand hygiene when emptying her catheter bag in order to prevent infections. The DON was interviewed on 5/15/25 at 1:39 p.m. The DON said Resident #46 should have been assessed to ensure she was able to perform proper hand hygiene when emptying her catheter bag to prevent infections. The DON said she was not sure how the assessment was missed before allowing the resident to empty her catheter bag. The DON said she would immediately provide education to all nursing staff regarding ensuring assessments were completed on residents who emptied their own catheters. She said she would complete an assessment to ensure Resident #46 could empty her catheter bag appropriately. Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) when providing care for Resident #62, Resident #27 and Resident #30, who were on enhanced barrier precautions (EBP); and, -Ensure Resident #46 followed appropriate infection control procedures when emptying her own indwelling catheter. Findings include: I. Failure to wear appropriate PPE when providing care for Resident #62, Resident #27 and Resident #30, who were on EBP A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 5/16/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs (multidrug resistant organisms). The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised March 2024, was received from the nursing home administrator (NHA) on 5/13/25 at 4:45 p.m. The policy read in pertinent part, EBP should be used as an infection prevention and control intervention to reduce the transmission of multi drug resistant organisms of (MDROs) to residents. EBP Employee targeted gown and glove use in addition to standard precautions during High contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. EBPs are indicated with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. C. Resident #62 1. Observations On 5/13/25 at 9:41 a.m. there was a sign on Resident #62's door that indicated the resident was on EBP. Certified nurse aide (CNA) #1 was providing incontinent care for Resident #62 in her bed. CNA #1 had gloves on. -However, CNA #1 failed to put on a gown prior to providing incontinence care to Resident #62, who was on EBP. D. Resident #27 1. Observations On 5/13/25 at 2:27 p.m. Resident #27 was lying in bed and had a foley catheter hanging on the side of the bed. There was a sign on Resident #27's door indicated the resident was on EBP. CNA #2 was providing incontinence care to Resident #27. CNA #2 removed the resident's soiled brief, provided foley care and applied a clean adult brief. CNA #2 put on gloves prior to providing incontinence care to the resident. -However, CNA #2 failed to put on a gown prior to providing incontinence care to Resident #27, who was on EBP. E. Resident #30 1. Observations On 5/13/25 at 3:30 p.m. there was a sign on Resident #30's door that indicated the resident was on EBP .CNA #7 and CNA #8 were assisting Resident #30 with transferring from her wheelchair to her bed via a mechanical lift Both CNAs were wearing gloves. -However, CNA #8 and CNA #7 failed to put on a gown prior to providing incontinence care to Resident #30, who was on EBP. F. Staff interviews CNA #2 was interviewed on 5/13/25 at 2:56 p.m. CNA #2 said she was supposed to wear a gown with incontinent care because the resident has a foley catheter. CNA #2 said it was important to maintain EBP to prevent the residents from getting any infections. CNA #8 was interviewed on 5/13/25 at 3:55 p.m. CNA #8 said if a resident was on EBP, she needed to put on gloves and a gown when providing resident care, such as toileting and dressing. She said she should have worn a gown when transferring Resident #30 from her chair to her bed. She said she was in a hurry to get the resident into bed quickly. CNA #8 said in the future, she would take her time to don the correct PPE for any resident who was on EBP. CNA #1 was interviewed on 5/13/25 at 4:16 p.m. CNA #1 said she was supposed to wear a gown when providing incontinent care to a resident who had pressure wounds. CNA #1 said she did not see the sign for EBP on Resident #62's door. CNA #1 said it was important to maintain EBP to prevent the residents' wounds getting infected. CNA #7 was interviewed on 5/13/25 at 4:53 p.m. CNA #7 said she did not see the storage bin outside of Resident #30's room and did not realize she was on EBP. CNA #7 said typically she looked for a storage bin of PPE to indicate if a resident was on EBP. CNA #7 said she would pay closer attention to individual resident requirements moving forward. Licenced practical nurse (LPN) #6 was interviewed on 5/15/25 at 10:29 a.m. LPN #6 said when a resident was on EBP, the staff providing care should don (put on) a gown and gloves when changing a wound dressing, assisting a resident with a transfer, giving medication through intravenous (IV) lines, changing a brief and changing the resident's clothes so they did not get an infection. LPN #5 was interviewed on 5/15/25 at 11:04 a.m. LPN #5 said EBP was used to prevent residents from getting an infection. LPN #5 said EBP was used during wound care, if a resident had a foley catheter or an IV. We are required to wear a gown in gloves during any type of transfer activity or incontinence care. The director of nursing (DON) was interviewed on 5/15/25 at 1:30 p.m. The DON said EBP was used when there was the potential for high-contact interaction between staff and residents. She said a resident would be placed on EBP, if they had an ostomy (surgical incision in the abdomen), wounds or foley catheter. She said the staff should wear PPE, including a gown and gloves, when assisting residents with activities of daily living who were on EBP. The DON said if a resident was on EBP, the facility's policy was to ensure there was a sign on the door to inform all staff that precautions needed to be followed. She said if the resident was on precautions, a cart with PPE was stored outside of the resident's room. She said the nursing staff was provided education upon hirer and annually and it was her expectation of all facility staff to know how to correctly care for the residents and prevent the transmission of bacteria or cause an infection.

Based on record review and interviews, the facility failed to ensure the resident's right to be informed of, and participate in his or her treatment for one (#77) of two residents out of 32 sample residents reviewed for the right to be informed and make treatment decisions. Specifically, the facility failed to inform Resident #77 and/or her legal representative of her laboratory (lab) bloodwork values before being sent to the hospital for a transfusion or her lab values after returning from the hospital. Findings include: I. Facility policy and procedure The Resident Rights policy, undated, was provided by the nursing home administrator (NHA) on 5/13/25 at 2:29 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be notified of his or her medical condition and of any changes in his or her condition, be informed of, and participate in, his or her care planning and treatment and access personal and medical records pertaining to him or herself. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee, provider and contracted staff member. In addition, staff will have appropriate in-service training on resident rights prior to having direct-care responsibilities for residents. II. Resident #77 A. Resident status Resident #77, age less than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included anemia, generalized weakness, chronic heart failure and chronic respiratory failure. According to the 4/4/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance with chair/bed and bed/chair transfers. B. Resident interview Resident #77 was interviewed on 5/12/25 at 3:59 p.m. Resident #77 said she was sent to the hospital for a blood transfusion in March 2025. Resident #77 said she asked the nurses about her bloodwork values after she returned from the hospital, but she did not get an answer. Resident #77 said she still did not know what her blood levels were because staff did not tell her. C. Record review The 3/21/25 at 12:15 p.m. nursing progress note indicated Resident #77's labs came back and her hemoglobin (HGB - an iron-rich protein within red blood cells that is essential for transporting oxygen throughout the body) level was 5.7 grams per deciliter (g/dl). The nurse practitioner (NP) ordered a stat (immediate) CBC (complete blood count) to be drawn for the resident. Nursing staff was to call the results of the CBC into the resident's physician for further orders. The resident's previous HGB was 5.7 g/dl. The 3/21/25 at 11:44 p.m. nursing progress note documented the on-call physician was notified at 9:00 pm with an update regarding Resident #77's stat CBC results. The resident's HGB level was 6.4 g/dl and the physician ordered for the resident to be sent to the emergency room. The progress note indicated the director of nursing (DON) and the resident's family were notified of the transfer. -However, the progress note did not indicate the resident or the resident's representative were informed of the resident's HGB level or the specific reason for the transfer to the hospital. Review of Resident #77's May 2025 CPO revealed the following physician's orders related to laboratory blood work: Laboratory blood work CBC with differential, Vitamin B12 level for diagnosis of anemia, depression and paresthesias, ordered 5/2/25. -There was no documentation in the resident's EMR to indicate the resident or the resident's representative was notified of her most recent HGB lab values or if the resident's lab values would be retaken. The 5/1/25 at 11:36 p.m. physician's progress note documented the physician discussed Resident #77's recent hospital stay with her and informed her that a source of bleeding was not identified. The physician documented she did not review the resident's hospital records, but it did seem as if no source of bleeding was located and the resident was scheduled for a colonoscopy in one month. III. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 5/15/25 at 1:13 p.m. LPN #5 said if a resident was having a change of condition, such as critically low lab values, it was the nursing staff's responsibility to inform the resident of their test results and plan of care right away because it was their right to be informed. The DON was interviewed on 5/15/25 at 1:44 p.m. The DON said nursing staff was to inform residents of any change of condition. She said this is important to do because the facility wanted the residents to stay informed of their current medical status. The DON said she was aware of Resident #77's transfer to the emergency room for a blood transfusion and she made sure to check in with the resident when she returned to see how she was doing and if she had any questions. The DON said she did not remember specifically discussing Resident #77's HGB levels with the resident. -There was no documentation to indicate the DON or nursing staff had informed the resident of her HGB levels (see record review above).

Based on observations, staff interviews, and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#46) of one resident out of 32 sample residents. Specifically, the facility failed to ensure Resident #46 was assessed for self-administration of Visine eye drops. Findings include: I. Facility policy and procedure The Self Administration of Medication policy, revised February 2021, was provided by the nursing home administrator (NHA) on 5/15/25 at 1:45 p.m. It read in pertinent part, Residents have the right to self-medication administrations if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers several factors when determining resident self-medication administration. The resident must be able to safely and securely store the medication. Self-administered medications are stored in a safe and secure place that is not accessible to other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests it. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. II. Resident #46 A. Resident status Resident #46, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, unspecified dementia, anxiety disorder and unspecified symptoms and signs involving cognitive function and awareness. The 2/13/25 minimum data set (MDS) assessment revealed Resident #46 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with mobility, dressing and eating. B. Observation and resident interview Resident #46 was interviewed on 5/13/25 at 1:18 pm. She was sitting on her bed in her room. There were three bottles of Visine eye drops lying on the resident's bedside table. The resident said she used the eye drops by herself, so the facility let her keep them by her bedside. Resident #46 said she did not know how often to use the eyedrops, however, she said she used the eye drops every day. C. Record review A review of the May 2025 CPO revealed the following physician's order: Visine dry eye relief ophthalmic solution. Instill one drop in both eyes every two hours as needed for dry eyes, ordered 3/19/25. -The physician's order did not indicate Resident #46 was approved to self-administer the eye drops. Review of Resident #46's May 2025 medication administration record (MAR), from 5/1/25 to 5/11/25, revealed no documentation that the Visine eyedrops had been administered to the resident. -However, Resident #46 said she used the Visine eye drops every day (see resident interview above). The cognition care plan, initiated 2/10/25 and revised 2/22/25, revealed Resident #46 had an impaired thought process related to dementia. Interventions included administering medication as ordered, reviewing medications and recording possible causes of cognitive deficit. -A review of Resident #46's electronic medical record (EMR) did not reveal an assessment for the self-administration of Visine eye drops had been completed for the resident. III. Staff interviews Registered nurse (RN) #4 was interviewed on 5/13/25 at 1:18 p.m. RN #4 said Resident #46 had a diagnosis of dementia and she did not think the resident could remember the number of times she used the Visine eye drops. RN #4 said Visine eye drops were medication and needed a physician's order before administering them. RN #4 said Resident #4 was capable of self-administering the eye drops and the eye drops were kept on top of the resident's bedside dresser unsecured. -However, there was no assessment in the resident's EMR to indicate she was safe to administer the Visine eye drops (see record review above). The director of nursing (DON) was interviewed on 5/15/25 at 1:39 p.m. The DON said Visine eye drops were medication and needed to be securely stored. She said before a resident could begin self-medication administration, the resident should be properly assessed and a physician's order obtained for the self-administration of the medications. The DON said she did not know why Resident #46, who had a diagnosis of dementia, would be allowed to administer her medication without being properly assessed. The DON said Resident #46 was assessed for self-administration of the Visine eye drops and a new physician's order was obtained for the resident to self-administer the medication, during the survey. She said the nursing staff was being re-educated to ensure all residents on self-medication administration were properly assessed and a physician's order was obtained before the residents were allowed to self-administer medications. E. Facility follow-up On 5/13/25 at 7:00 p.m. (during the survey), the facility obtained a physician's order for Resident #46 to self-administer her Visine eye drops. A self-medication evaluation was completed for the resident.

Based on record review and interviews, the facility failed to ensure three (#44, #45 and #41) of four residents were free from chemical restraint out of 32 sample residents. Specifically, the facility failed to: -Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #44, Resident #45 and Resident #41's psychotropic medications; and, -Document consistent behaviors or a physician's rationale for Resident #44, Resident #45 and Resident #41 to justify the continued use of psychotropic medications. Findings include: I. Facility policy and procedure The Antipsychotic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 5/13/25 at 12:23 p.m. It read in pertinent part, Diagnosis alone does not warrant the use of antipsychotics. Antipsychotic medications will generally only be considered if the following conditions are met: behavior interventions have been attempted and included in the plan of care. For enduring psychiatric conditions, antipsychotic medications will not be used unless the behavior symptoms are not sufficiently relieved by non-pharmological interventions. The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. The Behavioral Assessment, Interventions, and Monitoring policy, revised March 2019, was provided by the NHA on 5/13/25 at 12:23 p.m. It read in pertinent part, Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behaviors. The care plan will include at minimum, targeted and individualized interventions for the behavioral/psychosocial symptoms, the rationale for the interventions and approaches, specific and measurable goals for the targeted behaviors, and how the staff will monitor the effectiveness of the interventions. Non-pharmological approaches will be utilized to the extent possible to avoid and reduce the use of antipsychotic medications to manage behavioral symptoms. II. Resident #44 A. Resident status Resident #44, age less than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included disorganized schizophrenia. The 2/10/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. Resident #44 required one-person staff assistance with toileting, bathing and personal hygiene. He ambulated independently. The MDS assessment indicated the resident did not exhibit hallucinations or delusions, did not refuse care and did not have physically or verbally abusive behaviors during the assessment look back period. B. Record review The mood care plan, revised 4/29/25, revealed Resident #44 had alterations in mood related to disorganized schizophrenia. He preferred to be alone and not interact with others. The behaviors identified to monitor included hallucinations, delusions, pacing and refusing care. Resident #44 frequently refused showers, changing his clothes, or allowing the nurses to check his legs or feet. He suffered from a paranoid delusion his feet would fall off or he would die if he removed his socks. Interventions included to identify strengths and use positive coping skills to reinforce these, encourage and reassure, identify approaches that contributed to behaviors, attempt non-pharmacological approaches to redirect, offer praise for compliance with care and encourage Resident #44 to express his feelings. -The care plan failed to indicate what person-centered approaches were effective in redirecting the resident. Review of Resident #44's May 2025 CPO revealed the following physician's orders: Monitor behaviors for antipsychotic use (Latuda, Zyprexa, Clozapine). Behaviors: hallucinations, delusions, and pacing. Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication- ordered on 8/12/24. Clozapine (antipsychotic medication) 100 milligrams (mg). Give 100 mg by mouth every evening with 400 mg dose to equal 500 mg for schizophrenia- ordered 2/17/25. Clozapine 200 mg. Give 400 mg by mouth every evening for schizophrenia, ordered 2/17/25. Latuda (antipsychotic medication) 120 mg. Give 120 mg by mouth every evening for disorganized schizophrenia, ordered 3/17/25. Behavior monitoring for care refusals that are detrimental to resident's health. Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication, ordered 3/25/25. Behavior monitoring for refusal of lotion to bilateral lower extremities (legs and feet). Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication, ordered 3/25/25. Behavior monitoring for refusal to remove socks. Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication, ordered 3/25/25. Behavior monitoring for refusal to change clothes. Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication, ordered 3/25/25. Behavior monitoring for refusal to take showers. Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication, ordered 3/25/25. -The non-pharmological interventions documented for all six of Resident #44's behavior monitoring physician's orders indicated the same identical, non person-centered non-pharmological interventions were to be used for every behavior, regardless of the behavior. Resident #44's Level II preadmission screening and resident review (PASRR) evaluation for mental illness and/or intellectual disabilities, dated 8/16/23, revealed Resident #44 had a history of psychiatric symptoms at a young age, isolating himself, self harming behaviors (cutting himself, stabbing himself), exposure to violence in the home, hallucinations, delusions, repeated psychiatric hospitalizations, and stabbing his mother. The evaluation revealed symptoms of decompensation to his mental health included increased smoking, sleep disturbances, and distractions by internal stimuli (delusions, paranoia). The resident expressed during the evaluation that he enjoyed watching movies, smoking, going out to dinner and listening to music. -The resident's specific behaviors, symptoms of decompensation, and non-pharmological interests identified in the Level II PASRR were not incorporated in Resident #44's behavior monitoring physician's orders or the resident's care plan (see physician's orders and care plan above). Review of Resident #44's medication administration records (MAR) and treatment admission records (TAR) from 2/1/25 to 5/14/25 revealed the following: The February 2025 MAR/TAR, from 2/1/25 to 2/28/25, revealed there was no documentation to indicate Resident #44 exhibited behaviors during the month. The March 2025 MAR/TAR, from 3/1/25 to 3/31/25, revealed there was no documentation of behaviors of refusals detrimental to Resident #44's health, or refusals of showers, applying lotion, changing his clothes or changing his socks during the month. The resident exhibited two behaviors of hallucinations on 3/23/25 with interventions of staff redirection and offering food and fluids documented as being used. The documentation did not indicate if the interventions used on 3/23/25 were effective or not. The April 2025 MAR/TAR, from 4/1/25 to 4/30/25, revealed one behavior of refusals detrimental to Resident #44's health on 4/6/25 with the interventions of staff redirection and other documented as being used. The documentation did not indicate if the interventions used on 4/6/25 were effective or not. There was one behavior of Resident #44 refusing to allow lotion to be applied on 4/6/25 with the interventions of staff redirection and other documented as being used. The documentation did not indicate if the interventions used on 4/6/25 were effective or not There was one behavior of Resident #44 refusing to change his clothes on 4/5/25 and 4/6/25 with interventions of staff redirection and one-on-one documented as being used. The documentation did not indicate if the interventions used on 4/5/25 and 4/6/25 were effective or not. There was one behavior of Resident #44 refusing to change his socks on 4/5/25 and 4/6/25 with interventions of staff redirection and one-on-one documented as being used. The documentation did not indicate if the interventions used on 4/5/25 and 4/6/25 were effective or not. -A review of Resident #44's progress notes for 4/5/25 and 4/6/25 failed to identify what the term other indicated or what resident-specific redirection or one-on-one interventions were attempted when the resident exhibited refusal behaviors on 4/5/25 and 4/6/25. The May 2025 MAR/TAR, from 5/1/25 to 5/14/25, revealed Resident #44 had one behavior of refusing to change his socks on 5/3/25 with interventions of offering an activity and medication documented as being used and marked as effective. There was one behavior of Resident #44 refusing to change his socks on 5/4/25 with interventions of staff redirection and offering to use the toilet documented as being used. The documentation did not indicate if the interventions used on 5/4/25 were effective or not. There was one behavior of Resident #44 refusing to change his clothes with no interventions documented as being attempted on 5/13/25. -A review of the progress notes for 5/3/25 and 5/13/25 failed to identify what resident-specific activities of interest or redirection interventions were attempted when the resident exhibited refusal behaviors on 5/3/25 and 5/13/25. Review of the facility's quarterly psychotropic meeting minutes revealed Resident #44 was reviewed by the interdisciplinary team (IDT) on 2/17/25. The meeting minutes revealed Resident #44 had not had any behaviors within the three month look back period. -The 2/17/25 psychotropic meeting note did not indicate the facility had concerns regarding any behaviors for the resident and there was no documentation to indicate the justification for the continued use of the resident's antipsychotic medications. Review of Resident #44's electronic medical record (EMR) from 2/1/25 to 5/14/25 revealed the following progress notes: Between 2/1/25 and 2/28/25, the progress notes documented Resident #44 had two refusals for care (the notes did not specify what care was refused), one refusal to take a shower and change his clothes and one refusal of a physician ordered test. -The progress notes did not indicate any non-pharmological interventions were attempted for the refusals. -There was no documentation to indicate the resident was experiencing hallucinations, delusions, paranoia or sleep disturbances (see care plan and Level II PASRR above). Between 3/1/25 and 3/31/25, the progress notes documented Resident #44 had seven refusals to take a shower, one refusal to change his clothes, six refusals to allow skin checks, three refusals to allow the nurse to apply medicated lotion and one refusal to allow the nurse to take his blood pressure. -The progress notes did not indicate any non-pharmological interventions were attempted for the refusals. -There was no documentation to indicate the resident was experiencing hallucinations, delusions, paranoia or sleep disturbances. Between 4/1/25 and 4/30/25, the progress notes documented Resident #44 had seven refusals to allow the nurse to apply medicated lotion. -The progress notes did not indicate any non-pharmological interventions were attempted for the refusals. -There was no documentation to indicate the resident was experiencing hallucinations, delusions, paranoia or sleep disturbances. Between 5/1/25 and 5/14/25, the progress notes documented Resident #44 had three refusals to allow the nurse to apply medicated lotion and one refusal to take a shower. -The progress notes did not indicate any non-pharmological interventions were attempted for the refusals. -There was no documentation to indicate the resident was having hallucinations, delusions, paranoia or sleep disturbances. -Review of Resident #44's EMR did not reveal documentation of a physician's rationale to justify the continued use of the resident's antipsychotic medications. III. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the May 2025 CPO, diagnoses included Parkinson's disease, anxiety, obsessive compulsive disorder (OCD) and depression. The 4/16/25 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #45 required one-person staff assistance with toileting and bathing. He ambulated using a walker. The MDS assessment indicated the resident did not exhibit hallucinations or delusions, did not refuse care and did not have physically or verbally abusive behaviors within the assessment look back period. B. Resident interview Resident #45 was interviewed on 5/13/25 at 9:43 a.m. Resident #45 said he felt anxious sometimes over things he could not control but what helped him was to read, walk around the facility and leave his room to try to socialize in activities with staff and other residents. C. Record review The mood care plan, revised 4/7/25, revealed Resident #45 had a diagnosis of depression exhibited by increased sleep, decreased appetite and a fixation on events. He had a diagnosis of OCD, moderate. Interventions included to monitor for changes in mood and offer one-on-one interaction. The anxiety care plan, revised 4/7/25, revealed Resident #45 had a diagnosis of anxiety manifesting as verbalizations of anxiety, pacing and weighing himself after meals. Interventions included to assist him in problem solving abilities and logical strategies he could use when experiencing anxiety, encourage relaxation techniques, provide a quiet environment and reassurance. Review of Resident #45's May 2025 CPO revealed the following physician's orders: Prozac (antidepressant medication) 40 mg. Give two tablets a day by mouth for OCD, ordered 4/19/22. Abilify (antipsychotic medication) 15 mg. Give one tablet in the morning for OCD, ordered 8/21/24. Ativan (antianxiety medication) 0.25 mg. Give 0.25 mg one time a day in the afternoon for anxiety, ordered 12/26/24. Ativan 0.5 mg. Give 0.5 mg in the morning and 0.5 mg in the evening for anxiety,ordered 12/26/24. Behavior monitoring for weighing himself after meals and pacing. Document yes or no if the behavior occurred, ordered 8/7/24. Behavior monitoring for verbalizations of anxiety and pacing. Document yes or no if the behavior occurred, ordered 8/7/24. Behavior monitoring for increased sleep, decreased appetite and fixation on events. Document yes or no if the behavior occurred, ordered 8/7/24. -There were no non-pharmological interventions indicated on the behavior monitoring physician's orders. Resident #45's Level II PASRR evaluation, dated 11/26/23, revealed the resident had behaviors of avoidance, excessive handwashing, counting and checking things related to his diagnosis of OCD. The resident expressed during the evaluation that he enjoyed going to weekly Catholic mass, bible study, reading, watching television and playing games. The evaluation revealed if unable to follow rituals, the resident could feel anxious and stressed. -The resident's specific behaviors and non-pharmological interests identified in the Level II PASRR were not incorporated in Resident #45's behavior monitoring physician's orders or the resident's care plan (see physician's orders and care plan above). Review of Resident #45's MAR and TAR from 2/1/25 to 5/14/25 revealed the following: The February 2025 MAR/TAR, from 2/1/25 to 2/28/25, revealed there was no documentation to indicate Resident #45 exhibited behaviors during the month. The March 2025 MAR/TAR, from 3/1/25 to 3/31/25, revealed Resident #45 experienced one episode of increased sleep on 3/22/25 with no non-pharmological interventions being attempted. -There was no documentation to indicate Resident #45 exhibited any other behaviors during the month. The April 2025 MAR/TAR, from 4/1/25 to 4/30/25, revealed there was no documentation to indicate Resident #45 exhibited behaviors during the month. The May 2025 MAR/TAR, from 5/1/25 to 5/14/25, revealed Resident #45 experienced one episode of increased sleep on 5/3/25 with no non-pharmological interventions being attempted. -There was no documentation to indicate Resident #45 exhibited any other behaviors during the month. Review of the facility's quarterly psychotropic meeting minutes revealed Resident #45 was reviewed by the IDT on 3/17/25. The meeting minutes revealed Resident #45 had not had any behaviors within the three month look back period. -The 3/17/25 psychotropic meeting note did not indicate the facility had concerns regarding any behaviors for the resident and there was no documentation to indicate the justification for the continued use of the resident's antidepressant, antipsychotic or anti-anxiety medications. Review of Resident #45's EMR from 2/1/25 to 5/14/25 revealed two behavior progress notes, one dated 4/5/25 and the other dated 5/3/25. -Both notes revealed a behavior had occurred for Resident #45, however, neither note indicated what the behavior was or if a non-pharmological intervention had been attempted. -Review of Resident #45's EMR did not reveal documentation of a physician's rationale to justify the continued use of the resident's antidepressant, antipsychotic or anti-anxiety medications. IV. Resident #41 A. Resident status Resident #41, age less than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included childhood onset conduct disorder, unspecified intellectual disability, major depressive disorder and a traumatic brain injury (TBI). The 3/17/25 MDS assessment documented the resident was cognitively intact with a BIMS score of 13 out of 15. Resident #41 required one-person staff assistance with bathing. She ambulated using a walker. The MDS assessment indicated the resident had daily behaviors of wandering during the assessment look back period. B. Resident interview Resident #41 was interviewed on 5/13/25 at 9:17 a.m. Resident #41 said she was very unhappy living at the facility and she tried to occupy herself so she would not become depressed. Resident #41 said her family had placed her in the facility but she would like to go out on more activities and be part of a day program in the community. Resident #41 said she expressed her feelings to the staff and the staff would listen but she was unable to say what specifically the staff did that helped when she was feeling angry or sad about her placement in the facility. C. Record review The mood care plan, revised 4/7/25, revealed Resident #41 had a diagnosis of depression, TBI, unspecified intellectual disability and childhood onset conduct disorder. Depressive indicators include increased sleep, decreased appetite and verbalizations of depression. Interventions included to assist with positive coping skills, offer reassurance, encourage her to express her feelings and identify approaches contributing to behaviors. Review of Resident #41's May 2025 CPO revealed the following physician's orders: Zoloft (antidepressant medication) 100 mg. Give 100 mg one time a day for depression, ordered 12/14/24. Behavior monitoring for increased sleep, decreased appetite and decrease in complaints of depression. Document yes or no if the behavior occurred, ordered 9/13/24. -There were no non-pharmological interventions indicated on the behavior monitoring physician's order. Review of Resident #41's MAR and TAR from 2/1/25 to 5/14/25 failed to reveal any documentation to indicate the resident exhibited behaviors during that time period. Review of the facility's quarterly psychotropic meeting minutes revealed Resident #41 was reviewed by the IDT on 2/17/25. The meeting minutes revealed Resident #41 had not had any behaviors within the three month look back period. -The 2/17/25 psychotropic meeting note did not indicate the facility had concerns regarding any behaviors for the resident and there was no documentation to indicate the justification for the continued use of the resident's antidepressant medication. Review of Resident #41's EMR from 2/1/25 to 5/14/25 did not reveal any progress notes to indicate the resident had exhibited any behaviors during that time period. A review of Resident #41's psychiatrist visit notes revealed the last visit note was dated 12/29/24. The psychiatrist documented he had received an e-mail from the facility's social services director (SSD) on 12/13/24 which contained an attachment from an e-mail sent to the SSD by Resident #41's representative. The resident's representative stated in her e-mail to the SSD that Resident #41 had been extremely angry, having outbursts, and uncontrollable temper tantrums. The representative requested a review of Resident #41's medication by the psychiatrist. As a result of this communication, the psychiatrist increased Resident #41's Zoloft from 50 mg daily to 100 mg daily. The psychiatrist documented in his note that he later reviewed the documentation in Resident #41's EMR and found there were no progress notes written by the SSD describing her communications with Resident 41's representative. The psychiatrist documented in his note that he was having concerns regarding the lack of documentation as Resident #41's Zoloft dosage was increased for no apparent reason. The psychiatrist requested documentation that described the communications between the SSD and the resident's representative, as well as expressing the importance of having documentation due to no documented behaviors by staff since 11/26/24. When the psychiatrist met with Resident #41 on 12/29/24, the resident told him her behavioral outbursts were related to agitation towards her representative. The psychiatrist indicated during his visit that the resident did not display any evidence of agitation or anger and appeared no different than any prior visit he had had with her. -However, despite the psychiatrist's documented concerns on 12/29/24, regarding the increase in Zoloft, the medication was not decreased and Resident #41 continued to receive the increased dose of Zoloft (see physician's orders above). V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/13/25 at 3:00 p.m. CNA #1 said Resident #45 did not have any behaviors, he was just particular about how he liked things to be done. CNA #1 said she was not aware of any specific non-pharmological interventions used for Resident #45. She said she did not know Resident #44. She said Resident #41 had behaviors of verbalizing being unhappy and not wanting to live in the facility but CNA #1 said she had a hard time understanding what Resident #41 was saying and was not aware of any interventions to use when Resident #41 was having these verbalizations of depression. CNA #1 said the CNAs documented behaviors on the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. She said the CNAs could not customize the behaviors observed or interventions tried, and so if there were behaviors observed or intervention tried that were not on the generic list, she would notify the nurse for them to document in the residents' EMR. Licensed practical nurse (LPN) #2 and registered nurse (RN) #2 were interviewed together on 5/13/25 at 3:15 p.m. LPN #2 and RN #2 both said Resident #45 had behaviors of being compulsive and particular in how he wanted things done for him. RN #2 said what interventions worked with Resident #45 were to support him in being independent and accommodate how he wanted things done as much as possible. She said he enjoyed leaving his room, walking around the facility and talking to staff and other residents. RN #2 and LPN #2 both said they were unaware of any behaviors for Resident #44. RN #2 said Resident #41 had behaviors of verbalizations of being unhappy and sad about her placement in the facility. RN #2 said she was not aware of any specific interventions that helped the resident when she was feeling that way. She said the residents' behavior monitoring was in the physician's orders and popped up on the nurses' TAR to complete every shift. RN #2 said the director of nursing (DON) would email the nurses' specific behaviors to monitor for residents because the behaviors and interventions on the physician's orders were generic. CNA #4 was interviewed on 5/14/25 at 8:45 a.m. CNA #4 said Resident #45 did not have any behaviors. CNA #4 said Resident #44 had behaviors of frequently going outside to smoke cigarettes and refusing to perform basic hygiene tasks (changing his socks, clothes or showering). She said he would refuse to clean his own bottom after a bowel movement, claiming he was unable to reach the area even though the staff had tried to provide him encouragement and reassurance he could complete the task independently. She said the non-pharmological interventions indicated for Resident #44 on his behavior monitoring, such as offering to toilet the resident, offering a back-rub and offering activities, were not effective as these interventions would agitate him more if offered. She said she was not aware of any specific interventions that helped with Resident #44 when he was refusing care. CNA #4 said she was not aware of any behaviors for Resident #41. LPN #4 was interviewed on 5/14/25 at 9:00 a.m. LPN #4 said Resident #44 had behaviors of refusing to clean his own bottom after a bowel movement but she was not aware of what interventions the CNAs used with him for this behavior. LPN #4 said many of the non-pharmological interventions on the behavior monitoring physician's orders (offering activities, offering a back rub, offering toileting, repositioning and changing room temperature) for Resident #44 did not apply to him because he was independent and preferred to be alone. LPN #4 said Resident #45 did not have any behaviors and she did not know Resident #41 very well. LPN #3 was interviewed on 5/14/25 at 9:13 a.m. LPN #3 said Resident #44 had behaviors of refusing to change his clothes, socks or take a shower. LPN #3 said the interventions that worked were for staff to allow him to take the lead during personal cares, such as asking him what personal care he wanted to do first, what he needed from the staff and continuously providing positive reinforcement throughout the process. She said there were some staff he would perform these tasks for because the staff allowed him to direct the care and he felt comfortable with this approach. LPN #3 said Resident #45 had behaviors of weighing himself daily and pacing. She said he was concerned with his weight loss and wanted to gain weight and this was why he compulsively weighed himself. LPN #3 said when he started pacing, interventions that worked for him were to redirect him to an activity of interest, especially when there was an activity involving watching movies. The SSD and the social services consultant (SSC) were interviewed together on 5/14/25 at 2:07 p.m. The SSD said when a resident began taking a psychotropic medication, the DON and the SSD put together a behavior monitoring physician's order. She said the behaviors included on the order came from a list of standard behaviors that were associated with the specific drug classification, such as hallucinations for antipsychotic medications. The SSD said once the facility got to know the resident, the behavior monitoring physician's order would be modified in order to make it more resident-specific and personalized. The SSD said the purpose of monitoring residents' behaviors was to determine the efficacy of the psychoactive medication and to ensure there were non-pharmological interventions being tried and the facility was not solely relying on the psychoactive medications to help with decreasing the residents' behaviors. The SSD said she gathered information from the behavior monitoring documentation in the residents' TARs and progress notes before the monthly psychotropic medication meetings. She said she did not look at the CNA behavior monitoring tasks or interview the CNAs for the collection of information for the psychotropic medication meetings. The SSD said if a resident did not have any documented behaviors for three months, the medication associated with those behaviors should be reduced or discontinued. The SSD said she reviewed the residents' progress notes and the TARs for behaviors to discuss in the psychotropic medication meetings, but she said she had not noticed that the behavior monitoring physician's orders for Resident #44 had the same non-pharmological interventions or that Resident #41 and Resident #45 had no non-pharmological interventions indicated on their behavior monitoring physician's orders. She said she had not noticed that the TARs for Resident #45 or Resident #41 documented the residents had exhibited minimal or no behaviors for February 2025, March 2025, April 2025 and May 2025. She said she was unaware of Resident #44's history of self harm and harming others that was documented in his Level II PASRR, but she acknowledged the behaviors should be included in his care plan and on his behavior monitoring. She said she did not include behaviors identified in a resident's Level II PASRR on the behavior monitoring because the DON primarily managed the behavior monitoring process. The DON was interviewed on 5/14/25 at 3:06 p.m. The DON said a behavior monitoring physician's order was entered when a resident was admitted to the facility on psychoactive medications or had a change in psychoactive medications. The DON said the behaviors indicated on the physician's order came from the resident's history and a standard list of behaviors associated with the specific medication drug classification. She said once the facility became more familiar with a resident,, the behavior monitoring physician's order would be modified to be more personalized and resident specific. The DON said for the psychotropic medication meetings, the SSD brought a spreadsheet of the residents' behavior information she had compiled for the three month look back period. The DON said she assumed the SSD collected this information from the residents' TARs and progress notes. She said the behavior monitoring information was an important part of the psychotropic medication meetings because it helped the physicians make decisions about residents' psychotropic mediation changes, and if the information was not accurate, it would affect making informed decisions about the effectiveness of medications. The DON said the facility's medical director (MD) had explained to her the importa[TRUNCATED]

