Every finding on record at Twin Oaks Health & Rehabilitation Center

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 facility kitchens reviewed for food storage. The facility failed to store food in accordance with professional standards when frozen apple pies were observed stored in a ripped, opened, and undated bag in a freezer in the facility kitchen. The facility failed to store food in accordance with professional standards when pork chops were observed stored in an undated plastic bag in a freezer, and when ham was observed stored in an undated plastic bag in a refrigerator in the facility kitchen. This failure could place residents at risk of food-borne illness and diminished quality of life.Findings included: During an observation in the facility kitchen on 12/29/25 at 8:50 a.m., a freezer was observed to contain a plastic bag of frozen apple pies. The plastic bag was ripped, opened, and undated. During an observation in the facility kitchen on 12/29/25 at 8:55 a.m., a freezer was observed to contain a plastic bag of pork chops which were undated. A refrigerator contained a plastic bag of ham which was undated. During an interview on 12/31/25 at 8:45 a.m., [NAME] B said all food stored in the facility refrigerators and freezers should be labeled and dated. [NAME] B said it was the responsibility of all kitchen staff to check the freezers and refrigerators for undated and opened food. [NAME] B said any food found undated or opened in the refrigerators or freezers should be disposed of. [NAME] B said risks from improperly stored and/or labeled food was serving the residents expired food. During an interview on 12/31/25 at 9:00 a.m., the CDM said it was the responsibility of all kitchen staff to inspect the freezers and refrigerators for opened, undated, or unlabeled food which should be discarded. The CDM said she had signs posted in the kitchen to remind all staff to look for opened, undated, or unlabeled food when checking daily refrigerator and freezer temperatures. The CDM said she thoroughly checked all food in the facility freezers and refrigerators on Monday and Wednesday to remove any unlabeled or open food. The CDM said the risk of improperly stored and/or labeled food was serving freezer-burned or expired food to residents. The CDM said, going forward, she planned to conduct an in-service with all kitchen staff covering proper storage and labeling of food and implement a monitoring plan. During an interview on 12/31/25 at 11:00 a.m., the ADM said the CDM was responsible for supervising kitchen staff directly and he was responsible for oversight of all staff. The ADM said the facility policy was all food stored in the facility freezers or refrigerators were dated and sealed. The ADM said his expectation was that all staff follow the facility policy regarding labeling and storing food. The ADM said the risks to residents would be serving unpalatable food to residents which Review of a facility policy titled Food Storage and Supplies, dated 2012, indicated .Open packages of food are stored in closed containers with covers or in sealed bags, and dated as when opened.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and ensured food and drink were palatable for 3 of 3 residents receiving puree diets. Services. The facility failed to ensure that meals served to residents were palatable on 12/29/25 at 11:00 a.m. when excessively pureed spicy pork chop was served to residents. This failure could place residents at risk of weight loss and diminished quality of life.Findings included:During an interview on 12/29/25 at 1:15 p.m., the CDM said cooks were responsible for preparing pureed foods and were expected to follow recipes as provided. The CDM were expected to taste the food after seasoning to ensure it was palatable. CDM said she tasted the puree of pork chops from the 12/29/25 meal service after being made aware of the concern of it being too spicy and found the food to be too spicy. CDM said she had already conducted an in-service with kitchen staff regarding pureed diets texture and following recipes. CDM said the risks to residents of being served unpalatable food is that the residents won't eat it. During an interview on 12/31/25 at 10:00 a.m., the ADM said he was responsible for oversight of all staff including kitchen staff. The ADM said he tasted the puree of pork chops served for the 12/29/25 lunch service and it was too spicy. The ADM said he expected cooks to follow recipes when preparing food. The ADM said the risk of serving unpalatable food to residents would be unwanted weight loss. The ADM said he had already begun in-servicing kitchen staff on pureed foods and following recipes. Record review of an in-service training attendance roster titled Pureed - Texture/Taste, dated 12/29/25 at 2:15 p.m., indicated dietary staff and the CDM attended. During an observation and sample tasting of a pureed diet tray on 12/29/25 at 12:00 p.m., this surveyor tasted the pureed pork chops and found them to be spicy. During an interview on 12/29/25 at 1:00 p.m., [NAME] A said she prepared the pureed food for the 12/29/25 lunch service. [NAME] A said she added additional spices to the pureed pork chops including black pepper and a commercial spice blend. [NAME] A said, going forward, she planned to follow the recipes. [NAME] A said she tasted the puree of pork chops and found them to be a little too spicy. [NAME] A said she should have discarded the puree and prepared more. [NAME] A said the risk of serving unpalatable food to residents was that residents wouldn't be able to eat the food. Record review of an undated facility policy titled Texture Modified Diets indicated .How to prepare texture modified diet.The recipes must be out and must be followed! .

Based on interview and record review, the facility failed to ensure individuals identified with MI, DD, or ID were evaluated for services for 1 of 6 residents (Residents #2) reviewed for PASARR.The facility failed to ensure Resident #2 had a PASARR evaluation after being admitted to the facility on [DATE] with a mental illness diagnoses of bipolar disorder.This failure could place residents at risk of not receiving individualized specialized services to meet their needs.Findings included:Record review of a facility face sheet, dated 12/30/25, for Resident #2 indicated he was a [AGE] year-old male admitted on [DATE] with diagnosis including congestive heart failure and bipolar disorder.Record review of a quarterly MDS assessment, dated 11/24/25, for Resident #2 indicated a BIMS score of 14, which indicated he had intact cognition. He had a diagnosis of bipolar disorder. Record review of a PASSR level I screening form, dated 10/23/24, for Resident #2 indicated question C0100, which read: .Is there evidence or an indicator this is an individual that has a mental illness. was answered .No.Record review on 12/30/25 indicated there was no PASSR level II evaluation for Resident #2.During an interview on 12/31/2025 at 9:30 a.m., the MDS Coordinator said she was responsible for PASSR and was not informed of Resident #2's bipolar diagnosis and it just got missed. She said, going forward, she would run a report and review for new diagnoses added so it did not happen again. She said if a new screening was not done for residents, they could miss out on needed therapies and mental health services.During an interview on 12/31/2025 at 10:07 a.m. the DON said the MDS Coordinator was responsible for PASSR. She said she would be monitoring PASSR for residents as they were admitted and providing in-services for MDS. She said residents could miss out on needed care, medications and treatments if PASSR procedures were not followed appropriately. During an interview on 12/31/2025 at 10:12 a.m., the Administrator said he expected better communication between staff and would like to discuss in the morning meeting any new residents and diagnoses. He said if PASSR screenings were not conducted accurately, it could affect the resident's plan of care and residents could miss out on needed therapies. He said he expected PASSR would be handled right away, and diagnoses should be communicated to staff handling PASSR. He said the facility did not have a specific PASSR policy.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the residents' status for 2 of 7 residents reviewed for assessments. (Resident #2 and Resident #55)The facility failed to ensure Resident #2's MDS, dated [DATE], was coded for receiving IV medications.The facility failed to ensure Resident #55's MDS, dated [DATE], was coded for the resident having a diabetic foot ulcer.These failures could place residents at risk of not having individual needs met.Findings included:1. Record review of a facility face sheet, dated 12/30/25, for Resident #2 indicated he was a [AGE] year-old male, admitted on [DATE], with diagnosis including congestive heart failure and bipolar disorder.Record review of a quarterly MDS assessment, dated 11/24/25, for Resident #2 indicated a BIMS score of 14, which indicated he had intact cognition. Assessment Reference Date was 11/24/25. He was not coded for receiving IV medications during the 14-day lookback period (11/11/25 through 11/24/25). Record review of a comprehensive care plan, dated 11/11/25, for Resident #2 indicated he had a pressure ulcer and an intervention to administer medications as ordered. Record review of a Treatment Administration Record, dated 11/1/25 through 11/30/25 for Resident #2 indicated he received an IV infusion for wound and skin healing support on 11/18/25 consisting of 250ml of Normal Saline with Vitamin C 5g, B Complex 1ml, Zinc 10mg, Biotin 5mg, Magesium Chloride 1g, and Amino Blend 5ml.During an observation and interview on 12/30/2025 at 9:43 AM Resident #2 was observed sitting up in a geri-chair in his room. He had heel protectors on both feet. He had a dressing in place to right lower extremity. He said they took good care of his foot with the wound and had no complaints.2. Record review of a facility face sheet, dated 12/30/25, for Resident #55 indicated she was a [AGE] year-old female, admitted on [DATE], with diagnoses including Alzheimer's disease and type 2 diabetes mellitus. Record review of a Quarterly MDS assessment, dated 12/1/25, for Resident #55 indicated a BIMS score of 00, which indicated severe cognitive impairment. Assessment Reference Date was 12/1/25. She was not coded for diabetic foot ulcer or having application of dressings to feet (with or without topical medications). Record review of a comprehensive care plan, dated 10/12/25, for Resident #55 indicated she had a diabetic foot ulcer related to diabetes. Record review of a Treatment Administration Record, dated 11/1/25 through 11/30/25, for Resident #55 indicated she received daily treatments for diabetic ulcer to left foot during lookback period. Treatment consisted of cleaning, application of a topical medication, and covering with a dressing (a cover for the wound).During an interview on 12/31/25 at 9:30 a.m., the MDS Coordinator said she had been doing MDSs for about seven years and realized yesterday (12/30/25) that Resident #55's MDS was inaccurately coded for her diabetic foot ulcer. She said she was in the process of getting that corrected. She said she must have missed coding the IV medications on Resident #2's MDS. She said diabetic foot ulcers and IV medications should be correctly coded on MDS assessments. She said if MDS assessments were not accurate, it could affect the plan of care for residents. She said, going forward, she would double and triple check her work to ensure accurate coding.During an interview on 12/31/25 at 10:07 a.m., the DON said the MDS Coordinator was responsible for ensuring assessments were completed accurately. She said she, along with corporate, provided oversight . She said she would be holding an in-service with MDS Coordinator and providing further education to ensure accuracy. She said she expected her staff to accurately code the MDS assessments. She said inaccurate MDS assessments could affect the residents' care plan, and they could miss out on the care they needed.During an interview on 12/31/25 at 10:12 a.m., the Administrator said he expected accuracy with MDS assessments. He said residents could have their care affected if MDS assessments were inaccurate. He said they did not have a specific MDS policy, they just went by the RAI manual.Record review of CMSs RAI Version 3.0 Manual, dated October 2025, read: .code any drug or biological given by intravenous push, epidural pump, or drip through a central or peripheral port. and .coding instructions.check all that apply in the last 7 days.M1040B, Diabetic foot ulcer(s). and .coding instructions.check all that apply in the last 7 days.M1200I, application of dressing to feet (with or without topical medications).

Based on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (12/29/2025 and 12/30/2025) for nurse staffing posting.The facility failed to post the daily staffing information in a prominent place on 12/29/2025 and 12/30/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included:During an observation on 12/29/2025 at 11:00 a.m., the daily staff posting was not in or around the front entrance or by the nurse's desk.During an observation on 12/29/2025 at 12:39 p.m., the daily staff posting was not in or around the front entrance or by the nurse's desk. During an observation on 12/30/2025 at 9:59 a.m., the daily staff posting was not in or around the front entrance or by the nurse's desk.During an interview on 12/30/2025 at 10:06 a.m., the Staffing Coordinator said she was responsible for putting up the daily staff posting. She said she forgot to post it on 12/29/2025 and 12/30/2025 because she was working on the floor as a nurse aide. She said the posting was put up to inform residents, families, and visitors of how many residents to staff were in the facility for the day. She said if the staffing information was not put up daily then the visitors and families would not have the information about the staff in the facility. She said the staff posting was placed by the nurses' desk on the wall in a plastic placard. During an observation on 12/31/2025 at 10:10 a.m., a plastic placard was on a wall behind the nurses' desk by the front entrance but did not contain the staff posting.During an interview on 12/31/2025 at 9:14 a.m., the DON said the Staffing Coordinator was responsible for putting up the staff posting daily. She said the posting showed how many nurses and nurse aides were scheduled each day. She said the posting was placed by the nurses' desk so everyone could see it. She said if the posting was not present, then no one would know the number of staff in the facility each day. During an interview on 12/31/2025 at 10:11 a.m., the Administrator said the Staffing Coordinator was responsible for putting up the staff posting daily. He said the purpose of the posting was to show everyone how the facility was staffed. He said, going forward, the department heads would review and check to make sure it was posted daily. He said the Staffing Coordinator was in-serviced yesterday, 12/30/2025. He said the facility did not have a policy for the daily staff posting and they just followed the regulation. Record review of a facility in-service, dated 12/30/2025, indicated the Staffing Coordinator received training on the daily staffing sheet.

Based on interview and record review, the facility failed to ensure residents were able to remain in the facility and not discharge resident from the facility unless the discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility. 1 of 3 residents (Resident #1) reviewed for discharge rights. The facility failed to ensure Resident #1's discharged was necessary for his welfare and failed to show the facility could not met his needs. This failure could place residents at risk of unsafe or improper discharge, placing residents at risk of not having appropriate services when discharged . Findings included: Record review of Resident #1's face sheet dated 04/14/25 indicated he was a [AGE] year-old male, admitted on [DATE], and his diagnoses included altered mental status, (cognitive mental disorder), restlessness and agitation, chromic kidney disease, hypertension, (high blood pressure), lack of coordination, muscle weakness and atrophy, and Hypothyroidism (underactive thyroid). Record review of Resident #1's MDS assessment dated [DATE] indicated he was admitted with a BIMS score of six, which indicated he had impaired cognitive ability. He was sometimes able to express his ideas and wants and was able to respond adequately to simple and direct communication. He was independent with bathing, dressing, toileting and eating. He was able to ambulate without assistance. Record review of Resident #1's care plan dated 04/09/25 indicated he sometimes displayed verbally aggressive behaviors. Interventions included social services to evaluate and visit with me, activity staff to visit with the resident, provide diversional activities, and remove the resident from public area when their behavior was disruptive and unacceptable. Interventions included discuss behavior, monitor behavior episodes, and attempt to determine underlying causes. The interventions did not include resident specific interventions or supervision to prevent resident physical aggression towards others. Record review of Resident #1's elopement assessment dated [DATE] indicated he understood and verbalized the need for him to be in a skilled nursing facility. He was restless and showed behaviors of pacing and wandering. Record review of Resident #1's nurse's notes dated 03/27/25, indicated he displayed behaviors of wandering, non-compliance with medication, treatment and was resistant to care. Record review of Resident #1's physician's orders dated 03/27/25 revealed his behaviors were to be monitored and behaviors were to be documented in the progress notes. Record review of Resident #1's progress note dated 03/27/25 documented by RN C revealed Resident #1 was on 15-minute checks due to a history of elopement, per the family member; no s/s of elopement but the family member said he did like to wander and had gotten out house and another nursing home. Record review of Monitoring Chart for Resident #1, dated 03/27/25 and 03/28/25 revealed staff monitored his behavior and documented every 15 minutes. Review of medical records showed there was no documentation made by Resident #1's physician as to the need for the discharge or that the discharge or that the facility could not meet Resident #1's needs. Record review of Resident #1's progress note dated 03/28/25 at 6:00 p.m. documented by RN A revealed, Continue to monitor resident. The resident was noted to be more aggressive trying to get out .I'm leaving get out of my way.jerking and rattling door, alarm sounding. Threw table in lobby everything replaced. Given Ativan. Family called. family member said she would be out there as soon as we can. 7:50 p.m. continue to monitor. Resident stated he is going to throw a rock and break the door. Tried to get a planter in the lobby and throw at window. Removed from grip and replaced. Reached across nurse's station tore fire extinguisher off wall. Went outside to patio and refused to return. Trying to find a way off the premises. Continued to try to get resident to come in and wait for family. Resident refused. NP notified of behavior. Family came while outside on patio and resident came in with them. 9:00 p.m. Family states resident does not need to be discharged to the hospital, they won't do anything for him, they didn't last time. Requested resident be discharged home with them. Talked to family member by phone, who is out of town, and she agreed. NP was notified. Orders received for the resident to be discharged with family with belongings, meds counted and sent with resident. During an interview on 04/14/25 at 12:40 p.m., the Administrator said Resident #1 was discharged home with his family on the evening of 03/28/25 which was on a Friday. The Administrator said she was not notified of the discharge until the next Monday morning. The Administrator said staff did not follow facility policy regarding Resident #1's discharge. The Administrator said there was no discharge plan, and the ombudsman was not notified of the discharge. The Administrator said Resident #1 was sent home with a family member. The Administrator said she was told that Resident #1 was attempting to elope and was seeking a way out of the facility. The Administrator said it was reported that Resident #1 turned over a table in the lobby, but she could find no evidence of a table in the lobby. During an interview on 04/14/25 at 12:58 p.m., RN B said she was the compliance nurse. She said she was not saying that Resident #1 was properly discharged . RN B said it was reported to her that Resident #1 was exit-seeking and wanted to leave. RN B said in addition to the exit seeking behavior, Resident #1 was upset and throwing stuff. RN B said the Director of Nursing made the decision to call the family and tell them to come get him. RN B said the DON no longer worked at the facility. RN B said the DON texted the Administrator but did not call to report Resident #1 was being discharged nor was the ombudsman notified of the discharge. RN B said Resident #1 needed to be in a secure unit due to his exit seeking behaviors, but the facility did not assist in locating an alternative placement. RN B said she was told it was the family's decision to discharge Resident #1. During an interview on 04/14/25/25 at 1:38 p.m., RN D said she contacted by RN A that Resident #1 was turned over a table in the lobby and had broken a shelf. RN D said RN A told her Resident #1 was trying to get out and she needed her to come to the facility. RN D said she worked at the facility but was also a family member for Resident #1 and one of his emergency contacts. RN D said when she arrived at the facility, Resident #1 was in the smoking area and was calm. RN D said Resident #1 was not displaying any behaviors at the time. RN D said the DON told RN A to call the police if RN D did not take Resident #1 home with her. RN D said she did not want RN A to call the police, so she took Resident #1 to her house, and he stayed there for two nights and slept on her sofa. RN D said she signed a form when Resident #1 was discharged with his medication. RN D said one of the medications was for his behaviors. The sign medication release form could not be located. RN D said she did not see Resident #1 showing aggressive behaviors when she arrived at the facility and that RN A did not want to deal with Resident #1 and wanted him out of the facility. RN D said Resident #1 went to live with a family member after he left her home. RN D said Resident #1 will remain at the famiily member's until another facility can be found. During an interview on 04/14/25 at 3:59 p.m. Ombudsman said she had not received any notification concerning the discharge of Resident #1. During an interview on 04/14/25 at 5:50 p.m., RN A said she was the charge nurse on the evening of 03/28/25 when Resident #1 was discharged . RN A said Resident #1 was displaying aggressive behaviors, turning over a table in the lobby and was looking for something to throw at the glass in the window. RN A said she gave Resident #1 an Ativan, and he was cooperative in taking the medication. RN A said the medication did not appear to work and Resident #1 continued to show exit-seeking behaviors. RN A said she called the DON and was told to contact Resident #1's family. RN A said she attempted to call Resident #1's family member but she could not reach her. RN A said she called RN D, who was also a family member. RN A said RN D and her husband came to the facility. RN A said when RN D and her husband arrived at the facility, Resident #1 was on the patio. RN A said they went to the patio to talk with Resident #1. RN A said she called the NP and the NP said to send him to the hospital for evaluation if the family agreed. RN A said RN D said there was no need to send Resident #1 to the hospital because he was not showing signs of aggression and there was nothing that the hospital could do. RN A said RN D agreed to take Resident #1 home with her. RN A said she gave Resident #1's medication to RN D and she signed for them. RN A said she did not contact the Administrator or the ombudsman. RN A said the facility did not attempt other interventions other than to have him removed from the facility. Review of the facility's Discharge Planning Process Policy dated 11/28/16. .Facility must complete discharge planning when .discharging a resident to a private residence .Discharge planning includes A) Assessing the resident's continuing care needs, including: 1. Consideration of the resident's and family caregiver's preference for care; 2. How services will be accessed; and How care should be coordinated among multiple caregivers. B) Developing an interdisciplinary team discharge plan designed to ensure that the resident's needs will be met after discharge from the facility, including resident and family/caregiver educational needs; .D) Assisting the resident and family/caregivers in locating and coordinating post-discharge services Discharge summary must include: .2. A post-discharge plan of care will help the resident adjust to their new living environment Review of an undated facility's Discharge or transfer to another facility indicated Facility initiated discharge .The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility. The following limited circumstances, this facility may initiate transfers or discharges: A. The transfer or discharge is necessary for the resident's welfare and the resident's needs can not be met in the facility .C. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; . For circumstances A .the resident's physician must document information about the basis for the transfer or discharge. Additionally, for circumstances A .the inability to meet the resident's needs, the documentation made by the resident's physician must include: The specific resident needs the facility could not meet; The facility efforts to meet those needs; and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility. Documentation regarding the reason for the transfer or discharge may be completed by a nurse practitioner or other non-physician practitioner according to state law .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility did not operate the dish washer at the required temperature for sanitation of dishes. The facility staff was handling the lid of the trash can by the sink after washing their hands. These failures could place residents at risk for food-borne illnesses. Findings included: During an observation in the kitchen on 9/23/2024 at 9:10 AM a trash can next to the kitchen's handwashing sink did not have a foot-operated pedal to open the lid. During an observation on 9/23/2024 at 9:15 AM in the kitchen, Dietary Aid G ran the dishwasher at 110 degrees instead of the required 120 degrees according to the temperature gauge on the front of the dishwasher. A metal plate on the front of the dishwasher indicated dishwasher temperature must be 120 degrees for sanitization. A record review of Temperature/Chemical log dated September 1 through 24, 2024, revealed multiple instances of the dishwasher being operating temperatures between 100-200 degrees. During an interview on 9/23/2024 at 9:15 AM Dietary Aid G said that the dishwasher was supposed to be run at 120 degrees, but the Dietary Supervisor had not turned on the hot water. During an interview on 9/23/2024 at 9:20 AM the Dietary Supervisor said that staff use a clean paper towel or a clean towel to open the lid, or just leave the lid off and they were not using the trash can with a foot-operated pedal because it was too small. She said she was unaware of staff operating the dishwasher below 120 degrees because she was off sick. She said she always reminded staff and does frequent in-services regarding operating the dishwasher. Record review of an in-service dated 9/10/2024 indicated .check dishwasher, make sure you run machine to 120 before you start . During an interview on 9/26/2023 at 3:00 PM, the Administrator said the Dietary Supervisor was responsible for training all kitchen staff and that all kitchen staff had already been in-serviced again and Dietary Aide G had been counseled. She said the Dietary Supervisor would start checking the Temperature/Chemical log twice daily going forward. The Administrator said that the facility would obtain a larger trash can with a foot-operated lid for the kitchen. A copy of the kitchen sanitation policy was requested but not provided.

