Every finding on record at Windsor Atrium

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 6 residents reviewed for medical records accuracy. The facility failed to provide any MH NP documentation for the start and stop of psychotropic medications in the Progress Notes for Resident #1 on 03/08/2026. This failure could place residents at risk for errors in care and treatment.The findings included: A record review of Resident #1's face sheet dated 05/04/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance (a collection of symptoms where an individual temporarily loses touch with reality), mood disturbance (a mental health condition characterized by a persistent and severe disruption I a person's emotional state), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like a rapid heartbeat), heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), and atrial fibrillation (the most common type of treated heart arrhythmia, characterized by a rapid irregular, and often chaotic heart rhythm). A record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderate cognitive impairment. This MDS assessment medications antianxiety, antidepressants, anticoagulants, antibiotics, diuretics, and hypoglycemics (including insulin) were received on a routine basis. There were no potential indicators of psychosis (hallucinations or delusions). There were no behavioral symptoms. Resident #1 had Non-Alzheimer's Dementia, anxiety disorder and depression. He did not have psychotic disorder (other than schizophrenia). Record review of Resident #1's Progress Note written by LVN F dated 03/08/2026 at 08:26 pm revealed [MH NP G] rounded in facility and new orders received: -D/C Escitalopram -Start Depakote 500mg PO BID -Start Prozac 40mg PO. Record review of Resident #1's physician's order written by MH NP G dated 03/07/26 08:45 pm revealed Order Summary: PROzac Oral Capsule 40 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day for Antidepressant. Record review of Resident #1's physician's order written by MH NP G dated 03/07/26 08:45 pm revealed Order Summary: Depakote Oral Tablet Delayed Release 250 mg (Divalproex Sodium) Give 2 tablet by mouth two times a day for LABILE MOOD WITH MANIC FEATURES. During an attempted interview on 05/08/2026 at 06:10 pm, MH NP G was unable to be contacted. A voicemail was left with contact information requesting a call back. During an interview on 05/08/2026 at 08:10 pm, the DON stated Doctors, NPs, and nurses, all providers were expected to enter notes in the Progress Notes. She said documentation was important to track the resident's status. She said MH NP should have notes in the electronic medical record when any medication was started or stopped. During an interview on 05/08/2026 at 08:15 pm, the Administrator stated MH NP notes were to be in the electronic medical record when medications were started or stopped. Record review of facility's policy titled, Documentation in Clinical Record dated 10/24/2022, revealed: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview and record review, the facility failed to ensure the Pharmacist reported any drug regimen irregularities to the attending physician, the facility's medical director and the Director of Nurses, for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to detect and/or report drug regimen irregularities related to drug-to-drug interaction between Ibuprofen and Prozac which had a severe risk of gastrointestinal bleed. This facility failure could place residents at risk for harm related to drug-to-drug interactions that could place them at risk for adverse consequences related to medication therapy, and impact residents' ability to achieve or maintain their highest practicable level of physical, mental, and psychosocial well-being.The findings included: A record review of Resident #1's face sheet dated 05/04/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life), unspecified severity, without behavioral disturbance, psychotic disturbance (a collection of symptoms where an individual temporarily loses touch with reality), mood disturbance (a mental health condition characterized by a persistent and severe disruption I a person's emotional state), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like a rapid heartbeat), heart failure (a chronic condition where the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), and atrial fibrillation (the most common type of treated heart arrhythmia, characterized by a rapid irregular, and often chaotic heart rhythm). A record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated moderate cognitive impairment. This MDS assessment medications antianxiety, antidepressants, anticoagulants, antibiotics, diuretics, and hypoglycemics (including insulin) were received on a routine basis. There were no potential indicators of psychosis (hallucinations or delusions). There were no behavioral symptoms. Resident #1 had Non-Alzheimer's Dementia, anxiety disorder and depression. He did not have psychotic disorder (other than schizophrenia). A record review of Resident #1's physician's order dated 02/19/2026 revealed an active order for Apixaban Oral Tablet 5 mg (Eliquis an anticoagulant). Give 1 tablet by mouth two times a day for AFIB. A record review of Resident #1's physician's order dated 02/23/2026 revealed an active order for Ibuprofen Oral Tablet 200 MG (Ibuprofen)Give 2 tablet by mouth every 8 hours as needed for pain. Ibuprofen had a Drug-to-Drug Interactions warning attached with the following: PROzac (FLUoxetine HCl) Oral Capsule 40 MG Severe Toxic effects may be increased with concurrent administration of ibuprofen and FLUoxetine HCl (Prozac) Oral Capsule 40 MG, and PROzac Oral Capsule 40 MG. The risk of upper gastrointestinal bleeding may be increased. Patients taking both drugs concurrently should be educated about the signs and symptoms of GI bleeding. A record review of Resident #1's February 2026 MAR revealed Resident #1 received Apixaban 5 mg tablet twice a day from 02/19/2026 at 06:00 pm through 02/29/2026 at 06:00 pm. A record review of Resident #1's physician's order dated 03/07/2026 revealed an active order for PROzac Oral Capsule 40 MG (Fluoxetine HCl)Give 1 capsule by mouth one time a day for Antidepressant. Prozac 40mg capsule had a Drug-to-Drug Interactions warning: Drug-to-Drug Interaction:Order: PROzac Oral Capsule 40 MGIbuprofen Oral Tablet 200 MG Severe Toxic effects may be increased with concurrent administration of ibuprofen and PROzac Oral Capsule 40 MG. The risk of upper gastrointestinal bleeding may be increased. Patients taking both drugs concurrently should be educated about the signs and symptoms of GI bleeding. A record review of Resident #1's Progress Notes for medication order entered by LVN F on 03/08/2026 at 08:46 pm revealed, The order you have entered PROzac Oral Capsule 40 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day for Antidepressant Has triggered the following drug protocol alerts/warning(s): Drug to Drug Interaction ------------------------------------------- The system has identified a possible drug interaction with the following orders: Ibuprofen Oral Tablet 200 MG Give 2 tablet by mouth every 8 hours as needed for pain Severity: Severe Interaction: Toxic effects may be increased with concurrent administration of ibuprofen and PROzac Oral Capsule 40 MG. The risk of upper gastrointestinal bleeding may be increased. Patients taking both drugs concurrently should be educated about the signs and symptoms of GI bleeding. Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for AFIB Severity: Moderate Interaction: Antidepressants with antiplatelet effects (eg, PROzac Oral Capsule 40 MG) may enhance the anticoagulant effect of direct oral anticoagulants (eg, Apixaban Oral Tablet 5 MG and Eliquis Oral Tablet 5 MG). Apixaban Oral Tablet 5 MG Give 1 tablet by mouth two times a day for AFIB Severity: Moderate Interaction: Antidepressants with antiplatelet effects (eg, PROzac Oral Capsule 40 MG) may enhance the anticoagulant effect of direct oral anticoagulants (eg, Apixaban Oral Tablet 5 MG and Eliquis Oral Tablet 5 MG). A record review of Resident #1's physician's order dated 03/17/2026 revealed an active order for Ibuprofen Oral Tablet 200 MG (Ibuprofen)Give 2 tablet by mouth every 8 hours for pain. Ibuprofen had a Drug-to-Drug Interactions warning: PROzac (FLUoxetine HCl) Oral Capsule 40 MG Discontinued Severe Toxic effects may be increased with concurrent administration of ibuprofen, FLUoxetine HCl (Prozac) Oral Capsule 40 MG, and PROzac Oral Capsule 40 MG. The risk of upper gastrointestinal bleeding may be increased. Patients taking both drugs concurrently should be educated about the signs and symptoms of GI bleeding. A record review of Resident #1's March 2026 MAR revealed Resident #1 received:- Apixaban 5 mg tablet twice a day from 02/19/2026 at 06:00 pm through 02/29/2026 at 06:00 pm.