Every finding on record at Whites Creek Wellness and Rehabilitation Center

Based on policy review, observation, and interview, the facility failed to maintain and ensure the prevention and spread of infection during medication administration and catheter care for 4 of 7 (Resident #1, #22, #69, #88) sampled residents reviewed. The findings include: 1. Review of the undated facility policy titled, Medication Administration, revealed .Medications are administered by licensed nurses.as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Wash hands prior to administering medication. Review of the undated facility policy titled, Hand Hygiene revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.The use of gloves does not replace hand hygiene.perform hand hygiene prior to donning gloves, and immediately after removing gloves.Before preparing or handling medications. Review of the facility policy titled, Infection Prevention and Control Program, dated 1/24/2025, revealed .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.All staff shall use personal protective equipment (PPE) according to the established facility policy governing the use of PPE.All reusable items and equipment requiring.disinfection.shall be cleaned in accordance with our current procedures governing the cleaning and.contaminated equipment. Review of the facility undated policy titled, Enhanced Barrier Precautions, reveal .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted Gown and gloves use during high contact resident care activities.An order for enhanced barrier precautions will be obtained for residents with any of the following.wounds, indwelling medical devices.urinary catheters [tubing in the bladder], feeding tubes [tube placed into your stomach or bowel to help you get nutrition], tracheostomy [opening that allows air into the lungs].High contact resident care activities include.dressing.transferring.changing linens.Device care or use .urinary catheters, feeding tubes, tracheostomy .wound care. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Respiratory Failure, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was moderately cognitively impaired. Review of Resident #1's Physicians Orders revealed orders for the following oral medications: Oxcarbazepine (an anticonvulsant) 150 mg (milligrams) 1 tablet twice a day, Potassium Chloride ER (Extended Release) (a supplement) 20 mEq (milliequivalent) 1 twice a day, Metoprolol (a medication to treat high blood pressure) 12.5 mg 1 twice a day, Metformin hcl (Hydrochloride) (a medication to treat Diabetes) 850 mg twice a day, Escitalopram Oxalate (an antidepressant) 5 mg 1 daily, Levetiracetam (a medication to treat Seizures) 500 mg 1 twice a day, Escitalopram Oxalate 10 mg 1 every day, Apixaban (a blood thinner) 5 mg 1 twice a day, Bumetanide (a diuretic) 1 mg 1 every day, Famotidine (a medication to reduce stomach acid) 20 mg 1 twice a day, and Megestrol Acetate (a medication to increase appetite) 40 mg every day. During observation and interview during Medication Administration at the 200/300 hall medication cart on 3/10/2026 at 9:40 AM, revealed LPN B retrieved the following medications from the medication cart to administer to Resident #1: Oxcarbazepine 150 mg, Potassium Chloride ER 20 mEq , Metoprolol 12.5 mg, Metformin hcl 850 mg, Escitalopram Oxalate 5 mg, Levetiracetam 500 mg, Escitalopram Oxalate 10 mg, Apixaban 5 mg, Bumetanide 1 mg, Famotidine 20 mg, and Megestrol Acetate 40 mg. LPN B prepared the medications without preforming hand hygiene, entered the resident's room, and administered the medications to Resident #1. LPN B failed to perform hand hygiene prior to preparing and administering Resident #1's medications. LPN B was asked if she performed hand hygiene before preparing Resident #1 medications. LPN B stated, No, I did not. LPN B was asked if she should have performed hand hygiene prior to preparing medications she stated, Yes, ma'am I should have . The Director of Nursing (DON) was asked should hand hygiene be performed prior to preparing medication for administration. The DON stated, Yes . 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Dementia, Osteoarthritis, Chronic Pancreatitis, and Diverticulosis. Review of Resident #22's current Physician's Orders revealed an order for Alphagan P [eye medication to treat glaucoma] Solution 0.1% [percent] Instill 1 drop in both eyes every 12 hours. Review of the quarterly MDS assessment dated [DATE], revealed Resident #22 had a BIMS score of 9, which indicated moderate cognitive impairment. Observation during medication administration in the Resident's room on 3/11/2026 at 7:58 AM, revealed LPN D entered Resident #22's room and placed a plastic bag containing Alphagan eye drops half on the barrier and half on the table. LPN D pushed a blood pressure machine into Resident #22's room and used the machine to obtain a blood pressure that was elevated, she took the blood pressure 2 more times with that blood pressure machine. LPN D left the room to get a different blood pressure machine and used the second machine to obtain a blood pressure. LPN D donned gloves and took a clean tissue and wiped Resident #22's right eye with a dry tissue and then wiped the left eye with a dry tissue, each with one swipe. Then without performing hand hygiene, LPN D administered 1 drop of eye drops in the right eye and immediately administered 1 drop into the left eye wearing the same pair of gloves. Then LPN D took the eye drop bottle and placed it back in the plastic bag and returned the bag to the medication cart drawer without disinfecting the eye drop bottle or bag. LPN D failed to disinfect the eye drop bottle or bag and failed to disinfect the two blood pressure machines that she used to obtain a blood pressure on Resident #22. During an interview on 3/11/2026 at 8:11 AM, LPN D was asked, after taking the bag with the eye drops into the room, should you have cleaned the eye drop bottle, the bag, or the blood pressure machines. LPN D stated, Yes, I should have cleaned the eye drop bottle and I should have cleaned the blood pressure machines before and after using. During an interview on 3/11/2026 at 2:08 PM, the DON was asked during medication administration should the nurse have disinfected the eye drop bottle and bag that she replaced back into the medication cart drawer. The DON stated, Yes, at the least cleaned the bag. The DON was asked if the nurse should have cleaned the blood pressure machines she used on Resident #22. The DON stated, Yes, before and after use on a resident. 4. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Hypertension, and Polyneuropathy. Review of the admission MDS assessment dated [DATE], revealed Resident #69 scored a 15 on the BIMS assessment, which indicated she was cognitively intact. Review of Resident #69's current Physician's Orders revealed an order for Humalog Insulin 3 Unit subcutaneous before meals. Observation during Medication Administration at the 100 Hall Medication Cart, on 3/10/2026 at 11:29 AM, revealed LPN C put on (donned) gloves without performing hand hygiene, cleaned a glucometer machine with a disinfecting wipe, placed the glucometer machine in a plastic cup, and took off (doffed) gloves without performing hand hygiene. LPN C then placed an insulin needle, a plastic bag with an insulin pen inside, and alcohol pads into a second plastic cup. LPN C entered Resident #69's room, placed the cup with the insulin pen on the nightstand and the other plastic cup on the bedside table. LPN C donned gloves wiped Resident #69's right thumb with an alcohol pad to obtain a blood specimen. LPN C doffed gloves, without performing hand hygiene, and returned to the medication cart to obtain a blood glucose test strip. LPN C returned to Resident #69's room, donned gloves without performing hand hygiene, and obtained the blood specimen from right thumb. LPN C dropped a plastic cup on floor and the plastic bag with the insulin pen inside fell on the floor. LPN C picked the plastic bag up off the floor, placed it back into the plastic cup, doffed gloves without performing hand hygiene and returned to the medication cart. LPN C then placed the dirty bag into a clean plastic cup and returned to Resident #69's room. LPN C removed the insulin pen from the plastic bag with his right hand, then removed the cap from insulin pen, the end of insulin pen touched the dirty plastic bag while in his right hand, placed needle on insulin pen without disinfecting the end of the insulin pen and administered Lispro (Humalog) 3 units subcutaneously to Resident #69's right lower abdomen. During an interview on 3/10/2026 at 11:49 AM LPN C was asked when should hand hygiene be performed. LPN C stated, Before and after touching a resident and when my hands are soiled. LPN C was asked should he perform hand hygiene prior to preparing medication for administration. LPN C stated, Yes ma'am I should. LPN C was asked should you performed hand hygiene when donning and doffing gloves. LPN C stated, Yes. Ma'am. LPN C was asked should the end of the insulin pen be disinfected before connecting the needle. LPN C stated, I think that would be common practice to clean off the end . During an interview on 3/11/2026 at 11:01 AM, the DON was asked should staff perform hand hygiene before donning and doffing gloves. The DON stated, Yes, the staff should perform hand hygiene before donning and doffing gloves. The DON was asked should the end of the insulin pen be disinfected after touching a dirty plastic bag. The DON stated, Yes, it should have been disinfected . 5. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses including Acute Pyelonephritis, Hypertension, and Benign Prostatic Hyperplasia. Review of the MDS assessment dated [DATE], revealed resident #88 scored a 5 on the BIMS assessment, which indicated he was severely cognitively impaired. The resident required substantial to maximal assistance from staff for toileting hygiene and had an indwelling catheter. Review of the physician order dated 1/21/2026, revealed .Change [named] catheter and bedside drainage bag using 24 FR [French] 30ml [milliliter] bulb as needed AND at bedtime every 30 day(s) . Review of the Physician Order dated 2/11/2026, revealed .Enhanced Barrier Precautions r/t [related to] [named] Catheter/Wounds every shift . Random observation in the resident room Resident #88's room on 3/11/2026 at 9:21 AM, revealed CNA A emptying Resident #88's indwelling urinary catheter bag. CNA A failed to wear a gown when she emptied the urine from the catheter bag. During an interview on 3/11/2026 at 9:30 AM, CNA A was asked what PPE she should wear when a resident is on EBP. CNA A stated, wear gloves . CNA A was asked when she emptied the urine from Resident #88's catheter bag was she supposed to wear a gown and gloves. CNA A stated, I will be honest. I am not for sure. During an interview on 3/11/2026 at 3:12 PM, the DON was asked if staff should wear a gown and gloves when urine is emptied from the resident's catheter bag The DON stated, Yes, that is direct patient care.

Based on policy review, American Association of Post-Acute Care Nursing article review, observation, and interview, the facility failed to ensure neurological (neuro) checks were performed after falls and failed to follow the care plan for 1 of 3 (Resident #20) sampled residents reviewed for falls.The findings include: 1. Review of the facility undated policy titled, Comprehensive Care Plans, revealed .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions. Review of the facility undated policy titled, Fall Prevention Program, revealed .Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls. 2. Review of the American Association of Post-Acute Care Nursing article titled, Post-Fall Assessments, dated 8/202, revealed .An assessment of neurological status, often called a neuro check, should be done when a resident hits his or her head or if it is unknown if they hit their head (unwitnessed fall) . 3. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Pancreas, Bipolar, and Hypertension. Review of a Fall Risk assessment dated [DATE], revealed Resident #20 scored a 50, indicating she was at high risk for falling. The Resident had impaired, weak gait. Review of the Care Plan dated 2/16/2026, revealed the resident was at risk for falls related to weakness and required assistance with mobility. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #20 scored a 15 on the Brief Interview for Mental Status assessment, which indicated she had intact cognition. Resident #20 required partial to moderate assistance from staff for transfers and to walk. The resident was coded as no falls prior to admission and no falls during the assessment period. Review of an Incident Report dated 2/26/2026, revealed .Unwitnessed Fall .Resident notified nurse that she had fell while trying to get up off the toilet .Intervention: encourage resident to ask for assistance . injuries Observed at Time of Incident .No injuries observed at time of incident . Review of a Fall Risk assessment dated [DATE], revealed Resident #20 scored a 40, indicating she was at moderate risk for falling. The Resident overestimated or forgot limits. Review of the revised Care Plan for falls dated 2/26/2026, revealed the resident's call light was to be kept in the resident's reach and the staff encourage the resident to ask for assistance when needing help. The facility Incident Report dated 3/1/2026 at 6:15 AM, revealed .Witness fall . 3/1/2026 .Resident's roommate came into hallway .resident had fallen .Resident observed on the rt [right] side of the bed between the wall and the bed, face down .Injuries Observed at Time of Incident .Hematoma . Review of an Alert Note dated 3/1/2026 at 6:20 AM, revealed, .Staff entered room and observed resident [Resident #20] lying on the right side of the bed, face down. Resident's roommate stated that she [Resident #20] was coming out of the bathroom and fell onto the floor .Resident skin observed and resident did have a hematoma to the Rt [right] Side of her forehead that was growing in size .Resident sent to the hospital per family request ensure resident had not broken anything from fall . Review of a [Named Company] Weekly Skin Check, dated 3/1/2026, revealed . Resident had some redness to the Lt [Left] Knee; Hematoma to the Rt [Right] forehead; no open areas noted at this time . Review of a Fall Risk assessment dated [DATE], revealed Resident #20 scored a 95 indicating she was at high risk for falling. The resident had impaired, weak gait and overestimated or forgot limits. The facility failed to conduct neuro checks after Resident #20's fall on 3/1/2026. Review of the revised Care Plan dated 3/1/2026, revealed visual cues as an intervention for falls for Resident #20. Review of the facility incident Report dated 3/3/2026 at 12:30 AM, revealed .Witness Fall .Called to hallway outside of resident's room where resident is sitting on floor. CNA [Certified Nurse Assistant] stated she was in the room across the hall .looked up and noticed resident [Resident #20] was in the hall way .resident [Resident #20] got tangled up on her slides' and fell hitting the right side of her face and right shoulder against the the [NAME] [the door] frame .Resident [Resident #20] complaint of pain to rights side of face and right shoulder .Injuries observed at Time of Incident .Injured Type .hematoma .Injury Location .4) Face . Review of a Nurses Note dated 3/3/2026 at 12:35 AM, revealed .Called to hallway outside of resident's room where resident is sitting on floor .resident got tangled up on her slides [a type of light shoe that is characterized by having a loose heel that holds on to the foot from the front.] and fell hitting the right side of her face and right shoulder against the door frame. Resident states that she was trying to get up. Resident complaint of pain to right side of face and right shoulder . Review of the [Named Company] Weekly Skin Check, dated 3/3/2026, revealed .Any bruising or redness yes .face .right side of face around Eye . Review of a Fall Risk assessment dated [DATE], revealed Resident #20 scored a 65, indicating she was at high risk for falling. The Resident had impaired, weak gait and overestimated or forgot limits. Review of the revised Care Plan dated 3/3/2026, revealed the resident is to wear nonskid socks. The facility failed to conduct neuro checks after Resident #20's fall on 3/3/2026. During observation and interview in the Resident's room on 3/10/2026 at 2:51 PM, Resident #20's call light was under Resident #20's bedframe, between the frame and the mattress. LPN C confirmed he was the nurse currently assigned to Resident #20. LPN C was asked to explain why the resident's call light was not in her reach. LPN C stated, I have not made rounds to check for call lights .she has been back in bed about 30 minutes .had no idea .hospice tech left the call light under mattress. LPN C was asked who is responsible for making sure call lights are in place. LPN C stated, The nurses and techs [nurse aide technicians] at the facility. The facility failed to ensure Resident #20's call light was in reach as an intervention for fall. During an interview on 3/11/2026 at 9:55 AM, the Director of Nursing (DON) was asked what interventions were put in place after Resident #20's 3/1/2026 fall. The DON stated, Visual cues. The DON was asked to explain visual cues. The DON stated, .Signage [signs] in the room, it should be posted [displayed] and should say call don't fall . During an observation and in the resident's room on 3/11/2026 at 10:05 AM, the DON observed the walls in the Resident #20's room. The DON stated, She has no signage in room. Let me look to see if she has one lying somewhere. The DON was not able to find any sign in the resident's room. The DON was asked should Resident #20 have should call before fall, call for help to walk signage on her wall. The DON stated, Yes. The facility failed to provide signage in Resident #20's room as an intervention for falls. During an interview on 3/11/2026 at 10:53 AM, the DON was asked for Resident #20's neuro checks after the 3/1/2026 and the 3/3/2026 fall. The DON stated, the facility does not have any neuro checks related to Resident #20's falls on those days. During an interview on 3/11/2026 at 2:56 PM, the Nurse Practitioner (NP) confirmed she was made aware of Resident #20's falls on 3/1/20206, and 3/3/20206. The NP was asked did she expect staff to have conducted neuro checks for Resident #20 after each of those falls. the NP stated, Yes. During an interview on 3/11/2026 at 3:12 PM, the DON was asked should the facility staff have conducted neuro checks for the resident on 3/1/2026, and 3/3/2026. The DON stated Yes. During an interview on 3/11/2026 3:27 PM, the DON was asked for the facility's neuro check policy. The facility was unable to provide a neuro check policy.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 5 staff members (Licensed Practical Nurse (LPN) C) left medication unattended, and out of sight during Percutaneous Endoscopic Gastrostomy (PEG) medication administration.The findings include: 1. Review of the facility undated policy titled .Medication Storage, revealed .During a medication pass, medications must be under the direct observation of the person administering medications. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses including Neurogenic Bladder, Gastrostomy, Tracheostomy, Seizures, and Cocaine Abuse. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #8 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment, which indicated he was severely cognitively impaired. Review of the Physician Order dated 12/31/2025, revealed .Valproic Acid Oral Solution [medication used for seizures] 250 mg [milligrams] /[per] 5ml [milliliters] Give 5 ml via [by] G-[Gastrostomy] Tube [a feeding tube inserted directly into the stomach through the abdominal wall] four times a day for seizures. Observation in the resident's room during medication administration on 3/11/2026 at 12:10 PM, revealed LPN C entered Resident #8's room with Valproic Acid Oral Solution 5 ml in a medication cup. LPN C sat the medication on the over bed table and went to the bathroom to wash his hands. LPN C left the medication out of sight and unattended. LPN C returned to the resident's room then went back into the bathroom to obtain water in a plastic cup and left the medication unattended again. During an interview on 3/11/2026 at 12:34 PM, LPN C was asked should he have left the medication out of sight. LPN C stated, No ma'am. During an interview on 3/11/2026 at 2:08 PM, the Director of Nursing (DON) was asked should the nurse have left the medications out of sight and unattended. The DON stated, No, they should not be left unattended.