Based on observations, record review and interviews, the facility failed to provide provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life for one (#45) of two residents reviewed out of 32 sample residents. Specifically, the facility failed to provide the necessary assistance for Resident #45, who required physical assistance with meals due to tremors. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) Support policy, revised March 2018, was provided by the nursing home administrator (NHA) on 5/13/25 at 12:23 p.m. It read in pertinent part, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals, and recognize standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate. II. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease (a disease that causes involuntary movements), anxiety, obsessive compulsive disorder (OCD) and depression. The 4/16/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #45 required one-person staff assistance with toileting and bathing. The MDS assessment indicated the resident was independent with eating. -However, observations revealed Resident #45 needed assistance with meals (see observations below). B. Resident interview Resident #45 was interviewed on 5/13/25 at 9:43 a.m. He said he was supposed to get help with eating because of his tremors. He said he only received help if he asked for it and did not always get help even when he asked. Resident #45 said he had weighted utensils to assist with eating, but the utensils were not very helpful when his tremors were very bad. Resident #45 said the lunch meal on 5/12/25 when his tablemate helped cut his food for him was not an unusual occurrence and he often had a difficult time getting the staff's attention for assistance (see observations below). C. Observations During a continuous observation on 5/12/25, beginning at 12:05 p.m. and ending at 1:00 p.m., the following was observed in the main dining room: At 12:10 p.m. Resident #45 was served his meal, which consisted of navy bean soup, teriyaki chicken, fried rice, vegetable blend and a bread roll. Resident #45 was provided with built-up utensils (foam handled silverware). Resident #45 attempted to cut his chicken with his fork and knife. He was having difficulty cutting his chicken due to his hands shaking continuously throughout the process of cutting. Resident #45 attempted to get the attention of two unidentified staff members. The first attempt he tried to wave down an unidentified staff member walking by serving meal trays and the second attempt he called out to an unidentified certified nurse aide (CNA) who told him she would return to help him. The unidentified CNA did not return to assist him. At 12:30 p.m. Resident #45 continued to try to cut his chicken. The residents tremors were worsening At 12:35 p.m. another resident sitting next to Resident #45 cut up his chicken for him. Resident #45 was then able to eat his chicken. During a continuous observation on 5/13/25, beginning at 12:00 p.m. and ending at 1:11 p.m., the following was observed in the main dining room: At 12:10 p.m. Resident #45 was provided juice in a regular glass, which he struggled to prevent from spilling when he would try to take a drink due to his tremors, he was able to drink some of his supplement because it had a straw and was in a carton. At 12:19 p.m., Resident #45 was served his meal, which consisted of spaghetti with three meatballs and a garlic bread. Resident #45 was provided with built up utensils and attempted to use his fork to cut one of his meatballs. He kept losing the grip on his fork due to continuous tremors in his hands. From 12:19 p.m. to 12:41 p.m., Resident #45 attempted three separate times to cut his meatballs without success. After being unable to cut the meatballs, he would finally put the entire meatball into his mouth. When Resident #45 attempted to eat the spaghetti noodles, he lowered his face very close to the plate and used his fork to push the noodles into his mouth. Resident #45 was unable to bring his fork to his mouth without the spaghetti falling off of the fork. At 12:41 p.m. Resident #45's tremors became more severe and he began to struggle to push the spaghetti with his fork into his mouth, losing amounts of spaghetti in the process. When this would occur, Resident #45 would attempt to use his other hand to push the spaghetti into his mouth or prevent the spaghetti from falling out of his mouth. At 1:15 p.m., Resident #45 had finished his meal, eating approximately 75% and only drinking approximately 50% of his beverage. D. Record review The nutrition care plan, revised 5/8/25, revealed Resident #45 had a diagnosis of Parkinson's disease which put him at risk for a decreased ability to maintain nutritional status. The care plan documented the resident had experienced unplanned weight loss. Interventions, revised 5/8/25, included providing supplements as ordered, serving the resident's diet as ordered, registered dietitian (RD) to evaluate and make diet recommendations and continuing to provide a regular diet and fortified foods. -The care plan did not indicate the resident needed assistance with cutting up his meals. An interdisciplinary team (IDT) weight variance note, dated 12/20/24, revealed Resident #45 had an average intake amount of 60%. Potential contributing factors included rigid tremors. The root cause analysis determined the likely cause of weight loss to be Resident #45's tremors and not eating his entire meal. III. Staff interviews CNA #1 was interviewed on 5/13/25 at 3:00 p.m. CNA #1 said Resident #45 only needed staff to assist with cutting his food for him when he asked. -However, observations revealed the staff did not assist Resident #45 with cutting up his food (see observations above). Registered nurse (RN) #2 was interviewed on 5/13/25 at 3:15 p.m. RN #2 said Resident #45 liked to attempt to do things for himself and if he asked the staff for assistance with something, that meant he had already tried and failed several times to do it on his own. She said he would allow the staff to assist him with things like cutting his food, if the staff were discreet about providing him assistance. Licensed practical nurse (LPN) #3 was interviewed on 5/14/25 at 9:13 a.m. LPN #3 said Resident #45 did need assistance from staff with cutting his food up sometimes due to his tremors and would ask staff for help. The director of rehabilitation (DOR) was interviewed on 5/14/25 at 11:45 a.m. The DOR said Resident #45 had not worked with therapy since October of 2024, which was for shoulder pain. The DOR said the nurses or the director of nursing (DON) would request an order from the physician for therapy to do an evaluation for residents identified as potentially needing additional assisted devices or staff assistance with eating, however, she had not received a referral for Resident #45. The DON was interviewed on 5/14/25 at 12:00 p.m. The DON said she had observed Resident #45 eating and it took him over an hour to eat his meals because it required a lot of energy for him to concentrate on the task of eating due to his tremors. She said since it took so long for him to eat he would not request additional food if the task of eating was exhausting. The registered dietitian (RD) was interviewed on 5/14/25 at 12:29 p.m. The RD said she had never observed Resident #45 eating to see if there were any challenges with intake. She said she thought the staff assisted him with cutting up his food when he asked. She said she had not considered adding cut up meals to his diet order so he would not have to ask the staff. The RD said Resident #45 was determined to stay as independent as possible and had refused feeding assistance but she had never offered to him to have his food precut as a means to ensure eating was easier and then wouldn't require him to exert so much energy.

Based on observations, record review, and interviews, the facility failed to ensure an environment free from risk of accident and hazards for two (#84 and #6) of five residents reviewed for accident hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure the grab bar/hand rail in Resident #84's bathroom was repaired and a second one installed, per the recommendations of the occupational therapist (OT) as a fall intervention; and, -Ensure Dakin's solution (a topical antiseptic used in wound treatment) was not left unsecured in Resident #6's room. Findings include: I. Failed to ensure grab bar/hand rail was repaired and a second one installed in the bathroom for Resident #84 A. Facility policy and procedure The Falls Clinical Protocol policy, revised September 2012, was provided by the nursing home administrator (NHA) on 5/15/25 at 12:53 p.m. It read in pertinent part, As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. The risk of serious adverse consequences can sometimes be minimized, even if falls cannot be prevented. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. The Accommodation of Needs policy, revised March 2021, was provided by the NHA on 5/15/25 at 12:53 p.m. It read in pertinent part, The facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. To accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptations may include providing access to assistive devices, such as grab bars and toilet risers in the bathroom, installing mirrors at a height at which a wheelchair-bound resident can see, installing adaptive handles, or providing assistive devices so that drawers are easily opened and closed. B. Resident #84 1. Resident status Resident #84, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included spinal stenosis, chronic obstructive pulmonary disease (COPD), major depressive disorder and personal history of transient ischemic attack (a temporary interruption of blood flow to the brain). The 3/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He was independent with toileting, dressing, eating, and personal hygiene. 2. Observation and resident interview Resident #84 was interviewed on 5/13/25 at 9:16 a.m. He was sitting in his wheelchair in his room. The resident said the grab bar in his bathroom was loose and he was afraid to use it during toileting. He said he reported it to the OT, who completed a work order for the repairs. Observation of the resident's bathroom during the interview revealed there was only one grab bar in the resident's bathroom which was loose when it was pulled on. Resident #84 said a maintenance department staff member came to assess the grab bar in April 2025 and said he was going to come back with the appropriate tool to fix the loose grab bar and install the additional grab bar on the left wall of his toilet. However, Resident #84 said the maintenance staff member did not return and the work was not completed and the grab bar was still loose. Resident #84 said if the grab bars were installed and working properly, he would not have fallen. He said he did not feel safe using his toilet due to the loose grab bar and the unavailability of the additional grab bar that was recommended by the OT after a fall evaluation was completed. 3. Record review Review of Resident #84's at risk for falls care plan, initiated and revised on 1/10/25, revealed the resident was at risk for falls and fall-related injury related to incontinence, decreased functional ability and chronic pain. Pertinent interventions included an occupational and physical therapy (OT and PT) evaluation and treatment as needed, placement of a Call Don't Fall sign in the resident's room, and OT and PT evaluations for strengthening, mobility training, and activities of daily living (ADL) self-care activities. A fall incident report, dated 3/17/25 at 4:30 p.m., documented that registered nurse (RN) #3 responded to a loud voice coming from Resident #84's bathroom. The report indicated the resident was found lying on his left side on the floor. The resident was incontinent of bowel, and his pants were down below his knees. The report revealed the resident said he wanted to go to the bathroom. The 3/26/25 OT progress note revealed that a recommendation by the OT was made to install a new grab bar on the left wall in Resident #84's bathroom and also to repair the grab bar on the right side of the wall. -However, the existing grab bar was not repaired and the additional grab bar was not installed (see observation and resident interview above and OT interview below). C. Staff interviews The OT was interviewed on 5/13/25 at 2:50 p.m. The OT verified that the grab bar in Resident #84's bathroom was loose and there was no additional grab bar in the bathroom. The OT said Resident #84 was evaluated after a fall in his bathroom. The OT said she recommended an additional grab bar to be installed on the left wall of the resident's bathroom, due to his poor safety awareness, and she said she also completed a maintenance work order for the existing grab bar to be repaired. The OT said the work order was resolved as completed; however, the grab bar was not repaired and the additional grab bar was not installed. The OT said Resident #84 was a high risk for falls due to his decreased safety awareness. The maintenance director (MTD) was interviewed on 5/13/25 at 3:30 p.m. The MTD said all maintenance work orders were submitted through an electronic submission system. He said he did not remember receiving any maintenance work orders to fix and install a grab bar in Resident #84's room. The MTD said grab bars in residents' bathrooms were not part of the maintenance department's preventative list and therefore he did not routinely check them to ensure they were not loose. The MTD said he looked through all maintenance work orders he received via the electronic submission system and completed all safety concerns immediately. The MTD said when maintenance work orders were not completed promptly, it could cause injuries to the residents. Registered nurse (RN) #4 was interviewed on 5/15/25 at 11:50 a.m. RN #4 said She said she completed all maintenance work orders on the facility's electronic submission system. RN #4 said she was unaware that Resident #84 needed to have his bathroom grab bar fixed and an additional grab bar installed. She said when maintenance work orders were not completed promptly, it could potentially result in injuries for residents. The NHA was interviewed on 5/15/25 at 9:29 a.m. The NHA said all maintenance work orders should be completed promptly and any reason the work was not completed should be documented. He said all handrails and grab bars in residents' living areas, including bathrooms, should be inspected periodically. The NHA said he was unaware that residents' grab bars were not being inspected by the maintenance department. The NHA said he would immediately initiate a performance improvement plan to ensure that all maintenance work orders were completed, and periodic checks would be performed on all grab bars in the residents' bathrooms. II. Failed to ensure Dakin's solution was not left unsecured in Resident #6's room A. Facility policy and procedure The Medication Labeling and Storage policy, revised 2001, was provided by the NHA on 5/15/25 at 1:45 p.m. It read in pertinent part, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. The nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments, including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes containing medication and biologicals, are locked when not in use, and trays or carts used to transport such items are not left unattended. B. Resident #6 1. Resident status Resident #6, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 CPO diagnoses, included bipolar disorder, epilepsy, schizophrenia and pressure ulcer of the sacral region. The 4/17/25 MDS assessment revealed Resident #6 had severe cognitive impairment with a BIMS score of seven out of 15. He required total assistance from staff for transfers, toileting, personal hygiene and set up assistance with eating. 2. Observation On 5/12/25 at 11:30 a.m. Resident #6 was lying in his bed. The resident had paintings on his bedside table, which he was coloring. Resident #6 said he required assistance getting up out of bed, however, he was able to push himself once he was in his wheelchair. There were several personal care items sitting on top of a small dresser facing Resident #6's bed. Among the items was a bottle of Dakin's half-strength solution. C. Record review A review of a medication administration note, dated 3/9/25 at 11:31 p.m., documented the following treatment was administered to Resident #6: Treatment to open sacrum, cleanse with normal saline, apply gauze moistened with 1/2 strength Dakins and cover with an ABD (abdominal pad) at bedtime for wound care. D. Staff interviews Registered nurse (RN) #3 was interviewed on 5/12/25 at 5:40 p.m. RN #3 confirmed Resident #6 had a bottle of Dakin's solution sitting on his bedside table. She said the Dakin's solution was for the resident's wound care. RN #3 said the staff left the bottle of solution in the resident's room once it was opened to avoid contamination. RN #3 said the Dakin's solution was kept in the Resident's room to prevent contamination. The director of nursing (DON) was interviewed on 5/15/25 at 1:39 p.m. The DON said Dakin's solution was a form of medication and needed to be stored in a secured location and not in Resident #6's room at his bedside. The DON said all medications and treatments must be stored securely. The DON said the bottle of Dakin's solution was removed from Resident #6's room after being discovered on 5/12/25 and the nurses were re-educated to check his room for medications and treatments. The DON said Dakin's solution should not be left unsecured because it could cause potential harm if ingested by a resident.