Based on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility failed to follow their policy on smoking on 9/23/24 when cigarette ashes and multiple cigarette butts were observed in a trash can in smoking area. These failures could place residents at risk of injury, burns, and an unsafe smoking environment. Findings include: During an observation on 9/23/24 at 3:36 pm a silver metal trash can was observed in smoking area, it was lined with a clear plastic liner and ashes were observed on the liner. When the lid to trash can was opened, multiple cigarette butts were observed along with soda cans. One cigarette butt was observed still smoking. During an interview on 9/23/24 at 3:45 pm DON said there was risk for a fire if cigarette butts were not properly disposed . The DON said that today was her first day, but going forward they would be reworking their smoking policy to ensure this did not happen again. During an interview on 9/23/24 at 3:50 pm the ADON said the maintenance man was responsible for cleaning the ashtrays in the smoking areas. She said he was on vacation this week and unavailable by phone. During an interview on 9/25/24 at 3:06 pm the Administrator said the maintenance supervisor was responsible for checking the smoking area. She said she would be ordering more ashtrays for the smoking area and was considering removing the trash can altogether. She said there could be a risk for fire if cigarette butts were disposed of in the trash can. Record review of a facility policy titled Smoking Policy dated 11/1/17 read . ashtrays on noncombustible materials and safe design will be provided in all areas where smoking is permitted. Ashtrays will be a metal container with a self-closing cover device into which ash trays may be emptied. Ashtrays will be readily available in all areas where smoking is permitted .

Based on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #6, #45, #55, #62) reviewed for immunizations. The facility failed to document education offered for the influenza and pneumococcal vaccination to Residents #6, #45, #55, #62. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings include: Resident #45 Record review of a facility face sheet dated 9/23/24 for Resident #45 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cutaneous abscess of buttock (a localized collection of pus in the skin that may occur on any skin surface), seizures, and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #45 indicated that he had a BIMS score of 14, which indicated he was cognitively intact. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive his influenza vaccine in the facility for this year's influenza season because it was offered and declined. He was not up to date on his pneumonia vaccination. He did not receive the pneumonia vaccine because it was offered and declined. Record review of a comprehensive care plan dated 8/5/24 for Resident #45 indicated that he had no interventions for flu and pneumonia vaccinations. Record review of a physician order summary report dated 9/23/24 for Resident #45 indicated that he had the following orders: Influenza Vaccination Annually, dated 1/15/21. Record review of Resident #45's immunization tab in his electronic medical record indicated that he had refused the flu and pneumonia vaccination with no date of refusal listed. Resident #55 Record review of a facility face sheet dated 9/24/24 for Resident #55 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: pressure ulcer of the sacral region (a medical condition that involves tissue damage or necrosis in the area of the sacrum due to prolonged pressure), type 2 diabetes mellitus (uncontrolled blood sugars), and hypertension (high blood pressure). Record review of a quarterly MDS assessment dated [DATE] for Resident #55 indicated that he had a BIMS score of 11, which indicated he had moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive his influenza vaccine in the facility for this year's influenza season because it was offered and declined. He was not up to date on his pneumonia vaccination. He did not receive the pneumonia vaccine because it was offered and declined. Record review of a comprehensive care plan dated 7/30/24 for Resident #55 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . Record review of a physician's order summary report dated 9/24/24 for Resident #55 indicated that he had the following orders: Influenza vaccination Annually, dated 5/4/22, and Pneumonia vaccine per CDC recommendations, dated 7/5/24. Record review of Resident #55's immunization tab in his electronic medical record indicated that he had not received the flu vaccine for this influenza season and had not received the pneumonia vaccine due to refusal. There was no date of refusal listed. Resident #62 Record review of a facility face sheet dated 9/25/24 for Resident #62 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: paraplegia, iron-deficiency anemia, and bipolar disorder. Record review of a quarterly MDS assessment dated [DATE] for Resident #62 indicated that he had a BIMS score of 13, which indicated that he was cognitively intact. Section O (Special Treatments, Procedures, and Programs) indicated that resident did not receive his influenza vaccine in the facility due to not being in facility during this year's influenza season. He was not up to date on his pneumonia vaccination. He did not receive the pneumonia vaccine because it was offered and declined. Record review of a comprehensive care plan dated 9/20/24 for Resident #62 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . Record review of a physician's order summary report dated 9/25/24 for Resident #62 indicated that he had the following orders: pneumonia vaccine per CDC recommendations, dated 5/31/24. Record review of Resident #62's immunization tab in his electronic medical record indicated that he was not eligible for the flu vaccine, and his pneumonia vaccine was not given due to refusal, with no date of refusal listed. Resident #6 Record review of a facility face sheet dated 9/25/24 for Resident #6 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, hypertension, and schizophrenia. Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that BIMS should not be completed due to resident rarely/never being understood. He had moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) indicated that resident received his influenza vaccine in the facility on 9/28/23. He was not up to date on his pneumonia vaccination. He did not receive the pneumonia vaccine because it was offered and declined. Record review of a comprehensive care plan dated 7/3/24 for Resident #6 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . Record review of a physician's order summary report dated 9/25/24 for Resident #6 indicated that he had the following orders: Influenza Vaccine Annually, dated 6/25/19. Record review of Resident #6's immunization tab in his electronic medical record indicated that he last received the flu vaccine on 9/28/23, and did not receive pneumonia vaccine due to refusal, with no refusal date listed. During an interview on 9/25/24 at 4:07 pm the Regional Nurse said she could not provide documentation of resident education for immunization refusals. She said the nurses were supposed to have them sign a declination form after being educated if the resident refused. But there was no documentation of that in the facility. She said the DON would be responsible going forward to ensure that residents were educated on immunizations and providing documentation. She said residents could be at risk of not knowing what they were refusing if they were not provided education. During a joint interview on 9/25/24 at 4:12 pm the DON said she and the ADON both would be responsible for immunizations going forward. The ADON said the old DON had been responsible before she left. The DON said residents could be at risk of contracting infections, severe respiratory problems and even death if they were not properly educated and did not receive vaccinations. She said they would be providing education and have consent/declination forms signed going forward. During an interview on 9/25/24 at 4:19 pm Administrator said she would make the DON responsible for immunizations and ensure that she enforced it. She said that residents could get sick if they were not educated on the risks/benefits of immunizations. Record review of a facility policy titled Resident Influenza and Pneumonia Vaccine dated 2019 and revised 3/2024 read: .The following must occur prior to administering the immunization: * Provide a Vaccine Information Statement (VIS) to the resident and/or resident representative that corresponds to the influenza vaccine being administered to the recipient. The VIS will outline education, benefits and potential risks of the immunization. * The facility will maintain documentation of influenza vaccinations or refusals of the influenza immunization in the Point Click Care clinical record and will include: ^That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization or did not receive the influenza immunization due to medical contradiction or refusal . and .The following must occur prior to administering the immunization: *Provide a Vaccine Information Statement (VIS) to the resident and/or resident representative that corresponds to the pneumonia vaccine being administered to the recipient. The VIS will outline education, benefits, and potential risks of the immunization. *The facility will maintain documentation of pneumonia vaccinations or refusals of the pneumonia immunization in the Point Click Care clinical record and will include: ^That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumonia immunization; and ^That the resident either received the pneumonia immunization or did not receive the pneumonia immunization due to medical contraindication or refusal .

Based on observations, interviews, and record reviews the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 7 residents (Residents #16, #50 and #53) reviewed for call lights. The facility failed to ensure the emergency call lights in Resident #16, #50, and #53s bathrooms were accessible from the floor on 9/23/2024. These failures could affect residents who used their call light or desire to use the call light and place them at risk of not being able to notify staff of their needs. Findings include: Resident #16 Record review of a facility face sheet dated 9/25/24 for Resident #16 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: bipolar disorder (a mental health condition that causes extreme mood swings), dementia, and parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors). Record review of a comprehensive MDS assessment dated [DATE] for Resident #16 indicated that he had a BIMS score of 3, which indicated that he had severe cognitive impairment. He required partial/moderate assistance with toileting hygiene and supervision with toilet transfers. He was occasionally incontinent of bladder and always continent of bowel. Record review of a comprehensive care plan dated 9/20/24 for Resident #16 indicated that he was at risk for falls and had an intervention which read: .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Resident #50 Record review of a facility face sheet dated 9/25/24 for Resident #50 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on ,d+[DATE] with diagnoses including: respiratory failure (trouble breathing), lack of coordination, and type 2 diabetes (uncontrolled blood sugar). Record review of a quarterly MDS assessment dated [DATE] for Resident #50 indicated that he had a BIMS score of 12, which indicated that he had a moderate cognitive impairment. He required supervision with toileting hygiene and toilet transfers. He was always continent of bowel and bladder. Record review of a comprehensive care plan dated 9/18/24 for Resident #50 indicated that he was at risk for falls and had an intervention that read: .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . Resident #53 Record review of a facility face sheet dated 9/25/23 for Resident #53 indicated that she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: dementia, lack of coordination, and hypertension (high blood pressure). Record review of a quarterly MDS assessment dated [DATE] for Resident #53 indicated that she had a BIMS score of 6, which indicated that she had severe cognitive impairment. She required set up assistance for toileting hygiene and toilet transfers. She was always continent of bowel and bladder. Record review of a comprehensive care plan dated 9/20/24 for Resident #53 indicated that she was at risk for falls and had an intervention that read: .be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed . During an observation and interview on 9/23/24 at 10:23 am revealed the bathroom call light was wrapped around the grab bar multiple times. Resident #16 and #53 were observed in their room. Resident #16 did not speak, and Resident #53 said that they do use the restroom and have not had to use the call lights much. Resident #53 said they have not had any falls in the bathroom. During an observation and interview on 9/23/24 at 10:29 am the bathroom call light was wrapped around the grab bar multiple times in Resident #50's restroom. Resident #50 said he had never needed to use the call light in the bathroom but said he knew it was in there in case he had a fall. During an interview on 9/25/24 at 3:06 pm Administrator said the maintenance man was responsible for checking the bathroom call light to ensure they were long enough and not wrapped around grab bars. She said he was out this week on vacation and was unavailable by phone. She said resident's might not be able to call for help if they were to fall if the call lights were wrapped around the grab bars. She said she would be having the maintenance man checking them more often once he returned. She said she would be checking them until then. During an interview on 9/24/25 at 4:10 pm Administrator said they do not have a call light policy.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision with smoking materials to prevent accidents for 2 of 5 residents (Resident #47 and Resident#62) reviewed for accidents and hazards. The facility failed to ensure residents were returning lighters to the staff when returning from smoking. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: Resident #47 Record review of Admission Record for Resident #47 dated 9/25/24 indicated she was admitted to the facility on [DATE] and was [AGE] years old with diagnoses of nontraumatic intracerebral hemorrhage, and hemiplegia and hemiparesis affecting left non-dominate side. Review of quarterly MDS assessment dated [DATE] for Resident #47 indicated moderate cognitive impairment in thinking with a BIMS score of 10 She required extensive assistance with bed mobility, transfer, and toileting. She was independent with eating. Review of Safe Smoking assessment dated [DATE] for Resident #47 indicated she had a past accident / incident with smoking materials. Review of Nursing Progress note dated 6/19/2024 for Resident #47 revealed that she was falling asleep with cigarettes lit and resident was informed she had to be supervised while smoking and to keep smoking material at the nurses station. An observation on 9/23/2024 at 11:45 AM in the dining room revealed Resident #47 had a cigarette lighter lying on the arm of her wheelchair. In an interview at the same time Resident #47 stated that smoking materials are supposed to be kept at the nurse's station, but she keeps her lighter with her. Resident #62 Record review of an Admission Record for Resident #62 dated 9/25/24 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of paraplegia unspecified, tremor unspecified, stage 4 pressure ulcers right lower back, left lower back, sacral region, bilateral above knee amputations, and other specified bladder disorders. He required extensive assistance with bed mobility, transfer, and toileting. He was independent with eating. Review of a Quarterly MDS assessment dated [DATE] for Resident #62 indicated he did not have any impairment in thinking with a BIMS score of 13. A record review of Resident #62s safe smoking assessment dated [DATE] indicated all smoking materials would be kept at the nurses' station. An observation and interview on 9/23/2024 at 12:00 PM revealed Resident #62 had a cigarette lighter in his room, zipped up in a green bag. Resident #62 said that smoking materials are supposed to be kept at the nurses' station, but he don't let anyone touch his cigarettes or lighter. During an interview on 9/23/2023 at 1:00 PM, Administrator said that facility smoking policy was that all smoking materials are to be left at the nurse's station. She stated she was aware of an incident of Resident #47 falling asleep while smoking, but she was not injured. She said they would make sure staff were supervising residents when they are smoking and smoking materials would be kept at nurse's station. Record review of Smoking Policy dated 11/1/17 reveals that . Matches, lighters, or other ignition sources for smoking are not permitted to be kept or stored in a resident's room .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 6 residents (Resident #6, #31, #55 and #62) and 4 of 8 staff (CNA A, CNA B, RN M, CNA F) reviewed for infection control. CNA A failed to wear a gown while emptying a foley catheter drainage bag for Resident #6 who was on enhanced barrier precautions on 9/23/2024. CNA B did not sanitize or wash her hands between glove changes and touched clean items with dirty gloves when providing incontinent care to Resident #31 on 9/23/2024. The facility failed to ensure that RN M donned a gown while providing wound care to Resident #55 on 9/24/24. CNA F failed to keep Resident #62's foley catheter drainage bag off of the ground and stepped on the bag twice while assisting with wound care for Resident #62. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: 1.Record review of a facility face sheet dated 9/24/2024 indicated Resident #6 was a [AGE] year-old male that admitted to the facility on [DATE] for diagnosis of dementia. Record review of a Quarterly MDS assessment dated [DATE] indicated Resident #6 could not complete BIMS assessment and had an indwelling catheter. Record review of a comprehensive care plan dated 7/30/2024 indicated Resident #6 was on enhanced barrier precautions and gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity. Record review of a facility consolidated order report dated 9/24/2024 indicated Resident #6 had an indwelling catheter and required enhanced barrier precautions. During an observation on 09/23/24 at 10:15 am Resident # 6 was in the bed asleep with head elevated and call light in reach. Indwelling catheter present to bedside. Enhanced barrier precautions in place and sign and PPE outside the room. During an observation and interview on 9/23/24 at 10:20 am, CNA A entered the room of Resident #6 and emptied the foley bag wearing gloves only. She said she had worked at the facility for [AGE] years. She said Resident #6 was on precautions for a wound she thought. She said she was trained on enhanced barrier precautions and was told she only had to wear a gown if she was in contact with the resident's body. She said she should have put a gown on because she could come in contact with the resident's urine, and it could have splashed on her clothes that could spread infections. 2. Record review of an Admission Record for Resident #31 dated 9/24/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), neuromuscular dysfunction of bladder (abnormal function of the bladder due to nerve damage), type 1 diabetes (a chronic condition that occurs when the body does not make or produce enough insulin), and paraplegia (paralyzed on the lower half of the body). Record review of a Quarterly MDS assessment dated [DATE] for Resident #31 indicated he did not have any impairment in thinking with a BIMS score of 15. He was frequently incontinent of urine. Bowel was not rated because the resident had an ostomy (a surgical opening in the stomach that allows urine or feces to exit the body). Record review of a care plan dated 7/21/2017 for Resident #31 indicated he had bladder incontinence related to neurogenic bladder. Interventions included for incontinent care at least every 2 hours and apply moisture barrier after each episode. During an observation on 9/23/2024 at 3:33 PM, CNA B and CNA C were in the hallway outside of Resident #31's room gathering supplies to provide incontinent care. The supplies were gathered and placed in a plastic bag, both CNA B and CNA C put on gowns. CNA B placed gloves on her hands without washing or sanitizing them and CNA C went into the bathroom and washed her hands. CNA B said she made a mistake, removed her gloves, placed them in the trash and then went into the bathroom to wash her hands. CNA B placed gloves on both hands. CNA C opened Resident #31's brief and pulled it down between his thighs. CNA B removed wipes from the plastic bag and wiped across his abdomen and placed it in the trash. CNA C removed another wipe and wiped down his right thigh and placed it in the trash and then removed another wipe and wiped down his left thigh and placed the wipe in the trash. CNA B removed another wipe and wiped his penis in a circular motion and pushed his foreskin back and cleaned and placed the wipe and gloves in the trash. CNA B washed her hands in the bathroom and applied gloves. CNA C rolled the resident onto his right side. CNA B removed wipes from the plastic bag and wiped his rectal area and placed the wipe in the trash. CNA B grabbed a clean brief and placed it on the bed and removed the dirty brief and placed it in the trash. CNA B removed her gloves and placed them in the trash and put on clean gloves without washing or sanitizing her hands. CNA B placed the brief underneath the resident's buttocks, and he was rolled to his left side and the brief was secured. CNA B and CNA C removed their gloves and gowns and placed them in the trash and washed their hands. During an interview on 9/23/2024 at 4:06 PM, CNA B said she had been employed at the facility for 4 years and worked 6 am-6 pm shift. She said during the care provided to Resident #31, when she went to pull the brief off, she should have removed her glove and washed or sanitized them before she grabbed a clean brief. She said she should have washed or sanitized her hands after she removed her gloves. She said she had recent skills check off on incontinent care and should have had sanitizer in the room. She said staff should wash their hands if soiled in any type of way and get clean gloves. She said when going from dirty to clean, you should change gloves, sanitize, or wash hands whatever was best at the moment and get a clean pair of gloves. She said residents could be at risk for cross contamination and infections. Record review of a competency check off for CNA B dated 8/2/2024 indicated she was satisfactory in perineal care for a male resident and checked off by CNA E. During an interview on 9/25/2024 at 2:19 PM, CNA E said she had been employed at the facility for 7 years and was recently promoted to being the lead CNA. She said she was responsible for overseeing the CNA's to make sure they were doing their jobs and she conducted competency check offs with them every 2-3 months. She said CNA B had a competency check in July 2024 with her. She said staff should perform hand hygiene before they entered the room, after changing gloves, and when changing from dirty to clean. She said hands should be washed or sanitized. She said there could be a risk for cross contamination or spreading infections if staff did not perform hand hygiene properly. During an interview on 9/25/2024 at 2:25 PM, the ADON said hand hygiene should be performed at the beginning of care, after pericare and anal care, when changing gloves and when finished. She said staff should be sanitizing their hands or washing them when going from dirty to clean. She said residents could be at risk for infection if staff did not perform hand hygiene. During an interview on 9/25/2024 at 2:35 PM, the Regional Nurse said the DON and ADON's were responsible for competency check offs with staff. She said the DON just started on 9/23/2024. She said staff should wash or sanitize their hands when going from dirty to clean and should change gloves and wash hands. She said there was a risk for infections and would provide more education with staff and conduct check offs. During an interview on 9/25/2024 at 4:35 PM, the Administrator said staff should perform hand hygiene when they remove dirty or their gloves. She said the DON, ADON and lead CNA helped with educating the staff. She said all staff would be reeducated on how to provide proper pericare on every nurse aide in the facility. She said there was a risk for cross contamination or infections. 3. Record review of a facility face sheet dated 9/24/24 for Resident #55 indicated that he was admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: Stage 4 pressure ulcer of sacral region (Full thickness tissue loss with exposed bone, tendon, or muscle located on sacrum), type 2 diabetes mellitus (uncontrolled blood sugars), and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #55 indicated that he had a BIMS score of 11, which indicated that he had moderately impaired cognition. Section M (Skin Conditions) indicated that he had one Stage 4 pressure ulcer that was present upon admission/entry. Record review of a comprehensive care plan dated 7/30/24 for Resident #55 indicated that he was on enhanced barrier precautions with an intervention that read .Gloves and gown should be donned if any of the following activities are to occur: linen change, resident hygiene, transfer, dressing, toileting/incontinent care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activity . During an observation on 9/24/24 at 2:41 pm RN M did not don a gown while providing wound care to Resident #55. During an interview on 9/24/24 at 2:45 pm RN M said he thought they only had to wear the gown if they were handling his urine because he had MDRO in his urine. He said that he had received training on infection control and enhanced barrier precautions, but the enhanced barrier precautions were new and he just must have misunderstood. Record review of a Nurse Proficiency Audit dated 2/19/24 for RN M indicated that he had demonstrated proficiency with dressing changes and infection control on 2/19/24. 4. Record review of an Admission Record for Reisdent #62 dated 9/25/2204 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of paraplegia unspecified, tremor unspecified, protein-calorie malnutrition, iron deficiency anemia, bipolar, depressive disorders, insomnia, stage 4 pressure ulcers right lower back, left lower back, sacral region, bilateral above knee amputations, and other specified bladder disorders. Review of a Quarterly MDS assessment dated [DATE] for Resident #62 indicated he did not have any impairment in thinking with a BIMS score of 13. Resident has an indwelling foley catheter to manage incontinence and assist in healing of pressure ulcers. Record review of a care plan dated 9/20/2024 for Resident #62 indicated interventions for and maintaining the drainage bag off the floor. During an observation of Resident #62 on 09/25/2024 at 8:30 AM revealed that his foley catheter drainage bag was lying on the ground. During an observation of Regional Nurse on 09/25/2024 at 9:00 AM performing wound care for Resident #62 revealed his foley catheter drainage bag was still lying on the ground. CNA F, who was assisting Regional Nurse, stepped on the foley drainage bag twice, but did not pick the bag up off the floor. In an interview on 09/25/2024 at 9:45 AM the Regional Nurse, who was the facility Infection Preventionist, said that all CNA's received training in foley care, and the expectation was to hang the drainage bag where it was not touching the floor. She stated that risks to patient are infection. In an interview on 09/25/2024 at 9:50 AM CNA F said she had received training in foley care and that the drainage bag should be kept off of the floor. She stated that risks to patients include bacteria and infection. A record review on 09/25/2024 of a proficiency audit for CNA F dated 7/31/24 indicated she was successfully checked-off on skills providing foley care to male resident's as satisfactory on 7/31/24. In an interview on 09/25/2024 at 10:10 AM the Administrator said that all CNAS receive training in foley care and that the expectation was that foley drain bags are to be hung and kept off the floor. She stated that we have one resident that prefers to have his foley laying on the ground, but it would need to be in a basin and not on the floor. She stated that would need to be ordered and care planned to be implemented. A record review on 09/25/2024 of policy titled Catheter Care dated 2/13/2007 stated .Be sure the catheter tubing and drainage bag are kept off the floor . Record review of a facility policy titled Fundamentals of Infection Control Precautions undated, .A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions. 1. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: After contact with a resident's mucous membranes and body fluids or excretions; after removing gloves or aprons . Record review of a facility policy titled Enhanced Barrier Precautions undated indicated, .Enhanced Barrier Precautions (EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Indwelling medical device examples include urinary catheters. Donning PPE for Residents on EBP Based on Activity Provided / Assistance While in Resident Room: Perform wound care: any skin opening requiring a dressing .Don gloves and gown - YES 46273 46436 50818

Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid-19 immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 4 of 5 residents who were reviewed for immunizations. (Residents #6, #45, #55, #62). The facility failed to document education offered for the covid-19 vaccination to Residents #6, #45, #55, #62. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes. Findings include: Record review of a facility face sheet dated 9/23/24 for Resident #45 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: cutaneous abscess of buttock (a localized collection of pus in the skin that may occur on any skin surface), seizures, and hypertension (high blood pressure). Record review of a Quarterly MDS assessment dated [DATE] for Resident #45 indicated that he had a BIMS score of 14, which indicated he was cognitively intact. Record review of a comprehensive care plan dated 8/5/24 for Resident #45 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . and .following facility protocol for Covid-19 screening/precautions . Record review of a physician order summary report dated 9/23/24 for Resident #45 indicated that he had the following orders: may have Pfizer Covid Vaccine, dated 1/24/21. Record review of Resident #45's immunization tab in his electronic medical record indicated that he had refused the Covid booster with no date of refusal listed. Record review of a facility face sheet dated 9/24/24 for Resident #55 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: pressure ulcer of the sacral region (a medical condition that involves tissue damage or necrosis in the area of the sacrum due to prolonged pressure), type 2 diabetes mellitus (uncontrolled blood sugars), and hypertension (high blood pressure). Record review of a quarterly MDS assessment dated [DATE] for Resident #55 indicated that he had a BIMS score of 11, which indicated he had moderate cognitive impairment. Record review of a comprehensive care plan dated 7/30/24 for Resident #55 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . and .following facility protocol for Covid-19 screening/precautions . Record review of a physician's order summary report dated 9/24/24 for Resident #55 indicated that he did not have an order for Covid vaccination. Record review of Resident #55's immunization tab in his electronic medical record indicated that he had not received the covid-19 vaccine due to refusal, with no date of refusal listed. Record review of a facility face sheet dated 9/25/24 for Resident #62 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: paraplegia, iron-deficiency anemia, and bipolar disorder. Record review of a quarterly MDS assessment dated [DATE] for Resident #62 indicated that he had a BIMS score of 13, which indicated that he was cognitively intact. Record review of a comprehensive care plan dated 9/20/24 for Resident #62 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . and .following facility protocol for Covid-19 screening/precautions . Record review of a physician's order summary report dated 9/25/24 for Resident #62 indicated that he had no order for Covid vaccination. Record review of Resident #62's immunization tab in his electronic medical record indicated that he was not eligible for the flu vaccine, and his pneumonia vaccine was not given due to refusal and covid-19 vaccine was not given due to refusal, with no date of refusal listed. Record review of a facility face sheet dated 9/25/24 for Resident #6 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnoses including: dementia, hypertension, and schizophrenia. Record review of a quarterly MDS assessment dated [DATE] for Resident #6 indicated that BIMS should not be completed due to resident rarely/never being understood. He had moderate cognitive impairment. Record review of a comprehensive care plan dated 7/3/24 for Resident #6 indicated that he was at risk for signs and symptoms of Covid-19 and had interventions that read: .educate staff, resident, family and visitors of Covid-19 signs and symptoms and precautions . and .following facility protocol for Covid-19 screening/precautions . Record review of a physician's order summary report dated 9/25/24 for Resident #6 indicated that he had the following orders: may have Pfizer covid vaccine, dated 1/5/21. Record review of Resident #6's immunization tab in his electronic medical record indicated that he did not receive the covid booster due to refusal, with no refusal date listed. During an interview on 9/25/24 at 4:07 pm Regional Nurse said she could not provide documentation of resident education for immunization refusals. She said the nurses were supposed to have them sign a declination form after being educated if the resident refused. But there was no documentation of that in the facility. She said the DON would be responsible going forward to ensure that residents were educated on immunizations and providing documentation. She said residents could be at risk of not knowing what they were refusing if they were not provided education. During a joint interview on 9/25/24 at 4:12 pm DON said she and the ADON both would be responsible for immunizations going forward. ADON said the old DON had been responsible before she left. DON said residents could be at risk of contracting infections, severe respiratory problems and even death if they were not properly educated and did not receive vaccinations. She said they would be providing education and have consent/declination forms signed going forward. During an interview on 9/25/24 at 4:19 pm Administrator said she would make the DON responsible for immunizations and ensure that she enforced it. She said that residents could get sick if they were not educated on the risks/benefits of immunizations.

Based on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 3 of 18 residents (Resident #68, #63, #29) reviewed for call lights. The facility failed to ensure Resident #68, #63, and #29's emergency call button in the bathroom had a pull cord from 9/24/2024-9/25/2024. These failures could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings included: 1. Record review of an Admission Record for Resident #68 dated 9/25/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia, hypertension, and BPH (enlarged prostate). Record review of a Quarterly MDS Assessment for Resident #68 dated 8/12/2024 indicated he had severe impairment in thinking with a BIMS score of 5, He required supervision with toileting and was always continent of bowel/bladder. Record review of a care plan for Resident #68 dated 5/9/2024 indicated he was at risk for falls with interventions to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. 2. Record review of an Admission Record for Resident #63 dated 9/24/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of other cerebrovascular disease (stroke), hypertension and BPH with lower urinary tract symptoms (enlarged prostate). Record review of a Quarterly MDS Assessment for Resident #63 dated 8/9/2024 indicated he had severe impairment in thinking with a BIMS of 4. He required setup or clean up assistance with toileting hygiene. He was occasionally incontinent of urine and always continent of bowel. Record review of a care plan for Resident #63 dated 5/21/2024 indicated he had bladder incontinence related to confusion. Interventions included to ensure resident has unobstructed path to the bathroom. 3. Record review of an Admission Record for Resident #29 dated 9/25/2024 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnosis of schizophrenia (mental health condition that affects how people think, feel, and behave), major depressive disorder (persistent sadness or loss of interest) and BPH. Record review of a Quarterly MDS Assessment for Resident #29 dated 7/15/2024 indicated he had moderate impairment in thinking with a BIMS score of 12. He was independent with toileting and was occasionally of urine and always continent of bowel. Record review of a care plan for Resident #29 dated 1/16/2017 indicated he had an ADL self care performance deficit with interventions for toilet use was independent with toilet use. During an observation on 9/24/2024 at 7:58 AM, the bathroom for Resident's #68, #63 and #29 share a bathroom between two rooms and the call light in the bathroom did not have a pull string. During an observation on 9/25/2024 at 2:09 PM, the bathroom for Resident's #68, #63, and #29 had a call light string but was wrapped around the call light and would not reach the floor. During an interview on 9/25/2025 at 2:35 PM, the Regional Nurse and DON said the call lights in the bathrooms were the responsibility of the Maintenance Supervisor who was not at the facility and unavailable for an interview as he was on vacation. The Regional nurse said she noticed on yesterday 9/24/2024 that there were some call lights wrapped up and she unwrapped them, so they were long enough to reach close to the floor. She said she was not aware of the bathroom where Resident #68, #63 and #29 shared did not have a bathroom call light string until yesterday 9/24/2024 and one had been installed. She said if the call light strings were not attached or if they were wrapped, residents would not be able to reach them. During an interview on 9/25/2024 at 4:35 PM, the Administrator said the Maintenance Supervisor was responsible for ensuring the call lights in the bathrooms had strings and the staff were to ensure they were not wrapped around the bars. She said it was a collaborative effort by staff. She said maintenance had a program that staff utilized to tell what inspections and checks he had due. She said the Maintenance Supervisor was on vacation and not available for interview. She said the call light strings in the bathrooms should be hanging down from the wall and not short or wrapped around anything and easily accessible. She said residents may not be able to call for assistance, if too short may not be able to reach, which could result in an injury, and no one knew until someone made rounds. Record review of a Maintenance Task List dated 9/25/2024 indicated the nurse call system test: conduct a test of the nurse call system created on 9/17/2024. There was not a task list for checking the call light strings. A facility policy for call lights was requested, but none was provided as the facility said they did not have a policy for call lights.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program and ensure it was free of pests for 1 of 4 halls (Hall 300) reviewed for pest control. The facility failed to ensure an effective pest control program was in place to keep roaches out of the bathrooms for Resident # 42 and Resident #37. This failure could place residents at risk for injury due to an ineffective pest control program at the facility. Findings included: 1. Record review of an Admission Record for Resident #42 dated 9/25/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of schizoaffective disorder, bipolar (a condition that causes hallucinations and delusion with mood swings), hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet the body's needs), and fibromyalgia (widespread muscle and bone pain). Record review of a Quarterly MDS Assessment for Resident #42 dated 9/8/2024 indicated she had moderate impairment in thinking with a BIMS score of 8. She required set up/clean up assistance with toileting and was always continent of bowel/bladder. 2. Record review of an Admission Record for Resident #37 dated 9/25/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (a group of lung disease that affect breathing), malignant neoplasm of retroperitoneum (cancer that is in the hidden space behind the abdominal cavity that contains vital organs) and type 2 diabetes. Record review of a Quarterly MDS Assessment for Resident #37 dated 8/10/2024 indicated she had moderate impairment in thinking with a BIMS score of 11. She required supervision with toileting and was always continent of bladder and bowel. During an observation on 9/23/2024 at 10:12 AM, the bathroom of Resident #42 and Resident #37 had missing baseboards along the walls and two brown bugs were noted crawling on the floor when the light was turned on and went underneath the wall. During an observation and interview on 9/23/2024 at 10:14 AM, Resident #42 was in her room sitting on the side of her bed. She said she noticed some water bugs in the bathroom a couple days ago. During an interview on 9/23/2024 at 10:19 AM, Resident #37 was sitting up in a wheelchair in her room. She said she had been at the facility for 4 years. She said she noticed cockroaches in the bathroom at night and said she saw someone spray the facility a couple of weeks ago or last month some time. During an observation an interview on 9/24/2024 at 3:45 PM, Pest Control technician was in the facility and said he had been going to the facility for 9 years and visited on a monthly and prn basis. He said he was notified to visit the facility that day to treat the bathroom between the rooms of 303 and 305. He said during his monthly visits, he treated the exterior and interior of the facility for roaches. He said monthly they alternated the chemicals used. He said prior to 9/24/2024, he had not been told of the facility having a problem with roaches. He said he had a log at the nurse station for staff to indicate if they had any issues and during his visits would review and treat the areas indicated on the log. He said the facility never used the log. He said he was not sure what the problem was with roaches in room [ROOM NUMBER] and 305 but would inspect and treat. Record review of a facility pest control log undated indicated the facility did not complete the form, form was completed by the pest control technician. Record review of a pest control invoice dated 9/16/2024 indicated an additional service was requested for reports of little black ants. Treatment of Alpine WSG-BASF was used in target areas closets, laundry room and resident room. Record review of a pest control invoice dated 7/10/2024 indicated the kitchen was treated for roaches in the dish pit. Treatment used was Alpine WSG-BASF, Gentrol IGR-Zoecon, Bifen I/T-[NAME] to treat American Roaches and German Roaches, target areas were bathrooms, common areas, crack and crevice, dish pit, kitchen. During a follow-up interview on 9/24/2024 at 4:05 PM, Pest Control technician said he had treated the bathroom of 303 and 305 and said the problem was the issue of it not having baseboards. He said without baseboards, pests could come into the facility. During an interview on 9/25/2024 at 4:35 PM, the Administrator said pest control came to the facility monthly and prn and no one was aware about the facility having roaches. She said pest control came out on yesterday 9/24/2024 and treated bathroom for room [ROOM NUMBER] and the baseboards were replaced in the bathroom as well. She said residents could be at risk of infections if they did not have an effective pest control program. Record review of a facility policy undated titled Inset and Rodent Control indicated, .The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. 2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents .

Based on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident # 54) reviewed for resident rights. The facility did not ensure Resident # 54 was spoken to or addressed in a dignified manner. This failure could place residents at risk of decreased feelings of self-worth and decreased quality of life. Findings included: Record review of facility face sheet dated 09/25/2024 indicated Resident # 54 was a [AGE] year-old female admitted to facility on 07/03/2024 with diagnosis of Fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, lack of coordination, Depression, Anxiety Disorder. Record review of Admission MDS dated [DATE] indicated Resident # 54 had a BIMS of 09 indicating moderately impaired cognition and mood issues with feeling depressed and sad. During interview on 09/24/24 at 2:00pm CNA-F stated she did not witness the incident with Resident #54 initially but was called in to assist with getting her up off the floor and assuring she was ok and back in bed comfortably. CNA-F stated LVN-L voice was very heavy and she cannot say for sure if she was yelling at Resident #54 or if she was just reacting in an emergency manner to assure the resident was ok. CNA-F did witness Resident #54 crying and saying LVN-L was yelling and rude to her and she was angry at the nurse-L. During an interview on 09/24/24 at 02:17 PM the AD stated she remembered everything about the incident on 8/2/2024 with Resident #54. The AD stated she was going to Resident #54's room to get a list of items to be picked up from Wal-Mart and she saw her call light was on and she entered the room and Resident #54 was on the floor. The AD asked Resident #54 if she was ok and told Resident #54, she will be right back and went got the LVN-L on duty and NA-F. As soon as LVN-L entered the room LVN-L started yelling and asking her what the hell was she doing on the floor for approximately 30 seconds before LVN-L and NA-F picked her up and put her back on the bed. LVN-L continued yelling at Resident #54 as to why she got out of bed. Resident#54 was trying to explain that she did not get out of bed and was getting out of her chair to get back in the bed due to being left sitting up in her room. The AD said nurse and NA-F picked Resident #54 up from the floor and put her on her bed. The AD stated after about 30 minutes and Resident #54 was crying and getting increasingly upset she told LVN-L to leave the room. The AD said LVN-L left the room and NA-F went and got the ADON whom completed an assessment of Resident #54 and determined she had calmed down and not showing further signs of distress. The AD does not recall seeing LVN_L back at the facility since the incident. During an interview on 09/25/24 at 03:56 PM the Administrator stated she had been employed since February 2024. The Administrator said AD came to her and reported that Resident #54 was crying due to LVN-L raising her voice at her for trying to get out of bed on her own. Administrator stated she immediately went to Resident #54's room and Resident #54 was upset as she explained the situation. Administrator stated she assured Resident #54 that LVN-L would no longer be taking care of her. Administrator then reported to ADON that LVN-L would be sent home on a pending investigation concerning Resident #54. Administrator stated she suspended the LVN-L immediately pending further investigation. Administrator stated Resident #54 does not show other signs of distress since the incident. Administrator stated Resident #54 told her during the incident she was crying more from being angry due to the way she was talked to and not that she was harmed in any way. Administrator said LVN-L came back to the facility after the investigation was completed and only entered her office in the facility and she was then terminated. Administrator said no other issues of inappropriate interactions had been noted with Resident #54 or any other resident in the facility. During an interview on 09/24/24 at 10:50am RP stated Resident #54 had talked about staff mistreating her, treating her like shit or things will come up missing. RP identified Resident #54 as an honorary old lady and can be mean, negative, and short towards people. RP stated he normally weighs what she said as a complaint with a grain of salt. RP stated Resident #54 is lonely and he was working to get her moved into a facility near him so she can be closer to him and other family members so Resident #54 would get visits and be monitored better. RP stated Resident #54 had no one in the area where she resides, and he felt that contributed to her mood swings. RP stated Resident #54 don't like to talk about issues as she doesn't want to be a burden to anyone. RP stated no issues with staff and whenever he called to check on Resident #54 staff had been very helpful. On 09/24/2024 at 2:00 pm LVN-L was called twice with no answer and a text message was sent on 09/25/24 at 10:49am with no response. Record Review of facility policy (undated), titled Resident Rights indicated, .Respect and Dignity-The resident has a right to be treated with respect and dignity .

Based on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident #5) reviewed for significant medication errors. The facility failed to ensure Resident #5 was free of significant medication errors when a dose of digoxin 125 mcg and metoprolol tartrate 37.5 mg was administered on 09/22/2024. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician. Findings include: Record review of a facility face sheet dated 9/25/2024 indicated Resident #5 was a [AGE] year old female that admitted to the facility on [DATE] with diagnoses of polyneuropathy (a nerve damage condition), essential hypertension (high blood pressure), tachycardia (a condition where the heart rate is faster than normal, usually more than 100 beats per minute while resting), and mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). Record review of quarterly MDS dated [DATE] indicated Resident #5 had a BIMS score of 08 indicating moderately impaired cognition. She required supervision with ADL's. Record review of care plans dated 3/29/2024 indicated the Resident #5 had hypertension, impaired cognitive function and impaired vision. Record review of a facility medication error report dated 9/22/2024 revealed that Resident #5 was given the wrong medication. The report was completed by the ADON. The ADON was administering medications on the morning of 9/22/2024 and administered Resident #5 the wrong medication. Resident #5's physician was notified and orders to monitor resident every 30 minutes for 3 hours and if no change resume residents orders. The report did not indicate what medication was administered. Record review of physician orders dated 9/25/2024 revealed that Resident #5 received Metoprolol Tartrate 25mg one half tablet by mouth and Verapamil 40 mg tablet by mouth for hypertension every morning. Record review of blood pressure and pulse monitoring performed on 9/22/2024 every 30 minutes for 3 hours as ordered by the physician after administration of wrong medications. Vital signs remained stable during monitoring for Resident #5. During an interview with the ADON on 9/24/2024 at 11:35 AM she said had been employed at the facility since April 2024. She said on Sunday 9/22/2024 she had a medication aide that called in to work. She said she was assigned to pass medications for hall 300 and 400. She said another medication aide (MA D), was working in the facility also and had told her once she was caught up, she would come and help her with medication administration. She said MA D came and helped her. ADON said she was taking Resident #67's blood pressure and the MA D prepared the medications and placed them in a cup. The ADON said when she came back to the cart, the MA D handed her the pill cup with the medications and she administered the medications to Resident #5 that was meant for Resident #67. She said she realized after giving Resident #5 the medications, MA D told her that the medications were for Resident #67 and not Resident #5. The ADON reviewed the medications and noted that Digoxin 125 mcg and metoprolol tartrate 37.5 mg was administered to Resident #5. She said she immediately called the physician and reported to the physician that she had given Resident #67's medications to Resident #5. She said the physician told to monitor every 30 minutes for 3 hours. She said she called the physician back around 2 pm as it was time for the Resident #5 to have more medications and the physician told her it was ok to give and continue with everything. She said that Resident #5 did not have any adverse reactions from the medication error. She said she had training on medication administration on hire and had a competency skill check with the previous ADON. She said residents could be at risk for blood pressure problems and negative outcomes. During an interview with MA D on 9/25/2024 at 2:20 PM she said she had worked at the facility for 2 and a half years. She said that she was working on Sunday 9/22/2024 when the medication error occurred. She said that she had returned from break and that the ADON asked her to help the ADON pass out medications on hall 300. MA D said that she went over to help the ADON. MA D said that the ADON was taking residents blood pressures and MA D was preparing medications for residents to take. MA D said she was punching medications from the cards into cups. MA D said that the ADON was obtaining blood pressures, telling her the blood pressures to document and then the ADON was taking the medications to the residents. MA D said that Resident #67 was in the bathroom and her blood pressure was not obtained, MA D said she pushed her medications to the side and started to prepare Resident #5's medications. MA D said that the ADON took Resident #67's medications from the top of the medication cart. MA D said that when the ADON returned, MA D asked the ADON what Resident #67's blood pressure was and the ADON stated that she just gave Resident #5 her medication. MA D told the ADON she had not finished preparing Residents #5 medications so Resident #5 was given Resident #67's medication. MA D said that the ADON immediately went to the nurses station to notify the doctor. MA D said she gave the cart keys back to the ADON and went back to 100 hall to work. Record review of nurse proficiency audit dated 4/25/2024 indicated that the ADON was satisfactory in administering medication properly and documentation. During an interview with the administrator on 9/25/2024 she said that she has been working at the facility for 8 months. The administrator said that she was aware of the medication error that occurred on 9/22/2024. She said that medications errors are reviewed to make sure that all appropriate steps are performed to ensure resident safety. The administrator said that a review of the incident would be done during the QA/QI meeting. The administrator stated that she expected all of the nurses and medication aides to follow the five rights of medication administration. The administrator said that a resident could have adverse side effects from receiving the wrong medications. Record review of a facility policy titled Medication Administration Procedures, Pharmacy policy and procedure manual 2003 indicated, Medications are to be poured, administered, and charted by the same licensed person. 4. Before administering the dose, the nurse must make certain to correctly identify the resident to whom the medication is being administered 12. Medications prescribed for one resident are not to be administered to any other resident Any medication error will require a medication error report that includes the error and actions to prevent reoccurrence. 20. The five rights of medication should always be adhered to 1. right drug 2. right dose 3. right resident 4. right time 5. right route.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 6 residents (Resident #324) reviewed for pharmacy services: The facility did not ensure medications were stored properly for Resident #324. Medication was left on bedside table and resident #324 is not care planned to have medication at bedside or self-administer medications. Resident #324 does not have physician orders to have medication at bed side or self-administer. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. Findings included: Record review of facility face sheet dated 09/25/2024 indicated Resident # 324 was a [AGE] year-old male admitted to facility on 09/13/2024 with diagnoses of acute respiratory failure with hypoxia (low oxygen levels with breathing). Record Review of comprehensive care plan dated 09/13/2024 did not indicate Resident # 324 could keep medication at bed side or safely self-administer medications. The care plan reflects to administer medications as ordered. Record review of Admission MDS dated [DATE] indicated Resident # 324 had a BIMS of 10 indicating moderately impaired cognition. Record review of consolidated physician orders dated 09/25/2024 indicated Resident #324 had an order for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT (Ipratropium-Albuterol) 1 puff inhale orally four times a day related to Acute respiratory failure with hypoxia. During an observation on 09/23/24 at 10:30 am Resident # 324 was observed with medication on nightstand. He stated he did not self-administer any medications and did not know there were medication on his nightstand. During an observation on 09/24/24 at 1:25 pm Resident #324 had Clear Eyes maximum itchy eye relief (over the counter) eye drops on his bed side table. This medication was not care planed or ordered by a physician. During an interview 09/25/24 at 03:19 PM LVN-L stated she was employed with the facility for 10 months. LVN-L stated they do not store medications in resident's room. All medications are stored on each LVN's med cart for all residents in the facility. LVN-L stated due to Residen t #324 having a G-Tube and bed confined with limited ROM he cannot self-administer his medications. LVN-L stated if medications are left in the room someone else could get them or the resident could take extra doses which could be very harmful to the residents in the facility. LVN-L stated she always try to make sure all meds are put on the cart and cart is kept locked when not in use. LVN-L does not recall any meds every being left in the rooms in the past other than resident #324's inhaler. LVN-L stated they do have an issue with his wife bringing over the counter medications to him if he asks her to. LVN-L stated if she finds medication on the bedside table, she will immediately pick it up, identify it and report it to the responsible person so they can store it properly or discard it. During an interview on 09/25/24 at 03:38 PM LVN-K stated she has been employed with the facility for 7 1/2 month. LVN-K stated all medications should be stored in a locked med cart and not at the resident's bed side. She reports that if she sees medications inappropriately stored, she will get another nurse to witness, remove the medication, discard, or store the medication in a locked medication cart. LVN-K stated she will report the incident to her DON and report the medication error as directed by her superiors. LVN-K stated that if a resident takes the medication at the wrong time or an unprescribed med it could have minor to severe effects on a resident. She also stated that she would notify the Doctor if it were identified that the patient did not take their prescribed dose and it was too late to give or if a person took medications that were not prescribed. During an interview on 09/25/2024 at 2:10pm the ADON stated medications are never to be left at bedside or in a patient's room without a medication aide or nurse being present or in the process of administering the medication. The ADON stated all medication aides and nurses have been in-serviced on medication storage and should not have left any type of medication in a resident's room. Record Review of Medication Administration Policy dated October 25, 2017, titled Medication Administration Procedures did not address leaving medications at bed side.

