Every finding on record at Vivo Healthcare West Orange

Based on interview, and record review, the facility failed to honor a resident's wishes for Do Not Resuscitate (DNR) by not ensuring those wishes were completely and accurately documented to promote continuity of care between providers for 1 of 10 residents reviewed for advance directives, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) efforts in violation of an explicit wish for a natural and dignified death. There was likelihood resident #1 would have experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE] at approximately 5:45 AM, resident #1 was found unresponsive with no pulse and no respirations. Registered Nurse (RN) C verified resident #1's code status as DNR, then called Emergency Medical Services (EMS). RN C provided EMS with an incomplete Florida Do Not Resuscitate Order (DNRO) form. EMS determined the form was invalid due to being incomplete and began CPR. EMS discontinued CPR at 6:40 AM and resident #1 was pronounced deceased . The facility's failure to ensure complete and accurate documentation of the resident's do not resuscitate wishes placed all residents with a do not resuscitate order at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The census at the start of the survey was 106 with 23 residents identified as Do Not Resuscitate. Findings: Cross reference F678. Review of the face sheet revealed resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including stroke, type 2 diabetes, essential hypertension, Human Immunodeficiency Virus and unspecified dementia. Review of the Minimum Data Set Medicare 5-Day assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 12/15 which indicated he had moderate cognitive impairment. The document indicated the resident's primary reason for admission was stroke and had multiple medical conditions including heart failure, coronary artery disease, renal insufficiency and non-Alzheimer's dementia. Resident #1 had a care plan initiated on [DATE] and revised on [DATE] for impaired cognitive process related to history of dementia. Interventions included communicate with the resident and family regarding resident's needs. Review of physician orders revealed an order for Do Not Resuscitate (DNR) dated [DATE]. Review of resident #1's electronic medical record (EMR) revealed a 3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form from the hospital which indicated resident #1 was a DNR. The EMR also contained a Florida DNRO form signed only by the hospital physician. In a phone interview on [DATE] at 2:01 PM, Licensed Practical Nurse (LPN) Supervisor A confirmed she worked the night of [DATE] when resident #1 admitted to the facility. She recalled resident #1 was confused upon admission, so she and another nurse contacted the resident's daughter by phone for consent to treat. She stated the resident had a Florida DNRO form that was sent from the hospital signed by a physician. LPN Supervisor A explained she and the other nurse confirmed resident #1's wishes to be a DNR with his daughter. She stated she and the other nurse signed the Advance Directives Discussion Document but did not sign off on the Florida DNRO form. On [DATE] at 3:31 PM, the Social Services Director (SSD) stated she was responsible for addressing advanced directives with residents and/or their representatives. She explained she reviewed advanced directives for new admissions during morning meeting with other department heads as a follow up to efforts made by the nurse who admitted the resident. The SSD stated she verified residents' advanced directives and would request copies of other forms such as a Power of Attorney or Health Care Surrogate designation, if needed. She recalled resident #1 admitted on a Friday ([DATE]) and his advanced directives were reviewed on Monday morning ([DATE]). She stated the Florida DNRO form in the admission packet was only signed by a physician and lacked any other signature. The SSD reported that she, the former Director of Nursing (DON) and the former Assistant Director of Nursing (ADON) called resident #1's daughter to verify his wish not to have CPR. She verified the two nurses with her on the call were both RNs. The SSD was unable to state why the two nurses did not document the conversation, sign off on the Florida DNRO form until the resident or resident's proxy were able to sign, or obtain the signature by another means. In a phone interview on [DATE] at 4:53 PM, RN C verified she was the assigned nurse for resident #1 on the night of [DATE] going into [DATE]. She recalled his assigned Certified Nursing Assistant (CNA) approached her at 5:45 AM on [DATE] to let her know resident #1 was unresponsive. RN C stated she went to the resident's room, but he was unresponsive. She explained she left the room to get equipment to take his vitals. When she returned, she was unable to obtain a blood pressure, pulse or respirations. RN C stated she confirmed resident #1's code status as DNR and placed a call to EMS at approximately 5:54 AM. She recalled when EMS arrived, they viewed the DNR order in the EMR and requested a copy of the Florida DNRO form. The nurse stated she printed a copy of the form after locating the goldenrod-colored paper in the front office. RN C explained EMS personnel noticed the form was only signed by a physician and did not have the signature of the resident or authorized representative. The RN recalled EMS informed her the form was invalid. She stated EMS began CPR but ceased resuscitation and called time of death at 6:40 AM. In a phone interview on [DATE] at 10:49 AM, resident #1's daughter confirmed she was his health care proxy. She recalled she spoke with facility staff and informed them he was a DNR, when her father was admitted to the facility. She stated a facility staff member called her the morning of her father's death and told her EMS performed CPR as the Florida DNRO form was not signed. Resident #1's daughter did not know why the form was not signed. She explained she had signed several papers at the hospital but could not recall signing the gold Florida DNRO form. In a meeting with the Administrator and DON on [DATE] at 10:18 AM, the Administrator stated the Quality Assurance and Performance Improvement (QAPI) Committee met and reviewed the event in an Ad Hoc meeting on [DATE]. She acknowledged nursing staff had recognized resident #1 and his family's desire for DNR upon admission and placed a physician's order for DNR but did not ensure they had a valid Florida DNRO form signed by the resident or his proxy and available before his death. Review of the facility's policy and procedure dated [DATE] for Residents' Rights Regarding Treatment and Advance Directives, revealed it was the facility's policy to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate advance directives. The document explained that any decision making regarding the resident's choices would be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. The facility's policy and procedure for Documentation in the Medical Record revised [DATE] read, Each resident's medical record shall contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The document listed one of the principles of documentation was that documentation should be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team on [DATE] and [DATE]: *On [DATE], the attending physician, Medical Director, Administrator, interim DON and resident representative were notified of the incident and an investigation was initiated. *On [DATE], the SSD/Designee conducted an immediate 100% audit of all current residents' code status and care plan; verified the presence of a valid Florida DNRO form for each applicable resident in the EMR; confirmed the form contained the physician and resident/proxy signatures, signature dates, and legal proxy authority; and contacted attending physicians and legally authorized representatives immediately to complete any missing or incomplete Florida DNRO form documentation. *On [DATE], the SSD printed the Florida DNRO form for each applicable resident and put in Emergency Response Binders. These binders were placed on each unit, rehabilitation (therapy) room, and social services on [DATE]. *On [DATE], SSD/designee initiated advanced directives audits weekly for three months with focus to ensure the Florida DNRO form was complete and valid. *On [DATE], the facility implemented a revised admission/readmission process which included Resident Rights & Advance Directive education upon admission; completion of an Advance Directives Discussion Document and validation of advance directives by Social Services/designee. *On [DATE], the Regional Director of Education initiated education to licensed nurses, Social Services Director and Admissions Coordinator on location of goldenrod (yellow) paper for printing Florida DNRO forms. *On [DATE], the ADON initiated education with licensed nurses, Admissions Coordinator, and SSD on documentation in the medical record to ensure each resident's medical record contained complete, accurate, and timely documentation. *On [DATE], the SSD was educated on ensuring accuracy of advance directives/Florida DNRO form. *On [DATE], the facility implemented the Florida DNRO form admission & readmission Checklist to ensure verification of required signatures, confirmation of proxy authority, proper form completion and physical availability of the Florida DNRO form. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. Education and audits were reviewed. 100% chart audit of advanced directives including code status, DNR orders and Florida DNRO forms was completed by [DATE]. *From [DATE] to [DATE], the facility educated all licensed nurses on the topics of Resident Rights in regard to Advanced Directives; verification of advanced directives; DNR orders; Florida DNRO forms and requirements; and complete and accurate documentation in the EMR. A post-test was completed following the educations to ensure understanding of the training received. *On [DATE], 100 percent of licensed nurses were trained and completed post-tests. Education continued to include new employees. *Ad HOC QAPI meetings were held on [DATE], [DATE] and [DATE], and monthly QAPI meeting on [DATE] with Administrator, Director of Nursing, Medical Director and administrative staff. Education, audits and post-tests were reviewed and revised as indicated. *Interviews were conducted on [DATE] with 32 staff members representing all shifts (15 CNAs, 6 RNs, 9 LPNs, 1 SSD and 1 Admissions Coordinator). Staff interviews revealed they were knowledgeable of advanced directives; how to verify the code status; completion of Florida DNRO form and location of Emergency Response Binders. The surveyors validated the education through interviews and review of attendance sheets and post-tests for the in-services. Review of monthly and Ad HOC QAPI meetings revealed education was completed and audits were conducted as stated. The resident sample was expanded to include seven additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, #8, #9 and #10 related to advance directives. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on [DATE].

Based on interview, and record review, the facility failed to ensure a resident did not receive Cardiopulmonary Resuscitation (CPR) against his wishes by providing an invalid Florida Do Not Resuscitate Order (DNRO) form to Emergency Medical Services (EMS) during an emergency for 1 of 10 residents reviewed for advance directives, (#1). On [DATE] at approximately 5:45 AM, resident #1 was found unresponsive with no pulse and no respirations. Registered Nurse (RN) C verified resident #1's code status as Do Not Resuscitate (DNR) and called EMS. RN C provided EMS with an incomplete Florida DNRO form. EMS determined the form was invalid due to missing signatures and began CPR. After three rounds of CPR efforts, EMS discontinued CPR at 6:40 AM and resident #1 was pronounced deceased . The facility's failure to ensure complete and accurate documentation of the resident's DNR wishes placed all residents with a DNR order at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. Substandard Quality of Care was identified at F678. A partial extended survey was conducted on [DATE]. The noncompliance at F678 was determined to be past noncompliance as of [DATE]. Findings: Cross reference F578. Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses including stroke, type 2 diabetes, heart failure, Human Immunodeficiency Virus and unspecified dementia. Review of the Minimum Data Set Medicare Five-Day assessment with assessment reference date of [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 12/15 which indicated he had moderate cognitive impairment. The document indicated the resident's primary reason for admission was stroke and had multiple medical conditions including heart failure, coronary artery disease, renal insufficiency and non-Alzheimer's dementia. Resident #1's electronic medical record (EMR) contained a physician order dated [DATE] which read, DNR - DO NOT RESUSCITATE. There were no documents scanned in the EMR for power of attorney, health care surrogate, or health care proxy. Review of resident #1's EMR revealed a 3008 Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form from the hospital indicated resident #1 was alert, but disoriented. The form detailed that resident #1 required a surrogate for decision making and that he was a DNR. The EMR also contained a Florida DNRO form dated [DATE] signed only by the hospital physician. A Late Entry Nurses Note created [DATE] at 12:01 PM, with effective date of [DATE] at 7:15 AM revealed RN C was called to the room by Certified Nursing Assistant (CNA) D at 5:45 AM. Resident #1 was observed unresponsive. RN C the room to retrieve vital sign equipment. Upon her return to the resident's room, she checked resident #1's blood glucose level and attempted to obtain his vital signs. She documented she was unable to obtain a blood pressure, pulse, or respirations and left the room, again to check code status in the medical record The note indicated the nurse confirmed resident #1 's code status was DNR per the medical record, and at 5:54 AM she called EMS via 911. When EMS arrived, the DNR Code Status order was verified in the medical record. The RN documented that EMS responders requested a copy of the goldenrod-colored Florida DNRO form and were willing to wait up to 20 minutes for the form. The noted detailed that when the Florida DNRO form was presented, EMS responders stated the form was incomplete due to missing signature of resident or proxy and CPR was initiated. Resuscitation efforts were unsuccessful and EMS ceased efforts at 6:40 AM. In a phone interview on [DATE] at 11:52 AM, CNA D confirmed she was assigned to resident #1 during the night shift of [DATE] into [DATE]. She stated she checked on the resident several times during the shift. The CNA recalled when she checked on resident #1 again at about 5:45 AM, he was unresponsive and did not move when she shook him. She explained she notified RN C who said she would call emergency medical services, even though she told her the resident was a DNR. CNA D recalled EMS arrived and started doing CPR. They were asking for the paper (the DNR), she conveyed. In a phone interview on [DATE] at 4:53 PM, RN C confirmed she was resident #1's assigned nurse on the night shift from [DATE] into [DATE]. She recalled CNA D approached her at 5:45 AM on [DATE] and informed her resident #1 was unresponsive. RN C stated she went to the resident's room and rubbed him hard on the chest bone, but he did not respond. She explained she went to get equipment to check his vital signs but was unable to obtain a blood pressure or respirations. RN C said she was unable to locate a paper copy of the Florida DNRO form, only a scanned copy in the computer. She explained she thought she would see him take a small breath every so often, so she placed a call to EMS at approximately 5:54 AM. RN C was unable to explain why she documented she was unable to obtain respirations in the EMR if she thought she saw him take breaths. She clarified she called EMS because it was the policy of the previous company. RN C recalled when EMS arrived, she showed them the DNR order in the EMR and they asked for the paper copy of the Florida DNRO form. She stated since she was unable to locate a paper copy of the DNRO form she printed the copy from the EMR after locating some goldenrod (yellow) colored paper. RN C explained EMS realized the Florida DNRO form was only signed by a physician and did not contain the signature of the resident or authorized representative. She stated they informed her the form was therefore invalid. RN C recalled EMS began CPR but were unable to resuscitate him and called his time of death at 6:40 AM. RN C acknowledged all residents with DNR orders should have a valid, signed Florida DNRO form. In a phone interview on [DATE] at 10:49 AM, resident #1's daughter confirmed she was his health care proxy, having signed that and many other papers at the hospital. She recalled facility staff called her to confirm her father's advance directives, and she informed them he wished to be a DNR. She stated a facility staff member called her the morning of her father's death and told her EMS performed CPR on her father as the Florida DNRO form had not been signed. Resident #1's daughter did not know why the facility did not ensure the form was signed, as per his wishes. On [DATE] at 3:31 PM, the Social Services Director (SSD) stated she was responsible for addressing advanced directives with residents and/or their representatives. She recalled she reviewed resident #1's advanced directives on Monday, [DATE], following his weekend admission. She realized the Florida DNRO form in the admission packet was only signed by a physician and lacked any other signatures. The SSD explained she made the department heads aware of the incomplete form during morning report. She recalled she, the former Director of Nursing (DON) and former Assistant Director of Nursing (ADON) called resident #1's daughter to verify his wishes not to have CPR. The SSD was unable to state why the two nurses did not document the conversation or sign off on the Florida DNRO form until the resident or resident's proxy were able to sign. She explained resident #1 became unresponsive on the overnight shift and EMS performed CPR on him when the Florida DNRO form was determined to be invalid because the resident or resident's representative had not signed it. On [DATE] at 10:18 AM, the Administrator and DON discussed the incident investigation and Root Cause Analysis related to resident #1 receiving CPR despite the family's wishes and documentation of a DNR order. The Administrator stated during the investigation, it was discovered the hospital sent an incomplete Florida DNRO form in the admission packet for resident #1. She explained the admission nurse reviewed the admission packet and called the resident's daughter in the presence of another nurse to verify his code status. She verified the two nurses signed the advance directives discussion document for him to be a DNR, but did not sign the Florida DNRO form. The Administrator reported that resident #1's advanced directives were also reviewed in morning report with the interdisciplinary team on [DATE] and it was identified the Florida DNRO form lacked signatures of resident and/or authorized representative. She stated a call was placed to resident #1's daughter after the meeting but was unsure as to who was on the call as she left it to the interdisciplinary team to address. The Administrator reported the investigation timeline showed that resident #1 was found unresponsive at 5:45 AM on [DATE]. His nurse was notified and responded to the room but was unable to obtain vital signs. She said the nurse verified resident #1 was a DNR in the computer then placed a call to EMS. The Administrator was unable to state why the nurse called EMS. She stated EMS arrived at approximately 6:05 AM and requested a copy of the Florida DNRO form. Upon receiving the copy, EMS notified the nurse that the Florida DNRO form was invalid as it was not signed by the resident or his authorized representative. She stated EMS then initiated three rounds of CPR per their protocol before pronouncing the resident deceased at 6:40 AM. The Administrator and DON explained as part of their investigation they found a note in the hospital records that resident #1 expressed to hospital staff he wanted to be a DNR and understood what that meant. They acknowledged facility nurses recognized the Florida DNRO form from the hospital was not valid but failed to ensure a signed and valid copy was available. The facility's policy and procedure for Cardiopulmonary Resuscitation (CPR) revised [DATE] revealed, It is the policy of this facility to adhere to resident's rights to formulate advance directives. The form indicated the facility staff would provide basic life support in accordance with the resident's advanced directives. The facility's policy and procedure for Documentation in the Medical Record revised [DATE] indicated that documentation should be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team on [DATE] and [DATE]: *On [DATE], the facility initiated an internal investigation which included resident record review, staff interviews, notification to the Department of Children and Families, the Florida Agency for Health Care Administration, local law enforcement and validated the attending physician/medical director and resident's responsible party were notified regarding the event. *On [DATE], the SSD/Designee conducted an immediate 100% audit of all current residents' code status and care plan; verified the presence of a valid Florida DNRO form for each applicable resident in the EMR. *On [DATE], the facility initiated code blue drills and continued across all shifts. *On [DATE], the facility implemented Emergency Response Binders containing the Florida DNRO form for applicable residents, facility Florida DNRO verification checklist and code status reference guide for staff. Binders were placed at each nurses' station, rehabilitation department and the social services office. All binders were put into place by [DATE]. *On [DATE], the Regional Director of Education initiated education to licensed nurses, Social Services Director and Admissions Coordinator on location of goldenrod (yellow) paper for printing Florida DNRO forms. *On [DATE], the facility educated staff that CPR must be initiated by EMS unless a valid Florida DNRO form was physically available. *On [DATE], the facility established designated locations for goldenrod (yellow) paper for Florida DNRO forms to prevent delays. These were located in yellow folders at A Wing nurses station, B Wing nurses station and the front desk. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. Education and audits were reviewed. 100% chart audit of advanced directives including code status, DNR orders and Florida DNRO forms was completed by [DATE]. *From [DATE] to [DATE], the facility educated all licensed nurses on the topics of Resident Rights in regard to Advanced Directives; verification of code status and advanced directives; DNR orders; Florida DNRO forms and requirements; CPR policy and EMS response requirements; communication of code status; location of goldenrod (yellow) paper for printing Florida DNRO forms; and complete and accurate documentation in the EMR. A post-test was completed following the educations to ensure understanding of the training received. *On [DATE], 31 of 31 (100%) of licensed nurses were trained and completed post-tests. Education continued to include new employees. *On [DATE], the facility had conducted 28 Code Blue Drills with 30 of 31 (96.7%) licensed nurses. The remaining one staff member was scheduled to complete a code blue drill upon return from medical leave. *Ad HOC QAPI meetings were held on [DATE], [DATE], and [DATE], and Monthly QAPI meeting on [DATE] with Administrator, Director of Nursing, Medical Director and administrative staff. Education, audits, code blue drills and post-tests were reviewed and revised as indicated. *Interviews were conducted on [DATE] with 32 staff members representing all shifts (15 CNAs, 6 RNs, 9 LPNs, 1 SSD and 1 Admissions Coordinator). Staff interviews revealed they were knowledgeable of advanced directives; how to verify the code status; completion of Florida DNRO form and location of Emergency Response Binders. The surveyors validated the education, audits and participation in code blue drills through interviews and review of attendance sheets and post-tests. Review of Monthly and Ad HOC QAPI meetings revealed educations, audits and code blue drills were conducted as stated. The resident sample was expanded to include seven additional residents who elected DNR status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, #8, #9 and #10 related to advance directives. Based on the facility's corrective actions, the survey team determined the facility was in substantial compliance on [DATE].