Based on record review and interviews, the facility failed to ensure one (#74) of two residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 32 sample residents. Specifically, the facility failed to monitor Resident #74, who had a history of suicide attempts, for worsening signs and symptoms of identified depression. Findings include: I. Resident #74 A. Resident status Resident #74, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included mild dementia with anxiety, personality disorder, adjustment disorder, major depressive disorder, suicidal ideations and bipolar disorder. The 4/23/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. B. Resident interview Resident #74 was interviewed in her room on 5/14/24 at 11:00 a.m. Resident #74 said her depression had worsened in the last month due to her declining health. She said it was very difficult for her to physically go down to the activities room to find crafts and puzzles. Resident #74 said she had a history of depression and at least four hospitalizations related to her depression. She said what triggered her depression was the loss of abilities (no longer being able to drive, travel or take photographs) and changes in her health. She said she stayed in her room a lot more and tried to keep herself busy with projects and crafts. C. Record review The suicidal ideations care plan, revised 5/7/25, revealed Resident #74 had a history of suicidal ideations, per her preadmission screening and resident review (PASRR) evaluation for mental illness and/or intellectual disabilities. Interventions, revised 2/27/25, included administering medications as ordered, being alert for signs and symptoms of increased depression and engaging the resident in conversation during medication pass to assess mood. The mood care plan, revised 5/7/25, revealed Resident #74 had behaviors related to major depressive disorder. Interventions, revised 8/27/24, included to identify strengths and use positive coping skills to reinforce these, encourage and reassure and identify approaches that contributed to behaviors. The May 2025 CPO revealed the following physician's orders: Lexapro (antidepressant medication) 10 milligram (mg). Give one tablet in the morning for depression; ordered 1/31/24. Lithium (mood stabilizer medication) 150 mg. Give one tablet at bedtime for major depressive disorder, ordered 2/2/24. Abilify (antipsychotic medication) 2 mg. Give one tablet in the morning for major depressive disorder, ordered 1/29/25. Monitor hours of sleep, ordered 1/31/24. Behavior monitoring for increased sleep, decreased appetite and verbalizations of sadness. Document yes or no if the behavior occurred, ordered 9/13/24. Behavior monitoring for physician aggression. Interventions: redirect, one-on-one, see nurses notes, activity, return to room, toilet, offer food/fluids, change position, adjust room temperature, backrub, or medication, ordered 4/21/25. -The physician's orders did not include an order to monitor the resident for suicidal ideations. A review of the resident's depression screens, dated 12/5/24 to 4/21/25, revealed Resident #74's depression score increased from four (minimal depression) to an eight (mild depression) with expressions of feeling bad about herself and feeling hopeless. Resident #74's Level II PASRR, dated 1/27/24, revealed Resident #74 had been admitted to the hospital for suicidal ideations on 1/23/24. She had a history of expressing suicidal ideations without intent, however, she was admitted to the hospital after being found with antidepressants in her pocket after expressing depression. Her assisted living facility had been closed abruptly and she had to live with her son temporarily, causing her anxiety and depression. Resident #74 had expressed to the hospital staff that she felt like she had to depend on medication to walk and sleep and felt like she could no longer be me. She had a history of being active, social, and artistically creative (crafts and photography). The evaluation revealed she had taken pills in the past to overdose but was unsuccessful. -The resident specific identification of triggers (loss of abilities and medical decline) and non-pharmacological interests identified in the Level II PASRR were not incorporated in Resident #74's behavior monitoring physician's orders or the resident's care plan (see physician's orders and care plan above). Review of Resident #74's medication administration records (MAR) and treatment admission records (TAR) from 2/1/25 to 5/14/25 revealed the following: The February 2025 MAR/TAR, from 2/1/25 to 2/28/25, revealed there was no documentation to indicate Resident #74 exhibited behaviors during the month, however, the hours of sleep monitoring documentation revealed the resident had been sleeping an average of 10 hours a day. The March 2025 MAR/TAR, from 3/1/25 to 3/31/25, revealed there was no documentation to indicate Resident #74 exhibited behaviors during the month, however, the hours of sleep monitoring documentation revealed the resident had been sleeping an average of 11.5 hours a day. The April 2025 MAR/TAR, from 4/1/25 to 4/30/25, revealed there was no documentation to indicate Resident #74 exhibited behaviors during the month, however, the hours of sleep monitoring documentation revealed the resident had been sleeping an average of 10.5 hours a day. The May 2025 MAR/TAR, from 5/1/25 to 5/14/25, revealed there was no documentation to indicate Resident #74 exhibited behaviors during the month, however, the hours of sleep monitoring documentation revealed the resident had been sleeping an average of 10 hours a day. Review of Resident #74's electronic medical record (EMR), from 1/28/25 to 5/14/25, revealed the following progress notes: A psychiatrist visit note, dated 1/28/25, revealed Resident #74 expressed to the psychiatrist she was beginning to become more depressed and that it felt like episodes in the past when she became severely depressed. A Patient Health Questionnaire-9 (PHQ-9 - a tool used to screen for depression) note, dated 1/31/25, revealed Resident #74's depression score was an eight out of 27 (indicating mild depression) and she expressed feeling bad about herself and feeling hopeless to the social services director (SSD). A PHQ-9 note, dated 4/21/25, revealed Resident #74's depression score was an eight and she expressed decreased appetite and increased sleep to the SSD. -Despite Resident #74 expressing symptoms indicated on her behavior monitoring for depression (increased sleep, decreased appetite and verbalizations of sadness) on 1/28/25, 1/31/25 and 4/21/25 and her hours of sleep monitoring showing increased hours of sleep, there was no documentation to indicate the SSD followed up with the resident or that staff was made aware to increase monitoring of Resident #74 for worsening symptoms of depression and/or suicidal ideation. II. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 5/13/25 at 3:00 p.m. CNA #1 said Resident #74 did not have any history of depression or expressions of suicidal ideations. CNA #1 said sometimes Resident #74 isolated herself in her room away from the other residents but CNA #1 did not know why. Registered nurse (RN) #2 was interviewed on 5/13/25 at 3:15 p.m. RN #2 said sometimes Resident #74 could be tearful and isolate herself in her room but as long as she had an art craft to work on in her room, Resident #74 was fine. CNA #4 was interviewed on 5/14/25 at 8:45 a.m. CNA #4 said Resident #74 did not have any history of depression or expressions of suicidal ideations. CNA #4 said if Resident #74 became tearful, she would try to encourage her to do an art craft. The SSD and the social services consultant (SSC) were interviewed together on 5/14/25 at 2:07 p.m. The SSD said she was aware Resident #74 had a history of suicidal ideations and attempts but she did not recall any identified triggers from the resident's Level II PASRR. The SSD confirmed she was the one who completed the PHQ-9 screens with Resident #74 when her score increased, but she said she did not find the increase in the scores concerning. The director of nursing (DON) was interviewed on 5/14/25 at 3:06 p.m. The DON said she was not aware of Resident #74's history of suicidal ideations and attempts. She said the facility should be monitoring Resident #74 for resident specific signs and symptoms of depression so the staff could advise her (the DON) or the SSD of any concerning behaviors exhibited or statements made by Resident #74.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of two medication storage refrigerators. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the inside of the medication storage refrigerator. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, undated, was provided by the nursing home administrator (NHA) on 5/13/25 at 4:45 p.m. It read in pertinent part, Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. II. Observation On 5/14/25 at 10:32 a.m. the medication storage room on the third floor was observed with registered nurse (RN) #4. There was a lock on the outside of the medication storage refrigerator, however, the refrigerator was unlocked. A locked narcotic medication box, which contained two vials of liquid lorazepam (a narcotic medication for anxiety), was sitting on a shelf inside of the medication storage refrigerator. The locked narcotic medication box was not permanently affixed to the inside of the refrigerator. III. Staff interviews RN #4 was interviewed on 5/14/25 at 10:42 a.m. RN #4 said the narcotic box and the medication storage refrigerator should be locked at all times to avoid unauthorized access to the narcotic medications. RN #4 said she was the only nurse who currently had access to the medication storage refrigerator and the lock box and it was her responsibility to make sure the refrigerator was locked. She said she forgot to lock the refrigerator. RN #4 said there were only two nurses working on the third floor who had access to the locked medication storage room. RN #4 said she was the only one who had access to the contents inside the refrigerator. -However, the refrigerator was unlocked when observed (see observation above). The director of nursing (DON) was interviewed on 5/14/25 at 10:55 a.m. The DON said the medication storage refrigerator and the narcotic medication lock box inside the refrigerator should both be locked for the safety of the residents and it was the standard of care. The DON said she did not know that the refrigerated controlled medications should be in a permanently affixed container inside the medication storage refrigerator. The DON said she would see what she could do about affixing the narcotic medication lock box to the inside of the medication storage refrigerator. Licensed practical nurse (LPN) #4 was interviewed on 5/15/25 at 11:45 a.m. LPN #4 said the refrigerated controlled medications should always be in the narcotic medication lock box with the medication storage refrigerator locked as well. LPN #4 said this was important to make sure the medication was only accessed by the nurses.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#5) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to ensure Resident #5 received timely incontinence care. Findings include: I. Facility policy and procedure The Urinary Incontinence-Clinical Protocol, revised March 2018, was received from the nursing home administrator (NHA) on 2/6/25 at 3:11 p.m. It read in pertinent part, As appropriate based on assessment of the category and causes of incontinence the staff will provide scheduled toileting, prompted voiding or other interventions to try to improve the individual's incontinence status. The Activities of Daily Living (ADL) policy, revised March 2018, was received from the NHA on 2/6/25 at 3:11 p.m. It read in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care including appropriate support and assistance with: hygiene,. mobility and elimination (toileting). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. II. Resident #5 A. Resident status Resident #5, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO) diagnoses included wedge compression fracture of first lumbar vertebra, morbid (severe) obesity, pain in left knee, pain in right knee, unspecified symptoms and signs involving cognitive functions following cerebral infarction (also known as ischemic stroke). The 1/8/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS showed the resident was dependent on staff for toileting hygiene, for lower body dressing and dependent for chair/bed-to-chair transfer. The MDS indicated the resident was not on a toileting program and that she was always incontinent of urine and bowel. B. Observations During continuous observation on 2/6/25, starting at 9:11 a.m. and ending at 1:15 p.m. the following was observed: At 9:11 a.m. Resident #5 was in the activity room working on an independent activity. At 10:51 a.m. Resident #5 was assisted by an unidentified activity assistant back to her room to see the dentist. At 11:04 a.m. the resident received care from the dentist. At 11:38 a.m. the resident was assisted out of the room by the dentist. An unidentified occupational therapist (OT) asked Resident #5 if she would participate in a therapy session and Resident #5 said she would after lunch. Resident #5 was assisted to the dining room by the unidentified OT. At 12:55 p.m. the resident was assisted to the therapy gym by an unidentified nurse. Her pants were visibly wet in the crotch area. She was met by the unidentified OT for a therapy session in the gym. Resident #5 said that her new dentures were hurting. The unidentified OT offered to take Resident #5 her to her room to put her new dentures in a cup and they could work on therapy in her room. At 1:00 p.m. the unidentified OT began their session. Upon prompting, the unidentified OT asked the resident if she needed to use the bathroom. Resident #5 said she already did. The unidentified OT said she would help the resident change as part of the therapy session. -Resident #5 was not checked for incontinence care for three hours and 49 minutes, and was visibly soiled. C. Resident and Resident #5's representative interview Resident #5 was interviewed on 2/10/25 at 12:50 p.m. Resident #5 said the staff did not check on her during the day to see if she needed incontinence care. Resident #5 said she enjoyed staying active and attending activities. She said she did not want to be interrupted during the activities. She said she would be agreeable to be checked for incontinence care before or after meals. Resident #5's representative was interviewed on 2/10/25 at 1:33 p.m. The representative said she had concerns about incontinence care not being completed timely. She said Resident #5 went through two to three pairs of pants daily. The resident's representative said she did Resident #5's laundry. She said she visited the resident every weekday at 4:30 p.m. and often found Resident #5 dripping wet. D. Record review The urinary incontinence care plan, initiated 10/6/24 and revised on 2/6/25, indicated Resident #5 had urinary incontinence due impaired mobility. Pertinent interventions included checking and changing the resident per facility protocol. The care plan was updated on 2/6/25 (during the survey process) and indicated the resident had declined to be checked and changed on a schedule and preferred to alert staff when she would like to be changed. -However, Resident #5 said she preferred to be toileted before and after meals (see interview above). The skin integrity risk for impairment care plan, initiated 10/6/24 and revised on 11/1/24, and again 2/6/25, had the potential for impaired skin integrity as evidenced by decreased mobility, incontinence and morbid obesity. Pertinent interventions included providing the resident with prompt assistance with management of incontinence episodes. The care plan was updated on 2/6/25 (during the survey process) indicated the resident preferred to alert staff when she wanted or /needed to be changed rather than on a schedule. A review of the Resident #5's toileting schedule from 2/5/25 to 2/29/25 revealed the following: On 2/5/25 the resident was incontinent twice at 10:56 a.m. and 9:53 p.m. On 2/6/25 the resident was incontinent once at 10:29 a.m.; -On 2/7/25 the resident was incontinent two times at 12:19 a.m. and 9:40 p.m.; -On 2/8/25 there was no documentation indicating the resident was toileted; and, -On 2/9/25 the resident was incontinent twice at 12:05 a.m. and 8:39 p.m. -However, observations on 2/6/25 revealed the resident was not toileted from 9:11 a.m. until 1:00 p.m. (see observations above). E. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/6/25 at 12:35 p.m. LPN #2 said a resident should be checked and changed every two hours. LPN #2 said it was important to check a resident every two hours because it could put the resident at risk for developing pressure ulcers. LPN #2 said that Resident #5 sometimes refused to be changed because she did not like to leave an activity to be changed. The social services director (SSD) was interviewed on 2/10/25 at 1:49 p.m. The SSD said she was informed if a resident was noncompliant with care. She said she would then become involved to assist with reasons for the noncompliance and to assist with interventions. The SSD said she was not aware that Resident #5 had been noncompliant with incontinence care. The director of nursing (DON) was interviewed on 2/6/25 at 4:45 p.m. The DON said she expected the residents to be checked and changed every two hours. III. Facility follow up The NHA provided additional information via email on 2/12/25 at 3:00 p.m. that included an on the spot education provided to and signed by 22 staff members regarding frequent checks for incontinent and immobile residents.

Based on record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#4) of three residents out of 16 sample residents. Specifically, the facility failed to ensure Resident #4 was administered the correct pain medication per physician's orders and failed to provide non-pharmacological interventions prior to administering PRN pain medication. Findings include: I. Professional reference According to Treas, L. &, [NAME] K., & [NAME] M., (2022) Basic Nursing (3rd ed.) p. 1257, Medications administered PRN are given only when the patient meets certain conditions that were established in the medication prescription. II. Resident #4 A. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included quadriplegia, unspecified muscular dystrophy, unspecified pain and unspecified low back pain. The 1/26/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff for all activities of daily living (ADL). The assessment indicated the resident occasionally had pain and he rated his pain level during the assessment period as a 6 out of 10, on a pain scale of 1 to 10. B. Record review The pain care plan, initiated 11/29/23 and revised 1/24/25 identified Resident #4 had increased risks for alteration in comfort due to generalized pain related to decreased mobility and decreased functional abilities. Pertinent interventions included providing pain medication as ordered, non-pharmacological pain approaches and repositioning. Review of Resident #4's February 2025 CPO revealed the following physician's order for pain medications: Tramadol HCL oral tablet 50 milligrams (mg) give one tablet by mouth every eight hours as needed for moderate to severe pain (6 to10). Document nonpharmacological pain management interventions, ordered 11/10/23. Review of Resident #4's January 2025 and February 2025 medication administration records (MAR) revealed the Tramadol pain medication was administered outside of the physician ordered parameters on the following dates: -On 1/4/25 Tramadol was administered for a pain level of 5; -On 1/8/25 Tramadol was administered for a pain level of 5; -On 1/23/25 Tramadol was administered for a pain level of 5; and, -On 2/3/25 Tramadol was administered for a pain level of 5. -Review of Resident #4's January 2025 and February 2025 revealed there were no non-pharmacological interventions documented for pain. -Review of Resident #4's January 2025 and February 2025 progress notes did not identify documentation of attempted non-pharmacological interventions for the resident's pain. C. Staff interviews The director of nursing (DON) was interviewed on 2/6/25 at 3:43 p.m. The DON said physician ordered parameters for pain medications needed to be followed. She said if the parameters were not followed, a separate one-time physician's order should have been obtained prior to administering the medication for a pain level outside of the parameters.

Based on observations, record review, and interviews, the facility failed to ensure residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice to prevent or heal pressure injuries for one (#2) of three residents reviewed for pressure ulcers out of 16 sample residents. Specifically, for Resident #2, the facility failed to: -Ensure there was a physician's order in place for treating the resident's left knee wound; -Ensure staff utilized knee protectors, per the resident's care plan, when repositioning the resident to offload pressure; -Ensure staff appropriately cleansed the resident's left knee wound during a dressing change; and, -Ensure staff followed appropriate techniques when removing the resident's old knee wound dressing to avoid causing potential damage to the wound bed. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 2/17/25, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Ulcers/Skin Breakdown - Clinical Protocol policy, dated March 2014, was received on 2/10/25 from the nursing home administrator (NHA). It read in pertinent part, The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive) and application of topical agents if indicated for type of skin alteration. III. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included, pressure ulcer of sacral region, stage 4, paraplegia, unspecified, schizophrenia, and other chronic osteomyelitis, multiple sites. The 1/8/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15.The resident required extensive assistance from one staff member for activities of daily living (ADL). The MDS assessment indicated the resident had an unhealed stage 4 pressure ulcer. The MDS assessment revealed the resident did not refuse care. B. Observations On 2/10/25 at 3:27 p.m. Resident #2 was lying in bed. There were no pillows or wedges in bed to help offload pressure areas on his coccyx or knees. There were no pillow or wedges observed in the room other than the ones under Resident #2's head. -Resident #2 failed to have off loading interventions in place. On 2/10/25 at 3:49 p.m. Registered nurse (RN ) #1 was observed providing wound care to Resident #2's left knee wound. RN # 1 applied gloves and removed the old dressing of Kerlix (rolled gauze) around the resident's knee. There was no abdominal (ABD) pad underneath the Kerlix dressing. There was visible wet and dry serosanguineous drainage on the dressing. The Kerlix was stuck to the wound bed and RN #1 pulled the dressing off the wound bed without attempting to moisten it to loosen it. RN #1 then took dry gauze pads and dabbed the open wound bed. RN #1 dabbed the wound four times with the same piece of gauze. After dabbing the resident's wound with the gauze, RN #1 removed her gloves and applied new gloves. RN #1 collected a cotton tipped applicator and a cup with medi honey gel (a treatment for wounds) and applied the medi honey to the wound bed using the cotton tipped applicator. RN #1 took an ABD and placed it over the wound bed, securing the ABD pad with Kerlix around Resident #2's leg to hold the dressing in place. The dressing was secured by RN #1 with tape. RN #1 dated and initialed the dressing. -RN #1 failed to remove the old dressing without potentially causing damage to healthy tissue and she failed to clean the wound bed. -RN #1 failed to perform hand hygiene when changing her gloves. C. Record review Review of the February 2025 CPO, on 2/6/25 at 6:30 p.m., failed to reveal a physician's order for wound care treatment for Resident #2's left lateral knee wound. On 2/10/25, at 7:30 p.m. upon discovery that Resident #2 did not have a physician's order for treatment of his left knee wound, the following physician's order was entered into the resident's electronic medical record (EMR): Cleanse wound with normal saline (NS) or wound cleanser, pat the wound dry after cleaning, apply MediHoney (specialized wound ointment), cover the wound with an abdominal pad (ABD) and wrap with Kerlex (rolled gauze) at hour of sleep (HS). A review of Resident #2's care plan, revised 1/29/25, revealed the resident had chronic non-healing wounds and was admitted with chronic wounds. The resident had a history of pressure ulcers, immobility and paralysis. Pertinent interventions for chronic wound management included the use of a specialty air mattress, knee protectors, a wheelchair cushion for pressure relief, and encouragement of good nutrition and hydration to promote healing. -However, observation on 2/10/25 revealed there were no pillows or wedges in bed to help offload pressure areas on the resident's coccyx or knees (see observations above). The wound care physician's (WCP) progress note dated 1/28/25, documented a stage 3 full-thickness pressure wound to Resident #2's left knee. The WCP documented the wound was a chronic, recurring pressure wound due to the resident's contractures, inability to maintain repositioning, and compromised skin quality, making reoccurrence unavoidable. The dressing treatment plan included applying Leptospermum honey, a non-adherent pad (Telfa), and securing the wound with a gauze roll (Kerlix) and retention tape, all done once daily for 30 days. The note emphasized the need to offload the wound, reposition the resident, per facility protocol, and turn the resident side to side in bed every one to two hours if able. -However, observations of Resident #2's wound care on 2/10/25 revealed there was not a non-adherent Telfa pad underneath the resident's old wound dressing and RN #1 applied an ABD pad, which was not a non-adherent pad, to the resident's left knee wound when she applied a new dressing (see wound observations above). -Additionally, the physician's order entered into Resident #2's EMR on 2/10/25 (during the survey) indicated the use of an ABD pad and not a non-adherent Telfa pad, as was specified in the WCP's 1/28/25 progress note (see wound care order above). IV. Staff interviews RN #1 was interviewed on 2/10/25 at 4:06 p.m. RN #1 said she reviewed the wound care orders in the electronic medical record (EMR) system prior to completing Resident #2's treatment. RN #1 reviewed the resident's wound treatment orders again and said she was unable to locate a dressing order for the resident's left knee wound. RN #1 said she was unable to find the physician's order prior to providing care so she took it upon herself to find the order in the wound care physician's (WCP) orders from his last visit on 1/28/25. RN #1 said she completed the dressing change based on the WCP's wound visit notes. RN #1 said the wound dressing order should have been in the order section of the resident's EMR to ensure the nurses providing care were following the physician's orders. 47064

Based on observations, record review, and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#13) of four residents reviewed for pain out of 16 sample residents. Specifically, the facility failed to: -Ensure a thorough pain assessment was completed for Resident #13 which included recognizing the onset, presence of and characteristics of pain; and, -Offer non-pharmaceutical interventions before administering as needed pain medication. Findings include: I. Facility policy and procedure The Pain-Clinical Protocol, revised October 2022, was received from the nursing home administrator (NHA) on 2/6/25 at 4:05 p.m. It read in pertinent part, The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. II. Resident #13 A. Resident status Resident #13, age 75, was admitted [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included, pain in the right leg, mood disturbance, chronic obstructive pulmonary disease with acute exacerbation, and cerebral infarction without residual deficit (stroke). The 2/3/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required extensive assistance from one staff member for all activities of daily living (ALDs). The MDS assessment documented Resident #13 was not on a scheduled pain medication regimen but did receive as needed pain medication. The resident did not receive any non-medication interventions for pain management. B. Observations On 2/5/25 at 2:00 p.m. the resident was lying in bed on her left side. She was crying and moaning while with her eyes closed. The registered nurse (RN) #1 was notified and went in to assess the resident. Registered nurse (RN) #1 assessed the resident for pain. The resident did not respond and she continued to cry and moan. RN #1 said she would inform the resident's nurse as she was not the licensed nurse for the resident. At approximately 11:30 a.m. certified nurse aide (CNA) #2 assisted Resident #13 out of the facility for dialysis. As she left the room, she continued to moan as she was being transported by staff. On 2/6/25 at 9:14 a.m. Resident #13 was lying in bed and was moaning and crying. C. Record review The baseline care plan, dated 1/28/25, revealed the resident experienced intermittent pain located in the bilateral legs and feet. The interventions included providing opioids for pain management. -The baseline care plan did not include any non-pharmaceutical interventions or a scheduled pain management regimen. Review of the resident's electronic medical record (EMR) did not reveal a pain assessment was completed to identify the potential for pain, recognizing the onset, presence of pain and failed to assess the characteristics of pain upon admission. Review of the February 2025 CPO did not reveal a physician's order to indicate what type of pain scale was to be used to assess the resident's pain. Further review of the February 2025 CPO revealed the following physician's order for pain control included: -Oxycodone HCL Oral tablet 5 milligrams (mg) by mouth every 12 hours as needed for pain start with a start date of 2/5/25. Review of the February 2025 (2/5/25 to 2/6/25) medication administration record (MAR) revealed the resident was administered Oxycodone HCL 5 mg on 2/5/25 and 2/6/25. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/6/25 at 1:15 p.m. LPN #1 said Resident #13 was moaning and crying related to discomfort on 2/5/25 (see observations above). He said the resident had discomfort from a sacral wound and other comorbidities. LPN #1 said repositioning the resident was difficult due to the sacral wound. He said the resident frequently cried out in discomfort. LPN #1 said the resident was receiving rehabilitation care and the family had expressed interest in starting hospice services for improved pain management. LPN #1 said pain assessments should be completed at admission, with a change in condition and at least quarterly. -However, review of the resident's EMR did not reveal a pain assessment was completed since the resident's admission on 1/28/25 (see record review above). The director of nursing (DON) was interviewed on 2/6/25 at 3:43 p.m. The DON said pain assessments should be completed upon admission, with a change in condition and at least quarterly. The DON said there was a lot of redundancy in pain assessments. The DON said the MAR was more accurate and reliable for tracking pain assessments. The DON said she would look into the issue and ensure that all aspects of pain assessments, such as pain level, tolerable pain level, and factors that improve or worsen pain were consistently reviewed and documented. The DON said there was no documented pain goal for Resident #13. The DON reviewed Resident #13's MAR and said there was no documentation that non-pharmaceutical interventions were attempted. She said prior to the administration of an as needed pain medication, a non-pharmaceutical intervention should be offered. She said non-pharmaceutical interventions should be assessed upon admission and included in the care plan.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to: -Ensure proper infection control practices were followed for wound care; and -Ensure hand hygiene was performed appropriately. Findings include: I. Facility policy and procedure The Wound Care policy and procedure, revised October 2010, was received from the director of nursing (DON) on 2/10/25 at 6:50 p.m. It revealed in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Use disposable cloth (paper towel is adequate) to establish a clean field on the residents' overbed table. Place all items to be used during the procedure on the clean field. Arrange supplies so they can be easily reached. Wash and dry your hands thoroughly. Position resident. Place disposable cloth next to the resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Put on exam gloves. Loosen tape and remove dressing. Pull the glove over the dressing and discard the dressing into the appropriate receptacle. Wash and dry your hands thoroughly. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. Remove disposable cloth next to the resident and discard into the designated container. Remove disposable gloves and discard them into designated containers. Wash and dry your hands thoroughly. The Handwashing/Hand Hygiene policy and procedure, revised October 2023, was received from the DON on 2/10/25 at 6:50 p.m. It revealed in pertinent part The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Hand hygiene is indicated: immediately before touching the resident; before performing an aseptic task; after contact with blood, body fluids, or contaminated surfaces; after touching the resident; after touching the resident environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. The use of gloves does not replace hand washing/ hand hygiene. II. Observations On 2/10/25 at 3:27 p.m. registered nurse (RN) #1 was providing wound care to Resident #2. RN #1 entered Resident #2's room after applying personal protective equipment (PPE). RN #1 cleared Resident #2's bedside table of personal items, wiped the table down with a disinfectant wipe and allowed it to air dry. RN #1 returned to the room doorway where she left the treatment cart. She began collecting packages of gauze, abdominal pads (ABDs), a medicine cup with Medi Honey gel (specialized ointment used for wounds), package of long cotton tip applicators (similar to a Q-tip) and packages of scissors. RN #1 returned to the resident's bedside table and placed all supplies onto the table. -RN #1 failed to put a barrier pad onto the bedside table and failed to change her gloves and perform hand hygiene after touching the treatment cart. RN #1 was assisted by certified nurse aide (CNA) #1 to roll the resident onto his right shoulder. RN #1 removed the old dressing to the residents buttock area which was soiled with serosanguinous (clear and bloody mix of fluids) drainage and placed it into the trash can. RN #1 removed her gloves and applied new gloves without washing her hands. She then went to the treatment cart and opened two packages of drain sponges to which she applied wound cleanser to. RN #1 returned to the resident's bedside. She took one drain sponge and cleaned the larger wound to the buttock. RN #1 dabbed the same piece of sponge over the entire wound dabbing the wound eight times with the same sponge. RN #1 then took a second sponge and cleaned two other open areas on the resident buttock, dabbing each wound four times. -RN #1 failed to place a barrier pad under the resident for wound care. RN #1 failed to perform hand hygiene between glove changes. RN #1 failed to use a clean sponge for each site and failed to only wipe once with each sponge used. RN #1 then removed her gloves, applied new gloves and went to the treatment cart again. She opened a bottle of half strength Dakins (specialized wound liquid treatment ) and opened the drawers to the treatment cart to locate a package of Kerlex (rolled gauze). RN #1 opened a package of Kerlex and applied the Dakins to the Kerlex. RN #1 returned to the resident and opened the package of sterile scissors. RN #1 measured the rolled gauze and cut to fit the larger wound on the buttock. RN #1 applied the Dakins soaked gauze on the two other sites on the buttock. RN #1 opened two packages of ABD dressing placing them over the large wound and taped them down with CNA #1 assisting to hold the ABDs in place. RN #1 then opened a third ABD dressing to cover the smaller wounds. -RN #1 failed to perform hand hygiene after removing her gloves. RN #1 opened the treatment cart drawers, dressing packages and the Dakins bottle with the same gloves she used to apply the dressing to the resident's wounds. RN #1 removed her gloves and applied new gloves. RN #1 said she was going to complete the left knee dressing. -RN #1 failed to complete hand hygiene after removing her gloves and prior to applying the new set. RN #1 removed the old dressing to the resident's left knee. There were visible areas of wet and dry serosanguinous drainage dried on the Kerlex when she removed it. RN #1 then took dry gauze to the wound bed dabbing the wound four times with the same piece of gauze. RN #1 removed her gloves and put on new gloves. -RN #1 failed to place a barrier pad under the resident's left knee. RN #1 failed to clean the wound and failed to perform hand hygiene after removing her gloves and prior to applying the new set of gloves. III. Staff interviews RN #1 was interviewed on 2/10/25 at 4:06 p.m. RN #1 said she should have placed a barrier pad under each wound to prevent contamination of drainage onto linens or into the resident's wound. RN #1 said she should have at least used hand sanitizer when changing her gloves during wound care. RN #1 said hand hygiene was important to prevent the spread of infection. RN #1 said she was not aware that she did not clean the left knee wound with anything. The DON was interviewed on 2/10/25 at 4:49 p.m. She said the nurse should have placed a barrier pad on the bedside table after wiping it down with disinfectant to establish a clean working field. The DON said the nurse should have prepared all the items needed for the dressing change, so she would not need to go back to the treatment cart. The DON said having all supplies ready would decrease the possibility of infection. The DON said the nurses needed to complete hand hygiene with soap and water or alcohol based hand sanitizer when removing or changing gloves. The DON said hand hygiene was important to prevent the spread of infection. The DON said the nurses should only use a gauze once when cleaning a wound to prevent the spread of infection from one site to another. The DON said using the same piece of gauze multiple times increased the risk of infection. The wound care physician (WCP) was interviewed on 2/10/25 at 6:20 p.m. The WCP said Resident #2 had a history of osteomyelitis and infection prevention was a key component to maintaining current wound healing measures.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#1) of three residents reviewed for abuse out of three sample residents. Specifically, the facility failed to report an allegation of sexual abuse to the State Agency made by Resident #1. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised April 2021, was provided by the operations manager (OM) on 4/8/24 at 3:30 p.m. It revealed in pertinent part, Investigate and report any allegations within timeframes required by federal requirements. II. Resident #1 A. Resident status Resident #1, age 82, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included displaced fracture of the demur, major depressive disorder and anxiety. The 3/9/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required partial to moderate assistance with toileting, upper and lower body dressing and set up assistance for personal hygiene. The assessment indicated the resident had clear speech and was able to express her ideas and wants. B. Record review The 12/26/23 physician's progress note documented Resident #1 was discussed during the interdisciplinary team (IDT) meeting on 12/18/23. During IDT, the staff indicated the resident had made an accusation that a male staff member had inappropriately touched her. The physician, along with another staff member, interviewed the resident. She was asked about the incident alluded to above, and she described it with a fair amount of detail. She did not appear fearful of this writer, and was cooperative and pleasant throughout the interview. -The facility was unable to provide documentation that the facility had reported the allegation of abuse to the State Agency (see staff interviews below). Cross-reference F610 for the facility's failure to investigate an alleged violation. III. Staff interviews The director of nursing (DON) was interviewed on 4/8/24 at 2:11 p.m. The DON said she was at the facility on 12/16/23 when Resident #1 made an allegation of sexual abuse against certified nurse aide (CNA) #1. Resident #1 said he touched her inappropriately when he was changing her brief. The DON said she notified the nursing home administrator (NHA) immediately. The DON said she did not participate in an investigation of the abuse allegation. She said the former NHA was responsible for conducting all abuse investigations, including reporting the allegations to the State Agency. The OM was interviewed on 4/8/24 at 2:35 p.m. The OM said the former NHA was responsible for conducting abuse allegation investigations at the time the allegation was made by Resident #1. He said the former NHA no longer worked at the facility. The OM said he was not able to find any documentation that the allegation of abuse made by Resident #1 was reported to the State Agency. He said all allegations of abuse should be reported to the State Agency.