Based on observation, interview and record review, the facility failed to equip corridors with firmly secured handrails for 1 of 4 hallways (hall 400) reviewed for environmental conditions. The facility did not ensure a handrail found on 400 hall was firmly affixed to the wall. This failure could place residents at risk for avoidable accidents and decreased quality of life due to environmental hazards. Findings include: During an observation on 9/23/24 at 12:00 pm a handrail was observed loose in the hallway. It was detached from the wall on the end. The bracket was not secured to the wall. During an interview on 9/23/24 at 3:50 pm DON said the handrail being loose could cause residents to fall if it was not securely attached to the wall. During an interview on 9/25/24 at 3:06 pm Administrator said going forward she would ensure the maintenance supervisor inspected the handrails weekly. She said she would also be in-servicing the staff to use the computer system to put maintenance issues in the system that the maintenance supervisor needed to correct. She said maintenance supervisor was responsible for ensuring the handrails were securely attached to the wall. She said maintenance supervisor was off on vacation this week and was unavailable by phone. She said residents could be at risk of falls if they were using it to hold on to and it came off. She said they also could be at risk of being cut by the sharp edge. Record review of a facility policy titled Resident Rights dated 2003 and revised on 11/28/16 read Safe environment - The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 7 residents reviewed for notification of changes. (Resident #1) Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. These failures could place residents at risk for unnecessary pain, delay in treatment, and decreased quality of life. Findings included: Record review of Resident #1's face sheet, printed on 12/20/23 indicated she was an [AGE] year old female who admitted to facility on 2/25/22 and readmitted on [DATE] with diagnoses including Alzheimer's disease a type of dementia that affects memory, thinking and behavior), cognitive communication deficit (defined as an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle wasting and atrophy in right and left shoulders (is the wasting or thinning of your muscle mass), and age related osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall or, in serious cases, from sneezing or minor bumps). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #1 has ability to understand others. She had Brief Interview for Mental Status (BIMS) score of 3, which indicated a severe cognitive impairment. Section J indicated Resident #1 does not receive scheduled pain medication and had not received PRN pain medication, did not receive non-medication intervention for pain and had not been in pain over the 5 previous days. Record review of Resident #1's care plan indicated the following: Focus: The resident has a potential for uncontrolled pain due to Fracture of Right Humerus. Date Initiated: 12/20/23; Goal: -The resident will not have an interruption in normal activities due to pain. - The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -The resident will not have discomfort related to side effects of analgesia. Date Initiated: 12/20/23; Intervention:- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Ensure sling is in place to right arm. - Evaluate the effectiveness of pain interventions . Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. - Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss.- Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM , withdrawal, or resistance to care. - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort. Date Initiated: 12/20/23. Focus: The resident has an ADL Self Care Performance Deficit. Date Initiated: 03/01/23; Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score). Revised on: 11/13/23; Intervention: Required staff x1 assist with Bathing, Bed Mobility, Dressing, and Toilet use. Resident #1 required a lift for all Transfers. Revised on: 03/08/22. Record review of Resident #1's physician order dated 12/20/23 revealed Tramadol Tablet 50mg - give one tablet by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Tylenol with Codeine #3 Tablet 300-30mg (Acetaminophen-Codeine) - give two tablets by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Record review of Resident #1's Treatment Administration Record printed on 12/20/23 revealed Tramadol and Tylenol PRN pain medications were not given from 12/01/23 to 12/20/23; and no pain level was documented from 12/01/23 to 12/20/23. The page was blank. Record review of Resident #1's incident report dated 12/20/23 completed by LVN B indicated the incident happened in Resident #1's room. Nursing Description: Late Entry for 12/16/23 at 1:31pm Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to be hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and this behavior is very unlike resident. Resident Description: Resident #1 unable to give description. Immediate Action Taken: Order placed to obtain X-ray and called to get portable x-ray completed. Resident #1's family member notified, and NP notified. Injury Type: Fracture; Injury Location: Right upper arm. Record review of Resident #1's ER After Visit Summary dated 12/16/23 indicated the reason for visit: Arm Injury; Diagnosis: Closed displaced oblique fracture (occur when your bone is broken at an angle) of shaft of right humerus (upper arm bone) , initial encounter. Imaging Test: X-ray Humerus right 2 views; Application long arm splint and Orthopedic surgery referral. Record review of Resident #1's x-ray patient report dated 12/16/23 indicated Procedure: Right Humerus, 2+ views; Findings: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Rest of the right humerus show normal alignment. The bones show normal architecture. Degenerative changes were seen at the few joints. Rest of the articular margins and joint space of various joints appear normal. There was no radiological evidence of any loose bodies. There was no evidence of any osteomyelitis or sequestrum. No soft tissue calcification was seen. Impression: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 11:09am; Completed by ADON G: COVID Booster given in Left deltoid, tolerated well, with no redness or swelling noted. -On 12/15/23 at 9:23pm; Completed by LVN E: LATE ENTRY - Called to Resident #1's room by care by staff. Resident #1 complaining her right arm was hurting and was holding that arm across her chest. No bruising, redness or swelling noted on arm. No obvious deformity or protrusions. Resident #1 was able to grasp hands of nurse firmly. Noted gauze on center of arm where blood drawn done previously, asked Resident #1 if that was the area that was hurting, and she replied yes then said no I'm not sure. Resident #1 was cursing staff to leave her alone. Will report to AM nurse in report to monitor. -On 12/16/23 at 1:31pm; Completed by LVN B: Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and that behavior was very unlike Resident #1. -On 12/16/23 at 4:32pm; Completed by LVN B: Resident #1 was transferred to a hospital on 12/16/23 12:00am related to Resident #1 complaining of pain to right arm. Obtained portable x-ray which show a fractured humerus. -On 12/16/23 at 9:07pm; Completed by LVN E: Resident #1 returned from the ER. Sling to right arm in place, continue all previous orders and follow up with orthopedic doctor. During an observation on 12/30/23 at 1:55 p.m., Resident #1 was not interviewable. She was not able to answer or understand questions asked at that time. Resident #1 was well groomed, no odors, and did not appear distressed. Resident #1 was lying in bed resting with right arm was in a sling and propped on pillows. During an interview on 12/30/23 at 12:56 p.m., LVN B said she worked the 6am to 6pm shift, and she could not recall if the incident occurred on Saturday or Sunday, but CNA C came to her regarding Resident #1 favoring her right arm and would curse if anyone touched her which was not like Resident #1 to curse. She said Resident #1 had mentioned earlier (after breakfast, but before Lunch) that her arm was hurting, but LVN B said she assumed it was due to Resident #1 had received a COVID booster shot a few days before and that was the reason Resident #1's arm was sore. LVN B said Resident #1's right arm looked swollen compared to her left arm, which prompted her to go back and review Resident #1's COVID assessment to verify which arm Resident #1 received her booster shot and that was when she saw the booster was administered in Resident #1's left arm. LVN B said she called for an x-ray, and notified the MD, Resident #1's family member, and the DON. LVN B said the x-ray technician called her into Resident #1's room to view the x-ray and she said it was visible that Resident #1's arm was broken. LVN B said she sent Resident #1 to the ER for further evaluation and treatment. LVN B said she did not know how Resident #1's arm was fractured, possibly from Hoyer transfer but Resident #1 had not been transferred that day. During an interview on 12/30/23 at 1:17 p.m., CNA C said the morning of the incident, during the morning report she overheard the night nurse tell LVN B that Resident #1 had a booster shot and was complaining of arm pain. CNA C said whenever she made her first round (could not recall time) she observed Resident #1 holding her right arm, but she did not think too much of it because of what the night nurse had said during her report. CNA C said during her second round (did not recall time) Resident #1 was not wet, so she did not touch her arm. She said during her third round (did not recall time) Resident #1 was wet and she noticed Resident #1 was still holding her right arm. CNA C said CNA F asked her why Resident #1's right arm was hurting, CNA C said she explained that Resident #1's arm was hurting possibly due to booster shot she received a few days prior. She said CNA F asked Resident #1 location of pain, and Resident #1 pointed to location, she said CNA F touched area and Resident #1 yelled out in pain, so CNA F and CNA C propped arm and notified LVN B. CNA C said Resident #1 cursed at them and that was unlike her to curse because normally Resident #1 was cool, calm, and collected and gave them no issues. During an interview on 12/30/23 at 2:10 p.m., CNA D said on 12/15/23 around 7:00pm Resident #1's roommate asked for patient care and when she went to do patient care on the roommate, Resident #1 voiced pain and grabbed her arm. CNA D said she immediately notified LVN E and LVN E assessed Resident #1. She said she observed LVN E bend Resident #1's arm up and down, and Resident #1 squeezed LVN E' s hand. CNA D said Resident #1 did not voice being in pain when she performed patient care after LVN E's assessment. During an interview on 12/30/23 at 6:24 p.m., LVN E said she worked the 6pm to 6am shift and on 12/15/23. LVN E said after the CNAs first round the CNAs told her Resident #1 complained of arm pain and was holding her arm to her chest. LVN E said she observed Resident #1 holding her arm, and saw a gauze from the booster shot, and Resident #1 could not say exactly where her arm was hurting. LVN E said she did range of motion on Resident #1, with no issues. LVN E said she did not administer Resident #1 PRN pain medications because she did not feel pain medicine was needed. LVN E said she needed more facial grimacing . She said it was not normal for Resident #1 to hold her arm or complain of pain but during the rest of her shift Resident #1 did not complain of pain so did not think much of it. LVN E said she did not do any follow up interventions after her initial assessment, but she did verbally report to LVN B and documented on the 24-hour change of condition form to monitor Resident #1 because she complained of arm pain. During an interview on 12/30/23 at 4:23 p.m., the DON said staff did not document pain assessment on Resident #1 and she did an Inservice on pain management. She said Resident #1 had an order for PRN pain medication and no pain medication was given when Resident #1 complained of arm pain on 12/15/23 or on 12/16/23. The DON said Resident #1 was not cognitive enough to know she needed pain medication; therefore, pain medication should had been given whenever Resident #1 was complaining or showing signs of being in pain. She said the pain scale was not required if PRN pain medication was not given, because nurses only documented pain level if pain medications were given. The DON said the nurses should have notified the physician with any change of condition, but didn't; she did an in-service on 1-17-24 Topic, Notify the physician with any change of condition (SBAR). During an interview via phone on 1/8/24 at 8:56 a.m., CNA F said on 12/16/23 she worked the 6am-6pm shift on the 100 Hall. She said she assisted CNA C with the 200 Hall to do patient care with Resident #1 around 9:00am and during patient care Resident #1 told them that her arm was hurting and pointed at her right arm. CNA F said they told LVN B and LVN B explained to them that LVN E told her during morning report that Resident #1 started complaining of arm pain during the 6pm to 6am shift on 12/15/23 and was possibly due to lab drawn a few days prior. CNA F said she did see Resident #1 had gauze on her right hand and did not think anything of it after LVN B told them Resident #1 was sore from having blood drawn. CNA F said during her second round after lunch around 1pm she assisted CNA C with patient care on Resident #1 and when they rolled Resident #1 during patient care Resident #1 started cursing at them and calling them the B-word which was not like Resident #1, and she knew something was wrong. CNA F said after they finished patient care, they notified LVN B again that something was seriously wrong for her to react like that. CNA F said Resident #1 was not interviewable, and Resident #1 was able to answer questions, but her responses were random and often did not make sense. CNA F said Resident #1 did not normally complain of pain and was not cognitive enough to ask for pain medication, and she did not know if Resident #1 was given pain medication. During an interview via phone on 1/8/24 at 9:29 a.m., ADON G said she administered Resident #1's COVID booster shot on 12/13/23 and Resident #1 was not complaining of pain at that time. ADON G said her last time seeing Resident #1 was on 12/14/23 before she was on leave for the next three days, but on 12/14/23 it was after lunch and Resident #1 was up in her wheelchair outside her room on the 200 Hall, and she remembered seeing Resident #1's hands prayer style and she was resting her chin. ADON G said Resident #1 did not appear in pain during that time. ADON G said most residents had PRN pain meds and if a resident was complaining of pain, then nurses can give pain medications. ADON G said Resident #1 was non interviewable and did not normally complain of pain, she said Resident #1 should had been given pain medicine if she was showing signs and voicing pain. During an interview on 1/17/24 at 4:09 p.m., CNA H said on 12/15/23, she was walking down Hall 200 coming from her break and was going back to Hall 400 and saw CNA D standing outside Resident #1's door. CNA H said CNA D asked for someone to go get the nurse and CNA J left to get LVN E. CNA H said she was not involved much, and personally did not hear Resident #1 say she was hurting but she did see LVN E raise Resident #1's arm and ask Resident #1 if that hurt and Resident #1 said No. During an interview on 1/18/24 at 7:12 p.m., CNA J said on 12/15/23 around 9:15pm, she was working on hall 100 when she heard a call light on hall 200 and whenever she looked down hall 200 CNA D was coming out of Resident #1's room. She said CNA D motioned for her to come over and CNA D told her Resident #1 was saying her arm was broke and for CNA J to go get LVN E. CNA J said she left to go look for LVN E, and then she returned with LVN E to Resident #1's room. CNA J said CNA D and CNA H were both in Resident #1's room waiting for LVN E and Resident #1 was in bed holding her right arm. She said LVN E asked Resident #1 what was wrong, and she heard Resident #1 say my arm hurt, it's broke and was moaning ow, ow. CNA J said LVN E touched Resident #1's right arm and Resident #1 said it hurts. She said LVN E looked over at them and said Resident #1 had lab drawn earlier, and then LVN went to go verify in Resident #1's chart. CNA J said she returned to Resident #1's room around 5:00am to assist CNA D with rotating Resident #1 and Resident #1 was saying Oh my arm hurts, hurts so bad. CNA J said she made the comment to CNA D Are they not going to send Resident #1 out or get an x-ray because Resident #1 appeared to be in a lot of pain. CNA J said they did mention to LVN E that Resident #1 was still complaining of arm pain. Record review of revised pain management/assessment scaled policy dated 5/25/2016 indicated Pain is a subjective sensation `of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy: Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: 1) Residents identifies pain characteristics. 2) Resident articulates factors that intensify pain. 3) Resident expresses a feeling of comfort and relief from pain. 4) Resident states and carries out appropriate pain interventions from pain relief. 5) Cognitively impaired residents will demonstrate actions of pain relief. Procedures: 1) Assess resident's physical symptoms of pain, physical complaints, and daily activities. Plain questions based on a resident communication ability were included in the Admission/Readmission and weekly nursing summary. If a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAIN AD assessment. 2) Perform comfort measures to promote relaxation. 3) Plan activities with the resident to provide distraction, such as reading, craft, television, or visits, to help resident focus on non-pain related matters. 4) Manipulate the environment to promote periods of uninterrupted rest as much as possible. This promotes health, well-being, and increased energy level important to pain relief. 5) Apply heat or cold as ordered (specify) to minimize or relieve pain. 6) Help resident into a comfortable position and use pillows to splint or support painful area, as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 7) Ask resident to help establish goals and develop plan for pain control. This gives resident sense of control. 8) Instruct resident in use of relaxation techniques. 9) Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain. 10) Assist the resident in maintaining a pain management and rest schedule, exercise program and medication regimen. 11) Encourage self-care activities. 12) Talk with the resident about pain and assess for pain relief after interventions. 13) Monitor for effectiveness of pain interventions. 14) The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plan will be maintained for the management of the resident's pain. Record review of revised notifying the physician of change in status policy dated 03/11/13 indicated The nurse should not hesitate to contact the physician at any time when as assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to notify the MD/MP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on next workday notification of the physician. 1)The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2) Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3) The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record .6) The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide and nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7) The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions. On 01/17/2024 at 4:00p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The Plan of Removal (POR) was accepted on 1/18/24 at 11:45am and indicated the following: Plan of Removal - F697 Pain Management On January 17, 2024, the facility learned that an IJ was being called due to F697 Pain Management. The Facility failed to: -Adequately assess Resident #1 for pain and administer pain medications as ordered. Resident #1 did not receive as needed pain medications from 12/15/23-12/20/23. -Notify the physician when Resident #1 had a change in behavior and complained of pain. -Notify the Administrator when Resident #1 had a change in behavior and complained of pain -Follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. -Follow up and monitor for continued signs and symptoms of pain for Resident #1 between 12/15/23 and 12/17/23. The facility needs to take immediate action to correct this noncompliance to ensure residents receive the care and services needed to prevent residents from not receiving pain medications and a diminished quality of life, that could lead to serious injury, harm, or death. -As of 1/17/24 resident # 1 was assessed for pain by the DON. No complaints of pain or additional issues noted. Resident #1 has pain medication ordered. -All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 1/17/24. No additional residents were identified. -As of 1/17/24 the charge nurse B and charge nurse E were 1:1 in-serviced by the DON on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All charge nurses were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topics below. All charge nurses including agency staff, new hires and PRN charge nurses not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse. -Administering pain medication for residents with signs and symptoms of pain. -Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All clinical staff were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topic below. All clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse -Pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) -Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. -Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The medical director was notified by the DON on 1/17/24 on the immediate jeopardy situation by the Administrator. An AD HOC QAPI meeting was held on 1/17/24 by the Interdisciplinary Team to discuss the immediate jeopardy and review the plan of removal for pain. In attendance was the Administrator, DON, Regional Nurse, Medical Director, [NAME] President of Clinical Services, [NAME] President of Operations. On 01/18/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews and record reviews were conducted on 01/18/24 from 5:00 p.m. through 8:00 p.m. and included 5 LVNs, 6 CNAs, ADON, DON, and Regional Compliance Nurse. Staff were able to explain administering pain medication for residents with signs and symptoms of pain. Staff had knowledge on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff were able to explain pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Staff had knowledge on notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. All residents in the facility were assessed for any increased pain by the DON and Charge Nurses. This was verified by interview with DON and record review of audit sheets listing resident name and room number. In-Services addressed pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff was in-serviced on pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The Charge Nurses was in-serviced on administering pain medication for residents with signs and symptoms of pain. Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. This was verified by record review of staff in-services signature sheets and staff interviews. The Director of Nursing / designee will educate all clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of the above in-services. This was verified by interview with DON that it will occur and record review of staff signature sign-in sheets. Interview with Regional Compliance Nurse verified an Ad Hoc QAPI was conducted to discuss the immediate jeopardy concerning pain management and to develop the above-mentioned plan of care. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction.