Based on facility policy review, medical record review, and interview, the facility failed to place signage on a resident's door based upon the means of transmission in order to prevent or control infections for 2 (Resident #4 and Resident #7) of 10 sampled residents reviewed. The findings include: Review of the facility's undated policy titled Transmission-Based (Isolation) Precautions, revealed, .It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission .Transmission-based precautions [a.k.a. 'Isolation Precautions'] refer to actions [precautions] implemented in addition to standard precautions that are based upon the means of transmission [airborne, contact and droplet] in order to prevent or control infections .Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident .Initiation of Transmission-Based Precautions ['Isolation Precautions'] .e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident ' s room, wing, or facility-wide . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of Left Femur, Fracture of One Rib, Left Side, Weakness, and Elevated [NAME] Blood Cell Count. Review of the Medicare 5-Day MDS assessment dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the care plan revealed, .[2/27/2024] requires Isolation Precautions r/t [related to] Lice on Scalp .Observe (Specify) Isolation Precautions; Resident was treated for lice . During an interview on 2/27/2024 at 11:40 AM, Housekeeper #1 stated he was not aware of what type of isolation Resident #4 was on since there was no sign on the door. During an interview on 2/27/2024 at 11:50 AM, the Licensed Practical Nurse (LPN) Weekend Supervisor stated when a resident goes on isolation, there should be a stocked cart outside the door and a sign put on the door to alert staff to what kind of isolation the resident was on. Continued interview revealed, LPN Weekend Supervisor admitted Resident #4 did not have an isolation sign on her door for head lice. During an interview on 2/28/2024 at 2:45 PN, the Director of Nursing (DON), who is the Infection Preventionist, stated her expectation for an isolation patient would be for staff to set up the isolation cart with the proper supplies for what the isolation required. The DON stated there should have been a sign on Resident #4 ' s door that specified what type of isolation was needed for head lice. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included Dysphagia following Unspecified Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease, and Unspecified Protein-Calorie Malnutrition. Review of the Annual MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the care plan revealed, .[1/13/2024] Covid 19 Transmission prevention-Droplet/Contact Isolation Precautions r/t new symptoms .Interventions .Droplet Precautions . During a telephone interview on 2/28/2024 at 11:15 AM, Family Member (FM) #4, who is the Power of Attorney (POA) for Resident #7, stated he came to visit Resident #7 one morning and noticed she was lethargic. Resident #7 told FM #4 she tested positive for Covid. FM #4 recalled he asked staff why no one had contacted him. An unnamed Certified Nursing Assistant (CNA) went to get the unnamed nurse and she confirmed Resident #7 had tested positive for Covid. FM #4 stated there was no sign on Resident #7's door and he had been sitting in the room without a mask for a while. FM #4 stated about 30 minutes after he arrived at home, someone from the facility called and reported Resident #7 was positive for Covid. During an interview on 3/6/2024 at 2:25 PM, the Assistant Director of Nursing (ADON) stated isolation signs should have been placed on the Covid positive residents' doors and any other isolation room doors. During an interview on 3/6/2024 at 6:30 PM, CNA #13 stated during the Covid outbreak, the facility had Covid positive residents with no signs up and no isolation carts at the doors of the residents' rooms. CNA #13 then stated the facility eventually added the isolation signs and carts after Covid started to spread throughout the facility.

Based on facility policy review, medical record review, and interview the facility failed to ensure 1 (Resident #13) of 3 residents reviewed were free of significant medication errors. The findings include: 1. Review of the facility's policy titled, Medication Administration, undated, revealed, .Medications are administered .as ordered by the physician and in accordance with professional standards of practice . Review of the facility's document titled, Medication Administration Skills Assessment, undated, revealed, .Refused/withheld medications are properly note. Notify MD . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Fracture of Manubrium, Person injured in unspecified motor vehicle accident, Multiple fractures of Ribs, Right Side, Major Laceration of Liver, Contusion of Lung, bilateral, Wedge Compression Fracture of Second Lumbar Vertebra, Type 2 Diabetes Mellitus without complications, Acute Pyelonephritis, Other Seizures, and Other Abnormalities of gait and mobility. Resident #13 was discharged from the facility on 2/27/2024. Review of the Admission Minimum Data Set (MDS) assessment, dated 2/12/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated resident #13 was cognitively intact. Review of the Order Summary Report for Resident #13, dated 2/1/2024 through 2/29/2024, revealed, .Order Date 2/06/2024 .Enoxaparin Sodium Injection Solution (Enoxaparin Sodium) Inject 30 mg [Milligram] subcutaneously every 12 hours for DVT [deep vein thrombosis) Prophylaxis .Order Date 2/06/2024 .HumaLOG Injection Solution (Insulin Lispro) Inject as per sliding scale: If 0-60 IF ALERT, GIVE 4 OZ [ounce] SWEETENED BEVERAGE, IN NOT ALERT, GIVE GLUCAGON 1 MG [Milligram] IM [Intramuscular] or SC [Subcutaneous]; 61-200 = 0 NO ACTION; 201 -250 = 2 UNITS GIVE 2 UNITS; 251-300 = 4 UNITS GIVE 4 UNITS; 301 - 350 =6 UNITS GIVE 6 UNITS; 351 - 400 = 8 UNITS GIVE 8 UNITS; 401-500 = 10 UNITS GIVE 10 UNITS & NOTIFY MD, subcutaneously two times a day for DM II [Diabetes Mellitus Type II] .Administer @ [at] 0700 [7:00 AM], 1700 [5:00 PM] .Order Date 2/14/2024 .Lantus Subcutaneous Solution (Insulin Glargine) Inject 7 Units subcutaneously two times a day for DM [Diabetes Mellitus] .Order Date 2/6/2024 .Meloxicam 7.5 MG Tablet Give 1 tablet by mouth one time a day for arthritis .Order Date 2/6/2024 .Phenytoin Sodium Extended Oral Capsule (Phenytoin Sodium Extended) Give 400 mg by mouth one time a day for Seizures . Review of the Medication Administration Record (MAR), dated 2/1/2024 through 2/29/2024, revealed Resident #13 did not receive Phenytoin sodium Extended Oral Capsule Phenytoin Sodium Extended 400 mg a total of three (3) scheduled doses on 2/14/2024 at 9:00 PM, 2/16/2024 at 9:00 PM, and 2/23/2024 at 9:00 PM. Further review revealed on 2/14/2023 at 9:00 PM documentation of resident absent from facility with meds, on 2/16/2024 at 9:00 PM, and 2/23/2024 at 9:00 PM documentation of resident absent from facility without meds. Resident #13 did not receive Phenytoin Sodium Extended Oral Capsule 400 mg for seizures three (3) out of a total of twenty (20) opportunities. Review of the MAR, dated 2/1/2024 through 2/29/2024, revealed Resident #13 did not receive Enoxaparin Sodium Injection 30 mg subcutaneously a total of five (5) scheduled doses on 2/14/2024 at 9:00 PM, 2/16/2024 at 9:00 AM, 2/16/2024 at 9:00 PM, 2/18/2024 at 9:00 PM, and 2/23/2024 at 9:00 PM. Further review revealed on 2/14/2023 at 9:00 PM, documentation of Resident Absent from facility with meds, and on 2/16/2024 at 9:00 AM, 2/16/2024 at 9:00 PM, 2/18/2024 at 9:00 PM, and 2/23/2024 at 9:00 PM, due to documentation of Resident #13 Absent from facility without meds. Resident #13 did not receive Enoxaparin Sodium Injection Solution 30 MG for prevention of DVTS for five (5) scheduled doses out of forty-four (44) opportunities. Review of the MAR, dated 2/1/2024 through 2/29/2024, revealed Resident #13 did not receive Lantus Subcutaneous solution (Insulin Glargine) 7 Units subcutaneously a total of five (5) scheduled times 2/14/2024 at 9:00 PM, 2/16/2024 at 9:00 AM, 2/16/2024 at 9:00 PM, 2/18/2024 at 9:00 PM, and 2/23/2024 at 9:00 PM. Further review revealed on 2/14/2023 at 9:00 PM documentation of resident absent from facility with meds, and on 2/16/2024 at 9:00 AM, 2/16/2024 at 9:00 PM, 2/18/2024 at 9:00 PM, and 2/23/2024 at 9:00 PM due to documentation of resident absent from facility without meds. Resident #13 did not receive Lantus Subcutaneous Solution (Insulin Glargine) 7 units for DM for five (5) scheduled doses out of twenty-five (25) opportunities. On 2/16/2024 Resident #13 did not receive the two scheduled doses of Lantus Subcutaneous Solution (Insulin Glargine) with blood glucose on 2/17/2024 at 7:00 AM 378 requiring eight (8) Units sliding scale Humalog insulin per MD orders. Review of the MAR, dated 2/1/2024 through 2/29/2024, revealed Resident #13 did not receive blood glucose monitoring with Humalog Injection Solution (insulin Lispro) per sliding scale on a total of four (4) scheduled times 2/11/2024 at 5:00 PM, 2/18/2024 at 5:00 PM, 2/24/2024 at 7:00 AM with documentation of resident absent from facility without meds, and on 2/15/2024 at 7:00 AM documentation of resident absent from facility with meds. Resident #13 did not receive blood glucose monitoring with Humalog Sliding Scale Insulin on four (4) scheduled times out of forty-one (41) opportunities. On 2/15/2024 at 7:00 AM, and 2/24/2024 at 7:00 AM no blood glucose was checked after Resident #13 missed Lantus Subcutaneous Solution (Insulin Glargine) 7 Units on 3/14/2024 at 9:00 PM and 2/23/2024 at 9:00 PM. Review of the MAR, dated 2/1/2024 through 2/27/2024, revealed Resident #13 did not receive Meloxicam 7.5 MG tablet for arthritis one (1) scheduled dose on 2/16/2024 at 9:00 AM with documentation of resident absent from facility without meds. Resident #13 did not receive Meloxicam 7.5 MG tablet for arthritis one (1) scheduled dose on 2/15/2023 out of twenty (20) opportunities. Review of the Progress Notes for Resident #13, dated 2/10/2024 through 2/27/2024, revealed, there was no documentation to address scheduled medications that were not administered as ordered. There was no documentation the physician was notified of omitted medications that were not administered as ordered. Review of General Nurses Note for Resident #13, dated on 2/14/2024 at 11:50 PM, revealed, .resident arrived to facility via walker with boyfriend. Resident AAO3 [awake, alert, oriented to person, place, time] . with no documentation of physician notification of the 9:00 PM scheduled medications Phenytoin sodium Extended Oral Capsule (Phenytoin Sodium Extended) 400 mg capsule, Enoxaparin Sodium Injection Solution 30 MG subcutaneous injection, and Lantus Subcutaneous solution (Insulin Glargine 7 Units subcutaneous injection was held with Resident #13 returning to facility after medication administration time. 3. During an interview in the conference room on 3/6/2024 at 8:50 AM, the Director of Nursing (DON) was asked for the medication administration process when a resident signs out of the facility for an outing and medications are due while the resident is gone. The DON stated, Nurses are to ask the Nurse Practitioner if the resident is out when the medication is due to be administered if the medications can be given early or late and get a physician's order. Nurses are expected to contact the physician if critical medications are missed during an outing. Only residents with orders can take medications on outings when gone an extended period of time. Medications can be administered 1 hour before and 1 hour after the scheduled administration time. During a phone interview on 3/7/2024 at 11:45 AM, Resident #13 stated, .I can't remember the date or nurse's name. A friend took me out to eat and I got back to the facility around 12 midnight. The nurse refused to give me my medication including my seizure medicine. The nurse said it was too late to give the medications . During an interview in the conference room on 3/11/2024 at 11:20 AM, Licensed Practical Nurse (LPN) #6 was asked if medication were sent with residents on outings. LPN #6 stated, We never send residents out with medications without an MD (Medical Doctor)'s order. When residents go on outings a note should be in the progress note of when the resident left and when the resident returns. If a resident is out during medication pass, I mark on the MAR a 1, indicating resident is out of the facility without medications. If the resident returns during medication administration times I give them the scheduled medications. If it is after administration time the MD needs to be notified. During an interview in the conference room on 3/11/2024 at 11:50 AM, LPN #7 stated, I worked on 2/16/2024 from 7:00 PM to 10:00 PM. [Resident #13] had left the faciity on an outing prior to when my shift started at 7:00 PM. I got off work around 11:00 PM and Resident #13 still was not in the facility when I left. LPN #7 was asked about 9:00 PM medication administration for Resident #13. LPN #7 stated, I documented on the MAR resident not in facility. LPN #7 stated he did not write a progress not or notify the MD due to Resident #13 had not returned to the facility. During a phone interview on 3/11/2024 at 12:55 PM, LPN #8 was asked about documentation on Resident #13's MAR on 2/14/2024 about the 9:00 PM scheduled medications of a 3 (resident absent from facility with meds) and LPN #8's initials. LPN #8 stated Resident #13 was not in the building on 2/14/2024 during 9:00 PM Medication Administration and if a 3 was documented it was an error and should have been a 1 which indicates resident absent from facility without meds. LPN #8 was asked about the process when a resident is out and misses critical medications. LPN #8 stated, I document in the MAR the 1 and my initials, then if the resident returns within 1 hour past when the medication is due, I can give it and document it given. If they return later than 1 hour past administration time, the process is to call the physician for orders. LPN #8 was asked if she called the physician and where it was documented. LPN #8 stated, I usually call the physician and get orders and document it in the progress notes. I remember talking to the Nurse Practitioner; I don't remember if I documented it. No documentation was noted in the Progress Notes for Resident #13 for 2/14/2024, of contact with the physician or that on 2/14/2024 the scheduled 9:00 PM medications were not administered. During an interview in the conference room on 3/11/2024 at 2:30 PM, the DON was asked the process of medication administration if a resident is gone more than 1 hour past a scheduled medication is due. The DON stated, My expectation is for the nurse to contact the physician and see if medication can be given late. If resident is out when blood glucose testing is due, I expect the nurse to check the blood glucose when the resident returns. I expect the nurses to document in the progress notes when a resident's medication is not given and the physician notification. If a resident refuses a critical medication, I expect the nurse to call the MD and document in the progress notes. The DON was asked if omitting to give a physician ordered medication is a medication error. The DON stated, Omitting a physician ordered medication is a medication error. If a medication error is found, nurses are to assess the resident, call the physician, call the family or resident representative, and document it. During a phone interview on 3/11/2024 at 3:05 PM, Medical Doctor (MD) #1 stated the expectation is that the facility staff will notify him (MD#1) if a resident misses a dose of critical medications such as Insulin, seizure medications, and/or other medications, that missing the medication could have a negative impact on the resident. MD #1 stated the expectation is that the facility staff call him (MD #1) if residents refuse medications, if multiple doses of non-critical medication are missed, when medication is held due to the resident's condition, and anytime a critical medication is not given.

Based on facility policy review, medical record review, treatment administration record review, and interview, the facility failed to follow wound care as ordered by the physician to meet professional standards of practice for 1 (Resident #16) of 4 sampled residents reviewed. The findings include: Review of the facility's undated policy titled Medication Administration, revealed, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Other Lack of Coordination, Unspecified Viral Hepatitis C without Hepatic Coma, and Cellulitis of Unspecified Part of Limb. Review of the care plan revealed, .[8/1/2023] Self-Care Deficit .Focus .at risk for skin breakdown r/t (related to) cellulitis, diagnosis of HIV (Human Immunodeficiency Virus) and Hepatitis C .Interventions .assist resident to turn and reposition frequently and as desired .Braden [used to determine risk of developing a pressure ulcer] assessment completed and reviewed quarterly and PRN (as needed) .Float heels as tolerated .Head to toe skin check weekly .observe skin during care for any s/s (signs and symptoms) of redness and report to nurse immediately .pressure relieving cushion to w/c (wheelchair) as tolerated .standard pressure reducing mattress for bed .supplements as ordered per MD (Medical Doctor) to assist with wound caloric needs as indicated .treatments per MD [Medical Doctor] order . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed .Formal assessment instrument/tool (e.g., Braden, [NAME], or other) .Yes .Clinical assessment .Yes .Is this resident at risk of developing pressure ulcers/injuries? .Yes .Burn(s) (second or third degree) .Yes .Pressure reducing device for chair .Yes .Pressure reducing device for bed .Yes .Applications of ointments/medications other than to feet .Yes .Application of dressings to feet (with or without topical medications) .Yes . Review of the Treatment Administration Record (TAR) for Resident #16 dated 8/2023 revealed no documentation the treatment was performed according to the physician order to .Cleanse (L) [left] foot with Dakins 1/2 strength [a broad-spectrum antimicrobial cleanser gentle to the skin] then apply Xeroform gauze [a fine mesh gauze occlusive dressing for use on low exudating wounds], cover with ABD (abdominal pad) and wrap with Kerlex [a roll of gauze wrap] daily and PRN [as needed] . on 8/4/2023 and 8/24/2023. Review of the TAR for Resident #16 dated 8/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse (R) [right] foot with Dakins 1/2 strength then apply Xeroform gauze, cover with ABD and wrap with Kerlex daily and PRN . on 8/4/2023 and 8/24/2023. Review of the TAR for Resident #16 dated 9/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse (L) foot with Dakins 1/2 strength then apply Xeroform gauze, cover with ABD and wrap with Kerlex daily and PRN . on 9/6/2023, 9/7/2023, 9/13/2023, 9/19/2023, 9/21/2023, and 9/28/2023. Review of the TAR for Resident #16 dated 9/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse (R) foot with Dakins 1/2 strength then apply Xeroform gauze, cover with ABD and wrap with Kerlex daily and PRN . on 9/6/2023, 9/7/2023, 9/13/2023, 9/19/2023, 9/21/2023, and 9/28/2023. Review of the TAR for Resident #16 dated 10/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse Lt [left] foot with Dakins, apply Venelex [an ointment to help deodorize and cover wound], then wrap with Kerlex Daily & PRN . on 10/10/2023. Review of the TAR for Resident #16 dated 10/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse Rt [right] foot with Dakins, apply Venelex Ointment, then wrap with Kerlex Daily & PRN . on 10/10/2023. Review of the TAR for Resident #16 dated 10/2023 revealed, no documentation the treatment was performed according to the physician order to .Venelex External Ointment .Apply to both legs knee to toes topically every day shift for wound care . on 10/10/2023. Review of the TAR for Resident #16 dated 11/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse Lt. (Left) Foot with Dakins, apply Silvadene [a topical antimicrobial cream used to prevent and treat wound infections in second- and third- degree burns], then wrap with Kerlix Daily & PRN . on 11/21/2023 and 11/28/2023. Review of the TAR for Resident #16 dated 11/2023 revealed, no documentation the treatment was performed according to the physician order to .Cleanse Rt. Foot with Dakins, apply Silvadene, then wrap with Kerlix Daily & PRN . on 11/21/2023 and 11/28/2023. Review of the TAR for Resident #16 dated 11/2023 revealed, no documentation the treatment was done according to the physician order to .Silver Sulfadiazine Cream 1% [cream used to help prevent and treat wound infections in serious burns] .Apply to see additional directions topically every shift for wound care . 7a-7p on 11/21/2023 and 11/28/2023; 7p-7a on 11/1/2023 to 11/3/2023, 11/5/2023 to 11/16/2023, 11/18/2023 to 11/30/2023. Review of the TAR for Resident #16 dated 12/2023 revealed, no documentation the treatment was done according to the physician order to .Apply A &D ointment [used as a moisturizer to protect skin including burns] to bilateral feet Daily & PRN . on 11/22/2023 and 11/25/2023. Review of the TAR for Resident #16 dated 12/2023 revealed, no documentation the treatment was done according to the physician order to .Silver Sulfadiazine Cream 1% .Apply to see additional directions topically every shift for wound care . 7p-7a on 12/1/2023 through 12/2/2023 and 12/3/2023 through 12/15/2023. During an interview on 3/7/2024 at 2:35 PM, the Director of Nursing (DON) stated it was her expectation for the nursing staff to perform and document all treatments according to the physicians' orders. The DON admitted the treatments were not performed or documented on the TAR for Resident #16 from 8/2023 through 12/2023. During an interview on 3/7/2024 at 2:48 PM, Licensed Practical Nurse (LPN) #2 (Wound Care Nurse) admitted the treatments were not performed or documented on the TAR for Resident #16 from 8/2023 through 12/2023. During a telephone interview on 3/10/2024 at 5:05 PM, RN #4 stated Resident #16 did have an order on the TAR for a treatment to his feet, but the wound care nurse took care of the treatment during the day. The night shift nurses did not have to do the treatment. Continued interview revealed, Resident #16 ' s feet were always wrapped, and RN #4 did not observe what the feet looked like under the wrap. During a telephone interview on 3/10/2024 at 6:34 PM, RN #5 stated Resident #16 received wound care on the day shift by the wound nurse (LPN#2). RN #5 stated Resident #16's feet were always wrapped during the night shift. Continued interview revealed RN #5 stated wound care treatment was not provided on the night shift. Resident #16 did not receive wound care treatments as ordered in August 2023 on his left foot for 2 out of 31 opportunities. Resident #16 did not receive wound care treatments as ordered in August 2023 on his right foot for 2 out of 31 opportunities. Resident #16 did not receive wound care treatments as ordered in September 2023 on his left foot for 6 out of 30 opportunities. Resident #16 did not receive wound care treatments as ordered in September 2023 on his right foot for 6 out of 31 opportunities. Resident #16 did not receive wound care treatments as ordered in October 2023 on his left foot for 1 out of 31 opportunities. Resident #16 did not receive wound care treatments as ordered in October 2023 on his right foot for 1 out of 31 opportunities. Resident #16 did not receive wound care treatments as ordered in October 2023 on his bilateral legs for 1 out of 31 opportunities. Resident #16 did not receive wound care treatments as ordered in November 2023 on his left foot for 2 out of 30 opportunities. Resident #16 did not receive wound care treatments as ordered in November 2023 on his right foot for 2 out of 30 opportunities. Resident #16 did not receive wound care treatments as ordered in November 2023 on his bilateral feet and ankles for 2 out of 30 opportunities on 7 AM to 7 PM and 28 out of 30 opportunities for 7 PM to 7 AM. Resident #16 did not receive wound care treatments as ordered in December 2023 on his bilateral feet for 2 out of 31 opportunities.