-Prozac 40 mg at 06:00 am daily 03/09/2026 through 03/19/2026. - Ibuprofen 400 mg on 03/18/2026 at 06:00 am, 03:00 pm, and 11:00 pm and on 03/19/2026 at 06:00 am and 03:00 pm. A record review of Resident #1's Progress Note written by LVN A on 03/19/2026 at 12:07 pm revealed resident observed with blood clots present in stool during care. [NP B] notified of findings, received new orders to hold Eliquis for 3 days and [NP B] will be rounding later today. A record review of Resident #1's Change of Condition Progress Note written by RN C on 03/19/2026 at 12:15 pm revealed, The change in condition, symptoms, or signs to report: Multiple Blood clots noted in LG amount of soft brown stool, altered mental status. This started on: 03/19/2026. A record review of Resident #1's Doctor - MD Progress Note written by NP B on 03/19/2026 at 12:44 pm revealed Upon evaluation today, the patient is found to be lethargic and laying in bed. Nursing staff informed me that the patient was having bright red blood clots coming from rectum, earlier today. Eliquis was placed on hold. Patient did not look well, during my assignment. He was very restless. Patient to be sent to ED. A record review of Resident #1's Progress Note written by RN C on 03/19/2026 at 02:00 pm revealed [NP B] with [Doctor D] rounded in facility assessed pt d/t AMS and report of GI bleed. As per [NP B] send to ER for eval of GI bleed. A record review of Resident #1's Progress Note written by RN C on 03/19/2026 at 07:40 pm revealed [Resident #1] admitted to [hospital] DX AKI, AMS, GI bleed, and Elevated troponin Level (indicated the heart muscle was stressed or damaged). During an interview on 05/07/2026 at 02:50 pm, the DON stated when medications were given, there would be a window that popped up on the electronic medical record's Medication Administration that would show there was a drug-to-drug interaction. She said the nurse was required to click the boxes for her response (notify doctor, etc). She said that drug-to-drug interactions would also come out on the 24-hour report which she reviewed daily. She said pharmacy would email her if there was a drug-to-drug interaction that was severe and needed immediate response. She said the doctor would also be notified. During an interview on 05/07/2026 at 04:43 pm, Pharmacist E stated he reviewed the preliminary medications within a week of admission for a new resident. He said the pharmacy that fulfilled the prescriptions were the ones who would see the alert for interactions when new medications were ordered. He said he reviewed medications for established residents once a month. He said if he saw a drug-to-drug interaction while he was reviewing medications and that reaction was severe, he would email the DON and doctor. He said for all other interactions, he would email the doctor and would leave it up to their discretion on how to proceed. He said severe interactions should be identified by the pharmacy fulfilling the order. He said he did not know there was a severe drug-to-drug reaction of GI bleed with concurrent administration of Ibuprofen and Prozac. During an interview on 05/08/2026 at 11:58 am, Doctor D stated that the signs / symptoms of a GI bleed could vary depending on where the bleed was coming from. He said that was a difficult question to answer. Doctor stated for a significant GI bleed, there would be a significant amount of blood in the stool, tachycardia (rapid heart rate), and low blood pressure along with anemia would be key indicators of a significant GI bleed. He said with a septic ulcer or diverticulitis (a common digestive condition in which small pouches or sacs form and push outward through weak spots in the walls of the large intestine), having large blood clots in the stool could be an acute (begins suddenly) GI bleed and occur immediately. He said he was not aware of a severe drug-to-drug interaction between Ibuprofen and Prozac being given concurrently. He said their prescribing software will show counterindications and interactions when prescribing the medications. He said that between an anticoagulant, Ibuprofen, and Prozac, he would lean more toward the anticoagulant given twice a day long term as the culprit for the GI bleed. He said it depended on the GI bleed as to how long it could occur before it turned into hemorrhagic shock (a life-threatening condition caused by severe blood loss). He said for large clots of blood from the rectum would indicate an upper GI bleed and it could take hours rather than days for hemorrhagic shock to occur. He said significant blood loss would be detectable within hours in the stool, and he would want to be notified immediately. He said he would send the resident out to the ER. He said it would probably be an ongoing bleed. He said bright red blood from the rectum would be an intermittent bleed or constant. He said small amounts of blood in the stool which would appear dark would indicate chronic and large clots indicated a much larger bleed. He said he assessed Resident #1 on 03/19/2026 and found him with altered mental status and the nurses reported large blood clots from the rectum. He stated he was suspicious of a GI bleed, so he had [Resident #1] sent to the ER. During an interview on 05/08/2026 at 06:50 pm, LVN F stated when administering medications and there was a black box warning or a drug interaction warning for a medication ordered she called and faxed that medication information with the black box warning or drug interaction, with the resident's name to the doctor and they would tell her to continue the medication or discontinue the medication. LVN F stated the warnings popped up when the order was first created, but they would not pop up after that even during medication administration. She said it would be on the side on the Orders section on PCC. During an interview on 05/08/2026 at 07:25 pm, RN C said she was the nurse who assessed Resident #1 when the CNA (she could not remember which CNA notified her) came to get her to show her the blood clots in Resident #1's stool. RN C stated she reported the blood clots in Resident #1's stool to [NP B]. RN C stated NP B assessed Resident #1 and sent him out to the ER for a GI bleed. RN C stated that was the first report of blood in the stool received from CNAs. She said that the off going shift did not have any report from CNAs of bloody stools for Resident #1. RN C stated when an order was initially put in PCC, the black box warning and the drug interaction warning would open and they would have to notify the doctor by telephone or if the doctor was at the facility she would tell them then of the black box warning or drug interaction warning for the medication they had ordered. RN C stated the doctor was the one who decided whether to start the medication or discontinue it if there was a black box warning or drug interaction warning for the medication ordered. A record review of the facility's policy titled, Consultant Pharmacist Services dated 10/01/2019, revealed, PolicyThe consultant pharmacist performs a comprehensive review of each resident's medication regimen. (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and/or the administrator. Procedure 2. The consultant pharmacist reviews the medication regimen of each resident at least monthly.A. A more frequent review may be deemed necessary, e.g., if the medication regimen is thought to contribute to an acute change in status or adverse consequence, or the resident is notexpected to stay 30 days. 5. The consultant pharmacist identifies irregularities through a variety of sources including: medical record, Medication Administration Records (MARs); prescribers' orders; progress notes of prescriber, nurses, and/or consultants; the Resident Assessment Instrument (RAI); laboratory and diagnostic test results; behavior monitoring information; the facility staff; the attending physician, and from interviewing, assessing, and/or observing the resident. The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: J. Resident is monitored for adverse consequences when there is an addition or deletion of a medication, or a change in dose. R. Side effects, adverse reactions, and interactions (drug-drug, drug-diet, drug-lab test and drug-disease) are evaluated, and modifications or alternatives are considered. 6. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing, and/or prescriber as appropriate.A. Notification mode is dependent on severity of irregularity and is determined through consultation between consultant pharmacist and the director of nursing.