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, for 1 of 7 residents (Resident #1) reviewed for pain management. 1. Facility failed to ensure Resident #1 was adequately assess for pain and administer pain medications as ordered from 12/15/23-12/20/23. 2. Facility failed to ensure the physician was notified when Resident #1 had a change in behavior and complained of pain. 3. Facility failed to ensure the Administrator was notified when Resident #1 had a change in behavior and complained of pain 4. Facility failed to follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. 5. Facility failed to follow up and monitor for continued signs and symptoms of pain for Resident #1 between 12/15/23 and 12/17/23. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction. These failures could place residents at risk of not receiving pain medications and a diminished quality of life. Findings included: Record review of Resident #1's face sheet, printed on 12/20/23 indicated she was an [AGE] year old female who admitted to facility on 2/25/22 and readmitted on [DATE] with diagnoses including Alzheimer's disease a type of dementia that affects memory, thinking and behavior), cognitive communication deficit (defined as an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), muscle wasting and atrophy in right and left shoulders (is the wasting or thinning of your muscle mass), and age related osteoporosis (a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall or, in serious cases, from sneezing or minor bumps). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she has difficulty communicating some words or finishing thoughts but is able if prompted or given time. Resident #1 has ability to understand others. She had Brief Interview for Mental Status (BIMS) score of 3, which indicated a severe cognitive impairment. Section J indicated Resident #1 does not receive scheduled pain medication and had not received PRN pain medication, did not receive non-medication intervention for pain and had not been in pain over the 5 previous days. Record review of Resident #1's care plan indicated the following: Focus: The resident has a potential for uncontrolled pain due to Fracture of Right Humerus. Date Initiated: 12/20/23; Goal: -The resident will not have an interruption in normal activities due to pain. - The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -The resident will not have discomfort related to side effects of analgesia. Date Initiated: 12/20/23; Intervention:- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. - Ensure sling is in place to right arm. - Evaluate the effectiveness of pain interventions . Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. - Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. - Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. - Monitor/record/report to Nurse any s/sx of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). - Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss.- Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. - Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. - Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM , withdrawal, or resistance to care. - Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort. Date Initiated: 12/20/23. Focus: The resident has an ADL Self Care Performance Deficit. Date Initiated: 03/01/23; Goal: The resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene; ADL Score). Revised on: 11/13/23; Intervention: Required staff x1 assist with Bathing, Bed Mobility, Dressing, and Toilet use. Resident #1 required a lift for all Transfers. Revised on: 03/08/22. Record review of Resident #1's physician order dated 12/20/23 revealed Tramadol Tablet 50mg - give one tablet by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Tylenol with Codeine #3 Tablet 300-30mg (Acetaminophen-Codeine) - give two tablets by mouth every 6 hours as needed for pain; Order and Start Date: 2/25/22. Record review of Resident #1's Treatment Administration Record printed on 12/20/23 revealed Tramadol and Tylenol PRN pain medications were not given from 12/01/23 to 12/20/23; and no pain level was documented from 12/01/23 to 12/20/23. The page was blank. Record review of Resident #1's incident report dated 12/20/23 completed by LVN B indicated the incident happened in Resident #1's room. Nursing Description: Late Entry for 12/16/23 at 1:31pm Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to be hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and this behavior is very unlike resident. Resident Description: Resident #1 unable to give description. Immediate Action Taken: Order placed to obtain X-ray and called to get portable x-ray completed. Resident #1's family member notified, and NP notified. Injury Type: Fracture; Injury Location: Right upper arm. Record review of Resident #1's ER After Visit Summary dated 12/16/23 indicated the reason for visit: Arm Injury; Diagnosis: Closed displaced oblique fracture (occur when your bone is broken at an angle) of shaft of right humerus (upper arm bone) , initial encounter. Imaging Test: X-ray Humerus right 2 views; Application long arm splint and Orthopedic surgery referral. Record review of Resident #1's x-ray patient report dated 12/16/23 indicated Procedure: Right Humerus, 2+ views; Findings: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Rest of the right humerus show normal alignment. The bones show normal architecture. Degenerative changes were seen at the few joints. Rest of the articular margins and joint space of various joints appear normal. There was no radiological evidence of any loose bodies. There was no evidence of any osteomyelitis or sequestrum. No soft tissue calcification was seen. Impression: Acute displaced spiral fracture of mid shaft of the right humerus bone is noted. Record review of Resident #1's Progress notes indicated the following: -On 12/13/23 at 11:09am; Completed by ADON G: COVID Booster given in Left deltoid, tolerated well, with no redness or swelling noted. -On 12/15/23 at 9:23pm; Completed by LVN E: LATE ENTRY - Called to Resident #1's room by care by staff. Resident #1 complaining her right arm was hurting and was holding that arm across her chest. No bruising, redness or swelling noted on arm. No obvious deformity or protrusions. Resident #1 was able to grasp hands of nurse firmly. Noted gauze on center of arm where blood drawn done previously, asked Resident #1 if that was the area that was hurting, and she replied yes then said no I'm not sure. Resident #1 was cursing staff to leave her alone. Will report to AM nurse in report to monitor. -On 12/16/23 at 1:31pm; Completed by LVN B: Obtained Stat portable x-ray of right upper and lower arm and right elbow related to Resident #1 complaining of pain to that arm. Resident #1 was noted to hollering and cussing at aides when they touch that arm to roll or turn her to provide peri care and that behavior was very unlike Resident #1. -On 12/16/23 at 4:32pm; Completed by LVN B: Resident #1 was transferred to a hospital on 12/16/23 12:00am related to Resident #1 complaining of pain to right arm. Obtained portable x-ray which show a fractured humerus. -On 12/16/23 at 9:07pm; Completed by LVN E: Resident #1 returned from the ER. Sling to right arm in place, continue all previous orders and follow up with orthopedic doctor. During an observation on 12/30/23 at 1:55 p.m., Resident #1 was not interviewable. She was not able to answer or understand questions asked at that time. Resident #1 was well groomed, no odors, and did not appear distressed. Resident #1 was lying in bed resting with right arm was in a sling and propped on pillows. During an interview on 12/30/23 at 12:56 p.m., LVN B said she worked the 6am to 6pm shift, and she could not recall if the incident occurred on Saturday or Sunday, but CNA C came to her regarding Resident #1 favoring her right arm and would curse if anyone touched her which was not like Resident #1 to curse. She said Resident #1 had mentioned earlier (after breakfast, but before Lunch) that her arm was hurting, but LVN B said she assumed it was due to Resident #1 had received a COVID booster shot a few days before and that was the reason Resident #1's arm was sore. LVN B said Resident #1's right arm looked swollen compared to her left arm, which prompted her to go back and review Resident #1's COVID assessment to verify which arm Resident #1 received her booster shot and that was when she saw the booster was administered in Resident #1's left arm. LVN B said she called for an x-ray, and notified the MD, Resident #1's family member, and the DON. LVN B said the x-ray technician called her into Resident #1's room to view the x-ray and she said it was visible that Resident #1's arm was broken. LVN B said she sent Resident #1 to the ER for further evaluation and treatment. LVN B said she did not know how Resident #1's arm was fractured, possibly from Hoyer transfer but Resident #1 had not been transferred that day. During an interview on 12/30/23 at 1:17 p.m., CNA C said the morning of the incident, during the morning report she overheard the night nurse tell LVN B that Resident #1 had a booster shot and was complaining of arm pain. CNA C said whenever she made her first round (could not recall time) she observed Resident #1 holding her right arm, but she did not think too much of it because of what the night nurse had said during her report. CNA C said during her second round (did not recall time) Resident #1 was not wet, so she did not touch her arm. She said during her third round (did not recall time) Resident #1 was wet and she noticed Resident #1 was still holding her right arm. CNA C said CNA F asked her why Resident #1's right arm was hurting, CNA C said she explained that Resident #1's arm was hurting possibly due to booster shot she received a few days prior. She said CNA F asked Resident #1 location of pain, and Resident #1 pointed to location, she said CNA F touched area and Resident #1 yelled out in pain, so CNA F and CNA C propped arm and notified LVN B. CNA C said Resident #1 cursed at them and that was unlike her to curse because normally Resident #1 was cool, calm, and collected and gave them no issues. During an interview on 12/30/23 at 2:10 p.m., CNA D said on 12/15/23 around 7:00pm Resident #1's roommate asked for patient care and when she went to do patient care on the roommate, Resident #1 voiced pain and grabbed her arm. CNA D said she immediately notified LVN E and LVN E assessed Resident #1. She said she observed LVN E bend Resident #1's arm up and down, and Resident #1 squeezed LVN E' s hand. CNA D said Resident #1 did not voice being in pain when she performed patient care after LVN E's assessment. During an interview on 12/30/23 at 6:24 p.m., LVN E said she worked the 6pm to 6am shift and on 12/15/23. LVN E said after the CNAs first round the CNAs told her Resident #1 complained of arm pain and was holding her arm to her chest. LVN E said she observed Resident #1 holding her arm, and saw a gauze from the booster shot, and Resident #1 could not say exactly where her arm was hurting. LVN E said she did range of motion on Resident #1, with no issues. LVN E said she did not administer Resident #1 PRN pain medications because she did not feel pain medicine was needed. LVN E said she needed more facial grimacing . She said it was not normal for Resident #1 to hold her arm or complain of pain but during the rest of her shift Resident #1 did not complain of pain so did not think much of it. LVN E said she did not do any follow up interventions after her initial assessment, but she did verbally report to LVN B and documented on the 24-hour change of condition form to monitor Resident #1 because she complained of arm pain. During an interview on 12/30/23 at 4:23 p.m., the DON said staff did not document pain assessment on Resident #1 and she did an Inservice on pain management. She said Resident #1 had an order for PRN pain medication and no pain medication was given when Resident #1 complained of arm pain on 12/15/23 or on 12/16/23. The DON said Resident #1 was not cognitive enough to know she needed pain medication; therefore, pain medication should had been given whenever Resident #1 was complaining or showing signs of being in pain. She said the pain scale was not required if PRN pain medication was not given, because nurses only documented pain level if pain medications were given. During an interview via phone on 1/8/24 at 8:56 a.m., CNA F said on 12/16/23 she worked the 6am-6pm shift on the 100 Hall. She said she assisted CNA C with the 200 Hall to do patient care with Resident #1 around 9:00am and during patient care Resident #1 told them that her arm was hurting and pointed at her right arm. CNA F said they told LVN B and LVN B explained to them that LVN E told her during morning report that Resident #1 started complaining of arm pain during the 6pm to 6am shift on 12/15/23 and was possibly due to lab drawn a few days prior. CNA F said she did see Resident #1 had gauze on her right hand and did not think anything of it after LVN B told them Resident #1 was sore from having blood drawn. CNA F said during her second round after lunch around 1pm she assisted CNA C with patient care on Resident #1 and when they rolled Resident #1 during patient care Resident #1 started cursing at them and calling them the B-word which was not like Resident #1, and she knew something was wrong. CNA F said after they finished patient care, they notified LVN B again that something was seriously wrong for her to react like that. CNA F said Resident #1 was not interviewable, and Resident #1 was able to answer questions, but her responses were random and often did not make sense. CNA F said Resident #1 did not normally complain of pain and was not cognitive enough to ask for pain medication, and she did not know if Resident #1 was given pain medication. During an interview via phone on 1/8/24 at 9:29 a.m., ADON G said she administered Resident #1's COVID booster shot on 12/13/23 and Resident #1 was not complaining of pain at that time. ADON G said her last time seeing Resident #1 was on 12/14/23 before she was on leave for the next three days, but on 12/14/23 it was after lunch and Resident #1 was up in her wheelchair outside her room on the 200 Hall, and she remembered seeing Resident #1's hands prayer style and she was resting her chin. ADON G said Resident #1 did not appear in pain during that time. ADON G said most residents had PRN pain meds and if a resident was complaining of pain, then nurses can give pain medications. ADON G said Resident #1 was non interviewable and did not normally complain of pain, she said Resident #1 should had been given pain medicine if she was showing signs and voicing pain. During an interview on 1/17/24 at 4:09 p.m., CNA H said on 12/15/23, she was walking down Hall 200 coming from her break and was going back to Hall 400 and saw CNA D standing outside Resident #1's door. CNA H said CNA D asked for someone to go get the nurse and CNA J left to get LVN E. CNA H said she was not involved much, and personally did not hear Resident #1 say she was hurting but she did see LVN E raise Resident #1's arm and ask Resident #1 if that hurt and Resident #1 said No. During an interview on 1/18/24 at 7:12 p.m., CNA J said on 12/15/23 around 9:15pm, she was working on hall 100 when she heard a call light on hall 200 and whenever she looked down hall 200 CNA D was coming out of Resident #1's room. She said CNA D motioned for her to come over and CNA D told her Resident #1 was saying her arm was broke and for CNA J to go get LVN E. CNA J said she left to go look for LVN E, and then she returned with LVN E to Resident #1's room. CNA J said CNA D and CNA H were both in Resident #1's room waiting for LVN E and Resident #1 was in bed holding her right arm. She said LVN E asked Resident #1 what was wrong, and she heard Resident #1 say my arm hurt, it's broke and was moaning ow, ow. CNA J said LVN E touched Resident #1's right arm and Resident #1 said it hurts. She said LVN E looked over at them and said Resident #1 had lab drawn earlier, and then LVN went to go verify in Resident #1's chart. CNA J said she returned to Resident #1's room around 5:00am to assist CNA D with rotating Resident #1 and Resident #1 was saying Oh my arm hurts, hurts so bad. CNA J said she made the comment to CNA D Are they not going to send Resident #1 out or get an x-ray because Resident #1 appeared to be in a lot of pain. CNA J said they did mention to LVN E that Resident #1 was still complaining of arm pain. Record review of revised pain management/assessment scaled policy dated 5/25/2016 indicated Pain is a subjective sensation `of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy: Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals: 1) Residents identifies pain characteristics. 2) Resident articulates factors that intensify pain. 3) Resident expresses a feeling of comfort and relief from pain. 4) Resident states and carries out appropriate pain interventions from pain relief. 5) Cognitively impaired residents will demonstrate actions of pain relief. Procedures: 1) Assess resident's physical symptoms of pain, physical complaints, and daily activities. Plain questions based on a resident communication ability were included in the Admission/Readmission and weekly nursing summary. If a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAIN AD assessment. 2) Perform comfort measures to promote relaxation. 3) Plan activities with the resident to provide distraction, such as reading, craft, television, or visits, to help resident focus on non-pain related matters. 4) Manipulate the environment to promote periods of uninterrupted rest as much as possible. This promotes health, well-being, and increased energy level important to pain relief. 5) Apply heat or cold as ordered (specify) to minimize or relieve pain. 6) Help resident into a comfortable position and use pillows to splint or support painful area, as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 7) Ask resident to help establish goals and develop plan for pain control. This gives resident sense of control. 8) Instruct resident in use of relaxation techniques. 9) Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain. 10) Assist the resident in maintaining a pain management and rest schedule, exercise program and medication regimen. 11) Encourage self-care activities. 12) Talk with the resident about pain and assess for pain relief after interventions. 13) Monitor for effectiveness of pain interventions. 14) The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plan will be maintained for the management of the resident's pain. On 01/17/2024 at 4:00p.m., an Immediate Jeopardy (IJ) was identified. The Administrator was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The Plan of Removal (POR) was accepted on 1/18/24 at 11:45am and indicated the following: Plan of Removal - F697 Pain Management On January 17, 2024, the facility learned that an IJ was being called due to F697 Pain Management. The Facility failed to: -Adequately assess Resident #1 for pain and administer pain medications as ordered. Resident #1 did not receive as needed pain medications from 12/15/23-12/20/23. -Notify the physician when Resident #1 had a change in behavior and complained of pain. -Notify the Administrator when Resident #1 had a change in behavior and complained of pain -Follow their pain management policy by not administering as needed pain medications due to staff not believing pain medication was needed and that Resident #1 needed more facial grimacing. -Follow up and monitor for continued signs and symptoms of pain for Resident #1 between 12/15/23 and 12/17/23. The facility needs to take immediate action to correct this noncompliance to ensure residents receive the care and services needed to prevent residents from not receiving pain medications and a diminished quality of life, that could lead to serious injury, harm, or death. -As of 1/17/24 resident # 1 was assessed for pain by the DON. No complaints of pain or additional issues noted. Resident #1 has pain medication ordered. -All residents in the facility were assessed for any increased pain by the DON and Charge Nurses as of 1/17/24. No additional residents were identified. -As of 1/17/24 the charge nurse B and charge nurse E were 1:1 in-serviced by the DON on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All charge nurses were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topics below. All charge nurses including agency staff, new hires and PRN charge nurses not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse. -Administering pain medication for residents with signs and symptoms of pain. -Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. All clinical staff were in-serviced on 1/17/24 by the Compliance Nurse/DON/ADON regarding the following topic below. All clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-service by Compliance Nurse -Pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching) -Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. -Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The medical director was notified by the DON on 1/17/24 on the immediate jeopardy situation by the Administrator. An AD HOC QAPI meeting was held on 1/17/24 by the Interdisciplinary Team to discuss the immediate jeopardy and review the plan of removal for pain. In attendance was the Administrator, DON, Regional Nurse, Medical Director, [NAME] President of Clinical Services, [NAME] President of Operations. On 01/18/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews and record reviews were conducted on 01/18/24 from 5:00 p.m. through 8:00 p.m. and included 5 LVNs, 6 CNAs, ADON, DON, and Regional Compliance Nurse. Staff were able to explain administering pain medication for residents with signs and symptoms of pain. Staff had knowledge on pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff were able to explain pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Staff had knowledge on notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. All residents in the facility were assessed for any increased pain by the DON and Charge Nurses. This was verified by interview with DON and record review of audit sheets listing resident name and room number. In-Services addressed pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. Staff was in-serviced on pain management Policy -Signs and symptoms of pain verbal and non-verbal. (Change in behaviors such as crying, whining, groaning, facial expressions, grimacing, frowning, protecting body movements, guarding, or clutching). Notification of a change of condition to the charge nurse or physician immediately including fractures and signs and symptoms of increased pain. Abuse and Neglect. Reporting injuries of unknown origin to the administrator immediately. The Charge Nurses was in-serviced on administering pain medication for residents with signs and symptoms of pain. Pain management, monitoring for pain, administering pain medications for increased pain, monitoring for effectiveness of pain management interventions, and notifications of a change in condition including known or suspected fractures. This was verified by record review of staff in-services signature sheets and staff interviews. The Director of Nursing / designee will educate all clinical staff including agency staff, new hires and PRN staff not in-serviced by 1/17/24 will not be allowed to work in their assigned position until completion of the above in-services. This was verified by interview with DON that it will occur and record review of staff signature sign-in sheets. Interview with Regional Compliance Nurse verified an Ad Hoc QAPI was conducted to discuss the immediate jeopardy concerning pain management and to develop the above-mentioned plan of care. An Immediate Jeopardy (IJ) was identified on 01/17/2024 at 4:00 p.m. While the IJ was removed on 01/18/2024 at 8:00 p.m., the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction.