Based on facility policy review, medical record review, facility document, facility investigation, and interview, the facility failed to ensure an alleged violation involving exploitation and misappropriation of a resident's property was reported within 24 hours to the state agency for 1 (Resident #25) of 2 sampled residents reviewed. The findings include: Review of the facility policy titled, ABUSE, NEGLECT, EXPLOITATION, dated 10/18/2022, revealed, .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .'Exploitation' means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats, or coercion .'Misappropriation of Resident Property' .means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes .a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .4. Reporting to the state nurse aid registry or licensing authorities .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . Review of the facility policy titles, RESIDENT RIGHTS, dated 10/18/2022, revealed, .Grievances. The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment .b. The resident has the right to and the facility must make efforts by the facility to resolve grievances the resident may have . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Malignant Carcinoid Tumor of the Small Intestine, End Stage Renal Disease, and Type 2 Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed, a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the facility document (Abuse-Complainant Statement) dated 9/26/2023, revealed documentation which stated, In your own words, explain what occurred on the date of the incident. It was documented Resident #25 stated, I was half asleep in the bed and he [Licensed Practical Nurse (LPN) #4] came down and asked if he could borrow money for gas and he would pay me back the next pay day. I told him where the key to my safe was and where the safe was and I heard him get the money out . Can you describe the person who allegedly perpetrated the abuse? Resident stated that is was [Named LPN #4]. Review of the facility investigation dated 9/26/2023, revealed an investigation was completed for the allegation of misappropriation of funds reported by Resident #25 but was not reported to the proper authorities within the allotted timeframe of 24 hours. During an interview on 2/29/2024 at 10:15 AM, the Administrator stated she was the abuse coordinator and was responsible to report abuse allegations to the state agency within 24 hours. During a telephone interview on 3/6/2024 at 6:30 PM, Certified Nursing Assistant (CNA) #13 recalled LPN #4 had borrowed money from Resident #25. During an interview on 3/7/2024 at 8:45 AM, the Administrator stated LPN #4 was terminated because he took money from Resident #25. When the Administrator was asked why the allegation was not reported, she replied, I did not report the allegation because [Resident #25] had a high BIMS and voluntarily gave the money to the [LPN #4]. The Administrator stated LPN #4 violated the facility policy and acted in an unprofessional way.

Based on facility policy review, record review, and interview, the facility failed to protect a resident's right to be free from misappropriation and/or exploitation when a staff member borrowed money from a resident and failed to immediately report the alleged violation to the state agency and other authorities for 1 (Resident #25) of 3 sampled residents reviewed. The findings include: Review of the facility policy titled, ABUSE, NEGLECT, EXPLOITATION, dated 10/18/2022 revealed, .'Misappropriation of Resident Property' .means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident ' s belongings or money without the resident's consent .Reporting/Response .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies .within specified timeframes .a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .4. Reporting to the state nurse aid registry or licensing authorities .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . Review of the facility policy titled, RESIDENT RIGHTS, dated 10/18/2022, revealed, .Grievances. The resident has the right to: a. Voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal. Such grievances include those with respect to care and treatment .b. The resident has the right to and the facility must make efforts by the facility to resolve grievances the resident may have . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Malignant Carcinoid Tumor of the Small Intestine, End Stage Renal Disease, and Type 2 Diabetes Mellitus. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed, a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the facility document (Abuse-Complainant Statement) dated 9/26/2023, revealed documentation which stated, In your own words, explain what occurred on the date of the incident. Resident #25 stated, I was half asleep in the bed and he [Licensed Practical Nurse (LPN) #4] came down and asked if he could borrow money for gas and he would pay me back the next pay day. I told him where the key to my safe was and where the safe was and I heard him get the money out . Can you describe the person who allegedly perpetrated the abuse? .Resident stated that it was [Named LPN #4]. Review of the facility investigation dated 9/26/2023, revealed an investigation was completed for the state agencies within the allotted timeframe of 24 hours. During an interview on 2/29/2024 at 10:15 AM, the Administrator stated she was the abuse coordinator and was responsible to report abuse allegations to the state agency within 24 hours. During a telephone interview on 3/6/2024 at 6:30 PM, CNA #13 recalled LPN #4 had borrowed money from Resident #25. During an interview on 3/7/2024 at 8:45 AM, the Administrator stated LPN #4 was terminated because he took money from Resident #25. When the Administrator was asked why the allegation was not reported, she replied, I did not report the allegation because [Resident #25] had a high BIMS and voluntarily gave the money to the [LPN #4]. The Administrator stated LPN #4 violated the facility policy and acted in an unprofessional way. During a telephone interview on 3/12/2024 at 10:53 AM, Family Member (FM) #8 stated she was not notified about the allegation for misappropriation of funds that involved Resident #25.

Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's representative that the resident contracted Covid for 3 (Residents #2, #7, #8) of 10 sampled residents reviewed. The findings included: Review of the facility's undated policy titled Notification of Changes, revealed, .The purpose of this policy is to ensure the facility promptly informs the resident. Consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is change requiring notification .3. Circumstances that require a need to alter treatment .Additional considerations .b. A family that wishes to be informed would designate a member to receive calls . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Primary Osteoarthritis, Depression, and Polyneuropathy. During a telephone interview on 2/28/2024 at 10:50 AM, Family Member (FM) #1, who is the Power of Attorney (POA) for Resident #2, stated he did not receive a call from the facility that specified (Resident #2) had tested positive for Covid. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dysphagia following Unspecified Cerebrovascular Disease, Chronic Obstructive Pulmonary Disease (COPD), and Unspecified Protein-Calorie Malnutrition. During a telephone interview on 2/28/2024 at 11:15 AM, FM #4, the POA for Resident #7, stated he came to visit Resident #7 one morning and noticed she was lethargic. Resident #7 told FM #4 she tested positive for Covid. FM #4 recalled he asked staff why no one had contacted him. An unnamed CNA went to get the unnamed nurse and she confirmed Resident #7 had tested positive for Covid. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side, and Mild Intermittent Asthma. During a telephone interview on 2/28/2024 at 11:22 PM, FM #5, who is the responsible party for Resident #8, stated he did not receive a personal call stating Resident #8 was positive for Covid. During an interview on 3/4/2024 at 10:15 AM, the Director of Nursing (DON) was asked what her expectations were for notifying the responsible party when a resident tested positive for Covid. The DON replied, I expect the representative to be called individually and within a few hours, to notify them that their loved one has tested positive for Covid. During an interview on 3/12/2024 at 1:30 PM, the DON verified Resident #2, #7, and #8 responsible parties were not notified the residents contracted Covid in the facility.

Based on facility policy review, facility documentation review, medical record review, and interviews, the facility failed to adequately investigate an allegation of abuse for 1 of 10 sampled residents (Resident #9) reviewed. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, dated 10/18/2022, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Abuse' means the will infliction of injury, unreasonable confinement, intimidation, or punishment .V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence .3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation .VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: B. Examining the alleged victim for any signs of injury, including a physical examination or psychosocial assessment .F. Providing emotional support and counseling to the resident during the investigation . Review of Certified Nurse Assistant (CNA) #4's employee file revealed a hire date 2/8/2023 and a termination date of 9/1/2023. Background checks and Abuse Registry checks were completed upon hire. CNA #4 was educated on Abuse upon hire. CNA #4 received a Personnel Consultation Form on 5/22/2023 for going back and forth with staff making a harsh work environment. Another Personnel Consultation Form dated 9/1/2023 revealed, Termination .Employee has had multiple complaints regarding care and treatment by residents .Witnesses: [Named Witnesses] .Corrective Action Taken: Termination as we want to provide all residents with timely and quality care w/o [without] grievance . The form was signed by [Named Witnesses] on 9/1/2023. Review of the facility's investigation of alleged abuse revealed a copy of Resident #9's face sheet, a Brief Interview for Mental Status (BIMS) assessment from an MDS dated [DATE]. Review of the BIMS assessment revealed the resident was unable to complete the assessment and had severely impaired memory problems. Continued review revealed emails sent on 9/12/2023 from the Administrator to the Regional Liaison stating the Administrator spoke with Resident #9's roommate and Licensed Practical Nurse (LPN) #2 regarding Resident #9's behaviors the night of 8/28/2023 and if the LPN had witnessed Resident #9 being tied to the bed or restrained. Continued review revealed a written statement from the accused perpetrator, Certified Nursing Assistant (CNA) #4, a written statement from the Unit Manager, a written statement from LPN #1, and a written statement from CNA #2. The aforementioned (previously mentioned) documents were the only documents contained in the facility investigation. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] for a Hospice Respite stay. Diagnoses included Malignant Neoplasm of Appendix and Anxiety Disorder. Continued review of the medical record revealed documentation that Resident #9 was continent of bowel and bladder and required only supervision and stand by assistance for Activities of Daily Living. Continued review revealed a completed Baseline Care Plan, dated 8/25/2023, which indicated he was cognitively intact, required no assistance with Activities of Daily Living, and was continent of bowel and bladder. Continued review revealed Resident #9 had a fall on 8/26/2023 at 12:48 AM and another fall on 8/26/2023 at 10:32 PM. Continued review revealed a Brief Interview for Mental Status (BIMS) assessment for Resident #9, dated 8/24/2023, which revealed a score of 12, which indicated moderate cognitive impairment. During an interview on 9/12/2023 at 11:45 AM, The Unit Manager (UM) stated Certified Nurse Assistant (CNA) #4 was terminated because another CNA reported that CNA #4 had tied a sheet to the bed frame of Resident #9's bed in such a way as to prevent the resident from getting up. The UM stated she told the Administrator and the Human Resource (HR) Director about the incident. During a telephone interview on 9/12/2023 at 2:13 PM, the Administrator stated she did an investigation on an allegation against CNA #4 on 8/28/2023. The Administrator stated, I wanted to see if the CNA really did restrain a resident. The Administrator stated she obtained statements from CNA #4, a named day shift nurse, a named CNA, a named nurse who worked with CNA #4 on 8/28/2023, and Resident #9's roommate. The Administrator stated all of the statements were in her office. The Administrator stated the nurse on the hall the morning of 8/28/2023 reported the allegation to the UM, and the UM reported the allegation to her. When asked if tying someone to their bed would be considered abuse, the Administrator stated, yes. The Administrator confirmed the facility did not do a thorough investigation regarding the allegation of abuse on 8/28/2023 involving Resident #9. The Administrator confirmed no skin assessment was completed on Resident #9, no skin assessments were completed on the residents with low BIMS scores, no resident interviews were completed, and no in-services were held with staff related to the allegation of abuse.

Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to ensure that an alleged violation involving abuse was reported immediately to officials (including to the State Survey Agency, Adult Protective Services, and the Police Department ) for 1 of 10 sampled residents (Resident #9) reviewed. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation, dated 10/18/2022, revealed, .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .'Abuse' means the will infliction of injury, unreasonable confinement, intimidation, or punishment .Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . Review of Certified Nurse Assistant (CNA) #4's employee file revealed a hire date 2/8/2023 and a termination date of 9/1/2023. Background checks and Abuse Registry checks were completed upon hire. CNA #4 was educated on Abuse upon hire. CNA #4 received a Personnel Consultation Form on 5/22/2023 for going back and forth with staff making a harsh work environment. Another Personnel Consultation Form dated 9/1/2023 revealed, Termination .Employee has had multiple complaints regarding care and treatment by residents .Witnesses: [Named Witnesses] .Corrective Action Taken: Termination as we want to provide all residents with timely and quality care w/o [without] grievance . The form was signed by [Named Witnesses] on 9/1/2023. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] for a Hospice Respite stay. Diagnoses included Malignant Neoplasm of Appendix and Anxiety Disorder. Continued review of the medical record revealed documentation that Resident #9 was continent of bowel and bladder and required only supervision and stand by assistance for Activities of Daily Living. Continued review revealed a completed Baseline Care Plan, dated 8/25/2023, which indicated he was cognitively intact, required no assistance with Activities of Daily Living, and was continent of bowel and bladder. Continued review revealed Resident #9 had a fall on 8/26/2023 at 12:48 AM and another fall on 8/26/2023 at 10:32 PM. Continued review revealed a Brief Interview for Mental Status (BIMS) assessment for Resident #9, dated 8/24/2023, which revealed a score of 12, which indicated moderate cognitive impairment. During a telephone interview on 9/12/2023 at 2:13 PM, the Administrator stated she did an investigation on an allegation against Certified Nurse Assistant (CNA) #4 on 8/28/2023. The Administrator stated the nurse on the hall the morning of 8/28/2023 reported the allegation to the Unit Manager, and the Unit Manager reported the allegation to her. The Administrator stated, [Named CNA #1] reported the resident's right arm was tied to the bed. (The allegation reported was the bed sheet was found tied to the left side of the resident's bed. No witness interviewed stated Resident #9's arm was tied to the bed.) When asked if that would be considered a restraint, the Administrator confirmed it would be considered a restraint. When asked if tying someone to their bed would be considered abuse, the Administrator stated, yes. When asked if she reported the allegation to the State officials, police department, Ombudsman, or Adult Protective Services, the Administrator stated, No. The Administrator confirmed she should have reported the allegation of abuse to the State officials and proper channels within 2 hours. During an interview on 9/12/2023 at 3:05 PM, Licensed Practical Nurse (LPN) #1 stated he and CNA #2 went into Resident #9's room on the morning of 8/28/2023 and was checking him for incontinent care. LPN #1 stated he pulled back the bed sheet on the right side of Resident #9 to look at his brief. LPN #1 stated he did not notice the bed sheet tied on the left hand side of the bed at this time. LPN #1 stated about 30 minutes later, CNA #2 came to him and told him to go back to Resident #9's room. LPN #1 stated CNA #2 told him she was trying to get Resident #9 up, and noticed the top bed sheet was tied to the bed frame on the left hand side of the bed. LPN #1 stated he observed the end of the bed sheet wrinkled and in a pointed position. LPN #1 stated it was obvious the bed sheet had been tied to something. LPN #1 stated he reported the incident to the Unit Manager. LPN #1 stated the Administrator interviewed him related to the tied bed sheet.