Based on record review and interviews, the facility failed to investigate an allegation of abuse involving one (#1) of three residents reviewed for abuse out of three sample residents. Specifically, the facility failed to conduct an investigation when Resident #1 reported an allegation of abuse against certified nurse aide (CNA) #1. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and procedure, revised April 2021, was provided by the operations manager (OM) on 4/8/24 at 3:30 p.m. It revealed, in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements. Protect residents from further harm during investigations. II. Resident #1 A. Resident status Resident #1, age 82, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included displaced fracture of the femur, major depressive disorder and anxiety. The 3/9/24 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score of 12 out of 15. She required partial to moderate assistance with toileting, upper and lower body dressing and set up assistance for personal hygiene. The assessment indicated the resident had clear speech and was able to express her ideas and wants. The assessment indicated the resident did not exhibit depression or behaviors during the assessment period. B. Record review The 12/26/23 physician's progress note documented Resident #1 was discussed during the interdisciplinary team (IDT) meeting on 12/18/23. During IDT, the staff indicated that the resident had made an accusation that a male staff member had inappropriately touched her. The physician, along with another staff member, interviewed the resident. She was asked about the incident alluded to above, and she described it with a fair amount of detail. She did not appear fearful of this writer, and was cooperative and pleasant throughout the interview. -A review of the resident's medical record did not reveal any further documentation of Resident #1's allegation of abuse against CNA #1. The clock in and clock out details for CNA #1 documented on 12/16/23, CNA #1 clocked in when he arrived at work at 5:55 a.m. He clocked out at 8:54 a.m. He then clocked back into the facility at 2:23 p.m. and clocked out for the day at 6:44 p.m. -The facility was unable to provide documentation that the facility had conducted an investigation regarding the allegation of sexual abuse (see staff interviews below). III. Staff interviews The director of nursing (DON) was interviewed on 4/8/24 at 2:11 p.m. The DON said she was at the facility on 12/16/23 when Resident #1 made an allegation of abuse against CNA #1. She said he touched her inappropriately when he was changing her brief. The DON said she notified the nursing home administrator (NHA) immediately and then suspended CNA #1. The DON said she did not participate in an investigation of the abuse allegation. She said the former NHA was responsible for conducting all abuse investigations, including reporting the allegation to the State Agency (cross-reference F609 for reporting of an abuse allegation). The DON said the NHA had notified her later in the afternoon on 12/16/23 that CNA #1 could return to work. She said she called CNA #1 and he returned to work. The DON said the NHA never informed her of the outcome of the investigation. She said she did not follow up with the NHA. The OM was interviewed on 4/8/24 at 2:35 p.m. He said the former NHA was responsible for conducting abuse allegation investigations at the time the allegation was made by Resident #1. He said the former NHA no longer worked at the facility. The OM said he was not able to find any documentation that an investigation was conducted for the abuse allegation made by Resident #1. He said the former NHA had taken a flash drive with her, upon her dismissal, that held a lot of facility information, including QAPI (quality assurance and performance improvement) meeting notes. The OM said the DON should have followed up with the NHA as to the outcome of the abuse investigation. The DON was interviewed again on 4/8/24 at 3:30 p.m. The DON said she was new to her position as a DON and was new to the facility during the time of the abuse allegation made by Resident #1. She said she trusted her former NHA and trusted that she had conducted an abuse investigation. She said she should have followed up with the former NHA.

Based on record review and interviews, the facility failed to provide notice before discharge for one (#1) of three residents reviewed for discharge out of four sample residents. Specifically, the facility failed to provide Resident #1 and her responsible parties, an appropriate notice of discharge that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -A statement of the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State. Findings include: I. Facility policy The Facility-Initiated Transfer or Discharge policy, revised October 2022, was received from the director of medical records on 2/6/24 at 3:10 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident II Resident status Resident #1, age 80, was admitted to the facility on [DATE] and discharged on [DATE] to the hospital. According to the December 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar disorder, and depression. The 8/11/23 minimum data assessment (MDS) assessment showed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required substantial assistance with activities of daily living. III. Hospital case manager interview The hospital case manager (HCM) where Resident #1 was discharged to was interviewed on 2/6/24 at 3:06 p.m. The HCM said the facility refused to readmit Resident #1 because they could not meet her needs. The HCM stated on 1/15/24 a facility staff member informed the HCM that the facility would not accept Resident #1 back even if she began taking medication and her condition improved. The HCM said the facility refused to reassess Resident #1. The HCM said Resident #1 started court-ordered medications at the hospital and was doing well. IV. Resident representative interview The resident's representative was interviewed on 2/6/24 at 12:26 p.m. The representative said she was informed five to six months ago that Resident #1 may be discharged from the facility but did not hear anything further. The representative said she received a verbal notification from the facility that the resident was discharged from the facility. The representative did not disclose the reason for the discharge. The representative said she did not receive any written notice of Resident #1's discharge. V. Record review -A review of Resident #1's medical record did not reveal any progress notes or documentation indicating Resident #1 was discharged . It did not reveal any discharge notice for the resident nor the responsible party. -There were no progress notes documenting the resident's change of condition that led to her hospitalization on [DATE]. VI. Staff interviews The director of nursing (DON) was interviewed on 2/6/24 at 1:06 p.m. The DON said Resident #1 requested to go to the hospital on 12/22/23 and was sent to a hospital with a psychiatric unit in their emergency room . The DON said the facility did not reassess the resident for readmission but they spoke with the other facility's staff who reported the resident was continuing to have behaviors at their facility. The DON was interviewed again on 2/6/24 at 2:36 p.m. The DON said all discharge information was given to the other facility over the phone. The DON said there was no written notice of discharge provided to Resident #1 nor the responsible party. The regional resource nurse (RRN) was interviewed on 2/6/24 at 2:46 p.m. The RRN said Resident #1 did not have a responsible party to provide discharge information to and the resident was her own deciding person. -However, the facility failed to provide the resident with a discharge notice. -The facility failed to assess and readmit Resident #1 after she started taking her medication and was doing well according to the HCM (see interview above). Cross-reference F626 failure to readmit after hospitalization .

Based on record review and interviews, the facility failed to permit residents transferred to another facility to return to the facility for one (#1) of three residents reviewed for transfers out of four sample residents. Specifically, the facility failed to readmit Resident #1 to the facility following a transfer to the hospital. Findings include: I. Facility policy The Facility-Initiated Transfer or Discharge policy, revised October 2022, was received from the director of medical records on 2/6/24 at 3:10 p.m. It read in pertinent part: Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Under the following circumstances, the notice is given as soon as it is practicable but before the transfer or discharge: The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident II Resident status Resident #1, age 80, was admitted to the facility on [DATE] and discharged on [DATE] to the hospital. According to the December 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar disorder and depression. The 8/11/23 minimum data assessment (MDS) assessment showed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required substantial assistance with activities of daily living. III. Hospital care manager interview The hospital case manager (HCM) where Resident #1 was discharged to was interviewed on 2/6/24 at 3:06 p.m. The HCM said the facility refused to readmit Resident #1 because they could not meet her needs. The HCM stated on 1/15/24 a facility staff member informed the HCM that the facility would not accept Resident #1 back even if she began taking medication and her condition improved. The HCM said the facility refused to reassess Resident #1. The HCM said Resident #1 started court-ordered medications at the hospital and was doing well. IV. Resident representative interview The resident's representative was interviewed on 2/6/24 at 12:26 p.m. The representative said she was informed five to six months ago that Resident #1 may be discharged from the facility but did not hear anything further. The representative said she received a verbal notification from the facility that the resident was discharged from the facility. The representative did not disclose the reason for the discharge. The representative said she did not receive any written notice of Resident #1's discharge. V. Record review Discharge notes from a previous facility on 8/3/22 revealed Resident #1 did not take her prescribed psychiatric medication and had a long history of noncompliance with psychiatric medication. The 8/9/22 care plan identified Resident #1 had diagnoses of schizoaffective disorder, altered mental status and psychotic behaviors. The 8/18/22 care plan identified intentions to discharge Resident #1 from the facility to a facility that would better meet her behavioral needs but that Resident #1 was resistant to any interventions. Progress notes from 7/3/23 revealed Resident #1 was spitting on the floor, hallucinating and refusing care. Physician progress notes from 8/27/23 revealed the facility staff were at their wits end with Resident #1. Resident #1 had been verbally abusive, resistant to redirection and accusatory to facility staff members. Progress notes from nursing staff on 10/23/23 revealed Resident #1 declined psychiatric services and psychiatric medication. Social services staff were sending out referrals again to see if another facility could meet Resident #1's needs. Progress notes from 11/29/23 revealed Resident #1 was spitting on and hitting staff members after refusing to shower. Physician progress notes from 11/30/23 revealed Resident #1 had a normal mood and affect during the examination. Resident #1's schizoaffective disorder, bipolar disorder and depression were unstable. The physician's notes indicated that the facility could consider starting an antipsychotic for Resident #1. Behavior tracking sheets from October 2023 to December 2023 revealed limited instances of behaviors documented. -There were no progress notes documenting the resident's change of condition that led to her hospitalization on [DATE]. V. Staff interviews The social services director (SSD) was interviewed on 2/6/24 at 1:02 p.m. The SSD said Resident #1 was discharged from the facility for spitting on someone. The SSD said Resident #1 had a history of inappropriate defecation, hoarding food and behaviors toward staff. The SSD was not sure why the facility did not readmit Resident #1. The director of nursing (DON) was interviewed on 2/6/24 at 1:06 p.m. The DON said Resident #1 requested to go to the hospital on 12/22/23 and was sent to a hospital with a psychiatric unit in their emergency room . The DON said the facility tried to put Resident #1 on psychiatric medication in September 2023 but the resident was noncompliant. The DON said Resident #1 was discharged because of escalations in yelling, spitting and hitting staff members. The DON said the facility did not reassess the resident for readmission but they spoke with the hospital staff who reported the resident was continuing to have behaviors. -However, according to the HCM (see interview above) the resident had improved since she was taking court-ordered medication and Resident #1 had been at the hospital for several weeks. The DON was interviewed again on 2/6/24 at 2:36 p.m. The DON said Resident #1's behaviors were not directed toward nor involved other residents at the facility. The DON said the facility had talked to Resident #1's family about alternative placement for the resident but the resident's family had not provided a list of alternative facilities. The DON said all discharge information was given to the other facility over the phone. The DON verified that there was no written notice of discharge provided to Resident #1 nor the responsible party (cross-reference F623 for discharge notice). The regional resource nurse (RRN) was interviewed on 2/6/24 at 2:46 p.m. The RRN said Resident #1 did not have a responsible party to provide discharge information to and the resident was her own deciding person. -However, the facility failed to provide discharge notice to the resident (cross-reference F623). The RRN said that when the facility made the decision to discharge Resident #1 they had to weigh the pros and cons of the decision and thought discharging the resident was worth the risk.

Based on record review and interviews, the facility failed to ensure two (#8 and #52) of two out of 47 sample residents had the right to a dignified existence. Specifically, the facility failed to ensure call lights were answered timely for Resident #8 and Resident #52, who were both dependent on staff for assistance. Resident #8 said she felt lonely and ignored when staff took over an hour to answer her call light and Resident #52 said she felt humiliated when her call light was not answered timely resulting in an episode of incontinence. Findings include: I. Facility policy and procedure A. The Answering the Call Light policy and procedure, revised in March 2021, was provided by the nursing home administrator (NHA) on 9//14/23 at 7:25 p.m. It read in the pertinent part, The purpose of this procedure is to ensure timely responses to the resident's request and needs. Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. Ask the resident to return the demonstration. Explain to the resident that a call system is also located in their bathroom. Be sure that the call light is plugged in and functioning at all times. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident Some residents may not be able to use their call light. Be sure you check these residents frequently. Report all defective call lights to the nurse supervisor promptly. B. The Dignity policy and procedure, revised in February 2021, was provided by the NHA on 9//14/23 at 7:25 p.m. It read in the pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example, promptly responding to a resident's request for toileting assistance. II. Resident #8 status Resident #8, age 89, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO) diagnoses included displaced spiral fracture of the right and left femur, chronic respiratory failure, type two diabetes mellitus, muscle weakness, chronic fatigue and repeated falls. The 8/11/23 minimum data set (MDS) assessment documented that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required extensive assistance of two with bed mobility, dressing, eating, and personal hygiene. A. Observations On 09/13/23 at 11:44 a.m. Resident #8 activated her call light. Certified nurse aide (CNA) #4 was observed sitting at the nurses station with another unidentified CNA, the family advisor (FA) and one other unidentified staff member. None of the staff members responded to Resident #8's call light. -At 12:08 p.m. licensed practical nurse (LPN) #3 walked past Resident #8's room. She did not enter the resident's room to ask what the resident needed. -At 12:10 p.m. LPN #1 walked past Resident #8's room. She did not enter the resident's room to answer the call light. -At 12:13 p.m. LPN #4 entered another resident's room, near Resident #8. She exited the other residents room at 12:14 p.m., walked away from Resident #8's room and entered the elevator. She did not address Resident #8's call light. -At 12:16 p.m. the interim director of nursing (IDON) walked past Resident #8's room without answering the call light. -At 12:23 p.m. the FA, who was still sitting at the nurses station, told the IDON that Resident #8's call light had been activated. The DON walked into the dining room and had a brief conversation with CNA #4. -At 12:24 p.m. CNA #4 responded to the call light. A total of 40 minutes had passed. B. Resident interview Resident #8 was interviewed on 9/12/23 at 2:05 p.m. She said there had been times it took up to an hour or even more for staff to answer her call lights. She said that it made her feel lonely and ignored when no staff responded. C. Record review The call light log was provided by the NHA on 9/14/23 at 4:10 p.m. It documented the following from 9/7/23 to 9/14/23: -On 9/7/23 at 9:19 a.m the resident waited 48 minutes, at 11:31 a.m. she waited 37 minutes and at 3:36 p.m. she waited 28 minutes for her call light to be answered. -On 9/9/23 at 11:10 a.m the resident waited one hour and 18 minutes and at 2:03 p.m. she waited 24 minutes for her call light to be answered. -On 9/10/23 at 10:11 a.m the resident waited 28 minutes for her call light to be answered. -On 9/11/23 at 11:58 a.m the resident waited 45 minutes for her call light to be answered. -On 9/12/23 at 7:45 a.m the resident waited 30 minutes for her call light to be answered. -On 9/13/23 at 7:54 a.m the resident waited 32 minutes and at 11:40 a.m. she waited 43 minutes for her call light to be answered. III. Resident #52 status Resident #52, age 74, was admitted on [DATE]. According to the September 2023 CPO diagnoses included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), chronic respiratory failure, spinal stenosis (narrowing of the spinal canal), muscle weakness, chronic pain and repeated falls. The 7/23/23 MDS assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing and toileting. A. Resident interview Resident #52 was interviewed on 9/11/23 at 12:59 p.m. She said staff took over an hour sometimes to answer her call light. She said, recently, one evening she activated her call light when she needed to use the bathroom. She said it took over an hour for someone to answer her call light which resulted in her having an incontinent episode. She said that made her feel humiliated. B. Record review The call light log was provided by the NHA on 9/14/23 at 4:10 p.m. It documented the following from 9/7/23 to 9/14/23: -On 9/7/23 at 8:24 a.m the resident waited 55 minutes, at 11:53 a.m. she waited 27 minutes and at 5:02 p.m. she waited 52 minutes for her call light to be answered. -On 9/8/23 at 11:31 a.m the resident waited 24 minutes for her call light to be answered. -On 9/9/23 at 7:44 a.m the resident waited 20 minutes for her call light to be answered. -On 9/11/23 at 8:13 a.m the resident waited 24 minutes for her call light to be answered. -On 9/12/23 at 8:22 a.m the resident waited 28 minutes for her call light to be answered. IV. Staff interviews CNA #4 was interviewed on 9/14/23 at 10:49 a.m. She said call lights should be answered in 15 minutes or less. She said every staff member was responsible for answering the call lights. The IDON was interviewed on 9/14/23 at 4:14 p.m. She said that call lights should be answered in five minutes or less. She said if the response time was longer than five minutes, she said she would investigate and provide education to the facility staff on acceptable response times. She said that every staff member in the facility should answer call lights. She said it was not acceptable for anyone, including upper management, to walk past a call light without checking on the resident.

Based on record review, observations, and interviews, the facility failed to ensure one (#32) of four out of 47 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure Resident #32, who had a history of falls, was a high fall risk and was identified by the facility upon admission to be impulsive and not ask for assistance, received the care and services indicated in her comprehensive care plan. The facility failed to ensure Resident #32 received the supervision required to prevent the resident from getting up without assistance. The facility failed to implement the interventions effectively and identify the trend that the resident's falls focused around the resident using the bathroom. On 4/24/23 and 4/26/23, Resident #32 sustained a fall in the bathroom. The resident complained of severe pain to the left shoulder. Upon further studies, the resident had sustained a left shoulder fracture. Additionally, on 9/14/23 (during the survey process), a certified nurse aide (CNA) took the resident to the bathroom and left the resident unattended; the facility continued to fail to provide the resident the appropriate amount of supervision, even when it was identified that the resident was impulsive and had continued falls. Findings include: I. Facility policy and procedure The Falls and Fall Risk Management policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 9/14/23 at 5:44 p.m. It revealed in pertinent part, The purpose of this falls and fall risk management policy is the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident centered approaches to managing falls and fall risk included, the staff, with the input of the attending physician, will implement a resident centered fall prevention to reduce the specific risk factor (s) of falls for each resident at risk or with a history of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff choice to prioritizing interventions (to try one or a few at a time, rather than many at once). Examples of initial approaches might include exercise and balance training, a rearrangement of furniture, improving footwear, changing the lighting, In conjunction with the consulting pharmacist and nursing staff, the attending physician will identify, adjust medication that may be associated with an increased risk of falling, or indicate why medications could not be tapered or stopped even for a trial period. If falling recurs despite initial interventions, staff will implement additional or different interventions indicating why the current approach remains relevant. In conjunction with the attending physician, staff will identify and implement relevant interventions, hip padding or treatment of osteoporosis, as applicable to try to minimize serious consequences of falling. The staff will monitor and document each resident's response to interventions intended to reduce falling and the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or continue whether these measures are still needed if a problem that required the intervention (dizziness, weakness) has been resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. II. Resident #32 A. Resident status Resident #32, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the diagnoses included cerebral infarction (stroke), vascular dementia, history of falling, weakness and a left nondisplaced intra articular olecranon fracture (left elbow fracture). The 8/22/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for a mental status score of five out of 15. She required limited assistance of one person with bed mobility, transfers, walking throughout her room and on the unit and personal hygiene and extensive assistance of one person with dressing and toileting. It indicated the resident had one fall since the prior assessment. B. Observations On 9/12/23 at 11:41 a.m. Resident #32 was wheeled out of her room by an unidentified staff member and taken to the dayroom. The resident was observed with a bruise to the right side of her head. -At 12:05 p.m. resident was wheeled downstairs by an unidentified CNA to the main dining room for lunch. She was not offered toileting assistance prior to being taken to lunch. -At 3:33 p.m. the resident was observed in her room lying down in bed. Her bed was positioned high and was not in the lowest position as was indicated in the resident's comprehensive care plan. During a continuous observation on 9/13/23 beginning at 9:41 a.m. and ended at 5:30 p.m. the following was observed: -At 11:45 a.m. Resident #32 was observed lying in bed with her bed positioned in the lowest position watching television. -At 12:04 p.m. an unidentified CNA entered the resident's room and asked if she was ready to get up and go downstairs to eat lunch in the main dining room. She assisted the resident, in her wheelchair, to the elevator and proceeded downstairs to the main dining room. She did not offer the resident toileting prior to taking the resident to lunch. -At 1:15 p.m. Resident #32 was brought back to her room by an unidentified CNA. The CNA assisted the resident to lay down in bed. She did not offer the resident toileting assistance prior to leaving the resident's room. -At 1:47 p.m. the resident was lying in bed, sleeping. -At 3:28 p.m. an unidentified CNA entered the resident's room and assisted the resident to the bathroom. The CNA stood outside the resident's bathroom door and waited until the resident was done and assisted the resident back to her wheelchair and out into the day room. -At 4:44 p.m. an unidentified CNA wheeled the resident back to her room. -At 5:27 p.m. an unidentified CNA entered the resident's room and wheeled her to the elevator to go downstairs to the main dining room to eat dinner. She did not offer the resident toileting assistance prior to taking the resident downstairs for dinner. On 9/14/23 at 8:59 a.m. Resident #32 was observed sitting in the main dining room, visiting with a family member. -At 9:10 a.m. the resident's family member wheeled her out of the main dining room area and took her back to her room to visit. -At 9:46 a.m. CNA #5 entered the resident's room and closed the door. The resident's family member left the room and CNA #5 was observed wheeling the resident to the bathroom. CNA #5 closed the bathroom door. -At 9:49 a.m. CNA #5 stepped out of the resident's room and left the resident on the toilet unattended. CNA #5 walked across the hallway and into another resident's room. Approximately 10 minutes later, CNA #5 walked back into Resident #32's room. Resident #32 was observed standing up from the toilet in the bathroom. CNA #5 assisted the resident to her wheelchair and back to bed. C. Resident #32's status upon admission to the facility The 3/2/23 admission progress note documented that the resident had confusion and was able to make her needs known, however was impulsive and would forget to ask staff for assistance. The 3/3/23 physician's progress note documented that the resident was admitted to the hospital following a fall in the bathroom at home. The resident was admitted to the facility due to general debility and weakness with impaired activities of daily living. It indicated the resident was able to answer simple yes or no questions and follow simple commands but was unable to elaborate. The 3/7/23 nursing progress note documented that the resident required encouragement and did not ask to use the toilet. The fall risk care plan, initiated on 3/2/23 and revised on 6/8/23, documented that resident at risk for falls related to decline in activities of daily living (ADLs), incontinence and weakness. It indicated the resident did not have any safety awareness and the facility needed to anticipate her needs. The interventions included providing safety education with occupational therapy and physical therapy (4/24/23); placing the resident on frequent checks (5/22/23); encouraging and assisting the resident to toilet upon rising, before and after meals, at bedtime and as needed (6/8/23); anticipating and meeting the resident's needs (3/2/23); ensuring the resident's call light was within reach and encouraging the resident to use it for assistance (3/2/23); encouraging the resident to participate in activities that promote exercise (6/8/23); encouraging the resident to wear helmet for added safety (however, it indicated that the resident had chosen not to wear it) (8/8/23); ensuring that the resident was wearing appropriate footwear when ambulating or mobilizing in the wheelchair (6/8/23); adding call before you fall signs to the resident's room (3/27/23); providing a lipped mattress (8/8/23); keeping the resident's bed in lowest position (8/6/23); and providing the resident a safe environment free of clutter (6/8/23). 1. Fall incident on 3/27/23 The 3/27/23 nursing progress note documented that the resident was found on the floor in the bathroom, in the supine (lying horizontally with the face and torso facing up) position, with her head near the toilet and feet out the door. The resident was wearing socks without shoes. It indicated the resident appeared to have already used the toilet and was headed back to bed. The resident sustained a skin tear to both elbows. The 3/27/23 situation, background, assessment and recommendation (SBAR) documented Resident #32 had an unwitnessed fall. The recommendation included having a wheelchair close by the bed so the resident can use it to transport herself to the bathroom. The 3/27/23 fall assessment documented recommendations to ensure that the resident's call light was within reach, encouraging the resident to use it for assistance as needed, providing a prompt response to all requests for assistance and encouraging the resident to wear appropriate footwear when ambulating or mobilizing in the wheelchair. 2. Fall incident on 4/24/23 The 4/24/23 nursing progress note documented Resident #32 was found on the floor, laying on her back with her feet near the sink and her head toward the toilet. It indicated the resident had activated her call light, had just used the bathroom and was going back to wash her hands when she fell backward. Both the resident and her roommate said the resident had hit her head on the door frame. The resident complained of pain to the left shoulder, left arm, scapula, left leg and bilateral hips. The resident sustained a skin tear to the left elbow and two abrasions on her left scapula. The 4/24/23 SBAR documented the resident had sustained a fall with a recommendation to conduct neurological checks and to monitor the resident. It indicated an x-ray was completed with no fracture or displacement noted. The physician was contacted with the x-ray results. The 4/24/23 interdisciplinary team (IDT) progress note documented the IDT met to discuss the resident's fall. The intervention included waiting to see if the physician would order an x-ray and continue physical and occupational therapy for safety awareness. The 4/25/23 physician progress notes documented the x-rays were negative following the resident's fall, but would consider further diagnostics if the resident's pain persisted. The resident had full range of motion (ROM) with slight tenderness to the left shoulder upon palpation but no obvious deformities. 3. Fall incident on 4/26/23 The 4/26/23 SBAR documented the resident sustained a fall. It did not include any other details. The recommendation was to obtain an x-ray. -The facility was unable to provide a fall investigation during the survey process. The 4/29/23 nursing progress note documented the resident's family member was concerned when the resident's roommate informed him the resident had sustained a fall. The nurse documented that the resident had fallen on 4/26/23 in the early morning. The 5/3/23 nursing progress note documented the physician was notified that the resident was complaining of severe pain to the left elbow with mild light blue bruising. The resident experienced pain with ROM. The physician called back and ordered an x-ray to the left elbow. The 5/4/23 physician progress notes documented that the resident was seen that day because of reports that the resident had increased pain to the left elbow and decreased ROM. The physical examination completed by the physician documented the resident had areas of bruises on the arms and decreased ROM to the left elbow. It indicated the results of the x-ray were pending. The 5/5/23 physician note documented the results of the x-ray to the left elbow showing a nondisplaced intra-articular left olecranon fracture. Orthopedic referral was ordered to be scheduled and a sling to be applied to the resident's left arm. -The facility failed to identify that the resident was admitted to the facility due to a fall the resident sustained while in the bathroom at home and this was the resident's third fall since being admitted to the facility, all of which were in relation to the resident using the bathroom. The facility failed to implement interventions effectively to ensure the resident's needs were being met timely and provided the supervision required to prevent continued falls, with this fall resulting in a fracture. 4. Fall incident on 5/21/23 The 5/21/23 nursing progress note documented the nurse heard Resident #32's roommate calling out for help. The nurse found the resident on the floor, in the sitting position, between the bed and the wheelchair. The resident said that she needed to go to the bathroom and fell . The nurse documented that the resident's call light had been activated. The 5/21/23 SBAR documented the resident had a fall, however did not include any new recommendations. The 5/22/23 IDT progress note documented that the resident would be placed on frequency checks. -It did not indicate how often the frequency checks would be completed or where it would be documented. The 5/25/23 physician progress notes recommended that the resident be placed on strict fall precautions and restorative therapy. The 5/22/23 fall assessment identified that the resident required a prompt response to all requests for assistance. 5. Fall incident on 5/31/23 The 5/31/23 nursing progress note documented the resident was laying on the floor with her head bleeding from the right side of her forehead with noted swelling and bleeding from the right elbow with noted swelling. The nurse called emergency services and the resident was transported to the hospital. The hospital provided an update that the resident had a large hematoma to the right side of her head. Upon returning to the facility from the hospital, the nurse noted echolalia (meaningless repetition of words) when changing the dressing. The physician ordered for the resident to be sent back to the hospital to rule out a brain bleed. The resident returned from the hospital on 6/2/23. The 6/1/23 IDT progress note recommended to offer a helmet to the resident to help prevent falls with an injury. The 6/5/23 physician readmission history and physical documented that the resident had numerous traumatic falls which was the reason for her recent hospitalization . The MRI and CTA were negative for any acute process but the head CT was positive for an extracranial hematoma with no intracranial bleeding. -The 5/31/23 fall assessment did not document any new interventions. 5. Fall incident on 6/7/23 The 6/7/23 SBAR documented the resident sustained a fall with the recommendations to place a bandage on the resident's head and continue neurological checks. -It did not include any additional information regarding the fall. The 6/7/23 long term follow up note documented the resident had a fall where she tripped and hit the right side of her head about the same area where she had the right parietal scalp hematoma. Nursing stopped the bleeding and a bandaged was applied. Neurological checks were started and remained stable. The 6/8/23 IDT progress note documented on 6/7/23 the nurse heard yelling, entered Resident #32's room and saw the resident on the floor. Her roommate had called out for help. The intervention included offering toileting upon rising, before and after meals, at bedtime and as needed. -The 6/7/23 fall assessment did not document any additional interventions. III. Staff interviews CNA #5 was interviewed on 9/14/23 at 3:19 p.m. She said Resident #32 required assistance getting out of bed and with toileting. She said that Resident #32 was able to stand up by herself and hold onto the hand rail in the bathroom. CNA #5 said she provided toileting assistance to Resident #32 that day. She said she assisted the resident to the bathroom, left her on the toilet and walked across the hallway to assist another resident. She said when she returned to assist Resident #32, the resident was standing up in the bathroom. CNA #5 said she did not know she should not leave a resident unattended in the bathroom and walk away to assist another resident. She said if the resident was not going to be long then she would have stayed in the room but if the resident was going to be there for a while she would go and answer another call light. She was aware Resident #32 was a high fall risk. She said the resident should be checked on often throughout the day. She said she was unaware the resident should be offered toileting assistance upon rising, before and after meals. Registered nurse (RN) #3 was interviewed on 9/14/23 at 3:35 p.m. She said Resident #32 was unsteady on her feet but felt she was able to get to the bathroom on her own with stand by assistance. She said Resident #32 did not use her call light often but would let staff know when she needed to use the bathroom. She said the resident was a high fall risk. She confirmed the resident had sustained multiple falls since her admission. She said she was not aware the resident's falls centered around the bathroom. She said if the resident's falls happened because she needed to use the bathroom, then the resident should be checked on often throughout the day and offered toileting. The interim director of nursing (IDON) was interviewed on 9/14/23 at 4:16 p.m. She said that continence care should be done before and after meals, upon rising, as needed and before bedtime. She said the standard rule for continence care was every two hours but if a resident was at a higher risk of falling, then continence care should be provided. She said there were some residents that insisted that staff stand right outside their door when they used the bathroom. She said the CNA should not have left the room to assist another resident. She said she did not know Resident #32 falls were consistently around going to the bathroom. She said she did not know why frequent checks were not ordered for the resident after her history of multiple falls. She said significant interventions should have been put in place to prevent injuries after each fall.