Based on interview, and record review, the facility failed to consult with the physician for 1 of 5 residents reviewed for infections. (Resident #1) The facility did not immediately consult with the physician regarding Resident #1 who had a significant change of condition with a urinary tract infection and 2 falls ([DATE] and [DATE]). The facility did not: *consult with the physician regarding abnormal urinalysis results for five days after they were completed; *consult with the physician about Resident #1's continued confusion after [MEDICATION NAME] DS (antibiotic) was begun for her urinary tract infection [MEDICAL CONDITION], resistance of at least one organism to the ordered antibiotic, pupillary changes, extremity weakness, decreasing blood pressure, or held anti-hypertensive medications. Resident #1 was found dead 4.5 hours after the second fall and approximately 18 hours after her blood pressure began to decrease. An Immediate Jeopardy situation was identified on [DATE] at 11:15 a.m. The Immediate Jeopardy was removed on [DATE] at 10:35 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures may have contributed to Resident #1's death. This failure could place the census of 59 at risk of a delay in medical evaluation and treatment. Findings included: A face sheet (undated) indicated Resident #1 was [AGE] year old admitted on [DATE] with essential hypertension, acute chronic combined systolic (congestive) and diastolic (congestive) heart failure, history of [MEDICAL CONDITION], and cerebral infarction without residual deficits. The most recent MDS dated [DATE] indicated Resident #1 was cognitively impaired. It indicated she required supervision for transfers and one staff physical assistance or bed mobility. A care plan last revised on [DATE] indicated Resident #1 had poor balance; on [DATE] she experienced a fall with a fracture and on [DATE] had a fall without injury. Interventions included to monitor/document/report as necessary for 72 hours to her physician any pain, bruises, change in mental status, or new onset confusion, sleepiness, inability to maintain posture, or agitation. A nursing note dated [DATE] at 6 p.m., indicated the urinalysis (UA) results from a urine sample obtained earlier that day ([DATE]) were returned to the facility and faxed to the NP. There was no evidence the physician received or was consulted about the results. Laboratory results, reported [DATE] and collected [DATE], showed evidence of a urinary tract infection with abnormally high white blood cells of ,[DATE] (reference range ,[DATE]). There was no evidence the physician received or was consulted about the results. A final laboratory report of a urine culture and sensitivity (C & S) test collected on [DATE] and reported to the facility [DATE] indicated Resident #1 had a urinary tract infection that had at least one organism that was resistant to [MEDICATION NAME] DS, the ordered antibiotic. The nursing notes for Resident #1 described the following: [DATE] at 8:28 a.m.,- the final UA with C&S results were received and were faxed to the NP; There was no evidence the physician was consulted about the results. There was no evidence of an urinary assessment. [DATE] at 10:00 a.m., - the NP was paged regarding the ua results; awaiting return call. There was no evidence of further urinary assessments. 6:00 a.m., A message was left for the NP regarding urinalysis (U/A) and C&S results and about Resident #1's increased confusion and anxiety; There was no evidence of an urinary assessment. [DATE] at 9:15 a.m., the NP returned the call and provided new orders for an antibiotic to treat the Resident #1's UTI. There was no evidence of an urinary assessment. A physician telephone order dated [DATE] indicated the staff was to begin Bactrim DS ([MEDICATION NAME] DS) 1 tablet orally twice daily for 10 days for Resident #1's [DIAGNOSES REDACTED]. A nursing note dated [DATE] at 10:00 a.m., indicated Resident #1's initial dose of Bactrim DS 1 tablet was administered. There was no evidence of a urinary assessment. An event nursing note for a fall dated [DATE] at 8:45 a.m., indicated Resident #1 lost footing in her room and had a fall that was unwitnessed. The note indicated Resident #1 complained of back pain and Resident #1 had increased confusion due to urinary tract infection. Her blood pressure (BP) was ,[DATE]. The physician and family were notified at 9:00 a.m. and an order was received for x-ray of her lumbar spine. During an interview on [DATE] at 12:42 p.m., LVN C said she found Resident #1 lying on the floor on [DATE] (the first fall). She said Resident #1 was trying to get up from floor. She said she and a CNA tried to keep Resident #1 comfortable until she could be assessed. She said the next day ([DATE]), Resident #1 had another fall and she went to assist. She said Resident #1 denied hitting her head Resident #1 just kept trying to get up. She said Resident #1 was confused, but she thought it was from her urinary tract infection. She said she did not report the continued confusion to the physician. During an interview on [DATE] at 1:02 p.m., LVN D said she was working the day of the first fall. She said it was reported to her that Resident #1 was on the floor by LVN C. She said she went down and assessed Resident #1 and Resident #1 said she had slipped and fell , she said Resident #1 denied hitting her head. She said Resident #1 complained of back pain and she notified the physician and received an order for [REDACTED].#1 was confused but she had recently been [DIAGNOSES REDACTED]. She said Resident #1 was noted to have compression fractures to her spine. She said she did neurological checks as required and did not note any changes. She said if there had been changes she would have notified physician immediately. A physician telephone order dated [DATE] was to have an x-ray of Resident #1' s lower back due to fall and confusion. Neurological assessments on [DATE] for Resident #1 indicated following: 8:45 a.m., BP ,[DATE] (different than Event Note), Pulse (P) 75 ; 9:00 a.m., 9:15 a.m., 10:00 a.m., 10:30 a.m.(BP ,[DATE]), 11:30 a.m., 4:30 p.m., eyes: opened spontaneously, best verbal response : confused, best motor response : obeys commands, Pupils equal and react briskly. All extremities were strong. There was no evidence of further urinary assessments. 12:30 p.m., BP ,[DATE], P 80; neurological checks were the same, except the right lower extremity was weak. There was no evidence of a urinary assessment. 2:30 p.m., BP ,[DATE]; P 84; neurological checks indicated now both right and left extremity had weakness. There was no indication the physician or NP was notified. 4:30 p.m.,. BP ,[DATE]; P 68; neurological checks remained the same except now all extremities were documented as strong. There were no further neurological assessments until [DATE]. The MAR for [DATE] indicated Resident #1's [MEDICATION NAME] for hypertension was held due to low blood pressure on ,[DATE] at 8:00 p.m. and ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressures. The MAR for [DATE] indicated Resident #1's Carvedilol for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressure. The MAR for [DATE] indicated Resident #1's [MEDICATION NAME] HCl for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressure. A nursing note dated [DATE] at 1:45 p.m., indicated the x-ray report was received and showed Resident #1 had an age undetermined compression fracture of L-1 and L-3. The NP was notified and new orders were received for pain medication. An event nursing note for a fall dated [DATE] at 1:40 p.m., indicated Resident #1 was found on the floor next to her bed. The incident was unwitnessed. She was assessed head to toe and then assisted to bed without difficulty. Her vital signs were B/P ,[DATE], pulse 60, temperature 98.2, her left eye pupil was equal and reactive to light and right pupil sluggish. It indicated Resident #1 said she was attempting to get out of bed and fell on her left side and did not hit her head. It indicated at time of event Resident #1 was cognitively impaired, had new or increased confusion and restlessness at time of the event per event/incident report. There was no evidence of an urinary assessment. It indicated the physician was notified at 2:00 p.m. on [DATE], there were no new orders. During an interview on [DATE] at 11:40 a.m., and 12:30 p.m., LVN A said he responded to Resident #1's second fall on [DATE]. He said Resident #1 was found on floor and said she slipped. She denied hitting her head. He said he did an head to toe assessment and no injuries were noted. He said her right pupil was 5mm and sluggish. He said he was aware Resident #1 had a previous fall, but he did not have time to check to see if there had been a change in her pupil size or reaction. He said he was not Resident #1 ' s nurse and when Resident #1 nurse returned from lunch he reported to her. He said Resident #1 was confused but he did not feel there was any significant change in her condition. He said he notified the NP of the fall, but did not notify her of the sluggish pupils or her continued confusion. He said he felt she was stable and then all of a sudden, she was dead. During an interview on [DATE] at 11:45 a.m., LVN B said she was Resident #1 ' s nurse that day and had gone to lunch. She said when she returned from lunch, she was informed by LVN A of the incident. She said Resident #1 ' s pupils were at 4 and 5 mms. and were sluggish at the time she returned and checked them. She said Resident #1 ' s pupils after a while started to return to normal. She said she could not remember if she documented that Resident #1 ' s pupils were sluggish, but the first few times she checked them they were sluggish before returning to normal. She said she did not notify the physician of the change in the pupils, because they went back to normal after a while. She said she felt Resident #1 was confused due to her urinary tract infection, but did not report the continued confusion to the physician. During an interview on [DATE] at 12:51 p.m., CNA A said Resident #1 was found on side of her bed the first fall and she only complained of leg pain. She said Resident #1 denied hitting her head. She said Resident #1 fell the next day and was on the floor moving around a lot and did not want to be still. She said Resident #1 seemed really anxious, she said Resident #1 was very independent and had been more confused since her husband died . During an interview on [DATE] at 9:44 a.m., CNA B said she had worked with Resident #1 the day of the second fall. She said Resident #1 seemed more confused after the fall. She said Resident #1 was lying on floor in her room. She said LVN A came in and assessed Resident #1, then they assisted the resident back in bed. They left the door open, so staff could watch her because she kept trying to get out of bed. During an interview on [DATE] at 9:52 a.m., CNA C said Resident #1 was found lying on the floor in her room, she said Resident #1 kept trying to get up after the second fall and seemed more confused. She said the staff had to watch Resident #1 more after she had her first fall. She said Resident #1 would not call for assistance. A facility investigation reported indicated the facility reported the incident to DADS on [DATE] at 1:25 p.m. the facility investigation indicated that Resident #1 lost her footing and complained of back pain. The provider response indicated x-ray of lumbar spine done on [DATE] indicated undetermined age compression fracture of L-1 and L-3 and orders were obtain for pain medication and family brought new shoes for resident to wear due to Resident #1 had been wearing house slippers. Provider action post investigation indicated the facility was monitoring the resident ' s pain medications and reactions to them for controlling break through pain. There were no interventions put in place due to the fall. A neurological assessment on [DATE] at 12:30 a.m., for Resident #1 indicated BP ,[DATE], P 90; neurological checks unchanged from [DATE] at 4:30 p.m. The MAR for [DATE] indicated Resident #1 ' s Carvedilol for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1 ' s medication was held due to low blood pressure. The MAR for [DATE] indicated Resident #1 ' s [MEDICATION NAME] HCl for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1 ' s medication was held due to low blood pressure. Neurological assessments on [DATE] for Resident #1 indicated the following: 8:30 a.m. BP ,[DATE]; P 91; Neurological checks same as above with exception of right and left extremities were now weak. 1:40 p.m. BP ,[DATE]; P 60; (time of second fall), resident remained confused; upper extremities were weak; lower extremities remained weak; pupils were now unequal and the right one was now sluggish; 1:55 p.m. BP ,[DATE]; P 98; Pupils remain unequal and the right pupil continued to react sluggishly to light. Confused. 2:10 p.m. BP ,[DATE]; P 100; same as above with exception left upper extremity weak. 2:25 p.m. BP ,[DATE]; P 92; Pupils remain unequal and the right pupil continued to react sluggishly to light. Confused. 2:55 p.m. BP ,[DATE]; P 90; Pupils now equal and reacting briskly; Confused. 3:25 p.m. BP ,[DATE]; P 88; Pupils now unequal, but react briskly. Confused. 4:25 p.m. BP ,[DATE]; P 92; same as above. 5:25 p.m. BP ,[DATE]; P 98; pupils now both equal and reacting briskly. Confused. There was no indication on the neurological checklists that the physician was consulted regarding the blood pressure changes or the necessity to hold the anti-hypertensive medications. A nursing note for Resident #1 dated [DATE] indicated the following: 9:00 a.m., resident continues with periods of increased confusion and anxiety; continue to encourage resident to call for assist with transfers/ADLs; resident remains non-compliant. There was no indication that the physician was consulted regarding the blood pressure changes or the necessity to hold the anti-hypertensive medications. 2:20 p.m., resident placed on low bed with mat on floor next to bed. Resident instructed to leave door of room open so she could be monitored at all times. Resident stated okay. 5:57 p.m., Resident#1 was attempting to get out of bed going to see her deceased husband. She was redirected and assisted back into bed. 6:55 p.m. at approximately 6:35 p.m., resident was noted to be unresponsive, no respirations, pulse, or blood pressure noted. Resident had a DNR. DON pronounced resident expired at 6:44 p.m. The family was notified and a message was left for the NP. During interviews on [DATE] at 11:28 a.m., the DON said Resident #1 had some confusion and increased anxiety due to a urinary tract infection. She also had the recent loss of her spouse. She Resident #1 had falls on [DATE] and [DATE]. She said both falls were unwitnessed and Resident #1 denied hitting her head. She said she did not know if staff notified the physician of changes in the resident ' s pupils or continued confusion, but they should have. During an interview on [DATE] at 11:42 a.m., the DON said she was not sure if she would have notified the physician because she felt there were no other changes in Resident #1 ' s condition. She said the staff was inserviced on [DATE] and the physician would be notified of any changes in residents ' conditions, to include changes in pupil size and reaction. During an interview on [DATE] at 2:05 p.m., the NP said she was notified of Resident #1 ' s falls. She said she could not recall if the staff notified her of Resident #1 ' s neurological changes or continued confusion. She said she expected to be notified of any changes in residents ' conditions by the facility to include changes in neurological checks. She said if a resident ' s pupil size and reaction changed after a fall, she would expect to be notified immediately by the facility. During an interview on [DATE] at 2:25 p.m. the administrator said on [DATE] the nursing staff were in-serviced on physician notification and changes in condition. She said the staff was reeducated and would be monitored to ensure changes were followed up on and documentation was being done. According to AHC Media: Medical Education Publisher, accessed [DATE], .the elderly are a particularly challenging population that develops UTIs .Other challenges in this population include a [MEDICATION NAME] fever response and more atypical symptoms of UTI in institutionalized patients, for example change in mental status, weakness, lethargy .instead of pain symptoms, seniors with a UTI may show increased signs of confusion . A policy and procedure for neurologic checks revised on [DATE] included: .Neurologic checks are a combination of objective observations and measurements done to evaluate neurologic status that includes consciousness, orientation, pupillary changes, neuromuscular function and neurosensory perception. The results of the checks assist to determine nervous system damage and or deterioration . Number 19 of the policy indicated, .frequency of checks after initial neuro check : every 15 minutes times 4, every 30 minutes times 2 , one hour times 2, every two hours times 2, then every shift times 48 hours. 20. All deteriorations in neurologic status will be immediately reported to the physician. The nurse will document assessment and the time of physician notification in the clinical record. On [DATE] at 11:15 a.m., the administrator and DON were notified an Immediate Jeopardy was identified. On [DATE] at 4:02 p.m., the plan of removal was accepted and included: Interventions: · In-service the licensed nursed by the DON and/or ADON regarding: o Completion of neurological assessments o Neurological changes associated with head injury o Notification of the physician of a resident change in condition according to the Change in Condition: When to report to the MD/NP/PA o These in-services were started on [DATE] and all licensed nurse in services will be complete on [DATE]. All licensed nurses not present on the day shift (6am-6pm) on [DATE] will not be allowed to assume their duties until they have been in serviced by the DON or ADON. · An audit was performed by the DON on [DATE] at 12:50 to determine if any resident had any neurological assessments in progress or due. No neurological assessments are in progress or due at this time. · (The medical director) was notified of the immediate jeopardy on [DATE] by the administrator at 1:30 pm. Monitoring: · At least 5 times per week the DON and/or ADON will monitor the 24 report and review the documentation to monitor for compliance with physician notification of changes · At least 5 times per week the DON and/or ADON will monitor all Neurological assessments completed to monitor for changes and that physician was notified if required. On [DATE] and [DATE] it was confirmed the Plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 11:24 a.m., the DON said she provided training on physician notification, change of condition, neurological changes, and completion of neurological assessments to the nursing staff. She said she called the nursing staff in and provided one on one in servicing. The DON said all licensed nursing staff had been called to come in for training and for those who could not make on [DATE], would be in serviced before they could return to work. Five LVNs said they had been in-serviced on [DATE] and were able to identify what constituted a change in condition and when to notify the physician. They were able to identify how to initiate a neurological assessment and identify what would prompt a change of condition that would require physician notification. They said they had received copies of the facility change of condition policy. On [DATE] at 10:35 a.m. the administrator, DON and RNC were notified immediate jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 59 residents.

Based on interview, and record review, the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable well-being based on the comprehensive assessment and plan of care for 1 of 5 residents reviewed for quality of care. (Resident #1) The facility did not immediately consult with the physician or obtain emergency care for Resident #1 who had a significant change of condition with a urinary tract infection and 2 falls ([DATE] and [DATE]). The facility did not: *report abnormal urinalysis results for five days after they were completed; *consult with the physician about Resident #1 ' s continued confusion after [MEDICATION NAME] DS (antibiotic) was begun for her urinary tract infection [MEDICAL CONDITION], resistance of at least one organism to the ordered antibiotic, pupillary changes, extremity weakness, decreasing blood pressure, or held anti-hypertensive medications. Resident #1 was found dead 4.5 hours after the second fall and approximately 18 hours after her blood pressure began to decrease. An Immediate Jeopardy situation was identified on [DATE] at 11:15 a.m. The Immediate Jeopardy was removed on [DATE] at 10:35 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures may have contributed to Resident #1's death. This failure could place the census of 59 at risk for not receiving necessary medical care in the event of a change in condition. Findings included: A face sheet (undated) indicated Resident #1 was [AGE] year old admitted on [DATE] with essential hypertension, acute chronic combined systolic (congestive) and diastolic (congestive) heart failure, history of [MEDICAL CONDITION], and cerebral infarction without residual deficits. The most recent MDS dated [DATE] indicated Resident #1 was cognitively impaired. It indicated she required supervision for transfers and one staff physical assistance for bed mobility. A care plan last revised on [DATE] indicated Resident #1 had poor balance; on [DATE] she experienced a fall with a fracture and on [DATE] had a fall without injury. Interventions included to monitor/document/report as necessary for 72 hours to her physician any pain, bruises, change in mental status, or new onset confusion, sleepiness, inability to maintain posture, or agitation. A nursing note dated [DATE] at 6 p.m., indicated the urinalysis (UA) results from a urine sample obtained earlier that day ([DATE]) were returned to the facility and faxed to the NP. There was no evidence the physician received or was consulted about the results. Laboratory results, reported [DATE] and collected [DATE], showed evidence of a urinary tract infection with abnormally high white blood cells of ,[DATE] (reference range ,[DATE]). There was no evidence the physician received or was consulted about the results. A final laboratory report of a urine culture and sensitivity test collected on [DATE] and reported to the facility [DATE] indicated Resident #1 had a urinary tract infection that had at least one organism that was resistant to [MEDICATION NAME] DS, the ordered antibiotic. The nursing notes for Resident #1 described: [DATE] at 8:28 a.m, .- the final UA with culture and sensitivity (C&S) results were received and were faxed to the NP; There was no evidence the physician was consulted about the results. [DATE] at 10:00 a.m,.- the NP was paged regarding the ua results; awaiting return call. 6:00 a.m. ,A message was left for the NP regarding urinalysis (U/A) and C&S results and about Resident #1's increased confusion and anxiety; [DATE] at 9:15 a.m., the NP returned the call and provided new orders for an antibiotic to treat the Resident #1's UTI. A physician telephone order dated [DATE] indicated the staff was to begin Bactrim DS 1 tablet orally twice daily for 10 days for Resident #1's [DIAGNOSES REDACTED]. A nursing note dated [DATE] at 10 a.m., indicated Resident #1's initial dose of Bactrim DS ([MEDICATION NAME] DS) 1 tablet was administered. An event nursing note for a fall dated [DATE] at 8:45 a.m., indicated Resident #1 lost footing in her room and had a fall that was unwitnessed. The note indicated Resident #1 complained of back pain and Resident #1 had increased confusion due to urinary tract infection. Her blood pressure (BP) was ,[DATE]. The physician and family were notified at 9:00 a.m. and an order was received for x-ray of her lumbar spine. During an interview on [DATE] at 12:42 p.m., LVN C said she found Resident #1 lying on the floor on [DATE] (the first fall). She said Resident #1 was trying to get up from floor. LVN C said she and a CNA tried to keep Resident #1 comfortable until she could be assessed. She said the next day ([DATE]), Resident #1 had another fall and she went to assist. She said Resident #1 denied hitting her head Resident #1 just kept trying to get up. She said Resident #1 was confused, but she thought it was from her urinary tract infection. LVN C said she did not report the continued confusion to the physician. During an interview with LVN D on [DATE] at 1:02 p.m., LVN D said she was working the day of the first fall. She said it was reported to her that Resident #1 was on the floor by LVN C. She said she went down and assessed Resident #1 and Resident #1 said she had slipped and fell , she said Resident #1 denied hitting her head. She said Resident #1 complained of back pain and she notified the physician and received an order for [REDACTED].#1 was confused but she had recently been diagnosed with [REDACTED]. She said Resident #1 was noted to have compression fractures to her spine. She said she did neurological checks as required and did not note any changes. She said if there had been changes she would have notified physician immediately. A physician telephone order dated [DATE] was to have an x-ray of Resident #1's lower back due to fall and confusion. Neurological assessments on [DATE] for Resident #1 indicated following: 8:45 a.m., blood pressure (BP) ,[DATE] (different than Event Note), Pulse (P) 75 ; 9:00 a.m., 9:15 a.m., 10:00 a.m., 10:30 a.m.(BP ,[DATE]), 11:30 a.m., 4:30 p.m., eyes: opened spontaneously, best verbal response : confused, best motor response : obeys commands, Pupils equal and react briskly. All extremities were strong. 12:30 p.m., BP ,[DATE], P 80; neurological checks were the same, except the right lower extremity was weak. 2:30 p.m., BP ,[DATE]; P 84; neurological checks indicated now both right and left extremity had weakness. There was no indication the physician or NP was notified. 4:30 p.m., BP ,[DATE]; P 68; neurological checks remained the same except now all extremities were documented as strong. There were no further neurological assessments until [DATE]. The MAR for [DATE] indicated Resident #1's [MEDICATION NAME] for hypertension was held due to low blood pressure on [DATE] at 8:00 p.m. and [DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressures. The MAR for [DATE] indicated Resident #1's Carvedilol for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressure. The MAR for [DATE] indicated Resident #1's [MEDICATION NAME] HCl for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressure. A nursing note dated [DATE] at 1:45 p.m., indicated the x-ray report was received and showed Resident #1 had an age undetermined compression fracture of L-1 and L-3. The NP was notified and new orders were received for pain medication. An event nursing note for a fall dated [DATE] at 1:40 p.m., indicated Resident #1 was found on the floor next to her bed. The incident was unwitnessed. She was assessed head to toe and then assisted to bed without difficulty. Her vital signs were B/P ,[DATE], pulse 60, temperature 98.2, her left eye pupil was equal and reactive to light and right pupil sluggish. It indicated Resident #1 said she was attempting to get out of bed and fell on her left side and did not hit her head. It indicated at time of event Resident #1 was cognitively impaired, had new or increased confusion and restlessness at time of the event per event/incident report. It indicated the physician was notified of only the fall (not urinary status or continued confusion) at 2:00 p.m. on [DATE]. There were no new orders. During an interview on [DATE] at 11:40 a.m., and 12:30 p.m LVN A said he responded to Resident #1's second fall on [DATE]. He said Resident #1 was found on floor and said she slipped. She denied hitting her head. He said he did an head to toe assessment and no injuries were noted. He said her right pupil was 5mm and sluggish. He said he was aware Resident #1 had a previous fall, but he did not have time to check to see if there had been a change in her pupil size or reaction. He said he was not Resident #1's nurse and when Resident #1 nurse returned from lunch he reported to her. He said Resident #1 was confused but he did not feel there was any significant change in her condition. He said he notified the NP of the fall, but did not notify her of the sluggish pupils or her continued confusion. He said he felt she was stable and then all of a sudden, she was dead. During an interview on [DATE] at 11:45 a.m., LVN B said she was Resident #1's nurse that day and had gone to lunch. She said when she returned from lunch, she was informed by LVN A of the incident. She said Resident #1's pupils were at 4 and 5 millimeters (mms). and were sluggish at the time she returned and checked them. She said Resident #1's pupils after a while started to return to normal. She said she could not remember if she documented that Resident #1's pupils were sluggish, but the first few times she checked them they were sluggish before returning to normal. She said she did not notify the physician of the change in the pupils, because they went back to normal after a while. She said she felt Resident #1 was confused due to her urinary tract infection, but did not report the continued confusion to the physician. During an interview on [DATE] at 12:51 p.m., CNA A said Resident #1 was found on side of her bed the first fall and she only complained of leg pain. She said Resident #1 denied hitting her head. She said Resident #1 fell the next day and was on the floor moving around a lot and did not want to be still. She said Resident #1 seemed really anxious, she said Resident #1 was very independent and had been more confused since her husband died . During an interview on [DATE] at 9:44 a.m., CNA B said she had worked with Resident #1 the day of the second fall. She said Resident #1 seemed more confused after the fall. She said Resident #1 was lying on floor in her room. She said LVN A came in and assessed Resident #1, then they assisted the resident back in bed. They left the door open, so staff could watch her because she kept trying to get out of bed. During an interview on [DATE] at 9:52 a.m., CNA C said Resident #1 was found lying on the floor in her room, she said Resident #1 kept trying to get up after the second fall and seemed more confused. She said the staff had to watch Resident #1 more after she had her first fall. She said Resident #1 would not call for assistance. A facility investigation reported indicated the facility reported the incident to DADS on [DATE] at 1:25 p.m. the facility investigation indicated that Resident #1 lost her footing and complained of back pain. The provider response indicated x-ray of lumbar spine done on [DATE] indicated undetermined age compression fracture of L-1 and L-3 and orders were obtain for pain medication and family brought new shoes for resident to wear due to Resident #1 had been wearing house slippers. Provider action post investigation indicated the facility was monitoring the resident ' s pain medications and reactions to them for controlling break through pain. There were no interventions put in place due to the fall. A neurological assessment on [DATE] at 12:30 a.m., for Resident #1 indicated BP ,[DATE], P 90; neurological checks unchanged from [DATE] at 4:30 p.m. The MAR for [DATE] indicated Resident #1's Carvedilol for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressure. The MAR for [DATE] indicated Resident #1's [MEDICATION NAME] HCl for hypertension was held due to low blood pressure on ,[DATE] at 8:00 a.m. There was no indication the physician was notified that Resident #1's medication was held due to low blood pressure. Neurological assessments on [DATE] at for Resident #1 indicated the following: 8:30 a.m. ,BP ,[DATE]; P 91; Neurological checks same as above with exception of right and left extremities were now weak. 1:40 p.m., BP ,[DATE]; P 60; (time of second fall), resident remained confused; upper extremities were weak; lower extremities remained weak; pupils were now unequal and the right one was now sluggish; 1:55 p.m.,BP ,[DATE]; P 98; Pupils remain unequal and the right pupil continued to react sluggishly to light. Confused. 2:10 p.m.,BP ,[DATE]; P 100; same as above with exception left upper extremity weak. 2:25 p.m., BP ,[DATE]; P 92; Pupils remain unequal and the right pupil continued to react sluggishly to light. Confused. 2:55 p.m., BP ,[DATE]; P 90; Pupils now equal and reacting briskly; Confused. 3:25 p.m.,. BP ,[DATE]; P 88; Pupils now unequal, but react briskly. Confused. 4:25 p.m., BP ,[DATE]; P 92; same as above. 5:25 p.m., BP ,[DATE]; P 98; pupils now both equal and reacting briskly. Confused. There was no indication on the neurological checklists that the physician was consulted regarding Resident #1's blood pressure changes or the necessity to hold the anti-hypertensive medications. A nursing note for Resident #1 dated [DATE] indicated the following: 9:00 a.m., resident continues with periods of increased confusion and anxiety; continue to encourage resident to call for assist with transfers/ADLs; resident remains non-compliant. There was no indication that the physician was consulted regarding the blood pressure changes or the necessity to hold the anti-hypertensive medications. 2:20 p.m., resident placed on low bed with mat on floor next to bed. Resident instructed to leave door of room open so she could be monitored at all times. Resident stated okay. 5:57 p.m. Resident#1 was attempting to get out of bed going to see her deceased husband. She was redirected and assisted back into bed. 6:55 p.m. at approximately 6:35 p.m resident was noted to be unresponsive, no respirations, pulse, or blood pressure noted. Resident had a DNR. DON pronounced resident expired at 6:44 p.m. The family was notified and a message was left for the NP. During an interview on [DATE] at 11:28 a.m., the DON said Resident #1 had some confusion and increased anxiety due to a urinary tract infection. She also had the recent loss of her spouse. She said Resident #1 had falls on [DATE] and [DATE]. She said both falls were unwitnessed and Resident #1 denied hitting her head. She said she did not know if staff notified the physician of changes in the resident's pupils or continued confusion, but they should have. During an interview on [DATE] at 11:42 a.m., the DON said she was not sure if she would have notified the physician because she felt there were no other changes in Resident #1's condition. She said the staff was inserviced on [DATE] and the physician would be notified of any changes in residents' conditions, to include changes in pupil size and reaction. During an interview on [DATE] at 2:05 p.m., the NP said she was notified of Resident #1's falls. She said she could not recall if the staff notified her of Resident #1's neurological changes or continued confusion. She said she expected to be notified of any changes in residents' conditions by the facility to include changes in neurological checks. She said if a resident's pupil size and reaction changed after a fall, she would expect to be notified immediately by the facility. During an interview on [DATE] at 2:25 p.m., the administrator said on [DATE] the nursing staff were in-serviced on physician notification and changes in condition. She said the staff was reeducated and would be monitored to ensure changes were followed up on and documentation was being done. According to AHC Media: Medical Education Publisher, accessed [DATE], .the elderly are a particularly challenging population that develops UTIs .Other challenges in this population include a [MEDICATION NAME] fever response and more atypical symptoms of UTI in institutionalized patients, for example change in mental status, weakness, lethargy .instead of pain symptoms, seniors with a UTI may show increased signs of confusion . A policy and procedure for neurologic checks revised on [DATE] included: Neurologic checks are a combination of objective observations and measurements done to evaluate neurologic status that includes consciousness, orientation, pupillary changes, neuromuscular function and neurosensory perception. The results of the checks assist to determine nervous system damage and or deterioration . Number 19 of the policy indicated, .frequency of checks after initial neuro check : every 15 minutes times 4, every 30 minutes times 2 , one hour times 2, every two hours times 2, then every shift times 48 hours. 20. All deteriorations in neurologic status will be immediately reported to the physician. The nurse will document assessment and the time of physician notification in the clinical record. On [DATE] at 11:15 a.m., the administrator and DON were notified an Immediate Jeopardy was identified. On [DATE] at 4:02 p.m., the plan of removal was accepted and included: Interventions: · In-service the licensed nursed by the DON and/or ADON regarding: o Completion of neurological assessments o Neurological changes associated with head injury o Notification of the physician of a resident change in condition according to the Change in Condition: When to report to the MD/NP/PA o These in-services were started on [DATE] and all licensed nurse in services will be complete on [DATE]. All licensed nurses not present on the day shift (6am-6pm) on [DATE] will not be allowed to assume their duties until they have been in serviced by the DON or ADON. · An audit was performed by the DON on [DATE] at 12:50 to determine if any resident had any neurological assessments in progress or due. No neurological assessments are in progress or due at this time. · (The medical director) was notified of the immediate jeopardy on [DATE] by the administrator at 1:30 pm. Monitoring: · At least 5 times per week the DON and/or ADON will monitor the 24 report and review the documentation to monitor for compliance with physician notification of changes · At least 5 times per week the DON and/or ADON will monitor all Neurological assessments completed to monitor for changes and that physician was notified if required. On [DATE] and [DATE] it was confirmed the Plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 11:24 a.m., the DON said she provided training on physician notification, change of condition, neurological changes, and completion of neurological assessments to the nursing staff. She said she called the nursing staff in and provided one on one in servicing. The DON said all licensed nursing staff had been called to come in for training and for those who could not make on [DATE], would be in serviced before they could return to work. Five LVNs said they had been in-serviced on [DATE] and were able to identify what constituted a change in condition and when to notify the physician. They were able to identify how to initiate a neurological assessment and identify what would prompt a change of condition that would require physician notification. They said they had received copies of the facility change of condition policy. On [DATE] at 10:35 a.m. the administrator, DON and RNC were notified immediate jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 59 residents.