Based on observation, interview and record reviews, in accordance with accepted professional standards and practices the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 3 residents (Resident #2 and Resident #3) reviewed for clinical records.1. The facility failed to ensure documentation was completed on the Individual Narcotic Record for Resident #2 by ADON and LVN B on 10/12/2025 and 10/20/25.2. The facility failed to ensure documentation was completed on the Medication Administration Record for Resident #3 by LVN C on 10/0/25These failures could place residents at risk for errors by staff when reading information in the clinical record that was inaccurate or incomplete.Findings include:1. Record review of Resident #2's admission Record, dated 10/29/25, reflected an [AGE] year old female with a Principle Diagnosis of Megaloblastic Anemias (a type of anemia where the bone marrow makes abnormally large, immature red blood cells that do not work and live as long as normal red blood cells), and a diagnosis of Generalized Anxiety Disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness).Record review of Resident # 2's Quarterly MDS Assessment, dated 8/27/2025 and signed as completed on 9/02/25 by the MDS Nurse, reflected assessment observation end date of 8/27/2025. Resident # 2 had a BIMS score of 00, which indicated severe cognitive impairment.Record review of Resident # 2's Order Summary Report for the month of 10/01/25-10/31/25, reflected: -the order Lorazepam Oral Concentration 2 MG/ML Give 0.5 ML by mouth three times a day for anxiety related to Generalized Anxiety Disorder, start date 5/08/2025.Record review of Resident # 2's Medication Administration Record for the month of 10/01/25-10/31/2025 reflected medication Lorazepam 2 MG/ML Give 0.5 ML by mouth three times a day for anxiety related to Generalized Anxiety was initialed as given three times a day at, 8:00 AM, 4:00 PM, and 8:00 PM.Record review of Resident # 2's Individual Narcotic Record for Lorazepam, RX Instructions give 0.5 ML PO under tongue TID, Amount Received: 30 ML. reflected the medication had not been signed as given on 10/12/25 at 8:00 AM and 4:00 PM by ADON and on 10/20/2025 at 8:00 AM and 4:00 PM by LVN B.In an observation on 10/29/2025 at 10:52 AM of Resident # 2's bottle of Lorazepam revealed the amount in bottle of 12 ML and the amount remaining documented on the Individual Narcotic Record revealed an amount remaining of 6.5 ML.In an interview on 10/29/2025 at 10:50 AM, LVN B said the process for administering Lorazepam was I review the order first, I check the amount, check the label, verify the dose, and administer. I sign off on the narcotic sheet and document on the MAR. If the narcotic sheet is not signed, the count would be off and cause confusion for the oncoming shift. There can be miscommunication with the care plan regarding the resident. It can be communicated as a missed dose and communicated to the provider, and it can alter any new orders or care plan. She said she has been employed for 2 months, and her last in-service on medication administration and documentation was upon hire In an interview on 10/29/25 at 11:00 AM, the ADON said she checks the medication rights of administration, administers the meds, sign narcotic record and sign the MARS after the meds are given. She said if the narcotic sheet was not signed, there could be a discrepancy in the narcotic count and the resident could receive a double dose of the Lorazepam, which resulted in an increased effect of sedation. She said the last in-service she received was on 10/1/25 regarding medication administration.2. Record review of Resident # 3's admission Record, dated 10/29/2025, reflected a [AGE] year old female with Principle Diagnoses which included of Unspecified Fracture of Shaft of Humerus, Right Arm, initial Encounter for Closed Fracture, Striking Against Unspecified Object with Subsequent Fall, Initial Encounter, Diabetes Mellitus Type 2 (a chronic condition where the body cannot regulate blood sugar levels properly), and Other Cervical Disc Displacement, High Cervical Region (when a soft cushion between the neck bones {vertebrae} bulges or ruptures out of place) .Record review of Resident # 3's Quarterly MDS Assessment, dated 9/18/2025 and signed as completed on 9/24/25 by the MDS Nurse, reflected assessment observation end date of 9/18/2025. Resident # 2 had a BIMS score of 13, which indicated cognitively intact cognition.Record review of Resident # 3's Order Summary Report for the month of 10/01/25-10/31/25, reflected: -the order Hydromorphone HCl Oral Liquid 1 MG/ML Give 4 ML by mouth every 4 hours as needed for pain. start date 8/22/2025.Record review of Resident # 3's Medication Administration Record for the month of 10/01/25-10/31/2025 reflected medication Hydromorphone HCI Oral Liquid 1 MG/ML Give 4 ML by mouth every 4 hours as needed for pain, reflected the medication had not been initialed as given on 10/09/2025 at 10:28 AM by LVN CRecord review of Resident # 3's Individual Narcotic Record for Hydromorphone, RX Instructions give 4 ML PO Q 4 hrs PRN for pain, Amount Received: 120 ML. reflected the medication had been signed as given on 10/09/25 at 10:58 AM by LVN C.In an interview on 10/28/2025 at 11:58 PM, LVN C said she evaluated the resident before administering medication and 30 minutes after. She said after administering the medication, she documented it in the MAR and narcotic sheet. She said if too much medication was given, the resident could have a decrease in respiration and a decrease in the level of consciousness. She said she had an in-service on 10/27/2025 on medication carts being locked and 1 month ago she had an in-service on documentation and medication administration. In an interview on 10/29/2025 at 11:14 AM, the DON said she audited the resident charts on 10/01/25 on PRN narcotic medications and in-services were done on medication administration and documentation. She said in-services and returned demonstrations were continuous and were done weekly. She said narcotic discrepancies and medication errors could occur if not documented properly. The DON said incorrect dosages could affect residents if they were given too little or too much, causing potential complications. She said the pharmacy consultant provided services monthly and reviewed MARS for discrepancies and performed random narcotic count checks. She said the last visit by the consultant was on 10/13/25. In an interview on 10/29/2025 at 2:20 PM, LVN A said the process for medication administration was to withdraw medication, document narcotics as I'm pulling them out, administer med, sign off on MAR after med is given. She listed medication rights as right medication, right dose, right frequency, and right patient. LVN A said by not documenting the incoming nurse might administer too soon. Overdosing a resident can result from not documenting on MAR causing a decrease in heart rate. She said she had an in-service 3 weeks ago on medication administration and documentation.In an interview on 10/29/2025 at 3:57 PM, the Administrator said daily morning meetings were held with the Interdisciplinary Team in which problems and resolutions were discussed. He said Ad-Hoc QAPI meetings were held if trends were presented and initiate PIPS, reeducation, and audits for 3 months. He said after 3 months, the problem was assessed and if not resolved, the plan was remodified to something that works. Record review of the facility's policy titled: Medication Administration, dated 10/24/22, reflected: Policy Explanation and Compliance Guidelines: 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. 18. If medication is a controlled substance, sign the narcotic.Record review of the facility's policy titled: Documentation in Medical Record, dated 10/24/22, reflected: Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 3. Principles of documentation include, but are not limited to: e. Record date and time of entry. f. Sign each entry with name and credentials of the person making the entry.

Based on interviews and record reviews the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. If a child is admitted to the facility, the comprehensive care plan must be based on the child's individual needs. 1.The facility failed to develop and implement a comprehensive person-centered care plan to address Resident#1's refusal of medication. 2.The facility failed to ensure a care plan was developed and implemented to address Resident #4 getting out from bed without assistance. This failure could place residents at risk for their mental and psychosocial needs not being met. The findings include: 1.Record review of Resident #1's face sheet, dated 10/27/25, revealed a [AGE] year-old male and was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Muscle Weakness, unspecified sequelae of cerebral infraction (long-term complications or after-effects of a stroke that cannot be specifically identified or classified), muscle wasting and atrophy (the shrinking of muscle tissue due to lack of use, age, or diseases that damage the nerves controlling muscles), and gastroesophageal reflux disease (a digestive condition where stomach acid flows back into the esophagus, causing irritation and various symptoms). Record review of Resident#1's Quarterly MDS assessment, dated 9/16/25, revealed Resident#1:-had moderate cognitive impairment;-was able to make self understood;-was usually able to understand others; Record review of Resident #1's Comprehensive care plans revealed no focus, goals or interventions/tasks related to Resident #1's behavioral issues, refusing medications (protonix ). During an interview on 10/29/25 at 12:28 a.m., LVN G said Resident #1 refused his protonix medication. LVN G said when Resident #1 refused his medication she would let the physician know about the refusal. LVN G said she was sure the refusal of the medication was already care planned. LVN G said the negative outcome for refused medications