Based on facility policy review, review of the Facility Reported Investigation (FRI) #20230214092945, and interview, the facility failed to report allegations of abuse within 2 hours for 2 of 2 residents (Resident #2 and #3) reviewed for a resident-to-resident altercation. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, dated 10/18/2022 revealed, .to provide protections for the health, welfare and rights of each resident .Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking . Review of the facility's policy titled, Resident Rights, dated 10/18/2022, revealed, .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Review of the FRI #20230214092945, dated 2/14/2023 revealed an investigation was completed related to an abuse allegation involving Resident #2 and #3, which involved physical contact. Continued review revealed skin assessments were completed on all residents on 100 Hall's assignment with a BIMS score of less than 8 and conducted interviews with the residents with a BIMS (Brief Interview for Mental Status) score of 8 or more related to abuse. No concerns were found. An abuse in-service was completed for all staff. Resident #3 was sent out to the hospital for a psychiatric evaluation and Resident #2 refused that night, but requested to go to the hospital the next day. Continued review revealed no concerns after completion of the investigation. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Rheumatoid Arthritis, Heart Failure, Type 2 Diabetes, and Essential Hypertension. Review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE], for Resident #2, revealed a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed limited assist with one-person physical assist for bed mobility, dressing, and personal hygiene. Extensive assist with one-person physical assist for transfers and toilet use. Review of Comprehensive Care Plan for Resident #2 dated February 2023 revealed, a person-centered individualized care plan with appropriate goals and interventions. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Secondary Parkinsonism, Schizoaffective Disorder, Moderate Intellectual Disabilities, Anxiety Disorder, and Senile Degeneration of the Brain. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed, a BIMS score of 12 which indicated moderate cognitive impairment. Continued review revealed extensive assist with one-person physical assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Supervision and set up for locomotion on and off the unit. Review of Comprehensive Care Plan for Resident #3, dated February 2023, revealed a person-centered individualized care plan with appropriate goals and interventions that included will at times be physically and verbally aggressive related to Poor impulse control. During an interview on 3/14/2023 at 8:05 AM, the Assistant Administrator confirmed that she did not report the FRI #20230214092945, within the appropriate time (2 hours of the incident). She stated she was not made aware of the allegation by the Assistant Director of Nursing (ADON) until the day (2/14/2023) after the incident. During an interview on 3/14/2023 at 8:10 AM, the Administrator stated she was the abuse coordinator. The staff were trained on abuse upon hire, monthly, with any abuse allegation, and annually. She stated she was responsible to report abuse allegations to the state agency within 2 hours. She stated the ADON was notified of the incident which occurred on 2/13/2023 at 11:00 PM, but the ADON failed to notify the proper authorities immediately. Continued interview revealed the ADON was given an Employee Counseling Statement on 2/14/2023 on notifications.

Based on facility policy review, hospital medical record review, facility documentation review, medical record review, and interviews, the facility failed to ensure a medication was obtained and administered as prescribed for 1 of 3 sampled residents (Resident #8). The findings include: Review of the facility policy titled, Medication Administration, revealed, .Medications are administered as ordered by the physician . Review of Resident #8's hospital medical record dated 10/27/2022, revealed, .Active Non-VA [Veteran's Administration] Medications .Non-VA Temozolomide 140MG [milligram][chemotherapy medication used for brain tumors] Mouth Q [every] Daily .Filled through [named hospital] pharmacy .all current/active medications have been reviewed with the patient, family and/or caregiver and are correct as listed .[yes] .Patient was informed of his/her responsibility to maintain a current medication list and communicate information to all providers .ACTIVE means that you are presently taking these meds [medications] .NON-VA means you are getting this medication from somewhere besides the VA .Medication Reconciliation: Regardless of whether the status of the medication is ACTIVE, PENDING, SUSPENDED, or HOLD, they should be given unless the clinical appropriateness has changed as determined by your own medical staff . Review of the undated facility documentation titled, Admission Acceptance Protocol revealed, .Contact center for capability .Chemotherapy depending on if patient can provide medication (discontinued while admitted ) . Review of the Administrator's typed statement dated 11/16/2022 (this was provided when asked for an admission agreement), revealed, .When admitting a patient that is on any type of chemotherapy drug the facility is not able to accept the patient if they cannot provide the drug from home or unless the medication will be discontinued per the emergency room during patients stay. This is a contingency due to the cost of the medication. When admitting [named] Resident #8, we spoke to [named referral facility] to ensure we would not be responsible for his chemo [chemotherapy] medication . Review of the Admissions Director's handwritten statement dated 11/16/2022 (this was provided when asked for an admission agreement), revealed, .Patient was receiving chemo [chemotherapy] drug thru [named] pharmacy and was to bring from home since it was filled by [named] pharmacy . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Brain. Review of Resident #8's facility Admission Physician Orders dated 10/27/2022 revealed no order for Temozolomide 140 mg was listed. Review of Resident #8's Order Summary report for October and November 2022, revealed there were no orders listed for Temozolomide. Review of Resident #8's Physician Progress Note dated 10/28/2022, signed by [named] Nurse Practitioner revealed Temozolomide was listed on the resident's medication list. Review of Resident #8's Physician Progress History and Physical Note dated 10/31/2022, signed by [named] primary physician, revealed Temodar [brand name for Temozolomide] was listed on the resident's medication list. Continued review revealed, .Meds reviewed .continue current care .no changes needed . During a telephone interview on 11/16/2022 at 11:10 AM, [referral pharmacy] Pharmacy Technician #1 stated, [named] Resident #8 was prescribed Temozolomide 140mg daily on 10/10/2022 and was refilled on 11/1/2022. During a telephone interview on 11/16/2022 at 11:33 AM, [referring specialty pharmacy] Pharmacy Technician #2 stated, [named] Resident #8's medication was called into the pharmacy on 11/1/2022 and remained there to be picked up. During a telephone interview on 11/16/2022 at 11:42 AM, Complainant #1 stated [named] Resident #8 had not been receiving his chemotherapy medication since he was discharged from [named] hospital. She stated the facility did not get the resident's medication from the pharmacy. During an interview on 11/16/2022 at 12:24 PM, Registered Nurse (RN) #3 reviewed Resident #8's medical record and stated there were no orders for the resident to receive Temozolomide. During a telephone interview on 11/16/2022 at 12:36 PM, Licensed Practical Nurse (LPN) #2 confirmed she transcribed [named] Resident #8's admitting medications to the electronic medical record. Continued interview she stated chemotherapy medications were not listed on his orders. During a telephone interview on 11/16/2022 at 1:31 PM, RN #2 (nurse from Resident #8's oncologist office) stated, [named] resident was receiving radiation treatments through this office. He was seen on 11/10/2022 with his daughter present. I called the [named] facility and talked with [named] RN #3 who told me the resident was not receiving his chemotherapy medication; she stated that medication was not listed on his orders. During a telephone interview on 11/16/2022 at 1:36 PM, Resident #8's daughter (complainant #2) stated the resident did not receive chemotherapy medications while at [named] facility. During an interview on 11/16/2022 at 2:13 PM, the Administrator stated, Resident #8 was receiving chemotherapy medications at the hospital according to the hospital medical record. She stated, it was told to me the family knew about the drug and they were responsible for picking up the medication for the resident and bringing it to the facility, if he were to continue the medication. Continued interview revealed the chemotherapy medication was listed on the resident's hospital medical record as active on his medication list and no facility staff ensured his family brought his medications to the facility. She stated the resident had not received Temozolomide while he was a resident at the facility. During an interview on 11/16/2022 at 2:53 PM the Admission Director reviewed the hospital medical record for Resident #8 and confirmed Temozolomide was listed on his active medication list. During an interview on 11/16/2022 at 5:05 PM, the Director of Nursing reviewed Resident #8's hospital medical record and stated, I would only put in the 'active' medications in the resident's EMR [electronic medical record]. I would not put in the 'Non-VA' medication [Temozolomide] orders even though it said 'active' because it was filled at an outside pharmacy. The admission's person talks to the family to make sure they can bring the drug because the facility doesn't pay for chemotherapy medications. She reviewed his medical record and confirmed there were no orders for the medication, and he had not received Temozolomide while he was a resident at the facility.

Based on job description review, facility policy review, hospital medical record review, facility documentation review, medical record review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. The administration failed to ensure a medication was obtained and provided for 1 of 3 sampled residents (Resident #8). The findings include: Review of the undated Administrator's job description, revealed, .Leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Review of the facility policy titled, Medication Administration, revealed, .Medications are administered as ordered by the physician . Review of Resident #8's hospital medical record dated 10/27/2022, revealed, .Active Non-VA [Veteran's Administration] Medications .Non-VA Temozolomide 140MG [milligram][chemotherapy medication used for brain tumors] Mouth Q [every] Daily .Filled through [named hospital] pharmacy .all current/active medications have been reviewed with the patient, family and/or caregiver and are correct as listed .[yes] .Patient was informed of his/her responsibility to maintain a current medication list and communicate information to all providers .ACTIVE means that you are presently taking these meds [medications] .NON-VA means you are getting this medication from somewhere besides the VA .Medication Reconciliation: Regardless of whether the status of the medication is ACTIVE, PENDING, SUSPENDED, or HOLD, they should be given unless the clinical appropriateness has changed as determined by your own medical staff . Review of the undated facility documentation titled, Admission Acceptance Protocol revealed, .Contact center for capability .Chemotherapy depending on if patient can provide medication (discontinued while admitted ) . Review of the Administrator's typed statement dated 11/16/2022 (this was provided when asked for an admission agreement), revealed, .When admitting a patient that is on any type of chemotherapy drug the facility is not able to accept the patient if they cannot provide the drug from home or unless the medication will be discontinued per the emergency room during patients stay. This is a contingency due to the cost of the medication. When admitting [named] Resident #8, we spoke to [named referral facility] to ensure we would not be responsible for his chemo [chemotherapy] medication . Review of the Admissions Director's handwritten statement dated 11/16/2022 (this was provided when asked for an admission agreement), revealed, .Patient was receiving chemo [chemotherapy] drug thru [named] pharmacy and was to bring from home since it was filled by [named] pharmacy . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Brain. Review of Resident #8's Facility Admission Physician Orders dated 10/27/2022 revealed no order for Temozolomide 140 mg was listed. During a telephone interview on 11/16/2022 at 11:42 AM, Complainant #1 stated [named] Resident #8 had not been receiving his chemotherapy medication since he was discharged from [named] hospital. She stated the facility did not get the resident's medication from the pharmacy. During an interview on 11/16/2022 at 2:13 PM, the Administrator stated Resident #8 was receiving chemotherapy medication [Temozolomide] at the hospital according to his hospital medical record. Continued interview she confirmed the chemotherapy medication was listed on the resident's active medication list, and no facility staff ensured his family brought his medications to the facility to be administered to him. During an interview on 11/16/2022 at 2:53 PM the Admission's Director reviewed the hospital medical record for Resident #8 and confirmed his Temozolomide was listed on the resident's active medication list. Continued interview she stated she did not notify the family to bring his medications to the facility. During an interview on 11/16/2022 at 5:05 PM the Director of Nursing reviewed Resident #8's hospital medical record and confirmed Temozolomide was listed on the resident's active medication list. She reviewed his medical record and confirmed there were no orders for the medication, and he had not received Temozolomide while he was a resident at the facility. She stated she did not notify his family to bring that medication to the facility.

Based on facility policy review, medical record review, hospital medical record review, and interviews, the facility failed to notify 1 of 3 sampled residents (Resident #8's) physicians of the resident missing doses of a Chemotherapy [a medication used for brain tumors] medication [Temozolomide]. The findings include: Review of the undated facility policy titled, Notification of Changes, revealed, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification . Review of the facility policy titled, Medication Administration, revealed, .Medications are administered as ordered by the physician . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Brain. Review of Resident #8's facility Admission Physician Orders dated 10/27/2022 revealed no order for Temozolomide 140 mg was listed. Review of Resident #8's Order Summary report for October and November 2022, revealed there were no orders listed for Temozolomide. Review of Resident #8's Physician Progress Note dated 10/28/2022, signed by [named] Nurse Practitioner revealed Temozolomide was listed on the resident's medication list. Review of Resident #8's Physician Progress History and Physical Note dated 10/31/2022, signed by [named] primary physician, revealed Temodar [brand name for Temozolomide] was listed on the resident's medication list. Continued review revealed, .Meds reviewed .continue current care .no changes needed . Review of Resident #8's hospital medical record dated 10/27/2022, revealed, .Active Non-VA [Veteran's Administration] Medications .Non-VA Temozolomide 140MG [milligram][medication to treat brain tumors] Mouth Q [every] Daily .Filled through [named hospital] pharmacy .all current/active medications have been reviewed with the patient, family and/or caregiver and are correct as listed .[yes] .Patient was informed of his/her responsibility to maintain a current medication list and communicate information to all providers .ACTIVE means that you are presently taking these meds [medications] .NON-VA means you are getting this medication from somewhere besides the VA .Medication Reconciliation: Regardless of whether the status of the medication is ACTIVE, PENDING, SUSPENDED, or HOLD, they should be given unless the clinical appropriateness has changed as determined by your own medical staff . During an interview on 11/16/2022 at 5:05 PM, the Director of Nursing reviewed Resident #8's hospital medical record and stated, I would only put in the 'active' medications in the resident's EMR [electronic medical record]. I would not put in the 'Non-VA' medication, Temozolomide orders even though it said 'active' because it was filled at an outside pharmacy; The admission's person talks to the family to make sure they can bring the drug because the facility doesn't pay for chemotherapy medications; if the family brought the medicine in, then we would notify his doctor to get an order for it. Continued interview revealed she had not notified Resident #8's physician regarding the resident not receiving the medication. During a telephone interview on 11/17/2022 at 9:18 AM with Resident #8's Oncologist when asked if he was aware Resident #8 had not received Temozolomide while a resident at the [named] facility, he stated, I was not informed he missed his medication. During an interview on 11/17/2022 at 3:53 PM with Resident #8's primary care physician when asked if he was aware Resident #8 had not received Temozolomide while a resident at the [named] facility, he stated, no one communicated that to me.

Based on facility policy review, record review and interview the facility failed to ensure accurate documentation in the medical record for 1 (Resident #1) resident of 3 resident sampled for record review. The findings include: Review of the facility's undated policy titled, Documentation in Medical Record, revealed, .resident's medical record shall contain an accurate representation of the actual experiences of the resident . Review of the Progress Notes for Resident #1 revealed, .4/4/2022 .DON informed him that if he did not get on the stretcher that she would have to call Metro police . During an interview on 4/25/2022 at 3:48 PM, the Administrator reviewed the progress note for Resident #1 dated 4/4/2022. She confirmed the documentation stated, DON informed him that if he did not get on the stretcher that she would have to call Metro police. During continued interview she stated she had been present, and the DON did not say that to Resident #1. During continued interview she confirmed the documentation was inaccurate. During an interview on 4/25/2022 at 4:15 PM, the DON stated she did not threaten Resident #1 to make him go anywhere. During continued interview she confirmed the documentation was inaccurate. During a telephone interview on 4/25/2022 at 7:20 PM, LPN #5 stated her documentation in the progress note wasn't correct. Review of the progress note revealed LPN #5 documented, .DON informed him that if he did not get on the stretcher that she would have to call Metro police . During continued interview LPN #5 stated, the DON did not say that to [named, Resident] #1. I am not sure why I documented that she said that to him.

Based on facility policy review, observations, medical record review and interviews, the facility failed to promote dignity with assisted diners with 3 Residents (Resident #1, Resident #3 and Resident #4) out of 3 sampled assisted diners who receive meals in thier rooms. The findings include: Review of the facility's undated policy titled, Abuse, Neglect, and Exploitation revealed .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect exploitation and misappropriation of resident property . Review of the facility's undated policy titled, Resident Rights revealed .The facility will inform the resident orally and in writing .of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility .All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression .The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .The resident has a right to be treated with respect and dignity . Review of the facility's undated policy titled, Activities Of Daily Living revealed .The facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to: Bathe, dress, and groom; Transfer and ambulate; Toilet; Eat, and Use speech, language or other functional communication systems . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with a readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a BIMS score of 15, which indicated high cognitive functioning. Resident required extensive to total dependence with physical assist of 1-2 persons for all ADL (Activities of Daily Living)s. Review of the Comprehensive Care Plan for Resident #1 revealed care plans which included plans to remain in facility for long term care, ADL self-care deficit, declines showers/bathing at times, alteration in behavior patterns, episodes of making false allegations, risk for fluid imbalance and nutritional status with episodes of declining meals. Interventions and revisions were appropriately implemented.The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . Review of the medical record revealed Resident #3 was admitted to the facility on 3/18/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored 12 on the BIMS which indicated moderate cognitive functioning. The MDS also revealed Resident #3 required extensive assistance with bed mobility, dressing and eating and required total dependence in toileting and personal hygiene. Review of the Comprehensive Care Plan dated 3/18/200 on Resident #3 and revised as needed revealed no concerns. Review of the medical record revealed Resident #4 was admitted to the facility on 3/29/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored 11 on the BIMS which indicated moderate cognitive functioning. The MDS also revealed Resident #3 required limited assistance with bed mobility, transfers, dressing and extensive assistance with eating, toileting, and personal hygiene. Review of the Comprehensive Care Plan dated 3/29/2021 on Resident #4 and revised as needed revealed no concerns. Observation of Hall 400 on 4/25/2022 at 12:10 PM, revealed staff knocking on resident's door prior to entering the resident's room. Continued observation revealed resident were clothed with personal clothes or gowns. Hall was clean with no visible debris and no odors noted. Lunch trays arrived to hall and staff began delivering trays to residents that were dining in their room. A meal tray was delivered to room [ROOM NUMBER] B and no tray was delivered to 405 A. Observation of Hall 200 on 4/25/2022 at 12:25 PM, revealed staff knocking on resident's door prior to entering the room. Continued observation revealed residents were clothed with personal clothes or gowns. Hall was clean with no visible debris and no odors noted. Continued observation revealed tray was delivered to 205A for assistance with dining. Resident in 205B was finishing his meal, having been previously served. Observation and interview on 4/25/2022 at 12:34 PM, revealed the Administrator confirmed the assisted diners are the last meal trays to be served. She stated the reason they are served last was to ensure staff could immediately assist the residents with eating. At 12:36 PM, the Administrator delivered a tray to room [ROOM NUMBER] A. She sat down to assist the resident with her meal 26 minutes after 405 B's lunch meal was served. During an interview on 4/25/2022 at 12:20 PM, CNA #1 confirmed room [ROOM NUMBER] A did not have a tray on the cart for delivery. She stated the assisted diner trays would come out after the other trays were delivered. She stated the curtain is pulled halfway because 405 B has a tray before 405 A. During continued interview she confirmed the resident in 405 A could see the bedside table with the lunch tray on it when the tray was delivered. During an interview on 4/25/2022 at 2:27 PM, the Dietary Manager stated the last meal carts to be delivered to the hall contained meal trays for the residents that required assistance with meals. She stated this had been the protocol for a few weeks in an effort to feed assisted diners as soon as the tray was delivered. She confirmed the protocol for delivery of meals in the dining room was to serve all residents at the same table at one time. This would prevent residents from having to watch others at the table eating when they have nothing to eat themselves. During continued interview, she confirmed the same courtesy should be provided to residents that receive a meal tray in their rooms.