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate related to special treatments, procedures and programs for 3 of 3 residents reviewed for accuracy of assessments, of a total sample of 40 residents, (#4, #8 and #46). Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including epilepsy, chronic respiratory failure with hypoxia, and tracheostomy status. Review of the MDS quarterly assessment with assessment reference date (ARD) 2/21/25 revealed resident #4 had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated she was cognitively intact. The assessment indicated resident #4 received tracheostomy (a hole in the throat for breathing) care and dialysis. On 5/06/25 at 11:53 AM, resident #4 was reclined in bed with the head of the bed elevated. Resident #4 stated she did not go to dialysis. Resident #4 clarified she did not receive dialysis and had never received dialysis. 2. Resident #8 was admitted to the facility on [DATE] with diagnoses including nontraumatic brain bleed, acute respiratory failure with low oxygen and encounter for attention to tracheostomy. Review of the MDS quarterly assessment with ARD 1/25/25 revealed resident #8 had long-term and short-term memory problems and severely impaired cognitive skills for daily decision making. The assessment indicated resident #8 received tracheostomy care and had an invasive mechanical ventilator for breathing. On 5/06/25 at 10:25 AM, resident #8 was reclined in bed with the head of the bed slightly elevated. Tracheostomy tubing was in place. No ventilator tubing or equipment for a mechanical ventilator was seen in the room. On 5/07/25 at 10:28 AM, in resident #8's room, the MDS Coordinator and the A Wing Unit Manager verified resident #8 had a tracheostomy but did not use a ventilator for breathing. 3. Resident #46 was admitted to the facility on [DATE] with diagnoses that included bladder inflammation with blood in the urine. Review of the MDS admission assessment with ARD 3/28/25 revealed resident #46 had a BIMS score of 14/15 which indicated he was cognitively intact. The assessment indicated resident #46 received dialysis. On 5/05/25 at 11:29 AM, resident #46 was lying in his bed in his room. Resident #46 in response to what days he went to dialysis, stated he did not go to dialysis at all. He clarified he had never been on dialysis. On 5/07/25 at 10:32 AM, the MDS Coordinator stated she was the head of the MDS department. She reviewed the medical records for residents #4, #8 and #46. The MDS Coordinator compared each resident's diagnoses and care plans to the identified MDS assessment for each resident. She verified each MDS assessment was coded incorrectly. She was unable to explain why they were coded incorrectly. The MDS Coordinator explained the other MDS staff person completed those assessments. The MDS Coordinator stated the other MDS staff was not at the facility to explain why they MDS was coded incorrectly, and did not know when she would return. The MDS Coordinator acknowledged each resident's assessment should accurately reflect their status at the time of the assessment. The facility policy and procedure for Conducting an Accurate Resident Assessment implemented 10/01/22 indicated the purpose of the policy was to ensure all residents received an accurate assessment. The form defined accuracy of assessment meant that appropriate health care professionals correctly documented the resident's medical, functional and psychosocial problems. The form read, Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment by failing to replace a cracked bedside floor mat for 1 of 1 residents reviewed for environmental concerns, of a total of 40 sampled residents, (#70). Findings: Resident #70 was admitted to the facility on [DATE], with a history of falling, abnormal posture, unspecified lack of coordination. Review of resident #70's care plan with revision date of 7/11/23, indicated he was at risk for falls related to deconditioning, weakness, and having a history of a fracture. Interventions included fall mats at bedside, dated 12/30/24. On 5/05/25 at 3:23 PM, resident #70 was lying in bed, a beside fall mat was on the floor. The surface was cracked and split along its entire length which revealed the layer underneath the surface. On 5/06/25 at 8:40 AM, the beside fall mat was observed on the floor at the side of resident #70's bed. The surface remained cracked and split along its entire length which revealed the layer underneath the surface. On 5/06/25 at 3:25 PM, the Director of Maintenance confirmed the cracked surface of the fall mat on the floor next to resident #70's bed. The Director of Maintenance explained nursing staff was responsible to change out any fall mats in use by residents that were in disrepair. On 5/06/25 at 3:30 PM, the B side Unit Manager agreed resident #70's bedside fall mat had a cracked surface along its length which exposed the interior of the mat. The B side Unit Manager confirmed the mat was old, and referred to it as the older version. She verified a new beside fall mat had not been obtained from central supply nor had a service request been entered into the electronic maintenance service request system for a new mat. She acknowledged because the surface of the mat was cracked and split it could not be cleaned properly.

Based on interview and record review, the facility failed to re-admit residents who were transferred to a higher level of care for treatment of acute conditions, for 2 of 3 residents reviewed for hospitalization , out of a total sample of 9 residents, (#2 and #3). The facility's failure to permit residents who required its care and services to return from the hospital resulted in extended stays in acute care settings after medical issues were resolved, and necessitated adjustment to unfamiliar personnel and routines in new skilled nursing facilities (SNFs), actual harm, for residents #2 and #3. Findings: 1. Review of the medical record revealed resident #3 was admitted to the facility on [DATE]. His diagnoses included weakness, need for assistance with personal care, cognitive communication deficit, history of alcohol abuse, and noncompliance with medical treatments. The resident's medical record was updated on 10/16/23 with diagnoses of major depressive disorder, adjustment disorder with anxiety, and primary insomnia. On 12/18/23, resident #3 was diagnosed with bipolar II disorder and on 1/03/24 he was diagnosed with anxiety disorder. The resident's Admission Record or face sheet showed he had a court-appointed legal guardian who was his emergency contact and care conference representative. Review of the Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date (ARD) of 1/26/24 revealed resident #3 was discharged to a short-term general hospital. The document revealed during the 7-day look back period, resident #3 had physical behavioral symptoms directed towards others on one to three days, verbal behavioral symptoms directed towards others on four to six days, and other behavioral symptoms that were not directed towards others on one to three days. The document showed resident #3 rejected evaluation or care such as medications and assistance with activities of daily living on one to three days. He was totally dependent on staff for toileting hygiene, bathing, dressing, and personal hygiene. The resident required substantial to maximal assistance for bed mobility, was totally dependent on staff for transfers, and did not walk. The document indicated resident #3 had an indwelling urinary catheter. The MDS assessment revealed the resident received antipsychotic, antidepressant, hypnotic, anticoagulant, antibiotic, and opioid medication. Review of the medical record revealed resident #3 had a care plan initiated on 9/14/23 for falls related to weakness, bedbound status, and has not walked in 3 years. A care plan was initiated on 9/18/23 for behavior problems related to history of noncompliance with medications, treatment, and wound care, and verbal aggression including use of profanity, screaming, threatening, and cursing. The interventions instructed staff to administer medications as ordered and monitor or document medication effectiveness, anticipate and meet his needs, encourage him to comply with care, divert his attention, discuss his behavior, explain all procedures before starting, and intervene as necessary to protect the rights and safety of others. The resident had a care plan for the potential to be verbally aggressive due to his disease process, initiated on 9/19/23. The goal was the resident would demonstrate effective coping skills. The interventions instructed staff to administer medications as ordered, initiate a psychiatric consult as indicated, and analyze key times, places, circumstances, triggers, and what de-escalates behavior. Resident #3 had a care plan for a discharge goal of long term placement in the facility, initiated on 9/27/23. The goal was the resident would remain adjusted to long term placement. The intervention was the facility's Social Services Director (SSD) would explain the benefits of living in a long-term care facility. Review of resident #3's medical record revealed a Preadmission Screening and Resident Review (PASARR) form dated 9/13/23. The PASARR is a federal requirement to ensure individuals are not inappropriately placed in nursing homes for long term care. The Level I screen is a preliminary assessment to determine if there might be Serious Mental Illness (SMI) or Intellectual Disability (ID). If the Level I screen is positive, then referral for an in-depth Level II screen is required to determine the need for additional services and the appropriate setting, and recommend necessary services to be included in the plan of care (retrieved on 5/20/24 from www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). Resident #3's PASARR form indicated he was deemed appropriate for admission to a skilled nursing facility. The document revealed the Level I screen was negative as the resident had no diagnosis or suspicion of SMI or ID; therefore, he did not require a Level II screen. The medical record did not contain evidence of a revised PASARR form to reflect resident #3's new psychiatric diagnoses or a referral for a Level II screen. Review of a Psychiatric Evaluation note dated 10/16/23 revealed resident #3 was referred to psychiatry for a chief complaint of depression. The note indicated staff reported no recent issues and resident #3 was cooperative with no acute nervousness or depression. The psychiatrist noted the resident showed an adequate response to his current medications, Restoril 15 milligrams (mg) at bedtime for insomnia and Cymbalta 60 mg daily for depression. A Psychiatric Progress Note dated 11/13/23 revealed staff reported no acute changes. The psychiatrist noted resident #3 was calm, had no hallucinations or delusions, exhibited fair judgement and insight, and was aware of current events. The document read, Patient appears at baseline on current medication [regimen].no changes or recommendations at this time. Review of a Psychiatric Progress Note dated 12/18/23 revealed staff reported resident #3 had extreme mood swings with verbal outbursts. The psychiatrist observed the resident exhibiting extreme anger as he yelled profanities at staff. The progress note indicated he started Seroquel 50 mg, an antipsychotic medication, for a bipolar condition. The treatment plan was to gradually titrate the Seroquel dosage to 200 mg at bedtime. A Psychiatric Progress Note dated 1/03/24 revealed facility staff reported resident #3 had no recent issues and showed improvement on Seroquel. The psychiatrist described the resident as cooperative and wrote, Recent medication changes were beneficial for his mood and well-tolerated. Review of Progress Notes for January 2024 revealed resident #3 completed a course of antibiotic medication for a urinary tract infection (UTI) on 1/16/24. A note dated 1/16/24 indicated the interdisciplinary team (IDT) met to discuss resident #3's status and plan of care. There were no recommendations made for changes to the plan of care and no documentation of behavioral concerns. A note dated 1/16/24 revealed the resident's guardian was updated on the progress of his wounds, and there was no evidence of discussion of additional concerns. An IDT note dated 1/23/24 revealed the resident's plan of care was reviewed again with no changes required. Review of the Medication Administration Records for December 2023 and January 2024 revealed resident #3 received Seroquel 200 mg at bedtime as ordered, except for 1/23/24 and 1/24/24 when nursing documentation showed he refused the drug. Nursing notes from 1/12/24 to 1/22/24 indicated resident #3 was calm and did not exhibit behavioral symptoms. Documentation on 1/23/24 and 1/24/24 indicated nurses observed behaviors. A note dated 1/24/24 revealed he refused medication and hygiene care despite several attempts, and also cursed at staff. Progress notes dated 1/25/24 showed the resident continued to exhibit escalating behavioral symptoms, cursing/yelling at staff members and is using racial slurs. Staff were eventually able to calm him and he accepted medications and personal hygiene care. The facility notified the Advanced Practice Nurse Practitioner who ordered a urinalysis, a test of the urine to check for disorders including a UTI. Review of a Situation, Background, Appearance, Review and Notify (SBAR) form dated 1/26/24 revealed resident #3 had a change in condition related to altered mental status with symptoms of verbal aggression. The SBAR form read, Resident is screaming, cursing, lose his voice from yelling.Order to send out to [name of hospital] for evaluation and treatment. The document indicated the resident was in the facility for long term care. Review of resident #3's hospital record revealed an Emergency Department (ED) Provider Note dated 1/26/24 at 2:13 PM. The physician wrote that resident #3 presented to the hospital .for questionable altered mental status. According to [Emergency Medical Services] they were called for an altered mental status however they state the patient always acts like this.I attempted to call the facility twice both which times they hung up and I was unable to speak with any representatives. The physician's assessment showed the resident's vital signs were stable and he was in no acute distress. His admission diagnosis was cystitis, an inflammation of the bladder which is usually caused by a UTI, and he was started on intravenous antibiotic therapy. The document read, Based on the patient's presentation, it is expected that they will cross 2 midnights of care in the hospital. Review of the hospital record revealed a note dated 1/29/24, written by the hospital's Social Worker, regarding an attempt to arrange resident #3's return to the facility. The SW documented she spoke with the facility's admission staff who informed her the resident had only been there with short-term benefits, and the facility was .unable to accept [the resident] back due to being aggressive/violent towards other residents. The SW contacted the resident's guardian who informed her he was in the facility with long-term care benefits. Due to the facility's refusal to re-admit resident #3 and the absence of a home discharge location, the resident's guardian authorized the hospital SW to pursue alternate SNF placement. Review of hospital Case Management (CM) notes revealed resident #3 was medically cleared for discharge from the hospital on 1/29/24. However, over the next 10 weeks, the resident remained in the acute care hospital while the SW made continuous attempts to identify a SNF that would accept resident #3 for long-term care. A CM note dated 4/01/24 indicated the SW eventually found a SNF in another county, over 100 miles away from the facility where he resided pre-hospitalization . The note revealed there was a barrier to the discharge as the assigned court-appointed guardian was unable to follow the resident in that county, and arrangements would have to be made for a new guardian. A CM note dated 4/02/24 read, Unable to move forward with [discharge] until a new court appointed guardian. A CM note dated 4/09/24 revealed the hospital SW discussed resident #3's behaviors with his assigned nurse who stated he was cooperative and showed no signs of aggression. A CM note dated 4/12/24 revealed a local facility accepted resident #3 for long-term care on condition that the hospital arranged for a private sitter for three days to offer support during the resident's adjustment to the new facility. Review of the hospital Discharge Summary dated 4/13/24 revealed resident #3 was discharged to the local SNF with physician orders that included Seroquel 300 mg at bedtime. Review of the hospital record revealed when resident #3 arrived at the local SNF, staff refused to admit him due to verbal behavioral symptoms. There was no evidence the requested sitter was present to assist with a smooth transition to the new location. The transport company returned the resident to the hospital and he was readmitted for aggressive behavior. Resident #3 was restrained briefly in the ED to permit diagnostic testing, and soon calmed down. A Psychiatry Consult note dated 4/15/24 read, .the patient is calm, cooperative, not agitated, not threatening. The psychiatrist made a diagnosis of adjustment disorder with mixed disturbance emotion and indicated no medication changes were necessary. The resident was discharged to the SNF in another county on 4/19/24, once arrangements were finalized for the transfer of guardianship. On 5/08/24 at 2:35 PM, in a telephone interview, resident #3's court-appointed guardian stated the resident had a history of cardiac arrest with oxygen deprivation and alcoholism. She explained those factors contributed to his cognitive impairment and behavioral issues, and although he could be easily agitated and verbally aggressive, he never physically hurt anyone. The guardian stated on the day resident #3 was sent to the hospital, he had a UTI which probably worsened his behavioral symptoms. She explained the facility refused to take the resident back and the hospital eventually found another SNF. When asked if she knew why the facility could not re-admit resident #3, she said, That was my question. Why would another skilled nursing facility be able to provide different or better care? I really hoped they would have taken him back. The hospital and I tried to get them to take him back. I was very upset and I hoped they would take him back. The guardian confirmed she called the facility and someone told her they would not accept him. She explained she attended a care plan meeting in December 2023 or January 2024, and nobody at the facility mentioned anything out of the ordinary or that they wanted to get rid of him. She said, I am frustrated that he was being discharged for baseline behaviors that needed to be addressed. I don't think they exhausted all the available options. The guardian felt it was unfair for resident #3 to remain in the hospital for over two months, especially since his infection was resolved and his behavior was no different. She recalled while resident #3 was in the hospital, the attending physician updated her regularly, and never reported any worsening behaviors that prevented him from returning to the facility. The guardian explained the resident was currently at baseline in a regular long-term care bed in a SNF in another county. She stated the resident's court-appointed attorney said the resident liked her, but he would now have to build a relationship with a new guardian. On 5/08/24 at 10:42 AM and 5/09/24 at 11:34 AM, in telephone interviews with a hospital Case Manager, he explained resident #3 was admitted to the hospital on 1/26/24 and was medically cleared to return to the facility on [DATE]. He stated on 1/29/24, the hospital SW contacted the resident's guardian and facility admissions staff to arrange his return to the facility. The Case Manager stated the facility was unwilling to re-admit resident #3 and it took approximately 10 weeks, until 4/19/24, to locate a facility that would accept him for long-term care. He stated during the resident's extended stay in the hospital, he was seen by psychiatry and had minimal changes made to his medications. The Case Manager acknowledged the hospital record revealed a physician's note dated 2/27/24 that indicated resident #3 swung at a staff member and the physician planned to order restraints if the behavior continued. He stated there were no physician orders for restraints to indicate the behavior reoccurred. On 5/08/24 at 12:06 PM, the facility's Social Services Director (SSD) recalled resident #3 had behavioral issues. She explained nursing staff often used to ask her to intervene and talk him down. The SSD stated the resident was sometimes verbally abusive to staff, but never physically abusive. The SSD stated after she calmed the resident down, he was usually apologetic as he did not mean to offend anyone. She verified resident #3 was bedbound, unable to transfer himself to a wheelchair, and refused to get out of bed. On 5/08/24 at 2:55 PM, the Director of Nursing denied knowledge of the facility's refusal to re-admit resident #3 from the hospital. She confirmed the facility was able to meet the resident's needs prior to the hospital transfer. On 5/08/24 at 3:24 PM, the SSD acknowledged a hospital case manager called her to ask if the facility would re-admit resident #3. She stated she confirmed the facility would re-admit the resident. The SSD said, We do not turn down patients who already live here. We don't dump. This is their home. The SSD stated the resident's guardian called next and informed her the facility was not an appropriate setting for the resident. She said, I don't know what transpired between the guardian and the hospital. The SSD did not respond when informed her statement was inconsistent with the details provided by the hospital CM and the resident's guardian. On 5/08/24 at 3:32 PM, in a telephone interview, the facility's Outside Marketer/Care Liaison explained her role was to work with hospital case management staff to arrange admissions and re-admissions to the facility. She stated her last note dated 3/08/24 indicated the hospital planned to send resident #3 to a brain injury clinic. The Care Liaison stated she discussed the resident's return to the facility with facility nursing staff and they were concerned about his aggressive behaviors towards other residents. She explained he was a danger to other residents as he could walk. She said, Even his guardian did not want him to return. Unfortunately, I don't think I have it documented. They were all phone conversations. The Care Liaison stated the facility could not care for residents with severe brain injuries nor those who received excessive doses of medication, so the hospital canceled the referral. She stated she checked on the resident during his hospital stay and often observed that he was sedated or chemically restrained, and on some days he was even physically restrained. The Care Liaison acknowledged the hospital was not a discharge location. She was unaware resident #3 was not a threat to residents as he had been bedbound for years prior to admission to the facility. She did not respond when informed that her statements were not corroborated by the resident's medical record and interviews with hospital case management staff and the resident's guardian. On 5/08/24 at 4:34 PM, Certified Nursing Assistant (CNA) C stated she was regularly assigned to care for resident #3. She stated he often yelled, cursed, was very disrespectful, and used racial slurs. She confirmed he was never physical with her during care, and his behavior never really changed. On 5/09/24 at 12:09 PM, CNA F described resident #3 as very loud. She stated he shouted and yelled, never got out of bed, and could not walk. CNA F recalled the resident sometimes swung at staff during care. She acknowledged there were other residents in the facility who were combative or hit out at staff and CNAs were trained to re-approach later, use two people for care, and be careful. She stated there was another resident on the same unit who used to scream and shout a lot. On 5/10/24 at 12:22 PM, the Rehab Director recalled when resident #3 refused to participate in therapy or directed profane language at staff, she would go to his room to talk to him and re-direct him. She stated he had been bedbound for about two years in another SNF before admission to this facility. The Rehab Director stated she never felt physically threatened by the resident. She verified he might swing at staff occasionally but he was not the only resident who did so. The Rehab Director said, We have difficult residents and we redirect, re-approach, reorient to give care. Review of the Facility assessment dated [DATE] revealed the facility could meet the care needs of residents who had nervous system conditions including traumatic brain injury and psychiatric and mood disorders such as psychosis, impaired cognition, mental disorders, depression, bipolar disorder, and anxiety. The document indicated staff would provide behavior and mental health care to include management of medical conditions and identification and implementation of interventions to support residents with psychiatric conditions. 2. Review of the medical record revealed resident #2 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. His diagnoses included end-stage kidney disease with hemodialysis, left leg above knee amputation, type 2 diabetes with long-term insulin use, and need for assistance with personal care. Review of the MDS Medicare 5-day assessment with ARD of 2/16/24 revealed resident #2 had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment indicated the resident had functional impairment in range of motion with an impairment of one leg, and he used a prosthetic device and a wheelchair for mobility. The resident required partial to moderate assistance for toileting hygiene, bathing, and dressing. He was always incontinent of bladder and bowel and needed a mechanically altered, therapeutic diet. The MDS assessment revealed resident #2 had medically complex conditions and he received Occupational and Physical Therapy services for two days, from 2/14/24 to 2/15/24, prior to hospitalization on [DATE]. Review of a Notice of Denial of Medical Coverage letter dated 2/14/24 revealed resident #2's insurance company authorized SNF services until midnight on 2/23/24. Review of a nursing progress note dated 2/16/24 revealed that at approximately 3:50 AM, a CNA called the nurse to resident #2's room. The nurse indicated the resident moved his mouth but did not open his eyes. She checked his blood glucose level and obtained a critically low reading. The resident did not respond to two rounds of emergency medications administered by the nurse, and he was transferred to the hospital via ambulance. Review of the hospital record revealed a History & Physical dated 2/16/24 that indicated resident #2's chief complaint and admission diagnosis was acute metabolic encephalopathy (brain disorder) due to hypoglycemia or low blood sugar. The document read, Based on the patient's presentation, it is expected that they will cross 2 midnights of care in the hospital. Review of a Discharge Summary dated 2/19/24 revealed the physician described resident #2 as stable and expected him to return to the facility within 24 hours. A CM note dated 2/19/24 revealed the resident had active discharge orders. The CM notified the facility's Care Liaison who told her the patient has seven skilled days and the facility was unable to accept a 3-day waiver. A CM note on 2/21/24 indicated the facility's Care Liaison informed the hospital patient request has been sent for [physician] review, please look for an alternative. CM sent referrals to additional facility, waiting for response. A CM note dated 2/25/24 indicated the resident's length of stay was now nine days although his discharge plan on admission was to return to the facility. When the hospital CM reached out to the facility's Care Liaison regarding the delay, she informed the CM the resident was a complex case. A revised Discharge Summary dated 2/29/24 read, Case management working on placement. The hospital record showed resident #2 was eventually discharged to another SNF on the evening of 2/29/24. On 5/08/24 at 10:42 AM, in a telephone interview, a hospital Case Manager stated resident #2 was admitted to the hospital through the ED on 2/16/24 and medically cleared on 2/19/24, but the facility did not want to re-admit him due to an insurance issue. He explained the facility's Care Liaison told hospital case management staff the facility was unable to accept resident #2 as he had only seven Medicare covered days left and after that he would have to pay privately for his stay in the facility or apply for Medicaid as a payer source. The Case Manager stated resident #2's acute care needs were met and he should have left the hospital. However, he remained in the hospital for approximately two weeks, until the hospital found placement for him at another SNF. He said, We did not want him sitting in the hospital. It's not good for any patient's psychosocial well-being. The Case Manager explained any hospitalization was stressful for patients and families, even more so if there were changes with a discharge location. He stated the hospital provided hemodialysis and limited therapy services, but not the degree of therapy available in the SNF setting. The Case Manager stated there was a conference call between three hospital Case Management staff and the facility's [NAME] President (VP) of Census Development and the Care Liaison in an attempt to resolve the issue. The Case Manager stated hospital staff informed the facility representatives the Centers for Medicare & Medicaid Services (CMS) regulations indicated the SNF was obligated to re-admit resident #2 after his acute care needs were met in the hospital. He recalled the Care Liaison and the VP of Census Development informed the hospital that resident #2 could not return unless his family provided the necessary financial information to complete a Medicaid application. The Care Manager stated the hospital advised the facility representatives the financial aspect could be addressed in the facility and it should not delay discharge from hospital. He recalled the VP of Census Development stated he addressed the issue with senior leadership at the corporate level and the decision was made to deny resident #2's return to the facility. The Case Manager recalled the hospital representatives reiterated the decision was a regulatory violation, but the VP of Census Development stated they felt differently about the interpretation of that regulation. On 5/08/24 at 4:41 PM, the facility's Business Office Manager (BOM) recalled at the time resident #2 was last transferred to the hospital, he had seven paid Medicare days left. She explained prior to admission, the facility's Central Intake would request authorization from insurance companies. The BOM stated resident #2 required a new authorization each time he was readmitted . She stated when he did not return to the facility, she assumed he was discharged home. The BOM stated she would contact Central Intake to check whether resident #2's insurance company declined to authorize re-admission. As of 5/10/24 at 4:00 PM, despite numerous requests, the BOM did not provide the requested information. On 5/09/24 at 10:59 AM, the Administrator stated she was not aware of a decision to refuse readmission for resident #2. She confirmed she was aware there were issues related to the family's compliance with requests for information needed to change his payer source. The Administrator acknowledged if the resident remained in the facility after he exhausted his Medicare paid days but refused to provide the necessary documents, the facility had the option to proceed with a 30-day discharge notice for non-payment. On 5/10/24 at 3:08 PM, in a telephone interview, the VP of Census Development confirmed he participated in a conversation with hospital case management. He recalled the hospital wanted the facility to re-admit resident #2 prior to the family and resident completing the Medicaid application process. The VP of Census Development said, His insurance would not authorize him and the family would not cooperate. [Name of the facility] did not refuse to take him back. If there was a denial we would have been notified. On 5/10/24 at 3:24 PM, after review of the medical record, the SSD validated the insurance company authorized resident #2's stay in the facility until midnight on 2/23/24. She stated she was under the impression the resident or family called 911 for the hospital transfer as they had done that in the past to avoid discharge home from the facility when the insurance decided to cut his therapy. The SSD denied knowledge that the resident was sent out for critically low blood sugar, possibly resulting from a medication error, and was not allowed to return. She stated she was told the insurance company Case Manager wanted the resident to reserve the Medicare days he had left in case he needed them after he went home. In a telephone interview on 5/14/24 at 9:46 AM, in response to an email sent on 5/10/24 at 10:36 AM, resident #2's insurance company Case Manager reviewed his chart and discovered a SNF authorization was opened on 2/21/24. She explained an authorization stayed open for at least five days. The Case Manager provided details from a Communication Note dated 2/22/24 at 9:36 AM regarding a conversation between the insurance company and a representative of the facility's offsite corporate representative. The note read, Received call from [name of facility's corporate representative], that the facility isn't accepting [the resident] back, so she requested auth[orization] be voided. On 5/14/24 at 2:06 PM, in a telephone interview, the facility's Administrator explained [name of corporate representative] did not work onsite at the facility. She said, It is someone in corporate. I'm not sure of the person's title. Review of the facility's policy and procedure for Transfer and Discharge, revised in November 2023, read, It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer of discharge from the facility, except in limited circumstances. The document defined a transfer as the movement of a resident from one certified facility to another with the expectation of return to the original site. A facility-initiated transfer or discharge was one that the resident was opposed to or did not initiate .and/or is not in alignment with the resident's stated goals for care and preferences. The policy indicated residents had the right to remain in the facility unless a transfer was necessary for the resident's welfare and his/her needs could not be met in the facility, the resident's behaviors endangered the safety and health of individuals in the facility, or if the resident refused to pay for his/her stay after appropriate notice was given. The document revealed a notice must be provided at least 30 days before a facility-initiated transfer or discharge. The policy specified that discharge would not be initiated based solely on payer source or change in payer source. The document indicated residents who were transferred to the hospital for their safety and welfare .will be permitted to return to the facility upon discharge from the acute care setting. The policy revealed residents had the right to return to the facility from the hospital pending appeal of a facility-initiated discharge and the facility would document the danger the failure to discharge the resident would pose.

