Every finding on record at Trinity Trace Community Care Center

Based on record review, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure staff used proper PPE for 1 (R1) of 3 residents observed during incontinence and perineal care.Findings:Review of R1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Overactive Bladder and Constipation.An observation was made on 06/15/2026 at 1:43 p.m. of S3CNA performing incontinence care for R1. S3CNA entered R1's room and donned gloves. S3CNA unfastened soiled brief and wiped feces from R1's buttocks. Without removing the soiled gloves and performing hand hygiene, S3CNA removed the feces soiled brief, touched a clean brief, and placed clean brief onto R1. Without removing the soiled gloves and performing hand hygiene, S3CNA touched R1's clothing and bedsheets. S3CNA then removed gloves and performed hand hygiene.An interview was conducted on 06/15/2026 at 1:45 p.m. with S3CNA. She confirmed she did not change her gloves prior to touching R1's clean brief, clothing, and bedsheets. She stated when a resident had feces present during incontinence care, she should change her gloves prior to touching clean items.An interview was conducted on 06/16/2026 at 12:50 p.m. with S2DON. She stated she expected all staff to change gloves after cleaning feces and prior to touching any clean items.

Based on record reviews and interviews, the facility's staff failed to report an allegation of verbal abuse to the facility's administrator and to the State Agency in accordance with state law for 1 (#2) of 3 sampled residents reviewed for abuse. Findings: Review of the facility's policy dated 10/24/2022 and titled Abuse Components Plan Elder Justice Act and Affordable Care Act revealed the following, in part:Reporting Requirements Table:All alleged violations of abuse are to be reported to the facility administrator and other officials in accordance with state law. All alleged violations reported: 1) immediately but not later than 2 hours if the alleged violation involves abuse. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #2's quarterly MDS with an ARD of 05/15/2026 revealed Resident #2 had a BIMS of 15, which indicated she was cognitively intact. An interview was conducted on 06/15/2026 at 6:00 a.m. with Resident #2. She stated an incident happened about a month ago with S7CNA. She stated S7CNA came to her room, shut the door, stood very close to her, and started cursing at her. She stated S7CNA called her all kinds of names including f***ing wh*re and b**ch. She stated she was suspicious of S7CNA and afraid she would possibly hit her because she was full of rage and was close to her person. She stated it made her feel belittled. She stated S7CNA was not assigned to her care currently and she felt at peace the problem was resolved. She stated if she were to see S7CNA she would be on guard, but she was comfortable moving about the facility freely. She stated what S7CNA did was verbal abuse. She stated she did report the verbal abuse to a nurse and does not remember who. An interview was conducted on 06/15/2026 at 5:57 p.m. with S4CNA. S4CNA stated on 06/14/2026 Resident #2 reported to her a CNA, who recently was removed from Resident #2's care, had closed Resident #2 in her room and let her have it and yelled and cussed at her. She stated Resident #2 said it hurt her feelings because she was not expecting the CNA to act like that. S4CNA stated she did not recall the name of the CNA. S4CNA confirmed cussing and yelling at a resident was verbal abuse. S4CNA stated she did not report the verbal abuse to anyone because Resident #2 stated she had already reported it. An interview was conducted on 06/16/2026 at 1:45 p.m. with S2DON. S2DON stated she had never received a report from staff or a resident reporting staff cussed and yelled at a resident. She stated if she received a report about staff cussing and yelling at a resident she would report it immediately to S1ADM. An interview was conducted on 06/16/2026 at 2:03 p.m. with S1ADM. S1ADM stated he had not received a report about staff cussing and yelling at a resident. S1ADM stated if he received a report of verbal abuse he would immediately report it and complete an investigation.

Based on observations, interviews, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. The facility failed to ensure:1. Food was properly labeled in the facility's refrigerator; 2. Food products had not exceeded their expiration date; and3. Reheated food reached an internal temperature of 165 degrees Fahrenheit for 15 seconds. Findings:1.Review of the facility's policy, titled, Food Receiving and Storage, with a date of 2011, revealed:Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:8. All foods stored in the refrigerator .will be covered, labeled and dated.14. Food items and snacks kept on the nursing units must be maintained as indicated below:b. All foods belonging to residents must be labeled with resident's name, the item and the receives date and or open date. On 12/01/2025 at 9:06 a.m., an observation was made of POD D's resident refrigerator located in the kitchenette. Further observation revealed POD D's resident refrigerator contained 1 large to-go container covered with aluminum foil and 1 plastic container labeled with a resident's name but no date.On 12/01/2025 at 9:10 a.m., an interview was conducted with S5STAFF. She observed and confirmed POD D's resident refrigerator contained 1 large to-go container covered with aluminum foil and 1 plastic container labeled with a resident's name only but no date.On 12/01/2025 at 1:17 p.m., an interview was conducted with S1ADM. S1ADM confirmed all food brought in by a resident's family should be labeled with a date and resident's name. 2. On 12/01/2025 at 9:06 a.m., an observation was made of POD D's unit refrigerator. Further observation revealed 7 - 8 ounce cartons of chocolate protein shakes with an expiration date of October 2025. On 12/01/2025 at 9:10 a.m., an interview was conducted with S5STAFF. She confirmed POD D's unit refrigerator contained 7 - 8 ounce cartons of chocolate protein shakes with an expiration date of October 2025 and were readily available for resident consumption. On 12/01/2025 at 1:17 p.m., an interview was conducted with S1ADM. He confirmed expired food items should not be readily available for resident consumption. 3.Review of the facility's policy, titled, Food Preparation and Service, with a date of 2011, revealed:Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices.Policy Interpretation and ImplementationFood Preparation, Cooking and Holding Time/Temperatures9. Previously cooked food is reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. 11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 degrees Fahrenheit during preparation or they are reheated to 165 degrees Fahrenheit for at least 15 seconds. On 12/01/2025 at 11:05 a.m., an observation was made of S6STAFF instructing staff to reheat a plate of purred food in the microwave. Further observation revealed no temperature checks made after reheating the food and prior to serving to the resident.On 12/01/2025 at 11:25 a.m., an observation was made of a resident's meal consisting of a hotdog, bun and chili being reheated in the microwave. Further observation revealed no temperature checks made after reheating the food and prior to serving to the resident.On 12/01/2025 at 11:30 a.m., an interview was conducted with S6STAFF. She confirmed the initial temperatures of the above mentioned foods were below 135 degrees and required reheating. She further confirmed the temperatures of the pureed meal, and the hot dog and chili were not retaken after reheating in the microwave and should have been prior to serving to the residents.On 12/01/2025 at 1:13 p.m., an interview was conducted with S7STAFF. She stated the dietary aid was responsible for checking temperatures on all food served to residents. She confirmed if a food was not hot enough, she expected staff to reheat the food in the microwave and to retake the temperature prior to serving.On 12/01/2025 at 1:17 p.m., an interview was conducted with S1ADM. S1ADM confirmed staff should take food temperatures prior to serving residents.

Based on record review, observations, and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to transcribe physician's orders accurately for 1 (#100) of 4 (#33, #83, #100 and #119) residents reviewed for medication administration. Findings:Review of the facility's policy titled, Reconciliation of Medication on admission dated 2001, revealed the following, in part:Purpose:The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission . to the facility.Preparation1. Gather the information needed to reconcile the medication list: b. admission order sheetGeneral Guidelines1. Medication reconciliation is .creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care.4. Medication reconciliation helps to ensure that medications, routes and dosages has been accurately communicated.Review of Resident #100's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Glaucoma.Review of Resident #100's discharge instructions dated 07/02/2025-08/01/2025 revealed the following medication order:Dorzolamide 2% ophthalmic solution, place one drop into both eyes 2 times a day.Review of Resident #100's current physician's orders revealed the following:Start date 10/17/2025 - Dorzolamide HCL Solution 2%, Instill 1 drop in left eye two times a day.Review of Resident #100's November and December MARs revealed the following:Start date 10/17/2025 - Dorzolamide HCL Solution 2%, Instill 1 drop in left eye two times a day.On 12/02/2025 at 8:00 a.m., an observation was made of S8STAFF administering 1 drop of Dorzolamide HCL 2% into each eye of Resident #100. On 12/02/2025 at 10:55 a.m., an interview was conducted with S8STAFF. She reviewed and confirmed the Electronic Health Record's order was to administer 1 drop of Dorzolamide 2% in the left eye only. She then reviewed and confirmed the prescription on the bottle read to instill 1 drop in each eye. On 12/02/2025 at 3:32 p.m., an interview was conducted with S9STAFF. S9STAFF confirmed there was an error in transcription and the correct order for Resident #100 was Dorzolamide HCL Solution 2 %, instill 1 drop in both eyes. On 12/03/2025 at 8:50 a.m., an interview was conducted with S10STAFF. She stated she was responsible for transcribing physician orders for residents. She stated the LPN was then responsible for verifying the medication orders before releasing them for administration. She reviewed Resident #100's medication orders and the medication order placed into the Electronic Health Record and confirmed she had made an error. On 12/03/2025 at 9:26 a.m., an interview was conducted with S11STAFF. She confirmed she admitted Resident #100. She stated she was responsible for verifying the medication orders entered into the Electronic Health Record before releasing them for administration and she did not. On 12/03/2025 at 10:05 a.m., an interview was conducted with S2DON. She confirmed Medical Records should accurately transcribe physician orders when a resident was admitted to the facility. She confirmed the admitting nurse should verify the medication orders for accuracy prior to releasing the medication orders for administration.