Based on medical record review, observation, and interview the facility failed to have a call light in reach for 1 of 34 sampled residents (Resident #42) observed. The findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Observation in the resident's room on 7/12/2021 at 3:48 PM, revealed the call light lying on the floor out of Resident #42's reach. Observation and interview in Resident #42's room on 7/12/2021 at 3:55 PM, Certified Nurse Aide (CNA) #5 comfirmed the call light was on the floor out of the resident's reach. During an interview on 7/14/2021 at 3:13 PM, the Administrator confirmed call lights should be in reach for the residents.

Based on facility policy review, medical record review, facility documentation review, observations and interviews the facility failed to ensure that the mattress and bed were compatible for 1 of 34 sample residents (Resident #47). The findings include: Review of the facility's undated policy titled, Bed Maintenance and Inspection, revealed .the facility will ensure that the mattress and bed frame are compatible . Review of the facility's policy titled, Siderail Entrapment Zones and Dimensional Recomendations [Recommendations], dated 3/10/2006, revealed .Zone 7: Between the head or foot board and the mattress end. FDA (Federal Drug Administration) recognizes this area as potential for entrapment . Review of the Work History Report for bed and mattress inspection, revealed facility staff inspected beds and mattresses every 3 months. Review of the medical record revealed Resident #47 was admitted on [DATE] with diagnoses which included [CONDITION(S)], Muscle Weakness, and Need for Assistance with Personal Care. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #47 had a Brief Interview of Mental Status (BIMS) score of 10 which indicated moderate impaired cognition. Further review revealed the resident is independent for transferring. Observation in the resident's room on 7/12/2021 at 10:27 AM, Resident #47 was noted to have a significant space between the end of his mattress and the foot board of his bed. Observation and interview in Resident #47's room on 7/13/2021 at 7:59 AM, Resident's left leg was noted to be hanging over the end of mattress in the area of the gap between the mattress and the foot board. Resident #47 stated, I left my room one day and came back, and I had this big gap at the end of my bed, maybe you could get me one that will fit the bed. Observation and interview in Resident #47's room on 7/13/2021 at 8:04 AM, Licensed Practical Nurse (LPN) Supervisor confirmed the mattress didn't fit the bed and there was a gap at the end of Resident #47's mattress and foot board. She stated, either the mattress or the bed needs to be adjusted. Observation and interview in Resident #47's room on 7/13/2021 at 8:05 AM, the Maintenance Director stated an extension is on the bed. Continued observation the Maintenance Director measured the gap from the end of the mattress to the foot board which measured 6 ½ inches. During an interview on 7/13/2021 at 10:30 AM, the Administrator confirmed zone 7 (referring to Siderail Entrapment Zones and Dimensional Recommendations) between the head or foot board and the mattress end is a potential for entrapment and there should not be a gap between the mattress and the foot board of a resident's bed.

Based on medical record review, observation, and interview the facility failed to cover a catheter bag for 1 of 6 sampled residents (Resident #42) observed. The findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Continued review revealed Resident #42 required an indwelling catheter. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Supra Pubic catheter . Observation in the resident's room on 7/12/2021 at 10:15 AM, 11:20 AM, and 3:48 PM, revealed Resident #42's urinary drainage bag was hanging on the right side of the bed not covered with a privacy cover. Observation and interview in the resident's room on 7/12/2021 at 3:55 PM, revealed Resident #42's urinary drainage bag hanging on the right side of the bed not covered with a privacy cover. Continued interview with Certified Nurse Aide (CNA) #5 confirmed the catheter bag was not covered with a privacy cover. During an interview on 7/14/2021 at 3:14 PM, the Director of Nursing and the Administrator confirmed the resident's urinary drainage bag should have been covered with a privacy cover.

Based on facility policy review, facility investigation review, medical record review, and interview the facility failed to ensure the safety and well-being of a resident and failed to protect a resident from verbal abuse and threats of physical abuse for 1 (Resident #2) of 4 residents reviewed for abuse. This failure resulted in HARM to the resident. The findings included: Review of facility policy, Abuse Prevention, revised 2/26/18, revealed .This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical, and/or mental abuse, corporal punishment, involuntary seclusion, or misappropriation of resident property by anyone .All alleged violations involving abuse, neglect, exploitation, or mistreatment and misappropriation are reported immediately to the Administrator and DON .Verbal abuse is any use of oral, written, or gestured language that willfully includes the disparaging and derogatory terms to residents or within hearing distance, regardless of age, ability to comprehend, or infirmities .A screening process will be completed on all new hires .Training on activities that constitute abuse, neglect, exploitation, and misappropriation will be held in new hire orientation and annual training .All allegations will be thoroughly investigated under the direction of the Administrator .The completed investigation will be forwarded to the Facility's Quality Assurance/Performance Improvement Committee for review . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #2 required extensive assistance of 1 person with transfers, dressing, toileting, grooming, and bathing; and was frequently incontinent of bowel and bladder. Medical record review revealed on 6/5/19 Resident #2 reported to a staff member that nurse (CNA#2 ) came into the bathroom and was very angry at her. She was fussing at her for getting food on her clothing. The resident reported the employee threatened to spank her. She later reported to DON (Director of Nursing) and Administrator the employee actually shook her once. Review of facility investigation of a written report from RN (Registered Nurse) #2 and written statement from CNA (Certified Nursing Assistant)#2 dated 6/5/19 revealed . They found Resident #2 in her room sitting on the bed crying. When asked why she was crying (named Resident #2) reported verbally to the nurse and (named CNA #1) I'm in trouble I got spaghetti on my pants. She (CNA #2) was fussing at (named Resident #2) and said why do I always do this to her. I'm going to spank you. The resident described the nurse as being tall and wearing glasses. CNA #2 entered the room and resident stated that is her. Resident taken to private location . RN #2 reported this incident to the DON. Interview with the DON and ADON (Assistant Director of Nursing) on 6/18/19 at 2:30 PM in the conference room revealed Resident #2 has a [DIAGNOSES REDACTED]. When she told her story she was crying and was obviously afraid of CNA #2. The CNA is quite tall and loud. Even to this day (6/18/19) both the DON and ADON stated (named Resident #2) asks if that woman is coming back so there is definitely a fear factor present. Some aspects of her story changed in retelling but the issue of the CNA threatening to spank her has never changed - it comes out every time she talks about the incident. Interview with Resident #2 on 6/18/19 at 3:10 PM in the dining room revealed she remembered the incident and said the nurse (CNA #2) told her she was throwing one of her fits and she just needed a spanking. She said she didn't want that nurse (CNA#2) back. Interview with CNA #1 and RN #2 on 6/18/19 at 3:30 PM in the Administrator's office revealed he and (named RN #2) were walking past the room of (named Resident #2) and saw she was crying. When they asked what was wrong she said she was in trouble because she spilled spaghetti on her pants and changed them. They asked who was upset with her she said the tall nurse with glasses. At that point CNA #2 tried to enter the room but CNA #1 told her not to come into the room. When she saw CNA #2 the resident said that's her. She said CNA #2 is tall, very loud and to the point he has had to tell her not to be so loud in the halls. The Administrator asked CNA #2 to leave the building and sent someone to sit with her in the courtyard. (named Resident #2) is like a child in that they will change pants if they are soiled. As of this date (named Resident #2) asks CNA #1 daily if that nurse is coming back and says I don't want her. In summary, Resident #2 stated CNA #2 scolded the resident for changing her pants by herself and threatened to spank the resident. Resident #2 is still asking (6/18/19) if that nurse is coming back and states she does not want her. Resident #2 suffered psychological harm as a result of the actions of CNA #2.

Based on review of facility policy, medical record review, review of Emergency Department records, review of a facility investigation, and interview, the facility failed to notify the Physician in a timely manner for changes in residents' condition for 2 residents (#24, #61) of 29 residents reviewed. The facility's failure to notify the Physician timely resulted in a delay in treatment and placed Resident #24 and #61 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:05 PM in the Administrator's office. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. The findings included: Review of facility policy, Change in a Resident's Condition or Status, undated revealed .To insure the proper and timely reporting and documentation of any changes in a resident's condition or status .Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status .Nursing services will notify the resident's attending physician when .The resident is involved in any accident or incident; including injuries of an unknown source .The nurse will record in the resident's medical record any changes in the resident's medical condition or status . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assistance of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness tissue loss) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (wound beneath healthy tissue) of 2 cm at 11:00 (anatomically speaking the wound is located at the 11:00 position on the face of a clock). Continued review of the Nurses' Notes revealed Resident #24 went to the Wound Clinic weekly for treatment of [REDACTED]. Review of a facility investigation dated [DATE] revealed Resident #24 had an appointment at the Wound Clinic on [DATE] at 7:45 AM for treatment of [REDACTED].#1 and CNA #17 were getting Resident #24 up and dressed for her appointment, she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 who assessed the resident but took no further action. Review of the facility investigation revealed upon return to the facility, CNA #3 observed the resident's knee appeared swollen with the knee cap leaned over and reported her observations to LPN #3. Continued review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Further review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Continued review of the facility investigation dated [DATE] revealed CNA #5 was showering the resident on [DATE] and noted the resident's .right knee was swollen and the knee was not sitting straight up the way it was on [DATE] . Continued review revealed CNA #3 informed LPN #5 of the swollen knee who agreed the knee was swollen and stated she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, warm to touch, and notified the Charge Nurse (LPN #4). Review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, painful and notified the Physician who gave an order for [REDACTED]. Review of the ED record dated [DATE] at 12:02 AM revealed Resident #24 had a history of [REDACTED]. Continued review of the ED records revealed a statement the Resident had no trauma and was non-ambulatory according to facility records. Review of the ED records revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint . (fracture of femur (long bone of thigh) into many parts and extending into the knee separating the surface of the bone into many parts). Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weight bearing, swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Medical record review of Nurses' Notes dated [DATE] revealed no documentation of an assessment, pain level, or the status of the resident's knee by LPN #9 or LPN #3. Medical record review of Nurses' Notes dated [DATE] at 5:39 PM revealed Resident #24 was noted to have a right swollen knee per LPN #5 and LPN #4 agreed the knee was swollen, warm, and painful to touch. Continued review revealed the Physician was notified and gave orders for the resident to be transferred to the hospital. Interview with CNA #3 on [DATE] at 2:30 PM on the 100 hall revealed when Resident #24 returned from the Wound Clinic her knee was swollen. Continued interview revealed she notified the Charge Nurse (LPN #3) the resident's knee was swollen on [DATE]. Further interview revealed CNA #3 took Resident #24 to her room and assisted her to bed. Further interview revealed CNA #3, who initially saw the knee upon return from the Wound Clinic knew something was wrong and told LPN #3 but no action was taken. Further interview revealed LPN #3 saw Resident #24 and decided there was nothing wrong so took no action. Continued interview revealed from [DATE] - [DATE] there was no documentation of observation of the resident's knee and no action was taken. Interview with CNA #5 on [DATE] at 6:20 AM in the conference room revealed when Resident #24 returned from the Wound Clinic on [DATE], her legs looked different. Continued interview revealed she asked the LPN #5 to look at the resident's legs. CNA #5 continued to state the knee was turned inward and the resident was in severe pain. Continued interview with CNA #5 revealed LPN #5 resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed the LPN #5 asked Physical Therapy (PT) if they could help with positioning. The therapist stated not to bother doing anything because the (Resident's) leg didn't look right. Interview with CNA #1 on [DATE] at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on [DATE] at 7:45 AM and (CNA #1) asked a co-worker to assist the resident with getting dressed and into a wheelchair for pickup. Continued interview revealed the resident had no complaints or abnormalities. Further interview revealed about 2:00 PM Resident #24 complained of leg pain and LPN #3 assessed the leg but found no concerns. Interview with the Director of Nursing (DON) on [DATE] at 4:03 PM in her office revealed Resident #24 had a right heel pressure ulcer which was treated at the Wound Clinic and complained of foot pain regularly. Continued interview revealed CNA #9 notified LPN #1 of the knee swelling who thought a PT consult was needed. Further interview revealed when the swelling was reported a second time the resident was transferred to the ED and the femur fracture was diagnosed . Interview revealed Resident #24 returned to the facility in late ,[DATE] from the hospital with a right above the knee amputation and gastric tube (feeding tube in stomach) and was in poor health at the time. Continued interview revealed a few days later the resident's blood pressure and blood glucose became elevated so she was sent to the hospital again. Further interview revealed Resident #24 returned to the facility on [DATE]; her heart stopped on [DATE]; and died . Continued interview revealed there was no conclusion as to the cause of the fracture. Further interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed CNA #2 who accompanied the resident to the appointment, stated Resident #24 was transferred using a stand-pivot method. Interview with the DON confirmed there was a delay in notifying the Physician so medical treatment could be obtained for Resident #24 when she had pain and swelling of her knee. Telephone interview with CNA #2 on [DATE] at 5:35 PM revealed there was no problem observed with the van ride or getting (Resident #24) in and out of the clinic. Continued interview revealed once inside the staff stood the resident up and eased her to the treatment bed using the stand-pivot method of transfer; eased her legs onto the bed; and propped her right leg on a pillow. Further interview with CNA #2 revealed she accompanied Resident #24 to and from the Wound Care Clinic in the van and offered to assist with the resident's transfer at the clinic but was not needed. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had co-morbidities of Diabetes Mellitus and [MEDICAL CONDITION]. On [DATE] upon return from the Wound Clinic, CNA #3 noted the resident's right knee was swollen. LPN #3 assessed the knee; felt there was no significant swelling; and failed to document her assessment. CNA #3 stated she told the Nurse about Resident #24's swollen knee and pain but the Nurse failed to document any assessment of the resident's knee and failed to notify the Physician. On [DATE] Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation the Physician was notified from [DATE]-[DATE] when CNAs stated they reported the resident had pain. Resident #24 was sent to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. During this time the pressure ulcer on the heel deteriorated and the resident required surgical intervention with a right above the knee amputation and insertion of a feeding tube, by which she received her nutrition. The resident subsequently developed pneumonia and a systemic infection, her heart stopped, and died . The facility failed to notify the Physician timely of Resident #24's complaints of pain and change in condition and a delay of care resulting in Immediate Jeopardy for Resident #24. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of [DATE]. An additional [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was severely cognitively impaired. Continued review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017 revealed .(Resident #61) was in the bed .This morning, ([DATE]) she said her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated [DATE] at 8:21 PM and signed by the Director of Nursing (DON) who documented .CNA reported that nurse on ,[DATE] (night shift) was made aware around 5 AM of resident's complaint of pain to right knee . Review of a witness statement signed by Licensed Practical Nurse (LPN) #9 dated [DATE] included in the facility investigation revealed, .When I went in resident's room to give pain med (medication) for rt (right) leg (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM (night shift) on [DATE] . Medical record review of the Nurses' Notes for [DATE] revealed no documentation by LPN #9 regarding the resident's voiced pain, a man had dropped her, or any pain medication was given. Medical record review revealed a Physician's Telephone Order dated [DATE] at 12:30 PM Stat (immediately) right knee x-ray due to swelling and pain . signed by LPN #7. Medical record review of a Nurses' Note dated [DATE] at 12:43 PM by LPN #7 revealed .resident complain(ed) of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (medical doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on (mobile x-ray) to come to facility for x-ray . Interview with the DON on [DATE] at 3:50 PM in the Assistant Director of Nursing's (ADON) office, confirmed the facility did not follow their policy on promptly notifying the resident's Physician when Resident #61 reported to LPN #9 around 5:30 AM to be in pain and someone had dropped her, resulting in a delay of treatment until it was reported to the Physician approximately 7 hours later. Interview with the Administrator on [DATE] at 5:08 PM in the ADON's office, regarding the delay in reporting of a change in status in the resident's condition, stated You're not telling us anything we didn't know, that's why we fired them (LPN #9, CNA #10). The surveyor verified the Allegation of Compliance by: 1. On [DATE] the on-call Nurse who failed to notify the DON of the incident for 3 days was in-serviced on timely reporting and quality of care. 2. On [DATE] all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On [DATE] all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 4. On [DATE] all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On [DATE] all staff were educated on Notification of Change and Condition. 6. On [DATE] staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, and Reporting all Resident Claims. 7. On [DATE] licensed staff were educated on Incomplete Data on the Medication Administration Records and Treatment Administration Records. 8. From [DATE] - [DATE] all staff were educated again on the Abuse Policy and Procedure, notification, and Reporting. 9. Review of daily audits on [DATE] and [DATE], of resident observations for change in pain, change or decline in condition, assessment as indicated with Physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Licensed Staff and CNAs assigned to each resident. 10. Interview with staff members on [DATE] regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims revealed they were able to discuss each of the topics. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction.