Based on interview and record review, the facility failed to ensure effective communication, collaboration, and oversight of changes to the plan of care by members of the interdisciplinary team (IDT) for 1 of 3 residents reviewed for hospitalization , out of a total sample of 9 residents, (#2). The facility's failure to thoroughly review medication orders resulted in administration of an excessive dose of insulin that rendered a resident unresponsive due to a critically low blood glucose level, and required transfer to a higher level of care for treatment, actual harm, for resident #2. Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] and last readmitted on [DATE]. His diagnoses included type 2 diabetes with long-term insulin use, end-stage kidney disease with hemodialysis, left leg above knee amputation, and the need for assistance with personal care. Review of the Minimum Data Set (MDS) Medicare 5-day assessment with assessment reference date of 2/16/24 revealed resident #2 had clear speech, clear comprehension, and was able to express his ideas and wants. He had a Brief Interview for Mental Status score of 15 which indicated he was cognitively intact. The MDS assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The document indicated resident #2 had medically complex conditions. Resident #2 had a care plan for diabetes with use of insulin, initiated on 12/14/23. The goal was the resident would have no complications related to diabetes. The interventions instructed nurses to check his blood glucose levels as ordered, administer medication as ordered, monitor for effectiveness and side effects, and monitor for signs and symptoms of low blood glucose. Review of resident #2's medical record revealed an Admission Summary that showed he was readmitted from the hospital on 2/13/24 at approximately 8:00 PM. An Order Audit Report dated 2/13/24 at 10:08 PM revealed resident #2's attending physician ordered Detemir insulin 20 units once daily for diabetes. The order was confirmed a few minutes later at 10:12 PM by the evening shift Nursing Supervisor. Review of an Order Audit Report dated 2/14/24 at 12:50 PM revealed an Advanced Practice Registered Nurse (APRN) ordered Levemir 22 units at bedtime for type 2 diabetes. The order was confirmed on 2/15/24 at 10:55 AM by a Unit Manager (UM) who no longer worked at the facility. Detemir is the generic name for Levemir, a man-made long-acting insulin that starts to work several hours after injection and keeps working evenly over 24 hours. If prescribed once daily, Levemir is usually administered in the evening or at bedtime. The most common adverse reaction of insulin is hypoglycemia and long-standing diabetics may be less aware of symptoms (retrieved on 5/24/24 from www.drugs.com/levemir.html). Review of resident #2's Medication Administration Record (MAR) for February 2024 revealed he received a one-time dose of Detemir 22 units on 2/14/24 at 9:00 AM. The document indicated a nurse also signed for an additional dose of Detemir 20 units on 2/14/24 at 9:00 AM. The MAR was updated to reflect a new order for Levemir 22 units at bedtime on 2/14/24 at 9:00 PM, but the document was not initialed by a nurse to verify the dose was given. On 2/15/24 a 9:00 AM, resident #2 received 20 units of Detemir and the MAR showed he received an additional 22 units of Levemir 12 hours later at 9:00 PM, a total of 42 units in 24 hours. Review of a nursing progress note dated 2/16/24 revealed that at approximately 3:50 AM, a Certified Nursing Assistant called the nurse to resident #2's room. The note read, Upon arrival writer observed resident moving his mouth but not opening his eyes. Writer immediately check his blood sugar which read 25. The document indicated the nurse gave two doses of Glucagon in an attempt to increase his blood glucose level, but the resident remained unresponsive. The nurse contacted the resident's physician who instructed her to send resident #2 to the hospital via 911 for further evaluation. According to the American Diabetes Association (ADA), hypoglycemia or low blood glucose occur when the blood glucose level falls below 70 milligrams per deciliter (mg/dL). As blood glucose continues to drop, the brain is deprived of glucose and it stops functioning as it should. The ADA indicates a critical, life-threatening blood glucose value is one that is less then 54 mg/dL. Initially, hypoglycemia causes symptoms such as blurred vision, difficulty concentrating, confusion, slurred speech, numbness, and drowsiness. If untreated, low blood sugar levels can starve the brain of glucose, causing seizures, coma, and death (retrieved on 5/24/24 from www.diabetes.org/living-with-diabetes/treatment-care/hypoglycemia). Review of the Weights and Vitals Summary revealed resident #2's blood glucose level was checked on 2/16/24 at 5:30 AM and 5:35 AM, with resulting readings of 25 mg/dL. A blood sugar level below 54 mg/dL requires immediate action and severe hypoglycemia can be treated with an injection or nasal spray of Glucagon, a hormone that raises blood glucose levels (retrieved on 5/24/24 from www.medlineplus.gov). Review of the Emergency Medical Services (EMS) Run Sheet revealed a call was received from the facility on 2/16/24 at 5:15 AM, almost 90 minutes after the nurse indicated she was made aware of the resident's change in condition. The document indicated upon arrival at the facility, EMS personnel discovered resident #2 unresponsive. According to the Run Sheet, the nurse informed them she gave three doses of Glucagon and their primary impression of the resident was diabetic hypoglycemia. Resident #2 was transported to the hospital by ambulance with lights and sirens and arrived at the Emergency Department (ED) on 2/16/24 at 5:46 AM. Review of the hospital record revealed a History & Physical dated 2/16/24 that indicated resident #2 presented to the ED with altered mental status and per EMS report, he had a blood glucose level of 38 mg/dL. The document revealed his chief complaint and admission diagnosis was acute metabolic encephalopathy (brain disorder) due to hypoglycemia or low blood sugar. The ED physician documented that resident #2 was difficult to assess as he was somnolent and did not stay alert or awake long enough to respond to questions. A physician progress note dated 2/23/24 revealed resident #2's long-acting insulin was discontinued on admission to the hospital. Review of the hospital Discharge Summary dated 2/29/24 revealed physician orders for Humalog fast-acting insulin three times daily according to a sliding scale, and Humulin N intermediate-acting insulin 5 units twice daily. On 5/09/24 at 3:02 PM, the Director of Nursing (DON) recalled resident #2 was a very brittle diabetic as his blood glucose levels varied widely. She validated she was not aware the resident's insulin order was changed two days before he was found unresponsive until informed by State Survey Agency staff. She stated she did not recall any investigation regarding the resident's transfer to the hospital for unresponsiveness with a low blood sugar as this would have been viewed as a change in condition, not an incident. Review of the Weights and Vitals Summary for the period 10/31/23 to 2/15/24 revealed during a 4-month period that covered several admissions, resident #2's blood glucose level was checked approximately three to four times daily. The 9-page document showed his readings were below 70 mg/dL on only two other occasions, 52 mg/dL on 12/20/23 and 68 mg/dL on 2/08/24, and otherwise remained between 70 mg/dL and 453 mg/dL. Resident #2's blood glucose level never dropped to 25 mg/dL as it did on the morning of 2/16/24 after he received a combined dose of Levemir 42 units in the previous 24 hours. On 5/10/24 at 9:23 AM, the DON explained the facility held a clinical team meeting, Monday through Friday at 9:00 AM, that was attended by herself, UMs, the Assistant DON, the Social Services Director, the Administrator, and the Certified Dietary Manager. She stated during these meetings, the IDT reviewed the charts of newly admitted residents, the previous day's events, nursing notes regarding high priority items or events, and any other concerns placed on the 24-hour report. The DON stated high priority items included all new orders, and laboratory and radiology results. She validated the daily IDT meeting was the opportune setting for identification of any discrepancies related to new physician orders. On 5/10/24 at 12:26 PM, in a telephone interview, the APRN stated she did not recall the exact circumstances surrounding her order for Levemir 22 units for resident #2. She explained either a nurse or the UM probably called or informed her during facility rounds that the resident's blood glucose levels were trending upward. The APRN confirmed she would have ordered an increase of two units, from Levemir 20 units once daily to 22 units once daily after review of the medical record. She stated her order would never be to add Levemir 22 units to an existing daily dose of Levemir 20 units. The APRN verified no nurse or member of nurse management contacted her regarding clarification of insulin orders. She stated the facility never informed her resident #2 was found unresponsive with a critically low blood glucose level. The APRN reiterated she would never have doubled resident #2's daily dose of insulin in that way, especially since he was a dialysis patient. She said, On those patients, we make changes slowly. On 5/10/24 at 10:26 AM, in a telephone interview, resident #2's attending physician was informed the resident received Levemir insulin 20 units in the morning on 2/15/24 according to his orders, then received an additional 22 units of Levemir insulin 12 hours later per the order of another practitioner. The attending physician stated he was not aware an additional dose of insulin was ordered to provide the resident with more than double the dosage he intended. He acknowledged the incident and outcome were concerning. 5/10/24 at 1:07 PM and 2:17 PM, the DON stated her investigation showed at the time the APRN reviewed resident #2's medical record and wrote the order for Levemir 22 units at bedtime, the attending physician's order for 20 units showed as discontinued. She explained since there was no active order for long-acting insulin, the APRN wrote the order for Levemir 22 units, an increased dosage of only two units based on resident #2's blood glucose readings. The DON explained the APRN's order was transcribed to the MAR for administration at bedtime and scheduled for 9:00 PM. When asked why the attending physician's order for Levemir 20 units daily at 9:00 AM was not visible to the APRN and then re-appeared on the MAR as a continuing order, she said, There were two orders bouncing back and forth due to the pharmacy process. She explained the facility had an automatic therapeutic interchange agreement with the physicians and as a result, the pharmacy could make adjustments to medication orders to reflect its formulary drugs. The DON stated the original order for Levemir 20 units that was entered under the attending physician's name was for a vial of Levemir. She explained the pharmacy discontinued that order and replaced it with an order for a Levemir pre-filled FlexPen. She acknowledged the APRN might have reviewed the orders at the time the pharmacy was in process of making that change. The DON stated the pharmacy's order was system-generated but still needed to be confirmed by a nurse. She validated the APRN's new order was confirmed by resident #2's UM but the order for Levemir 20 units was not discontinued at that time. The DON stated the IDT review process in the daily clinical meeting involved reviewing new physician orders, but the team did not actually pull up residents' charts during the process. She acknowledged the IDT would therefore not be able to identify if there was an associated order that needed to be discontinued or if there were any contraindications. The DON validated IDT members were ultimately responsible for the identification of concerns and discrepancies regarding medication orders. She confirmed resident #2's new order for Levemir 22 units at bedtime would not have triggered concerns as a isolated order, but if chart had been reviewed, the IDT would have noticed that the original order for Levemir 20 units in the morning remained active. The DON stated the facility never identified the IDT review process as a concern with the potential to cause medication errors. Review of the Facility assessment dated [DATE] revealed the facility could care for residents with common conditions including endocrine and metabolic diseases such as diabetes. The document indicated nursing leadership participated in daily clinical meetings to review clinical issues on each unit. The Facility Assessment revealed general care and services would include management of medical conditions by on-site physicians, nursing assessments, and early identification of changes in condition.