Based on record reviews and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 2 (#6 and #28) of 16 sampled residents reviewed for resident assessment. Resident #6 Review of Resident #6's Clinical Record revealed an admission date of 08/19/2022 with diagnoses, which included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Carotid Artery. Review of Resident #6's Annual MDS with an Assessment Reference Date (ARD) of 05/23/2025 revealed in part, the following: Question N0415E1: Medications: Anticoagulant: Yes. Review of Resident #6's Quarterly MDS with an ARD of 08/23/2025 revealed in part, the following: Question N0415E1: Medications: Anticoagulant: Yes. Review of Resident #6's Physician Orders revealed in part, the following: Start date: 11/22/2025, Clopidogrel Bisulfate 75 milligram (mg), give 75 mg by mouth one time a day. Further review revealed no physician order for anticoagulant. Review of Resident #6's Medication Administration Record (MAR) for May 2025 and August 2025 revealed no documented anticoagulant given. An interview was conducted on 12/03/2025 at 9:23 a.m. with S3MDS. She reviewed Resident #6's MDS with an ARD of 05/23/2025, Resident #6's MDS with an ARD of 08/23/2025, and Resident #6's current and discontinued Physician Orders. She confirmed Question N0415E1 was coded yes on both assessments, indicating Resident #6 was taking an anticoagulant, and further confirmed the coding was inaccurate. Resident #28 Review of Resident #28's Clinical Record revealed an admission date of 07/23/2024 with diagnoses, which included Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Atrial Fibrillation. Review of Resident #28's Quarterly MDS with an ARD of 10/15/2025 revealed in part, the following: Question N0415I1: Medications: Antiplatelet: No. Review of Resident #28's Physician Orders revealed in part, the following: Start date: 12/10/2024, Aspirin 81 mg, give 81 mg by mouth one time a day. Review of Resident #28's MAR for October 2025 revealed documented administrations of Aspirin 81mg by mouth daily per Physician Order. An interview was conducted on 12/03/2025 at 4:00 p.m. with S3MDS. She reviewed Resident #28's MDS with an ARD of 10/15/2025 and Resident #28's current and discontinued Physician Orders. She confirmed Question N0415I1 was coded no, indicating Resident #28 was not taking an antiplatelet, and further confirmed the coding was inaccurate. An interview was conducted on 12/03/2025 at 4:15 p.m. with S2DON. She reviewed the above mentioned MDS assessments and confirmed all residents' MDS should be accurately coded for the medications they received.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the development and transmission of infection as evidenced by S4STAFF failing to practice safe injection practices for 1 (#119) of 1 resident observed for insulin injections. Findings: Review of the facility's policy dated 2001 and titled, Insulin Administration , revealed the following, in part:Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes.General GuidelinesSteps in the Procedure (Insulin Injection via Syringe)17. Clean the injection site with an alcohol wipe and allow to dry.Flex Pen Insulin Administration:10. Cleanse site with alcohol. Review of Resident #119's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus.Review of Resident #119's current Physician Orders revealed the following:Order date: 11/19/2025-Insulin Glargine Subcutaneous Solution 100units/ml, inject 12 units subcutaneously one time a day. On 12/02/2025 at 8:35 a.m., an observation was made of S4STAFF injecting Insulin Glargine into Resident #119's left, upper arm without cleansing the skin with alcohol prior to the injection.On 12/02/2025 at 8:36 a.m., an interview was conducted with S4STAFF. She confirmed she did not cleanse Resident #119's skin with alcohol prior to injecting insulin and should have. On 12/02/2025 at 9:08 a.m., an interview was conducted with DON. She confirmed staff should always cleanse the residents' skin with alcohol prior to injecting insulin.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff: 1. Properly utilized Enhanced Barrier Precaution (EBP) Personal Protective Equipment (PPE) during incontinence care for 2 (#2 and #R1) of 3 (#2, #3 and #R1) residents whom required EBP; and 2. Performed appropriate hand hygiene during incontinence care for 1 (#2) of 3 (#2, #3 and #R1) residents observed for incontinence care. Findings: Review of the facility's policy with a revised date of 04/2024, titled, Enhanced Barrier Precautions revealed the following, in part: Enhanced barrier precautions are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents. 2. EBP employ targeted gown and glove use during high contact resident care activities, when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP .include transferring, providing hygiene, changing linens, changing brief. 4. EBP are indicated when contact precautions do not otherwise apply for residents colonized with Vancomycin-resistant Enterococci (VRE). Review of the facility's sign titled Enhanced Barrier Precautions revealed the following instructions, in part: Enhanced Barrier Precautions .providers and staff must clean their hands when entering and when leaving the room. Wear gloves and a gown for the following high contact resident care activities: Transferring, changing linens, providing hygiene, and changing briefs. 1. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Personal History of Urinary Tract Infections with VRE. Review of Resident #2's current Physician Orders revealed the following, in part: Start date-02/03/2025 Enhanced Barrier Precautions related to history of VRE. Review of Resident #2's current Care Plan revealed the following, in part: Problem: I am at risk for developing MDRO infections related to colonized MDRO-VRE. I require the use of EBP. Intervention: PPE as required. An observation was made on 04/14/2025 at 5:25 a.m. of Resident #2's door to her room. A sign was observed on the door which read EBP with the above facility sign instructions, along with a caddy of gloves and gowns. An observation was made on 04/14/2025 at 5:25 a.m. of S3CNA providing incontinence care for Resident #2. S3CNA applied gloves and entered Resident #2's room without a gown. S3CNA changed Resident #2's urine and feces soiled brief, provided perineal care, removed gloves and then exited Resident #2's room. S3CNA applied gloves and entered Resident #2's room again without a gown. S3CNA repositioned her from side to side to place the mechanical lift pad underneath Resident #2. S3CNA removed gloves and exited the room. An interview was conducted on 04/14/2025 at 5:45 a.m. with S3CNA. S3CNA confirmed Resident #2 had an EBP sign and caddy with gowns and gloves on her door. S3CNA stated she did not wear a gown during incontinence care and placement of the lift pad underneath Resident #2 because she did not know she required the EBP PPE precautions. Resident #R1 Review of Resident #R1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Personal History of Urinary Tract Infections with VRE. Review of Resident # R1's current Physician Orders revealed the following, in part: Start date-03/25/2025 Enhanced Barrier Precautions related to MDRO. Review of Resident # R1's current Care Plan revealed the following, in part: Problem: I am at risk for developing MDRO infections related to colonized MDRO-VRE. I require the use of EBP. Intervention: PPE as required. An observation was made on 04/14/2025 at 5:10 a.m. of Resident #R1's door to her room. A sign was observed on the door which read EBP with the above facility sign instructions, along with a caddy of gloves and gowns. An observation was made on 04/14/2025 at 5:10 a.m. of S4CNA providing incontinence care for Resident #R1. S4CNA applied gloves and entered Resident #R1's room without a gown. S4CNA changed Resident #R1's urine soiled brief, provided perineal care, removed gloves and then exited Resident #R1's room. An interview was conducted on 04/14/2025 at 5:23 a.m. with S4CNA. S4CNA confirmed Resident #R1 had an EBP sign and caddy with gowns and gloves on her door. S4CNA confirmed she did not wear a gown during incontinence care because she did not think it was required. 2. Review of facility's policy revised date 08/2015 and titled Handwashing/Hand Hygiene revealed the following, in part: This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; h. Before moving from a contaminated body site to a clean body site during resident care; j. After contact with bodily fluids; and m. After removing gloves. 8. Hand hygiene is the final step after removing and disposing of PPE. 9. The use of gloves does not replace hand washing/hand hygiene. Review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/10/2025 revealed that the resident was incontinent with urinary and bowel. An observation was made on 04/14/2025 at 5:25 a.m. of S3CNA providing incontinence care for Resident #2. S3CNA applied gloves and entered Resident #2's room. S3CNA changed Resident #2's urine and feces soiled brief and cleaned her perineal area with wipes. S3CNA then, with the same soiled gloves and no hand hygiene performed, retrieved a clean brief and applied it to Resident #2, touched Resident #2's clean linen, bed railing and her hand to remove it from the bed rail, and repositioned resident in the bed. S3CNA removed gloves and then exited Resident #2's room with a trash bag, removed trash can lid and disposed the trash bag. After, S3CNA retrieved the mechanical lift from the hallway, applied gloves and entered Resident #2's room again and repositioned Resident #2 from side to side to place the mechanical lift pad underneath Resident #2. S3CNA, with assistance, used the mechanical lift remote and transferred Resident #2 by touching Resident #2 to guide her into the wheelchair. S3CNA removed gloves and exited the room. S3CNA did not perform hand washing or hand sanitizer. An interview was conducted on 04/14/2025 at 5:45 a.m., with S3CNA, S3CNA confirmed she did not change her gloves or perform hand hygiene after she performed incontinence care and before touching clean items in the room and Resident #2, and should have. S3CNA confirmed she did not perform hand hygiene after she removed her gloves and exited the room to discard the trash bag and/or before and after retrieving the mechanical lift and performing the transfer for Resident #2, and should have. An interview was conducted on 04/15/2025 at 1:15 p.m., with S1DON. S1DON confirmed Resident #2 and Resident #R1 were on EBP precautions because of a history of MDRO. S1DON stated Resident #2 and Resident #R1 had EBP signage on their door, which the staff should follow and wear a gown and gloves during high contact resident care activities. S1DON stated after handling urine and feces soiled diaper and providing perineal care for residents, she would expect the staff to remove soiled gloves and perform hand hygiene before handling a clean diaper, touching other clean linens and resident. S1DON stated she expected nursing staff to perform hand hygiene immediately after direct care with resident and before touching equipment and/or providing care for residents.