Based on facility policy review, medical record review, review of facility investigations, observation and interview, the facility failed to provide goods and services necessary to treat pain and provide prompt medical attention for 3 residents (#24,#61,#32) failed to prevent resident to resident abuse for 8 residents (#43, #62, #64, #67, #75, #81, #93, #167) reviewed for abuse of 48 sampled residents. The facility's failure to prevent neglect placed Resident #24, Resident #61, and Resident #32 in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The Administrator was notified of the Immediate Jeopardy on [DATE] at 4:05 PM in the Administrator's office. F-600 is Substandard Quality of Care. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. The findings included: Review of facility policy, Abuse Prevention Policy and Procedure, revised [DATE] revealed, The facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any staff member, other residents .It is the policy of this facility .to protect the residents from harm at all times, including protection from physical and verbal abuse from other residents .A resident to resident altercation should be reviewed as a potential situation of abuse .Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions . Medical record review revealed Resident #24 was admitted to the facility on [DATE], readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness wound where the wound extends below layers of healthy skin) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (wound beneath healthy tissue) of 2 cm at 11:00 (using a face of a clock showing 11:00 anatomically). Continued review of Nurses' Notes revealed Resident #24 went to an off-site Wound Clinic once weekly for treatment of [REDACTED]. Medical record review of Wound Clinic notes revealed Resident #24 had a pressure ulcer on her right heel which was necrotic and was debrided on [DATE] (prior to her admission to the facility). Continued review of the Wound Clinic notes dated [DATE] revealed the wound had deteriorated and the upper edges were necrotic. Further review of the Wound Clinic notes dated [DATE] revealed the wound had undermining; was debrided; and an x-ray was ordered to rule out osteo[DIAGNOSES REDACTED]. Continued review of the Wound Clinic notes dated [DATE] revealed Resident #24 had a Stage III pressure ulcer on the right heel longer than 9 months and the facility had been using [MEDICATION NAME] with minimal improvement. Further review revealed the ulcer measures 0.9 cm x by 0.6 cm x 1.8 cm with red granulation in the wound bed. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of Nurses' Notes dated [DATE] at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by Licensed Practical Nurse (LPN) #9. Medical record review of the MAR for ,[DATE] revealed no documentation of the Tylenol administration. Review of a facility investigation dated [DATE] revealed Resident #24 went to the Wound Clinic weekly. Continued review revealed when Certified Nursing Assistant (CNA) #1 and CNA #17 were getting the resident ready for her appointment when she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 of the resident's pain and slight swelling and LPN #9 assessed Resident #24. Continued review revealed upon return from the wound care clinic the resident's knee appeared swollen with the knee cap leaned over. CNA #3 reported her observations to the nurse. Further review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of Nurses' Notes dated [DATE] revealed no documentation of an assessment of the resident's knee by either LPN #9 or LPN #3. Medical record review of Nurses' Notes dated [DATE] at 3:19 PM revealed Resident #24 had no complaints of pain or discomfort. Medical record review of Nurses' Notes dated [DATE] at 8:45 AM revealed Resident #24 had no complaint of pain voiced. Continued review of the Nurses' Notes revealed at 1:07 PM the resident had no complaint or indication of pain. Further review of the Nurses' Notes at 1:11 PM revealed the resident's right heel had deteriorated with the wound being smaller but the depth had increased. Medical record review of the Comprehensive Care Plan revealed an update on [DATE] with a problem of swelling of the right knee and painful to touch. Continued review revealed approaches included cool compresses as needed; administer pain medications; inform provider; and X-ray if ordered and inform provider of results. Review of a PT evaluation dated [DATE] revealed Resident #24 was wheelchair bound prior to admission. Continued review revealed the resident required maximum assistance to go from supine to sitting as well as to roll from side to side for care. Further review revealed the resident required total assistance of 2 people to scoot up in bed. Review of a facility investigation dated [DATE] revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on [DATE]. Continued review revealed CNA #3 informed LPN #3 of the swollen knee who agreed the knee was swollen and said she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, warm to touch, and notified the Charge Nurse (LPN #4). Continued review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, and painful, notified the Physician who ordered transfer to the Emergency Department (ED). Further review of the facility investigation revealed the ED nurse called the facility to find out if the resident had fallen because she had a femur fracture. Review of the Emergency Department (ED) record dated [DATE] at 12:02 AM, revealed Resident #24 had a history of [REDACTED]. Continued review revealed a statement there was no trauma and the resident is non-ambulatory. Further review od the ED record revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint . (fracture of femur into many parts and extending into the knee separating the surface of the bone into many parts). Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weightbearing; swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Review of the hospital record of a consult from the Infectious Diseases Physician dated [DATE], revealed the right heel wound was necrotic and had an odor suggesting infection. Continued review revealed the Physician documented would require further medical or surgical debridement or right [MEDICAL CONDITION]. Further review revealed the Physician documented Resident #24 had very poor nutritional intake which was a risk factor for poor healing of a wound or surgical site. Continued review revealed the resident was very frail with Dementia and was expected to have poor quality of life. Further review revealed the Physician hoped the amputation could be done within the next week to avoid prolonged use of antibiotics with their side effects. Review of hospital notes dated [DATE] revealed Resident #24 underwent an .above the knee amputation of the right leg due to non healing distal right femoral shaft fracture, [MEDICAL CONDITION], non-healing right foot wound . Medical record review revealed Resident #24 returned to the facility on [DATE] with a right above the knee amputation, [DEVICE] (used to instill feeding directly into the stomach) and tube feeding infusing, as well as a Stage III pressure ulcer on the coccyx. Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 was admitted to the hospital with [REDACTED]. Continued review revealed Resident #24 was diagnosed with [REDACTED]. Review of a Physician's Note dated [DATE] revealed the resident had been doing poorly for the last few months and was expected to have poor quality of life. Continued review revealed the Hospitalist discussed the resident's medical condition with the family but they wanted aggressive measures. Further review of a Physician's Note dated [DATE] revealed .had long discussion with daughter and son. They want to continue full code and aggressive therapy. Patient is lethargic and encephalopathic . Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 had returned from the hospital. Medical record review of Nurses' Notes dated [DATE] revealed Resident #24 was .found by a CNA and it looked as if she was not breathing . Further review revealed the Nurse was notified and Cardiopulmonary Resusitation (CPR) was begun. Continued review revealed Resident #24 was transferred to the hospital where she expired. Review of the Certificate of Death revealed the cause of death included [MEDICAL CONDITION], Diabetes Mellitus with [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Telephone interview with LPN #9 on [DATE] at 10:35 AM revealed she had no idea Resident #24 had a [MEDICAL CONDITION] because no one had told her about it. Continued interview revealed Resident #24 had pressure ulcers on both heels and usually complained of heel pain. Further interview revealed when the resident complained of pain she assumed it was from the heel. Continued interview revealed the facility was unable to find a cause for the fracture. Interview with CNA #3 on [DATE] at 2:30 PM on the 100 hall revealed when Resident #24 came back from the Wound Clinic on [DATE], her knee was swollen. Continued interview revealed she notified LPN #3 about the knee. Further interview revealed CNA #3 took Resident #24 to her room and put her in bed. Medical record review of the ,[DATE] MAR indicated [REDACTED]. Medical record review of Nurses' Notes revealed no documentation LPN #9 or LPN #3 assessed the resident to determine her pain level or the status of the resident's knee. Interview with CNA #5 on [DATE] at 6:20 AM in the conference room revealed when Resident #24 returned from the Wound Clinic on [DATE], her legs looked different. Continued interview revealed she asked LPN #5 to look at the resident's legs and the knee was turned inward and the resident complained of severe pain. Continued interview revealed LPN #5 stated the resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed LPN #5 asked PT if they could help with positioning and the therapist stated not to bother doing anything because the leg didn't look right. Interview with CNA #1 on [DATE] at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on [DATE] and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the Nurse assessed the leg but found no concerns. Medical record review of the ,[DATE] MAR indicated [REDACTED]. Medical record review of Nurses' Notes dated [DATE] revealed no documentation LPN #5 assessed the resident's knee. Interview with the Director of Nursing (DON) on [DATE] at 4:03 PM in her office revealed Resident #24 had a heel pressure ulcer which was treated at the Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the Nurse of the knee swelling who thought a PT consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the hospital and the femur fracture was diagnosed . Interview revealed Resident #24 returned to the facility in late ,[DATE] with a right above the knee amputation and a PEG tube and was unstable at the time. Continued interview revealed a few days later the resident's blood pressure and glucose became unstable so she was sent to the hospital again. Further interview revealed Resident #24 returned to the facility on [DATE]; coded on [DATE]; and expired. Interview revealed there was no conclusion as to the cause of the fracture. Continued interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed the CNA who accompanied the resident to the appointment, finding out Resident #24 was transferred using a stand-pivot method. Interview the DON confirmed there was a delay in obtaining medical treatment for [REDACTED]. Telephone interview with CNA #2 on [DATE] at 5:35 PM revealed there was no problem observed with the van ride or getting Resident #24 in and out of the clinic. Continued interview revealed once inside the clinic the wound clinic staff stood the resident up; used a stand-pivot method to ease her to the treatment bed; eased her legs onto the bed; and propped her right leg on a pillow. Interview revealed the CNA (#5) who initially saw the knee upon return from the Wound Clinic knew something was wrong and told both the Charge Nurse and the facility Wound Care Nurse but no action was taken. Further interview revealed the Charge Nurse assessed Resident #24 and decided there was nothing wrong so took no action. Continued interview revealed from [DATE] - [DATE] there was little documentation of observation of the resident's knee and no treatment was provided. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had co-morbidities of Diabetes Mellitus and [MEDICAL CONDITION]. On [DATE] upon return from the Wound Clinic, the CNA noted the resident's right knee was swollen. The LPN assessed the knee; saw no significant swelling; and failed to document her assessment. The resident was also complaining of pain in her legs; the LPN stated in interview she administered Tylenol; but she failed to document the administration. The CNAs stated they told the nurses about Resident #24's swollen knee and pain but the Nurses failed to document any assessment of the resident's knee; Nurses failed to document administration of pain medication; and Nurses failed to notify the Physician of the resident's complaint of pain. On [DATE] Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation pain medication was administered when the resident was complaining of pain; the Physician was notified; Resident #24 was transferred to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. During this time the pressure ulcer on the heel deteriorated and the resident underwent [REDACTED]. The resident subsequently developed pneumonia [MEDICAL CONDITION]; coded; and died . The failure to notify the Physician in a timely manner of the swollen knee; failure to administer pain medication when the CNAs notified the Nurses the resident was complaining of pain; and the failure of the Nurses to document assessments of the resident's knee constituted neglect for Resident #24 at an Immediate Jeopardy level. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of [DATE]. An additional [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated [DATE] revealed Resident #61 was at risk for poor nutritional status related to [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated [DATE] revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Continued review of the Care Plan revealed the resident was at risk for falls related to decreased mobility, cognitive and physical function deficits. Further review revealed approaches for the Care Plan included bed in low position and safety mats at bedside. Continued review revealed Resident #61 required assistance with Activities of Daily Living (ADL's) due to decreased mobility, multiple chronic disease processes, generalized weakness and Above the Knee Amputation of the Left Leg. Further review revealed the resident had .Decreased vision related to: blind in left eye and poor vision in right eye. I do not wear glasses as they do not help me . Continued review revealed Resident #61 had cognitive loss present as evidenced by her short term memory loss. Medical record review of the MAR for [DATE] revealed Resident #61 had an order dated [DATE] for [MEDICATION NAME]/[MEDICATION NAME] (pain medication) ,[DATE] mg one tablet by mouth three times daily (TID) prn. Continued review revealed no [MEDICATION NAME] pain medication was administered [DATE] through [DATE]. Medical record review of the Nurses' Notes for [DATE] revealed no documentation by LPN #9 regarding the voiced pain, that a man had dropped her, or that any pain medication was administered. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017 revealed .(Resident #61) was in the bed .This morning, [DATE] she complain(ed) that her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated [DATE] at 8:21 PM and signed by the DON and documented .CNA reported that Nurse on ,[DATE] was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated [DATE] included in the facility investigation revealed, .When I went in (the) resident's room to give pain med (medication) for rt (right) leg that (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on [DATE] . Review of an interview conducted by LPN #2/Unit Manager with Resident #61 on [DATE] at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on. 4. ' Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review of a Physician's Telephone Order dated [DATE] at 12:30 PM revealed Stat (immediately) right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated [DATE] at 12:43 PM by LPN #7 revealed .resident complain(ed) of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (Medical Doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on mobile x-ray to come to facility for x-ray . Medical record review of a Social Service Note dated [DATE] revealed .SSD (Social Services Director) met with resident in room. Resident resting in bed with eyes open .Is HOH (hard of hearing) and suffers with vision problems which can make communication difficult at time(s), even when getting down at resident's level . Medical record review of a Social Servise Note dated [DATE] revealed .SSD met with resident in room .Could be heard yelling out which is baseline for resident . An interview was attempted with Resident #61. Although she was able to speak at the time of the incident, she had been in the hospital in the interval and was now unable to speak. Interview with LPN #7 on [DATE] at 7:55 AM on the 200 hall revealed she was passing medications the morning of [DATE] and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed the LPN went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and the LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to her pain level. The LPN stated she called the doctor and received an order for [REDACTED]. Interview with LPN #9 on [DATE] at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on [DATE] and completed on the morning of [DATE]. Surveyor asked LPN #9 what she remembered about Resident #61 the morning of [DATE] and LPN #9 stated the resident complained of foot and leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of the physician's orders [REDACTED]. Interview with CNA #10 on [DATE] at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on [DATE] and he notified LPN #9 and she went in to check on her. Interview with LPN #2 on [DATE] at 3:35 PM in the Restorative Nursing office revealed she came to the facility on [DATE] about dusk dark and assessed Resident #61 upon arrival. Continued interview revealed the resident told her that her leg was hurting. The Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on [DATE] at 3:50 PM in the Assistant Director of Nursing (ADON)'s office, confirmed the facility failed to follow their policy on administering pain medication. Continued interview with the DON confirmed the facility failed to promptly notify the resident's Physician when the resident had a change of status. These failures resulted in neglect, which is classified as abuse, due to Resident #61 not receiving pain medication and a delay in treatment of [REDACTED]. Interview with the Administrator on [DATE] at 5:08 PM in the ADON's office, after reviewing Resident #61's care regarding the reporting of pain with no pain medication given, and the neglect in the delay in reporting and a change in status in the resident's condition, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9, CNA #10) Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 14 indicating he was cognitively intact. Medical record review of the MAR indicated [REDACTED].[MEDICATION NAME] (opioid) 12 MCG (Micrograms)/HR (Hour) Patch apply on epatch (one patch) every 3 days for apin (pain). Rotate site . Was not documented as administered. Medical record review of the MAR for ,[DATE] revealed on [DATE] at 3:00 PM the resident's scored ,[DATE], (pain level scored from 1 - 10 with 1 being the lowest pain level and 10 being the highest pain level); on [DATE] at 3:00 PM it was ,[DATE]; on [DATE] it was ,[DATE], and on [DATE] it was ,[DATE]. Observation of Resident #32 on [DATE] at 12:20 PM in his room with the DON present revealed she performed a skin assessment. Continued observation revealed no [MEDICATION NAME] Patch could be located on the resident. Resident #32 stated .I was wondering why my hip was hurting . Interview with LPN #1 on [DATE] at 12:25 PM in Resident #32's room, revealed staff are notified to check placement of [MEDICATION NAME] Patch, when it pops each shift on the computer . Interview with LPN #1 on [DATE] at 2:33 PM in the Medication Room at the back Nurses' Station revealed Resident #32 needed another written prescription to be faxed to the pharmacy. I don't believe he got a [MEDICATION NAME] Patch on that day ([DATE]) Interview with LPN #2 on [DATE] at 3:15 PM revealed the Pharmacy was called regarding filling the Fenatyl patch. The original order was faxed on [DATE]. But mg was placed on the order instead of mcg. Continued interview revealed Resident #32 did not have a [MEDICATION NAME] Patch on and the correct order was faxed on [DATE]. Interview with the DON on [DATE] at 3:30 PM at the back Nurses Station confirmed the facility failed to ensure Resident #32 received his [MEDICATION NAME] Patch, which resulted in Resident #32 not receiving pain medication for 10 days and while experiencing pain. Medical record review revealed Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #43 scored 8 on the BIMS indicating she was moderately cognitively impaired. Medical record review revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #62 scored 12 on the BIMS, indicating she was mildly cognitively impaired. Review of the facility investigation revealed on [DATE] two residents (#43, #62) had an altercation. Continued review of a statement from the Activity Aide dated [DATE] revealed .At or around 4:05 PM while finishing up the movie matinees, I witnessed two residents (#43, #62) in a fist fight in the middle of the room. As I was trying to separate the two (#62) would not let go of (#43) arm and would not stop hitting her . Further review of the facility investigation on [DATE] revealed a statement from Resident #85 who stated she witnessed both residents hitting one another but (Resident #62) started it. Continued review of the facility investigation revealed a statement from another resident who stated .Resident #62) pinched (Resident #43) and (Resident #43) pinched back and they started fighting . Medical record review of Nurses' Notes dated [DATE] revealed LPN #2 was called to the dining room by the Activity Director and found Resident #62 in a physical altercation with Resident #43. Continued review revealed Resident #62 stated She hit me. Further review revealed the residents were separated but Resident #62 hit Resident #43 on the back of the shoulder. Continued review revealed Resident #62's son requested the resident be sent to the ED. Interview with the DON on [DATE] at 2:30 PM in the DON's office, confirmed Resident #43 and Resident #62 were involved in a resident-to-resident altercation. Medical record review revealed Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #167 had a BIMS of 3 indicating the resident as severely cognitively impaired. Review of facility investigation dated [DATE] revealed Resident #43 was in the dining when she was hit with a coffee cup by Resident #167. Interview with Resident #43 on [DATE] at 8:15 AM in her room revealed Resident #167 hit Resident #43 on the head with a coffee cup and Resident #43 hit Resident #167 on the shoulder. Interview with the LPN #2 on [DATE] at 10:57 AM at the front Nurses Station revealed LPN #2/Unit Manager was called to the dining room because Resident #167 threw a coffee cup at Resident #43. When LPN #2/Unit Manager got to the dining room she observed Resident #167 was agitated and was slinging her arms and trying to self-propel. Resident #43 was seated at another table. Continued interview with LPN #2/Unit Manager confirmed the facility failed to prevent the resident to resident altercation. Medical record review revealed Resident #64 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED].