Based on observation, interview, and record review, the facility failed to promote the right to a clean, comfortable, and homelike environment for 4 of 6 residents reviewed for environmental concerns out of a total sample of 9 residents, (#5, #6, #7, and #9), on 2 of 2 units, (A & B Wings). Findings: 1. Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, and a skin infection with surgical amputation of her right great toe. Review of a progress note dated 5/07/24 at 9:49 PM revealed resident #6 arrived on the A Wing and was assisted to her room. On 5/08/24 at 11:10 AM, resident #6's granddaughter expressed dissatisfaction with the condition of her grandmother's room and bathroom when she arrived from the hospital the previous night. She stated it was obvious the room had not been properly cleaned and prepared for a new resident. The granddaughter provided photographs that showed stained sheets on the bed, a significant amount of dried, brown urine stains underneath the toilet seat, and a used plastic container with brown paper towel inside was on the lid of the toilet. The plastic container was of the type used to collect and measure body fluids such as urine. The granddaughter explained after she complained, it took about two hours for someone to remove the container. She stated when no staff returned to replace the sheets as requested, she asked for clean sheets and changed them herself. On 5/08/24 at 12:22 PM, the facility's Admissions Concierge stated she was made aware of resident #6's planned admission yesterday, 5/07/24 at 8:25 AM. She stated she provided the marketing liaison at the hospital with the room number for the new resident and then updated the nurse of the pending admission. The Admissions Concierge confirmed the room was to be cleaned after removal of the previous resident's items, in preparation for the new resident. She stated she also told the Certified Nursing Assistant on the 3:00 PM to 11:00 PM shift about resident #6's expected arrival. The Admissions Concierge recalled she saw a housekeeper in the room during the day on 5/07/24. She stated she checked the room at about 4:00 PM, but did not go into the bathroom. On 5/09/24 at 11:37 AM, the Floor Technician stated on Wednesday 5/08/24, he was informed of the granddaughter's complaints and the need to clean resident #6's room. He validated the condition of the toilet was as described by the granddaughter and shown in the photograph. The Floor Technician stated Housekeeper D told him she cleaned the room on Tuesday, 5/07/24. He said, I told her she should pay more attention to cleaning. He explained all rooms were to be cleaned once daily, but prior to a new admission, rooms required a special deep clean procedure. Review of a Deep Clean Check Off List (undated) revealed the procedure included thorough cleaning of the bed frame, mattress, call bell, air conditioning unit, furniture, floors, blinds, and the toilet. On 5/09/24 at 11:57 AM, Housekeeper D stated she cleaned resident #6's room in the morning on 5/07/24, after the breakfast meal carts left the unit. She explained after lunch, she was instructed to do a deep clean for that room as there would be a new resident. Housekeeper D acknowledged a deep clean involved cleaning all areas and surfaces of the room and bathroom. She did not respond when asked to explain why the condition of the resident's room did not reflect requirements of the deep cleaning procedure. On 5/09/24 at 12:17 PM, the Rehab Director confirmed she spoke with resident #6's granddaughter on Wednesday 5/08/24. She verified the granddaughter expressed concerns about the lack of cleanliness of the room on admission and pointed out issues including dirty window blinds. The Rehab Director acknowledged she viewed the granddaughter's photographs of the dirty bathroom and said, I apologized and told her it was not acceptable. 2. Review of the medical record revealed resident #5 was admitted to the facility on [DATE]. Her diagnoses included right hip fracture, history of falling, abnormal gait and mobility, and need for assistance with personal care. Review of the Minimum Data Set (MDS) with assessment reference date of 4/29/24 revealed resident #5 had a Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. On 5/08/24 at 10:26 AM, resident #5 confirmed there was a roach problem on the unit and in her room on the 500 hall. She stated she was in the A Wing common room with a visitor a few days ago, when a big roach ran across the room. The resident stated the incident occurred during the day, but she also saw big roaches in the hallway at night, headed towards her room. She explained she even used her trash can to squash a small roach on the floor. She pointed to the trash can beside her bed and said, It's under there. Resident #5 stated she asked her daughter to bring a can of roach spray for her yesterday and she stored it inside her bedside commode. She said, I wouldn't be able to sleep if I saw one near me. On 5/09/24 at 10:06 AM, Registered Nurse A lifted the lid of resident #6's bedside commode and removed a full can of ant, roach, and spider spray. Photographic evidence was obtained. Review of the A Wing Pest Sighting/Evidence Log showed documentation on 3/29/24 of roach issues on the 400, 500, and 600 hallways. On 5/03/24, the MDS Coordinator noted roaches in the MDS office and in rooms 608, 609, 610, and 611. The log indicated on 5/09/24, roaches issues were identified in room [ROOM NUMBER]. 3. Review of the medical record revealed resident #7 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, heart disease, and need for assistance with personal care. On 5/10/24 at 2:10 PM, resident #7 was interviewed in her room on the B Wing. She said, We have a bad roach problem, day and night. The roaches are the biggest issue. I kill the little bitty ones, but the big ones are hard to catch. The resident explained she used to be able to catch the big roaches, but she was no longer fast enough. Resident #7 confirmed she told numerous staff members, many times. During the interview, a large dark brown roach scurried from behind the oxygen concentrator near the resident's wheelchair and traveled approximately six feet to stop under the roommate's bed. The roach remained under the bed for less than one minute, then quickly crossed the room, and headed towards the area behind resident #7's bedside table. The roommate, resident #9, interjected and stated she was not surprised the roach ran around the room as it was a huge problem and everyone was aware. Resident #9 complained she had a roach in her bed as recently as last night. Review of the facility's policy and procedure for Resident Rights, revised on 9/09/22, revealed residents had rights to a dignified existence and .a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review, the facility failed to ensure timely and effective pain management, according to professional standards of practice, for 1 of 1 resident reviewed for pain management out of a total sample of 9 residents, (#6). Findings: Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes, a skin infection with surgical amputation of her right great toe, peripheral vascular disease, and heart disease. Resident #6 had a care plan for risk for pain related to her right foot wound initiated on 5/08/24. The goal was the resident would not have interruptions in normal activities due to pain. The care plan interventions included administer pain management as ordered, and monitor and record pain characteristics such as quality, severity, anatomical location, onset, and duration. The document instructed nursing staff to monitor, record, and report the resident's complaints of pain or requests for pain treatment. A care plan for pain medication related to resident #6's right foot wound and acquired absence of her right great toe was initiated on 5/08/24. The goal was the resident would be free of discomfort. The approaches instructed nurses to administer pain medications as ordered. Review of the medical record revealed resident #6 had a physician order dated 5/07/24 for Tramadol 25 milligrams (mg) every eight hours as needed for severe pain, levels 7 to 10. The order was revised on 5/08/24 to administer Tramadol 50 mg every six hours as needed for moderate to severe pain. On 5/08/24 at 10:01 AM, 11:10 AM, and 1:39 PM, resident #6's granddaughter stated her grandmother was admitted to the facility at about 9:30 PM the previous night. She expressed frustration that her grandmother had not received the proper medication. The granddaughter recalled when she arrived at the facility last night, her grandmother was crying and complained of severe pain in her right foot. Resident #6's granddaughter stated she asked a nurse to administer pain medication. She said, She was to get 25 mg of Tramadol and the nurse did give a pill at about 10-ish. The granddaughter explained she left the facility and returned a few hours later, at about 4:00 AM. She stated she found her grandmother crying again, as she sat upright on the side of the bed with her legs hanging down. Resident #6 told her granddaughter the pain was much worse when her legs were elevated so she decided to remain seated instead of lying down. The granddaughter indicated when she asked the nurse for another dose of pain medication for her grandmother, the nurse informed her the pharmacy delivery had not yet arrived and .she didn't have anything to give her now. On 5/08/24 at 1:27 PM, Licensed Practical Nurse (LPN) B confirmed she was resident #6's assigned nurse yesterday, during the evening shift. LPN B explained she did not have access to the facility's medication dispensing machine, but when the resident's granddaughter requested pain medication, another nurse retrieved it from the machine. On 5/08/24 at 1:39 PM, resident #6 sat in a wheelchair in her room. Her eyes were closed, her brow was furrowed, and she explained she asked for pain medication about 15 minutes ago. The resident described her pain as severe, sharp, and intermittent, and she made a grabbing motion towards her right foot. Resident #6 explained the onset of pain was usually sudden and although it might go away for a while, it returned with the same severity if she did not receive pain medication. The resident verified when the nurse gave her a pain pill last night, her pain level was level 10, on a 0 to 10 scale. She validated at 4:00 AM this morning when her granddaughter returned to the facility, she again had level 10 pain. Resident #6 stated the nurse never brought any pain medication this morning and she eventually fell asleep sitting up. She confirmed she received pain medication only once in the 16 hours since admission. On 5/08/24 at 1:49 PM, the Director of Nursing (DON) stated an Advanced Practice Nurse Practitioner (APRN) assessed resident #6 early this morning. She acknowledged after assessing and speaking with the resident, the APRN increased the dosage and frequency of her pain medication. On 5/08/24 at 3:54 PM, in a telephone interview, Registered Nurse (RN) E stated she was assigned to resident #6 for the overnight shift which ended at 7:00 AM this morning. In a statement that conflicted with findings of interviews conducted with resident #6 and her granddaughter, RN E denied knowledge of the resident's complaints of pain during the night shift. She stated she was never asked to administer pain medication for the resident. On 5/09/24 at 9:58 AM, resident #6's son complained that despite an increase in the dosage of his mother's pain medication, they still had problems managing her pain. He said, They come in and ask if she's in pain, and if she's not in pain at that moment, they don't come back for a while. By then she is really hurting. He stated her pain was not constant, and he described it as all over the place. Resident #6's son stated neither he nor his mother was aware the pain medication was not scheduled at regular intervals, but had to be requested. Review of resident #6's Medication Administration Record (MAR) for May 2024 revealed no nursing documentation regarding administration of Tramadol 25 mg on 5/07/24 during the evening shift. The document showed resident #6 received her first dose of pain medication, Tramadol 50 mg, on 5/08/24 at 1:41 PM. The MAR indicated the resident's pain levels were 0 to 4 between 5/07/24 and 5/08/24, and not level 10 as reported by the resident and described by her granddaughter. A Nurses Note dated 5/07/24 at 10:38 PM read, Resident complain of pain at surgical site pain medication tramadol 25 mg was given will continue to monitor. The note did not include a description of the pain or its severity. The document was created by LPN B the following day, on 5/08/24 at 11:41 AM, after State Survey Agency staff identified pain management concerns for resident #6. On 5/09/24 at 1:08 PM, the DON discussed the absence of documentation regarding Tramadol 25 mg that was allegedly given to resident #6 on Tuesday, 5/07/24. The DON confirmed she investigated the situation and said, We have a little concern. She explained the pharmacy provided a report that showed removal of Tramadol 50 mg from the medication dispensing machine on 5/08/24, but there was no transaction recorded for the drug on 5/07/24. On 5/09/24 at 1:24 PM, the evening shift Nursing Supervisor validated resident #6's granddaughter came to the nurses' station soon after the resident's admission on 5/07/24. She recalled the granddaughter informed the nurses of the resident's pain. The Nursing Supervisor stated after LPN B assessed resident #6, she returned to the nurses' station and explained the resident's medications were not yet available The Nursing Supervisor stated she called the pharmacy to obtain an authorization and access code to retrieve Tramadol 50 mg from the medication dispensing machine. She stated LPN B administered half a tablet and they wasted the other half. On 5/09/24 at 4:31 PM, the DON stated she followed up with the pharmacy and there was no documentation to show an authorization code was provided for the Nursing Supervisor to access the medication dispensing machine on 5/07/24. The DON acknowledged although resident #6 and her granddaughter confirmed the nurse administered a pill, there was no evidence the pill was Tramadol. On 5/10/24 at 9:16 AM, the DON stated pharmacy staff made an onsite visit within the last 24 hours and conducted a medication reconciliation that showed no discrepancies. She validated the Tramadol count in the machine matched the pharmacy's record. The facility's policy and procedure for Pharmacy Services, revised in June 2023, revealed the facility would provide pharmaceutical services to ensure accurate acquiring, dispensing, and administration of all routine and emergency drugs to meet the needs of each resident. Review of the medication dispensing machine Transactions record for the period 5/02/24 to 5/08/24 revealed no drugs were removed from the machine on 5/07/24. A Tramadol Transaction report for resident #6 was provided to the DON from the pharmacy in an email dated 5/09/24 at 11:36 AM. The document showed Tramadol 50 mg was pulled from the machine on 5/08/24 at 1:38 PM. The email read, The cabinet was not accessed for medication May 6-7. Review of the facility's policy and procedure for Pain Management, revised in August 2023, revealed the facility would provide pain management for residents that was consistent with professional standards of practice, person-centered care plans, and residents' goals. The document indicated the facility would prevent or manage a resident's pain by observation of non-verbal indicators such as restlessness, grimacing, and negative vocalizations. The policy revealed nurses would conduct pain assessments that included key characteristics and descriptors. The document showed pharmacological interventions would include consideration of around the clock administration of pain medication rather than as needed.

Based on interview and record review, the facility failed to ensure the medical record accurately reflected the status of and services provided for 1 of 3 residents reviewed for hospitalization , out of a total sample of 9 residents, (#2). Findings: Review of the medical record revealed resident #2 was admitted to the facility on [DATE] and last readmitted on [DATE]. His diagnoses included type 2 diabetes with long-term insulin use. Resident #2 had a care plan for diabetes with use of insulin, initiated on 12/14/23. The goal was the resident would have no complications related to diabetes. The interventions instructed nurses to check his blood glucose levels and administer diabetes medication as ordered by the physician. A nursing progress note dated 2/16/24 revealed at approximately 3:50 AM, resident #2 was discovered unresponsive in bed with a critically low blood glucose level. The resident's physician gave an order to send the resident to the hospital via 911 for further evaluation. Review of a Hospital Transfer Form dated 2/16/24 at 5:40 AM revealed resident #2 was transferred to the hospital. Review of the medical record indicated resident #2 was not readmitted from the hospital. Review of the Weights and Vitals Summary revealed a nurse documented resident #2's blood glucose level on 2/18/24 at 6:09 PM as 165 milligrams per deciliter (mgdL) and on 2/18/24 at 6:45 PM as 145 mg/dL. Review of the Medication Administration Record (MAR) for February 2024 revealed documentation of medications given to resident #2 two days after he was discharge from the facility as follows: 2/18/24 at 8:00 AM Sevelamer Carbonate 1600 mg 2/18/24 at 9:00 AM Amlodipine 5 mg 2/18/24 at 9:00 AM Finasteride 5 mg 2/18/24 at 9:00 AM Saccharomyces boulardii 250 mg 2/18/24 at 9:00 AM Dorzolamide HCl-Timolol Maleate Ophthalmic Solution 2-0.5% 2/18/24 at 9:00 AM Pregabalin 25 mg capsule 2/18/24 at 9:00 AM Cyclopentalate HCl Ophthalmic Solution 1% 2/18/24 at 9:00 AM Dicyclomine HCl 20 mg 2/18/24 at 10:00 AM Prednisone 50 mg 2/18/24 at 12:00 PM Sevelamer Carbonate 800 mg 2/18/24 at 1:00 PM Cyclopentalate HCl Ophthalmic Solution 1% 2/18/24 at 1:00 PM Dicyclomine HCl 20 mg The MAR revealed the assigned nurse checked and recorded resident #2's blood glucose levels on 2/18/24 at 7:30 AM and 11:30 AM. On 5/10/24 at 1:07 PM, the Director of Nursing (DON) was informed of nursing documentation on resident #2's MAR that indicated on 2/18/24 during the 7:00 AM to 3:00 PM shift, the assigned nurse administered all scheduled medications and checked his blood glucose levels, although the resident had been in the hospital since 2/16/24. She reviewed the medical record and validated the documentation was inaccurate. The DON stated her expectation was nurses would document the actual care provided and medications administered. Review of the facility's policy and procedure for Documentation in the Medical Record, revised in November 2023, read, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident.through complete, accurate, and timely documentation. The policy indicated licensed staff would document services provided in the resident's medical record, at the time of service. The document read, False information shall not be documented.

Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to medication error rates over 5%. Findings: Review of the facility's survey history revealed repeat deficiencies concerns for medication errors over the past 5 years, and again during the current survey related to a medication error rate of 20.69%. The survey history revealed facility error rates of 6.45% on 2/10/22, 10.71% on 1/16/20 and 6.25% on 10/25/18. This will be the facility's fourth deficiency in 5 years for mediation error rate equal to or greater than 5%. On 7/13/23 at 5:18 PM, 6:23 PM, and 6:26 PM interviews were conducted with the facility's Administrator, Interim Director of Nurses (DON), and Corporate [NAME] Present (VP) of Operations regarding the facility's QAPI program. The Administrator verified they completed a plan of correction for medication errors last year but could no locate current audits for this year for medication errors except for ones done by the pharmacy nurse consultant. The DON was able to show the pharmacy consultant nurse did medication administration audits with 4 nurses in April of 2023. The VP verified that if they had ongoing PIP (Performance Improvement Plan) and audits of mediation errors that they should have documentation readily available for review but they did not. The facility could not show evidence of medication errors being discussed in QAPI meetings this year or that they had an actual PIP currently in effect for medications errors. The facility could not show evidence of current audits regarding medication errors except for routine ones that were done by the pharmacy consult nurse. The Administrator acknowledged the facility did not currently have a QAPI plan in place for Medication Errors. Review of the facility policy for Quality Assurance and Performance Improvement revised 9/1/22 read, QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including when and why facility performance is at risk or has failed to meet standards .Develop and implement appropriate plans of action to correct identified quality deficiencies .prioritizing quality deficiencies. Systematically analyzing underlying causes of systemic quality deficiencies .Monitoring and evaluations the effectiveness of corrective action/performance improvement activities and revising as needed .The facility must consider incident, prevalence, and severity of problems or potential problems identified .

Based on observation, interview, and record review, the facility failed to follow physician orders and standards of practice for residents who received their nutrition and medications through a gastrostomy tube (GT) for 1 of 2 sampled residents with a gastric tube (GT) out of a total sample of 29 residents, (#298). Findings: Review of resident #298's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included diabetes mellitus type 2, dysphagia (difficulty swallowing), and gastrostomy tube. A gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach (www.medlineplus.gov retrieved 08/01/23). Resident #298's Nursing Comprehensive assessment dated [DATE], revealed he was oriented to self, non-verbal, totally dependent on staff for his activities of daily living and received nutrition via tube feeding. The physician order dated 7/9/23 instructed nurse to flush tube with 30 ml (milliliters) before and after medications pass and flush with 5 ml between medications. The tube flush order did not specify what type of tube or what type of solution to flush with. The facility provided a policy dated 1/2023 for Medication Administration via Enteral Tube that read, Enteral tube placement must be verified prior to administering any fluids or medication. On 7/13/23 at approximately 6:23 PM, the facility provided an updated policy revised July 2023 which did not include checking tube placement. Review of the facility updated policy for Medication Administration via Enteral Tube read, Pharmacy will be notified that an order to give medications through an enteral tube has been received and suspensions for medications will be supplied when possible .Each medication will be administered separately, not combined or added to an enteral feeding .Flush enteral tube with at least 15 ml of water prior to administering medications unless otherwise ordered by prescriber. Dilute the solid or liquid medication and administer using a clean syringe .Flush tube again with at least 15 ml water taking into account residents volume status. Repeat with the next medication .Flush tube with a final flush . On 7/11/23 at 9:40 AM, Licensed Practical Nurse (LPN) A prepared to administer resident #289's scheduled morning medications. LPN A placed 8 different medications into 8 small plastic cups at the medications cart that included, Vitamin C 500 milligrams (mg) 1 tablet, Acetazolamide 250 mg 1/2 tablet, Amlodipine 10 mg 1 tablet, Carvedilol 3.125 mg 1 tablet, Carbidopa-Levodopa 25-100 mg 1 tablet, Isosorbide Mononitrate 20 mg 1 tablet, Guaifenesin extended release 600 mg 2 tablets, and Multivitamin with minerals 1 tablet. LPN A then proceeded to take the 8 small plastic cups containing medications and pill crusher into resident #289's room and placed them on the over bed table. Resident #289 was in bed with his eyes open and was nonverbal. LPN A proceeded to identify the resident and explained to him that she was going to be giving his medications via his G-tube and turned off the feeding pump which had been infusing Glucerna nutrition formula at 50 ml per hour. On 7/11/23 from approximately 10:10 AM to 10:40 AM LPN A put all 8 medications in 1 small plastic bag and proceeded to crush them with the pill crusher at the bedside. When the bedside table started to buckle due to the increased pressure, she took the pill crusher to the dresser and completed crushing them. LPN A then put all crushed tablets into a medium sized plastic cup with 30 ml of water. She mixed the medications with a spoon and poured them back and forth in another plastic cup. There were large clumps of undissolved medications in the thick mixture. LPN A did not check placement of the feeding tube prior to medication administration. LPN A initially flushed the feeding tube with 30 ml of sterile water using a 60 ml piston tip syringe. She then drew up approximately 1/3 of the thick medication mixture with the same 60 ml syringe and proceeded to administer medications via the resident's G-tube. The nurse continued intermittent flushes with 5-10 ml water and 10 to 20 ml of air in the 60 ml syringe. The medication mixture would not easily administered so she continued to add more water to the mixture and went back and forth at least 4 times putting in the water and air. She then disconnected the control valve at the end of the feeding tube attached to the resident and started milking the tubing with her fingers attempting to unplug the clumps of medication. The adapter was plugged with medication particles and could not be used any more. The nurse did a final flush of the feeding tube with 60 ml of water via piston syringe directly into resident via feeding tube without the adaptor. She then connected the formula tubing directly to the resident minus the adaptor and left the pump off with the feeding formula hanging on the IV pole. LPN A stated she was instructed to give all medications together via G-tube and was not aware if there was an order to flush the tube between each medication. On 7/11/23 at 11:34 AM, the Interim Director of Nursing (DON) said it was basic nursing to give G-tube medications separately and flush in between so the tube did not get plugged. The DON said LPN A should have put each medication in their own cup and mixed them with 5-15 ml of water and given them one at a time and flushed between them as well. On 7/11/23 at 2 PM, a follow up interview was conducted with LPN A and the DON. LPN A acknowledged the 6 medication errors and acknowledged it would have been better to give medications 1 at a time because there would be less chance of clogging up the resident's G-tube. LPN A and the DON validated that it was not appropriate to instill air into the resident's G-tube. Review of the facility policy and procedures for Care and Treatment of Feeding Tubes dated Dec. 2022 read, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standard of practice, with intervention to prevent complications to the extent possible .In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right locations .Tube placement will be verified before beginning a feeding and before administering medications .Medication Flush Order: Give 30 ml before and after medications pass, 5 ml between meds .