Based on observations, interviews, and record review, the facility failed to manage pain in a manner consistent with professional standard of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one (#3) of three residents reviewed for pain out of 47 sample residents. Resident #3 had a diagnosis of schizophrenia (brain disorder), developmental disorder, anxiety, post-traumatic stress disorder (PTSD), restless leg syndrome, and pain. In an interview on 9/11/23 the resident, holding her left knee and grimacing, said the knee pain had started a couple of months ago. Resident #3 said her pain level had increased on 9/10/23 and progressively gotten worse. It was more intense, frequent, and extreme which made it difficult for her to complete her daily activities of living and to attend facility activities. In an interview on 9/13/23, Resident #3 was crying and holding her knee. She said her pain was so bad she did not want her dinner; she said she wanted to go to the hospital. Record review confirmed the resident reported high levels of pain, documenting the resident reported pain at level 8 (severe) on 9/11 and 9/13/23, and level 10 (severe/worst pain) on 9/14/23. Observations, record reviews, and interviews revealed the facility failed to take steps to effectively manage this pain. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, dated October 2022, was provided by director of medical records (DMR) on 9/14/23 at 7:25 p.m. It revealed in pertinent part, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions consistent with the resident's goals and needs and that address the underlying causes of pain. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Recognizing pain: Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. II. Resident #3 A. Resident status Resident #3, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the September 2023 computerized physician orders (CPO), the resident's diagnoses included schizophrenia, developmental disorder, anxiety, post-traumatic stress disorder, restless leg syndrome, and pain. The resident's minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The assessment revealed the resident was on a scheduled pain medication program and received as-needed pain medications. The resident reported she had severe pain (occasionally), the pain made it difficult for her to sleep at night and limited her day-to-day activities. B. Resident #3's pain management plan The resident's pain care plan, initiated on 7/1/23 and revised on 8/30/23, revealed Resident #3 was at an increased risk for alteration in comfort due to overall pain secondary to falls. The interventions included: administering pain medications as ordered, monitoring and documenting the effectiveness of administered pain medications, providing pain medication as an effective way to provide pain relief and that providing a quiet place was an effective way to manage pain, observing changes in routine that could be related to pain, monitoring and recording any signs or symptoms of non-verbal pain, completing an evaluation of the effectiveness of the resident's pain and monitoring and documenting any side effects of pain medication The September 2023 CPO revealed Resident #3 had the following physician orders for pain management: -Ropinirole HCL oral tablet .25 MG (milligram) (Ropinirole Hydrochloride), give .25 MG by mouth at bedtime for RLS (restless leg syndrome) 1 MG for total dose 1.25 MG, ordered 4/11/23. -Ropinirole HCL oral tablet 1 MG (Ropinirole Hydrochloride), give 1 MG by mouth at bedtime for RLS - combine with .25 MG for a total dose of 1.25 MG, ordered 4/11/23. -Gabapentin Capsule 300 MG, give one capsule by mouth two times a day for restless leg, neuropathic pain, related to restless leg syndrome, ordered 3/10/23. -Biofreeze external gel 4% (Menthol Topical Analgesic), apply to left shoulder topically three times a day for left shoulder pain, ordered 6/1/23. -Biofreeze gel $% (menthol topical analgesic), apply to both knees and low back topically three times a day for pain, ordered 9/28/22. -Acetaminophen tablet, give 650 MG by mouth every eight hours as needed for pain 1 to 6, ordered 5/1/23. -Document non-pharmacological pain management intervention 1 = deep relaxation, 2 = heat to site, 3 - cold/ice to site, 4 = massage, 5 = meditation, 5= music, 7= going to bed, 8 = quiet place, 9 = repositioning, 10 = aromatherapy, 11 = guided imagery, 12 = other/see progress note as needed for pain document non-pharmacological pain management intervention, ordered 12/27/21. -IBU oral tablet 600 MG (Ibuprofen), give 600 MG by mouth two times a day for pain until 9/14/23 20:01, ordered 9/14/23, discontinued on 9/14/23. -Voltaren external gel 1% (diclofenac sodium topical), apply to bilateral knee topically two times a day for pain to knees, apply four grams to each knee, ordered 9/14/23, discontinued on 9/14/23. (This medication was never administered). -Voltaren external gel 1% (diclofenac sodium topical), apply to bilateral knee topically two times a day for pain to knees for five days, apply four grams to each knee, ordered 9/14/23. -IBU oral tablet 600 MG (Ibuprofen), give 600 MG by mouth STAT (immediately) for pain, ordered 9/14/23. The physician orders did not include any orders for pain level 7 to 10. C. Frequent reports of pain A 6/30/23 pain evaluation documented that the resident did not verbalize pain and said she rarely had pain; however, a review of the resident's medication administration records (MARs) in June, July, and August revealed the resident frequently reported pain at level 7 (moderate) and occasionally at level 8 (severe) for which the facility administered 650 MG, ordered for complaints of pain at levels 1 - 6. -A review of Resident #3's June 2023 MAR (6/1/23 through 6/30/23) documented that the resident was administered acetaminophen 650 MG when Resident #3 rated her pain level at a 7 on 6/1, 6/8, 6/9, 6/10, 6/13, 6/15, 6/16, 6/22, 6/23, 6/28 and 6/29/23. -A review of Resident #3's July 2023 MAR (7/1/23 through 7/31/23) documented that the resident was administered acetaminophen 650 MG when Resident #3 rated her pain level at a 7 on 7/2, 7/6, 7/7, 7/8, 7/12, 7/13, 7/20, 7/22, 7/26, 7/27, 7/28 and 7/30/23. Resident #3 rated her pain level at 8 on 7/13 and 7/21/23. -A review of Resident #3's August 2023 MAR (8/1/23 through 8/31/23) documented that the resident was administered acetaminophen 650 MG when Resident #3 rated her pain level at a 7 on 8/3, 8/4, 8/5, 8/7 and 8/16/23. -A review of Resident #3's September 2023 MAR (9/1/23 through 9/14/23 documented that the resident was administered acetaminophen 650 MG when Resident #3 rated her pain level at 8 on 9/11/23 and 9/13/23. It also revealed she was administered acetaminophen 650 MG when Resident #3 rated her pain level at 10 (severe/worst pain) on 9/14/23. D. Evidence that the facility's plan management plan was not consistently implemented and not effective in managing the resident's pain. 1. Observations and Resident #3 interviews a. On 9/11/23 at 1:58 p.m., Resident #3 was interviewed. Resident #3 said she has had increased pain in her left knee for several weeks. Resident #3 said she was administered pain medication but the pain medication often did not help. Resident #3 grabbed her left knee and grimaced. b. On 9/13/23 at 3:05 p.m., Resident #3 was lying in bed, crying. An unidentified staff member entered Resident #3's room. Resident #3 said there was a lot of pain in her left knee. -At 3:14 p.m. licensed practical nurse (LPN) #2 administered 650 MG acetaminophen and applied Biofreeze to the resident's knees. Resident #3 was crying and said she wanted to stay in bed for the rest of the day. -At 5:36 p.m. Resident #3 was interviewed. She was crying and said her left knee was causing her a lot of pain. Resident #3 was grimacing and holding her left knee. Resident #3 said her pain was so bad she wanted to go to the hospital. Resident #3 said she did not want to eat her dinner, because she was in pain. Her dinner was on her bedside table, untouched. -At 5:37 p.m. LPN #2 said she was aware Resident #3 was crying in pain. -At 5:40 p.m., two and a half hours after the resident, crying, reported her pain to LPN #2, the unit manager (UM) said she was going to call the physician. c. On 9/14/23 at 10:35 a.m., Resident #3 was interviewed. Resident #3 said she was still in pain. Resident #3 said the nurse gave her ibuprofen, but it did not help. Resident #3 was lying in bed, grabbing her knee in pain. 2. Record review a. See MAR review above. Further review of Resident #3's MARs revealed no evidence staff implemented the nonpharmacological interventions that were care planned in June, July, and August when the resident reported pain at levels 7 and 8 (see above). 2. Record review did not reveal evidence staff sought new pharmacological or nonpharmacological intervention to address Resident #3's pain levels of 7 and 8. See September CPOs above; Resident #3 did not have orders for pain medication when levels exceeded 1-6. 3. Medical record review indicated acetaminophen was not always monitored for effectiveness and not always effective in managing the resident's pain. Specifically: See facility policy above; Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. -A review of the resident's medical record revealed Resident #3 was administered acetaminophen 650 MG on 7/12/23 at 9:46 p.m. Resident #3 reported her pain level was an 8 on 7/13/23 at 2:15 a.m. A nursing progress note documented on 7/13/23 at 3:24 a.m., five and a half hours after the medication was administered documented the pain medication was effective. However, Resident #3 reported a pain level of 8 on 7/13/23 at 2:15 a.m., which revealed the pain medication that was administered on 7/12/23 at 9:46 p.m. was not effective. -A review of the resident's medical record revealed Resident #3 was administered acetaminophen 650 MG on 7/13/23 at 9:47 p.m. Resident #3 reported her pain level was at level 7 on 7/14/23 at 12:42 a.m. A nursing progress note documented on 7/14/23 at 4:06 a.m., six hours after the medication was administered documented the pain medication was effective. However, Resident #3 reported a pain level of 7 on 7/14/23 at 12:42 a.m., which revealed the pain medication that was administered on 7/13/23 at 9:47 p.m. was not effective. -A review of the resident's medical record revealed Resident #3 was administered acetaminophen 650 MG on 8/16/23 at 11:46 p.m. Resident #3 reported her pain level was an 8 at 12:08 a.m. A nursing progress note documented on 8/17/23 at 2:35 a.m., two and a half hours after the medication was administered documented the pain medication was effective. However, Resident #3 reported a pain level of 8 on 8/17/23 at 12:08 a.m. which indicated the pain medication administered on 8/16/23 at 11:46 p.m. was not effective. -A review of the resident's medical record documented the observations (see above) on 9/13/23. The nursing progress note documented on 9/13/23 at 3:14 p.m., Resident #3 was administered acetaminophen 650 MG. The note documented the resident was complaining of leg pain and was in tears. The nursing progress note further documented at 5:50 p.m., Resident #3's pain was reported to the UM and was informed Resident #3 had already received the as-needed Tylenol. The UM called the on-call provider and left a message. -At 5:55 p.m., Resident #3 reported her pain level was a 10 and the pain medication was not effective. -A nursing progress note documented on 9/13/23 at 8:21 p.m. revealed Resident #3 said she had pain in her left knee. The licensed nurse administered the as-needed pain medication (acetaminophen 650 MG) and rubbed her left knee and legs with Biofreeze. The nurse elevated the resident's legs. The progress note documented Resident #3's left knee was edematous (swollen) and painful to touch. There was no redness or warmth to the area. Resident #3 woke up at 12:50 a.m. and wanted something for her pain and for the nurse to call the physician. At this time the swelling to the resident's left knee had gone down. The nurse applied ice to the left knee. The nurse called the on-call physician and received an order for ibuprofen every eight hours for three doses. The resident's vital signs were taken. -A nursing progress note documented on 9/14/23 at 2:56 p.m. revealed the UM spoke with Resident #3. Resident #3 appeared sad and teary-eyed. The resident said her pain was not getting any better and the new order for ibuprofen was not working. The UM called the physician and received orders for an x-ray to be completed immediately of the left knee. The physician ordered to discontinue the ibuprofen and start Tylenol 1000 MG three times a day, not to exceed 300 MG in 24 hours. The physician also ordered to discontinue the Biofreeze and begin Voltaren gel 1% four grams twice a day for five days. 4. A review of the resident's medical record revealed an x-ray of the resident's left knee was completed on 8/21/23. The conclusion was no acute osseous abnormality and to consider a repeat multi-view study in one week or sooner if symptoms continue to persist or progress.An 8/25/23 medical director chart review progress note documented in part that the resident had a synovial cyst of the popliteal space (fluid-filled) behind the resident's right knee, and an 8/27/23 physician progress note documented the resident complained of knee pain. However, as the resident's pain continued and increased in the resident's left knee (see MAR and record review above), a repeat x-ray of the resident's left knee was not ordered until 9/13/23 during survey (see nursing note above). III. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 9/14/23 at 10:22 a.m. CNA #5 said Resident #3 was in extreme pain on 9/13/23. CNA #5 said she was crying in pain.CNA #5 said he wrote a note and placed it on the nurses' cart on 9/13/23 to alert the nurse that the resident was in pain. Registered nurse (RN) #3 and RN #4 were interviewed on 9/14/23 at 1:17 p.m. RN #4 said Resident #3 was still in pain. RN #4 said the physician ordered ibuprofen and Biofreeze. RN #4 said when the Biofreeze wore off, Resident #3 began crying again. RN #4 said the nurse practitioner would be in the building on 9/14/23 and she would follow up with the nurse practitioner when they did their rounds. RN #3 said if a resident had increased pain she would call the physician to get orders. RN #3 and RN #4 said the pain parameters that were in the physician's orders should be followed. The UM and the minimum data set coordinator (MDSC) were interviewed on 9/14/23 at 1:31 p.m. The UM said she called the physician on 9/13/23 regarding Resident #3's pain. The UM said she left a message for the physician. The UM said the licensed nurse called the physician again later that night and received an order for ibuprofen. -The UM confirmed Resident #3 had not had a follow-up x-ray after the 8/21/23 x-ray. The UM said Resident #3 had not had any increased pain after the x-ray until 9/13/23. However, see above; Resident #3 continued to report pain and reported a pain level of 8 on 9/11/23. -The UM said the CPOs indicated 650 MG of acetaminophen should be given when Resident #3 reported her pain level was between 1 and 6. The UM said if the resident reported a pain level above a 6, the licensed nurses needed to call the physician to get further orders. The director of nursing (DON) was interviewed on 9/14/23 at 1:52 p.m. -The DON said when a resident reported pain, the licensed nurses should offer nonpharmacological pain interventions first. However, a review of the MARs for August and September failed to document any nonpharmacological approaches had been implemented. -The DON said the licensed nurses needed to follow the pain parameters that were specified on the physician's orders. The DON said if the resident had an increase in pain or did not have a medication that covered the reported pain level, the licensed nurse needed to call the physician for orders. -The DON said the physician thought Resident #3 had a cyst on the back of her knee. The DON said she would have the licensed nurses call the physician to clarify the pain medication orders.

Based on interviews and record review, the facility failed to ensure residents on one out of three units had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely to include Residents #10, Resident #7, Resident #9 and Resident #8's roommate. The feeling of dehuminization is evidenced by the residents' interviews. Resident #9 dependent on staff said, it made her feel as though she was not importnant. She said it really bothered her to sit in a dirty brief for a long period of time. She felt it provided her with an undignified existence and she felt her care was not as important as the certified nurse aides (CNAs) socialized with one another Resident #10, who was a paraplegic and dependent on staff said, it made her feel angry, and felt the staff did not care about people like her who were dependent on staff for everything. She said she felt, insignificant Resident #7, said she felt as though she, was not important and it was very upsetting. Resident #8, whose roommate needed the help from staff, said it made her really sad to watch other residents not get the care they need because they are unable to move around. Findings include: I. Facility policy and procedure The Answering Call Lights policy and procedure, effective September 2018, was provided by the nursing home administrator (NHA) on 5/19/21 at 3:30 p.m. It revealed, in pertinent part, Respond to call lights activated by residents in a timely manner. The Resident Rights policy and procedure, effective September 2018, was provided by the NHA on 5/19/21 at 3:33 p.m. It revealed, in pertinent part, Each resident has the right to be treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life and that recognizes the resident's individuality. II. Resident interviews Resident #9 was interviewed on 5/18/21 at 2:17 p.m. She said she was dependent upon staff for all of her activities of daily living. She said she typically pushed the call light when she needed toileting assistance or a brief change. She said it would take staff almost an hour, on a lot of occasions, to answer the call light. She said it made her feel as though she was not important. She said it really bothered her to sit in a dirty brief for a long period of time. She said she felt it provided her with an undignified existence. She said she recently became the resident council president a couple of months prior. She said her peers had told her a lot about having to wait a long time for call lights to be answered. She said she would hear a group of certified nurse aids (CNA) chit chatting in the hallway and not answering call lights. She said, some days, CNAs from other floors will come to her floor to socialize with the other CNAs. She said she felt her care was not as important as the CNAs socialized with one another. Resident #10 was interviewed on 5/18/21 at 2:27 p.m. She said it typically took the staff 30 minutes to an hour to answer the call light. She said she required staff assistance with all activities of daily living. She said she was a paraplegic and required the use of an electric wheelchair. She said she was dependent upon staff for assistance with transfers, moving around in bed, toileting and dressing. She said it made her feel angry when the staff took a long time to answer the call light. She said she felt the staff did not care about people like her who were dependent on staff for everything. She said she felt insignificant. Resident #7 was interviewed on 5/18/21 at 2:01 p.m. She said call lights can take over an hour to be answered by a staff member. She said it was not during any particular part of the day, but all day long. She said she felt as though she was not important and it was very upsetting. She felt if the staff wanted to answer the call light, they would. Resident #8 was interviewed on 5/18/21 at 2:08 p.m. She said she was able to get up and move about her room without staff assistance, but her roommate required help. She said staff took a long time to answer the call light for her roommate. She said she would often go out in the hallway to get a staff member to assist her roommate and the resident across the hallway, who was unable to use her call light. She said it made her really sad to watch other residents not get the care they need because they are unable to move around. III. Record review Call light logs were requested and provided by the nursing home administrator (NHA) on 5/18/21 at 1:30 p.m. The 5/14/21 to 5/17/21 call light logs showed the following call light response times: For room [ROOM NUMBER]: -On 5/14/21, the call light was activated at 6:19 a.m. The report indicated the call light was activated for 63 minutes and 28 seconds. -On 5/15/21, the call light was activated at 8:29 p.m. The report indicated the call light was activated for 26 minutes and 18 seconds. -On 5/16/21, the call light was activated at 9:16 a.m. The report indicated the call light was activated for 42 minutes and 40 seconds. At 1:39 p.m., the report indicated the call light was activated for 45 minutes and 39 seconds. -On 5/18/21, the call light was activated at 5:47 p.m. The report indicated the call light was activated for 32 minutes and 32 seconds. For room [ROOM NUMBER]: -On 5/14/21, the call light was activated at 6:53 p.m. The report indicated the call light was activated for 54 minutes and 41 seconds. -On 5/15/21, the call light was activated at 1:37 p.m. The report indicated the call light was activated for 65 minutes and 21 seconds. -On 5/16/21, the call light was activated at 1:47 p.m. The report indicated the call light was activated for 68 minutes and 17 seconds. -On 5/17/21, the call light was activated at 7:04 a.m. The report indicated the call light was activated for 27 minutes and 49 seconds. At 1:39 p.m., the report indicated the call light was activated for 78 minutes and 22 seconds. At 4:34 p.m., the report indicated the call light was activated for 201 minutes and 55 seconds. At 8:39 p.m., the report indicated the call light was activated for 80 minutes and 27 seconds. For room [ROOM NUMBER]: -On 5/14/21, the call light was activated at 6:26 a.m. The report indicated the call light was activated for 29 minutes and 19 seconds. At 11:30 a.m., the report indicated the call light was activated for 28 minutes and 27 seconds. At 12:01 p.m., the report indicated the call light was activated for 29 minutes and 35 seconds. At 6:03 p.m., the report indicated the call light was activated for 26 minutes and 11 seconds. -On 5/15/21, the call light was activated at 7:16 a.m. The report indicated the call light was activated for 105 minutes and 27 seconds. At 1:12 p.m., the report indicated the call light was activated for 27 minutes and 10 seconds. At 1:59 p.m., the report indicated the call light was activated for 45 minutes. At 3:37 p.m., the report indicated the call light was activated for 28 minutes and 21 seconds. At 6:47 p.m., the report indicated the call light was activated for 80 minutes and 58 seconds. At 8:18 p.m., the report indicated the call light was activated for 33 minutes and 22 seconds. At 10:41 p.m., the report indicated the call light was activated for 27 minutes and 11 seconds. -On 5/16/21, the call light was activated at 8:00 a.m. The report indicated the call light was activated for 51 minutes and 45 seconds. At 9:33 a.m., the report indicated the call light was activated for 111 minutes and 51 seconds. At 2:28 p.m., the report indicated the call light was activated for 113 minutes and 39 seconds. At 5:22 p.m., the report indicated the call light was activated for 87 minutes and 22 seconds. -On 5/17/21, the call light was activated at 10:38 a.m. The report indicated the call light was activated for 49 minutes and 22 seconds. At 7:52 p.m., the report indicated the call light was activated for 113 minutes and 52 seconds. At 1:10 p.m., the report indicated the call light was activated for 32 minutes and 50 seconds. -On 5/18/21, the call light was activated at 4:09 a.m. The report indicated the call light was activated for 26 minutes and 21 seconds. At 4:44 a.m., the report indicated the call light was activated for 47 minutes and 11 seconds. For room [ROOM NUMBER]: -On 5/14/21, the call light was activated at 7:13 a.m. The report indicated the call light was activated for 54 minutes and 1 second. At 6:54 p.m., the report indicated the call light was activated for 30 minutes and 58 seconds. -On 5/15/21, the call light was activated at 7:25 a.m. The report indicated the call light was activated for 90 minutes and 10 seconds. At 7:37 p.m., the report indicated the call light was activated for 55 minutes and 33 seconds. -On 5/16/21, the call light was activated at 4:22 p.m. The report indicated the call light was activated for 68 minutes and 43 seconds. At 9:52 p.m., the report indicated the call light was activated for 29 minutes and 26 seconds. -On 5/17/21, the call light was activated at 5:28 p.m. The report indicated the call light was activated for 105 minutes and 18 seconds. At 11:32 p.m., the report indicated the call light was activated for 26 minutes and 22 seconds. For room [ROOM NUMBER]: -On 5/14/21, the call light was activated at 7:37 a.m. The report indicated the call light was activated for 93 minutes and 27 seconds. -On 5/16/21, the call light was activated at 2:02 p.m. The report indicated the call light was activated for 59 minutes and 5 seconds. At 5:25 p.m., the report indicated the call light was activated for 54 minutes and 7 seconds. -On 5/17/21, the call light was activated at 10:02 a.m. The report indicated the call light was activated for 51 minutes and 44 seconds. At 2:10 p.m., the report indicated the call light was activated for 31 minutes and 2 seconds. At 2:46 p.m., the report indicated the call light was activated for 26 minutes and 8 seconds. At 5:46 p.m., the report indicated the call light was activated for 76 minutes and 15 seconds. IV. Staff interviews CNA #1 was interviewed on 5/18/21 at 2:32 p.m. She said a call light button was in each resident's room. She said when the call light button was pushed, the board would light up with the room number displayed. She said a display was at the end of each hallway and at the nursing station. She said if the display was green, then the call light at the bedside was activated. If the display was red, then the call light in the bathroom was activated. She said she did not know the facility policy on how quickly the call light should be answered. She said she just tried to answer the lights and she was able. She said she felt there was enough staff on the floor to answer call lights timely. She said she felt some staff members would hide and avoid answering call lights. She said it did not surprise her to hear a resident had said CNAs were talking in the hallway when call lights were activated. The NHA and director of nursing (DON) were interviewed on 5/18/21 at 4:12 p.m. She said a call light was located at each resident's bedside and in the bathroom. She said when the call light was activated, the room number would be shown on the display at the nursing station and the end of each hallway. She said the color on the display changed if the resident was in bed or in the bathroom. She said call lights should be answered within 15 to 20 minutes of being activated. She confirmed the call light reports showed excessive call light wait times. V. Follow-up No additional information or documentation was provided by the facility after the survey.