Based on interview and record review, the facility failed to promptly notify the physician of abnormal laboratory results for 1 of 1 resident reviewed for laboratory services. (Resident #1) Resident #1 had an urinalysis (UA) obtained [DATE] with results returned as abnormal that same day. The facility did not report the results to the physician until [DATE] at which time an antibiotic was begun. The resident died 2 days later. An Immediate Jeopardy situation was identified on [DATE] at 11:15 a.m. The Immediate Jeopardy was removed on [DATE] at 10:35 p.m. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 59 residents at risk for delays in medical evaluation and treatment. Findings included: A face sheet (undated) indicated Resident #1 was [AGE] year old admitted on [DATE] with essential hypertension, acute chronic combined systolic (congestive) and diastolic (congestive) heart failure, history of [MEDICAL CONDITION], and cerebral infarction without residual deficits. The most recent MDS dated [DATE] indicated Resident #1 was cognitively impaired. It indicated she required supervision for transfers and one staff physical assistance or bed mobility. A nursing note dated [DATE] at 6 p.m., indicated the urinalysis (UA) results from a urine sample obtained earlier that day ([DATE]) were returned to the facility and faxed to the NP. There was no evidence the physician received or was consulted about the results. The laboratory results, reported [DATE] and collected [DATE], showed evidence of a urinary tract infection with abnormally high white blood cells of ,[DATE] (reference range ,[DATE]). There was no evidence the physician received or was consulted about the results. A final laboratory report of a urine culture and sensitivity test collected on [DATE] and reported to the facility [DATE] indicated Resident #1 had a urinary tract infection that had at least one organism that was resistant to [MEDICATION NAME] DS (Bactrim DS), the ordered antibiotic. The nursing notes for Resident #1 described: [DATE] at 8:28 a.m., - the final UA with culture and sensitivity (C&S) results were received and were faxed to the NP; There was no evidence the physician was consulted about the results. There was no evidence of a urinary assessment. [DATE] at 10:00 a.m.- the NP was paged regarding the ua results; awaiting return call. There was no evidence of further urinary assessments. 6:00 a.m., A message was left for the NP regarding urinalysis (U/A) and C&S results and about Resident #1 ' s increased confusion and anxiety; There was no evidence of an urinary assessment. [DATE] at 9:15 a.m., the NP returned the call and provided new orders for an antibiotic to treat the Resident #1's UTI. There was no evidence of an urinary assessment. A physician telephone order dated [DATE] indicated the staff was to begin Bactrim DS ([MEDICATION NAME] DS) 1 tablet orally twice daily for 10 days for Resident #1's [DIAGNOSES REDACTED]. A nursing note dated [DATE] at 10 a.m. indicated Resident #1's initial dose of Bactrim DS 1 tablet was administered. There was no evidence of a urinary assessment. An event nursing note for a fall dated [DATE] at 1:40 p.m., indicated Resident #1 was found on the floor next to her bed. The incident was unwitnessed. Her vital signs were B/P ,[DATE], pulse 60, temperature 98.2, her left eye pupil was equal and reactive to light and right pupil sluggish. There was no evidence of an urinary assessment. It indicated the physician was notified at 2:00 p.m. on [DATE], there were no new orders. 6:55 p.m., at approximately 6:35 p.m., resident was noted to be unresponsive, no respirations, pulse, or blood pressure noted. Resident had a DNR. DON pronounced resident expired at 6:44 p.m. The family was notified and a message was left for the NP. During interviews on [DATE] at 11:28 a.m., the DON said Resident #1 had some confusion and increased anxiety due to a urinary tract infection. She also had the recent loss of her spouse. She said Resident #1 had falls on [DATE] and [DATE]. She said both falls were unwitnessed and Resident #1 denied hitting her head. She said she did not know if staff notified the physician of Resident #1's final urinalysis report and the changes in the resident's pupils or continued confusion, but they should have. During an interview on [DATE] at 11:42 a.m., the DON said she was not sure if she would have notified the physician because she felt there were no other changes in Resident #1's condition. She said the staff was in-serviced on [DATE] and the physician would be notified of any changes in residents' conditions, to include changes in pupil size and reaction. During an interview on [DATE] at 2:05 p.m., the NP said she was notified of Resident #1's falls. She said she could not recall if the staff notified her of Resident #1's final urinalysis report, neurological changes or continued confusion. She said she expected to be notified of any changes in residents ' conditions by the facility to include laboratory results of that identify at least one organism that was resistant to the ordered antibiotic, changes in neurological checks and final laboratory results. She said if a resident ' s pupil size and reaction changed after a fall, she would expect to be notified immediately by the facility. During an interview on [DATE] at 2:25 p.m. the administrator said on [DATE] the nursing staff were in-serviced on physician notification and changes in condition, including laboratory results. She said the staff was reeducated and would be monitored to ensure changes were followed up on and documentation was being done. A policy and procedure for neurologic checks revised on [DATE] included: Neurologic checks are a combination of objective observations and measurements done to evaluate neurologic status that includes consciousness, orientation, pupillary changes, neuromuscular function and neurosensory perception. The results of the checks assist to determine nervous system damage and or deterioration . Number 19 of the policy indicated, .frequency of checks after initial neuro check : every 15 minutes times 4, every 30 minutes times 2 , one hour times 2, every two hours times 2, then every shift times 48 hours. 20. All deteriorations in neurologic status will be immediately reported to the physician. The nurse will document assessment and the time of physician notification in the clinical record. On [DATE] at 11:15 a.m., the administrator and DON were notified an Immediate Jeopardy was identified. On [DATE] at 4:02 p.m., the plan of removal was accepted and included: Interventions: · In-service the licensed nursed by the DON and/or ADON regarding: o Completion of neurological assessments o Neurological changes associated with head injury o Notification of the physician of a resident change in condition according to the Change in Condition: When to report to the MD/NP/PA o These in-services were started on [DATE] and all licensed nurse in services will be complete on [DATE]. All licensed nurses not present on the day shift (6am-6pm) on [DATE] will not be allowed to assume their duties until they have been in serviced by the DON or ADON. · An audit was performed by the DON on [DATE] at 12:50 to determine if any resident had any neurological assessments in progress or due. No neurological assessments are in progress or due at this time. · (The medical director) was notified of the immediate jeopardy on [DATE] by the administrator at 1:30 pm. Monitoring: · At least 5 times per week the DON and/or ADON will monitor the 24 report and review the documentation to monitor for compliance with physician notification of changes. · At least 5 times per week the DON and/or ADON will monitor all Neurological assessments completed to monitor for changes and that physician was notified if required. On [DATE] and [DATE] it was confirmed the Plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: During an interview on [DATE] at 11:24 a.m., the DON said she provided training on physician notification, change of condition, neurological changes, and completion of neurological assessments to the nursing staff. She said she called the nursing staff in and provided one on one in servicing. The DON said all licensed nursing staff had been called to come in for training and for those who could not make on [DATE], would be in serviced before they could return to work. Five LVNs said they had been in-serviced on [DATE] and were able to identify what constituted a change in condition and when to notify the physician. They were able to identify how to initiate a neurological assessment and identify what would prompt a change of condition that would require physician notification. They said they had received copies of the facility change of condition policy. On [DATE] at 10:35 a.m. the administrator, DON and RNC were notified immediate jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 59 residents.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services based on the comprehensive assessment to promote healing of pressure sores for 1 of 15 residents reviewed for pressure sores. (Resident #7) Resident #7 was admitted on [DATE] with a right leg brace; since being admitted to the facility she developed five (5) avoidable pressure ulcers. On 5/5/15, she developed an unstageable pressure sore on her left heel. On 5/24/15, she developed a Stage 3 pressure sore to her right heel. On 6/29/15, she developed a Stage 3 pressure sore to the top of her right foot. On 6/29/15, she developed a Deep Tissue Injury (DTI) to her right ankle On 7/20/15, she developed a stage 3 pressure sore to her right lower back above her buttocks. The facility did not protect her skin the right foot brace. The facility did not provide Resident #7 pressure relieving surfaces to prevent development of other pressure sores until after she developed three pressure sores. The facility did not try new interventions when Resident #7 continued to obtain new pressure ulcers. These failures contributed to the development of Resident #7's pressure sores and placed 4 residents with pressure sores at risk for worsening of pressure sores and further skin breakdown. Findings included: 1. An undated electronic face sheet indicated Resident #7 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An admission MDS dated [DATE] indicated Resident #7 had a BIMS of 6 (very forgetful, unable to recall words or situations, but was able to make her needs known and made herself understood. The resident required assistance with her ADLs, but was independent for eating. She had a brace to her right foot and was occasionally incontinent of urine and bowel. She did not have any skin issues or pressure sores on admission to the facility Resident #7 ' s Care Plan initiated on 5/5/15 indicated: *A deep tissue injury to left plantar surface of heel on 5/5/15. *A stage 2 pressure ulcer on right heel on 5/25/15 *A unstageable ulcer to top of right foot on 6/26/15 *A deep tissue injury to inside right ankle on 6/29/15 *A unstageable ulcer to right lower back on 7/20/15 Interventions included: *Ensure heels are floated with the use of pillows on 5/27/15 *Resident requires the use of an air mattress on 7/21/15 There was no indication of use other interventions were implemented to protect her feet. Resident #7 ' s admitting Braden score indicated she was at risk for pressure sores. A nursing note dated 3/20/15 indicated upon admission Resident #7 was able to voice needs some forgetfulness, boot in place to right foot. There were no notes regarding skin issues. A nursing note dated 4/10/15 indicated Resident #7 developed a 2.3 cm (centimeter) x 2.8 cm clear fluid blister to left malleolus (ankle joint), redness, and 2+ [MEDICAL CONDITION] to her lower leg. The note indicated the resident was educated to keep her feet off-loaded. Nursing notes from 04/29/15 through 7/16/15 indicated Resident #7 had even and strong pedal pulses and capillary refill less than 3 seconds almost every day until the boot was discontinued on 7/16/15. The nursing notes did not address her blister on her left foot. During an interview on 8/12/15 at 9:30 a.m., Resident #7 said she slept with a brace on her right leg for a long time and they took it off about 3 weeks ago. She said she was unsure how she obtained the sores on her feet and back. During an observation on 8/13/15 at 9:00 a.m. Resident #7 was in bed with a blue wedge pillow underneath her lower legs with her feet off loaded. An interview on 8/12/15 at 11:30 a.m., the treatment nurse said she assessed Resident #7's skin weekly while she had her brace on her leg. She said the resident developed the pressure sore on her left heel and they started to off load her feet with pillows, but the resident would knock the pillows off the bed. She said the resident had [MEDICAL CONDITION] to her feet and ankles. The treatment nurse said Resident #7 developed pressure sores on her right foot in June, but she was unsure why. They had an order to use the brace to her right leg for ambulation and 25% toe touch. Then about a month later, they were to use the brace for ambulation. About a month ago, the brace was discontinued. Resident #7 developed two (2) pressure sores to her right foot, one on top and one on the outside ankle, she was unsure why, but said it could be from the brace and how Resident #7 crosses her legs in bed. They started using a wedge pillow after the third pressure sore to off load her feet, but she would cross her feet in bed when she slept even though staff would place pillows between her legs. The treatment nurse said Resident #7 was able to reposition herself and chose to lay in one spot. She said the resident developed the pressure sore on her back from lying in one spot. The facility obtained a low air loss mattress for Resident #7 after the PU to her back showed up. After the pressure ulcers showed up on her feet the facility ordered an X-ray to rule out any condition that might be causing the sores. In July, the facility had a vascular Doppler study to rule out circulation issues. Also, a wound care consult was done in July. Resident #7 was getting increased vitamins and protein after the first pressure sore. The states of her wounds were they get a little better then a little worse, but none have resolved. The facility did not try Podus boots to protect her feet when she crossed them in bed. Physical Therapy has discussed getting a boot she can walk on with her sores, a couple of weeks ago, but the treatment nurse was unsure if it has been ordered or not. Skin assessment sheets for Resident #7 indicated the following: Pressure Sore 1 *5/5/15 - An unstageable pressure sore developed on her left heel measuring 2.6 cm x 5.1 cm with a depth unable to determine. The pressure sore was described as open with [MEDICATION NAME] wound bed margins, pink and black wound bed with eschar. 100% necrosis, light exudate, pink exudate, mild odor. The resident had no complaints of pain. A new wound treatment order indicated to clean with normal saline and apply [MEDICATION NAME], absorbent bandage (ABD), and tape twice a day. *8/10/15 - Stage 3 measuring 2.3 cm x 4 cm and unable to determine depth. Physicians orders dated 5/7/15 indicated Resident #7 25% or toe touch weight bearing to right ankle for 4 weeks, wear boot for transfers and walking only. Pressure sore 2 *5/24/15 - Stage 3 pressure sore to right heel measuring 0.7x1.2 cm and 0.2 in depth. healing wound bed margins, pink and yellow wound bed. Light exudate, yellow exudate, no odor. No complains of pain. Wound treatment order, Normal Saline (NS), [MEDICATION NAME], calcium alginate and bordered foam every other day. As of 8/10/15 the pressure sore continues to be 0.5x0.6 cm and 0.1 in depth. A telephone physician order [REDACTED].#7 in boot (brace) with ambulation to right ankle. Pressure sore 3 *6/29/15 - A deep tissue injury (DTI) pressure sore developed on her right ankle measuring 1.3 cm x 3 cm. A new wound treatment order indicated to apply skin prep every other day. *8/10/15 - A deep tissue injury pressure sore measuring 0.4 cm x 0.1 cm and unable to determine depth and to apply skin prep every other day. Pressure sore 4 *6/29/15 - A Stage 3 pressure sore developed on her right dorsal (top) foot measuring 0.4 cm x 0.3 cm and 0.2 cm in depth. The pressure sore was described as open with [MEDICATION NAME] wound bed margins and a yellow wound bed. Light exudate, yellow exudate, no odor. No complains of pain. A new wound treatment order indicated to clean with normal saline, apply skin prep and a [MEDICATION NAME] dressing every third day. *8/10/15 Stage3 Measuring 0.3 cm x 0.1 cm and 0.1 in depth. A wound consult notes dated 7/17/15 indicated Resident #7 ' s wounds were facility acquired and did not indicate Resident #7 had vascular issues. A Vascular Doppler study dated 7/9/15 indicated Resident #7 had calcified plaque and sclerotic vessels, but no occlusions noted. A telephone physician order [REDACTED].#7 ' s boot on right ankle. Pressure sore 5 *7/20/15 - A Stage 3 pressure sore developed on her right lower back measuring 2.9 cm x 2.3 cm and unable to determine depth. The pressure sore was described as open wound bed margins, pink, red, and yellow wound bed. Slough present, light exudate, yellow exudate, no odor. No complains of pain. A new wound treatment order indicated to clean with normal saline, apply skin prep, apply Santyl to wound bed, and bordered foam every day. *8/10/15 - Stage 3 measuring 1.7 cm x 2 cm and unable to determine depth. An interview with the wound treatment nurse on 8/13/15 at 10: a.m., she said they did not get a low air loss mattress until the pressure sore on her back because it would not help her feet. An unavoidable pressure ulcer assessment dated [DATE] for Resident #7, signed by the physician, indicated vascular studies obtained indicated plaque and calcifications probably impeding normal circulation. Resident #7 was non-compliant with turning and repositioning and keeping her right leg on wedge pillow. There were no orders for Podus boots (padded boots that wrap and protect the resident ' s feet) for Resident #7. Indicating not all interventions were tried to avoid further pressure sores. During an observation 8/12/15 at 10:30 a.m., Resident #7 was sitting in her wheelchair, without a brace, tan grip socks and slippers on her feet. Wound treatments were observed and the wounds appeared to be in a state of healing with no signs of infection. During an observation and interview on 8/13/15 at 1:00 p.m. LVN N assessed Resident #7's pedal pulses and capillary refill. She said the pulses were present, but hard to find, and Resident #7's capillary refill was less than 3 seconds. LVN N did not have a reason why the facility did not try additional interventions to protect Resident #7's skin from further pressure ulcers. The Policy of Wound Nurse Orientation updated 1/30/2009 included Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. The CMS 672 dated 8/10/15 indicated 4 residents had pressure sores