Based on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 1 of 3 residents sampled for medication administration, (#298). There were 6 medication errors in 29 opportunities for a medication error rate of 20.69%. Findings: Review of resident #298's medical record revealed he was admitted to the facility on [DATE] from an acute care hospital. His diagnoses included diabetes mellitus type 2 (DM), dysphagia (difficulty swallowing), hypertension, anemia, benign prostatic hyperplasia (BPH), and gastrostomy tube. A gastrostomy tube (also called a G-tube) is a tube inserted through the belly that brings nutrition directly to the stomach (www.medlineplus.gov retrieved 08/01/23). On 7/11/23 at 9:40 AM, Licensed Practical Nurse (LPN) A prepared to administer resident #289's scheduled morning medications. LPN A placed 8 different medications into 8 small plastic cups at the medications cart that included, Vitamin C 500 milligrams (mg) 1 tablet, Acetazolamide 250 mg 1/2 tablet, Amlodipine 10 mg 1 tablet, Carvedilol 3.125 mg 1 tablet, Carbidopa-Levodopa 25-100 mg 1 tablet, Isosorbide Mononitrate 20 mg 1 tablet, Guaifenesin extended release 600 mg 2 tablets, and Multivitamin with minerals 1 tablet. On 7/11/23 at approximately 9:50 AM, LPN A explained she did not have the resident's antibiotic or vitamin D3 available on the medication cart and that she would retrieve them from the medication storage room and from their automated medication dispenser for administration later. LPN A was informed that she would not have medication errors for vitamin D3 or antibiotic as she informed surveyor she would give them later. LPN A did not verbalize any other medications that were scheduled that she would not be giving at this time. On 7/11/23 at approximately 10 AM, LPN A proceeded to take the 8 small plastic cups containing medications and pill crusher into resident #289's room and placed them on the over bed table. Resident #289 was noted in bed with his eyes open and was nonverbal. LPN A proceeded to identify the resident and explained to him that she was going to be giving his medications via his G-tube and turned off the feeding pump which had been infusing Glucerna nutrition formula at 50 milliliters (ml) per hour. On 7/11/23 from approximately 10:10 AM to 10:40 AM LPN A put all 8 medications in 1 small plastic bag and proceeded to crush them with the pill crusher at the bedside. When the bedside table started to buckle due to the increased pressure, she took the pill crusher to the dresser and completed crushing them. LPN A then put all crushed tablets into a medium sized plastic cup with 30 ml of water. She mixed the medications with a spoon and poured them back and forth in another plastic cup. There were large clumps of undissolved medications in the thick mixture. LPN A initially flushed the feeding tube with 30 ml of sterile water using a 60 ml piston tip syringe. She then drew up approximately 1/3 of the thick medication mixture with the same 60 ml syringe and proceeded to administer medications via the resident's G-tube. The nurse continued intermittent flushes with 5-10 ml water and 10 to 20 ml of air in the 60 ml syringe. The medication mixture would not easily administered so she continued to add more water to the mixture and went back and forth at least 4 times putting in the water and air. LPN A stated she was instructed to give all medications together via G-tube and was not aware if there was an order to flush the tube between each medication. A review of the resident #298's medical record post medication administration revealed the following 6 errors for medications scheduled at 9 AM: 1.) 1000 mg of Vitamin C was ordered and only 500 mg was given 2.) Plain Multivitamin was ordered, and it was given with minerals 3.) Aspirin 81 mg oral chewable tablet for CVA (stroke) was error of omission 4.) Glipizide 10 mg tablet via G-tube for DM was error of omission 5.) Tamsulosin 0.4 mg capsule daily for BPH was error of omission 6.) Polyethylene Glycol 17-gram packet via G-tube for constipation was error of omission On 7/11/23 at 11:34 AM, the Interim Director of Nursing (DON) said it was basic nursing to give G-tube medications separately and flush in between so the tube did not get plugged. The DON was apprised of the 6 medications errors and concerns regarding LPN A not administering medications via G-tube safely and as per standards of practice. The DON said LPN A should have put each medication in their own cup and mixed them with 5-15 ml of water and given them one at a time and flushed between them as well. On 7/11/23 at 2 PM, a follow up interview was conducted with LPN A and the DON. LPN A acknowledged the 6 medication errors and said her computer mouse was not working properly and she did not see a page of the resident's medications to be given at 9:00 AM. The DON stated LPN A had not reported the computer issue to anyone. Review of the facility policy for Medication Administration revised January 2023 read, Medications are administered by licensed nurses .Review MAR [medication administration record] to identify medication to be administered. Compare medications source [bubble pack, vial, etc.] with MAR to verify resident name, medication name, form, dose, route, and time .Administer medications as ordered and in accordance with manufacturer specifications .Crush medications as ordered. Do not crush medications with [do not crush] instructions .Crushed meds are not to be combines and given all at once, if via tube feeding tube

Based on interview and record review, the facility failed to report an allegation of neglect made by a resident's representative to the State Agency for 1 of 1 resident reviewed for abuse of a total sample of 7 residents, (#1). Findings: Review of resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's Minimum Data Set (MDS) assessment with Assessment Reference Date of 8/12/22 revealed she had a Brief Interview for Mental Status score of 3 which indicated she was severely cognitively impaired. The MDS showed resident #1 required extensive assistance on staff for transfers and toilet use and limited assistance for bed mobility, dressing, and personal hygiene. The MDS revealed resident #1 was always incontinent of bladder and bowel. The assessment noted no rejection of care necessary to obtain goals for her health and well-being. On 9/15/22 at 11:31 AM, via telephone interview, resident #1's sister and Power of Attorney (POA) stated she had sent several emails to the facility with concerns she had about her sister's care. The POA indicated she did not receive a response for each email and sometimes the facility responded days later. She noted the facility had not responded to her last email sent on 9/12/22. The POA said among other things, It is a consistent neglect by the Certified Nursing Assistants (CNAs) leaving her wet in urine and feces. She explained she had visited resident #1 at night and had provided the care the CNAs should have done. She stated she had hung signs on the wall to remind staff of the personal care her sister needed, sent messages to the facility, and the situation was still the same. She indicated all she was trying to do was to give her sister the best possible care. On 9/15/22 at 4:49 PM, the Social Services Director (SSD) stated she was the Grievance Officer and had received various emails from resident #1's POA which listed several concerns. The SSD explained the last email received on 9/12/22 included concerns about missing items, a barrier cream that needed to be applied after toileting care and a report of bugs in resident #1's room. The SSD stated the interdisciplinary team (IDT) called the POA on 9/15/22 and addressed each concern with her. The SSD could not explain why the report of neglect mentioned more than once on the POA's email was not reported to the Abuse Coordinator during her morning meeting report. On 9/15/22 at approximately 5:15 PM, the Administrator acknowledged she was the Abuse Coordinator. The Administrator stated the Abuse Log provided during survey showed the allegations received and investigated for July 2022. She indicated there were no allegations of abuse or neglect received during August or September 2022. The Administrator confirmed she also received the email sent by resident #1's POA on 9/12/22. The Administrator explained she had not read the message and did not know about the allegation of neglect from the POA. She indicated she did not file an immediate report with the appropriate agencies because she did not read the email. She acknowledged she received the email but repeated she did not read it. She stated the concerns were discussed in the morning meeting by the SSD but there was no mention of an allegation of neglect, therefore, it was treated as a grievance. On 9/15/22 at approximately 5:20 PM, the Regional Director of Clinical Operations (RDCO) stated the administrator had filed a report for neglect for resident #1 in June 2022 for the same allegations and they did not feel it needed to be filed again. The RDCO acknowledged when abuse or neglect was suspected or reported, the process included reporting to the appropriate agencies and initiating an investigation. As requested, the RDCO read out loud the message from the POA which noted, These repeated neglect issues keep arising. On 9/15/22 at approximately 6:05 PM, the Director of Nursing (DON) stated she received a copy of the email sent by the POA on 9/12/22. She stated the email was addressed by the SSD. The DON explained the SSD summarized the concerns from the email during their morning meeting, but she did not recall the exact day the discussion took place. The DON stated the SSD, Administrator, Unit Manager and her had called the POA earlier on 9/15/22 and discussed the peri-care, bugs and missing items concerns detailed in the email. The DON stated they allowed the POA to explain herself and her concerns and the POA did not use the word neglect. The DON validated they did not clarify the neglect allegation with the POA during that call. Review of the facility Abuse Neglect and Exploitation (ANE) policy, revised on 9/8/22, read, The facility will designate an Abuse Prevention Coordinator .who is responsible for reporting allegations or suspected ANE to the state survey agency and other officials in accordance with state law. The policy included under the Identification of ANE section the possible indicators of abuse included resident, staff or family report of abuse. The Investigation section covered, An immediate investigation is warranted when suspicion of ANE or report of ANE occurs. The Reporting/Response section included, Reporting of all alleged violations to the Administrator, state agency, adult protective services and all other required agencies .no later than 24 hours if the events that abuse the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, and record review, the facility failed to verify medication orders to ensure accuracy of dosage strength for over the counter medications, ([MEDICATION(S)], Benadryl), failed to ensure timely re-ordering of routine medications and failed to ensure antifungal cream was applied twice per day as per physician orders for 1 of 2 residents reviewed for medication administration, (#1). Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses including hypertension, [CONDITION(S)], allergies, and vitamin B12 deficiency [CONDITION(S)]. His current medication orders included Benadryl by mouth (PO) at bedtime for allergies dated 12/19/21 and [MEDICATION(S)] 1 tablet daily dated 5/3/21. Both of the ordered medications did not specify the dosage strength to be given. The physician had also ordered [MEDICATION(S)] 5 milligrams (mg) by mouth in the morning dated 11/30/21 for hypertension, [MEDICATION(S)] Extended Release 25 mg for hypertension dated 5/3/21 and [MEDICATION(S)] Cream 1% apply to affected area topically two times a day for itching dated 7/6/21. On 2/9/22 at 9:50 AM, during medication administration observation, Registered Nurse (RN) A said [MEDICATION(S)] 5 mg, and [MEDICATION(S)] 25 mg scheduled to be given at 9:00 AM were not available on the medication cart. RN A added she would not be able to give [MEDICATION(S)] as there was no dosage strength included in the physician order. RN A explained she worked at the facility infrequently and nursing staff who had worked on the cart prior to today should have re-ordered the medications. RN A attempted to obtain the [MEDICATION(S)] and [MEDICATION(S)] from the B Wing Unit Manager (UM). The UM could only provide [MEDICATION(S)] that she obtained from the facility's automated medication dispensing system. On 2/9/22 at 3:11 PM, during interviews with RN A and the Assistant Director of Nursing (ADON), the ADON stated, nurses should re-order mediations when the supply is low. We reorder medications on the computer. The ADON added that if they ran out of medications completely and it was not available in their automated dispensing system, the medication could be ordered from pharmacy and it would be delivered within an hour. The ADON acknowledged it had been over 5 hours and resident #1 still had not received [MEDICATION(S)] as the pharmacy had not delivered it. A review of resident #1's Medication Administration Record (MAR) with the ADON showed [MEDICATION(S)] cream was ordered to be applied topically two times a day for itching since 7/6/21 and was only applied once per day. The ADON said the order on the computer showed the cream was to be applied only once daily and should have been validated by the nurse when it was entered into the system. On 2/9/22 at 4:36 PM, Licensed Practical Nurse (LPN) B said she had worked the past 2 days and was assigned to resident #1. She stated she had not clarified the order for [MEDICATION(S)] and, I just gave the house stock that is on the cart. LPN B said she had given resident #1 his 9 PM Benadryl last night and could not remember the dosage given only that she had given 1 pill. LPN B said she applied [MEDICATION(S)] cream to resident #1 yesterday at 4 PM and did not realize it was ordered twice per day. The ADON acknowledged physician orders should have been clarified as the dosage for [MEDICATION(S)] and Benadryl were missing. The ADON indicated the [MEDICATION(S)] cream only showed to be given once per day as it was entered into the computer system incorrectly. On 2/10/22 at 10:22 AM, the ADON acknowledged resident #1 had only been getting [MEDICATION(S)] cream applied once per day for the past 6 months and should have been done twice per day. She also acknowledged resident #1 had [MEDICATION(S)] ordered over 8 months ago on 5/3/21 and Benadryl ordered almost 2 months ago on 12/19/21 without dosage strength specified in the order. She noted [MEDICATION(S)] and Benadryl were available in various strengths and the order should have been clarified with the physician. On 2/10/22 at 2:15 PM, during a telephone interview, the facility's Consultant Pharmacist (CP) verified the pharmacy did monthly reviews of residents' medications. She acknowledged resident #1's Benadryl and [MEDICATION(S)] orders were not identified by the pharmacist as unclear orders. She spoke about reordering medications and noted, the nurse should not let medications run out and needs to order 3-5 days in advance. If re-ordered between 3-5 days in advance, then it would not be an issue and there would be multiple doses left. On 2/10/22 at 3:18 PM, LPN C who was regularly assigned to resident #1 on the 7-3 shift said he gave the resident 400 micrograms (mcg) of [MEDICATION(S)] as that was available on the medication cart. He said he did not think to call the physician to clarify the order. LPN C said he reordered the resident's [MEDICATION(S)] and [MEDICATION(S)] on 2/6/21 when he noticed the supply was low. LPN C acknowledged the purpose of timely re-ordering of medications ensured they won't run out completely. On 2/10/22 at approximately 3:30 PM, the ADON checked an electronic report that showed resident #1's [MEDICATION(S)] and [MEDICATION(S)] were not re-ordered until yesterday, 2/9/22. The policy and procedure (P&P) Medication Regimen Review [MMR] effective August 2019, read, The consultant pharmacist performs a comprehensive review of each resident's medication regiment and clinical record at least monthly .The MRR also involves a thorough review of the resident records .The facility assures the consultant pharmacist has access to residents' and their medical records; the resident medication profiles .In performing medication regiment review, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards .The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record, pharmacy records, and other applicable documents. The facility shall make available to pharmacist all appropriate records .such as medication administration records (MARs); prescriber's orders .At least monthly, the consultant pharmacist reports any irregularities to the attending physician, medical director and director of nursing, at a minimum . The Provider Pharmacy Requirements dated April 2018 read, Regular and reliable pharmaceutical service is available to provide residents with prescription and nonprescription medications services .The provide pharmacy is responsible .Screening each new medication ordered for an appropriate indication .drug dose .Implementing procedures when medication delivery is delayed or medication not available . Review of the facility's P&P Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy dated April 2018, read, Medications and related products are received from the dispensing pharmacy on a timely basis .The written entry includes .Medicating name and strength, when indicated .Reorder medication 3-5 days in advance of need . The LPN and RN facility job descriptions revised 6/16/17, read Responsibilities/Accountabilities .Contacts attending physician to obtain orders as indicated .Oversees medication management to ensure adequate supplies .Ensures that physician orders are followed as prescribed .

Based on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 2 residents sampled for medication administration, (#2 and #1). There were 2 medication errors in 31 opportunities for a medication error rate of 6.45%. Findings: 1. On 2/9/22 at 8:55 AM, Registered Nurse (RN) A prepared resident #2's scheduled medications. She removed 1 tablet Oyster Shield Calcium 500 milligrams (mg) from the cart stock medication bottle and placed it in a pill cup with the resident's other oral medications. A pill count was done with the RN when she had completed preparation of the medications that showed 15 pills. She then proceeded to administer the medications to the resident who was in his room. Review of resident #2's medical record revealed he was admitted to the facility on [DATE]. A current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/9/22 at 3:20 PM, RN A in the presence of the Assistant Director of Nursing (ADON) stated the pill count was 15 and she should have had a total of 16 pills in the cup. RN A said that she did a triple check of the medications by counting number of medications on the computer screen but only explained 2 ways to check for accuracy of medication administration. 2. On 2/9/22 at 9:50 AM, RN A prepared resident #1's scheduled medications. RN A stated, we have one hour before and one hour after the time the medication is due for it to be given. A pill count with RN A showed 13 ½ pills in the medication cup. RN A explained the resident's scheduled medications, [MEDICATION(S)] and [MEDICATION(S)] were not available on the cart to be given at 9 AM. Upon entry to resident #1's room, the RN took resident #1's blood pressure which was 217/84 on the right arm and 225/87 on the left arm. RN A proceeded to give the resident his morning medications by mouth minus the [MEDICATION(S)] and [MEDICATION(S)]. She was then able to obtain [MEDICATION(S)] from the B Wing Unit Manager (UM) who indicated that it came from their automated medication dispensing system but [MEDICATION(S)] was not available and would have to be ordered immediately from the pharmacy. Review of the medical record for resident #1 revealed he was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/9/22 at 3:11 PM, RN A and the ADON acknowledged their policy was to give medications either 1 hour before or 1 hour after the time the medication was scheduled and as of now the [MEDICATION(S)] was over 5 hours late. Review of the facility's policy for Medication Administration revised April 2019 read, Medications are administered in accordance with prescribed orders, including required time frame .within one hour before the prescribed time and up to one hour after the prescribed time, unless otherwise specified .The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation, interview and record review, the facility failed to store medications and biologicals under proper temperature controls as indicated by manufacturer's recommendations in 1 of 2 medications rooms, (A wing). Findings: On 8/24/21 at 4:12 PM, the A wing medication room refrigerator was opened by Registered Nurse (RN) B and the thermometer inside was immediately read at 48 degrees Fahrenheit (F). The door of the refrigerator was closed at the request of State Survey Agency staff and on 8/24/21 at 4:14 PM, the Assistant Director of Nursing (ADON) opened the door and validated the temperature on the thermometer inside the refrigerator still read 48 degrees F. The ADON explained the 11:00 PM to 7:00 AM shift nurse was supposed to check the refrigerator's temperature every night. On 8/24/21 at 4:19 PM, the Director of Nursing (DON) stated if the refrigerator temperature was out of range, the nurse was expected to initiate a maintenance request. She explained the refrigerator was frozen earlier that day and the temperature was raised to defrost it. The ADON again opened the refrigerator and immediately checked the temperature of the medications with a handheld, instant-read laser thermometer gun. The thermometer temperatures read 52 to 57 degrees F when pointed at the vials and boxes of medications. The affected medications inside the A wing refrigerator included Moderna Corona Virus Disease 2019 (COVID 19) Vaccine, [MEDICATION(S)] injections, [MEDICATION(S)] Intravenous solution, Acidophilus, [MEDICATION(S)], [MEDICATION(S)], Epoetin, [MEDICATION(S)] insulin, [MEDICATION(S)] insulin, Novolog insulin, [MEDICATION(S)] suppositories, and [MEDICATION(S)]. Review of the medication labels found in the refrigerator revealed all medications were to be stored within 36 to 46 degrees F (retrieved on 8/27/21 from accessdata.fda.gov). The US Centers for Disease Control and Prevention Temperature Monitoring Best Practices for refrigerated vaccines listed a range of 36 to 46 degrees F, with the ideal temperature of 40 degrees F (retrieved on 8/27/21 from cdc.gov). The U.S. Pharmacopeia chapter 1079 Good Storage and Shipping Practices revealed refrigerators used to store drugs were required to maintain the product temperature between the limits as defined on the product's label. The document indicated the allowable range was 36 degrees to 46 degrees F (retrieved on 8/27/21 from usp.org). On 8/25/21 at 9:42 AM, the Maintenance Director said he had not received any service requests regarding the A wing medication room refrigerator. He explained the nurse should have submitted a work order for the refrigerator when it was identified the temperature was out of range. Review of the facility's Health Care Center Refrigerator/Freezer Temperature Log Sheet from the A wing medication room refrigerator dated August 2021 revealed temperatures logged at 48 degrees F on 8/23/21 and 8/24/21. No temperatures were recorded for 8/20/21 or 8/22/21. The Recommended Temperature Guides listed at the bottom of the log revealed refrigerated storage as 36-40 degrees F, and Although 36-45 F is acceptable, 36-40 F is the ideal refrigerated range. Review of the log for August 2021 revealed all recorded temperatures above 40 degrees F. Review of the July 2021 Medication room log sheet revealed temperatures of 50 degrees F on 7/14/21, 56 degrees F on 7/20/21, and 51 degrees F on 7/29/21. On 8/25/21 at 10:27 AM, Pharmacist D confirmed that medication refrigerators were supposed to be kept under 46 degrees F. She stated the Moderna Covid-19 vaccine, and the [MEDICATION(S)] syringes should be discarded if stored at 48 degrees F as shown on the facility's temperature log. On 8/26/21 at 9:45 AM, the DON reviewed the Refrigerator/Freezer log sheet and acknowledged that if no temperature was recorded on 8/22/21 there was no way to tell if the temperature was out of range on that day. On 8/26/21 at 12:23 PM, the A wing UM stated she reviewed the refrigerator log every morning, Monday through Friday, but did not realize there was no documentation on 8/20/21 and 8/22/21. She stated she was not aware the temperature in the refrigerator had to be 36-46 degrees F. The A wing UM said, I thought that 48 degrees was ok. On 8/26/21 at 12:32 PM, in a telephone interview, RN C confirmed she recorded the temperatures of the A wing medication room on 8/23/21 and 8/24/21 when the temperature log showed 48 degrees F. RN C stated she had never received information regarding acceptable temperature ranges for the medication room refrigerator. She recalled receiving a message from the UM to simply check the temperature and write it on the log. She said, It is the only thing I received from them. RN C said she was never told to report discrepancies to maintenance or anyone else if there was a problem. On 8/26/21 at 12:58 PM, Pharmacist E stated that per the temperatures of 48 degrees F recorded on the A wing medication refrigerator log on 8/23/21 and 8/24/21, the medications were not good, and should be discarded. The facility's Medication Storage in the Facility Policy and Procedure dated April 2018, read, Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The document revealed medication storage conditions would be monitored on a monthly basis by a pharmacy designee and any problems identified would be corrected. The policy emphasized, All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC). Refrigerated: 36 degrees F to 46 degrees F with a thermometer to allow temperature monitoring.

Based on record review and interview, the facility failed to comprehensively asses a significant change for 1 of 1 resident sampled for decline in Activities of Daily Living (ADL) of a total sample of 41 residents, (#33). Finding. Review of resident #33's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was independent for Bed Mobility, Transfers and Eating. The assessment showed the resident required supervision for Walking, Locomotion and Dressing. The facility assessed the resident as needing Limited Assistance of 1 staff for Toileting and Personal Hygiene. The resident was frequently incontinent of urine and bowels. Review of the quarterly MDS assessment dated [DATE] revealed the resident now required extensive assistance of 1 staff for Bed Mobility, Transfers, Toilet use and Personal Hygiene. The assessment showed the resident had declined and was now always incontinent of urine. On 8/26/21 at 4:56 PM, the resident's status was discussed with the Assistant Director of Nursing (ADON). She stated the facility did not have a MDS Coordinator. She explained the company's corporate staff had assumed the duties of completing the MDS assessments. She added the Social Service Director was completing the care plans. On 8/26/21 at 7:01 PM, the resident's MDS and ADLs were reviewed with the Director of Nursing. She stated she would have to call corporate office to find out why a significant change MDS was not completed for resident #33.