Based on record review and interviews, the facility failed to ensure an accurate Minimum Data Set assessment for 1 (#1) of 3 (#1, #2 and #3) Residents sampled for falls. The facility failed to ensure falls were accurately coded for Resident #1. Findings: Review of Resident #1's Clinical Record revealed an admitted [DATE]. Review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/2024 revealed a Brief Interview for Mental Status (BIMS) of 14, which indicated she was cognitively intact. Further review revealed the following, in part: Section J Health Conditions J1800-Any falls since admission/entry or reentry or prior assessment. Marked No J1900-Number of falls since admission/entry or reentry or prior assessment. This section was disabled due to No marked on the previous section (J1800). Review of the facility's incident log dated 11/11/2024 - 02/11/2025 revealed Resident #1 had an unwitnessed fall on 11/26/2024, which she did not report to staff until 11/27/2024. Review of the nurse's notes for Resident #1 dated 11/11/2024 - 02/11/2025 revealed on 11/27/2024 at 6:00 p.m., Resident #1 self-reported she fell in her room on 11/26/2024. Review of the facility's Post Fall Evaluation dated 11/27/2024 at 6:00 p.m. revealed Resident #1 was evaluated for an unwitnessed fall in her bedroom. On 02/13/2025 at 9:38 a.m., an interview was conducted with S2LPN. S2LPN stated she was responsible for completing MDS assessments for Resident #1. S2LPN reviewed Resident #1's Clinical Record, including the Quarterly MDS with an ARD of 12/03/2024. S2LPN confirmed Resident #1 had a fall since her previous MDS assessment. S2LPN confirmed she did not correctly code the Quarterly MDS with an ARD of 12/03/2024 for Resident #1's fall and should have. On 02/14/2025 at 10:14 a.m., an interview was conducted with S3RN. S3RN confirmed she was responsible for reviewing and signing off on Resident #1's MDS assessments completed by S2LPN. S3RN reviewed Resident #1's Clinical Record, including the Quarterly MDS with an ARD of 12/03/2024, in which S3RN had signed off on. S3RN confirmed Resident #1 had a fall since her previous MDS assessment. S3RN confirmed Resident #1's fall was not correctly coded on the Quarterly MDS with an ARD of 12/03/2024 and this should have been corrected prior to her (S3RN) signing off on the MDS. On 02/14/2025 at 11:45 a.m., an interview was conducted with S1DON. S1DON reviewed Resident #1's Clinical Record, including the Quarterly MDS with an ARD of 12/03/2024 and confirmed it was not coded correctly for Resident #1's fall on 11/26/2024 and should have been.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 2 (#1 and #107) residents out of a total of 25 sampled residents by failing to ensure: 1. Resident #1 was coded correctly for the use of an antidiuretic; and 2. Resident #107 was coded correctly for discharge. Findings: 1. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #1's Quarterly MDS with an ARD of 07/23/2024 revealed Section N:G: Diuretic: No. Review of Resident #1's Physician Orders revealed the following: Start date: 05/21/2024, End Date: 09/08/2024: Furosemide 20 mg Give 20 mg by mouth two times a day. On 09/24/2024 at 9:48 p.m., an interview was conducted with S4CCC. She stated she was responsible for the July 2024 Quarterly MDS assessment. She verified Resident #1 had a Physician's Order for Furosemide 20 mg twice daily with a start date of 05/21/2024. She reviewed Resident #1's Quarterly MDS and confirmed Section N:G was not coded for taking a diuretic and should have been. On 09/25/2024 at 3:00 p.m., an interview was conducted with S1DON. She confirmed if Resident # 1 was taking Furosemide during the look back period then the Quarterly MDS should have been coded for it. 2. Review of Resident #107's Clinical Record revealed she was admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident #107's Discharge MDS with an ARD of 08/26/2024 revealed Section A2105 Discharge Status: Short Term General Hospital. Review of Resident #107's Discharge Summary dated 08/26/2024 revealed the resident was discharged to a local assisted living facility. On 09/24/2024 at 12:38 p.m., an interview was conducted with S3CCC. She stated she was responsible for the MDS Assessments. She verified Resident #107 she was discharged to an assisted living facility. She reviewed Resident #107's Discharge MDS and confirmed Section A2105 indicated the resident was discharged to the hospital, and should have been coded for discharge to assisted living. On 09/24/2024 at 12:55 p.m., an interview was conducted with S1DON. She verified Resident #107 was discharged to a local assisted living facility. She reviewed Resident #107's MDS and confirmed she was coded for being discharged to the hospital and should have been coded for discharge to an assisted living facility. 47173

Based on record review, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure insulin pens were primed prior to administration of insulin per manufacturer's guidelines for 3 of 3 (#11, #30, and #76) residents observed for insulin administration. Findings: Review of the facility's policy titled Insulin/Insulin Flexpens and Insulin Documentation dated 01/29/2013, revealed the following, in part: FlexPen Insulin Administration 7. Air Shot steps: turn the device dose selector to 2U, holding pen with needle up, tap cartridge a few times to move any air bubbles to the top of the device, complete air shot by pressing the injector push button all the way in (the dose selector will return to 0), a drop of insulin should be present on the needle tip. Review of the manufacturer's insert for Insulin Aspart FlexPen (Novolog) revealed the following, in part: Giving the airshot before each injection- Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select 2 units F. Hold your Novolog Flexpen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge G. Keep the needle pointing upwards, press the push button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. Resident #11 Review of Resident #11's current Physician Orders revealed, in part, an order for Insulin Aspart FlexPen Solution Pen-Injector 100Unit/ML(InsulinAspart) Inject as per sliding scale. On 09/24/2024 at 11:16 a.m., an observation was made of S7LPN preparing and administering Resident #11's Insulin Aspart FlexPen. S7LPN dialed the Insulin Aspart FlexPen to 6 units. S7LPN did not prime the Insulin Aspart FlexPen prior to administration to Resident #11. On 09/24/2024 at 11:17 a.m., an interview was conducted with S7LPN. S7LPN confirmed she did not prime the Insulin Aspart FlexPen prior to administration. S7LPN stated she was unaware the Insulin Aspart FlexPen needed to be primed prior to administration. Resident #30 Review of Resident #30's current Physician Orders revealed, in part, an order for Insulin Aspart Subcutaneous Solution Pen-injector 100Unit/ML(InsulinAspart) Inject as per sliding scale. On 09/24/2024 at 10:59 a.m., an observation was made of S6LPN preparing and administering Resident #30's Insulin Aspart. S6LPN dialed the Insulin Aspart FlexPen to 2 units and administered it to Resident #30. S6LPN did not prime the Insulin Aspart FlexPen prior to administering to Resident #30. On 09/24/2024 at 11:00 a.m., an interview was conducted with S6LPN. S6LPN confirmed she did not prime the Insulin Aspart FlexPen prior to dialing the insulin dose. S6LPN stated she was unaware the Insulin Aspart FlexPen needed to be primed prior to administration. Resident #76 Review of Resident #76's current Physician Orders revealed, in part, an order for Novolog Injection Solution 100 Unit/ML(Insulin Aspart) Inject as per sliding scale. Remove space On 09/24/2024 at 10:27 a.m., an observation was made of S8LPN preparing and administering Resident #76's Novolog (Insulin Aspart). S8LPN dialed the Insulin Aspart FlexPen to 2 units and administered it to Resident #76. S8LPN did not prime the Insulin Aspart FlexPen prior to administering to Resident #76. On 09/24/2024 at 10:28 a.m., an interview was conducted with S8LPN. S8LPN confirmed she did not prime the Insulin Aspart FlexPen prior to dialing the insulin dose. S8LPN stated she was unaware the Insulin Aspart FlexPen needed to be primed prior to administration. On 09/24/2024 at 1:00 p.m., an interview was conducted with S1DON. She reviewed the manufacturer's insert for Insulin Aspart FlexPen and confirmed it required a priming of 2 units of insulin prior to administering each dose. On 09/24/2024 at 1:05 p.m., an interview was conducted with S5QI. She confirmed Insulin Aspart FlexPen required a priming of 2 units of insulin prior to administering each dose.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. The facility failed to ensure: 1. Temperatures were documented for the medication refrigerator in 1 of 1 (Med Room a) medication storage rooms observed; and 2. Expired medications were not available for administration to residents in 1 (Med Cart c) of 4 (Med Cart a, Med Cart b, Med Cart c, and Med Cart d) medication carts observed. Findings: An observation was made of Med Room a on 09/23/2024 at 9:33 a.m. with S1DON. Review of the Daily Refrigerator Task Log dated September 2024 for the refrigerator located in Med Room a revealed the only dates in which temperatures were documented were on 09/02/2024, 09/03/2024, 09/04/2024, 09/08/2024, 09/14/2024, 09/15/2024, and 09/21/2024. An interview was conducted on 09/23/2024 at 9:37 a.m. with S1DON. She reviewed the Daily Refrigerator Task Log and confirmed the temperatures of the medication refrigerator should have been documented daily by the night shift nurses, and were not. An observation was made of Med Cart c on 09/23/2024 at 9:44 a.m. with S2LPN. An observation was made of a box of Artificial Tear eye drops with an open date of 08/01/2024. There was an expiration date of 03/2024 on both the bottle and the box of the Artificial Tears. The bottle of the Artificial Tears was observed to be 3/4 empty. An interview was conducted on 09/23/2024 at 9:46 a.m. with S2LPN. She verified there was an expiration date of 03/2024 on the box and bottle of the Artificial Tears eye drops. She verified there was a written open date on the Artificial Tears of 08/01/2024, and the eye drops were available for use. She stated the nurse who opened the Artificial Tears should have checked the expiration date before administering the eye drops. She confirmed expired medications, including eye drops, should be discarded and not administered to residents. An interview was conducted on 09/23/2024 at 10:25 a.m. with S1DON. She was notified of the above findings. She confirmed expired eye drops should be discarded and not be administered to residents.

Based on record reviews and interviews, the facility failed to ensure a resident's facility discharge had the required physician documentation in the medical record identifying the residents needs that could not be met by the facility for 1 (#1) of 2 (#1, #R1) residents reviewed for emergency transfers. Findings: Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] and discharged on [DATE]. Review of the facility's Action Summary revealed Resident #1 was transferred from the nursing home to a local hospital on 06/24/2024 and did not return to the facility. Review of the facility's Discharge Instruction and Summary for Resident #1 revealed the facility discharged the resident on 06/24/2024 after an emergency transfer to a local hospital. Further review of the Discharge Instruction and Summary revealed this resident had abusive behaviors. Review of Resident #1's medical record, physician notes, and nursing notes revealed no documentation justifying the reason for discharge. On 07/30/2024 at 9:34 a.m. a telephone interview was conducted with the emergency room physician at the local hospital. He stated he treated Resident #1 on 06/24/2024. He stated the resident was later discharged to home on 06/24/2024 after S2DON said the resident could not return to the facility due to her abusive behavior. On 07/30/2024 at 9:57 a.m. a telephone interview was conducted with the Triage Nurse at the local hospital. He stated on 06/24/2024, S2DON told him as a result of Resident #1's family members making threats to staff and Resident #1's behaviors she could not return to the facility. He stated the hospital later discharged the patient to home. On 07/31/2024 at 11:50 a.m. an interview was conducted with S2DON. She confirmed there was no documentation justifying the reason for discharge of Resident #1 by the Medical Director. She stated Resident #1 exhibited abusive behaviors and the resident left the facility via ambulance to the local hospital on her own accord. She stated her abusive behaviors put the safety of other residents at risk. On 07/31/2024 at 12:01 p.m. an interview was conducted with S1ADM. He confirmed he had no documentation justifying the reason for discharge of Resident #1 by the Medical Director. On 07/31/2024 at 12:01 p.m. an interview was conducted with S3MD. He confirmed he did not document the reason Resident #1 was for discharged from the facility in the medical record. He stated Resident #1 exhibited abusive behaviors and the resident left the facility via ambulance to the local hospital on her own accord. He stated her abusive behaviors put the safety of other residents at risk.