Based on facility policy, medical record review, observation, and interview, the facility failed to accurately document administered medication on the Medication Administration Record [REDACTED]. The facility's failure to accurately document and ensure medication was administered resulted in further pain and placed Resident #24, #61, and #32, in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 2/28/18 at 4:05 PM in the Administrator's office. The Immediate Jeopardy was effective from 11/21/17 - 2/23/18. An Acceptable Allegation of Compliance which removed the Immediacy of teh Jeopardy was received and corrective actions were validated through review of documents, observation, and staff interivews conducted onsite on 3/2/18. The findings included: Review of facility policy, Medication: Controlled Drugs, revised 6/16/16 revealed .Records must be accurate and include: Name of the resident, Prescription number and name of issuing pharmacy, Drug name and strength, Medication form, Route of administration, Strength and dose administered, Date and time of administration, Signature of the person administering the drug . Medical record review revealed Resident #24 was admitted to the facility on [DATE], 12/27/17, and 1/15/18, with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness wound (where the wound extends below layers of healthy skin) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (undermining is wound beneath healthy tissue) of 2 cm at 11:00 (using a face of a clock showing 11:00 anatomically). Continued review of Nurses' Notes revealed Resident #24 went to the off-site Wound Clinic once weekly for treatment of [REDACTED]. Medical record review of the Medication Administration Record [REDACTED]. Medical record review of Nurses' Notes dated 11/20/17 at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by LPN #9. Medical record review of the MAR for 11/2017 revealed no documentation of the Tylenol administration. Review of a facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic for treatment to her heels. Continued review revealed when CNA (Certified Nursing Assistant) #1 and CNA #17 were getting the resident ready for her appointment she complained of leg pain. Further review revealed CNA #1 notified Licensed Practical Nurse (LPN) #9 of the pain and slight swelling and LPN #9 assessed Resident #24. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. CNA #3 reported her observations to LPN #3. Further review revealed LPN #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of Nurses' Notes dated 11/21/17 revealed no documentation of an assessment of the resident's knee by either LPN #9 or LPN #3. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Interview with CNA #1 on 2/1/18 at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on 11/21/17 and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the nurse assessed the leg but found no concerns. Medical record review of the 11/2017 MAR indicated [REDACTED]. Medical record review of Nurses' Notes dated 11/21/17 revealed no documentation LPN #5 assessed the resident's knee. Interview with the DON on 2/1/18 at 4:03 PM in her office revealed Resident #24 confirmed there was no documentation of any assessments by the LPNs regarding Resident #24's pain level and status of the knee. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional [DIAGNOSES REDACTED]. Medical record of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was not cognitively intact. Continued review revealed the resident had clear speech with distinct intelligible words, made herself understood and understands with clear comprehension. Further review revealed Resident #61 required extensive assistance with bed mobility and was totally dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of the MAR for December 2017 revealed Resident #61 had an order dated 12/4/17 for [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligrams, one tablet by mouth three times daily prn (as needed). Continued review revealed no [MEDICATION NAME]/[MEDICATION NAME] pain medication was administered 12/4/17 through 12/9/17. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017, revealed .(Resident #61) was in the bed .This morning, 12-9-2017 she complained that her knee was hurting .As I was changing her she complained of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM signed by the DON and documented .CNA reported that nurse on 11-7 was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med (medication) for rt (right) leg that (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Review of an interview conducted by LPN #2/Unit Manager with Resident #61 on 12/9/17 at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on.' Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review of the Nurses' Notes for 12/9/17 revealed no documentation by LPN #9 regarding the voiced pain, that a man had dropped her, or that any pain medication was administered. Medical record review revealed a Physician's Telephone Order dated 12/9/17 at 12:30 PM Stat (immediately) right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain(ed) of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (Medical Doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on mobileex (mobile x-ray) to come to facility for x-ray . Interview with LPN #9 on 1/31/18 at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. Surveyor asked LPN what she remembered about Resident #61 the morning of 12/9/17 and LPN stated the resident complained of foot/leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of the physician's orders [REDACTED]. Interview with CNA #10 on 1/31/18 at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed she came to the facility on [DATE] about dusk dark and she went and assessed Resident #61 upon arrival. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on 2/1/18 at 3:50 PM in the Assistant Director of Nursing office, after discussion of Resident #61's complaint of being dropped and of knee pain, confirmed the facility failed to follow their policy on administering and documenting pain medication. Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #32 had a Brief Interview Mental Status (BIMS) of 14 indicating he was cognitively intact. Medical record review of the MAR indicated [REDACTED]. Rotate site . Further review revealed the medication was not administered as ordered on [DATE], 1/26/18, and 1/29/18. Continued review revealed the medication placement was not checked as ordered on [DATE], 1/26/18, and 1/29/18. Interview with the resident in the resident's room revealed the resident stated no wonder I was hurting. Medical record review of the 1/2018 MAR indicated [REDACTED]. Further review revealed the medication was not administered as ordered on [DATE], 1/22/18, and 1/23/18. Medical record review of the Controlled Drug Record dated 1/12/18 revealed .[MEDICATION NAME]-Acetamin (sic) 5 mg- 325 mg 1 TAB by Mouth Three times Daily . Further review revealed the medication was signed out on the dates 1/21/18 at 9:00 PM, 1/22/18 at 2:00 PM, and 1/23/18 at 6:00 AM. Interview with Registered Nurse #2/Unit Manager on 2/1/18 at 3:47 PM in his office revealed there were some issues with the computer and the Electronic Medication Administration Record [REDACTED]. Continued interview confirmed the documented medication was not given in order to clear the EMAR. Interview with Director of Nursing (DON) on 2/1/18 at 4:00 PM in her office revealed the computer screen would lock up for the incoming Nurse if the previous Nurse did not complete documentation for administration. Continued interview revealed RN #2 had management access and inaccurately documented the narcotics were not administered to Resident #32. This inaccuracy could result in a potential for Resident #32 to recieve the drug twice. The Surveyor verified the Allegation of Compliance by: 1. On 11/27/17 the on-call Nurse who failed to notify the DON of the incident for 3 days was in-serviced on timely reporting and quality of care. 2. On 11/27/17 all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On 11/27/17 all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 4. On 11/27/17 all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On 11/29/17 all staff were educated on Notification of Change and Condition. 6. On 12/9/17 staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, and Reporting all Resident Claims. 7. On 2/2/18 licensed staff were educated on Incomplete Data on the Medication Administration Records and Treatment Administration Records. 8. From 2/5/18 - 2/23/18 all staff were educated again on the Abuse Policy and Procedure, notification, and Reporting. 9. Review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with Physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Licensed Staff and CNAs assigned to each resident. 10. Interview with staff members regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims and they were able to discuss each. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F580 Refer to F-600 Substandard Quality of Care Refer to F-641 Refer to F-697 Substandard of Quality Care

Based on facility policy review, medical record review, observation, and interview, the facility failed to manage or prevent pain to help residents attain or maintain the highest practicable level of well being for 3 residents (#24, #61, #32) of 29 residents reviewed for pain. This failure to manage pain effectively placed Resident #24, Resident #61, and Resident #32 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy on 2/28/28 at 4:05 PM in the Administrator's office. F-697 is Substandard Quality of Care. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 3/2/18. The Immediate Jeopardy was effective from 11/21/17 through 2/23/18. The findings included: Review of facility policy, Pain Management, undated revealed .Pain is defined as an individual's unpleasant sensory or emotional experience. Acute pain is pain of abrupt onset or escalation. Chronic pain is pain that is persistent or recurrent. Pain is a highly subjective, personal experience for which there are no consistent objective biological markers .In the long-term care setting the comfort and well-being of the individual resident should always be paramount .Adequate pain management should be sought in each case .The same pain control measures that are used for residents who are able to communicate should be used for residents unable to communicate their pain due to dementia, [MEDICAL CONDITION] or other causes . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Medical record review of Wound Care Notes dated 11/21/17 revealed Resident #24 was admitted to the facility with a Stage IV pressure ulcer (full thickness tissue loss with extensive destruction) to the right heel, measuring 1.2 centimeters (cm) x (by) 1.5 cm x 1.3 cm with undermining (deep tissue damage) of 2 cm at 11:00 (using the 11:00 o'clock position on a clock). Continued review of Nurses' Notes revealed Resident #24 went off-site to the Wound Clinic weekly for treatment of [REDACTED]. Medical record review of Wound Clinic notes dated 11/21/17 revealed Resident #24 had a Stage III ulcer (full thickness loss to tissue) on the right heel longer than 9 months and the facility had been using [MEDICATION NAME] (wound care mixture) with minimal improvement. Further review revealed the pressure ulcer measures 0.9 centimeters (cm) x (by) 0.6 cm x 1.8 cm with red granulation in the wound bed. Medical record review of the Medication Administration Record (MAR) for 11/2017 revealed Resident #24 was ordered [MEDICATION NAME] (Tylenol) 325 milligrams (mg), give 2 tablets every 4 hours as needed. Medical record review of Nurses Notes dated 11/20/17 at 9:22 AM revealed Resident #24 complained of heel pain and was medicated with Tylenol 650 mg by LPN #3. Medical record review of the MAR for 11/2017 revealed no documentation of the Tylenol administration. Review of facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic. Continued review revealed when CNA #1 and CNA #17 were getting Resident #24 ready for her appointment, when she complained of leg pain. Further review revealed CNA #1 reported the resident's pain to LPN #9 who assessed the leg but took no action. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. Certified Nurse Aide (CNA) #3 reported her observations to the nurse. Further review revealed Licensed Practical Nurse (LPN) #3 assessed the resident who complained of heel pain when questioned. Continued review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified a second time and assessed the resident, but did not observe excessive swelling to the leg. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Review of facility investigation dated 11/27/17 revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on 11/21/17. Continued review revealed CNA #5 informed LPN #5 of the swollen knee who agreed the knee was swollen and said she would have Physical Therapy look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, and warm to touch, and notified the Charge Nurse (LPN #4). Continued review revealed LPN #4 assessed the right knee of Resident #24 and agreed it was swollen, warm, and painful and notified the physician who ordered transfer to the Emergency Department (ED). Further review of the facility investigation revealed the ED nurse called the facility to find out if the resident had fallen because she had a femur fracture. Review of the Emergency Department (ED) record dated 11/25/17 at 12:02 AM, revealed Resident #24 had a history of [REDACTED]. Continued review revealed a statement there was no trauma and the resident is non-ambulatory. Continued review revealed the resident suffered a .comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint .(fracture of femur into many parts and extending into the knee separating the surface of the bone into many parts) Review of the ED information sheet revealed .Elderly people typically have poor bone quality and a fall from a standing position can cause such a fracture. Symptoms of this type of fracture include pain with weightbearing; swelling and bruising; tenderness to touch; knee may look out of place and the leg may appear shorter and crooked . Medical record review of the Comprehensive Care Plan revealed an update on 11/24/17 with a problem of swelling of the right knee and painful to touch. Continued review revealed approaches included cool compresses as needed; administer pain medications; inform provider; and X-ray if ordered and inform provider of results. Telephone interview with LPN #9 on 1/31/18 at 10:35 AM revealed she had no idea Resident #24 had a [MEDICAL CONDITION] because no one had told her about it. Continued interview revealed Resident #24 had pressure ulcers on both heels and usually complained of heel pain. Further interview revealed when the resident complained of pain she assumed it was from the heel. Continued interview revealed the facility was unable to determine the cause for the fracture. Interview with CNA #3 on 1/31/18 at 2:30 PM on the 100 hall revealed when Resident #24 came back from the Wound Clinic her knee was swollen. Continued interview revealed she told the LPN #3 about the knee. Further interview revealed CNA #3 took Resident #24 to her room and put her into bed. Medical record review of the 11/2017 MAR revealed no documentation Tylenol was administered. Interview with CNA # 5 on 2/1/18 at 6:20 AM in the conference room revealed when Resident #24 came back from the Wound Clinic on 11/21/17, her legs looked different. Continued interview revealed she asked LPN #4 look at the resident's legs and the knee was turned inward and she complained of pain. Continued interview revealed LPN #5 said the resident's knee was not right and she would notify the Charge Nurse (LPN #4). Further interview revealed the LPN #5 asked Physical Therapy if they could help with positioning and the therapist stated not to bother doing anything because the leg didn't look right. Interview with CNA #1 on 2/1/18 at 6:35 AM in the conference room revealed Resident #24 had an appointment at the Wound Clinic on 11/21/17 at 7:45 AM and she asked a co-worker to help get the resident dressed and into a wheelchair for pickup. Continued interview revealed about 2:00 PM Resident #24 complained of leg pain and the LPN assessed the leg but found no concerns. Medical record review of the 11/2017 MAR revealed no documentation of Tylenol administration in spite of the resident complaining of pain. Interview with the Director of Nursing (DON) on 2/1/18 at 4:03 PM in her office revealed Resident #24 had a heel pressure ulcer which was treated at the off-site Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the nurse of the knee swelling who thought a physical therapy consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the hopsital Emergency Department (ED) and the femur fracture was diagnosed . Continued interview revealed there was no conclusion as to the cause of the fracture. Further interview revealed the DON called the Wound Clinic to find out how the resident was transferred and interviewed CNA #2 who accompanied the resident to the appointment, finding out Resident #24 was transferred using a stand-pivot method. Continued interview with the DON confirmed Resident #24 did not receive appropriate pain management. Telephone interview with CNA #2 on 2/1/18 at 5:35 PM revealed there was no problem observed with the van ride or getting Resident #24 in and out of the clinic. Continued interview revealed once inside the (wound clinic) staff stood the resident up and eased her to the treatment bed; eased her legs onto the bed; and propped her right leg on a pillow. Interview with CNA #3 saw the knee upon return from the Wound Clinic and knew something was wrong and told both LPN #3 and LPN #4. Further interview revealed LPN #3 saw Resident #24 and decided there was nothing wrong. Continued interview revealed from 11/21/17 - 11/23/17 there was little documentation of observation of the resident's knee. In summary, Resident #24 was admitted to the facility on [DATE] with a right heel Stage IV pressure ulcer. The resident had comorbidities of Diabetes Mellitus and [MEDICAL CONDITION]. On 11/21/17 upon return from the Wound Clinic, CNA #3 noted the resident's right knee was swollen. The resident was complaining of pain in her legs; LPN #3 stated in interview she administered Tylenol; but she failed to document the administration. The CNAs stated they told the nurses about Resident #24's swollen knee and pain however, the nurses failed to document any assessment of the resident's knee and failed to document administration of pain medication. On 11/24/17 Nurses' Notes revealed the first documentation of the resident's knee being swollen, painful, and warm to touch. There is no documentation pain medication was administered for the knee when the resident complained of pain. The Physician was notified on 11/24/17 and Resident #24 was sent to the ED where a comminuted interarticulated displaced angulated distal femoral fracture extending into the knee joint was identified. The failure to administer pain medication when the CNAs notified the Nurses' the resident was complaining of pain constituted inadequate pain management for Resident #24. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #61 had a Brief Interview of Mental Status (BIMS) score of 1 indicating the resident was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was total dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed resident had a range of motion limitation in the upper and lower extremities on both sides. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated 12/29/16 revealed Resident #61 was at risk for poor nutritional status related to [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 1/4/17 revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Medical record review of the Medication Administration Record, (MAR) for December 2017 revealed Resident #61 had an order dated 12/4/17 for [MEDICATION NAME]/[MEDICATION NAME] (pain medication) 5/325 milligrams, one tablet by mouth three times daily prn. Continued review revealed no [MEDICATION NAME] pain medication was administered 12/4/17 through 12/9/17. Continued review revealed there was no order for Tylenol. Review of a witness statement signed by CNA #10 dated Saturday, 9, 2017 revealed .(Resident #61) was in the bed .This morning, 12-9-2017 she complain(ed) her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM and signed by the DON who documented .CNA reported that nurse on 11:00 PM-7:00 AM was made aware around 5:00 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN (Licensed Practical Nurse) #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med (medication) for rt (right) leg that (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Review of a witness statement signed by LPN #7 dated 12/9/17 revealed .When passing AM (morning) meds (medications) resident was complaining her knee was hurting while they transferred her to her chair. After being in chair resident was calm. I ask her why she was yelling. She said that man drop(ped) her while putting her in bed. Resident then told (RN #2) the same thing about being drop(ped). Resident calm and quiet while in chair, sleeping at intervals in chair. After lunch resident was put to bed and calm the rest of the shift waiting to be x-rayed . Medical record review of the Nurse Notes for 12/9/17 revealed no documentation by LPN #9 regarding voiced pain, that a man had dropped her, or that any pain medication was administered. Medical record review of a Physician's Telephone Order dated 12/9/17 at 12:30 PM revealed Stat (immediately) right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (medical doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on mobil x-ray to come to facility for x-ray . Medical record review of the hospital History and Physical to which Resident #61 was transferred to dated 12/9/17 revealed .The patient is a [AGE] year old lady who was sent to ED (Emergency Department) this evening from her nursing facility for a suspicion of right femoral fracture . Continued review revealed Resident #61 had been admitted to this hospital in December 2016 for generalized weakness and again in November 2017 for an episode of coffee-ground emesis. Further review revealed .She is status [REDACTED].She is immobile and is blind in the left eye and is significantly deaf .She seems reasonably comfortable, resting in bed, but does hurt when her left leg is manipulated .She has been apparently bed bound at the nursing home for at least the last year and it is not clear how she broke her right leg at this point . Interview with LPN #7 on 1/31/18 at 7:55 AM on the 200 hall revealed she was passing medications the morning of 12/9/17 and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed LPN #7 went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to her pain level. LPN stated she called the doctor and received an order for [REDACTED]. Continued interview revealed the mobile x-ray service came at the change of shift around 2:30 - 3:00 PM on 12/9/17. Telephone interview with LPN #9 on 1/31/18 at 10:18 AM by telephone revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. Surveyor asked LPN #9 what she remembered about Resident #61 the morning of 12/9/17 and LPN #9 stated the resident complained of foot and leg pain a lot and then stated I gave her Tylenol that morning. Medical record review of Physician order [REDACTED]. Telephone interview with CNA #10 on 1/31/18 at 11:08 AM by telephone revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed on 12/9/17 she went and assessed Resident #61. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the Director of Nursing (DON) on 2/1/18 at 3:50 PM in the Assistant Director of Nursing's (ADON) office, after discussion of Resident #61's complaint of being dropped and of knee pain, confirmed the facility did not follow their policy on administering pain medication when a resident reported to be in pain. Interview with the Administrator on 2/1/18 at 5:08 PM in the ADON's office, after reviewing Resident #61's care regarding the reporting of pain and no pain medication given, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9. CNA #10) Medical record review revealed Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #32 had a BIMS of 14 indicating he was cognitively intact. Medical record review of the MAR dated 1/2018 revealed for dates 1/23/18 thru 1/26/18 .[MEDICATION NAME] (opioid) 12 MCG (Micrograms)/HR (Hour) Patch apply on epatch (one patch) every 3 days for apin (pain). Rotate site . Was not documented as administered. Observation of Resident #32 on 1/31/18 at 12:20 PM in his room with the DON present revealed she performed as skin assessment. Continued observation revealed no [MEDICATION NAME] Patch could be located on the resident. Resident #32 stated .I was wondering why my hip was hurting . Interview with LPN #1 on 1/31/18 at 12:25 PM in Resident #32's room, was interviewed on how staff was notified when to check placement of [MEDICATION NAME] Patch. LPN #1 responded .The computer has a reminder that pops each shift . Interview with LPN #1 on 2/1/18 at 2:33 PM in the Medication room at the back nurses' station revealed Resident #32 needed another hard script to be faxed to pharmacy. I don't believe he got a [MEDICATION NAME] Patch on that day. Interview with LPN #2 on 2/1/18 at 3:15 PM revealed the pharmacy was called on 1/31/18. The original order was faxed on 1/23/18. But MG (Milligrams) was placed on the order instead of MCG (Micrograms). Continued interview revealed Resident #32 did not have a [MEDICATION NAME] Patch on and the order was refaxed on 1/31/18. Interview with the DON on 2/1/18 at 3:30 PM at the back nurses station confirmed the facility failed to ensure Resident #32 received his [MEDICATION NAME] Patch (pain patch), which resulted in Resident #32 not receiving the [MEDICATION NAME] for 10 days and the resident complaining of pain. The surveyor verified the Allegation of Compliance by: 1. On 12/4/18 - 12/5/18 pain assessments were completed on all residents with no further residents being affected and reviewed on 3/1/18. 2. On 2/2/18 licensed staff were educated on Incomplete Data on MAR and TAR, and [MEDICATION NAME] Patch and Verification. 3. On 2/28/18 review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Charge Nurse and CNA assigned to each resident. 4. On 3/2/18 observation of all residents with [MEDICATION NAME]es revealed patches were in place; dated with the date of placement; and dosage. 5. On 3/1/18 review of audits comparing pain medication ordered and its presence in the medication cart. 6. On 3/2/18 review of pain assessments revealed they were current on all residents. 7. On 3/1/18 - 3/2/18 interview with licensed staff members regarding [MEDICATION NAME]es, placement, verification of dosage, ordering patches, and how to handle Pharmacy issues revealed they were aware of the correct procedures. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F-580 Refer to F-600 Substandard Qualtiy of Care Refer F-641