Based on interview and record review, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 1 of 2 residents reviewed for assessment accuracy of a total sample of 41 residents, (#67). Findings: Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67's MDS annual assessment with assessment reference date of 7/19/21 revealed he received insulin injections on 7 of 7 days in the look-back period. Review of resident #67's medical record revealed no physician orders for insulin. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/26/21 at 12:30 PM, the Director of Nursing (DON) stated the staff who completed the MDS assessment worked part-time and was not currently present in the facility. During review of the MDS assessment with the DON, she acknowledged the assessment was inaccurate. She stated she reached out to Registered Nurse A, the MDS coordinator, who said he made an error as the resident never received insulin injections. The DON explained the facility used the Resident Assessment Instrument (RAI) manual for instructions on coding different types of drugs. Review of the RAI version 3.0 Manual revealed section N0300: injections and N0350: insulin. These sections included directions for MDS staff to review residents' MARs for the 7-day look-back period and Count the number of days insulin injections were received The (RAI) manual revealed the results of the MDS assessment, should accurately reflect the resident's status.

Based on record review and interview, the facility failed to ensure medical equipment was delivered to the discharge location for 1 of 4 discharged residents of a total sample of 41 residents, (#43). Finding: Resident #43 was admitted to the facility for short term rehabilitation on 6/23/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3008 transfer form noted the resident's primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident's Brief Interview for Mental Status (BIMs) score was 15/15 which indicated the resident was cognitively intact. The resident required extensive assistance from staff for bed mobility, dressing and personal hygiene. The assessment noted the resident required assistance of 2 staff for transfers. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician noted the resident required oxygen, wheelchair, 2 wheeled walker and a 3 in 1 commode. A review of the progress note dated 8/21/21 noted the resident was discharged home with medications and oxygen. On 8/25/21 at 4:33 PM, a telephone call to resident #43's representative revealed the resident had difficulty walking to his third floor apartment as the building did not have an elevator. He explained the resident was discharged home on Saturday, 8/21/21, but the medical equipment that he needed was not delivered. On 8/26/21 at 6:29 PM, the Social Worker (SW) stated resident #43 was admitted to the facility for short term rehabilitation and had commercial insurance from his employer. She said the resident's insurance only allowed for 60 days in the nursing home and that he maxed out his insurance on 8/21/21. She stated the resident was not able to walk up the stairs to his third floor apartment so she arranged a transport company to bring him up to his apartment. She said she set up home health services to start on Monday, August 23rd. She said she was aware the medical equipment was not delivered to the resident's apartment on 8/21/21. She said she found out on Monday, August 23rd that DME provider was behind on their faxed orders. She said the resident received the oxygen concentrator on 8/24/21 and the walker and commode were delivered on 8/25/21. She added there was a back order for the wheelchair but did not provide a date when the wheelchair would be delivered. The SW said she called the DME provider the day before resident's discharge but did not document the phone call. A review of the progress note dated 8/23/21 (Monday) read, .Both companies stated they had not received fax requesting DME in their system but were still waiting for faxes to upload.

Based on observation, interview and record review, the facility failed to provide dressing changes for a Midline Catheter according to professional standards of practice for 1 of 2 residents with Intravenous (IV) catheters of a total sample of 41 residents, (#335). Finding: Resident #335 was admitted to the facility from a specialty hospital on 8/21/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/23/21 at 11:10 AM, resident #335 was observed in bed with a Midline IV Catheter to her left upper arm. The transparent dressing that covered the IV site was dated 8/14/21, and the lower end of the dressing was lifted from her skin. Resident #335 stated the IV was inserted at the hospital, and she was unsure if she was getting medications through it. A Midline Catheter is a small tube used to give treatments and to take blood samples. It is inserted into a vein in your arm . the end of the tube does not go past the top of the armpit . it can stay in place up to 30 days(retrieved on 8/27/21 from www.drugs.com). On 8/24/21 at 9:55 AM, the A wing Unit Manager (UM) stood at resident #335's bedside and noted resident #335 had a Midline IV catheter in her left arm. She acknowledged the IV dressing was loose at the lower end and was dated 8/14/21. She said, It is a problem. She explained because the dressing was lifted off the skin it was compromised and could lead to infection. She said the dressing needed to be changed or the IV discontinued if no longer needed. She stated her expectation was all assigned nurses should assess the IV site every shift. On 8/24/21 at 10:15 AM, during review of resident #335's medical record, the A Wing UM confirmed there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She acknowledged the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, It should have been done. She explained Midline IV dressings should be changed every 4 days and that the nurse who admitted the resident should have assessed the IV site and obtained IV care orders from the physician at that time. The A wing UM acknowledged there was no way to confirm the Midline IV was assessed because there were no related physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of resident #335's Nursing Comprehensive assessment dated [DATE] revealed no documentation of the presence of any IV catheters. Review of resident #335's Baseline Care Plan dated 8/21/21 revealed no documentation in the Special Treatments/Procedures section under IV type, location or dressing change. Review of resident #335's Order Summary Report dated 8/24/21 revealed no orders for Midline IV dressing changes or assessment. An order dated 8/23/21 read, Flush Midline/PICC every shift for patency and D/C midline/picline one time only for IV. Review of the resident's Treatment Administration Record (TAR) and Progress Notes from 8/21/21 to 8/23/21 revealed no documentation for IV dressing changes to resident #335's Midline IV. The TAR showed the Midline IV was discontinued on 8/23/21 as ordered although a progress note that read, 20 cm Midline to R upper arm was discontinued using aseptic technique per DR. order was dated 8/24/21. Facility nurses continued documenting on resident #335's Midline IV under Check Midline placement every shift and flush Midline /PICC every shift for patency through 8/25/21, even though the line was no longer in place. On 8/26/21 at 7:35 PM, the Director of Nursing stated a Midline IV should be reported to the physician on admission for their decision regarding whether the IV catheter would be utilized, discontinued, or to obtain appropriate orders for IV care. She acknowledged the nurse who received a newly admitted resident should assess and note findings including presence of an IV catheter. She acknowledged resident #335's Order Summary Report dated 8/24/21 contained no orders for the Midline IV dressing change. She confirmed the Baseline Care Plan completed at admission, dated 8/21/21 had no documentation indicating the resident had an IV. She said, It's important to assess the resident in general and what the resident needs. The facility's Policy and Procedure, Midline Dressing Changes 005-N dated October 2019 read, Midline catheter dressings will be changed at specified intervals, or when needed, to prevent catheter- related infection associated with contaminated, loosened or soiled catheter site dressings . Change midline catheter dressing 24 hours after insertion if placed with gauze, every 7 days or if it is wet, dirty, not intact or compromised in any way.

Based on observation, interview and record review, the facility failed to perform adequate pre-admission screening to determine the appropriate level of supervision and necessary services required to prevent elopement; and failed to conduct a thorough search for a missing person, for 1 of 6 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility in the dark, unsupervised, there was a high likelihood he could have fallen, gotten lost or been hit by a car. On 10/27/20 at approximately 8:00 PM, the facility failed to prevent resident #1, a newly admitted , cognitively impaired resident, from exiting the facility in the dark, unsupervised. Resident #1 exited the facility through a secondary exit door and hid behind a hedge while staff searched the parking lot and adjacent sidewalks. When staff re-entered the building, resident #1 walked through a retention pond to the sidewalk, and then continued along a heavily trafficked 4 lane highway, over uneven pavement and crossed several business entrances. A concerned passerby called the police to report a man with a wobbling gait who wore a hospital gown, walking on the sidewalk near a busy shopping center approximately 0.2 miles away. Facility staff were unaware of resident #1's whereabouts until he was returned to the facility by a police officer at approximately 8:30 PM. The facility's failure to provide adequate supervision and conduct a thorough search for a missing person resulted in Substandard Quality of Care. Past Non-Compliance at the Immediate Jeopardy level was identified as occurring from 10/27/20 to 11/09/20. Findings: Resident #1 was admitted from the hospital to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident was transferred to the hospital on [DATE] and did not return to the facility. A hospital emergency department (ED) Workflow form dated 10/12/20 revealed resident #1 was brought to the hospital by emergency medical personnel with a chief complaint of altered mental status. The document indicated resident #1 was found at home covered in feces and was attempting to bathe in and eat his own feces. The family informed ED staff that resident #1 was not able to care for himself but refused placement in a facility. Resident #1 was admitted to the hospital with [REDACTED]. The hospital transfer form, AHCA Form 5000-3008 dated 10/12/20 revealed resident #1 did not have a risk alert for elopement. The document indicated resident #1 was alert and disoriented but could follow simple instructions. The Admission Data Collection Tool dated 10/26/20 revealed that when resident #1 arrived at the facility, he was oriented to person only and had an altered level of consciousness. The admission nurse noted resident #1 had disorganized thinking, was incoherent, had rambling or irrelevant conversation, unclear or illogical flow of ideas, switching from subject to subject. An Elopement/Wandering Risk Data Set evaluation dated 10/26/20 at 5:30 PM was completed by the facility's Risk Manager (RM). The document revealed resident #1's risk factors for elopement were independent ambulation, at least 1 predisposing diagnosis, orientation to person only and new admission status. Questions regarding resident #1's cognitive status and historic evidence were left blank. The document indicated resident #1 had no history of elopement episodes in the past 6 months and he was deemed Not at risk for elopement. A nursing note dated 10/26/20 at 10:13 PM, written by the admission nurse, Licensed Practical Nurse (LPN) A, revealed he obtained information on resident #1 from the hospital report and an interview with a family member. The note indicated resident #1 had altered mental status, slow thought process and .can barely response to admission questions . LPN A's evaluation revealed resident #1 was quickly forgetful after being redirected not to ambulate due to his risk for falls. The Minimum Data Set (MDS) discharge assessment with assessment reference date of 10/28/20 revealed resident #1 had an acute onset mental change with fluctuating inattention and disorganized thinking. He displayed trouble concentrating, was restless and was short-tempered during his 2-day stay in the facility. The MDS assessment indicated resident #1 experienced delusions, rejected care and had wandering behavior. He required supervision to limited assistance for walking and had unsteady balance but was able to stabilize without staff assistance. The document revealed resident #1 used a walker and/or wheelchair for mobility. The MDS assessment revealed resident #1 had a fall 2 to 6 months before admission to the facility. On 11/13/20 at 2:59 PM, LPN A recalled resident #1 was confused, but was easily redirectable and could obey commands and answer simple questions. LPN A stated that on the evening resident #1 was admitted , he remained quietly in bed. LPN A stated the resident was unable to sign paperwork and answer some questions so he called a family member. LPN A said, I called the sister and she did not report anything that would concern me. LPN A stated on the following day, before he eloped, resident #1 was calm, took all his medication and sat in the wheelchair in his room and watched television. On 11/13/20 at 4:49 PM, Certified Nursing Assistant (CNA E) stated she was assigned to resident #1 on the evening he exited the facility unsupervised. CNA E recalled the resident sat in his wheelchair in his room and watched television for most of the shift. She recalled she walked with him to the bathroom once and then provided him with his dinner tray. CNA E stated resident #1 ate all his dinner and when she gave him a snack between 7:30 PM and 7:45 PM, he was still in his room. CNA E said, Resident was calm, quiet and polite . and was not restless or exit-seeking. Review of time-stamped video recordings from the facility's exterior and interior cameras revealed that on 10/27/20 at 7:59 PM, resident #1 walked from the A Wing, along a hallway with administrative offices towards the therapy gym. He reached the glass doors near the therapy gym and looked outside while he held pressure on the handle of the door. The lock on the fire door eventually released and resident #1 exited the facility. At 8:01 PM, the video showed resident #1 turned right and walked along the pathway that led to the west side of the building. He wore a hospital-type gown and his gait was slow and slightly unsteady. At 8:04 PM the video showed a staff member crossed the parking lot, looked around and then walked down the driveway toward the sidewalk. Resident #1 remained on the pathway crouched behind a hedge on the west side of the building while staff searched for him. He raised his head then stood up for a brief period before stooping again to remain hidden while the staff member walked up the driveway toward the building a few minutes later. The video showed resident #1 waited until staff re-entered the facility before he stood up and continued walking along the pathway that led toward the back of the building. On 11/12/20 at 4:15 PM, during a telephone interview with the evening shift nursing supervisor LPN B, she described the events surrounding resident #1's elopement on 10/27/20. LPN B stated she observed resident #1 in his room on the A Wing at approximately 7:30 PM during her rounds. She stated she completed her rounds on the B wing and on her way back to the A Wing, she heard an alarm sounding from the exit door near the therapy gym. LPN B said she directed staff to do a head count of all residents in the building and instructed LPN C to search outside the facility, from the therapy exit door towards the east and the back parking lot. LPN B recalled she checked the west side of the front parking lot and headed down the driveway towards the adjacent street. She stated she walked to two busy intersections nearby and did not see a resident on any of the sidewalk. LPN B said, That is one of the reasons I went straight out there. It's a very busy road. LPN B confirmed she did not search the west side or the back of the building before re-entering the facility with LPN C to finalize the head count, verify which resident was missing, and notify the facility's RM and law enforcement. LPN B stated that before she was able to notify law enforcement, a police officer showed up at the front lobby door and said, I found somebody for you. He told me his name is (resident #1) and he was from this building. On 11/12/20 at 2:33 PM, during a telephone interview, Records Department staff at the local police station stated they received a non-emergency call on 10/27/20 at 8:22 PM regarding a man in a hospital gown, wobbling on the sidewalk near a popular ice cream store. The Records Department staff stated Officer D was dispatched to respond to the call, and he closed the case at 8:45 PM. In a written statement dated 11/15/20, Officer D indicated on 10/27/20 at about 8:30 PM, he responded to a call in the vicinity of the ice cream store near the facility. He noted the call was in reference to an elderly male dressed in a hospital gown. Officer D wrote, When I got there I made contact with him and he had a wrist bracelet on from (the) facility. I asked if he was ok and he said he wanted to go home. I checked best I could for any injuries and did not see any. He started crying saying he just wanted to go home. I got him calmed and transported him back to the (facility). The statement revealed Officer D returned resident #1 to the care of facility staff. On 11/12/20 at 2:48 PM, resident #1's elopement route was retraced from his room on the A Wing to the shopping plaza approximately 0.2 miles away where he was rescued by Officer D. Resident #1 walked through the double doors that separated the A Wing from the administrative office hallway and stopped at the secondary exit doors near the therapy gym. He pressed on the door handle until the lock released and exited the facility. Resident #1 turned right and followed the pathway that led towards the west side and back of the building. On the west side of the building, was a large dry bottom retention pond that had a sloping concrete channel to collect water runoff from the driveway on one end, and a concrete inlet structure at the opposite end. The pathway at the back of the building was parallel to a steep embankment that dropped 3 to 4 feet into the parking lot of a business next door. The temperature on 10/27/20 at 7:53 PM was 80 degrees Fahrenheit, and it was already dark, with a sunset set time of about 6:44 PM (retrieved from timeanddate.com). The darkness created an even more perilous situation for resident #1 as he could have fallen down the embankment without realizing it was there. Resident #1 would have traversed down the sloping side of the retention pond, walked approximately 60 feet across the pond, climbed the sloping far side of the pond and then down onto the sidewalk along a busy 4-lane road. Resident #1 turned right on the sidewalk and headed towards a heavily trafficked 6-lane highway. The uneven pavement was covered with gravel in some areas and cars sped past continuously. Resident #1 would have crossed at least 3 driveways before arriving at the main entrance road into the busy shopping center. A continuous stream of cars entered and left the shopping center which housed businesses including a popular ice cream store, a gym and several restaurants. On 11/12/20 at 1:00 PM, the RM stated on 10/27/20 at about 8:20 PM, she received a telephone call from the evening shift nursing supervisor, LPN B. The RM stated LPN B informed her of resident #1's elopement. She was informed staff searched the facility and grounds but were not able to find him. The RM stated she arrived at the facility at about 8:40 PM and resident #1 had already been returned by the police. The RM stated she fully assessed resident #1 and noted no injuries, but he was crying and apologetic. She stated resident #1 described how he hid behind the hedge while staff searched for him. The RM explained she re-assessed resident #1's elopement risk factors and based on the elopement incident she obtained a physician's orders [REDACTED]. In addition, she assigned a staff member to provide continuous 1:1 supervision. The RM stated she did resident #1's initial elopement assessment on admission and deemed him not at risk for elopement. She confirmed she left questions blank on the initial elopement risk assessment because she did not know the answers. The RM did not respond when asked if failure to answer the question regarding resident #1's cognitive status could have impacted his elopement risk level, and possibly triggered a recommendation for an electronic wander bracelet. On 11/12/20 at 1:00 PM, the Director of Nursing (DON) stated the facility was not aware resident #1 had any behaviors that contributed to an increased risk for elopement. She explained the facility's Marketing Liaison was responsible for conducting a pre-admission screening in the hospital of all residents prior to admission. She added that he should have contacted her regarding potential care issues. The DON explained that during investigation of the elopement incident, the Marketing Liaison informed her he had not been able to thoroughly evaluate resident #1 in the hospital because he was heavily sedated. She explained the hospital had not provided full access to resident #1's medical record prior to admission. The DON stated the facility was not aware resident #1 required two medications to treat psychotic behaviors and also wrist restraints to secure his arms while in the hospital. She explained if she had been aware of a sudden discontinuation of an antipsychotic medication, she would have asked how patient #1's symptoms were being managed. The DON stated resident #1's hospital discharge orders did not include those medications and the facility received copies of relevant progress notes and medical history when resident #1 arrived in the building. The DON acknowledged clinical decisions regarding the facility's capability to meet residents' needs was the responsibility of herself and the RM. Review of the job description for the Marketing Liaison (no date) revealed he/she was .an advocate for patients beginning during the pre-admission process and continuing until resident is discharged from the medical facility. The essential duties of the Marketing Liaison included communicating with the patient's family, assessing the patient and reviewing the medical record. The job description for the Director of Nursing (no date) revealed he/she was responsible for the planning, organizing, direction, supervision, and evaluation of all the nursing services provided in the facility. On 11/13/20 at 2:39 PM, in a telephone interview with the Medical Director he stated he participated in the Root Cause Analysis conducted by the Quality Assurance and Performance Improvement (QAPI) committee on the day after resident #1 eloped. The Medical Director stated he reviewed resident #1's medical record at that time and noted information that would have made a difference in the decision to admit and/or development of the plan of care. He stated the facility did not have all available clinical information necessary to make fully informed decisions. He explained sections of the medical record that would have triggered alerts were not received until resident #1 arrived at the facility. The Medical Director stated resident #1's mental status was not known to the facility prior to admission. He explained the QAPI committee immediately addressed the issue under his guidance and updated the pre-admission screening questionnaire to delve deeper into every patient's mental state over the 72-hour period prior to admission. The Medical Director explained the intent was not to deny admissions, rather to ensure residents' care needs would be met. He explained any potential concerns should have been and will be escalated to a higher level of scrutiny from a clinical staff member such as the DON. The Facility Assessment updated on 10/30/20 and reviewed by the QAPI committee in November 2020, revealed the facility may accept residents with psychiatric and mood disorders including [MEDICAL CONDITION], mental disorders and behaviors that need intervention. Review of corrective measures implemented by the facility revealed the following: * Resident #1 was reassessed after being returned to the facility and deemed to be at risk for elopement. The facility obtained a physician's orders [REDACTED].#1's left ankle and initiated continuous 1:1 supervision. A care plan was created for alteration in mood and behaviors as evidenced by a history of elopement. * All residents in the facility were re-assessed for elopement risk and their care plans were reviewed and updated as needed. *Staff education was provided on evaluating and monitoring residents at risk for elopement, responding to door alarms and conducting a thorough search. Review of in-service attendance sheets and elopement drill records revealed education was initiated on 10/27/20. By 11/09/20, 136 of 143 staff members from all departments, a total of 95% had been educated. Remaining staff had either not worked in over 3 months, were on extended leave or out of the country. The scheduler would ensure none of these staff returned to work without proof of education. Interviews conducted from 11/12/20 at 9:31 AM to 11/13/20 at 5:28 PM with 7 LPNs, 7 CNAs, 3 receptionists, the Admissions Coordinator, therapy staff person and a housekeeper from all 3 shifts indicated they were knowledgeable about elopement procedures, supervision of residents at risk for elopement, response to door alarms and proper search procedures. *The QAPI committee developed an elopement assessment audit tool. Daily audits were initiated on 10/28/20 and included residents who were deemed at risk for elopement, all newly admitted residents, and randomly selected residents including those with risk factors such as a change in condition or a dementia diagnosis. Results of the audits were reviewed by the Medical Director, administrator and members of the interdisciplinary team (IDT) on 11/04/20. Effectiveness of the audit tool will be monitored during weekly IDT meetings and monthly QAPI meetings. The QAPI committee revised the pre-admission assessment/observation tool to promote effective communication amongst the IDT regarding potential residents. The sample was expanded to include all residents who wore monitoring devices due to the risk for elopement and 3 residents admitted after resident #1 eloped from the facility. Observations and record reviews conducted revealed no concerns related to elopement risk assessments, care plans and placement of electronic monitoring devices for residents #3, #4, #5, #6 & #7. Record reviews for newly admitted residents #8, #9 and #10 revealed elopement risk assessments were completed and audited for accuracy.