Based on record review and interviews, the facility failed to ensure one (#1) of four residents reviewed for nutritional status out of 10 total sample residents maintained acceptable parameters of nutritional status such as usual body weight or desirable body weight. Specifically, the facility failed to implement interventions to prevent a significant weight loss for Resident #1 with nutritional risks including poor nutritional intake and requiring staff assistance for cueing at meals, and was not outlined on her comprehensive care plan. The resident had a weight loss of 26.2 pounds over a period of six months, which was 19.4%, which was not addressed timely with her family since the resident had cognitive impairments. The resident was ordered supplements, however these interventions were not effective in aiding in maintaining her nutritional status which led to her sustaining severe decline in health status, hospitalization for severe-protein calorie malnutrition where the resident passed away. Findings include: I. Facility policy and procedure The Nutrition Management Program policy, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 10:30 a.m. It read, in pertinent part: The purposes of the nutrition management program are to: provide each resident with palatable, attractive meals, that meet the resident's daily requirements; provide nutritional services to each resident consistent with the resident's comprehensive assessment; provide a dining experience, which enhances the residents ' needs, including food service and staff support during the dining experience; provide a method of review and documentation of a resident's meal intake; and provide a method to determine a resident's daily caloric intake. Clinical policies and procedures serve as clinical guidelines to assist in clinical staff decision making, staff education and training, and evaluation of employee performance. The nursing and food and nutrition services departments regularly communicate regarding issues related to residents ' nutritional status. Residents are evaluated and nutritional needs are addressed on an individual basis, considering specific needs and medical conditions. Appropriate assistive feeding devices are used as indicated in the resident's care plan. The licensed nurse is responsible for the supervision and coordination of Certified Nursing Aide (CNA) staff during meals. Each meal is monitored for the overall dining experience and promotes optimum resident meal intake. Nursing staff are available to assist residents at mealtimes. The nursing staff notifies food and nutrition services if a resident meets any of the following criteria: -Weight loss or gain of 3% or more in one week; 5% of more in one month; 7.5% or more in three months; or 10% or more in six months. -Resident non-compliance with diet or anything that interferes with the meal/fluid intake. Documentation of meal intakes in the progress notes including any decline in meal intake and notification to family and physician if indicated and interdisciplinary team referral as applicable. The care plan is revised and reviewed to reflect current nutritional status. The Weight Management policy and procedure, revised [DATE], was provided by the DON on [DATE] at 10:30 a.m. It read, in pertinent part: This policy provides guidelines for maintaining acceptable parameters of nutritional status and weight management for each resident and implement interventions for managing unplanned weight change in residents. Factors that may impact weight include: -Current medical conditions; medications; therapeutic diets; decreased meal intake; [MEDICAL CONDITION]; physical activity level; and psychosocial. II. Resident status Resident #1, age 87, was admitted on [DATE] and admitted to the hospital [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively impaired with a staff assessment for mental status which revealed the resident had short and long term memory problems, severely impaired decision making skills, disorganized thinking and inattention. She exhibited verbal behaviors which significantly interfered with her care. She required extensive assistance of one to two staff members with mobility and activities of daily living with the exception of eating for which she required supervision of one staff member. She did not exhibit any chewing or swallowing problems, she did have a weight loss and was not on a prescribed physician weight loss regimen. She did not have any pressure ulcers and received hospice services until [DATE] when she transferred to the hospital. III. Family interview On [DATE] the resident's daughter was interviewed. She stated the resident had lost a significant amount of weight since visitation was restricted at the facility in [DATE]. She stated she visited the facility daily prior to the restrictions to encourage and help the resident eat. She brought snacks and outside meals, and could always get her to eat. She stated she did not become aware of how significant the weight loss was until a meeting in [DATE], at which point it was too late for her to recover. She stated once she was allowed to visit on [DATE], the staff were surprised at how much the resident consumed when she was there. She stated she insisted the resident go to the hospital and she later passed away in the hospital. She stated she was allowed window visits and would bring snacks and outside food during the shutdown, but the staff were not assisting or encouraging her to eat her meals. She stated the resident was receiving hospice services for 18 months, though this type of decline was not expected as she could always get the resident to eat. IV. Record review A care plan was initiated on [DATE] and revised on [DATE] and read the resident was at risk for inability to maintain nutrition. Pertinent interventions included: Provide and serve diet as ordered. Monitor intake and record every meal; and registered dietician (RD) to evaluate and make diet change recommendations as needed. Review of Resident #1's weights revealed the resident lost 26.2 pounds between [DATE] and [DATE] falling from 135 pounds on [DATE] to 108.8 pounds on [DATE], which was 19.4% between a six month period. Meal intake records for [DATE] revealed out of 86 documented meals, the resident consumed less than 50% for 42 of those meals, 17 meals of 25% or less. The resident received supervision or cueing at one meal, and refused three meals. -The interdisciplinary team did not address the resident's poor intake identified in [DATE] until [DATE] when a supplement was added (see below). On [DATE] a progress note revealed a message was left for the resident's daughter related to visitor restrictions due to the threat of viruses in the surrounding community. On [DATE] an activity note revealed the resident had a one-to-one visit with activities staff where the resident spoke of talking to her daughter on the phone the day prior and could not wait until she could visit her in person again. On [DATE] nursing progress note revealed the resident was not eating and for the past three days, the resident had not eaten more than 25% of any of her meals other than ice cream and an occasional cookie and her current intake would not sustain her. The resident was offered small meals throughout the day but had refused. She was started on a supplement, Ensure, daily to help meet her nutritional needs. -However, the resident being offered small meals and the supplement daily was not added to her nutrition care plan to direct staff with appropriate meal assistance. On [DATE] an interdisciplinary team (IDT) note indicated the resident was started on a daily supplement due to poor meal intake. On [DATE] a nutrition note revealed the resident's current weight was 124.8 pounds which indicated a significant weight loss of 8.8 pounds or 6.5% in 30 days. The weight loss was not desirable, but expected due to overall decline. Her oral intake was sporadic and poor and the resident was accepting approximately 75% of the ordered supplement. The resident was started on an additional daily supplement of a Magic Cup (high calorie ice cream supplement) with lunch to meet her nutritional needs and to continue care per hospice. -The note indicated that her weight loss was not desirable, therefore additional interventions should have been implemented when the daughter was not able to encourage the resident to eat in [DATE]. On [DATE] an IDT note indicated the resident had lost almost nine pounds over 30 days, her intakes were sporadic and the resident was sleeping more. She received two supplements daily and her care plan was updated. A care plan was initiated on [DATE] and read the resident was at risk for social isolation related to limited mobility in the community during the COVID-19 pandemic. Pertinent interventions included: Encourage the resident to eat healthy well balanced meals of choice. On [DATE] a nutritional evaluation was completed and revealed the resident's appetite was fair, she consumed ,[DATE]% of meals, she ate in front of the nurses ' station, and she was independent with meals with staff providing tray set up. The resident weighed 124.8 pounds which indicated a significant weight loss of 8.8 pounds or 6.5% over 30 days and 19 pounds or 13% over 180 days. The resident received supplements and the resident's daughter brought outside food. -The nutritional intervention of supplements being offered was not reviewed to determine if effective with her additional weight loss nor were new interventions started with her having additional weight loss. An intervention was added on [DATE] to her nutrition care plan and read: IDT review for weight loss of 8.8 pounds or 6.5% in 30 days. Intervention: continue care per hospice, initiate supplement daily. No weekly weights related to hospice care. A revision was added on [DATE] to monitor, record and report to the resident's physician signs and symptoms of malnutrition: emaciation, muscle wasting, significant weight loss. Meal intake records for [DATE] revealed out of 85 meals documented, the resident ate less than 50% for 45 of those meals, 18 meals she ate 25% or less. She received supervision and cueing for eight meals and refused six meals. On [DATE] a care plan conference was held, the resident's daughter was not in attendance due to her visiting the facility everyday prior to visitation restrictions in [DATE] (see social service director interview below). The summary indicated the resident's weight loss was discussed. The resident weighed 124.4 pounds, which was a loss over 90 and 180 days. The resident's meal intake was between ,[DATE]% and the resident received nutritional supplements. -The resident's weight loss was not reviewed with the daughter at the time of the care conference with her having short term and long term cognitive impairments. Meal intake records for [DATE] revealed out of 84 meals documented, the resident ate less than 50% for 51 of those meals and 25% or less for 20 meals. She received cueing for 10 meals, limited assistance for one meal, and total assistance for three meals. She refused nine meals. On [DATE] an IDT note read the resident was losing weight and staff continued to offer snacks between meals. -However, no new interventions were added or reviewed with her continued weight loss. On [DATE] a nutrition note revealed the resident weighed 120 pounds which indicated a significant weight loss of 14 pounds or 9% over 90 days. The weight loss was not desirable but expected related to overall decline. The resident received supplements daily and accepted ,[DATE]% of the supplements and snacks as desired throughout the day. Continue care per hospice. -The nutritional intervention of supplements being offered was not reviewed and determined if effective with additional weight loss nor was the supplement increased with her having additional weight loss. The note indicated that her weight loss was not desirable, therefore additional interventions should have been implemented when the daughter was not able to encourage the resident to eat in [DATE]. An intervention was added to the resident's nutrition care plan on [DATE] and read: IDT review for weight loss of 13.6 pounds or 10% over 90 days. Intervention: continue current supplements plus snacks as desired. Meal intake records for [DATE] revealed out of 84 meals documented, the resident ate less than 50% for 56 of those meals and 25 % or less for 15 meals. She received supervision or cueing for eight meals and refused nine meals. On [DATE] an annual nutritional evaluation was completed and revealed the resident's appetite was fair, she consumed ,[DATE]% of meals, she ate in front of the nurses station, and she was independent with meals with staff providing tray set up. The resident weighed 120.1 pounds and was noted to have chronic severe malnutrition as evidenced by greater than 10% weight loss in six months. -There were no additional changes or nutritional interventions added with the resident having overall 10% weight loss. Meal intake records for [DATE] revealed out of 81 meals documented, the resident ate less than 50% for 49 of those meals and 25% or less for 26 meals. She received supervision or cueing for four meals and extensive assistance for one meal. She refused 19 meals. On [DATE] an order note revealed an additional nutritional supplement, MedPass 60 milliliters (ml) was ordered twice a day. On [DATE] a nutrition note revealed the resident's current weight was 117.4 pounds which indicated a 17 pound or 12% weight loss over 180 days. The weight loss was not desirable but was expected due to overall decline. The resident's intake was sporadic and poor and the resident received snacks from staff as desired. The resident was accepting ,[DATE]% of the ordered supplements. Continue care per hospice and continue to monitor weight, oral intake, and supplement tolerance. -Additional supplementation was added on [DATE], however the resident's intake of supplements was declining to 25 to 50%. The note indicated that her weight loss was not desirable, therefore additional interventions should have been implemented when the daughter was not able to encourage the resident to eat in [DATE]. On [DATE] an IDT note revealed the resident had experienced a 17 pound weight loss over six months and the resident received supplements at ,[DATE]% intake. An intervention was added to the resident's care plan on [DATE], it read: IDT review for weight loss of 17 pounds or 12% over 180 days. Intervention: continue current supplements plus snacks as desired. Initiate additional supplement twice daily. No weekly weights related to hospice care. On [DATE] a care plan meeting was held and the resident's daughter was in attendance via telephone. The summary indicated the resident's weight loss was discussed. The resident weighed 117.4 pounds, had poor and sporadic oral intake of meals, and received supplements. The summary read the resident's daughter visited frequently and brought outside snacks. On [DATE] an IDT note revealed the resident had experienced a 17 pound weight loss over six months and the resident received supplements at ,[DATE]% intake. On [DATE] a health status note revealed the resident experienced a change in condition as evidenced by coughing and fever. A chest x-ray revealed aspiration pneumonia and an antibiotic was ordered. On [DATE] a health status note revealed the resident ate a bit of dinner being fed, had her supplement and a good amount of fluids. Meal intake records for [DATE] revealed out of 81 meals documented, the resident ate less than 50% for 53 of those meals and 25% or less for 29 meals. The resident received supervision or cueing for 12 meals. She refused 11 meals. On [DATE] a health status note revealed the resident had a poor appetite but snacks were offered and accepted. On [DATE] a health status note revealed a call was placed to hospice related to the resident's condition of a deep productive cough. On [DATE] a nutrition note revealed the resident's current weight was 108.8 pounds which indicated a 8.6 pound weight loss or 7% loss over 30 days. The note recommended the resident received a high calorie supplement added to pudding to help meet nutritional needs. On [DATE] a health status note revealed an additional chest x-ray was completed and showed worsening findings from the x-ray on [DATE]. Hospice was called for orders. On [DATE] a health status note revealed an order for [REDACTED]. On [DATE] a nutrition note revealed the resident was refusing the high calorie supplement in pudding and the resident continued to decline. On [DATE] a rehab note revealed the resident was seen for a speech therapy evaluation related to a recent swallowing decline and recommended the resident continue on nectar thickened liquids related to aspiration risk. On [DATE] a health status note revealed the resident's daughter requested the resident be taken off of hospice services and be sent to the hospital due to her decline over the previous six months. Meal intake records for [DATE] revealed out of 57 meals documented, the resident ate 50% or less of 35 of those meals and 25% or less of 21 meals. She received supervision or cueing for four meals, limited assistance for two meals, and total assistance for four meals. She refused 10 meals. Review of the resident's progress notes, care plans, nutritional assessments and meal intake records revealed no additional interventions or actions, other than adding supplements, were implemented or considered by facility staff to prevent further weight loss. There were no orders or interventions written for the resident to consistently receive assistance or cueing at meals and not indicated on her comprehensive care plan. Additionally, there was no evidence of discussion with the resident's responsible party related to the resident's significant weight loss until a care plan meeting held [DATE] after she had a 17 pound weight loss (cross-reference F580 notification of change). The resident's hospital records were received via email and reviewed on [DATE]. Review of the hospital records revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A physician note dated [DATE] from the hospital revealed the resident had experienced a progressive overall decline over the past several months with significant weight loss and inability to maintain adequate nutritional intake. The decline was ultimately not recoverable and her weight was 106 pounds. The resident was ultimately transferred to the hospice unit at the hospital and expired on [DATE]. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 10:08 a.m. She stated she worked on the resident's floor a few times and the resident needed cueing to remember to eat. She stated the resident would sit in the hallway by the nurses station and got distracted and would not eat. She stated as staff were passing by they reminded her but she stated someone should have sat with her throughout the meal to keep her focused and remind her to eat. CNA #11 was interviewed on [DATE] at 12:49 p.m. during lunch. She stated there were a few residents on her floor that needed cueing and encouragement and sat out in the common area for meals. She stated the residents were served their meals and that staff would remind them to eat throughout the meal time. CNA #5 was interviewed on [DATE] at 12:33 p.m. She stated she worked with the resident often. She stated the resident needed to be assisted to eat because she would get distracted and not eat her meals. She stated she was physically able to feed herself, but would not unless she was reminded and encouraged. Registered nurse (RN) #2 was interviewed on [DATE] at 12:38 p.m. He stated the resident fed herself, though required cueing and prompting often. He stated she sat at the nurses ' station for meals so the staff could cue her to eat. The assistant director of nursing (ADON) was interviewed on [DATE] at 3:15 p.m. She stated she was also the unit manager of the floor where Resident #1 resided. She stated the resident was encouraged to eat by staff. She stated the resident liked soup, sandwiches, mashed potatoes and her family brought in snacks. She stated the staff communicated with the resident's daughter frequently and let her come in and visit as often as they could during the shutdown. She stated the resident's daughter came to the facility a couple times to help the resident eat but was not specific when. The social services director (SSD) was interviewed on [DATE] at 3:37 p.m. She stated the resident was refusing to eat and needed encouragement. She stated the resident would sit at the nurses station most of the day, including meal times, and staff would encourage her to eat as well as offer her snacks all throughout the day. The registered dietitian (RD) was interviewed on [DATE] at 4:10 p.m. She stated when a resident experienced a weight loss, herself and the IDT team reviewed the resident's meal intakes, medications, food preferences, and possible supplements. She stated the facility staff reviewed weights weekly and nutritional assessments were completed quarterly and annually. She stated the facility tried to talk to families related to meal intakes and weight loss as soon as possible and at care plan meetings. She stated the resident was on hospice and the weight loss was expected. She stated the resident could feed herself and she knew the resident's daughter brought her in outside food. She stated there were no other documented or implemented interventions or actions by the facility for the resident's weight loss other than the supplements the resident received. The DON was interviewed on [DATE] at 10:30 a.m. She stated if a resident is experiencing poor intakes, the facility staff would encourage them to eat, she stated if the resident responded well to cueing and improvement was seen, the facility put the resident on a restorative dining program, either in the dining room with one on one staff or in their room. She stated Resident #1 did need cueing and encouragement from staff to eat her meals and she stated she did receive the encouragement at meals. She stated this was not an official or ordered intervention, but she believed all staff did encourage the resident. She stated since the resident ate at the nurses station, it was primarily the nurses who provided her encouragement at meals, so it may not have been documented correctly by CNAs. She stated she did not remember discussing or considering other options to prevent the resident's weight loss in their weekly IDT meetings. She did not recall involving the resident's daughter in discussions related to the resident's weight loss or how to prevent it. The nursing home administrator (NHA) was interviewed on [DATE] at 12:43 p.m. She stated she would expect the facility to follow the policy and procedure when a resident experienced a weight loss. She stated she would expect for interventions to be put into place for weight loss or poor intake and if the interventions were not effective, she would expect the staff to go back to the drawing board and try any and all interventions at their disposal. She would expect for all interventions and discussions to be documented in the resident's record. She stated she did believe the staff did provide Resident #1 with cueing, encouragement, and snacks because she had provided the resident with the care on multiple occasions.