Based on record review and interviews, the facility failed to ensure a resident had a neurology appointment scheduled as ordered by the physician for 1(#1) of 3(#1, #2, #3) residents reviewed for physician orders. Findings: Review of the Clinical Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included: Chronic Kidney Disease-Stage 5, Non-Alzheimer's Dementia, Parkinson's Disease, Bipolar Disorder, Schizophrenia, Generalized Anxiety Disorder, Major Depressive Disorder, History of Falling. Review of Physician Notes revealed the following: 1/11/2023- Resident seen by S2NP for continued confusion and weakness. Delusions present. Plan to obtain Neurologist appointment. Review of the current Physician Orders revealed the following: 01/11/2023- Appointment with neurology for dementia, CKD due to decline ordered per S2NP. Further review of Physician Notes revealed the following: 1/24/2023- Resident seen by S2NP. Resident continues with confusion, awaiting Neurology appointment. On 10/30/2023 at 1:10 p.m., an interview was conducted with an employee from the Neurologist provider's office. She stated Resident #1 was last seen on 07/2022 by the Neurologist provider. She stated Resident #1 had no prior or current scheduled appointments in the year of 2023. On 10/31/2023 at 11:03 a.m. an interview was conducted with S3MR. She stated she was responsible for making appointments as ordered by the NP/MD. She stated she attempted to make an appointment for Resident #1 with the Neurologist provider twice in January, 2023 and left messages. She stated she failed to follow up and schedule the Neurology appointment ordered by S2NP, and should have. On 11/01/2023 at 3:35 p.m. an interview was conducted with S1DON. She verified S3MR was responsible for scheduling appointments as ordered by the NP/MD. S1DON stated S3MR should have made an appointment for Resident #1 with the Neurologist provider as ordered per S2NP and did not.

Based on interviews and record review, the facility failed to ensure that a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 2(#1 and #77) of 5 (#1, #12, #22, #37 #77) sampled residents reviewed for PASARR Level II. Findings: Resident #1 Review of the Clinical Record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included: Bipolar 1 Disorder and Depression. Further review revealed additional medical diagnosis of Borderline Personality Disorder on 10/05/2022 and Delusional Disorder on 04/20/2023. On 08/30/2023 at 9:00 a.m., an interview was conducted with S2DON. She stated the clinical coordinator was responsible for submitting a Resident Review Form when a resident received a new mental illness diagnosis. S2DON confirmed Resident #1 did not have a Resident Review submitted to the state when Resident #1 received a new diagnosis of Personality Disorder and Delusional Disorder, and should have. She stated she was unaware of Resident #1 having these diagnoses. Resident #77 Review of the Clinical Record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder. Further review revealed additional medical diagnoses of Schizophrenia on 08/04/2022. On 08/29/23 at 2:12 p.m., an interview was conducted with S3RN. She confirmed Resident #77 did not have a Resident Review submitted to the State when she was diagnosed with Schizophrenia on 08/04/2023 and she should have. On 08/30/2023 at 8:45 a.m., an interview was conducted with S1NFA. He confirmed a resident review was not completed on Resident # 77 and they have scheduled one. 47173

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 1 (Medication Cart b) of 3 (Medication Cart a, Medication Cart b, and Medication Cart c) Medication Carts observed for medication storage. Findings: Review of the facility's policy titled, Storage of Medications revealed in part, the following: 3. The nursing staff is responsible for maintaining medication storage. 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. An observation was made on 08/28/2023 at 9:18 a.m. of Medication Cart b with S4LPN. One bottle of Morphine 20mg/mL for Resident #58 was observed in the narcotic lock box drawer of the medication cart. The Morphine bottle revealed a label which read Refrigerate. An interview was conducted on 08/28/2023 at 9:19 a.m. with S4LPN. S4LPN confirmed the label on Resident #58's bottle of Morphine read Refrigerate and should have been placed back into the refrigerator after each dose. S4LPN confirmed the bottle of Morphine was room temperature. S4LPN reviewed the narcotic log book for Resident #58's Morphine and confirmed it was delivered on 07/17/2023. S4LPN stated the bottle of Morphine had been in the narcotic lock box since it was delivered, and it had not been refrigerated. S4LPN confirmed the bottle of Morphine was available for use for Resident #58. An interview was conducted on 08/28/2023 at 9:24 a.m. with S2DON. S2DON confirmed all medications requiring refrigeration, as indicated on the label of the medication, should be returned back into the medication refrigerator after each use. S2DON confirmed Resident #58's Morphine should have been stored in the Medication Room Refrigerator. An interview was conducted on 08/30/2023 at 10:19 a.m. with Resident #58's Hospice Agency ADON. She confirmed Resident #58 had a current order for Morphine 20mg/mL. She stated she expected nurses to refrigerate medications labeled Refrigerate by the pharmacy. An interview was conducted on 08/30/2023 at 10:29 a.m. with the facility's Pharmacist. She confirmed if a medication was labeled Refrigerate, she expected the nurses at the facility to refrigerate those medications. She stated any medications requiring refrigeration are delivered in a refrigeration pouch. She stated the nurses should then place those medications requiring refrigeration in the medication refrigerators located in the medication storage rooms. She stated it was unacceptable for a medication requiring refrigeration to be left at room temperature. She confirmed Morphine required refrigeration. 48184

Based on record review and interviews the facility failed to ensure the Care Plan was revised for safe smoking for 1 (#52) of 22 sampled residents reviewed for care plans. Findings: Review of the policy titled Care Plans, Comprehensive Person-Centered revealed, in part: 3. The care plan intervention are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: g. receive the services and /or items included in the plan of care 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 11. Assessments of residents are ongoing and care plans are revised as information about the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: d. at least quarterly Review of Resident #52's Smoking assessment dated [DATE] revealed Resident #52 was safe to smoke with staff assistance and supervision. Smoking supplies to be kept at nursing station. Review of Resident #52's Smoking assessment dated [DATE] revealed Resident #52 was safe to smoke without supervision and is able to store own items. Review of Resident #52's most recent Care Plan dated 08/15/2023 revealed Resident #52 was a smoker and needed supervision while smoking and required smoking supplies to be stored at the nurse's station. An interview was conducted on 08/29/2023 at 4:00 p.m. with S2DON. She stated the Clinical Coordinator was responsible for updating the resident's Care Plan at least quarterly and when a resident had any changes. After S2DON reviewed Resident #52's current Care Plan dated 08/15/2023 and most current Smoking assessment dated [DATE], she confirmed Resident #52's Care Plan did not reflect the most current Smoking Assessment data. She stated the current Care Plan, dated 08/15/23, should have been updated to reveal Resident #52 was a safe smoker without supervision and it was not.