Based on record review and interview, the facility failed to ensure effective communication and collaboration between members of the interdisciplinary team (IDT) to provide necessary care and services to attain the highest practicable well-being for 1 of 10 sampled residents, (#1). The facility's failure to recognize and treat a change in condition resulted in actual harm. Resident #1 was admitted to the facility for wound care and rehabilitation services. After 3 weeks, he developed signs and symptoms of an infection and had changes from his baseline status. He was transferred to the hospital a few days later for a change in level of consciousness, fever and decreased oxygen levels. Resident #1 was diagnosed with [REDACTED]. He died 4 days later on hospice. Findings: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set discharge return anticipated assessment dated [DATE] indicated resident #1 had an unplanned discharge to the hospital. On [DATE] at 11:06 AM, in a telephone interview with resident #1's daughter, she stated she spoke to her father on [DATE], the day before he was transferred to the hospital. She described him as . very confused, very different from his usual self. The daughter stated she had not received any phone calls from the facility regarding any changes, infections or worsening of her father's condition. Resident #1's daughter stated on [DATE], she received a telephone call from a hospital to inform her that her father was transferred there from his nursing home. She said, The doctor at the hospital told me he was not doing well. He was in a bad condition. Resident #1's daughter explained her father was diagnosed with [REDACTED]. Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. This response to an existing infection triggers a chain reaction throughout the entire body that can cause organ failure, tissue damage and death if not treated in a timely manner. The symptoms [MEDICAL CONDITION] include confusion or disorientation, shortness of breath, high heart rate, fever, shivering or feeling cold. (The Centers for Disease Control and Prevention website at www.cdc.gov, accessed on [DATE]) Review of a nursing progress note dated [DATE], revealed resident #1 was . received in bed prior to breakfast noted shaking, trembling, complain of pain bilateral lower extremities scale of ,[DATE] (severe pain) . Behavior disoriented, hallucinating and cannot follow simple directions . The note indicated resident #1 attempted to get out of bed several times and had a decreased appetite. The respiratory therapist was notified, and resident #1 was given supplemental oxygen at 2 liters per minute . due to anxiety/hyperventilating. The nurse documented she notified the physician and was awaiting a response. A physician's progress note revealed resident #1 was seen by his attending physician on [DATE] (time of visit unknown) . to assess multiple comorbidities. There was no evidence nursing staff communicated resident #1's change in condition to the attending physician, and there were no new orders for diagnostic tests and no changes made in the treatment plan. The following day, on [DATE], resident #1 was seen by the Advanced Registered Nurse Practitioner (ARNP) C. Her progress note indicated he was confused and had increased anxiety. Review of ARNP C's progress notes for visits on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed the symptoms of confusion and anxiety were a change from resident #1's baseline status of Calm; cooperative. ARNP C ordered diagnostic laboratory tests and a psychology consult. Review of the laboratory result report dated [DATE] at 11:37 AM, revealed resident #1 had abnormal complete blood count values including a white blood cell (WBC) count of 24.8 K/ul (thousand per cubic milliliter). This is double the upper level of the normal range of 4.1 to 10.9. In comparison, resident #1's WBC count was 10.1 on [DATE], the day after he was admitted to the facility. On [DATE], the attending physician examined resident #1 and reviewed the laboratory results. The physician initialed the laboratory result report, but did not otherwise address resident #1's elevated WBC count in his documentation. His progress note revealed recommendations for a liquid multivitamin supplement and to continue current medications and treatments. Resident #1 was also seen by a cardiology ARNP on [DATE], who also signed a copy of the laboratory results but did not give any new orders related to the high WBC count. On [DATE], ARNP C reviewed resident #1's laboratory results. Her progress note revealed resident #1 had [MEDICAL CONDITION] or a low number of red blood cells, and although his hemoglobin level was improved, she referred him to a specialist for further evaluation. ARNP C also noted resident #1 had hyperleukocytosis, a high number of WBCs, but her progress note did not include documentation on possible causes and treatments, or orders for additional diagnostic tests or consults. White blood cells are part of the body's immune system. They defend against infection and disease by destroying foreign materials and infectious agents. An elevated WBC count is normally seen when the body attempts to fight off bacterial, [MEDICAL CONDITION] or parasitic infections (Medscape website at www.medscape.com accessed on [DATE]) Review of Departmental Notes from [DATE] to [DATE] revealed no documentation of collaborative efforts between physicians, ARNPs, floor nurses, unit manager (UM), Director of Nursing (DON), infection control nurse, wound nurse, rehab director or respiratory therapist regarding resident #1's sudden change in mental status, respiratory issues and high WBC count. Although resident #1 was evaluated by several clinicians and nurses during this period, there was no evidence the interdisciplinary team (IDT) reviewed evaluations by all disciplines and revised his plan of care to reflect an increased risk for or actual infection and discussed appropriate follow-up procedures. A nursing note dated [DATE] at 9:15 AM, revealed a nurse found resident #1 non-responsive with axillary temperature (taken under the armpit) of 100.1 degrees Fahrenheit, which is the equivalent of an oral temperature of 101.1 degrees Fahrenheit. His blood pressure was ,[DATE] mmHg and his oxygen level was 93% saturation on room air, which was outside the normal range of 95% to 99%. (Mayo Clinic website at www.mayoclinic.org accessed on [DATE]). The facility obtained a physician's orders [REDACTED].#1 to the hospital via 911 for evaluation and treatment. Review of the hospital record revealed when ambulance personnel arrived at the facility, resident #1's blood pressure had decreased to ,[DATE] mmHg and his oxygen level was 94% saturation on oxygen at 3 liters per minute. By the time resident #1 arrived at the hospital, his respiratory rate was 44 breaths per minute (normal range is 16 to 20) and his oxygen level was 92% saturation. The emergency department record revealed resident #1 did not open his eyes or speak but responded with only .incomprehensible sounds. The document read, He was made [MEDICAL CONDITION] alert secondary to reports of low-grade fever, altered mental status, low blood pressure and increased respiratory rate. Diagnostic tests done in the hospital emergency department showed resident #1's WBC count was even higher than before, now increased from 24.8 to 29.3 K/ul. In addition, a chest x-ray indicated pneumonia in both lungs and a urinalysis showed he had a urinary tract infection [MEDICAL CONDITION]. Resident #1 was started on intravenous (IV) antibiotics and admitted as an inpatient with [DIAGNOSES REDACTED]. Review of an Infectious Disease (ID) physician's note dated [DATE] revealed resident #1 continued on IV antibiotics for UTI and pneumonia, and his WBC count had decreased to 15.5 K/ul. However, nurses informed the attending physician resident #1 was .doing poorly . and had very low oxygen saturation levels. The hospital Discharge Summary dated [DATE] revealed resident #1's family selected comfort measures only, and he was discharged to a hospice inpatient unit. In interviews on [DATE] at 1:30 PM and 4:20 PM, the DON explained laboratory results were received by fax and distributed to the appropriate nurses by unit secretaries and UMs. The DON stated her expectation was nurses would communicate abnormal results to the physicians or ARNPs and then document that the notification was made. She described a WBC count of 24.8 as alarming and stated it indicated a probable infection. She stated if the provider was in the facility and did not address an abnormal test result, it was appropriate for a nurse to ask if there was any further action required, such as a re-check or another type of test. The DON stated the medical record should be updated with the physician's or ARNP's response so all staff would have access to the information. The DON stated her expectation was UMs would review results and new orders on the nursing unit, and again with the IDT/clinical team in daily morning meetings. She confirmed the daily clinical meeting attendees included the infection control nurse, wound nurse, UMs, care plan coordinator and herself. The DON stated as a result of care plan review by the clinical team, decisions could be made regarding residents' existing orders and if necessary, requests for new orders from the attending physician or consultants. On [DATE] at 3:04 PM and 4:44 PM, in telephone interviews with ARNP C, she recalled resident #1 had a change in mental status and became anxious and confused. She stated she ordered laboratory tests and a psychology consult. She reviewed her notes and confirmed she visited the facility on [DATE], reviewed the laboratory report and noted resident #1 had leukocytosis. ARNP C confirmed resident #1's WBC count of 24.8 was very high and indicated he had an infection. She asked if resident #1 was being seen by Infectious Disease (ID) and was informed there were no ID progress notes in the medical record. When asked what her usual course of action would be for this situation, ARNP C said, Usually I would repeat the lab then consult the doctor . The ID doctor would have been seeing him from the beginning. ARNP C was again informed there was no evidence resident #1 had an order for [REDACTED]. On [DATE] at 9:46 AM, in a telephone interview with the attending physician he confirmed he noted resident #1's laboratory results on [DATE] but did not refer to the abnormal results in his progress note. He explained he attributed resident #1's high WBC count to his open wounds. The attending physician recalled resident #1 was being followed by a wound care specialist. When asked why he did not provide orders to treat the abnormal WBC count, he explained the wound team would have initiated IV antibiotics if they felt it was necessary. The attending physician was informed ARNP C saw resident #1 the following day, but possibly did not address the high WBC count because she thought resident #1 was being followed by an ID specialist. He was informed the facility conducted a daily clinical meeting attended by nursing management, the wound nurse, infection control nurse and other IDT members, with a purpose of coordinating residents' care needs. The attending physician acknowledged that venue could have been used to discuss any other appropriate interventions for resident #1.

Based on record review and interview, the facility failed to provide care and services to identify, monitor and treat pressure ulcers for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 10 residents, (#2). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments resulted in actual harm. Resident #2, a long-term resident of the facility, was transferred to the hospital for a change in health status. Hospital staff noted stage II pressure injuries on her coccyx and deep tissue injuries to both heels that were not reported by the facility. Approximately 5 weeks before the hospital transfer, resident #2's medical record showed documentation of redness which worsened to an open area on her buttocks over a 2 week period. There was no record of skin breakdown on her heels, and no treatment orders for pressure injuries implemented. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was transferred to the hospital on [DATE] for a fever. The Minimum Data Set (MDS) discharge return anticipated assessment with assessment reference date of 7/04/20 revealed resident #2 had modified independence in cognitive skills for daily decision making. She required extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene, and was totally dependent on staff for bathing. Resident #2 was occasionally incontinent of urine and always incontinent of bowel. The MDS assessment showed resident #2 did not .reject evaluation or care necessary to achieve the resident's goals for health and well-being . and had no pressure ulcers. Review of resident #2's medical record revealed a care plan for risk for pressure ulcers related to limited mobility, revised on 5/22/20. Interventions directed nurses to conduct weekly skin checks and certified nursing assistants (CNAs) to perform skin checks every shift. Nursing staff were to provide resident #2 with incontinence care as needed, off load her heels, turn and reposition her at least every 2 hours, apply lotion to her legs and place compression stockings in the morning then remove them in the evening. The care plan indicated resident #2's physician, family and responsible party should be notified of changes in skin condition. On 7/31/20 at 12:11 PM, in a telephone interview with resident #2's sister, she explained she was the designated healthcare surrogate and primary emergency contact for her sister. The sister stated the facility notified her of resident #2's transfer to the hospital on [DATE]. She explained she was not aware her sister was being treated for [REDACTED]. The sister said, I was shocked because another thing I found out was she had very bad pressure sores on her bottom and both heels. Her skin was fine as far as I knew. They used to call me for anything about her. I even got a call from the facility the day before she went out to tell me they had COVID ([MEDICAL CONDITION] Disease 2019) patients in the facility and sent to the hospital. She reiterated the facility never informed her about her sister developing pressure sores. Review of Weekly Skin Check forms revealed on 5/26/20, resident #2's skin was evaluated as Intact. On 6/02/20 there was Redness to buttock area and on 6/09/20 a skin check revealed an open area to buttocks. On 6/16/20, the weekly skin check indicated resident #2 still had an open area to her buttocks. Weekly skin check forms were blank, struck through and not signed by a nurse for 6/23/20 and 6/30/20. Review of the Physician order [REDACTED]. Review of resident #2's medical record revealed no nursing notes or change in condition forms regarding resident #2's skin breakdown. There was no documentation the physician, family, unit manager and/or wound nurse were notified of alterations in skin integrity. Resident #2's plan of care did not reflect any revisions related to interventions for actual skin breakdown. A nursing progress note dated 7/04/20, written by Registered Nurse (RN) E, revealed she received an order to transfer resident #2 to the hospital. The note read, Skin check produce no wounds but resident refused to take shoes off for nurse to examine her feet. Review of the hospital emergency department history and physical dated 7/04/20 revealed resident #2's [DIAGNOSES REDACTED]. The hospital admission nursing assessment dated [DATE] detailed 3 pressure injuries. Resident #2 had a wound on her sacrum that measured approximately 5 inches x 7 inches with beefy red tissue and black eschar, or dead tissue noted. The surrounding skin was red, and the wound had bloody drainage. The nurse also observed deep tissue injuries (DTIs) that covered ¾ of the surface of both heels. Both heels had blisters and black eschar. Wound treatments orders were implemented at admission for the 3 pressure injuries. The National Pressure Injury Advisory Panel defines a pressure injury as . localized damage to the skin and underlying soft tissue usually over a bony prominence . The injury can present as intact skin or an open ulcer . A stage 2 pressure injury involves partial-thickness skin loss that presents as a shallow open ulcer. A DTI (deep tissue injury) is a persistent, dark discoloration on intact or non-intact skin that can have a dark wound bed or present as a blood-filled blister. This injury results from intense and/or prolonged pressure . (The National Pressure Injury Advisory Panel website at www.npiap.com accessed on 8/14/20) Review of the hospital Wound/Ostomy Progress Note (Inpatient) dated 7/06/20 revealed resident #2's wounds were present on admission. The sacrum/buttocks wound measured 14.5 x 13 x 0.1 centimeters (cm) and had a small amount of drainage. The right heel had an intact blood-filled blister that measured 6.2 x 3.0 cm and the left heel also had an intact blood-filled blister that measured 4.0 x 3.0 cm. On 8/05/20 at 11:33 AM, Certified Nursing Assistant (CNA) D stated during care she noted resident #2 had redness on her bottom. CNA D could not recall the date, but she remembered telling the assigned nurse, Licensed Practical Nurse (LPN) B that he should check resident #2's skin. CNA D stated LPN B told the wound nurse at that time. On 8/05/20 at 12:18 PM, LPN B stated he was regularly assigned to resident #2. He explained he attempted to complete her weekly skin assessments, but it was sometimes difficult because resident #2 was very modest. LPN B explained he would have to encourage resident #2 to allow him to do a full skin check and he often had to ask other nurses or CNAs to assist him. He recalled CNA D asked him to evaluate an area of concern she identified on resident #2's buttocks. LPN B stated the area was red, but he did not recall an open area, so he instructed CNA D to apply a protective barrier cream. He could not recall the date but thought the incident occurred during resident #2's last week in the facility. LPN B explained resident #2 was usually continent and used the bathroom even though she wore disposable briefs. However, due to her illness that week she was in bed and incontinent. LPN B said, I didn't document the skin problem. I told the wound nurse . LPN B acknowledged he should have notified the physician and documented the new area of skin concern. On 8/05/20 at 3:45 PM, Registered Nurse (RN) E stated she completed a full skin assessment on resident #2 prior to the hospital transfer. RN E said, I had to coax her into a skin assessment. She's very private but she allowed me to do a full body assessment . I would have seen an open area on her bottom even if there was barrier cream on it. RN E stated she did not assess resident #2's heels because she refused to remove her shoes. She explained resident #2's skin was assessed while she was in bed. RN E stated resident #2 was wearing her shoes in bed at that time. On 8/05/20 at 4:30 PM, the Director of Nursing (DON) stated her expectation was nurses would document on and report any newly identified areas of skin breakdown to the physician and wound nurse, who would consult the wound physician if indicated. She stated her expectation was nurses would use a change in condition form and a progress note to record any skin issues. She confirmed a family member or representative should be notified of any change in skin condition and treatments ordered. The DON explained CNAs should inspect their assigned residents' skin during care every shift and update nurses on their findings. The DON was informed resident #2's weekly skin check forms showed nurses identified areas of skin breakdown but there was no documentation of physician or family notification and no treatments were implemented. She acknowledged the importance of completing weekly skin check forms and explained the wound nurse reviewed them in the daily clinical meeting. The DON stated all aspects of wound prevention and healing should be addressed by interdisciplinary team once they were made aware. Review of the Skin System Policy & Procedure revised in September 2004, revealed all residents would have weekly skin assessments to identify areas of concern. The procedure included at least weekly meetings of the skin committee attended by the wound nurse, a nurse manager and a nurse administrator . to discuss changes, complex wounds, or problems related to skin . Staging and measurements were to be done by the wound nurse. The policy read, On admission and when observed skin is compromised, the Nurse finding the problem will initiate a treatment using formulary product . as approved by the physician, refer to the wound nurse and document on the 24 hour report. The document indicated the physician and family must be notified at the time of discovery, and notification must be documented in the medical record.