not being on the care plan was the nurses would not give the care for the GERD . During an interview on 10/29/25 at 11:30 a.m., the MDS nurse said Resident #1's behaviors were not on the care plan. He stated he did not know they were supposed to be on the care plan. During an interview on 10/29/25 at 3:35 p.m., the DON said Resident #1 refused medications. The DON said the MDS nurse and all nurses were responsible for updating the care plan. The DON said when a resident refused medications, it should have been care planned. The DON said the negative outcome would be not following the plan of care. 2.Record review of Resident #4's face sheet, dated 10/29/25, revealed a [AGE] year-old female and was initially admitted to the facility on [DATE]. Resident #4 had diagnoses which included: Muscle Weakness, Unspecified Dementia, unspecified severity (a diagnosis used in medical coding when a person has symptoms of dementia, but there is not enough information to identify the specific type of dementia) and muscle wasting and atrophy (the shrinking of muscle tissue due to lack of use, age, or diseases that damage the nerves controlling muscles). Record review of Resident #4's Quarterly MDS assessment, dated 8/8/25, revealed Resident #4:-had severe cognitive impairment;-was not able to make self understood;-was not able to understand others. Record review of Resident #4's Progress Notes, dated 9/08/25, revealed: Nurse was alerted by aide that resident had fallen. Nurse went to assess resident. Resident was on the floor in the shower room lying on her front left side. Nurse called for assistance from staff to assist. Resident was rolled to her side. Pressure was applied to laceration on resident's forehead. Vital signs obtained. Resident was assessed by NP and EMS was called. Patient was sent to Emergency department. Record review of Resident #4's Comprehensive care plans revealed no focus, goals or interventions/tasks related to Resident #4's behavioral issues (tried to get out of bed without assistance). During an interview on 10/29/25 at 3:10 p.m., CNA E said Resident #4 tried to get out of bed without assistance, she did not press the call light for assistance. During an interview on 10/29/25 at 3:20 p.m., CNA F said Resident #4 tried to get out of bed without assistance, she did not press the call light for assistance. During an interview on 10/29/25 at 11:08 a.m., LVN D said Resident #4 had fallen twice with her. LVN D said Resident #4 tried to get out of bed without assistance and Resident #4 was not able to voice her needs or use the call light. During an interview on 10/29/25 at 11:30 a.m., the MDS nurse said Resident #4's behaviors were not on the care plan. The MDS nurse said he did not know the behaviors were supposed to be care planned . During an interview on 10/29/25 at 3:35 p.m., the DON said Resident #4 had some falls and the resident tried to get out of bed without assistance. The DON said nurses were responsible for updating the care plan. The DON said Resident #4 had dementia and that was a disease process not a behavioral issue. The DON said there was not a negative outcome . The DON said staff made frequent rounds on residents with high risk for falls . Record review of the facility's policy, Comprehensive Care Plan, with implemented date 10/24/2022, revealed:It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of medication 9 carts (300 hall medication cart) reviewed for storage. The facility failed to ensure the nurses medication cart for 300 hall was secured by a lock when it was left unattended by LVN A. This failure could place residents at risk of injury to other residents if medication left unsecured were consumed.Findings include: During an observation on 10/27/2025 at 03:28 PM revealed the 300 Hall nurse's medication cart was left unlocked and unattended against the nurse's station. LVN A approached the nurses' medication cart and noticed it was unlocked and secured the cart by locking it. There was no one around the medication cart. During an interview on 10/27/2025 at 03:30 PM with LVN A revealed she was responsible for the nurse's medication cart that was left unlocked. She stated he was expected to lock the nurse's medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take anything that was not for them or medications could get stolen. She stated she forgot to lock the cart. During an interview on 10/27/2025 at 04:18 PM with the DON revealed numerous staff, which included her and the ADON, were responsible for ensuring medications carts were locked. The DON stated her expectation of staff when they walked away from the medication cart was to lock it. The DON stated the negative outcome for leaving the cart unlocked was a resident or visitor could grab the medication from the cart, and it could harm them. She stated she provided in-services to the staff, and she visually monitored daily. Record review of the facility's, undated, policy Medication Administration: revealed .The purpose of the mobile medication system is to ensure appropriate control and surveillance of resident assigned medications. The medication cart is locked at all times when not in use. Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered- care plan, and the resident's choices for 1 (Resident #9) of 5 residents reviewed for quality of care. CNA N and CNA E on 08/04 25 identified a loose, abnormal arm while providing R#9 care and continued to provide care without communicating with the nurse. R#9 was not assessed for the abnormality several hours later after the CNA N remembered she had not reported the abnormality to the charge nurse. R#9 x-ray results: acute oblique displaced fracture of the distal humorous (upper arm bone) An Immediate Jeopardy was identified on 08/27/2025. The Immediate Jeopardy template was provided to the facility on [DATE] at 05:23 p.m. While the Immediate Jeopardy was removed on 08/28/2025 at 4:24 p.m. The facility remained out of compliance at a scope of isolation and a severity of harm with potential for more than minimal harm that was not an immediate jeopardy because of the facility's need for continued monitoring of implemented procedures.This failure could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death. Findings included: Record review of Resident #9's order summary report dated 08/05/2025 reflected a [AGE] year-old female with an admission date of 01/19/2025 with pertinent diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life), hemiplegia and hemiparesis following cerebral infarction (stroke) affecting left dominant side. Record review of Resident #9's quarterly MDS assessment dated [DATE] reflected a Brief Interview for Mental Status was not performed. Resident #9 had functional limitations in range of motion on upper and lower extremities. Resident#9 was totally dependent for all activities of daily living. Record review of Resident #9's comprehensive care plan dated date initiated 02/14/2025 revealed she required total assistance for all functional performance: transfer, eating, dressing, lying to sitting, oral, personal hygiene, and bed mobility. Record review of Resident #9's change in condition progress notes on her electronic medical record dated 08/04/2025 at 2:46 p.m., authored by LVN A reflected: left arm noted flaccid, started 08/04/2025. Record review of Resident#9's progress notes on her electronic medical record dated 08/04/2025 at 1:40 p.m., revealed LVN I was the nurse for Resident #9, patient received her morning meds, during this time patient noted on bed semi-Fowlers, medication and feedings administered via peg. During administration of medications patient noted comfortable no apparent distress noted, no nonverbal signs of pain noted during administration, respirations even and unlabored, no nonverbal signs of pain or facial grimacing noted at that time. Nystatin powder applied to affected area, during administration Resident #9's arm was not moved due to hx of contracture applied powder on the sides, then in the afternoon CNA N brought to LVN I's attention a concern regarding Resident #9' s left arm that it seemed loose . LVN I then ask the CNA N to go with her to show her the concern regarding Resident #9's left arm. CNA N explained Resident #9's arm was contracted but seem loose. LVN I then assessed Resident#9's arm and noted flaccid effect to arm with sensitivity to touch. LVN I notified the Nurse Practitioner, new orders for x-ray to Resident #9's left arm. PRN pain management was in place.Record review of Resident#9's progress notes on her electronic medical record dated 08/04/2025 at 7:07 p.m., revealed Resident #9's x-ray results were received and reported to the Nurse Practitioner who gave order to send Resident #9 to the emergency room. signed by LVN JJRecord review of Resident#9's progress notes dated 08/04/2025 at 8:43 p.m., revealed Received x-ray results and impression is: acute oblique displaced fracture of the distal humorous (upper arm bone). Resident ordered to be sent to emergency room . signed by Nurse PractitionerRecord review of facility's investigation report dated 08/08/25 revealed., R#9 was admitted to hospital with fracture and was re-admitted to facility on 08/12/25. In an interview on 08/05/2025 at 11:08 AM., with CNA N revealed she and another CNA on 08/04/25 went inside Resident#9's room around 7:30 a.m ., to provide assistance with incontinent care and a bed bath. CNA N said she knew that Resident#9's left arm was contracted inward across her chest, but when she and the other CNA provided care, she noticed that the arm appeared loose. She said they finished care, and she was going to mention to it the LVN, but she did not do it until close to lunch. CNA N said she got busy with other residents and forgot to talk to nurse about Resident#9. She said during the care Resident #9 did not appear to be in pain. In an interview on 08/05/2025 at 11:25 a.m., LVN I said, CNA N told her after lunch on 08/04/25 that there was something different