Based on interview and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 1 of 3 residents reviewed for falls. (Resident #1) CNA B was aware Resident #1 required two-person physical assistance with transfers. The CNA transferred Resident #1 without assistance and without a gait belt. The resident fell during the transfer and CNA B asked CNA A to help, and neither CNA A nor B notified a charge nurse of the incident for 5 days. CNA B continued to work as scheduled. Resident #1 complained of pain for four days; she was diagnosed with [REDACTED]. This failure contributed to Resident #1's fracture to both legs. This failure could place 61 residents that required assistance with transfers at risk for neglect and injury. Findings included: A computerized physician order [REDACTED]. Resident #1's latest MDS dated [DATE] indicated she was moderately impaired cognitively. The MDS indicated she required extensive assist with bed mobility and two- person physical assistance with transfers. Resident #1's balance when moving from seated to standing, and from surface-to-surface was not steady and she could only stabilize with staff assistance. Her ability to walk, turn around, face the opposite direction, and move off the toilet were not assessed, as these activities did not occur during the assessment period. Resident #1's functional limitation in range of motion was impairment on one side for the upper extremity and impairment on both sides for the lower extremities. A care plan with an initial date of 1/15/09 updated 5/9/12 indicated Resident #1 had problems of osteoporosis and a potential for fractures. Approaches included two staff for transfers and may use gait belt as needed, and monitor for spontaneous fractures with redness, swelling and signs and symptoms of pain. A care plan with an initial date of 1/11/10 updated 6/29/12 indicated Resident #1 had a problem of potential for falls. The care plan indicated the resident had a fall while being transferred that resulted in bruising to her knee. Interventions were appropriate amount of staff to transfer, use gait belt as needed, and one or two staff for transfers. A fall risk assessment/care plan dated 5/9/12 updated 6/24/12 indicated Resident # 1 was a high risk for falls. The resident had a score of 14 (a score of 10 or higher represents a high risk.) A weekly skin assessment sheet 6/26/12 indicated on 6/26/12 Resident #1 had a pale green bruise to the right side of her thigh that measured 3.2 cm x 2.8 cm. The assessment indicated the resident complained of pain to both legs and the charge nurse was informed. Nursing notes dated 6/27/12 for Resident #1 indicated the following: *7:00 a.m. complained of pain in both legs. She was crying and received one Tylenol 500 mg. *8:30 a.m. Resident #1 said the pain was a little better. *12:45 p.m. complained of neck and leg pain. She continued to frown and cry. She was given Tylenol 500 again. *1:45 p.m. the physician was notified and ordered Vicodin 5/325 every six hours as needed for pain and Tylenol 500 mg every 4 to six hours for break through pain. A nursing note dated 6/28/12 at 8:30 a.m. indicated Resident #1 complained of pain to both legs. The note indicated a pain score of 5 using a pain scale of 1-5. The resident was frowning and grimacing with pain she was given one Vicodin 5/325 for pain. An incident report dated 6/29/12 at 7:00 a.m. indicated Resident #1 complained of leg pain to both legs. There was swelling, heat, and bruising to the left leg, and slight swelling to the right knee. The resident said she had fallen but was unable to tell when. an order for [REDACTED]. The results were the left knee was fractured. The incident report indicated the resident required two-person assist with transfers. A statement with the incident report dated 6/30/12 signed by CNA B stated "On 6/25/12 I was getting Resident # 1 up for supper. When doing so her legs folded, so I put her down slowly on the floor and leaned her on her right side. I got help to help me get her up." An x-ray report dated 6/29/12 indicated Resident # 1 had a slanted fracture of the left knee, osteoporosis, and severe peripheral vascular disease. A Resident Transfer form dated 6/29/12 indicated Resident #1 had a left knee fracture. She was transferred to the hospital. The Preliminary Transcription Results from the hospital dated 6/29/12 indicated the nurses noted both of Resident #1's knees were swollen and the right one was worse. An x-ray showed a fracture. The resident had fractures to both of her knees when she came to the emergency room . During an interview on 7/2/12 at 12:10 p.m. the ADON said she received a call at home on 6/30/12 from CNA B. CNA B told her when she transferred Resident #1 on 6/25/12 the resident's legs "buckled" during the transfer. The ADON said she informed the DON on 6/30/12 of the incident. During a telephone interview on 7/2/12 at 12:20 p.m., CNA A said on 6/25/12 she was in another resident's room when CNA B asked her to assist her with getting Resident #1 off the floor. CNA A said she did not know what happened but when she arrived in the room Resident #1 was on the floor on her knees. CNA A said Resident #1 was a two person transfer and she did not know why CNA B did not request assistance before transferring the resident alone. During a telephone interview on 7/2/12 at 12:28 a.m., CNA B said she transferred Resident #1 alone and without a gait belt. During the transfer Resident #1's legs "folded" and she lowered the resident to the floor. She said she then got CNA A to assist Resident #1 off the floor. She said they lifted the resident off the floor without a gait belt. She said she did not notify a nurse or have the resident assessed before moving her off the floor. During an interview on 7/2/12 at 12:30 p.m. the DON said she was informed on 6/30/12 that CNA B did not follow policy and procedures regarding transfers. She said the CNA admitted she lowered the resident to the floor and had not told anyone. She said the CNA said she did not think it was a fall. The DON said she conducted in-services in the past on falls, and transfers but none since the incident. She said CNA B worked yesterday and was scheduled to work today. During an interview on 7/2/12 at 1:47 p.m. the DON said CNA B said she transferred Resident #1 without assistance and without a gait belt. She said Resident #1 required two people for transfers and their policy was to use a gait belt for transfers. During an interview on 7/2/12 at 2:00 p.m. CNA B said she transferred Resident #1 in the past without assistance and nothing happened. She said she knew Resident # 1 was a two person transfer and a gait belt was used for transfers. CNA B said she was in a hurry and tried to complete the transfer alone. She said Resident #1 could bear "a little weight sometimes". She said she tried to complete the transfer by "grabbing" the resident under her arms and Resident #1's legs "folded". She said Resident #1 was not able to assist her with the transfer so she "lowered her gently to the floor." She said she did not report the fall until she was told the resident had a broken leg on 6/30/12. CNA B said she worked on a different hall on 6/26/12 and 6/27/12 and that she was off the two days after that. CNA B said she was asked to write a statement and "that was all". During an interview on 7/2/12 at 2:28 p.m. LVN D said Resident #1 was a two person transfer. During an interview on 7/2/12 at 2:30 p.m. CNA E said Resident #1 was a two person transfer. She said the resident could not stand, pivot, or transfer. She said they used gait belts for all transfers. The facility policy on Moving a Resident from the Bed to the Chair dated 2003 indicated staff were to use a gait belt with one or two person transfers. The CMS 672 dated 7/2/12 indicated 61 residents required the assistance of one or two people for transfers

Based on interview and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 1 of 3 residents reviewed for falls. (Resident #1) CNA B was aware Resident #1 required two-person physical assistance with transfers. The CNA transferred Resident #1 without assistance and without a gait belt. The resident fell during the transfer and CNA B asked CNA A to help, and neither CNA A nor B notified a charge nurse of the incident for 5 days. CNA B continued to work as scheduled. Resident #1 complained of pain for four days; she was diagnosed with [REDACTED]. This failure contributed to Resident #1's fracture to both legs. This failure could place 61 residents that required assistance with transfers at risk for neglect and injury. Findings included: A computerized physician order [REDACTED]. Resident #1's latest MDS dated [DATE] indicated she was moderately impaired cognitively. The MDS indicated she required extensive assist with bed mobility and two- person physical assistance with transfers. Resident #1's balance when moving from seated to standing, and from surface-to-surface was not steady and she could only stabilize with staff assistance. Her ability to walk, turn around, face the opposite direction, and move off the toilet were not assessed, as these activities did not occur during the assessment period. Resident #1's functional limitation in range of motion was impairment on one side for the upper extremity and impairment on both sides for the lower extremities. A care plan with an initial date of 1/15/09 updated 5/9/12 indicated Resident #1 had problems of [MEDICAL CONDITION] and a potential for fractures. Approaches included two staff for transfers and may use gait belt as needed, and monitor for spontaneous fractures with redness, swelling and signs and symptoms of pain. A care plan with an initial date of 1/11/10 updated 6/29/12 indicated Resident #1 had a problem of potential for falls. The care plan indicated the resident had a fall while being transferred that resulted in bruising to her knee. Interventions were appropriate amount of staff to transfer, use gait belt as needed, and one or two staff for transfers. A fall risk assessment/care plan dated 5/9/12 updated 6/24/12 indicated Resident #1 was a high risk for falls. The resident had a score of 14 (a score of 10 or higher represents a high risk.) A weekly skin assessment sheet 6/26/12 indicated on 6/26/12 Resident #1 had a pale green bruise to the right side of her thigh that measured 3.2 cm x 2.8 cm. The assessment indicated the resident complained of pain to both legs and the charge nurse was informed. Nursing notes dated 6/27/12 for Resident #1 indicated the following: *7:00 a.m. complained of pain in both legs. She was crying and received one Tylenol 500 mg. *8:30 a.m. Resident #1 said the pain was a little better. *12:45 p.m. complained of neck and leg pain. She continued to frown and cry. She was given Tylenol 500 again. *1:45 p.m. the physician was notified and ordered [MEDICATION NAME] 5/325 every six hours as needed for pain and Tylenol 500 mg every 4 to six hours for break through pain. A nursing note dated 6/28/12 at 8:30 a.m. indicated Resident #1 complained of pain to both legs. The note indicated a pain score of 5 using a pain scale of 1-5. The resident was frowning and grimacing with pain she was given one [MEDICATION NAME] 5/325 for pain. An incident report dated 6/29/12 at 7:00 a.m. indicated Resident #1 complained of leg pain to both legs. There was swelling, heat, and bruising to the left leg, and slight swelling to the right knee. The resident said she had fallen but was unable to tell when. an order for [REDACTED]. The incident report indicated the resident required two-person assist with transfers. A statement with the incident report dated 6/30/12 signed by CNA B stated "On 6/25/12 I was getting Resident #1 up for supper. When doing so her legs folded, so I put her down slowly on the floor and leaned her on her right side. I got help to help me get her up." An x-ray report dated 6/29/12 indicated Resident #1 had a slanted [MEDICAL CONDITION] knee, [MEDICAL CONDITION], and severe [MEDICAL CONDITION]. A Resident Transfer form dated 6/29/12 indicated Resident #1 had a left knee fracture. She was transferred to the hospital. The Preliminary Transcription Results from the hospital dated 6/29/12 indicated the nurses noted both of Resident #1's knees were swollen and the right one was worse. An x-ray showed a fracture. The resident had fractures to both of her knees when she came to the emergency room . During an interview on 7/2/12 at 12:10 p.m. the ADON said she received a call at home on 6/30/12 from CNA B. CNA B told her when she transferred Resident #1 on 6/25/12 the resident's legs "buckled" during the transfer. The ADON said she informed the DON on 6/30/12 of the incident. During a telephone interview on 7/2/12 at 12:20 p.m., CNA A said on 6/25/12 she was in another resident's room when CNA B asked her to assist her with getting Resident #1 off the floor. CNA A said she did not know what happened but when she arrived in the room Resident #1 was on the floor on her knees. CNA A said Resident #1 was a two person transfer and she did not know why CNA B did not request assistance before transferring the resident alone. During a telephone interview on 7/2/12 at 12:28 a.m., CNA B said she transferred Resident #1 alone and without a gait belt. During the transfer Resident #1's legs "folded" and she lowered the resident to the floor. She said she then got CNA A to assist Resident #1 off the floor. She said they lifted the resident off the floor without a gait belt. She said she did not notify a nurse or have the resident assessed before moving her off the floor. During an interview on 7/2/12 at 12:30 p.m. the DON said she was informed on 6/30/12 that CNA B did not follow policy and procedures regarding transfers. She said the CNA admitted she lowered the resident to the floor and had not told anyone. She said the CNA said she did not think it was a fall. The DON said she conducted in-services in the past on falls, and transfers but none since the incident. She said CNA B worked yesterday and was scheduled to work today. During an interview on 7/2/12 at 1:47 p.m. the DON said CNA B said she transferred Resident #1 without assistance and without a gait belt. She said Resident #1 required two people for transfers and their policy was to use a gait belt for transfers. During an interview on 7/2/12 at 2:00 p.m. CNA B said she transferred Resident #1 in the past without assistance and nothing happened. She said she knew Resident #1 was a two person transfer and a gait belt was used for transfers. CNA B said she was in a hurry and tried to complete the transfer alone. She said Resident #1 could bear "a little weight sometimes". She said she tried to complete the transfer by "grabbing" the resident under her arms and Resident #1's legs "folded". She said Resident #1 was not able to assist her with the transfer so she "lowered her gently to the floor." She said she did not report the fall until she was told the resident had a broken leg on 6/30/12. CNA B said she worked on a different hall on 6/26/12 and 6/27/12 and that she was off the two days after that. CNA B said she was asked to write a statement and "that was all". During an interview on 7/2/12 at 2:28 p.m. LVN D said Resident #1 was a two person transfer. During an interview on 7/2/12 at 2:30 p.m. CNA E said Resident #1 was a two person transfer. She said the resident could not stand, pivot, or transfer. She said they used gait belts for all transfers. The facility policy on Moving a Resident from the Bed to the Chair dated 2003 indicated staff were to use a gait belt with one or two person transfers. An abuse policy dated 1/8/03 indicated "Neglect was failure to provide essential needs or protection for a person incapable of providing for himself independently." Prevention: reports of abuse or suspicion of abuse/neglect will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator within 24 hours of complaint, and appropriate notification to the state office. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. Identification when suspected neglect is expected by employee they must immediately make a verbal report to the 5G coordinator or designee. If the discovery occurs outside of normal business hours the coordinator will be paged. Facility employees must report neglect which causes serious accidental injury or hospitalization to DADS. Investigation: with an allegation of neglect the employee will immediately be suspended pending an investigation. The CMS 672 dated 7/2/12 indicated 61 residents required the assistance of one or two people for transfers.

Based on interview and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 1 of 3 residents reviewed for falls. (Resident #1) CNA B was aware Resident #1 required two-person physical assistance with transfers. The CNA transferred Resident #1 without assistance and without a gait belt. The resident fell during the transfer and CNA B asked CNA A to help, and neither CNA A nor B notified a charge nurse of the incident for 5 days. CNA B continued to work as scheduled. Resident #1 complained of pain for four days; she was diagnosed with [REDACTED]. This failure contributed to Resident #1's fracture to both legs. This failure could place 61 residents that required assistance with transfers at risk for neglect and injury. Findings included: An abuse policy dated 1/8/03 indicated "Neglect was failure to provide essential needs or protection for a person incapable of providing for himself independently." Prevention: reports of abuse or suspicion of abuse/neglect will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator within 24 hours of complaint, and appropriate notification to the state office. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. Identification when suspected neglect is expected by employee they must immediately make a verbal report to the 5G coordinator or designee. If the discovery occurs outside of normal business hours the coordinator will be paged. Facility employees must report neglect which causes serious accidental injury or hospitalization to DADS. Investigation: with an allegation of neglect the employee will immediately be suspended pending an investigation. A computerized physician order [REDACTED]. Resident #1's latest MDS dated [DATE] indicated she was moderately impaired cognitively. The MDS indicated she required extensive assist with bed mobility and two- person physical assistance with transfers. Resident #1's balance when moving from seated to standing, and from surface-to-surface was not steady and she could only stabilize with staff assistance. Her ability to walk, turn around, face the opposite direction, and move off the toilet were not assessed, as these activities did not occur during the assessment period. Resident #1's functional limitation in range of motion was impairment on one side for the upper extremity and impairment on both sides for the lower extremities. A care plan with an initial date of 1/15/09 updated 5/9/12 indicated Resident #1 had problems of [MEDICAL CONDITION] and a potential for fractures. Approaches included two staff for transfers and may use gait belt as needed, and monitor for spontaneous fractures with redness, swelling and signs and symptoms of pain. A care plan with an initial date of 1/11/10 updated 6/29/12 indicated Resident #1 had a problem of potential for falls. The care plan indicated the resident had a fall while being transferred that resulted in bruising to her knee. Interventions were appropriate amount of staff to transfer, use gait belt as needed, and one or two staff for transfers. A fall risk assessment/care plan dated 5/9/12 updated 6/24/12 indicated Resident #1 was a high risk for falls. The resident had a score of 14 (a score of 10 or higher represents a high risk.) A weekly skin assessment sheet 6/26/12 indicated on 6/26/12 Resident #1 had a pale green bruise to the right side of her thigh that measured 3.2 cm x 2.8 cm. The assessment indicated the resident complained of pain to both legs and the charge nurse was informed. Nursing notes dated 6/27/12 for Resident #1 indicated the following: *7:00 a.m. complained of pain in both legs. She was crying and received one Tylenol 500 mg. *8:30 a.m. Resident #1 said the pain was a little better. *12:45 p.m. complained of neck and leg pain. She continued to frown and cry. She was given Tylenol 500 again. *1:45 p.m. the physician was notified and ordered [MEDICATION NAME] 5/325 every six hours as needed for pain and Tylenol 500 mg every 4 to six hours for break through pain. A nursing note dated 6/28/12 at 8:30 a.m. indicated Resident #1 complained of pain to both legs. The note indicated a pain score of 5 using a pain scale of 1-5. The resident was frowning and grimacing with pain she was given one [MEDICATION NAME] 5/325 for pain. An incident report dated 6/29/12 at 7:00 a.m. indicated Resident #1 complained of leg pain to both legs. There was swelling, heat, and bruising to the left leg, and slight swelling to the right knee. The resident said she had fallen but was unable to tell when. an order for [REDACTED]. The incident report indicated the resident required two-person assist with transfers. A statement with the incident report dated 6/30/12 signed by CNA B stated "On 6/25/12 I was getting Resident #1 up for supper. When doing so her legs folded, so I put her down slowly on the floor and leaned her on her right side. I got help to help me get her up." An x-ray report dated 6/29/12 indicated Resident #1 had a slanted [MEDICAL CONDITION] knee, [MEDICAL CONDITION], and severe [MEDICAL CONDITION]. A Resident Transfer form dated 6/29/12 indicated Resident #1 had a left knee fracture. She was transferred to the hospital. The Preliminary Transcription Results from the hospital dated 6/29/12 indicated the nurses noted both of Resident #1's knees were swollen and the right one was worse. An x-ray showed a fracture. The resident had fractures to both of her knees when she came to the emergency room . During an interview on 7/2/12 at 12:10 p.m. the ADON said she received a call at home on 6/30/12 from CNA B. CNA B told her when she transferred Resident #1 on 6/25/12 the resident's legs "buckled" during the transfer. The ADON said she informed the DON on 6/30/12 of the incident. During a telephone interview on 7/2/12 at 12:20 p.m., CNA A said on 6/25/12 she was in another resident's room when CNA B asked her to assist her with getting Resident #1 off the floor. CNA A said she did not know what happened but when she arrived in the room Resident #1 was on the floor on her knees. CNA A said Resident #1 was a two person transfer and she did not know why CNA B did not request assistance before transferring the resident alone. During a telephone interview on 7/2/12 at 12:28 a.m., CNA B said she transferred Resident #1 alone and without a gait belt. During the transfer Resident #1's legs "folded" and she lowered the resident to the floor. She said she then got CNA A to assist Resident #1 off the floor. She said they lifted the resident off the floor without a gait belt. She said she did not notify a nurse or have the resident assessed before moving her off the floor. During an interview on 7/2/12 at 12:30 p.m. the DON said she was informed on 6/30/12 that CNA B did not follow policy and procedures regarding transfers. She said the CNA admitted she lowered the resident to the floor and had not told anyone. She said the CNA said she did not think it was a fall. The DON said she conducted in-services in the past on falls, and transfers but none since the incident. She said CNA B worked yesterday and was scheduled to work today. During an interview on 7/2/12 at 1:47 p.m. the DON said CNA B said she transferred Resident #1 without assistance and without a gait belt. She said Resident #1 required two people for transfers and their policy was to use a gait belt for transfers. During an interview on 7/2/12 at 2:00 p.m. CNA B said she transferred Resident #1 in the past without assistance and nothing happened. She said she knew Resident # 1 was a two person transfer and a gait belt was used for transfers. CNA B said she was in a hurry and tried to complete the transfer alone. She said Resident #1 could bear "a little weight sometimes". She said she tried to complete the transfer by "grabbing" the resident under her arms and Resident #1's legs "folded". She said Resident #1 was not able to assist her with the transfer so she "lowered her gently to the floor." She said she did not report the fall until she was told the resident had a broken leg on 6/30/12. CNA B said she worked on a different hall on 6/26/12 and 6/27/12 and that she was off the two days after that. CNA B said she was asked to write a statement and "that was all". During an interview on 7/2/12 at 2:28 p.m. LVN D said Resident #1 was a two person transfer. During an interview on 7/2/12 at 2:30 p.m. CNA E said Resident #1 was a two person transfer. She said the resident could not stand, pivot, or transfer. She said they used gait belts for all transfers. The facility policy on Moving a Resident from the Bed to the Chair dated 2003 indicated staff were to use a gait belt with one or two person transfers. The CMS 672 dated 7/2/12 indicated 61 residents required the assistance of one or two people for transfers.