Based on review of facility policy, review of facility investigation, medical record review, and interview, the facility failed to correctly document residents' medical problems including assessments of residents with pain for 2 residents (#24, #61) of 48 residents reviewed. The facility's failure to provide accurate assessments placed Resident #24 and Resident #61 in Immediate Jeopardy (a situation where the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death to a resident). The Administrator was notified of the Immediate Jeopardy on 2/28/18 at 4:05 PM in the Administrator's office. The Immediate Jeopardy was effective from 11/21/17 through 2/23/18. An Acceptable Allegation of Compliance which removed the immediacy of the jeopardy was received and corrective actions were validated through review of documents, observations, and staff interviews conducted onsite on 3/2/18. The findings included: Review of facility policy, Pain Management, undated revealed .Pain is defined as an individual's unpleasant sensory or emotional experience. Acute pain is pain of abrupt onset or escalation. Chronic pain is pain that is persistent or recurrent. Pain is a highly subjective, personal experience for which there are no consistent objective biological markers .In the long-term care setting the comfort and well-being of the individual resident should always be paramount .Adequate pain management should be sought in each case .The same pain control measures that are used for residents who are able to communicate should be used for residents unable to communicate their pain due to dementia, [MEDICAL CONDITION] or other causes . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #24 scored 9 on the Brief Interview for Mental Status (BIMS) indicating she was moderately cognitively impaired. Continued review of the MDS revealed Resident #24 required extensive assistance of 2 people for transfers and dressing; extensive assist of 1 person for grooming and bathing; and was always incontinent of bowel and bladder. Further review revealed Resident #24 was non-ambulatory; was placed in a wheelchair; and was unable to propel the wheelchair. Review of a facility investigation dated 11/21/17 revealed Resident #24 went to the Wound Clinic weekly for treatment to the right and left heels. Continued review revealed upon return the resident's knee appeared swollen with the knee cap leaned over. Certified Nurse Aide (CNA) #3 reported her observations to the Nurse. Further review revealed Licensed Practical Nurse (LPN) #3 assessed the resident who complained of heel pain when questioned. Review revealed CNA #1 later transferred the resident who complained of leg pain; LPN #3 was notified and assessed the resident, but did not observe swelling to the leg. Medical record review of Nurses' Notes dated 11/21/17 revealed no documentation of an assessment by LPN #3 or LPN #9. Medical record review of the MAR for 11/2017 revealed no documentation Tylenol was administered for the resident's complaint of pain. Medical record review of Nurses' Notes on 11/23/17 at 1:11 PM revealed the resident's right heel had deteriorated with the wound being smaller but the depth had increased. Review of a facility investigation dated 11/24/17 revealed CNA #3 was showering the resident and noted the resident's right knee was swollen and the knee was not sitting straight up the way it was on 11/21/17. Continued review revealed CNA #3 informed LPN #10 of the swollen knee who agreed the knee was swollen and stated she would have Physical Therapy (PT) look at it. Further review revealed LPN #5 observed the knee to be swollen, painful to move, and warm to touch, and notified the Charge Nurse (LPN #4). Medical record review of Nurses' Notes dated 11/24/17 at 5:39 PM revealed Resident #24 was noted to have a right swollen knee per LPN #5 and LPN #4 agreed the knee was swollen, warm, and painful to touch. Continued review revealed the Physician was notified at 5:39 PM by LPN #4 and gave orders for the resident to be transferred to the hospital. Review of the facility investigation revealed the ED nurse called the facility to ask if the resident had fallen because she had a femur fracture. Interview with the Director of Nursing (DON) on 2/1/18 at 4:03 PM in her office revealed Resident #24 had a heel ulcer which was treated at the Wound Clinic. Continued interview revealed she complained of foot pain regularly. Further interview revealed the CNA notified the nurse of the knee swelling who thought a PT consult was needed. Continued interview revealed when swelling was reported a second time the resident was transferred to the Emergency Department (ED) and the femur fracture was diagnosed . Further interview with the DON confirmed Nurses had failed to assess Resident #24 appropriately when the CNAs reported the resident was having leg pain. Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] and 12/12/17 with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged to the hospital on the evening of 12/9/17. An additional [DIAGNOSES REDACTED]. Medical record of the Quarterly MDS dated [DATE] revealed Resident #61 had a BIMS score of 1 indicating the resident was was severely cognitively impaired. Further review revealed Resident #61 required extensive assistance with bed mobility and was total dependent for transfer, dressing, toilet use, personal hygiene and bathing. Continued review revealed the resident had a range of motion limitation in the upper and lower extremities on both sides and was unable to ambulate. Further review revealed the resident received PRN (as needed) pain medication. Medical record review of a Care Plan dated 12/29/16 revealed Resident #61 was at risk for poor nutritional status related to [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated 1/4/17 revealed Resident #61 was at risk for alteration in comfort related to a history of right leg pain, decreased mobility, and multiple chronic disease processes. Continued review of the Care Plan revealed the resident was a risk for falls related to decreased mobility, and cognitive and physical function deficits. Further review revealed approaches for the Care Plan included bed in low position and safety mats at bedside. Continued review revealed Resident #61 required assistance with Activities of Daily Living (ADLs) due to decreased mobility, multiple chronic disease processes, generalized weakness and Above the Knee Amputation (AKA) of the Left Leg. Further review revealed the resident had .Decreased vision related to: blind in left eye and poor vision in right eye. I do not wear glasses as they do not help me . Continued review revealed Resident #61 had cognitive loss present as evidenced by her short term memory loss. Medical record review of the Medication Administration Record, (MAR) for December 2017 revealed Resident #61 had an order dated 12/4/17 for [MEDICATION NAME]/[MEDICATION NAME] (pain medication) 5/325 milligrams (mg), one tablet by mouth three times daily (TID) as needed (PRN). Continued review revealed no [MEDICATION NAME] pain medication was administered 12/4/17 through 12/9/17. Review of a witness statement signed by Certified Nurse Aide (CNA) #10 dated Saturday, 9, 2017 revealed .(Resident #61) was in the bed .This morning, 12-9-2017 she complain(ed) that her knee was hurting .As I was changing her she complain(ed) of pain in her knee . Continued review of the witness statement revealed an addendum dated 12/9/17 at 8:21 PM and signed by the Director of Nursing (DON) and documented .CNA reported that nurse on 11 AM-7 PM shift was made aware around 5 AM of residents complaint of pain to right knee . Review of a witness statement signed by LPN #9 dated 12/9/17 included in the facility investigation revealed, .When I went in resident's room to give pain med (medication) for rt (right) leg that (CNA #10) told me she was hurting she mentioned that man dropped me .This occurred between 5:30 AM and 6:00 AM on 12/9/17 . Medical record review of the Nurses' Notes for 12/9/17 revealed no documentation by LPN #9 regarding the voiced pain, a man had dropped her, any assessment of the resident for injuries, or any pain medication was administered. Review of a facility investigation and an interview conducted by LPN #2/Unit Manager with Resident #61 on 12/9/17 at 5:50 PM revealed .1. Can you tell me what happened? 'I fell out of bed and that man picked me up. I fell last night.' 2. Date and Time of day/night when the incident occurred? 'Last night.' 3. Who was involved? Give name and/or description of person(s). 'Tall boy, brown skinned, with uniform on.' 4. Were there witnesses? 'No.' 5. When did you report this incident? 'My leg hurt all day.' 6. Who did you report this incident to? 'I told a nurse.' 7. Is this the first time this incident or a similar incident has occurred? If no, explain: 'My leg hurt lady.' . Medical record review revealed a Physician's Telephone Order dated 12/9/17 at 12:30 PM revealed Stat (immediately) right knee x-ray due to swelling and pain . and signed by LPN #7. Medical record review of a Nurses' Note dated 12/9/17 at 12:43 PM by LPN #7 revealed .resident complain(ed) of R (right) knee pain stated she was drop(ped) by a man last night right knee noted to be swollen painful to touch or move MD (medical doctor) made aware order to have x-ray done and call him .will continue to monitor waiting on mobile x-ray to come to the facility for x-ray . Medical record review of a Social Service Note dated 12/13/17 revealed .SSD (Social Services Director) met with resident in room. Resident resting in bed with eyes open .Is HOH (Hard of Hearing) and suffers with vision problems which can make communication difficult at time, even when getting down at resident's level . Medical record review of a Social Service Note dated 12/13/17 revealed .SSD met with resident in room .Could be heard yelling out which is baseline for resident . Interview with LPN #7 on 1/31/18 at 7:55 AM on the 200 hall revealed she was passing medications the morning of 12/9/17 and she heard Resident #61 hollering out. Continued interview revealed the resident hollered out a lot but this was a different tone. Further interview revealed the LPN went to Resident #61's room to check on her and staff were getting the resident up in her geri-chair. Continued interview revealed Resident #61 said her leg hurt and that a man had dropped her. Surveyor asked What did her leg look like? and the LPN stated the resident's knee was swollen but no bruising, she had pain with movement. Continued interview revealed Once she was in her chair she was ok referring to Resident #61's pain level. The LPN stated she called the doctor and received an order for [REDACTED]. Continued interview revealed the mobile x-ray service came at the change of shift around 2:30 - 3:00 PM on 12/9/17. Telephone interview with LPN #9 on 1/31/18 at 10:18 AM revealed she worked the 11:00 PM to 7:00 AM shift which began on 12/8/17 and completed on the morning of 12/9/17. The Surveyor asked the LPN what she remembered about Resident #61 the morning of 12/9/17 and the LPN stated the resident complained of foot and leg pain frequently and then stated I gave her Tylenol that morning. Medical record review of physician's orders [REDACTED]. Medical record review of the hospital History and Physical dated 12/9/17 revealed Resident #61 .who was sent to ED (Emergency Department) this evening from her nursing facility for a suspicion of right femoral fracture . Continued review revealed Resident #61 had been admitted to this hospital in December 2016 for generalized weakness and again in November 2017 for an episode of coffee-ground emesis. Further review revealed .She is status [REDACTED].She is immobile and is blind in the left eye and is significantly deaf .She seems reasonably comfortable, resting in bed, but does hurt when her left leg is manipulated .She has been apparently bed bound at the nursing home for at least the last year and it is not clear how she broke her right leg at this point . Telephone interview with CNA #10 on 1/31/18 at 11:08 AM revealed Resident #61 complained of leg pain in the early morning hours on 12/9/17 and he told LPN #9 and she went in to check on her. Interview with LPN #2 on 1/31/18 at 3:35 PM in the Restorative Nursing office revealed she went and assessed Resident #61. Continued interview revealed the resident told her that her leg was hurting. Surveyor asked What medication did (LPN #9) give to this resident? and LPN #2 stated there was nothing charted, we went back and did narcotic counts and nothing was given. Interview with the DON on 2/1/18 at 3:50 PM in the Assistant Director of Nursing office confirmed the facility failed to promptly notify the resident's Physician when the resident had a change of status. Further interview the DON confirmed the resident was not assessed appropriately after telling the nurse she fell . These failures resulted in pain due to Resident #61 not receiving pain medication and due to a delay in treatment of [REDACTED]. Interview with the Administrator on 2/1/18 at 5:08 PM in the Assistant Director of Nursing's office, after reviewing Resident #61's care regarding the reporting of pain and no pain medication given, and regarding the neglect in the delay in reporting of a change in status in resident condition, stated You're not telling us anything we didn't know, that's why we fired them. (LPN #9, CNA #10). The surveyor verified the Allegation of Compliance by: 1. On 12/4/18 - 12/5/18 pain assessments were completed on all residents with no further residents being affected. 2. On 11/27/17 all staff were educated on Incidents, Accidents, Abuse, Reporting, Customer Service, and Quality of Care. 3. On 11/29/17 all staff were educated on Notification of Change and Condition. 4. On 11/27/17 all cognitively intact residents were interviewed regarding abuse with no concerns elicited. 5. On 11/27/17 all cognitively impaired residents underwent a head-to-toe skin assessment with no concerns apparent. 6. On 12/9/17 staff were educated on Transfers, ADLS (Activities of Daily Living), How to Care for Residents, Knowing Your Residents, Abuse, Neglect, Reporting all Resident Claims. 7. On 2/2/18 licensed staff were educated on Incomplete Data on MAR and TAR, and [MEDICATION NAME] Patch and Verification. 8. From 2/5/18 - 2/23/18 all staff were educated again on Abuse Policy and Procedure, Notification, and Reporting. 9. On 2/28/18 review of daily audits of resident observations for change in pain, change or decline in condition, assessment as indicated with physician and/or Nurse Practitioner notification, and follow-up revealed audits were completed with Charge Nurse and CNA assigned to each resident. 10. On 3/1/18 - 3/2/18 interview with staff members regarding education received on abuse, transfers, notification, knowing residents, reporting resident claims revealed they were able to discuss each topic. 11. On 3/2/18 observation of all residents with [MEDICATION NAME]es revealed all residents had patches in place with the date of application and dosage on each patch. Noncompliance continued at a scope and severity of D for monitoring the effectiveness of corrective actions and evaluation of monitoring by the Quality Assurance Committee. The facility is required to submit a plan of correction. Refer to F-580 Refer to F-600 Substandard Qualtiy of Care

Based on fall investigation review, medical record review, observation, and interview, the facility failed to follow the care plan for placement of fall mats at the bedside for 1 of 18 (Resident #94) sampled residents of the 34 residents included in the stage 2 review. The failure of the facility to place fall mats resulted in actual harm when Resident #94 was found face down in the floor at bedside and suffered a broken nose and a broken maxilla. The findings included: Medical record review revealed Resident #94 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, required extensive assistance with 2 person physical assist with transfers, and a previous fall since the previous assessment. The care plan dated 2/10/16 documented, .at risk for falls .keep bed in low position with safety mats . A Resident Incident Report dated 11/9/16 documented, .Narrative of Event .Upon initial assessment res (resident) noted to be lying face down on floor . A witness statement dated 11/17/16 written by Certified Nursing Assistant (CNA) #1 documented, .At exactly 12:00 a.m .found (Named Resident #94) on the floor bleeding .I notice that the fall mats were not down . Interview with the Director of Nursing (DON) on 11/30/16 at 2:00 PM, in the DON office, the DON was asked if she expected safety measures to be in place for the residents. The DON stated, Yes .it was human error .it shouldn't have happened . The COMPUTERIZED TOMOGRAPHY (CT) - CT MAXILLO-FACE-W/O (without) CON (contrast) . dated 11/9/16 documented, .IMPRESSION .Subtle fractures of the left nasal bone and frontal process of the left maxilla . The facility failed to follow Resident #94's care plan for fall mats at the bedside. Resident #94 was found on the floor at the bedside and transported to the hospital. A CT scan revealed fractures which resulted in actual harm.

Based on fall investigation review, medical record review, observation, and interview, the facility failed to implement accident prevention interventions for 1 of 3 (Resident #94) sampled residents. The failure of the facility to place fall mats resulted in actual harm when Resident #94 was found face down in the floor at bedside and suffered a broken nose and a broken maxilla. The findings included: Medical record review revealed Resident #94 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, required extensive assistance with 2 person physical assist with transfers, and a previous fall since the previous assessment. The care plan dated 2/10/16 documented, .at risk for falls .keep bed in low position with safety mats . A Resident Incident Report related to a fall dated 10/15/16 documented, .continue fall mats (at) bedside . A Resident Incident Report dated 11/9/16 documented, .Narrative of Event .Upon initial assessment res (resident) noted to be lying face down on floor . A written statement from Certified Nursing Assistant (CNA) #1 dated 11/17/16 documented, .At exactly 12:00 a.m .found (Named Resident #94) on the floor bleeding .I notice that the fall mats were not down . The COMPUTERIZED TOMOGRAPHY (CT) - CT MAXILLO-FACE-W/O (without) CON (contrast) . dated 11/9/16 documented, .IMPRESSION .Subtle fractures of the left nasal bone and frontal process of the left maxilla . The CNA care plan located in the kiosk documented, .fyi (for your information) .safety mats at bedside . Interview with CNA #2 on 11/30/16 at 9:45 AM, in the back hall dining room, the CNA was asked how a CNA would know what safety measures were in place for a residents. The CNA stated, .nurses' reports .in the kiosk on their care plan . Telephone interview with Licensed Practical Nurse (LPN) #3 on 11/30/16 at 11:02 AM, in the Assistant Director of Nursing (ADON) office, the LPN was asked how she would relay to the CNAs safety measures used for a resident. The LPN stated, Everything is outlined in their care plan .their plan of care that is available to them .in the computer system that they have access to the care plans . Telephone interview with CNA #1 on 11/30/16 at 11:52 AM, in the Business Office Manager's office, the CNA was asked how she would know what safety measures were in place for her residents. The CNA stated, .report from CNA or nurse .computer has it on there . CNA #1's statement regarding the fall on 11/9/16 was read to the CNA. CNA #1 was asked if she wanted to add or change her statement, the CNA declined to make any changes to her statement. Interview with the Director of Nursing (DON) on 11/30/16 at 2:00 PM, in the DON office, the DON was asked if she expected safety measures to be in place for the residents. The DON stated, Yes .it was human error .it shouldn't have happened . Resident #94 had a history of [REDACTED]. On 11/9/16 Resident #94 was found at the bedside, face down. The fall mats had not been put into place and that resulted in Resident #94 suffering actual harm with fractures to his nose and maxilla.