Based on record review, observations and interviews, the facility failed to ensure four (#81, #88, #74 and #10) of 34 sample residents were provided the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically: -The facility failed to ensure that insulin was administered per physician orders for residents #81 and #88. This failure created the potential for resident #81 to experience low blood sugar with the potential for serious harm (unresponsiveness, dizziness, [MEDICAL CONDITION], coma and death), a situation of immediate jeopardy. -The facility failed to provide timely and adequate pain management for resident #74 who exhibited she was in pain during cares. -The facility failed to provide appropriate care and services to identify and address skin breakdown for resident #10. The findings include: I. Immediate Jeopardy A. Failure to ensure that insulin was administered per physician orders and to take necessary action to address hypo- or [MEDICAL CONDITION] Record review, observations and interviews revealed that resident #81 experienced very low blood sugar in May 2013, and that the physician's order for insulin, dated 5/14/13, was not being followed. Record review, observations and interviews revealed that resident #88 experienced low blood sugar without notification of the physician or interventions administered to address this concern. The above facility failures to protect from undue adverse medication consequences and failure to provide medications as prescribed created a situation of immediate jeopardy for serious potential harm. B. Imposition of Immediate Jeopardy On 6/4/13 at 4:05 p.m., the facility was notified by the Health Facilities and Emergency Medical Services Division (HFEMSD) of the State Health Department that the failures to protect resident #81 and #88 from undue adverse medication consequences and failure to provide medications as prescribed created a situation of Immediate Jeopardy for serious potential harm. On 6/5/13 at 4:04 p.m., the facility presented a revised plan to HFEMSD to remove the Immediate Jeopardy situation. The plan implemented by the facility concurrently, included the following: 1. (For) the 8 residents identified during survey: On 6/4/2013 by 5 p.m., the residents identified by the surveyors as having the potential for immediate Jeopardy related to Diabetic Control and Monitoring were evaluated by a licensed nurse to include finger stick blood glucose. All 8 residents are free from signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. 2. All residents have the potential to be affected: -On 6/3/2013 after being notified of a concern regarding a medication error specific to insulin administration, the facility immediately identified 8 other residents in the facility that receive insulin. -On 6/3/13 a review of resident records was completed of all 8 residents who currently receive insulin to ensure that appropriate Diabetic Control and Monitoring is in place, specifically that Insulin orders are being followed appropriately and that appropriate follow up is taken and documented when blood glucose levels are outside physician ordered parameters, and that the blood glucose monitoring sheet is in place. The audit also included an evaluation of the residents' record(s) to ensure a care plan was in place. 3. System changes implemented: -On 6/3/13 beginning at 3:00 p.m. and completed 6/4/13 by 5:30 p.m., (Nurses will not be scheduled to work until they have been inserviced and are able to verbalize a return demonstration) the DON, the Regional Nurse, and designee began immediate inservices for the Licensed nursing staff on the diabetic management policy to include follow up of blood sugars and interventions for hyper/[DIAGNOSES REDACTED] and communication of blood glucoses outside the ranges to the MD as well as documenting the follow up. The inservicing included the importance of following insulin orders specific to sliding scales and/or instruction regarding meal intake. Content of inservicing can be referenced in the 3 attachments. Nurses will be required to verbalize a return demonstration prior to their next scheduled shift, regarding following up on blood sugars outside ranges and/or what the follow up would be for a resident with symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. The inservicing will continue for all newly hired nurses here at Springs Village on orientation. Content of inservicing can be referenced in the 3 attachments. -When administering insulin the licensed nurse will now have a second nurse validate with the insulin order in view, to ensure the nurse is appropriately following the order and the appropriate amount of insulin is being given. -Beginning 6/5/13 for any Residents receiving insulin will get their insulin at a specified time. Therefore, "after breakfast," will be 9 a.m., "after lunch" will be 1 p.m., and "after dinner" will be 7 p.m. Nurses will document the specific times that blood sugars are taken. -For Residents whose insulin orders depend on meal and snack intakes, the meal and snack intake percentages will be recorded on the Medication administration record. For any other insulin dependent resident, the monitoring system for meal and snack intake is accessible and used by licensed nurses via a care tracker system. -Certified nursing assistants will be re-inserviced by the DON/Designee on signs and symptoms that may indicate hyper/[DIAGNOSES REDACTED] and the importance of reporting these signs to a licensed nurse. This inservice will be completed by 6/7/13 or prior to their next scheduled shift. -Telephone orders will be reviewed by the DON/Designee each business day and all insulin orders will be followed up on and clarified. 4. Monitoring -Effective 6/4/13 the DON/Nurse managers will review the MARS (medication administration records) and blood glucose flow sheets on all residents who are receiving insulin daily for one month, then 3 times weekly for three months and then monthly and prn thereafter. DON/Designee will observe 3 random nurses for completion of blood sugars and insulin administration per week for 3 months, then monthly thereafter. Issues identified will be immediately followed up on appropriately. -DON/Designee will pull the meal and snack intake care tracker reports after random meals each business day and follow up with licensed nurses to ensure licensed nurse has reviewed the meal intakes on insulin dependent residents. Issues identified will be address at that time with on the spot re-education. Issues and concerns will be tracked and reviewed by the DON/Designee in QA&A monthly to ensure system is implemented and sustained. -Administrator; Will be responsible to ensure that system changes have been implemented and report compliance monthly through the facility QA Committee meetings. C. Removal of Immediate Jeopardy On 6/5/13 at 4:45 p.m., the facility was informed that Immediate Jeopardy was removed based on the review and the facility's implementation of their plan as described above. Record review, observations and interviews revealed that the facility had reviewed all physician orders for insulin and blood glucose parameters, obtained needed clarifications from the physician, documented the medication errors for resident #81 and notified the physician, and conducted inservices for staff. After the removal of Immediate Jeopardy, deficient practice remained at a G level, representing actual harm that is isolated. II. Diabetic Management A. Expectations 1. Facility Policy The facility policy for diabetic monitoring was requested from the DON on 6/3/13 and again on 6/5/13 at 11:09 a.m., from the Regional Nurse Consultant (RNC). The RNC acknowledged on 6/5/13, that the facility did not have a specific diabetic monitoring policy in place, but followed the Lippincott Manual of Nursing Practice. The Lippincott 9th Edition Manual of Nursing Practice (2010), Chapter 25, pp 944 -969, Diabetes mellitus, reads in pertinent part: -"Goals of treatment for [REDACTED]. -Standards of Care guidelines (caring for patients with diabetes mellitus), when caring for patients with diabetes mellitus: "...assess adherence to diet therapy, monitoring procedures, medication treatment and exercise regimen, assess for signs of [DIAGNOSES REDACTED]; sweating, tremor, nervousness, [MEDICAL CONDITION] light-headedness, confusion, make sure that appropriate insulin dosage is given at the right time and in relation to meals and exercise." See: Page 960 2. According to the website:www.diabetesresourcecenter.org/[DIAGNOSES REDACTED].html, the following are symptoms of [DIAGNOSES REDACTED]: "...feeling shaky, sweating, dizziness, weakness and/or overwhelming tiredness, rapid heartbeat, numbness or tingling in mouth or lips, hunger. Complications: It is important to remember that like diabetes [DIAGNOSES REDACTED] remains a potential life-threatening condition with short-term and long-term complications. For those taking insulin, [DIAGNOSES REDACTED] or low blood sugars is a constant concern. If the low blood sugar is allowed to go on untreated, you may experience: Increased confusion and disorientation; difficulty standing or sitting; convulsions or [MEDICAL CONDITION], and unconsciousness." B. Resident Failures 1. Resident #81, age 73, was admitted to the facility on [DATE]. According to the June 2013 computerized physician orders (CPO), the resident had [DIAGNOSES REDACTED]. According to a quarterly minimum data set (MDS), dated [DATE], the resident's short-term memory was impaired with intact long-term memory. The resident was independent with all activities of daily living including eating. a. Resident Status Review of a yearly physician progress notes [REDACTED]. Dosages have been adjusted throughout the yr d/t (due to) increasing episodes of [DIAGNOSES REDACTED]. Continue to monitor finger stick glucoses and adjust insulin as needed." Orders: The May 2013 computerized physician orders revealed the resident had orders to receive [MEDICATION NAME] in the morning (start date 5/21/12) and [MEDICATION NAME]twice daily after meals and at bedtime (HS), if blood sugars (BS) were greater than 200. BS was ordered to be checked before meals and at bedtime. (Per the glucose monitoring sheet, if BS is < 70 or > 300, contact the physician.) However, a telephone order (TO), dated 5/14/13, documented the following changes in the [MEDICATION NAME] orders above. Specifically, the TO read: -"DC (discontinue) [MEDICATION NAME] 5 units HS; -[MEDICATION NAME] 5 unit pc (after meals) supper; -DC [MEDICATION NAME] 5 units HS (at bedtime) if FSBS (finger stick blood sugar) greater than 200; -[MEDICATION NAME] 5 units pc (after meals) breakfast if FSBS greater than 350." [MEDICATION NAME] (insulin [MEDICATION NAME]), according to <http://www.webmd.com/drugs/drug- -[MEDICATION NAME]+SubQ.aspx?drugid= &drugname=[MEDICATION NAME]+SubQ>, and the Lippincott Manual of Nursing Practice (see above) is fast-acting (onset 5-15 minutes, peak 30-90 minutes, duration less than 5 hours) and not eating immediately after a dose of this insulin may lead to low blood sugar ([DIAGNOSES REDACTED] <http://diabetes.webmd.com/tc/[DIAGNOSES REDACTED]-low-blood-sugar-topic-overview>) ..." which may occur if the individual does not consume enough calories (from food, juices, fruit, etc.) or has received too much [MEDICATION NAME]. Care Plan: Review of the resident's diabetic care plan, originating 2/23/11 and last reviewed on 3/11/13, revealed the following problem: "Potential for hypo/[MEDICAL CONDITION] r/t (related to) dx (diagnosis) of diabetes." -Goal: "risks of hypo-[MEDICAL CONDITION] will be minimized with interventions x90 days." -Approach: "check BS as ordered, administer medications as ordered, provide diet as ordered, educate responsible party as to risks of being non-compliant with diabetic diet, notify physician of any changes in status, monitor for any sxs (symptoms) of [DIAGNOSES REDACTED] (change in mentation, sweating, shaking, etc), monitor for sxs (symptoms) of [MEDICAL CONDITION] (flushed face, change in mentation shaking, etc.)" b. Observations and Interviews 5/29/13 On 5/29/13 beginning at approximately 11:15 a.m., the resident was interviewed in his room. His female companion/roommate was present. The resident was wearing a bathrobe and lying on his bed. The resident was alert and oriented to self and place and able to answer the interview questions appropriately. At 11:29 a.m., during the interview, the licensed practical nurse (LPN) entered the room to check the resident's blood sugar (BS) before lunch. The result of the resident's BS reading was "42." The LPN stated this was a very low BS and told the resident she was going to get him some apple juice to drink right away. The LPN asked the resident how he was feeling and if he had eaten breakfast that morning. The resident stated he could not remember and turned to the female friend and asked her if he had eaten. She responded that he had not eaten breakfast. The LPN told the resident she was going to get the apple juice and lunch would be coming soon. At 11:35 a.m., the LPN returned to the resident's room with a large styrofoam cup of apple juice and stayed with the resident while he drank it. At 11:43 a.m., the LPN was interviewed. She stated she had called and reported the findings to the physician with no new orders other than to monitor the resident. The LPN stated she had not rechecked the resident's BS yet as it had not been 15 minutes since the resident had drank the juice. At 12:30 p.m., the LPN was interviewed again. The LPN stated the resident's BS had come up to "71" after the juice was consumed and then he was given his lunch tray. The LPN stated she would check his BS again after he finished his lunch. The LPN stated the resident continued to be without symptoms of [DIAGNOSES REDACTED] and that he usually does not have "tell-tale" signs when his BS is low. c. Record Review (1) Record review on 6/3/13 revealed staff failed to follow the 5/14/13 physician orders on 5/29/13 for [MEDICATION NAME] administration. Specifically: Review on 6/3/13 of the resident's glucose tracking sheet for May 2013, revealed that on 5/29/13 at 5:30 a.m., the resident's BS was recorded as 133. Review on 6/3/13 of the May 2013 MAR showed the resident received [MEDICATION NAME] 5 units on 5/29/13 "OA," with the day nurse's initials. Per review of facility medication pass times as set forth in a document provided to surveyors on the first day of the survey, "OA" represents medication pass times between 7:00 a.m. to 10:30 a.m. Current [MEDICATION NAME] orders, however, read to administer [MEDICATION NAME] 5 units after breakfast "only if the resident's blood sugar was greater than 350." There was no evidence on 6/3/13, based on the documentation on the glucose tracking sheet, that on 5/29/13, the resident's insulin order was followed. The BS recorded before breakfast was below the parameter for administering insulin. Moreover, review of the resident's meal intake records as documented in the computer care tracker for 5/13 through 6/11/13 (last day of the survey) revealed that on 5/29/13, the resident's intake at the breakfast meal was documented as "refused." (2) Record review on 6/4/13 revealed conflicting documentation On 6/4/13 at approximately 10:30 a.m., a second copy of the resident's May 2013 MAR was requested from the Director of Nurses (DON) as the copy obtained on 6/3/13 had the documentation for days after 5/29/13 cut off and illegible. Review of the copy of the MAR received on 6/4/13 revealed the nurse's signature on 5/29/13 was now circled, indicating, contrary to the documentation on 6/3/13, that the [MEDICATION NAME] had not been given on 5/29/13 after breakfast. Review of the May 2013 MAR on 6/4/13 also documented the resident had consumed 50 percent of his breakfast meal on 5/29/13 which conflicted with the breakfast refusal noted in the care tracker on 6/3/13. (3) Although MAR documentation for 5/29/13 on 6/3 and 6/4/13 were in conflict, further review of the resident's May 2013 MAR and May 2013 glucose tracking sheet revealed evidence of additional failures relating to the current orders for [MEDICATION NAME]. Specifically: Review of the May 2013 MAR after the order changes 5/14/13 showed the resident received the [MEDICATION NAME] 5 units "OA" on the following dates: 5/15, 5/16, 5/17, 5/20, 5/21, 5/22, 5/29, 5/30 and 5/31/13. Review of the May 2013 blood glucose tracking sheet showed the BS on the above dates were as follows: -5/15/13 at 5:00 a.m., the BS was 211 -5/16/13 at 5:10 a.m., the BS was 126 -5/17/13 at 5:30 a.m., the BS was 94 -5/20/13 at 5:00 a.m., the BS was 93 -5/21/13 at 5:30 a.m., the BS was 70 -5/22/13 at 5:30 a.m., the BS was 106 -5/30/13 at 5:00 a.m., the BS was 183 -5/31/13 at 5:30 a.m., the BS was 70 There was no evidence, based on the documentation on the glucose tracking sheet, that on 5/15, 5/16, 5/17, 5/20, 5/21, 5/22, 5/30 and 5/31/13, the resident's insulin order was followed. The BS recorded before breakfast was below the parameter for administering insulin. d. Systemic failures in facility policies and practices relating to diabetic management (1) Blood glucose monitoring policy Review of a blood glucose monitoring policy with a revision date of 2/3/10 was provided by the DON as requested on 6/3/13. The policy was titled "Blood Glucose Monitoring" - "Documentation Requirements" and read in part, "5.0 Documentation. In progress, treatment records or blood glucose monitoring record document ... 3. any physician notifications or treatment provided." The above policy did not define symptoms and management for hypo-[MEDICAL CONDITION] and did not include standing orders for treatment of [REDACTED]. (2) Medication Administration and Meal Intake Review of the facility medication administration policy provided after the survey exit of 6/11/13 via fax on 6/13/13 and last revised on 5/1/10 read in pertinent part: "prior to administration of medication, facility staff should take all measures required by facility policy ... -4.1.1 verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident as set forth in by facility policy ... -5.4 administer medications within time frames specified by facility policy." "...After medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 6.1 document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site) on appropriate forms ..." Review of the facility medication pass times document provided on the first day of survey and updated 8/10/09 revealed in part the following: -OA; 7:00 a.m. to 10:30 a.m. (AM); -MD: 11:00 a.m. to 2:30 p.m.; -EE: 3:00 p.m. to 6:00 p.m. (PM); -HS: 6:30 p.m. to 11:00 p.m. "If the doctor orders certain times, use those ..." Review of the facility policy on meal intake documentation revealed that meal intakes were also recorded as OA, MD, HS on the MAR. The above facility policies failed to ensure staff properly implemented physician orders for diabetic management. Specifically: -The policies, as written, provided no means to identify/track what time the "OA" [MEDICATION NAME] was administered (either before the resident ate or after eating breakfast). -The policies allowed at least five hours in between the time the first blood sugar of the day was checked (5:00-5:30 a.m.) and when the resident ate breakfast which, too, had no specific time recorded. -Blood sugars were not being re-checked prior to administering a rapid acting insulin (see [MEDICATION NAME] onset times above). e. Staff Interviews - Confirmation of practices that failed to ensure proper implementation of physician orders for diabetic management On 6/3/13 at 6:18 p.m., the director of nursing (DON), with the nursing home administrator (NHA) and regional nurse consultant (RNC) present, were interviewed. -The DON was shown the insulin order written on 5/14/13 for resident #81 (see above). The DON stated she did not like the way the order was written, stating it was confusing. The DON interpreted the order to read if the blood sugar was less than 350, insulin should not be given. -The DON reviewed the resident's May 2013 MAR and stated it looked as if the insulin was given on the 5/20, 5/21, 5/30 and 5/31/13, but she could not tell based on the initials, whether the insulin was given on other days. The DON stated the order for the OA [MEDICATION NAME] could have been written as a PRN (as needed) and needed to be clarified with the physician. -The DON stated that prior to administering the OA [MEDICATION NAME], the nurses followed the breakfast BS (obtained between 5:00 and 5:30 a.m.) On 6/5/13 at 10:00 a.m., the LPN assigned to the resident's care on 5/29/13 was interviewed. -The LPN stated she checks/observes for herself whether a resident has eaten or looks in the computer (care tracker) or asks a certified nurse aide (CNA) before administering insulin. The LPN stated resident #81 normally eats in his room with his roommate. -The LPN acknowledged the time of the morning (a.m.) [MEDICATION NAME] was not being documented on the MAR or in the nurses' notes and stated staff should be documenting in the nurses' notes if the insulin is not given. The LPN stated each time a medication was given it should be signed for. -The LPN stated she thought the resident's 5/14/13 order for '[MEDICATION NAME] 5 u after breakfast if BS greater than 350' was based on the resident's intake and it would have been better if the order was written as a PRN. The LPN stated they had a time frame in which to administer the insulin, clarifying the "OA" pass started from the time she started her shift in the morning (approximately 6:30 a.m.) up until she was done around 10:00 or 10:30 a.m. f. Facility follow-up during survey On 6/3/13 at approximately 6:45 p.m., the DON, with the RNC present provided a copy of the telephone order, clarifying resident #81's insulin order. It read "clarification: [MEDICATION NAME] 5 units pc brkfst (breakfast) if FSBS greater than 350 in AM; [MEDICATION NAME] 5 units pc lunch SQ (subcutaneous), [MEDICATION NAME] 5 units pc dinner SQ." The DON stated that when speaking to the physician, the physician told her the [MEDICATION NAME] OA order was intended to be a rescue dose. The DON acknowledged it should have been noted if the resident had eaten prior to giving the insulin and, in addition, if the BS was under 350 the OA insulin should not have been given. The DON said a medication error report had been filled out for the nurse that administered the insulin on several of the days in May. The DON stated she had spoken to the nurse who worked on 5/29/13 day shift and the nurse told her she had not given the OA [MEDICATION NAME]. The RNC stated at the end of the interview that they were now auditing all the diabetics in the building, in servicing and assuring the nurses are following the policy. On 6/5/13 at 12:45 p.m., during a follow up interview with the NHA and RNC, the medical director (MD) was present. The MD said the insulin orders written by resident #81's physician on 5/14/13 were very complex which put the resident in uncertain zones. The MD stated he would be contacting the resident's physician. 2. Resident #88, age 69, was re-admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS), dated [DATE], the resident scored a 15/15 on the Brief Interview for Mental Status (BIMS) indicating that she was cognitively intact. The resident was independent with transfers, eating and bathing. She required supervision with locomotion in her wheelchair, dressing and hygiene. a. Resident Status In a Progress Note, dated 2/1/13, the physician wrote in pertinent part, "... For her diabetes, she is on [MEDICATION NAME] 10 units every morning with sliding scale regular insulin. Attempts to take her off the sliding scale failed. She has Type I diabetes and has been managing diabetes her own way and attempts to change that have been unsuccessful." Care Plan: The resident's care plan revealed a Problem/Need of "Potential for hypo/[MEDICAL CONDITION] Diagnosis: [REDACTED]. -The Goal was stated as "Risks of hypo/[MEDICAL CONDITION] will be minimized with interventions x 90 days." --The Approaches included: "Check BS (blood sugar) as ordered - AC and HS" (before meals and at bedtime). -Administer medications as ordered. -Provide diet as ordered. -Educate patient/responsible party as to risks of being non-compliant with diabetic diet. -Notify responsible party of any changes in status. -Monitor for any symptoms of [DIAGNOSES REDACTED] (changes in mentation, sweating, shaking etc.) -Monitor for symptoms of [MEDICAL CONDITION] (flushed face, change in mentation, shaking etc.)" Orders: The resident had an order dated 7/31/12 for "[MEDICATION NAME] 100 units/ml insulin - Inject 10 units sub-q every morning." Review of the June 2013 Computerized Physician's Orders (CPO) revealed the following insulin orders for the resident: "[MEDICATION NAME] 100 unit/1 ml unit. Inject sub-q (subcutaneously) per sliding scale. Start date 12/5/12. Blood Sugar 151 - 200 = 1 unit 201 - 250 = 3 units 251 - 300 = 5 units 301 - 350 = 7 units Greater than 350 = 8 units and call MD." The above order did not include a low blood sugar (BS) parameter that would trigger physician notification. b. Record Review The resident's Blood Glucose Tracking Sheet and Sliding Scale Insulin Administration Records were reviewed for April, May and June 2013. The resident's blood sugars were being checked four times a day. The instructions at the bottom of the Blood Glucose Tracking Sheets read: "PLEASE NOTE: -If the blood glucose is ABOVE or BELOW the parameters the physician must be notified immediately and interventions implemented. -If the resident is UNRESPONSIVE, the nurse MUST proceed with 1mg [MEDICATION NAME] IM , call 911 and the physician. -Document on the reverse 15 minute follow ups of accuchecks below parameter requiring intervention." On the June 2013 Tracking Sheet, a low parameter of "60" and a high parameter of "350" were written across the top of the form. For the recorded dates of 6/1/- 6/3/13, the resident did not have any low blood sugars. Both the April and May 2013 Tracking Records had the high blood sugar parameter written across the top of the form, but there was no low parameter written on either form. -In April 2013, on 4/30/13, the tracking records showed the resident had a blood sugar result of 44 at 1645 (4:45 p.m.) The nurse had written in "Ensure" as an intervention, and initialed the space documenting MD notification. There was not any documentation of a blood sugar re-check on the reverse side of the tracking sheet, and no narrative note for this date was found in the Nurses' Progress Notes. -In May 2013, the resident had two blood sugar results that were less than 60: On 5/14/13 at 11:00 a.m., the resident had a blood sugar of 58. The nurse wrote in the intervention of "Ensure" and initialed that she had notified the MD. There was no documentation on the form of a blood sugar re-check, and no narrative Nurses' Note. On 5/27/13 at 4:50 p.m., the resident had a blood sugar of 50. No intervention was documented on the tracking form, and written in the space for MD notification, was the word "no." There was no documentation of a blood sugar re-check on the back of the form. Review of the Nurses' Progress Notes revealed an entry at 11:50 a.m. on 5/27/13, documenting that the [MEDICAL TREATMENT] center had called to notify the facility that the resident's left upper extremity had been infiltrated. There was not a later note addressing the resident's low blood sugar of "50" at 4:50 p.m., or notification of the physician. c. Interview On 6/3/13 at 6:00 p.m., the DON was interviewed. The DON said the minimum documentation for low blood sugar readings would be to write the intervention on the Blood Glucose Tracking Sheet, and initial notification of the physician. She stated that a narrative note in the Nurses' Progress Notes would be helpful, but was not required. On 6/4/13 at 9:50 a.m., the resident was interviewed regarding her blood sugars. The resident stated that she can't usually tell that her sugars are low unless they are really low. She said that when her sugars are really low, she sees "light' in the middle of her eyes. The resident stated that the nurses check her blood sugar at 2:00 a.m., and give her a can of Ensure (nutritional supplement) if it is low. The resident said that the nurses check her blood sugar four times a day. d. Facility follow-up during survey On 6/3/13, after informed of the omission of a low blood sugar parameter in the resident's orders and care plan, a clarification for a low parameter for blood sugar was added to the resident's Care Plan. The new approach read "Call MD if BS is less than 60." -On 6/4/13 at 11:00 a.m., the Regional Nurse brought a copy of Telephone Order that clarified orders for the resident's blood sugar: "Clarification order: Check FBS (fingerstick blood sugars) AC (before meals) and HS (at bedtime). -Give [MEDICATION NAME] 100 units/1 ml unit. Inject sub-q (subcutaneously) per sliding scale. -Blood Sugar 151 - 200 = 1 unit 201 - 250 = 3 units 251 - 300 = 5 units 301 - 350 = 7 units Greater than 350 = 8 units and call MD. Call MD if BS is less than 60." On 6/4/13 at 3:00 p.m., the DON brought in a Staff Interview/Investigation dated 6/4/13, to document that on 5/27/13, the nurse did notify the physician of the resident's low blood sugar, even though she had not correctly initialed the Blood Glucose Tracking Form. The Investigation read in pertinent part: "On 5/27/13 (Name of nurse) checked (Name of resident)'s blood sugar at 1700 and it was 50. She was asymptomatic and (Name of nurse) gave her an Ensure. She did notify the doctor and she also spoke to them about the compress(ion) order due to her infiltrate at [MEDICAL TREATMENT] that day. No new orders were received related to blood sugar." III. Pain Management A. Facility Policy Review of the facility pain policy revealed it read in part: Purpose: "To provide a consistent method for the review, planning, development and evaluation of a pain management plan of care. The treatment plan is guided by the needs of the resident and may include medication, physical or occupational therapy, pain psychology, [MEDICATION NAME] procedures, referrals to other medical specialists or non-medical interventions." Definitions: "pain is whatever the experiencing person says it is, existing whenever he/she says it does." Procedure: "...a resident pain review is to be completed, at minimum: within 8 hours of admission/re-admission, then at a minimum quarterly or with a significant change in pain symptoms, intensity or location ..." It further provided: -Review pain level prior to administration of "PRN" and standard scheduled pain medications and after administration for effectiveness of medication. -Document all findings in the resident's record. Pain level is to be reviewed as needed based on each resident's individual need. -Observe resident for indicators of pain. Indicators include but not limited to: moaning, crying and other vocalizations, wincing or frowning and other facial expressions, body posture such as guarding or protecting an area of the body, or lying very still ...residents who have dementia and cannot verbalize they are feeling pain, should be reviewed for symptoms of pain. Symptoms can be manifested by particular behaviors such as: calling out for help ..." Monitoring and Evaluation of pain and the plan of care: "the interdisciplinary team will be responsible for monitoring the effectiveness of the plan of care. Areas of review include, but are not limited to the following: effectiveness of the current

Based on record review, observations and interviews, the facility failed to ensure two (#81 and #53) of 34 sample residents were free from significant medication errors. Specifically: -The facility failed to ensure that insulin was administered per physician orders [REDACTED]. -The facility failed to ensure that [MEDICATION NAME] was administered according to physician's orders [REDACTED]. The findings include: I. Immediate Jeopardy A. Record review, observations and interviews revealed that resident #81's physician order [REDACTED]. The facility's failure to follow resident #81's 5/14/13 insulin orders created the potential for serious harm (unresponsiveness, dizziness, [MEDICAL CONDITION], coma and death) and created a situation of immediate jeopardy. B. Imposition of Immediate Jeopardy On 6/4/13 at 4:05 p.m., the facility was notified by the Health Facilities and Emergency Medical Services Division (HFEMSD) of the State Health Department that the failures to provide medications as prescribed created a situation of Immediate Jeopardy for serious potential harm for resident #81. On 6/5/13 at 4:04 p.m., the facility presented a revised plan to HFEMSD to remove the Immediate Jeopardy. The entire plan, implemented by the facility concurrently, was reported in F309 above. The sections of plan pertinent to F333 included: -On 6/3/13 after being notified of a concern regarding a medication error specific to insulin administration, the facility immediately identified 8 other residents in the facility that receive insulin. -On 6/3/13 a review of resident records was completed of all 8 residents who currently receive insulin to ensure that appropriate Diabetic Control and Monitoring is in place, specifically, that Insulin orders are being followed appropriately and that appropriate follow up is taken and documented when blood glucose levels are outside physician ordered parameters, and that the blood glucose monitoring sheet is in place. The audit also included an evaluation of the residents' record(s) to ensure a care plan was in place. -When administering insulin the licensed nurse will now have a second nurse validate with the insulin order in view, to ensure the nurse is appropriately following the order and the appropriate amount of insulin is being given. -Beginning 6/5/13...any Residents receiving insulin will get their insulin at a specified time. Therefore, "after breakfast," will be 9 a.m., "after lunch" will be 1 p.m., and "after dinner" will be 7 p.m.. Nurses will document the specific times that blood sugars are taken. -Telephone orders will be reviewed by the DON/Designee each business day and all insulin orders will be followed up on and clarified. C. Removal of Immediate Jeopardy On 6/5/13 at 4:45 p.m., the facility was informed that Immediate Jeopardy was removed based on the review and the facility's implementation of their plan as described above. Record review, observations and interviews revealed that the facility had reviewed all physician orders [REDACTED].#81 and notified the physician, and conducted inservices for staff. After the removal of Immediate Jeopardy, deficient practice remained at G level, representing actual harm that was isolated. II. Significant Medication Errors A. Facility Policies (1) Review of the facility medication administration policy provided after the survey exit of 6/11/13 via fax on 6/13/13 and last revised on 5/1/10 read in pertinent part: "Prior to administration of medication, facility staff should take all measures required by facility policy... -4.1.1 verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident as set forth in by facility policy... -5.4 administer medications within time frames specified by facility policy." "...After medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 6.1 document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application site \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\) on appropriate forms..." (2) Review of a blood glucose monitoring policy with a revision date of 2/3/10 was provided by the DON as requested on 6/3/13. The policy was titled "Blood Glucose Monitoring" -"Documentation Requirements" and read in part, "5.0 Documentation. In progress, treatment records or blood glucose monitoring record document... 3. any physician notifications or treatment provided." B. Resident Failures 1. Resident #81, age 73, was admitted to the facility on [DATE]. According to the June 2013 computerized physician orders [REDACTED]. According to a quarterly minimum data set ((MDS) dated [DATE], the resident's short-term memory was impaired with intact long-term memory. The resident was independent with all activities of daily living including eating. a. Resident Status Review of a yearly physician progress notes [REDACTED]. Dosages have been adjusted throughout the yr d/t (due to) increasing episodes of [DIAGNOSES REDACTED]. Continue to monitor finger stick glucoses and adjust insulin as needed." The May 2013 computerized physician orders [REDACTED]. BS was ordered to be checked before meals and at bedtime. (Per the glucose monitoring sheet, if BS is < 70 or > 300, contact the physician.) However, a telephone order (TO) dated 5/14/13 documented the following changes in the [MEDICATION NAME] orders above. Specifically, the TO read: - " DC (discontinue) [MEDICATION NAME] 5 units HS; -[MEDICATION NAME] 5 unit pc (after meals) supper; - DC [MEDICATION NAME] 5 units HS (at bedtime) if FSBS (finger stick blood sugar) greater than 200; - [MEDICATION NAME] 5 units pc (after meals) breakfast if FSBS greater than 350." [MEDICATION NAME] (insulin [MEDICATION NAME]), according to <http://www.webmd.com/drugs/drug- -[MEDICATION NAME]+SubQ.aspx?drugid= &drugname=[MEDICATION NAME]+SubQ>, and the Lippincott Manual of Nursing Practice (see above) is fast-acting (onset 5-15 minutes, peak 30-90 minutes, duration less than 5 hours) and not eating immediately after a dose of this insulin may lead to low blood sugar ([DIAGNOSES REDACTED] <http://diabetes.webmd.com/tc/[DIAGNOSES REDACTED]-low-blood-sugar-topic-overview>)..." which may occur if the individual does not consume enough calories (from food, juices, fruit, etc.) or has received too much [MEDICATION NAME]. b. Observations and Interviews 5/29/13 On 5/29/13 at 11:29 a.m., during the interview with the resident, the licensed practical nurse (LPN) entered the room to check the resident's blood sugar (BS) before lunch. The result of the resident's BS reading was "42." The LPN provided the resident juice, followed by the lunch meal and at 12:30 p.m., the LPN reported the resident's blood sugar had increased to "71." c. Record Review (1) Record review on 6/3/13 revealed staff failed to follow the 5/14/13 physician orders [REDACTED]. Specifically: Review on 6/3/13 of the resident's glucose tracking sheet for May 2013, revealed that on 5/29/13 at 5:30 a.m., the resident's BS was recorded as 133. Review on 6/3/13 of the May 2013 MAR showed the resident received [MEDICATION NAME] 5 units on 5/29/13 "OA," with the day nurse's initials. Per review of facility medication pass times as set forth in a document provided to surveyors on the first day of the survey, "OA" represents medication pass times between 7:00 a.m. to 10:30 a.m. Current [MEDICATION NAME] orders, however, read to administer [MEDICATION NAME] 5 units after breakfast "only if the resident's blood sugar was greater than 350." There was no evidence on 6/3/13, based on the documentation on the glucose tracking sheet, that on 5/29/13, the resident's insulin order was followed. The BS recorded before breakfast was below the parameter for administering insulin. Moreover, review of the resident's meal intake records as documented in the computer care tracker for 5/13 through 6/11/13 (last day of the survey) revealed that on 5/29/13, the resident's intake at the breakfast meal was documented as "refused." (2) Record review on 6/4/13 revealed conflicting documentation On 6/4/13 at approximately 10:30 a.m. a second copy of the resident's May 2013 MAR was requested from the Director of Nurses (DON) as the copy obtained on 6/3/13 had the documentation for days after 5/29/13 cut off and illegible. Review of the copy of the MAR received on 6/4/13 revealed the nurse's signature on 5/29/13 was now circled, indicating, contrary to the documentation on 6/3/13, that the [MEDICATION NAME] had not been given on 5/29/13 after breakfast. Review of the May 2013 MAR on 6/4/13 also documented the resident had consumed 50 percent of his breakfast meal on 5/29/13 which conflicted with the breakfast refusal noted in the care tracker on 6/3/13. (3) Although MAR documentation for 5/29/13 on 6/3/13 and 6/4/13 were in conflict. Further review of the resident's May 2013 MAR and May 2013 glucose tracking sheet revealed evidence of additional failures relating to the current orders for [MEDICATION NAME]. Specifically: Review of the May 2013 MAR after the order changes 5/14/13 showed the resident received the [MEDICATION NAME] 5 units "OA" on the following dates: 5/15/13, 5/16/13, 5/17/13, 5/20/13, 5/21/13, 5/22/13, 5/29/13, 5/30/13 and 5/31/13. Review of the May 2013 blood glucose tracking sheet showed the BS on the above dates were as follows: -5/15/13 at 5:00 a.m., the BS was 211 -5/16/13 at 5:10 a.m. the BS was 126 -5/17/13 at 5:30 a.m. the BS was 94 -5/20/13 at 5:00 a.m. the BS was 93 -5/21/13 at 5:30 a.m. the BS was 70 -5/22/13 at 5:30 a.m. the BS was 106 -5/30/13 at 5:00 a.m. the BS was 183 -5/31/13 at 5:30 a.m. the BS was 70 There was no evidence, based on the documentation on the glucose tracking sheet, that on 5/15/13, 5/16/13, 5/17/13, 5/20/13, 5/21/13, 5/22/13, 5/30/13 and 5/31/13, the resident's insulin order was followed. The BS recorded before breakfast was below the parameter for administering insulin. d. Staff Interview On 6/3/13 at 6:18 p.m. the director of nursing (DON), with the nursing home administrator (NHA) and regional nurse consultant (RNC) present, were interviewed. -The DON reviewed the insulin order written on 5/14/13 for resident #81 (see above). The DON stated she did not like the way the order was written, stating it was confusing. The DON interpreted the order to read if the blood sugar was less than 350, insulin should not be given. -The DON reviewed the resident's May 2013 MAR and stated it looked as if the insulin was given on the 5/20/13, 5/21/13, 5/30/13 and 5/31/13, but she could not tell based on the initials, whether the insulin was given on other days. The DON stated the order for the OA [MEDICATION NAME] could have been written as a PRN (as needed) and needed to be clarified with the physician. On 6/3/13 at approximately 6:45 p.m. the DON, with the RNC present provided a copy of the telephone order, clarifying resident #81's insulin order. It read "clarification: [MEDICATION NAME] 5 units pc brkfst (breakfast) if FSBS greater than 350 in AM; [MEDICATION NAME] 5 units pc lunch SQ (subcutaneous), [MEDICATION NAME] 5 units pc dinner SQ." The DON stated that when speaking to the physician, the physician told her the [MEDICATION NAME] OA order was intended to be a rescue dose. The DON acknowledged it should have been noted if the resident had eaten prior to giving the insulin and, in addition, if the BS was under 350, the OA insulin should not have been given. The DON said a medication error report had been filled out for the nurse that administered the insulin on several of the days in May (but not 5/29/13). The DON stated she had spoken to the nurse who worked on 5/29/13 day shift and the nurse told her she had not given the OA [MEDICATION NAME]. The DON, interviewed again on 6/4/13 at 11:34 a.m. said that, with regard to the change in the MAR entry on 5/29/13 from 6/3/13 (see above), she assumed the day nurse had come in and circled it after the fact. The DON stated, "She should not have circled that; she just should have made the late entry." See F309 for further details. 2. Resident #53, age 77, was admitted to the facility on [DATE]. According to the 5/13 computerized physician orders [REDACTED]. According to the most recent MDS, dated [DATE], the resident had cognitive impairments and severely impaired decision making skills. The resident required supervision with activities of daily living. The 5/17/13 physician telephone order documented the resident was to receive [MEDICATION NAME] (anticoagulant) 8 mg by mouth on Monday and Friday at 7:00 p.m. In addition, the resident was to receive [MEDICATION NAME] 7 mg by mouth on Sunday, Tuesday, Wednesday, Thursday and Saturday at 7:00 p.m. Review of the [MEDICATION NAME] flow sheet documented the resident was to have a therapeutic international normalized ratio (INR) range (therapeutic level) of 2.0-3.0 for [MEDICAL CONDITION]. INR in the interval 2.0-2.5 give the lowest risk of stroke and death in patients with nonvalvular [MEDICAL CONDITION]. See: A Oden, "Optimal INR for prevention of stroke and death in [MEDICAL CONDITION]: a critical appraisal," Thromb Res 2006; 117(5):493-9. Epub 2004 [DATE]. <http://www.ncbi.nlm.nih.gov/pubmed/ 250> The 3/21/12 care plan identified the use of the anticoagulant therapy. The goal was for the resident to not show any adverse effects of the anticoagulant and also to maintain a therapeutic lab level. Pertinent approaches were to provide medication as ordered, monitor lab results, and to obtain labs as ordered. Facility Failures: Review of the 5/13 Medication Administration Record (MAR) documented the resident did not receive the ordered [MEDICATION NAME] 7 mg on 5/18/13, 5/19/13, and the ordered [MEDICATION NAME] 8 mg on 5/20/13. On 5/21/13, the resident's INR dropped to 1.7 from a level of 3.1 on 5/17/13. Interviews: -The licensed practical nurse charge nurse (LPN) was interviewed on 6/5/13 at 3:35 p.m. The LPN stated the resident received [MEDICATION NAME] for [MEDICAL CONDITIONS] and also for [MEDICAL CONDITION]. -The LPN stated the dose was given as ordered at 7:00 p.m. on 5/16/13. The INR was measured on the night shift on 5/17/13 and the day shift nurse followed up with the physician on 5/17/13. The physician then gave the telephone order to continue the same dose. The LPN reviewed the MAR and confirmed that the [MEDICATION NAME] was not initialed as being given for 5/18/13, 5/19/13 and 5/20/13, but said that it did not mean that he did not receive the medication. However, after looking at the changes of the INRs from 5/17/13 to 5/20/13, she indicated that the [MEDICATION NAME] may not of been given. The regional clinical nurse (RCN) was interviewed on 6/10/13 at 6:32 p.m. The RCN stated a medication error report was initiated 6/6/13 (during survey). She stated that when she reviewed the MAR, the [MEDICATION NAME] was not initialed as being administered.