46308 46981 Based on record reviews and interviews, the facility failed to be administered in a manner which enabled it to use its resources effectively and efficiently to ensure an effective system was in place to ensure advance directives were followed for 3 (#7, #103, and #106) of 32 (#7, #10, #11, #23, #36, #42, #43, #49, #51, #54, #58, #62, #65, #71, #79, #82, #84, #91, #92, #101, #103, #104, #106, #107, #306, #405, #406, #407, #408, #409, #410, and #411) sampled residents reviewed for Advanced Directives. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] for Resident #106 when she was found unresponsive, and CPR was not initiated by S5LPN as requested in Resident #106's Advanced Directive. The physical chart revealed a full code status, meaning this resident required CPR, while the electronic medical record revealed a DNR (Do Not Resuscitate) code status. S5LPN indicated she discovered and reported the discrepancy to S2DON on [DATE]. The facility failed to put corrective actions in place after the discrepancy in code status was discovered for Resident #106. The Immediate Jeopardy situation ended for Resident #106 when the resident expired on [DATE] but continued for Resident #7 and Resident #103 when their code statuses were also found with discrepancies. Resident #7, who had a diagnosis which included Acute and Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, and Chronic Diastolic Congestive Heart Failure, wished to have a DNR code status, but the electronic medical record revealed a full code status. Resident #103 who had a diagnosis which included Essential Hypertension and Atherosclerosis of Aorta, wished to have a full code status, but the electronic medical record revealed a DNR code status. S1ADMN was notified of the Immediate Jeopardy on [DATE] at 7:40 p.m. when record review revealed Resident #7 and Resident #103 had discrepancies related to code status. The Immediate Jeopardy was removed on [DATE] at 3:59 p.m. when the provider presented an acceptable plan of removal. Through interviews and record reviews, the surveyor confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of removal included the following information: 1. Corrective actions taken for Residents #7 and #103 found to have been affected by the deficient practice are as follows: a. On [DATE], discrepancies of Residents #7 and #103 advanced directive were corrected to reflect current status. b. On [DATE], all current active resident's medical record were checked to ensure advanced directives and physician orders matched related to code status in resident electronic record as well as chart. c. On [DATE], in-service conducted with Medical Records Supervisor, Nurse Practitioner, and Admissions Coordinator related to accuracy of inputting resident advance directives into electronic medical record as well as verifying admission advanced directive orders. d. On [DATE], all resident's closed death records were audited back to [DATE], to verify physician orders related to code status for accuracy. e. On [DATE], over bed care plans for all residents have been audited to ensure reflection of correct code status. f. On [DATE], audit of all current resident face sheets performed to ensure accurate code status. g. On [DATE], a root cause analysis was completed, and QA initiated with medical director notified. 2. Residents identified as having the potential to be affected by the deficient practice were identified. 3. The following measures were implemented in an effort to achieve substantial compliance: a. As of [DATE], upon admission of a new resident, a copy of Consent for Cardiopulmonary Resuscitation will be presented to NFA for verification. b. As of [DATE], DON or designee will review all current resident electronic medical records monthly to ensure the residents advanced directives match current physician orders. c. As of [DATE], changes or revocations of advanced directives must be submitted in writing to the administrator. d. As of [DATE], during facility stand up/QA meeting all new admission advanced directive orders will be verified for accuracy. e. As of [DATE], results of audits will be reviewed with QA committed on a quarterly basis. 4. Quality Assurance measures put into place to ensure continued compliance are: a. As of [DATE], during facility daily stand up/QA meeting, NFA and/or DON will verify new admission code status was accurate per patient wishes. b. As of [DATE], monthly audit of all resident code status will be conducted by DON or designee. c. As of [DATE], any changes to a resident's advanced directive will be presented to the NFA in writing prior to DON or designee reviewing and updating the resident's chart. d. As of [DATE], DON or designee will monitor verification process upon admission and any changes of code status. 5. Proposed substantial compliance will be achieved on or before [DATE]. Findings: Cross Reference F678 Review of the facility's policy, Advance Directives, revealed the following, in part: Information about whether or not the resident had executed an advance directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. Review of the facility's policy, Emergency Procedure-Cardiopulmonary Resuscitation, revealed the following, in part: If the resident's DNR status was unclear, CPR will be initiated until it was determined there was a DNR. An interview was conducted on [DATE] at 4:15 p.m. with S10CNA. She stated she went into Resident #106's room at 1:30 a.m. to assist the resident to the bathroom. S10CNA stated Resident #106 stated she was ok, and there were no concerns noted. She stated at 3:20 a.m. S5LPN called her into Resident #106's room. She stated S5LPN listened to Resident #106's heart with her stethoscope, and tried to obtain vital signs. She stated CPR was not initiated and a code was not called because Resident #106 was a DNR. She stated she checked the electronic medical record to verify the resident's code status. An interview was conducted on [DATE] at 4:30 p.m. with S5LPN. She stated on [DATE] at 3:20 a.m. she went into Resident #106's room and found her unresponsive. She stated she was unable to obtain vital signs on the resident. She stated the electronic medical record indicated Resident #106 was a DNR. She stated she did not call a code and did not initiate CPR. She stated while charting, she found the physical chart had a code status of full code, and the electronic medical record had a code status of DNR, which was her normal process. She stated she checked with S2DON about the discrepancy and S2DON recommended not initiating CPR because she believed the resident was a DNR. She confirmed she did not return to initiate CPR. An interview was conducted on [DATE] at 5:39 p.m. with S6LPN, a floor nurse. She verified her name was located on Resident #106's physician orders as verified, but could not recall this resident's accurate code status. She stated when a resident was admitted , she would activate a resident's code status order in the electronic medical record without checking the accuracy on the physical chart. An interview was conducted on [DATE] at 11:15 a.m. with S12LPN. She stated to find a resident's code status she would locate it in the physical chart. She stated Resident #7 was Full Code status per documentation in the physical chart. She stated she was responsible for Resident #7's admit orders. She stated when a resident was admitted , orders are cued from administration, and then she was responsible for activating the orders. She confirmed she did not double check the orders with the resident's advance directive. An interview was conducted on [DATE] at 11:28 a.m. with S8MR. She stated she was responsible for entering all residents' code status and advanced directives. She stated S9AC completed all new admit packets in the facility's computer system. Once the packet was completed, S8MR opened the document titled CPR Patient Family Consent, and then saved the document into the resident's EMR (Electrical Medical Record). She stated she made the physical chart and placed the code status on the chart. She stated she then added orders under the physician orders for the resident, which includes the resident's code status. She stated the orders were placed in the order section on the EMR for the nurse to verify the order. She stated verification should include looking at the physician order and comparing it to the resident's advanced directive to make sure it was accurate. She stated if it was inaccurate, the nurse should not activate the order, and it should be brought to S8MR's attention for change. She stated she entered Resident #103's code status as a DNR on [DATE], and revised it on [DATE]. She stated a chart audit was conducted on [DATE], when the facility realized Resident #103's code status was incorrect. She confirmed Resident #103's code status should had been Full Code. She confirmed Resident #7 and Resident #106's code statuses were also incorrect and put in by error by herself. S8MR verified her credentials did not include any certifications of nursing. An interview was conducted on [DATE] at 5:02 p.m. with S9AC. She stated she was responsible for all admissions, which included documentation of Advanced Directives. She stated when a resident was admitted , she spoke with the resident or the resident representative in regards to their code status. She stated she explained to them what each code status meant, and once the decision was made, she had the resident representative or resident to sign the advanced directive. She stated she signed as a witness on the advanced directive. An interview was conducted on [DATE] at 5:33 p.m. with S7NP. She stated when she saw an order for a code status for her to sign, she did not check the advance directive to ensure the order and the advanced directive matched for accuracy. She stated she signed the order without questioning if it was correct. She could not verify if she was responsible for verifying orders on Residents #7, #103, #106. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. She stated S9AC was in charge of contacting the family, and explaining to them the difference between full code and DNR status. She stated once the family or resident had made the decision on what code status they wished for, the Resident/Family Consent for Cardiopulmonary Resuscitation form was signed by the Resident Representative or resident, and then witnessed by S9AC with her signature. S2DON stated after the form was completed, it was uploaded to the electronic medical record, where S8MR then saw the form, and put in an order under physician orders stating the resident's code status. She stated the order showed up on the nurses' computers to check for accuracy. She stated nurses were responsible for checking the advance directive and the order to make sure it was accurate. She stated the nurse then verified the order if accurate, and should report to S8MR if inaccurate. She stated the doctor or nurse practitioner would see the verified order, verified with the advance directive and order to make sure it was correct, and then signed the order. S2DON stated an incorrect code status was brought to her attention on [DATE] for Resident #7, and the facility started to conduct chart audits on all residents residing in the facility. She stated she was aware of Resident #103's code status being incorrect in the system. She confirmed this could have had the potential for harm. S2DON confirmed Resident #106 should had been a full code status, and verified the physician orders and care plan stated the resident was a DNR. She stated on [DATE], she reviewed the call from S5LPN regarding Resident #106's death. She stated she asked S5LPN what the resident's code status was, and was told she was a DNR. She stated she did not know Resident #106 was a full code until [DATE]. She stated it was the responsibility of Medical Records, the nurses, and the Nurse Practitioner and/or Physician to verify accuracy of all orders including Code Status. S2DON confirmed the facility failed to ensure all staff members who were responsible for entering, verifying, and signing Code Status orders were comparing both the physical signed Advanced Directive with the EMR for accuracy. An interview was conducted on [DATE] at 6:30 p.m. with S1ADMN. He stated the advanced directive process started with S8MR entering the orders. He stated the floor nurses were responsible for verifying the orders. He stated the orders for code status then go to the doctor or nurse practitioner to sign after they also verify the accuracy of the orders. He confirmed there were discrepancies with Resident #7, #103, and #106 related to code status.