with Resident#9's arm. LVN I said she went inside Resident# 9's room to assess her and when CNA N moved the resident's arm she noticed that Resident#9's arm appeared loose. She said she called nurse practitioner, informed family and, immobilized the arm. LVN I said nurse practitioner ordered x-rays and pain medication. LVN I said not reporting on time could cause additional discomfort or possible fracture progress. In an interview on 08/05/2025 at 1:02 pm CNA E said she worked on 08/04/2025 during the 6 am to 2 pm shift. She said on 08/04/2025 around 7:30 am, she and CNA N provided incontinent care and a bed bath to Resident #9. CNA E said during the care Resident #9 did not complain of pain. She said she and CNA N noted that Resident# 9's left arm appeared different. She said the reason that she did not report it to the charge nurse was because CNA N said that she was going to report it. She said later on 08/04/2025, she found out that CNA N had not reported it to the nurse immediately like they were trained to do. In an interview on 08/05/2025 at 1:23 pm the DON said on 08/04/2025 around 7:30 am., CNA N and CNA E provided care to Resident #9 and noticed that Resident#9's arm was different. It was flaccid. The DON said CNA N and CNA M went to provide care to Resident #9 around 11:30 am. The DON said that was when CNA N got ahold of LVN I to let her know about Resident#9's left arm. The DON said CNAs were trained to report any changes immediately to charge nurse. The DON said not reporting immediately could further prolong the distress of the resident and the assessment, also residents could continue without been treated and delay the treatment. She said CNAs were to report any changes immediately to the nurse. The DON said CNAs had a stop and watch system in place where staff were supposed to document any residents' changes observed during care. Interview on 08/07/2025 at 11:59 am, the Nurse Practitioner said he saw Resident #9 on 08/04/2025 around 2:30 pm, due to LVN I had mentioned Resident #9's left arm was flaccid. He said he assessed Resident #9 and did not notice that her arm was swollen, or any redness, however when he touched Resident#9's left arm he saw some facial grimacing. He said ordered pain medication, x-rays, and to immobilize the arm. He said Resident#9 was [AGE] years old with osteopenia (characterized by a lower bone mineral density [BMD] than usual) and brittle bones that probably caused the fracture. He said Resident #9's pain assessment indicated a pain level of 3 out of 10. He said his main concern at the time of the assessment was to immobilize the arm to prevent further injury. In an interview on 08/07/2025 at 12:12 pm, Treatment Nurse R said she saw Resident#9 on 08/04/2025 between 7:45 am and 7:45 am because she needed to provide treatment. She said with the assistance of a CNA she repositioned Resident#9 from one side to the other. She said at that time Resident #9 did not have any swelling or redness to her left arm that indicated something different. She said she was asked to do another skin assessment in the afternoon of 08/04/2025 due to Resident #9 swelling of her left arm. An Immediate Jeopardy was identified on 08/27/2025. The Immediate Jeopardy template was provided to the administrator's facility on 08/27/2025 at 05:23 p.m. The following Plan of Removal was accepted on 08/28/2025 at 08:03 a.m.:F 684 quality of CareCNAs on 8/4/25 identified a loose, abnormal arm while providing R #9 care and continued to provide care without communicating with the nurse. R#9 was not assessed for the abnormality several hours later after the CNA remembered she had not reported the abnormality to the charge nurse. R#9 x-ray results: acute oblique displaced fracture of the distal humorous (upper arm bone)Actions for Resident InvolvedOn 8/4/25, Licensed Nurse performed a head-to-toe assessment on Resident #9 and identified change of condition on Resident #9's left arm. Licensed Nurse administered pain medicine after pain evaluation was conducted and notified physician of change in condition and orders for X-ray was carried out.Resident #9 was sent to emergency room on 8/4/25 for evaluation and management. On 8/12/25, Resident #9 was re-admitted to facility.Identification of Others:On 8/27/25, head-to-toe assessments were completed by DON/Designee on all residents to identify for any changes in condition. Should any change in condition is identified, evaluation will be documented, and the physician and responsible party will be notified. Findings revealed there were no changes in conditions identified. Systemic Changes/ EducationOn 8/4/25 and 8/27/25, the Director of Nursing/Designee initiated and completed education with 100% of Direct Care Staff. Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents.Direct Care Staff were educated on the following: Immediate Notification of Changes of Condition to include stopping care to promote safety and timely reporting to licensed nurse/supervisor when a change in resident condition is identified. Safe Resident handling Abuse and Neglect License nurses will document in the record of assessment/evaluation completed with any change in resident condition to include MD and Responsible Party notifications. Re-educated Licensed nurses on keeping continuous rounding and communication with direct care staff to identifyThose that are PRN and/ or out of town -FMLA-will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift.Beginning 8/27/25 and ongoing, newly hired licensed nurses will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational componentsBeginning 8/27/25, and going forward, the Director of Nursing/ designee will review the Stop and Watch and 24- hour report.in the morning clinical meeting to ensure that changes of condition are. documentedin the clinical record, communicated with the physician and the resident representative and actions aretaken timely to address the change in condition.MonitoringBeginning 8/27/25, and on-going, the Director of Nursing or designee will monitor the following:Changes in condition are promptly reported, documented and addressed by reviewing the 24- hour report and clinical record during morning clinical meetings and on weekends.Beginning 8/27/25, and on-going, the Administrator will attend the morning clinical meeting to ensure compliance with review of the Stop and Watch, 24-hour report and medical record in the morning clinical meeting to identify changes in condition and actions carried out and documented. On 8/27/25, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal.On 8/27/25, The following monitoring system will be in place for the two C.N.A's involved in this event:1. Suspend deficient C.N.A's for Thursday 8/28/25 and Friday 8/29/25.2. C.N.A will be brought in Monday and Tuesday for a classroom lnservice training for the prevention of re occurrence.3. Assistant director of nurses will be assigned to monitor deficient C.N.A's x 30 days4. DON or assigned designee will then monitor this progress weekly and present to QAPI We respectfully submit this action plan for the removal of Immediate Jeopardy. Verification of IJ: Started on 08/28/2025 at 08:04 a.m. and included: Record review of an In-Service with subject of Stop and watch, dated 08/04/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Turning and reposition, dated 08/05/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Safe Resident Handling/Transfers, dated 08/07/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Abuse, Neglect, and Exploitation, dated 08/09/2025 and 08/27/25, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Patient safety and handling, dated 08/27/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Notification of changes, dated 08/27/2025, indicated that working staff signed the in-service record. Record review of an In-Service with subject of Clinical rounding, dated 08/27/2025, indicated that working staff signed the in-service record. Record review of QAPI with subject of notification of changes condition,, dated 08/27/2025, indicated that Director of Nurses, Medical director, Dietary Representative, Activities representative, therapy services representative and medical records representative participated in the QAPI meeting. During interviews on 08/28/2025 from 9:15 a.m., to 3:41 p.m. CNAs ZZ, AA, BB, CC were from the 6 am to 2 pm shfit, CNAs EE, FF from the 10 pm to 6 am shift, CNAs HH and II from the 2 pm to 10 shifts and Med Aide from 6 a.m. to 6 p.m.,revealed. were all knowledgeable of the expectation that if when providing care to a resident a change was noticed CNAs were to stop the care and inform the charge nurse verbally and with the stop and watch form. CNAs indicated where the stop and watch form was located at the nurses' station. LVNs KK, P, and LL from the 6 a.m. to 6 p.m. shift and LVN MM from the 6 p.m. to 6 a.m., shift revealed were knowledgeable of the procedure of that the CNAs should follow when a change was noted in a resident. LVNs interviews revealed LVNs should immediately assess resident after CNAs notified them of a change. 1 Medication aide was knowledgeable of the expectation to inform LVNs of any change noticed in a resident. A Hoyer lift observation was done on 08/28/25 at 11:10 a.m., for Resident#101 assisted by CNAs AA and BB revealed CNAs follow procedure to transfer resident from wheelchair to bed using Hoyer lift. CNAs used a bed sheet to assist with bed reposition as instructed by training. An observation on 08/28/25 at 2:20 p.m., revealed CNAs II and HH follow procedure to reposition a Resident # 66 with contractures. CNAs used a bed sheet to assist with moving resident from one side to the other. The Administrator was informed that the Immediate Jeopardy was removed on 8/28/2025 at 4:24 p.m., however, the facility remained out of compliance at a severity of actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated due to the facility need to evaluate the effectiveness of the corrected system.