Based on observations, record review and interviews, the facility failed to ensure that a resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable for one (#74) of 34 sample residents. Specifically: -The facility failed to provide range of motion (ROM) services to prevent a contracture. The findings include: Cross reference F309 Care and Services, failure to ensure timely and adequate pain control. Facility Policy: Review of the facility policy for range of motion (ROM) documented in part, "Range of motion exercises is a program of passive or active movement that is focused on maintaining flexibility and useful motion in the joints of the body. Range of motion is essential for the ability to perform activities of daily living. Limitations in range of motion can severely restrict functional abilities and limit safe positioning options for the resident while in bed or a wheelchair. Joints that are stiff or contracted may result in pain for the resident and negatively impact quality of life ...range of motion exercise is beneficial to prevent contractures and maintain flexibility. Characteristics: residents who exhibit the following characteristics may benefit from active range of motion (AROM), active assistive range of motion (AAROM), resisted range of motion (RROM) and/or passive range of motion(PROM) ...pain, spasm, and/or immobility secondary to arthritis ... Goals: the goals of the AROM, AAROM, RROM and PROM activities are ...prevent the formation of a contracture, increase joint motion to the best possible range, and prevent joint pain and skin breakdown ..." Sample resident #74, [AGE] years of age, was admitted to the facility on [DATE]. According to the 6/13 computerized physician orders (CPO), the resident had [DIAGNOSES REDACTED]. In addition, the current face sheet documented the resident with sciatica and polyarthritis not otherwise specified (multiple sites). According to the admission minimum data set (MDS), dated [DATE], documented the resident had significant cognitive impairments with both short- and long-term memory loss and moderately impaired with decisions of daily living. The resident required extensive assistance with most all activities of daily living, independent with eating and although not ambulatory was able to move between locations per wheelchair. The resident was coded as having functional limitation in range of motion only to one lower extremity. The resident was coded/identified as having pain at a level "6" on routine pain medication management and use of PRN (as needed) pain medication during the review period. A recent significant change MDS, dated [DATE], coded the resident with decline in function from the admission assessment. She was now significantly impaired with daily decision-making skills, with altered level of consciousness and was totally dependent on staff for bed mobility, eating and toileting. She was no longer mobile with decrease balance with sit to stand and transferring across surfaces. Her ROM continued to be impaired to the lower extremities on one side only and no identification of decrease in function to the upper extremities. Observations: On 5/30/13 at 9:08 a.m., during observations of provision of personal care, the resident was lying in bed. Two staff Certified Nurse Aides (CNA's) began to assist the resident by pulling her covers down below her feet leaving her extremities exposed. The resident was clothed in a hospital gown. The resident was observed to have swelling to her bilateral hands. Both hands were curled inward toward the palms in what appeared to be a "fixed state" where the fingertips of each hand pressed into the palm area. Her legs were extended straight and flat with a slight bend in her knees. Her heels were floated off the mattress on pillows. On 6/10/13 at 6:15 p.m., the unit charge nurse (CN), where the resident currently resided, was asked to accompany the surveyor to the resident's room. The CN was asked if she could assess the resident's ability to move her hands. The CN approached the resident and explained to her what she was about to do. The CN verbally directed the resident to try and open or move her hands and the resident was able to move her second digit on the left hand slightly. The resident was not able to move the right hand at all. The CN then physically lifted the resident's hands, one at a time, and attempted to provide PROM. The resident screamed out in pain and the CN immediately placed her hand/arm back down. The CN agreed the resident was not able to open either of her hands very well and that the resident tends to have more pain in the left extremity. Record Review: Review of the clinical record revealed an initial physical therapy assessment and plan of treatment with a start date of 6/25/12. The plan identified and documented in part the resident's functional range of motion to the bilateral upper and lower extremities as follows: "bilateral upper extremity ROM (range of motion) and strength WFL (within functional limit); bilateral lower extremity ROM WFL and unable to straighten knees with gait/ (illegible word), slow with bed mobility ..." There was no quantitative measurements for ROM noted on this evaluation. The resident's current level of function was identified as moderate independent with bed mobility, minimal assist of one with sit to stand transfers. The resident's sitting and standing balance was poor and she was a moderate assist of one with ambulation of 50 feet or less. The assessment did not mention anything regarding contractures or show that any measurements or percentages of function were obtained. The resident was discharged from PT services 7/11/12 secondary to a decline in ability to transfer or ambulate. After therapy discharge, there was no referral to continue any type of restorative services to help maintain the resident's functional status or range of motion abilities. Review of an activities of daily living (ADL) care plan initiated on 6/22/12 and last reviewed on 3/28/13 documented in part, the resident required assist with ADL's related to weakness and chronic back pain. The resident was to receive assistance from staff to complete ADL's. Some of the approaches were: "call light in reach, encourage to call for assist as needed, encourage to participate in ADL's each shift, breakdown ADL's into individual tasks for resident to complete one at a time, notify MD (Medical Doctor) of any changes in status, refer to therapy; PT/OT ..." The care plan did not comprehensively or adequately describe the resident in her current functional state in order for her to complete or participate in any of her ADL's related to (r/t) her contractures and decreased range of motion (ROM). Review of an impaired mobility care plan initiated on 6/22/12 and last reviewed on 3/28/13 documented in part the resident had impaired mobility r/t pain or discomfort, musculoskeletal impairment, and neuromuscular impairment. The resident's goal was to perform physical activity independently or with assistive devices as needed. Some of the approaches were: "assist as needed with frequently changing position, call light in reach, check on frequently for needs, assess need of assistive devices to increased mobility, refer to PT/OT/restorative nursing program as needed, notify physician of any changes in status ..." Again, the care plan did not comprehensively or adequately describe the resident in her current functional state. Review of a quarterly data collection tool dated 4/27/13 documented in part in the section titled, "ROM," noted the resident with limitation of ROM for contractures in the hand. There was no further documentation in the assessment regarding the contracture(s). Hospice Documentation: Review of a telephone order dated 4/5/13 documented the resident was admitted to routine hospice care with a primary [DIAGNOSES REDACTED]. Review of an initial hospice admission visit dated 4/5/13 by the skilled nurse documented in part, "Musculoskeletal; limited range of motion, bed bound, dependent on others for movement ..." Review of an initial hospice physician evaluation dated 4/8/13 documented in part the physician had discussed the resident's case with nurses and aides on the floor. The evaluation further documented: "when I saw her on Thursday, she was saying, "help me, help, help me." Though it was hard to find out where her pain was, it appeared to be coming from the abdomen and back, but she was tender to touch anywhere on the body or with any body movement..." The resident's physical examination documented in part, "neurologic ...what was surprising to me was the hyperalgesia of her skin; even the lightest touch caused tenderness. Also, she had increased pain when I moved her upper extremities through range of motion and there was definitely increased tone without cog wheeling ...she did not move her upper or lower extremities on her own or with coaxing from me..." In the physician's final impression, the following was documented: "...cervical stenosis. She may have a cervical [DIAGNOSES REDACTED] from compression of the central canal in the lower cervical spine. To me that would be a better explanation for her increased extremity tone than Parkinsonism which can accompany Alzheimer dementia." Plan: "...we may need to increase the [MEDICATION NAME] (pain medication) doses beyond 6mg (milligram) every four hours, especially on the days when she has dressing changes, obviously that would be every day. We will watch that closely with our nurses ..." Review of hospice aide visit records on 4/11/13, 4/16/13, 4/18/13 and 5/21/13 documented the resident with "a lot of pain" with movement and specifically on 5/21/13 pain to her left thumb. The visit notes documented the hospice aide notified facility staff of the concerns. There was no corresponding documentation found in the facility documentation that staff was aware or followed up on these concerns. On 6/10/13 at approximately 2:20 p.m., the Director of Nursing (DON) was asked to provide any documentation the resident was currently on a restorative program. At the end of the day at approximately 4:45 p.m., the DON provided a computer print out for the last three months. The document reflected the resident had not received restorative ROM services. The DON had no further information or comment. Interviews: On 6/5/13 at 11:30 a.m., a certified nursing assistant (CNA) familiar with the resident was interviewed. The CNA stated they usually placed small rolled up washcloths in the resident's hands so that her fingers would not dig into her palms. The CNA was asked to check the resident at this time to see if she had towels in place. The CNA accompanied the surveyor to the room and checked. The resident did not have anything inside her hands upon observation. On 6/5/13 at 6:00 p.m., the physical therapy director (PTD) was interviewed. The PTD stated she first met the resident when admitted to the sub acute unit on the 3rd floor. The PTD stated from what she recalled the resident did not have contractures in her upper extremities and that therapy was working with her for mobility, strengthening and wheelchair fitting. The PTD stated she recalled the resident began to decline and was eventually transferred to the 2nd floor for long-term care. The PTD confirmed the resident was no longer on therapy services. The PTD did not know if the resident was currently on a restorative program, but was aware the resident was on hospice. The PTD acknowledged that if a resident was involved with hospice, they (the facility) were usually not involved because hospice had their own therapy provider they went through. On 6/6/13 at 9:00 a.m., a supervisor with the hospice entity contracted with the facility and involved with resident #74's care was interviewed via phone conversation. The supervisor stated she was not directly familiar with the resident and the primary case manager overseeing the resident's care was out on medical leave. The supervisor did acknowledge, however their hospice was not opposed to the facility assessing the resident's current physical condition. She stated if the resident's contractures were causing her pain and the facility, family and hospice nurse wanted to intervene to provide care, the resident could be referred to the hospice therapy provider. On 6/6/13 at 4:24 p.m. during and end of the day meeting with the director of nursing (DON) and the PTD, the DON stated the goal of care with resident #74 was keeping her comfortable and managing her pain. The DON stated it was not the wish of the resident or the resident's Power of Attorney (POA) to aggressively treat the contractures or provide splints. The DON acknowledged that although the resident was on hospice they would still treat the resident's contractures based on their plan of care. The DON stated ever since the resident came to the facility her "calling out" was a constant thing and they have been addressing it. The PTD acknowledged she did not want to imply in an earlier interview that they (the facility) would not treat the resident just because she was in hospice. The DON and PTD were informed that the concern was the lack of evidence that the resident was appropriately assessed and that she was not receiving services to prevent her contractures from becoming worse and causing more pain. The DON provided no comment, but shook her head acknowledging the information. On 6/10/13 at 10:53 a.m., the MDS coordinator was interviewed. She stated when new residents come in she opens the assessments and primarily oversees the nursing piece. She stated that the computerized care tracker interfaced with the matrix system and she could go in there and see how the information for section G (functional status) and H (bowel and bladder) coordinates. She stated if something seemed contradictory she would go and talk directly to staff. The MDS coordinator confirmed information for the functional ROM section of the MDS was completed by therapy department. She stated if the resident was not on therapy anymore then that department would not give her any additional information. The MDS coordinator stated a resident could have a contracture, but still have functional ROM.

Based on interview and record review, the facility failed to ensure that one (#3) resident out of four sample residents was kept free from accidents and hazards. Specifically, the facility failed to provide appropriate supervision and safety measures for resident #3 resulting in her falling in the dining room, obtaining a fractured femur, contusion on the head and subsequently dying within 48 hours of the fall. Resident #3 was a [AGE] year old female admitted to the facility on [DATE] and died in the facility on [DATE]. According to her resident face sheet, her [DIAGNOSES REDACTED]. There was no minimum data set (MDS) assessment available for the resident. According to a psychosocial review conducted on [DATE], her brief interview for mental status score was 1, which indicated that she had severe cognitive impairment. She was also noted as being confused and being independent with supervision when eating. a. Record review: Care plan, dated [DATE], stated that the resident was at risk for falls related to mental status, ambulation status, gait/balance, and medications. Approaches included: place call light in reach, encourage resident to obtain assistance for transfers and ambulation, ensure that resident has proper footwear when ambulating, ensure that lighting in room will support visual mobility, orient resident to room environment, provide assistive device for ambulation of wheelchair, encourage resident to call for assistance getting out of bed, transferring to chair, bed up next to wall, mattress on other side of bed with fall mat next to mattress for safety (discontinued on [DATE]) bed in lowest position, bed and chair alarm, fall mat beside bed (initiated [DATE]). Nurse's notes: [DATE]- "has very poor safety awareness" [DATE]- "Bed alarm and mat on floor for safety secondary to increased fall risk due to mentation." [DATE]- "Confused. Poor awareness of safety measures. Chair alarm functioning and in use." There was no evidence a fall risk assessment and the resident's care plan had been updated to reflect the resident's poor safety awareness, even though it had been noted in nurses notes on several occasions. [DATE]- Record review revealed a nurse's note, dated [DATE] at 1800 (6:00 p.m.), noted as a late entry. It stated, "Resident fof (found on floor) in the dining room at 1830 (6:30 p.m.) by CNA's (certified nursing aids). Resident noted with a lg (large) contusion to the back of the head without bleeding noted. R (right) hip appeared to be broken. Resident sheet lifted by 3 staff members back into bed." X-ray report: [DATE] 10:09 p.m. indicated that the resident had sustained an acute fracture of the right femoral neck. Hospice nursing note: [DATE] 7:15 p.m. "CNA reports pt was sitting in wheelchair in dining room. When left unattended to transport second resident to elevator pt had unwitnessed fall." Incident report: Incident report form, dated [DATE], stated under, "brief description of incident" - "Resident was in main dining room and stood up w/c brakes were not on and resident fell back hitting head on floor and caused possible fracture to right hip and contusion to back of head" Interdisciplinary progress notes: [DATE]- IDT (interdisciplinary team) falls meeting: Resident had fall on [DATE] at 6:30 p.m. Resident was in MDR (main dining room) on 1st floor and stood up after her meal. The brakes on her w/c (wheelchair) were not locked and the resident fell backwards hitting her head. Resident had fx (fracture) to right hip. b. Interviews: -The unit manager present on [DATE] when the fall occurred was interviewed on [DATE] at 6:40 p.m., regarding the resident's fall on [DATE]. She stated the following: "While I was giving report to the on-coming unit manager, a nurse came to us and said that (resident #3) had fallen. I went downstairs, and she was on the floor; you could tell that her hip was broken. I had (two CNA's) help me get her off the floor and take her to her room. The CNA's who are down there are responsible for watching (residents in dining room), we (the nurses) are no longer responsible for staying down there the whole time." When asked how long ago the dining supervision changed (nurses not available) she stated, "It changed just a few months ago, it hasn't been a long time." -[DATE] at 6:10 p.m. the unit manager was interviewed regarding resident #3's fall on [DATE]. She stated that the nurse called her to tell her that resident #3 had fallen and hit her head when she was done with dinner. She added that the nurse had stated that the wheelchair brakes were not locked and the resident fell , and had an issue with her leg. The nurse had reported to her that they had gotten the resident up to her room and that hospice was there. -On [DATE], the CNA assigned to be in the dining room on [DATE] was interviewed at 4:15 p.m. She stated that she was the only one in the dining room, sitting right next to resident #3. She thought she would do some charting while there. There were probably ten other residents in the dining room and she turned around and the resident had fallen and the alarm was not going off. She stated that she was at the kiosk and the resident's seat was at the service window (measured as 13 feet). She added that the resident was acting perfectly fine. She stated that she looked down the resident was lying on her back, about a foot away from the table where she stood up. When asked if the resident had foot pedals, a chair alarm and her brakes on, the CNA stated that they usually lock their wheelchair brakes and that they should have been locked. She also stated that there was no alarm sounding from the wheelchair. She added that she had started in November and no one had told her that resident #3 required constant supervision (also not included in the fall risk care plan). When asked how many CNA's were assigned to the dining room, she stated that only two aids go in the dining room to supervise the residents during meal time. When the residents are done eating she and the other CNA push four residents half way down the hall then put another four into the elevator. One CNA is supposed to hold the elevator and the other CNA brings residents around (to the elevator). She stated that this was harder that night, due to the main elevator being out of use, and they had to use the elevator in the main lobby of the facility leaving the residents alone in the dining room. She added that she did not receive any in-servicing or education for the incident. She added that the DON was busy on Monday so she wrote her a statement and gave it to her. She stated that she was never asked to make a statement or discuss the incident by management.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and that two (#1 and #2) of 12 sample residents received adequate supervision and assistive devices to prevent accidents. The findings include: This deficiency was originally cited during the abbreviated survey ending on 1/27/12. The facility alleged compliance as of 3/2/12. A revisit was conducted on 3/21/12, and the facility was recited for continued noncompliance. 1. Resident #1, an [AGE] year old female, was admitted to the facility on [DATE]. According to her face sheet, [DIAGNOSES REDACTED]. The 2/16/12 quarterly Minimum Data Set (MDS), documented that the resident had moderately impaired cognitive skills with long and short-term memory problems. The resident required extensive assistance of one person with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. The resident's mobility device was the wheelchair. The resident was frequently incontinent of urine and continent of bowel. The resident did not have any falls prior to this assessment period. Record Review: On 2/22/12, the fall care plan documented the resident's safety interventions included wheelchair and bed alarms, bed in low position when the resident was in bed, and a fall mat on the floor. On 2/22/12, the Interdisciplinary Progress Notes documented that an alarm was placed on the bed and wheelchair due to a previous fall. No Physician's Order was found regarding the wheelchair and/or bed alarms, low bed position when in the bed, and/or mat on floor. Observation and Interview: On 3/21/12 at 12:10 p.m., the resident was observed in the main dining room eating lunch. The wheelchair alarm was not found to be attached to her wheelchair. The Restorative Certified Nurse Aide (RCNA) was sitting next to the resident, giving her verbal cues during the meal. He reported that the resident had been on his service since her admission to the facility and he had "never" seen an alarm on her wheelchair. He was not aware of any alarms attached to her bed since his service did not entail that activity with the resident. On 3/21/12 at 12:30 p.m., the CNA on the resident's unit was not able to locate an alarm on the resident's wheelchair. She stated that if the resident was supposed to have an alarm, it would be attached to the side of her wheelchair towards the back of the chair. On 3/21/12 at 12:41 p.m., one of the floor nurses reported that it was the nurse's responsibility for updating the resident's care plan of nursing-related issues. On 3/21/12 at 12:48 p.m., after speaking to staff (see above) regarding the resident's missing wheelchair alarm, the resident was observed sitting in the hallway in front of the nurses' station without a wheelchair alarm in place. On 3/21/12 at 12:58 p.m., the Director of Nursing (DON) stated that her expectation was to see the alarm in place. She reported that the alarm would be transferred from the bed to the wheelchair by the staff. She reported that the alarms were a nursing service and would not be expected to have a Physician Order. She reported that the resident was frequently observed by the staff turning the alarm off, but she would expect to see the alarm in place as long as it was in the care plan. She stated that she would have to look into why the alarm was not in place. On 3/21/12 at 1:20 p.m., the DON reported that when the resident had fallen previously, her thyroid (TSH) levels were abnormal, but recently had stabilized, so she did not believe the resident needed the alarm. She reported that the physician had ordered a Physical Therapy (PT) evaluation regarding the necessity for the alarms. She reported that she had updated the care plan during this revisit. On 3/21/12 at 2:31 p.m., the DON reported that the Fall Risk Assessment forms were no longer part of the facility's policy and that they used the data collection tool, which had the same question as the MDS regarding the resident having a fall in the last 30 days. She stated that the data collection tool was done on admission and quarterly to identify the need for fall risk measures. However, the tool did not include what type of safety measures to use and/or how severe the fall risk was for the resident. 2. Resident #2, a [AGE] year old female, was admitted to the facility on [DATE]. According to her face sheet, [DIAGNOSES REDACTED]. She was admitted for Respite Care with Hospice services. On 2/1/12, the annual Minimum Data Set (MDS), documented that the resident's Brief Interview for Mental Status (BIMS) score was eight, which indicated that the resident had moderately impaired cognition. The resident required extensive assist of one person with dressing, toilet use, and personal hygiene. She required limited assist of one person with bed mobility, transfer, locomotion on and off the unit, and bathing. She required supervision assist of one person with walking in room and eating. The resident's mobility device was the walker. The resident was frequently incontinent of bowel and bladder. The resident did not have any falls during this assessment period. Record Review: On 2/13/12, the fall care plan documented the following safety interventions: wheelchair and bed alarms, walker had been removed from room; bed in low position when in bed; and no fall mat secondary to self transfer. On 1/9/12, the Interdisciplinary Progress Notes, documented the wheelchair and bed alarms were in place. Observation: On 3/21/12 at 1:16 p.m., the resident was observed lying in the bed with the wheelchair locked on one side and not on the other side. The alarm wire was not connected to the alarm box and was laying in the bed with the resident. No pressure pad or alarm box was found in the wheelchair. -A CNA was called into the resident's room to assist in finding the alarm. The CNA on the unit reported that all the CNAs were responsible for doing safety checks once at the end of their eight hour shifts. The CNA searched the bed, bedside cabinet, and wheelchair without finding the alarm box. He then found the alarm box and the wheelchair pressure pad on the lounge chair at the foot of the bed underneath blankets. -The CNA reported that the resident was observed frequently disconnecting the alarm box and hiding it in her dresser or under the bed. Interview and Record Review: On 3/21/12 at 1:55 p.m., the DON reported that if the resident was able to disconnect the alarms, then the intervention was no longer effective and she would expect the CNA to report the issue to the nurse so that the intervention could be changed to an effective intervention. The DON reported that she had updated the care plans and verbally educated the staff working with resident. On 3/21/12 at 2:09 p.m., (during survey), the updated fall care plan documented that the resident would, "remove the alarm box and hide it at times."