46981 Based on record reviews and interviews, the facility failed to have effective system in place to ensure residents' advanced directives were correctly initiated for 1 resident (#106), and ensure residents' medical records reflected the residents' wishes for emergency basic life support for 3 (#7, #103, and #106) of 32 (#7, #10, #11, #23, #36, #42, #43, #49, #51, #54, #58, #62, #65, #71, #79, #82, #84, #91, #92, #101, #103, #104, #106, #107, #306, #405, #406, #407, #408, #409, #410, and #411) sampled residents reviewed for Advance Directives. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] for Resident #106 when she was found unresponsive, and CPR was not initiated by S5LPN as requested in Resident #106's Advanced Directive. The physical chart revealed a full code status, meaning this resident required CPR, while the electronic medical record revealed a DNR (Do Not Resuscitate) code status. S5LPN indicated she discovered and reported the discrepancy to S2DON on [DATE]. The facility failed to put corrective actions in place after the discrepancy in code status was discovered for Resident #106. The Immediate Jeopardy situation ended for Resident #106 when the resident expired on [DATE] but continued for Resident #7 and Resident #103 when their code statuses were also found with discrepancies. Resident #7, who had a diagnosis which included Acute and Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, and Chronic Diastolic Congestive Heart Failure, wished to have a DNR code status, but the electronic medical record revealed a full code status. Resident #103 who had a diagnosis which included Essential Hypertension and Atherosclerosis of Aorta, wished to have a full code status, but the electronic medical record revealed a DNR code status. S1ADMN was notified of the Immediate Jeopardy on [DATE] at 7:40 p.m. when record reviews revealed Resident #7 and Resident #103 had discrepancies related to code status. The Immediate Jeopardy was removed on [DATE] at 3:59 p.m. when the provider presented an acceptable plan of removal. Through interviews and record reviews, the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit. The Immediate Jeopardy Plan of removal included the following information: 1. Corrective actions taken for Residents #7 and #103 found to have been affected by the deficient practice are as follows: a. On [DATE], discrepancies of Residents #7 and #103 advanced directive were corrected to reflect current status. b. On [DATE], all current active residents' medical records were checked to ensure advanced directives, care plans, EMR, and physician orders were accurate. c. On [DATE], in-services were conducted with Medical Records Supervisor, Nurse Practitioner, and Admissions Coordinator related to accuracy of inputting resident advance directives into electronic medical record as well as verifying admission advanced directive orders. d. On [DATE], all residents' closed death records were audited from [DATE] to present, to verify physician orders related to code status for accuracy. e. On [DATE], facility educated all professional nursing staff of the process to verify code status of a resident by use of Consent for Cardiopulmonary Resuscitation, physician order, and patient face sheet. f. On [DATE], over bed care plans for all residents had been audited to ensure reflection of correct code status. g. On [DATE], audit of all current resident face sheets performed to ensure accurate code status. h. On [DATE], a root cause analysis was completed, and QA initiated with medical director notified. 2. Residents identified as having the potential to be affected by the deficient practice were identified. 3. The following measures were implemented in an effort to achieve substantial compliance: a. As of [DATE], upon admission of a new resident, a copy of Consent for Cardiopulmonary Resuscitation will be presented for verification. b. As of [DATE], DON or designee will review all current resident electronic medical records monthly to ensure the residents advanced directives and physician orders are accurate. c. As of [DATE], changed or revocated advanced directives must be submitted in writing to the administrator. 4. Quality Assurance measures put into place to ensure continued compliance are: a. As of [DATE], during facility daily stand up/QA meeting, NFA and/or DON will verify new admission code status was accurate per patient wishes. b. As of [DATE], monthly audit of all resident code status will be conducted by DON or designee. c. As of [DATE], any changes to a resident's advanced directive will be presented to the NFA in writing prior to DON or designee reviewing and updating the resident's chart. d. As of [DATE], DON or designee will monitor verification process upon admission and any changes of code status. e. As of [DATE], during facility stand up/QA meeting all new admissions advanced directive orders will be verified for accuracy. f. As of [DATE], results of audits will be reviewed with QA committed on a quarterly basis. 5. Proposed substantial compliance will be achieved on or before [DATE]. Findings: Review of the facility's policy, Advance Directives, revealed the following, in part: Information about whether or not the resident had executed an advance directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. Review of the facility's policy, Emergency Procedure-Cardiopulmonary Resuscitation, revealed the following, in part: If the resident's DNR status was unclear, CPR will be initiated until it was determined there was a DNR. Resident #106 Review of Clinical Records for Resident #106 revealed she was admitted to the facility on [DATE] with diagnoses, which included Aftercare Following Joint Replacement Surgery. Review of the MDS with an ARD of [DATE] revealed Resident #106 had a BIMS of 15, which indicated she was cognitively intact. Record review revealed Resident #106 had an advanced directive dated [DATE] which stated CPR should be done on this resident in case of extreme emergency. Review of the physician's orders for Resident #106 revealed an order, which stated Do Not Resuscitate and was initiated on [DATE]. In addition, a review of Miscellaneous Document Tab in the electronic medical record revealed the Resident/Family Consent for CPR was signed by the resident representative on [DATE] for the resident to be a Full Code was labeled as a DNR. Review of Progress/Nurses Notes for Resident #106 dated [DATE] revealed S5LPN stated Resident was found this morning at 3:20 a.m. by nurse unresponsive. Vital signs unable to be established. Resident was listed DNR as of August of 2022. Protocols were followed thereafter. An interview was conducted on [DATE] at 4:15 p.m. with S10CNA. She stated she went into Resident #106's room at 1:30 a.m. to assist the resident to the bathroom. S10CNA stated Resident #106 stated she was ok, and there were no concerns noted. She stated at 3:20 a.m. S5LPN called her into Resident #106's room. She stated S5LPN listened to Resident #106's heart with her stethoscope, and tried to obtain vital signs. She stated CPR was not initiated and a code was not called because Resident #106 was a DNR. She stated she checked the electronic medical record to verify the resident's code status. An interview was conducted on [DATE] at 4:30 p.m. with S5LPN. She stated on [DATE] at 3:20 a.m. she went into Resident #106's room and found her unresponsive. She stated she was unable to obtain vital signs on the resident. She stated the electronic medical record indicated Resident #106 was a DNR. She stated she did not call a code and did not initiate CPR. She stated while charting, she found the physical chart had a code status of full code, and the electronic medical record had a code status of DNR, which was her normal process. She stated she checked with S2DON about the discrepancy and S2DON recommended not initiating CPR because she believed the resident was a DNR. She confirmed she did not return to initiate CPR. An interview was conducted on [DATE] at 5:39 p.m. with S6LPN, a floor nurse. She verified her name was located on Resident #106's physician orders as verified, but could not recall this resident's accurate code status. She stated when a resident was admitted , she would activate a resident's code status order in the electronic medical record without checking the accuracy on the physical chart. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. She confirmed Resident #106 should had been a full code status, and verified the physician orders and care plan stated the resident was a DNR. She stated on [DATE], she reviewed the call from S5LPN regarding Resident #106's death. She stated she asked S5LPN what the resident's code status was, and was told she was a DNR. She stated she did not know Resident #106 was a full code until [DATE]. Resident #7 Review of current Clinical Records for Resident #7 revealed she was admitted to the facility on [DATE] with diagnoses, which included Acute and Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, and Chronic Diastolic Congestive Heart Failure. Review of the MDS with an ARD of [DATE] revealed Resident #7 had a BIMS of 13, which indicated she was cognitively intact. Review of Resident #7's Advanced Directive titled Resident/Family Consent for Cardiopulmonary Resuscitation form located on the resident's physical chart stated the resident was to receive CPR in case of extreme emergency. This was signed by Resident #7's Responsible Party on [DATE]. Review of the facesheet located on the electronic medical record revealed Resident #7 had a DNR status. Review of the Physician orders for Resident #7 revealed an order for a DNR code status dated [DATE]. Review of Resident #7's current Care Plan revealed resident had a DNR code status. An interview was conducted on [DATE] at 11:15 a.m. with S12LPN. She stated to find a resident's code status she would locate it in the physical chart. She stated Resident #7 was Full Code status per documentation in the physical chart. She stated she was responsible for Resident #7's admit orders. She stated when a resident was admitted , orders are cued from administration, and then she was responsible for activating the orders. She confirmed she did not double check the orders with the resident's advance directive. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. S2DON stated an incorrect code status was brought to her attention on [DATE] for Resident #7, and the facility started to conduct chart audits on all residents residing in the facility. An interview was conducted on [DATE] at 9:52 a.m. with Resident #7. When asked about her code status wishes, she stated her wishes for her code status were to be a DNR. Resident #103 Review of current Clinical Records for Resident #103 revealed she was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes, Essential Hypertension, and Atherosclerosis of Aorta. Review of the MDS with an ARD of [DATE] revealed Resident #103 had a BIMS of 15, which indicated she was cognitively intact. Record review revealed Resident #103 had an advanced directive dated [DATE], which stated CPR should be done on this resident in case of extreme emergency, located in the resident's physical chart. Review of Resident #103's physician orders revealed an order which stated Do Not Resuscitate and was initiated on [DATE]. On [DATE], a revision was made to the physician orders to initiate Full Code status. An interview was conducted on [DATE] at 10:00 a.m. with Resident #103. She stated she was a full code, and wished for CPR to be initiated. An interview was conducted on [DATE] at 11:28 a.m. with S8MR. She stated she was responsible for entering all residents' code status and advanced directives. She stated S9AC completed all new admit packets in the facility's computer system. Once the packet was completed, S8MR opened the document titled CPR Patient Family Consent, and then saved the document into the resident's EMR (Electrical Medical Record). She stated she made the physical chart and placed the code status on the chart. She stated she then added orders under the physician orders for the resident, which includes the resident's code status. She stated the orders were placed in the order section on the EMR for the nurse to verify the order. She stated verification should include looking at the physician order and comparing it to the resident's advanced directive to make sure it was accurate. She stated if it was inaccurate, the nurse should not activate the order, and it should be brought to S8MR's attention for change. She stated she entered Resident #103's code status as a DNR on [DATE], and revised it on [DATE]. She stated a chart audit was conducted on [DATE], when the facility realized Resident #103's code status was incorrect. She confirmed Resident #103's code status should had been Full Code. She confirmed Resident #7 and Resident #106's code statuses were also incorrect and put in by error by herself. S8MR verified her credentials did not include any certifications of nursing. An interview was conducted on [DATE] at 5:02 p.m. with S9AC. She stated she was responsible for all admissions, which included documentation of Advanced Directives. She stated when a resident was admitted , she spoke with the resident or the resident representative in regards to their code status. She stated she explained to them what each code status meant, and once the decision was made, she had the resident representative or resident to sign the advanced directive. She stated she signed as a witness on the advanced directive. An interview was conducted on [DATE] at 5:33 p.m. with S7NP. She stated when she saw an order for a code status for her to sign, she did not check the advance directive to ensure the order and the advanced directive matched for accuracy. She stated she signed the order without questioning if it was correct. She could not verify if she was responsible for verifying orders on Residents #7, #103, #106. An interview was conducted on [DATE] at 5:43 p.m. with S2DON. She stated S9AC was in charge of contacting the family, and explaining to them the difference between full code and DNR status. She stated once the family or resident had made the decision on what code status they wished for, the Resident/Family Consent for Cardiopulmonary Resuscitation form was signed by the Resident Representative or resident, and then witnessed by S9AC with her signature. S2DON stated after the form was completed, it was uploaded to the electronic medical record, where S8MR then saw the form, and put in an order under physician orders stating the resident's code status. She stated the order showed up on the nurses' computers to check for accuracy. She stated nurses were responsible for checking the advance directive and the order to make sure it was accurate. She stated the nurse then verified the order if accurate, and should report to S8MR if inaccurate. She stated the doctor or nurse practitioner would see the verified order by the nurse. She stated the doctor or nurse practitioner would then verify the order matched the advance directive prior to signing the order. S2DON stated an incorrect code status was brought to her attention on [DATE] for Resident #7, and the facility started to conduct chart audits on all residents residing in the facility. She stated she was aware of Resident #103's code status being incorrect in the system. She confirmed this could have had the potential for harm. An interview was conducted on [DATE] at 6:30 p.m. with S1ADMN. He stated the advanced directive process started with S8MR entering the orders. He stated the floor nurses were responsible for verifying the orders. He stated the orders for code status then go to the doctor or nurse practitioner to sign after they also verify the accuracy of the orders. He confirmed there were discrepancies with Resident #7, #103, and #106 related to code status.