Based on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 facility in that: The facility failed to have pest control effectively treat the facility for roaches and ants. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings include: During an observation on 08/03/2025 at 11:15 a.m., revealed a live roach on the wall in the hallway of the 100 hall. This observation was pointed out to LVN Q and walked away to notify staff. Maintenance staff captured the roach. LVN Q was in the hallway where the live roach was with her medication nurse cart. During an observation on 08/03/2025 at 11:38 a.m., revealed a large black live ant on the wall by the light fixture near the main dining area. During an interview on 08/03/2025 at 11:16 a.m., LVN Q stated that he had not seen roaches in the facility until now. He stated that he does not know how often pest control comes. He stated that they have a pest control sighting logbook in place at the nurse's station where they were to document if they see any ants or roaches. Maintenance staff will take care of contacting pest control. He stated the roaches can create infections to the residents. During an interview on 08/03/25 at 11:25 a.m., the Maintenance Director stated that pest control comes every month per contract. He stated that pest control came out about a week and a half ago. They fumigated the whole facility and the exterior. He stated that have not had issues with roaches. Occasionally they might come inf from the drains but they spray around them. The facility has two pest control sighting logbooks at each nurse station for the staff to document whenever they have a sighting of any bugs. He stated that he checks the logbook monthly but they do report it to him. He stated that he captures, collects and disposes of the bug. Pest control would then be provided with a list of all sightings. The Maintenance Director stated the negative outcome was that they can bring in infection. During an interview on 08/05/2025 at 2:57 p.m., the Administrator stated they have a pest control vendor was scheduled once a month and as needed. He stated there were two sighting logbooks and the maintenance director reviews them. This information gets entered into TELS (building management digital platform). If they find a roach, they immediately get rid of it. Then they call pest control to come in right away. Maintaining a pest and rodent free environment keeps the residents safe from bites and food gets spoiled if roaches were nearby. He stated they do not have a pest control policy. Record review of Pest Control sighting logbooks revealed two entries for the month of June 2025- dated 06/9/2025 noted room [ROOM NUMBER] lots of ants and 06/09/2025 noted room [ROOM NUMBER] roaches in room and restroom. No sightings for the month of July 2025. Record review of Pest Control Invoice, dated 06/21/2025, revealed the following services, Regular Pest Service and Flying Insect Program. Under General Comments/Instructions: Talked to contact looked over sighting logs and treated rooms [ROOM NUMBERS]. Interior. Inspected and treated all common areas, hallways, bathroom, kitchen, dining, offices and. changed glue boards as well. Exterior .Inspected and treated perimeter of building and replaced baits in rodent bait stations. Record review of Pest Control Invoice, dated 07/21/2025, revealed the following services, Regular Pest Service and Flying Insect Program. Under General Comments/Instructions: Talked to contact looked over sighting logs nothing noted. Interior. Inspected and treated all common areas, hallways, bathroom, kitchen, dining, offices and. changed glue boards as well. Exterior .Inspected and treated perimeter of building and replaced baits in rodent bait stations. Record review of Pest Control Agreement, dated 04/01/2017, revealed the following, Service Program Specifications: Interior crawling Insect & Rodent Programs. Frequency: Every Month. Interior Flying Insect Program (if applicable). Frequency: Every Month Exterior Crawling Insect & Rodent Programs: Frequency: Every Month Service Log Sightings:

Based on interviews, and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 5 residents (Resident #16) reviewed for consent for antipsychotic medications in that: Resident #16 was prescribed and administered Lorazepam (a psychotropic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. The findings included: Record review of Resident #16's admission record dated 08/04/2025, revealed a [AGE] year-old female with an admission date of 03/20/2023. Resident #16's diagnoses included amnesia (the loss of memories, including facts, information and experiences), anxiety disorder, history of falling, and chronic obstructive pulmonary disease (a lung disease characterized by persistent airflow limitation and chronic inflammation of the airways and lungs). Record review of Resident #16's Annual MDS, dated [DATE], revealed a BIMS score of 01, indicating severe cognitive impairment. There were no psychiatric/mood/anxiety disorder noted. Record review of Resident #16's Physician's orders dated 06/17/2025 revealed Lorazepam Oral Concentrate 2mg/mL (Lorazepam) *Controlled Drug* Give 0.5 mL by mouth every four hours as needed for anxiety or agitation for 14 days. Record review of Resident #16's care plan, dated 06/20/2025, revealed no mention of the psychotropic (Lorazepam) Resident #16 was receiving. Record review of Resident #16's medical record did not reveal a consent for the psychotropic Lorazepam until 07/08/2025. Record review of Resident #16's June 2025 MAR revealed Resident #16 was administered Lorazepam 2 mg/mL on 06/17/2025 at 09:08 PM and 06/22/2025 at 02:27 PM by mouth. During an interview on 08/07/2025 at 4:35 PM, the Administrator stated he did not know why there was not a consent in PCC (electronic health record) for the Lorazepam before the administration of the medication for Resident #16. He said it was the nurse who took the order who was responsible for getting the consents for psychotropics and antipsychotics and the consent needed to be signed before the medication was administered. He said if the consent was not signed and the resident received the psychotropic or antipsychotic, it would violate the resident's right to be informed. During an interview on 08/07/2025 at 04:07 PM, LVN I stated for antipsychotics and psychotropics a consent was completed with signatures for those medications (before giving the medication). During an interview on 08/07/2025 at 04:54 PM, the ADON stated a consent needed to be signed before the antipsychotic or psychotropic was given. During an interview on 08/07/2025 at 5:07 PM, RN J stated psychotropics and antipsychotics needed a consent form. RN J stated a consent must be signed before medication was given. RN J stated verbal consent was allowed. During an interview on 08/07/2025 at 5:34 PM the DON stated a consent was needed immediately on receipt of an antipsychotic or psychotropic before giving the medication. The DON stated if they did not get a consent from the resident or their RP, their right to know (about the medication) was being violated. A record review of the facility's policy Use of Psychotropic Medication(s), dated 03/05/25, revealed, Policy Explanation and Compliance Guidelines: 9.Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11.The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 (Resident #10 and Resident #13) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #10's oxygen was administered at the correct setting of 2 liters per minute on 08/3/2025 as ordered by the physician. 2. The facility failed to ensure Resident #13's oxygen was administered as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1.Record review of Resident #10's admission record dated 08/3/2025 reflected a [AGE] year-old male with an admission date of 6/18/2025. Pertinent diagnoses included Tracheostomy status (the presence or absence of a tracheostomy, a surgical procedure that creates an opening in the trachea to allow breathing), acute respiratory failure with hypoxia (is a serious medical condition where the lungs are unable to adequately oxygenate the blood and/or remove carbon dioxide). Record review of Resident #10's Quarterly MDS assessment, dated 07/8/2025 revealed oxygen therapy while a resident. Record review of Resident #10's person-centered care plan, initiated date 7/22/2025 reflected Resident #10 used oxygen therapy related to acute respiratory failure status post tracheostomy status. Intervention included oxygen settings: oxygen settings via trach collar at 6 liters per minute continuous. Record review of Resident #10's physician order dated 08/3/2025, revealed oxygen at 2 LPM via trach tube every shift for hypoxia. During an observation of Resident #10 on 08/3/2025 at 9:50 a.m., the oxygen level on the oxygen concentration machine was at 1.5Liters Per Minute via tracheostomy. Resident #10 was in bed with head of the bed slightly elevated. No signs of respiratory distress noted. In an interview on 08/3/2025 at 9:55 a.m., LVN A, stated she was the nurse for Resident #10. LVN A said the Oxygen was set at 1.5 Liters Per Minute. She stated the oxygen setting was supposed to be at 2 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. LVN A stated that she checked Resident #10's oxygen tubing and saturation this morning. She stated that she usually checks the oxygen once a day and as needed. LVN A stated that the negative outcome to keeping Resident# 10's oxygen setting at 1.5 Liters Per Minute was that resident could go into respiratory distress or oxygen level might drop. In an interview on 08/7/2025 at 09:45 a.m., the DON stated the nurses assigned to that hall was responsible for checking the Oxygen settings. She stated that the nurses was to check the setting once per shift. The DON stated they are to follow oxygen settings on physician orders. The DON stated that the negative outcome could be the resident could have a respiratory distress and hypoxia (low oxygen levels). 2. Record review of Resident #13's electronic face sheet dated 08/03/2025 reflected the resident was a 90 -year-old female admitted to the facility on [DATE] with an original admission date of 05/24/2021. Resident #13 pertinent diagnoses which included the following: Congestive Heart Failure, Dysphagia (difficulty swallowing), Dementia, Hypertension (high blood pressure), Muscle Wasting and Atrophy (thinning or loss of muscle mass, usually from a lack of muscle use). Record review of Resident #13's Quarterly MDS assessment, dated 07/17/2025 reflected a BIMS score of 2, which indicated Resident #13 had severe cognitive impairment. Record review of Resident #13's physician order dated 07/31/2025, reflected oxygen at 2 LPM via nasal cannula every shift for hypoxia. During an observation of Resident #13 on 08/03/2025 at 10:50 a.m. the resident was in bed with head of the bed slightly elevated and had no oxygen via NC. No signs of respiratory distress noted. In an interview on 08/03/2025 at 10:58 a.m., LVN O, stated she was the nurse for Resident #13. She stated Resident #13 was not on oxygen. She stated that she had checked her SpO2 this morning and it was 98. She then verified that Resident#13 had a physician order for oxygen and she was to follow through with orders. LVN O stated that Resident #13 oxygen levels had been reading above 95. She was not aware that Resident #13 had an active oxygen order for continuous but will call doctor to get an prn order. LVN O stated the negative outcome was that Resident #13 can decline and go into hypoxia (low oxygen levels). In an interview on 08/03/2025 at 04:21 p.m., the DON, stated that the nurse assigned to that hall was responsible for checking the oxygen orders. She stated that the nurse was to check the oxygen orders per shift. The DON stated the nurse was to follow through with the active oxygen physician orders. She stated that the nurses were checking Resident #13's oxygen levels every shift. The DON stated that the negative outcome would be that the resident was not getting the required oxygen as required and could have a respiratory distress. Record review of the Lippincott Nursing Procedures 8th edition published on November 1, 2018 Oxygen Administration implementation section revealed: verify the practitioner's order for the oxygen therapy, because oxygen is considered a medication or therapy and should be prescribed. Record review of the facility's Medication Administration policy dated 10/01/2019, revealed Policy, Explanation and Compliance Guidelines: 14. Administer medications as ordered in accordance with manufacturer specifications.