Based on observation, interview and record review, the facility failed to provide adequate supervision and a secure environment for newly admitted residents at risk for elopement for 1 of 5 sampled residents, (#1). These failures contributed to the elopement of resident #1, placing him at risk for serious injury/impairment/death. While the resident was out of the facility unsupervised, there was high likelihood the resident could have been hit by a car or become lost. On 07/07/19 at 12:45 PM, resident #1 who was cognitively impaired exited the facility through the therapy entrance door unsupervised, less than 24 hours after admission. He walked through the facility's parking lot, along the facility's driveway down a steep decline to the sidewalk. He then walked along the sidewalk adjacent to a busy 4-lane highway which had continuous heavy traffic flow in both directions. Resident #1 was spotted by his granddaughter who was driving by. The resident's whereabouts were unknown to the facility until they were notified by the family approximately 15 minutes after the resident exited the facility. The facility's failure to provide adequate supervision and a secure environment resulted in substandard quality of care at the Immediate Jeopardy level, starting on 07/07/19. The Immediate Jeopardy was removed at the time of exit on 07/13/19. Findings: Cross Reference to F835 Resident #1 was a [AGE] year-old male admitted to the facility from home for respite care on 07/06/19. His [DIAGNOSES REDACTED]. Review of resident #1's Admission (MDS) data set [DATE], revealed it was completed within 4 hours of his admission. It documented he was admitted from home where he lived with his wife and was at the facility for respite care. He was alert, oriented to person and had short-term and long-term memory problems. The Elopement Risk Status section of the form indicated that he had a medical [DIAGNOSES REDACTED]. No history of wandering or pacing, no expressing anger at nursing home placement or verbalizing desire to leave the facility, no history of elopement from the home or facility environment and no history of devising schemes or making plan for elopement. Resident #1 was not assessed to be an elopement risk. The Communication Function section documented the resident sometimes understands-responds adequately to simple, direct communication only. He was taking [MEDICAL CONDITION] medications, had poor safety awareness and cognitive impairment. Review of the Nurses Note dated 07/06/19 at 11:49 PM, documented he was confused, ambulated with a cane and will be monitored closely. There was no other documentation indicating the level of monitoring required for a newly admitted resident with a [DIAGNOSES REDACTED]. We do not have a policy for the timeframe or frequency of observations for newly admitted residents or residents with a [DIAGNOSES REDACTED]. Review of the Baseline Care Plan dated 07/06/19, documented he was alert with no behaviors. He required set up for bed mobility, transfers, toileting, eating, grooming and bathing and he was independent with walking and locomotion with the use of a cane. Resident was admitted to the facility for respite care under Hospice and will be provided with skilled nursing support to maintain optimal dignity, health, safety, nutrition/hydration status, psychosocial wellbeing, quality of life, and discharge planning support until family is ready to admit him back home. On 07/11/19 at 9:05 AM, the Director of Nursing (DON) revealed that on 07/07/19 at 12:30 PM, the resident was in his room and the Certified Nursing Assistant (CNA) had set up his lunch tray. At 12:45 PM, he was seen by his nurse while she was preparing to send another resident in the room directly across from resident #1's room to the hospital. She stated that as the Emergency Medical Technicians (EMT) were leaving the facility, the resident followed them. The staff did not notice him trailing the EMTs. The EMT exited the facility through the Therapy exit door as they knew the door code to enter and exit the facility. They held the door open for the resident thinking he was a visitor. The resident exited the facility along with the EMT at 12:55 PM, unsupervised. At that time resident #1 did not have a wander/elopement device on his person. She stated the resident walked out of the facility parking lot and was observed near the bank by his granddaughter who happened to be driving by. The granddaughter returned the resident to the facility. The DON stated that he was most likely trying to find his wife. The resident was admitted to the facility for a 10-day respite. The DON stated that resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. He was in the facility for less than 24 hours when the incident occurred. She stated that they were not aware that resident #1 had left the facility unsupervised until they were notified by the resident's wife by phone. The staff were monitoring him, and he was only missing from the facility for a maximum of 10 minutes. Review of the Incident Report completed by Registered Nurse (RN) B on 07/07/19 showed the elopement incident occurred on 07/07/19 at 12:55 PM when resident #1 was found to be walking on the sidewalk heading towards the gas station. The granddaughter found her grandfather (resident #1) and returned him to the facility. A body assessment was completed, and no injuries were identified. A wander transmitter was placed on his right ankle and every 15-minute observations were implemented. Review of Certified Nursing Assistant (CNA) C statement documented on 07/07/19 noted that she observed the transport guy holding the door open for a tall guy with a cane and she thought he was a family member. She however did not question the resident to find out who he was. On 07/11/19 at 1 PM (at the same time resident #1 eloped from the facility) the surveyor retraced resident #1's elopement route from his room to the bank where resident #1 was found. The resident had walked approximately 125 feet from his room to the Therapy entrance door. He then exited the facility through the Therapy door. He walked approximately 120 feet across the parking lot, followed the facility's driveway and walked down a steep decline to the sidewalk. He turned right and walked along the sidewalk adjacent to a busy 4-lane highway which had constant heavy traffic on both sides. He then walked approximately 110 feet until he was observed by his granddaughter in front of the bank. Further observations revealed that if resident #1 had turned left at the end of the facility's driveway and walked 35 feet he would have entered an extremely busy 4-way intersection. If he had continued walking past the bank he would have reached another extremely busy 4-way intersection. Just past the bank on the same side of the street were several small restaurants, businesses and a gas station. According to (www.time and date.com) the temperature on 07/07/19 at 12:45 PM was 91 degrees with 93% humidity. Review of the Facility Assessment, dated 08/28/18, documented the facility accepted residents with [MEDICAL CONDITION], anxiety, cognitive impairment. The Competency Assessment section of the Facility Assessment revealed, All staff is required to complete training for management of persons with dementia and CNAs must have no less than 12 hours per year which includes dementia management training. On 07/11/19 at 9:23 AM, the Maintenance Director stated that all the exit doors had 2 alarms. One alarm had a number code system and the other alarm needed a key to reset. The front entrance door, the employee door in the back of the building and the Therapy entrance door all had a wander alarm protection system. Residents at risk for wandering had a wander transmitter device attached to their right ankle. When the transmitter device came close to the receiving device located on both sides of the door, the door would lock and alarm. The Therapy door however did not alarm as the resident #1 did not have a wander device on. The Maintenance Director stated that all the door codes were the same and were changed monthly. He stated that the facility staff, EMT, residents who smoked and family members were all aware of the code to enter and exit the facility. On 07/11/19 at 12:27 PM, CNA D stated she was assigned to resident #1 on 07/07/19. She revealed that she was new and as part of her facility orientation she attended an orientation program which included education on residents with Alzheimer's dementia. She stated that on 07/07/19 resident #1 was confused as to his location and stayed in his room for breakfast. He did walk around in the hallway by his room. He needed assistance with his activities of daily living (ADL) and he was independent with toileting. On 07/07/19 at 12:30 PM she remembered it was hectic in the hallway because they were transferring the resident across the hall from resident #1's room to the hospital. She stated that she had set up resident #1's lunch tray and then went to assist another resident down the hall with their meal. She stated that the resident had told her, I want to get out of here. She stated that she had not informed the nurse, she just redirected the resident. The CNA said that another CNA told me that he had left the facility and was now back in the facility. When I asked him where he was going, he replied, I did not go anywhere. He did not remember leaving the facility. On 07/13/19 at 9:15 AM, CNA [NAME] stated that she was assigned to resident #1 on the day he was admitted to the facility and his is wife and son were present at the time of his admission. Resident #1 had Alzheimer's and he kept asking for his wife because he was in an unfamiliar place. He was confused, walked with a cane, and was a fall risk. He left his room a few times but was redirected back to his room. I remember that his wife and son left the facility as it was getting dark outside. I got him into bed, but he did not want to stay in the bed. He sat in the chair by the window. I understand there are different stages of dementia. A resident with dementia does not like changes to his routine or being in an unfamiliar place. They get restless and talking about the past helps to calm them down. After his wife left, he just kept asking for her. I guess that is why he left the facility. On 07/13/19 at 1 PM, a phone interview was conducted with resident #1's wife. She stated that her husband had Alzheimer's dementia and had been living at home with her. Care givers came to the home several time per week for a total of 10 hours. She stated that he used to take walks around the neighborhood with the caregivers but recently he had stopped going for walks. He would sit in front of the television all day. She would tell him to go sit outside which he really enjoyed. Recently, she noticed that he had become agitated with his inability to communicate and was talking gibberish. He had also become verbally hostile with her and even tried to punch her. I would find him pacing from room to room and he had defecated in the garage. She stated that he would become agitated when he did not see her. He always looks for me. On 07/06/19, I was present during his admission to the facility and I stayed until about 5 PM. On Sunday, 07/07/19 my granddaughter called me and told me that she was driving by the facility and found him walking on the sidewalk near the bank. I told my granddaughter to take him back to the facility. I immediately called the facility and spoke to a nurse. She told me that the EMT held the Therapy door open and he left the faciity on his own. I was extremely upset that the facility did not have enough security at the door to make sure my husband did not get out of the facility. I told them at admission that they need to watch him closely as he would always be trying to look for me. The reason I placed him in the facility was to have someone watch him and to keep him safe. He would not know to wait for the traffic signal. He could have tried to cross the busy street and been hit by a car. On 07/12/19 at 8:40 AM, an interview was conducted with the Administrator, DON and Risk Manager (RM). The Administrator stated that the facility was able to care for residents with Alzheimer's dementia. The DON stated that resident #1 followed the EMTs out the Therapy door while CNAs were busy passing trays for lunch. He was most likely trying to find his wife. The RM stated that the facility provided person centered care and services for each resident which were based on their individual needs. The DON stated that there were different stages of Alzheimer's and resident #1 was most likely in stage 1-2 based on his nursing assessment. Resident #1 was placed in the facility because his wife needed someone to watch him for 10 days while she had surgery. The DON stated that resident #1 was being supervised on the day of his elopement. The DON could not explain the extent of supervision required for newly admitted residents with a [DIAGNOSES REDACTED]. When asked how the resident was able to exit the facility, the RM stated, The EMT staff were given the door code. If they did not know the door code, then the facility staff would have had to physically escort them out of the facility. The staff would then have seen resident #1 trying to exit the facility and prevented his elopement. On 07/13/19 at 12:36 PM the Administrator stated that newly admitted residents who had a [DIAGNOSES REDACTED]. The facility's failure to secure their doors and closely supervise a newly admitted cognitively impaired resident resulted in resident #1 exiting the facility unsupervised as he was looking for his wife. This also provided 5 other elopement risk residents the opportunity to leave the facility unsupervised placing them at risk for serious injury, harm and death. Review of the facility's corrective measures in their Immediate Jeopardy removal plan revealed the following: Resident #1 was observed with elopement transmitter placed on his right ankle. His care plan was updated and he had a 1:1 sitter. An audit documented residents within the facility were reassessed for wandering and elopement. Education was completed with all current staff related to resident security door alarms, missing residents, monitoring of wandering residents and door codes will not be shared with residents, families, visitors and vendors. The facility was continuing with training until 100% of staff were trained. The facility had a process to ensure staff that had not yet been trained would receive training before they started working on the units. Documentation of elopement drills was verified. All door codes were changed and were scheduled to be changed monthly by the Maintenance Director. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 07/11/19 with all department heads and the medical director. The incident regarding resident #1 was discussed and implementation of corrective measures were reviewed. Enhanced supervision guidelines for monitoring residents that were wandering and exit seeking was implemented. It included observations every 15 minutes for 24 hours, then every 30 minutes for 24 hours, then every hour for 24 hours to establish a pattern for residents with [DIAGNOSES REDACTED]. Additional signage was placed at each entrance to check with a staff member before letting a resident out of the facility. The Therapy entrance was being monitored 24 hours a day by an assigned employee 7 days per week. The survey team expanded the sample to include resident #5 who was newly identified as a wander/elopement risk. Observations of residents #2, #3, #4 and #5 were conducted with no identified concerns. Interviews, training plans and audits verified training regarding wandering/elopement, supervision and door code security.

Based on observation, interview and record review the facility failed to use its resources effectively to provide an adequate level of supervision to ensure the safety of newly admitted residents at risk for elopement and failed to secure doors for entering and exiting for 1 of 5 sampled residents, (#1). These failures contributed to the elopement of resident #1 placing him at risk for serious injury/impairment/death. While the resident was out of the facility unsupervised, there was high likelihood the resident could have been hit by a car or become lost. Resident #1 was newly admitted and capable of leaving the facility at the time of the event. On 07/07/19 at 12:45 PM, resident #1 who was cognitively impaired exited the facility through the therapy entrance door unsupervised, less than 24 hours after admission. He walked through the facility's parking lot, along the facility's driveway down a steep decline to the sidewalk. He then walked along the sidewalk adjacent to a busy 4-lane highway which had continuous heavy traffic flow in both directions. Resident #1 was spotted by his granddaughter who was driving by. The resident's whereabouts were unknown to the facility until they were notified by the family approximately 15 minutes after the resident exited the facility. The facility's failure to identify the need for supervision for newly admitted residents and maintain a secure environment resulted in substandard quality of care at the Immediate Jeopardy level, starting on 07/07/19. The Immediate Jeopardy was removed at the time of exit on 07/13/19. Cross Reference to F689 Findings: Resident #1 was a [AGE] year-old male admitted to the facility from home for respite care on 07/06/19. His [DIAGNOSES REDACTED]. The Admission Data Set completed within 4 hours of admission revealed that resident #1 was physically able to leave the building on his own and had cognitive impairment. The form indicated that he was not an elopement risk, however he had a medical [DIAGNOSES REDACTED]. On 07/11/19 at 9:05 AM, the Director of Nursing (DON) revealed that on 07/07/19 at 12:55 PM resident #1 had eloped from the facility. He had exited through the Therapy entrance door and was found off facility premises walking on the sidewalk in front of the bank. The DON explained that the resident was admitted to the facility from home for a 10-day respite while his wife had surgery. He was last seen on 07/07/19 at 12:30 PM by his Certified Nursing Assistant (CNA) when she set up his lunch tray. He was then seen by his nurse at 12:45 PM while she was preparing to send the resident in the room directly across from resident #1 room to the hospital. At that time resident #1 did not have a wander/elopement device on his person. The Administrator stated that the Emergency Medical Technicians (EMT) held the Therapy entrance door open and resident #1 exited the facility. The DON confirmed that resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. The staff were monitoring him, and he was only missing from the facility for a maximum of 10 minutes. On 07/12/19 at 11:47 AM, during a telephone interview, the Medical Director stated that he was notified of resident #1's elopement on 07/08/19. He was told that the resident exited the facility behind the EMTs. He then stated that the level of supervision was different for each resident when in a new environment. The Medical Director explained that the goal was to have a safe facility and that the door codes needed to be changed more frequently. On 07/13/19 at 11:39 AM, the DON explained that the expectation was for staff to observe the residents as frequently as possible. She confirmed that there was no specific frequency for doing rounds and checking on newly admitted residents. The DON stated that every resident was to be checked at a minimum of every 2 hours. On 07/13/19 at 1 PM, a phone interview was conducted with resident #1's wife. She stated that her husband had Alzheimer's dementia and had been living at home with her. She stated that he would become agitated when did not seen her. He always looks for me. On 07/06/19, I was present during his admission to the facility and I stayed until about 5 PM. On Sunday, 07/07/19 my granddaughter called me and told me that she was driving by the facility found him walking on the sidewalk. I told her to bring him back to the facility. I immediately called the facility and spoke to a nurse. She told me that the EMT held the Therapy door open and he left the faciity on his own. I was extremely upset that the facility did not have enough security at the door to make sure my husband did not get out of the facility. I told them at admission that they need to watch him closely as he would always be trying to look for me. The reason I placed him in the facility was to have someone watch him and to keep him safe. He would not know to wait for the traffic signal. He could have tried to cross the busy street and been hit by a car. On 07/11/19 at 9:23 AM, the Maintenance Director stated that all the exit doors had 2 alarms. One alarm had a number code system and the other alarm needed a key to reset. The front entrance door, the employee door in the back of the building and the Therapy entrance door all had a wander alarm protection system. Residents at risk for wandering had a wander transmitter device attached to their right ankle. When the transmitter device came close to the receiving device located on both sides of the door, the door would lock and alarm. The Therapy door however did not alarm as resident #1 did not have a wander device on. The Maintenance Director stated that all the door codes were the same and were changed monthly. He stated that the facility staff, EMT, residents who smoked and family members were all aware of the code to enter and exit the facility. On 07/13/19 at 12:36 PM, the Administrator confirmed that she was responsible for the facility, the staff and the residents. She stated that facility security was a major concern and there should never be any resident leaving the facility unsupervised. Once a resident leaves the facility unaccompanied anything can happen to them especially since the facility is in a busy traffic area. The Administrator stated that she was aware that the staff and families had the code to the doors. She was not aware that the residents who smoked also had the code to the doors and that the door codes were all the same. She stated that the facility could provide care and services for residents with a [DIAGNOSES REDACTED]. The expectation was that the nurses and CNAs monitor the resident at least every 2 hours but the monitoring depends on the resident's need and may need to be more frequent. As the Administrator I am responsible for the safety of the residents and I should have known what was happening with the door codes. On 07/13/19 at 2:25 PM a review of the facility's Quality Assurance (QA) process was conducted with the Administrator, DON and Risk Manager. They explained that they had not had a QA meeting to discuss the elopement until 07/11/19 at 7:45 PM (4 days after the event). The DON stated that they were so focused on resident #1, they failed to identify other residents in the facility that were at risk for elopement. They identified the root cause of the elopement was due to the facility giving the door code to the EMTs. The DON then stated they had completed Elopement/Wander Risk evaluations for all the residents in the facility. It was identified that 1 other resident with a [DIAGNOSES REDACTED]. Review of the Facility Assessment, dated 08/28/18, documented the facility accepted residents with [MEDICAL CONDITION], anxiety, and cognitive impairment. Although the facility assessment noted they were able to care for residents with cognitive impairment, the administrator and DON could did not explain the extent of supervision required for newly admitted residents with dementia. They were unable to explain how resident #1 was able to follow the EMT personnel in the facility for over 125 feet and exit the facility without being seen. Review of the facility's corrective measures in their Immediate Jeopardy removal plan revealed the following: Resident #1 was observed with elopement transmitter placed on his right ankle. His care plan was updated and he had a 1:1 sitter. An audit documented residents within the facility were reassessed for wandering and elopement. Education was completed with all current staff related to resident security door alarms, missing residents, monitoring of wandering residents and door codes will not be shared with residents, families, visitors and vendors. The facility was continuing with training until 100% of staff were trained. The facility had a process to ensure staff that had not yet been trained would receive training before they started working on the units. Documentation of elopement drills was verified. All door codes were changed and were scheduled to be changed monthly by the Maintenance Director. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 07/11/19 with all department heads and the medical director. The incident regarding resident #1 was discussed and implementation of corrective measures were reviewed. Enhanced supervision guidelines for monitoring residents that were wandering and exit seeking was implemented. It included observations every 15 minutes for 24 hours, then every 30 minutes for 24 hours, then every hour for 24 hours to establish a pattern for residents with [DIAGNOSES REDACTED]. Additional signage was placed at each entrance to check with a staff member before letting a resident out of the facility. The Therapy entrance was being monitored 24 hours a day by an assigned employee 7 days per week. The survey team expanded the sample to include resident #5 who was newly identified as a wander/elopement risk. Observations of residents #2, #3, #4 and #5 were conducted with no identified concerns. Interviews, training plans and audits verified training regarding wandering/elopement, supervision and door code security.

Based on observation, interview, and record review, the facility failed to provide pain medication for extreme pain during a wound care procedure (#149) and moderate pain (#68) for 2 of 3 residents reviewed for pressure ulcers. Findings: 1. Record review revealed resident #149 was admitted to the facility on [DATE] status [REDACTED]. The resident was readmitted back to the facility on [DATE] with [MEDICAL CONDITION] resistant staphylococcus infection (MRSA) in the nares and [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) infection in the stools. There was an order to refer the resident to Vohra wound team for an open area to the right ankle. physician's orders [REDACTED]. Admission assessment dated [DATE] assessed the resident as alert and oriented, able to make needs known, and requires extensive assistance with activities of daily living (ADLs). On 2/8/12 at 2:30 p.m. during a brief interview with the resident she stated she was in lot of pain in her lower extremities and was not feeling well. She further stated the medication they were providing was not effective. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the nurses' progress notes revealed no documentation that the resident has complained of pain, nor was she assessed with [REDACTED]. The physician was not informed of the severe pain in the right lower extremity. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) administer 10/650 mg. every 4 hours for severe pain. The last time the resident received the pain medication was on 2/8/12 at 10:22 p.m. It was documented it was given for pain and it marked effective. There was no documentation in the nurses' notes regarding the location and the intensity of the pain. An observation was conducted on 2/9/2012 at 11:15 a.m. during a wound care procedure by the staff nurse. The nurse gathered his equipment; a stack of 4 x 4 unsterile gauze, polymen tape, normal saline, and santyl ointment and placed this on top of the bedside table without any barrier. He proceeded to remove the soiled dressing and disposed it in the red trash bin inside the room. He started to cleanse the wound with normal saline, attempting to remove the cream colored slough on the wound bed and the resident grimaced in pain, grabbing into the bed sheets and verbalized pain when asked by this surveyor. The resident demonstrated signs of extreme pain and verbally complained of the pain in the right leg and the wound. The nurse validated that he had not given the resident pain medication prior to the dressing procedure and indicated he offered the medication earlier and the resident had declined. The surveyor asked the nurse to stop the procedure and he did. The nurse left the room to obtain the pain medication and returned and gave it to the resident. The nurse did not assess the pain of the resident and did not ask the resident the scale level/severity of the pain (e.g. location and intensity of the pain). In an interview with the resident on 2/9/12 at 2:00 p.m., she stated during the wound care procedure earlier that day, the pain was at a 10 on a scale of 1-10. Review of the nursing admission assessment dated [DATE] at 7:18 p.m. the resident did not verbalize pain. The minimum data set (MDS) assessment dated [DATE] on the pain interview conducted by the MDS staff, the resident had verbalized frequent pain in the last 5 days and had difficulty sleeping related to the pain. The pain was assessed on a scale of 1-10 as a 9 and was described as severe. Review of the care plans dated 1/2/12 revealed the resident was at risk for pain related to ulcers on the heels and ankle and a recent right distal femur fracture. Interventions were to: monitor and record any complaints of pain, location and intensity; and offer use of pain medication prior to care tasks, treatments, and therapy. 2. On 02/07/2012 at 11:50 a.m., interview with resident #68's unit coordinator and review of the resident's admission assessment revealed that the resident had been admitted to the facility with an intact deep tissue injury (DTI) of the right heel. On 2/9/12 at 10:30 a.m., observation of wound care treatment and dressing change for resident #68's right heel pressure ulcer revealed that the resident was fidgety and restless with verbal confusion. When the nurse applied medication into the wound bed with a Q-tip, the resident exhibited non-verbal facial signs of pain by squeezing her eyes shut at least three times. The facial grimacing stopped after the treatment ended. The resident did not yell or cry out during the treatment. Observation revealed that the pressure ulcer measured about 1 centimeter (cm) in length, about 1 cm in width, and 1/2 in depth. Review of the February medication administration (MAR) revealed that the nurse had not given the resident pain medication prior to the pressure ulcer treatment. Review of the MAR indicated [REDACTED]. review of the resident's medical record revealed [REDACTED]. The physician described the pressure ulcer as deteriorated, unstageable necrosis with 40% necrotic tissue, and moderate serous drainage. The measurements after the debridement were documented as 1cm x 1cm x 0.5 cm. After the debridement, the physician changed the treatment orders to include the application of the medication, Iodosorb, with a Q-tip into the center of the wound bed and cover with a [MEDICATION NAME] dressing daily and as needed until healed. Review of resident #68's admission nursing assessment dated [DATE] included a pain assessment which revealed that the resident did not have pain. Review of her monthly nursing assessments from September 2011 through January 2012 also revealed that she did not have any pain. The resident was assessed to have memory problems and was confused. [DIAGNOSES REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. Interview with the unit coordinator on 2/9/12 at about 11:30 a.m. validated that her pain needs had not been reassessed after the debridement and new orders. He validated that a pain medication order had not been obtained prior to wound treatment. He also validated that the pressure ulcer treatment prior to debridement did not involve a Q-tip to apply the medication to the wound bed, but the new treatment after the debridement did. He stated that the change from applying the medication into the wound bed with gauze to a Q-tip could have made the difference in the resident's increased pain observation during treatments. Interview with the resident's nurse at about 1:30 p.m. validated that she noticed the resident squeezing her eyes shut while applying the medication to the wound bed, but thought it would be ok to continue. review of the resident's medical record revealed [REDACTED]. The patient was not a candidate for being able to verbalize pain levels. In an interview with the DON on 2/9/11 at about 1:30 p.m., she stated that the nurses were to assess for pain levels; verbal and non-verbal. If a resident was confused and couldn't verbalize pain levels then, body/face signs were to be assessed.