Based on observations, interview and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure: 1. Packages of food were properly sealed in the kitchen's spice rack, walk-in freezer, and reach-in freezer. Review of a facility policy, provided by administration, titled Food Receiving and Storage revealed the following, in part: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (received and/or open date.) Findings: On 06/14/2021 at 9:22 a.m., an initial tour of the facility's kitchen was performed with S1DS. An observation of the walk-in freezer revealed a 9.84 pound box of frozen enchiladas approximately ¾ full, that was not sealed or labeled correctly. An observation of the reach-in freezer revealed the following items were not properly sealed and labeled: 1. 12 pound opened box of frozen beef corn dogs, approximately ¾ full. 2. 35 pound opened box of frozen southern style biscuits, approximately ¾ full. 3. 26.88 pound opened box of frozen pizza, approximately ½ full. 4. 1 small opened bag of frozen hash brown patties loosely wrapped in plastic. On 06/14/2021 at 9:40 a.m., the spice rack was observed with the following noted: 1. 21 ounce container of salt-free Mrs. Dash seasoning, approximately ¼ full, with a flip-top lid that was open. 2. 12 ounce container of gumbo file, approximately ¾ full, with a flip-top lid that was open. During the tour of the kitchen, an interview was conducted with S1DS. She verified the frozen items in the walk-in freezer and reach-in freezer were not properly sealed and labeled. She further verified the open items on the spice rack were not properly sealed.

Based on record reviews, interviews, and observations, the facility failed to ensure the residents received adequate assistance to prevent accidents for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for falls. This deficient practice had the potential to affect 29 residents identified by the facility as needing 2 person physical assistance during bathing and for bed mobility. An Immediate Jeopardy occurred for Resident #2 on [DATE] at 1:30 p.m. when during a bed bath given by one CNA, the resident fell off the side of the bed unto the floor. The resident, who required extensive physical assistance of 2 staff members for bathing and bed mobility, sustained multiple injuries including abrasions bruises and skin tears. The resident also complained of pain to the right arm, right shoulder and bilateral knees, but she initially did not want to go to the hospital. The resident's N.P. was called and orders were obtained for portable x-rays. The N.P. was later called due to the resident experiencing increased pain and orders were given to send the resident to hospital. The resident was transferred to a local hospital where x-ray results revealed the resident had a right fracture/dislocation of the humeral head, an acute comminuted distal right femur fracture and an impacted distal left femoral fracture. After being seen in the emergency room , the resident was transferred to ICU. The facility implemented corrective actions prior to the State Agency's investigation on [DATE], thus, it was determined to be a Past Noncompliance Citation. Findings: Review of Resident #2's clinical record revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] included the following: Section C: Cognitive ability - BIMS- 15 (cognitively intact) Section G: Activities of Daily Living: Bed Mobility: (how resident moves to and from lying position , turns side to side, and positions body while in bed or alternate sleep furniture)- extensive with 2 plus person assist, Transfer - Total Dependence with 2 plus person assist. Bathing - Physical help with 2 plus person physical assist. Lower Extremity- impairment on both sides. Height- 66 inches Weight- 271 lbs Review of Resident #2's incident report dated [DATE] at 1:30 p.m. revealed the following in part: Resident Description: Resident stated that she turned over too much and rolled out of bed. Injuries observed at time of incident: abrasion- right knee, abrasion- left knee, abrasion- face, bruise- right ankle, bruise- face. Level of Consciousness: alert. Mobility; bedridden Mental Status: oriented to Person, Situation, Place and Time. Notes: She c/o right shoulder and arm pain and Bilateral Knee Pain. Resident stated that she turned too much during care and rolled out of the bed. She is noted to have bruising to right breast, redness to bilateral knees and bruise to right ankle anterior aspect. Resident's chin with red scraped area with bruising noted. Fracture to Bilateral knees. Dislocated Right shoulder. Review of the Nurses Notes dated [DATE] 15:32 (3:32 p.m.) revealed the following: S6LPN was called to resident's room and noted this resident was face down with upper body suspended between chair and bed frame, on the left side of her bed, using her arms and shoulders. Feet to knees and abdomen completely on the floor. Resident was morbidly obese. She was calling for help due to she could not release self. She did not hit her head. She was assisted to release the weigh to her body and was eased completely to a prone position. 4 assistants aided with turning resident over and onto the Hoyer Lift pad for transfer. She c/o right shoulder and arm pain and bilateral knee pain. Resident stated that she turned too much during care and rolled out of the bed. She was noted to have bruising to right breast, redness to bilateral knee and bruise to right ankle anterior aspect. Resident's chin with red scraped area with bruising noted. Resident was assisted up to the bed with the Hoyer Lift. Nurse Practitioner was made aware of the incident and gave new orders for portable x-rays of right arm and shoulder and bilateral knees. The Nurse Practitioner also gave the okay for a 1 time extra dose of PRN [MEDICATION NAME]. This was administered. A call was placed to resident's sister. Local imaging provider was notified of the need of x-rays to be done. Review of the Nurses Notes dated [DATE] 16:09 (4:09 p.m.) revealed the following: S/P fall skin assessment completed. Skin tear to right outer forearm, abrasion to chin, bruise to left chest wall, abrasion to right shin, bruise to right ankle anterior side, bruise to right chest wall, bruise to upper abdomen, bruise to forehead, abrasion to left cheek, skin tear to right breast, abrasion to right foot 1st digit. Resident complains of bilateral knee pain, right shoulder and arm pain. Primary nurse medicated the resident for pain prior to assessment. X-ray orders put in by NP. New treatment orders put in and carried out. Review of the resident's Skin and Wound Evaluations dated [DATE] revealed the following: Bruise to face- 8.7 cm, length- 5.1 cm, Width- 2.4 cm. Skin Tear- Category Linear (full thickness) - Right Chest- 16.8 cm, Length-14.0 cm, Width- 1.6 cm. other pink or red, Exudate- light, sanguineous/Bloody Abrasion to face- 6.3 cm., Length- 5.4 cm., Width- 1.5 cm., other- pink or red. Bruise to upper left abdomen- 40.7 cm , length- 15.3 cm., Width- 3.4 cm. Bruise to Right Chest- 55.6 cm. Length- 5.5 cm. Width 7.7 cm. Bruise to Right Medial Malleolus- 15.2 cm. Length 5.1 cm. 4.1 cm. Abrasion to Right Shin- 14.8 cm. Length- 12.9 cm. Width- 1.8 cm. Bruise to Left Chest- 1.2 cm. Length- 1.6 cm. Width- 1.0 cm. Abrasion to face- 7.3 cm. Length - 4.1 cm. Width - 2.3 cm. Skin tear- right outer forearm- 0.2 cm. Length- 0.9 cm. Width- 0.2 cm. Review of the Nurses Notes dated [DATE] 21:09 (9:09 p.m.) revealed the following: Called NP with report of the resident at 19:06 (7:06 p.m.) stated to send resident out. X-rays were completed, awaiting results. Transferred to local hospital via Ambulance Review of the medical record from the treating hospital revealed the following: X-ray: Shoulder Comp. Right-Impression-Fracture/dislocation of the humeral head. Knee AP Lateral Right- Impression- Acute comminuted distal right femur fracture. Knee AP Lateral Left- Impression- Impacted distal left femoral fracture. Review of the local emergency room record revealed, in part; the resident arrived at the emergency roiagnom on [DATE] at 2007 (8:07 p.m.) via EMS for evaluation of right shoulder and bilateral Knee Fractures. Per nursing home report, the resident fell out of her bed during bath sustaining these injuries. Upon arrival to the emergency department she is awake and alert, does not complain of any midline neck or back pain. No tenderness over the midline chest or the abdomen. Is baseline bedbound. Residents blood pressure also noted to be systolic of the 60's EMS reported this in route as well. Resident stated that her blood pressure is always low in that range. Focused Review of Systems: Reports: weakness - generalized. Musculoskeletal: Reports: Extremity pain, Joint pain. Physical Exam: Vital Signs- Pulse Oximeter reading -95%, B/P-,[DATE], Temperature-97.7, Pulse-97, Respirations-20. Focused physical exam: Awake, Alert, No acute distress, well appearing, well developed, well hydrated, well nourished, Cooperative, not toxic appearing. Bruising over the chin and along the left side of the mandible. Tenderness over the right anterior shoulder and right clavicle. Tenderness over the anterior aspect of both knees. Neurologic: Awake and alert, oriented times 3, moving upper extremities well, at baseline weakness to bilateral lower extremities. Free text MDM notes: Resident states that her blood pressure is always low in that range. On exam resident chronically ill-appearing, tender over the left and right knee and right shoulder, extremities neurovascular intact. Is hypotensive and reports this is chronic. X-rays as above with fracture to left and right distal femur as well as dislocation to the right shoulder associated with a fracture. On [DATE] at 9:45 a.m., an observation was performed of R1 during a bed bath and occupied bed linen change. MDS dated [DATE] assessed the resident as extensive assist with bed mobility. Proper technique was used and 2 staff performed the task and maintained safety at all times. The sign on the wall behind the bed indicated the resident was a 2 person assist. On [DATE] at 9:40 a.m., an observation revealed 2 CNAs performed Resident #5's bed bath and linen change using proper technique, aseptic technique, and maintained safety. Resident #5's MDS dated [DATE] revealed he required extensive 2 person assist with bed mobility. On [DATE] at 2:45 p.m., an interview was conducted with S10CNA. She was asked to explain what happened on [DATE] at 1:30 pm when she was bathing Resident #2. She stated the resident wanted a bed bath. She said she was bathing the resident and washing her hair and the resident rolled over onto her left side. S10CNA said she started putting her fitted sheet on. She stated she put the top on and was working on the bottom corner. She said suddenly the resident said I'm going over, I'm going over. Then she said the resident fell off the bed. She explained Resident #2's left hand was resting on the mattress and her right hand was resting on the chair beside the bed, her abdomen down to her feet was on the floor. She said Resident #2's breast were suspended above the floor as she was held up by her arms. She said she stepped outside the door, yelled for help and S6LPN and S11CNA responded. She explained S10CNA got the additional help of S12CNA and another CNA. The Hoyer Lift was brought into the room. She said it took everyone to get her on the lift pad. She stated they put her completely flat, the nurse assessed her and the resident complained of pain to her right shoulder, right arm, both knees and legs. She was placed back in the bed with the Hoyer Lift. S10CNA stated she and another CNA usually bathed her together, but if one of them were not working; the CNA working bathed the resident alone. She explained the quarter rail was up but her legs fell off the end of the bed and the weight of her legs propelled her body off onto the floor. She stated she knew the resident required 2 CNA's for bed mobility but the resident told her she could help and it would be ok for her to bath and change her alone. She had done this before with no problem. On [DATE] at 8:45 a.m., a telephone interview was conducted with the complainant. She confirmed Resident # 2 was admitted to the hospital with [REDACTED]. She stated after being treated in the emergency room , the resident was admitted to the ICU and was talking with the ICU staff when she suddenly coded. She expired at 2:30 am. On [DATE] at 9:45 a.m., an interview was conducted with S6LPN. She stated on [DATE] at 1:30 p.m. she heard someone yelling Help! Help! I need help! S10CNA was the CNA yelling for help and the resident was yelling for help also. She stated when she entered the room the resident was not in her bed, she was lying on the floor on the left side of the bed. She explained Resident #2's left hand was resting on the mattress and her right hand was resting on the chair beside the bed, and her abdomen down to her feet were on the floor. S6LPN stated 3 other CNAs were called into the room to assist getting the resident up. After the bed was unlocked and moved, the resident was lowered to the floor in a prone position. She explained the resident was then turned onto her back onto the lift pad. S6LPN stated at that time she was able to assess her. Resident #2 was noted to have bruising on her breast, an abrasion to her chin, under her breast area was raw, and redness to her knees. She also complained of shoulder and knee pains. S6LPN said the resident was lifted back into the bed with the Hoyer Lift. The doctor was notified and gave a one-time order for [MEDICATION NAME]/[MEDICATION NAME]. S6LPN stated the resident told her she did not want to go to the hospital so the NP ordered portable x-rays. On [DATE] at 10:20 a.m., an interview was conducted with S12CNA. She stated on [DATE] at 1:30 p.m., S11CNA came and got her to help get someone off the floor. She said when she entered the room she saw Resident #2 lying on her back on the floor and the nurse was in the room along with S10CNA. She said then S11CNA and another CNA came into the room together to assist getting the resident back into the bed with the Hoyer Lift. S11CNA explained Resident #2 was alert, oriented and talkative but complained of pain to her knees and right shoulder. She stated she had helped bath her before but never by herself. On [DATE] at 10:30 a.m., an interview was conducted with S11CNA. She stated on [DATE] at around 1:30 p.m. she was coming in from outside with a resident when she heard a loud noise and someone yelling help me. She explained it was S10CNA yelling for help in Resident #2's room. She stated she then yelled for S6LPN as she was going into the room to help. She said when she was in the room she saw that the resident was between the bed and her chair. She further explained the resident's upper body was suspended with her left arm on the bed and the right arm on the chair. S11CNA stated the residents' abdomen, legs and feet were on the ground. She explained everyone helped move the bed and lowered her to the floor in a prone position. They were then able to turn her over onto a sheet and lift pad and move her into the bed by the Hoyer Lift. She said once she was in the bed the nurse reassessed her. She further explained the resident was a one person assist with the bath, a 2 person assist with changing linen, a 2 person assist with bed mobility and a 2 person assist to transfer. On [DATE] at 10:45 a.m., an interview was conducted with S1DON. She stated she was made aware of the incident right after the fall occurred. She said the nurse reported to her Resident #2 was receiving care, adjusted herself in the bed, adjusted too far and fell out of the bed. She stated the doctor and the sister were notified immediately following the incident. She said when the doctor was notified he ordered a one-time dose of an extra pain pill. She stated when she went to the resident's room, S6LPN demonstrated to her the position the resident was found in and reported the resident had some bruising in different areas. She said later in the day the resident continued to complain of pain so the doctor was notified again and an order for [REDACTED]. Throughout the survey on dates [DATE] - [DATE], observations and record reviews were conducted to ensure signage behind the residents' beds were consistent with the MDS assessment of assistance for bed mobility. Staff interviews confirmed they were knowledgeable of how to identify the residents' level of assistance needed during a bed bath, bed mobility and linen change. The facility has implemented the following actions to correct the deficient practice: 1.The bathing and bed mobility needs/requirements for each resident in the facility were re-evaluated by S5MDS/CC on [DATE]. 2.The side rail needs/requirements for each resident in the facility that used them were re-evaluated by S1DON and S5MDS/CC on [DATE]. 3.In-service training to all staff on all shifts regarding bed mobility, over bed care plan, complete bed bath safely and making an occupied bed was completed on [DATE]. 4.Created new signage for behind the bed indicating if the resident is a 1 or 2 person assist for bed mobility, bath and linen change. Placed the signage behind each resident's bed. 5.Monitoring tool for monitoring bed mobility signage and that staff are using appropriate number of staff and using safety measures. 6.Quality Improvement Corrective Action Plan was put into place. Monitoring will be conducted 3 x week for 4 weeks- correct number of staff in the room, was the procedure performed correctly- safety and positioning. Monitoring will be done by the Clinical Coordinators on the units and the House Coordinators. Spot checks will be done by the Director of Nursing. 7.Noncompliance was corrected on [DATE].