Based on observation and interview, the facility failed to ensure that diabetic equipment were stored in a locked compartment for 1 of 4 medication carts. The facility failed to ensure a (diabetic) lancet, sitting on top the unattended medication cart, was secured. This failure could place residents at risk of access or injury from a lancet.Findings were: During an observation on 08/06/2025, at 12:05 PM, revealed on top of the 600 hall medication cart sitting in the 600 hallway unattended, there was a diabetic lancet. During an interview on 08/06/2025 at 12:07 PM, RN J walked up to cart. RN J stated the (diabetic) lancet was supposed to be secured in the medication cart. RN J stated the negative outcome could be someone could come by and grab it off the cart. RN J secured the lancet in the medication cart. During an interview on 08/07/2025 at 5:34 PM, the DON stated the lancet should be kept in the medication cart until use. She said it would be a safety issue if it were left on top the medication cart unattended. During an interview on 08/07/2025 at 06:30 PM, LVN H stated the lancet was supposed to be locked inside the medication cart and not left unattended. LVN H said if the lancet were left unattended in top of the cart a resident could grab it and get hurt. She said the last in-service on sharps was last month During an interview on 08/07/2025 at 06:40 PM, the ADON said that was not ok to leave the lancet unattended in top of the cart. The ADON said the lancets needed to be locked inside the cart. The negative outcome could be that any resident could grab it and get hurt. The ADON said the in-services on how to handle sharps are done every month and as needed. Record review of the facility's Medication Administration policy dated 10/01/2019, revealed:Procedure:3.Do not leave the medication cart unlocked or unattended in the resident care area.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #16) of 4 residents reviewed for medical records accuracy, in that: The facility failed to provide any documentation in the Progress Notes for Resident #16's from 01/31/2025 through 06/04/2025. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.The findings included: Record review of Resident #16's admission record dated 08/04/2025, revealed a [AGE] year-old female with an admission date of 03/20/2023. Resident #16's diagnoses included amnesia (the loss of memories, including facts, information and experiences), anxiety disorder, history of falling, and chronic obstructive pulmonary disease (a lung disease characterized by persistent airflow limitation and chronic inflammation of the airways and lungs). Record review of Resident #16's Annual MDS, dated [DATE], revealed a BIMS of 01, indicating severe cognitive impairment. Record review of Resident #16's Progress Notes revealed there was no documentation written from 01/31/2025 through 06/04/2025. During an interview on 08/07/2025 at 04:07 PM, LVN I stated LVNs were responsible for documentation. LVN I stated if the nurses had not documented, it was not done. She said that was what was taught in nursing school. During an interview on 08/07/2025 at 04:54 PM, the ADON stated anything and everything was documented on PCC (change of meds, change of condition, etc.) In an interview on 08/07/2025 at 05:34 PM, the DON stated the nurses' notes are to be thorough and complete. She said if the notes were not written, it does not show the care or progress of the resident. In an interview on 08/07/2025 at 05:47 PM, the Administrator stated when the nurses wrote their risk management or nursing assessments, there was a button to click that would transfer the notes to the resident's progress notes. He stated the nurses must not be doing that although they knew they should do it. The administrator stated he was aware of the missing progress notes for Resident #16 and nurses were being in-serviced.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program which ensured standard and transmission-based precautions were followed to prevent the spread of infection, for 2 (Resident#39 and Resident #47) of 5 residents reviewed for infection control issues. 1. The facility failed to prevent family members from entering R#39's isolation room without donning PPE. 2. The facility failed to ensure the dressing on Resident #39's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. 3.CNA C failed to remove contaminated gloves after catheter care prior placing clean brief on Resident #47. These failures could place residents at risk of cross contamination and infection. Record review of Resident #39's Face Sheet revealed Resident #39 was a [AGE] year-old male admitted to facility on 07/11/25 for diagnoses of sepsis (a life-threatening medical emergency caused by the body's extreme and overactive response to an infection) due to methicillin resistant staphylococcus aureus (a group of gram-positive bacteria that were genetically distinct from other strains of staphylococcus aureus that was resistant to many antibiotics) and bloodstream infection due to central venous catheter. Record review of Resident #39's 5-day Medicare Part A MDS assessment revealed Resident #39 was understood by others, was able to understand others, and had a BIMS score of 11 which indicated he had moderate cognitive impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #39 had an IV peripheral access. Record review of Resident #39's comprehensive care plan dated 07/14/25 revealed Resident #39 had infection of the blood stream (MRSA) and revision on 08/03/25 revealed the family refused to follow isolation precautions regarding proper use of PPE with interventions to administer antibiotics, contact isolation precautions, and education on contact isolation precautions and proper use of PPE provided to family, however non-compliance continues. Further documentation revealed Resident #39 had infection of the blood stream (MRSA) and revision on 08/03/25 revealed administer antibiotic as ordered by physician, Record review of Resident #39's Order Summary Report dated August 2025 revealed Resident #39 had order for contact isolation DX: MSSA Bacteremia every shift until 08/15/25 start date of 08/02/25 and orders for vancomycin HCl intravenous Solution 750 mg/150 ml use 750 mg intravenously at bedtime every Tue, Thurs, Sat for MSSA Bacteremia for two weeks, start date 07/29/25. Observation on 08/03/2025 at 11:57 a.m., revealed a sign on the door instructing visitors to check with the nurse before entering the room. There was PPE (gowns, gloves, masks) available outside the doorway. In an interview Resident #39 said he was admitted to the facility because he had an infection to his A/V shunt. Resident #39 said he was supposed to be discharged Saturday but his labs indicated he still had organisms in his blood so he would continue with antibiotics via IV. On 08/03/25 at 12:22 p.m., Surveyor observed a family member, and a child go into Resident #39's room. Resident #39 was on contact isolation for MRSA to the blood and the family members did not use PPE. In an interview on 08/03/2025 at 12:23 p.m., CNA G said Resident #39 was on contact isolation. CNA G said the family had been educated several times on the importance of putting on PPE, but they had refused to wear the PPE. CNA G said anyone that went into a room of a resident on contact isolation needed to use PPE to prevent the speed of infection. CNA G said visitors going into a resident's room that was on contact isolation had to use a gown, and gloves. In an interview on 08/03/2025 at 12:39 p.m., the FM said the nurse did educate them about the importance of wearing PPE. The FM said her sister was an NP and she told them that as long as they do not have contact with blood or other body fluids, they should be ok. The FM said they do not provide any care to Resident #39, so she was not worried about being infected. The FM said she washed her hands when she comes into the room and washed her hands before leaving. She knows how important it was to wash her hands. In an interview on 08/03/25 at 3:15 p.m. LVN H said they had educated the family several times and they were still refusing to don PPE. LVN H said Resident #39 had MRSA to the blood and if the family had contact with any body fluids there could be transmission of the infection. LVN H said the chance of them getting infected was very small, but it was still a probability. LVN H said they could not prevent the family from seeing Resident #39 because he had a right to have visitors. Observation on 08/04/2025 at 9:45 a.m. revealed Resident #39 was in his room lying in bed. He had a peripheral intravenous lock covered with a transparent dressing with no date and no initials on his right hand. There were no signs or symptoms of infection or infiltration noted at the IV site. In an interview on 08/04/2025 at 9:49 a.m. LVN P stated she was the nurse for Resident #39. She stated that the nurse who initiated the IV was responsible for labeling the dressing with the date and initials. LVN P stated that it was important to label the IV site to know when the last time it was changed. She stated that if was not changed within three days then it can cause infection. She stated that she has not checked his IV site yet. LVN P stated that the IV site should be checked every shift. The site was to be checked for any signs of infection, the date and signature on the dressing, check that the saline lock cap was in place. She stated she had training on IV administration once a month as well as skill check offs. LVN P confirmed the resident had a peripheral IV lock in his right hand covered with a transparent dressing that was not labeled. In an interview on 08/04/2025 at 11:00 a.m., the DON stated that the charge nurse was responsible for labeling the IV dressing. The IV dressing was to be labeled with the date and initials of the nurse who inserted the IV. She stated that the negative outcome of not labeling dressing was that it go over the recommended standard time of every 72 hours and could cause infection. She stated that IV administration class was done annually and as needed. In an interview on 08/05/2025 at 4:38 PM the DON said Resident #39 was on contact isolation and anyone entering into his room had to wear PPE. The DON said if someone was not wearing PPE, they could potentially be infected with the same organism that Resident #39 had or they could carry some of the bacteria and spread it to other areas of the facility if they touched the doorknobs, handrails or other areas of the facility. The DON said she had never had a situation where visitors refused to wear PPE. The DON said she had instructed the nurses to educate the families that came to visit a resident on transmission-based precautions on the importance of wearing PPE. The DON said even though the family did not don the PPE, they could not prevent the family from visiting the resident. The DON said she told the family to stay in the room and before leaving the room to wash their hands. 