Based on observations, interviews, and record reviews, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (#119) residents experiencing pain during wound care. This had the potential to affect 7 residents, identified by the facility on the 672 (Resident Census and Conditions), who were being treated for [REDACTED]. This failed practice resulted in an actual harm for resident #119 on 06/23/17 when pain medication was not effective in relieving the residents pain, and no new pain management interventions were implemented. The facility failed to implement pain management interventions prior to Resident #119 receiving wound care treatments on 07/11/17 and 07/13/17. The resident was observed on 07/20/17 to cry out in pain during positioning and dressing removal and hollering and groaning during wound care treatment. Findings: Review of the clinical record revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set with an assessment reference date of 06/28/17, revealed the facility assessed the resident as significantly cognitively impaired (Brief Interview for Mental Status score of 0), required extensive assistance with all Activities of Daily Living (ADL) and transfers, received pain management, and had multiple pressure ulcers (1- Stage I, 4- Unstageable with slough or eschar, 3- Unstageable deep tissue). Review of the Care Plan revealed the following in part: Problem/Need: Potential for alteration in comfort r/t pain (Problem On-set 6/22/2017) Goal and Target Date: No increase in reports of pain; review next CP conference 9/22/2017 Approaches: Meds as ordered; Assess location, duration, and intensity of pain; Evaluate effectiveness of meds; Contact MD as needed; Reposition as needed. Review of Physicians Orders for June and July 2017 revealed the following orders for pain: 06/22/17- [MEDICATION NAME] 5-325 milligrams by mouth every 4 hours as needed for pain 06/22/17-Tylenol 650mg by mouth every 6 hours as needed for pain 07/20/17- [MEDICATION NAME] 5-325 milligrams 2 tabs by mouth every 4 hours as needed for pain Review of the Wound Assessment Report for June 2017 revealed the following: 06/23/17- Pressure Ulcer Sacrum. Pain with treatment Yes. Pain intensity 7. Pain Management ineffective. There were no new orders for pain medication following this treatment. Review of Departmental Notes revealed the following in part: 6/23/2017 at 7:26 a.m.- had some trouble resting this shift. Calling out with repeated verbalizations and complaints of pain to sacral wound. Only able to redirect for short periods of time. PRN (as needed) pain medications administered x2 this shift every 4 hours as ordered. Resident able to rest approximately 5 a.m. 6/23/2017 at 12:02 p.m. -wound care difficult due to resident screaming during care/even after pain meds were given prior to wound care. Review of electronic Treatment Administration Record (eTAR) and electronic Medication Administration Record [REDACTED] eTAR 07/11/17 - wound care treatment was performed (on deep tissue injury to left lateral ankle, Stage 2 pressure ulcer to left hip, left foot Stage 2 pressure ulcer, right hip Stage 3 pressure ulcer, sacral Stage 4 pressure ulcer) e[DATE]/11/17- No pain medication administered before or after wound care treatment eTAR 07/13/17 - wound care treatment was performed (on deep tissue injury to left lateral ankle, Stage 2 pressure ulcer to left hip, left foot Stage 2 pressure ulcer, right hip Stage 3 pressure ulcer, sacral Stage 4 pressure ulcer) e[DATE]/13/17- No pain medication administered before or after wound care treatment On 07/17/17 at 11:00 a.m., an observation was made of Resident #119 in her room. She was resting quietly in bed on a pressure relieving mattress. An interview was attempted with Resident #119, but when questions were asked, her responses were barely audible and indistinguishable. On 7/19/17 at 10:00 a.m., an observation was made of S11RN and S3RN moving Resident #119 into position for wound care treatment. Resident #119 vocalized loudly her discomfort with the movement and cried out, OW! It hurts! That hurts. S3RN stated they always gave the resident pain medication prior to wound care because it hurts her so much, and stated the resident had received pain medication about 30 minutes ago. On 07/20/17 at 8:00 a.m., an observation was made of S3RN and S11RN performing wound care treatment to the resident's sacral pressure ulcer. S11RN stated the resident received pain medication 30 minutes prior to starting wound care treatment. Resident #119 cried out in pain upon positioning and dressing removal. While wound care was being provided, S3RN stated she would estimate Resident #119's pain level as a 10 as evidenced by hollering and groaning. On 07/20/17 at 10:40 a.m., an observation was made of the resident in her room crying out my butt and it hurts. On 07/20/17 at 10:45 a.m., an interview was conducted with S12LPN. She was informed that Resident #119 was crying out in pain. She said the resident had received her pain medication at 7:30 a.m., right before wound care, and she was not due for any at this time. S12LPN stated she had noticed over the last couple of days that the resident's pain had increased and Resident #119 was in pain within a couple hours of administering her pain medication. On 07/20/17 at 1:10 p.m., a phone interview was conducted with S10RN. She stated she worked with Resident #119 on the weekends. She stated when wound care was provided to the resident, it was very painful for her. She stated she always made sure her pain medication were administered 30 minutes prior to changing her dressings. On 07/20/17 at 2:15 p.m., an interview was conducted with S3RN, with S2RNDON present. S3RN stated she was the treatment nurse and was currently training S11RN. S3RN stated the resident experienced increased pain during wound care treatments and pain medication should always be given prior to implementing wound care. She reviewed the clinical record and verified Resident #119 received wound care treatments on 07/11/17 and 07/13/17, and she verified there was no pain medication administered. She stated that following the resident's admission to the facility on [DATE], there were no new interventions or MEDICATION ORDERS FOR [REDACTED].