3. Record review of Resident #47's face sheet dated 8/4/25 revealed a [AGE] year old female admitted originally on 7/8/25. Her diagnoses included, neurogenic bladder (a condition where nerve damage affects bladder control, leading to problems with either storing or releasing urine), needs for assistance with personal care. Record review of Resident #47's Comprehensive Care Plan initiated: 07/12/2025 documented, Problem: Resident #47 is dependent on staff for meeting emotional, intellectual, physical and social needs related to physical limitations. Interventions: Resident #47 needs assistance with ADLs as required during the activity. Record review of Resident #47's MDS dated [DATE] documented a Brief Interview of Mental Status score of 11/moderate impaired cognition, as well as dependent of staff to assist in activities of daily living. Indwelling catheter used. During an observation on 08/4/2025 at 9:29 AM, CNA C entered Resident #47's room after knocking. CNA C began with washing hands for 30seconds, gloved up, and prepared table of needed supplies. CNA C continued by raising bed and then discarded gloves. After discarding the gloves, CNA C continued with applying hand sanitizer and she did apply new gloves. CAN C proceeded with catheter care and proceeded placed a new brief on resident, using same pair of gloves, catheter care, and applied new brief. During an interview on 08/4/2025 at 9:58 AM with CNA C stated that they should have changed those gloves after cleaning the foley catheter, for the reason to minimize contraction of infection. CNA C stated they should have washed hands/use hand sanitizer and changed gloves, before, during, and after care to minimize chance of infection. CNA C stated that resident could get an infection because she did not changed gloves when changing from one area to another area. During an interview on 08/7/25 at 10:05 AM with the DON, The DON stated that after perineum care, hand hygiene should have been performed prior to moving to the second part of applying the new brief. The DON stressed the importance of infection prevention and stated that personnel were educated and observed by her performing specific care during checkoffs, before being allowed to work on floor independently. DON stated this practice could put Resident #47 at risk for infection. Record review of the facility's Infection Control policy dated 05/13/23 revealed: This facility has established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 2.All staff are responsible for following all policies and procedures related to the program. 5. Isolation Protocol (Transmission Based Precautions) a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. b. Resident will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances. .13. Resident/Family/Visitor Education and Screening a. Residents, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions, and conditions, for which to notify the nursing staff. b. Information on various infectious diseases is available from our Infection Preventionist. c. Isolation signs are used to alert staff, family members, and visitors of transmission-based precautions.

Based on observation, interviews and record reviews, the facility failed to review and revise comprehensive care plans after each assessment for 2 (Resident #10, Resident #4) of 8 residents reviewed for comprehensive care plan revisions. 1.The facility failed to review and revise Resident #10's comprehensive person-centered care plan for catheter use. 2.The facility failed to review and revise Resident #4's comprehensive person-centered care plan for insulin use. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. The findings included: 1.Record review of Resident #10's admission record dated 08/05/2025, revealed a [AGE] year-old male with an original admission date of 04/10/2025 and a readmission date of 06/12/2025. Resident #10's diagnoses included cerebral infarction (stroke) affecting his left side, seizures, hypertension (high blood pressure), chronic kidney disease, and pain, unspecified. Record review of Resident #10's admission MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Resident #10 was always incontinent of bladder (Resident #10 returned to the facility with and order for a catheter on 06/12/2025). Resident #10's weight at the time of the assessment was 220 pounds with weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Record review of Resident #10's Weight and Vitals dated 04/10/2025 revealed Resident #10's weight was 233 pounds. Record review of Resident #10's Physician's order dated 06/12/2025 revealed a catheter was ordered. Record review of Resident #10's care plan dated 06/19/2025 revealed no mention of weight loss or a catheter. Record review of Resident #10's Progress Notes dated 06/12/2025 at 09:54 PM revealed Bladder Function: Bladder function unchanged Cath: Foley Catheter with care provided. Record review of Progress Notes dated 06/12/2025 at 10:59 PM, written by LVN I revealed, Patient admitted with indwelling foley catheter. Observation on 08/03/2025 at 12:04 PM revealed Resident #10's Foley catheter hanging on the left side of the bed, below the bladder, in a privacy cover. During an interview on 08/07/2025 at 05:07 PM, RN J stated Foley catheters were care planned. If the resident was a new admission, the admitting nurse would care plan a Foley, but if the resident was returning from the hospital, MDS staff would update the care plan. During an interview on 08/07/2025 at 05:23 PM, MDS RN stated he was the MDS coordinator. MDS RN stated MDS was responsible for updating the care plans. He stated ADONs put the acute changes for a resident in the care plan (changes that occurred after the resident's baseline care plan had been completed). MDS RN said when a MDS assessment was completed, the resident's care plan was updated. During an interview on 08/07/2025 at 05:34 PM, the DON stated the DON, ADONs, and MDS coordinators were responsible for updating the care plan. The DON stated the care plan was to be revised immediately. The DON stated the negative outcome would be they were not communicating the plan of care. During an interview on 08/07/2025 at 05:47 PM the Administrator stated meetings were every morning which covered the prior admissions making sure everything was in order, every department was gone over, medical records request, care plans updated, etc. 2. Record review of Resident #4's electronic admission record dated 08/07/2025, revealed an [AGE] year-old female with an original admission date of 04/15/2021 and a readmission date of 07/06/2025. Resident #4's pertinent diagnoses included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out simple tasks), Type 2 Diabetes Mellitus (high blood sugar levels), Congestive Heart Failure, Metabolic Encephalopathy (any disease or disorder of the brain, characterized by changes in brain function or structure), Dysphagia (difficulty swallowing). Record review of Resident #4's Comprehensive MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Resident #4 was noted for taking a high risk medication of insulin. Record review of the Physician's Order Summary dated 08/07/2025 revealed Resident #4 was prescribed Tresiba Insulin with a start date 07/07/2025. Record review of Resident #4's care plan dated 07/14/2025 revealed no mention of insulin. During an interview on 08/06/2025 at 5:05 p.m., the MDS RN K stated that he was responsible for updating Resident #4's care plan. He stated that he had seven days to complete the comprehensive care plan. MDS RN K stated he did not care plan the insulin because it was not flagged as black box (a serious warning given by the Food and Drug Administration for medications that may cause serious harm or death) that may but he would add it to the care plan. He stated that it was important for the insulin to be care planned because it was a way of good communication for the nurses and so that Resident #4 received the best quality of care. During an interview on 08/06/2025 at 5:19 p.m., the DON stated the ADON, MDS coordinator, and she were responsible for updating the care plan. She stated the care plan was to be revised within 48 hours but immediately was best practice. The DON stated insulin should be care planned even if it was not flagged as a black box medication. The DON stated the negative outcome would be they were not communicating how they cared for the resident. Record review of facility's policy Care Plan Revisions Upon Status Change dated 10/24/2022 revealed: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1.The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2.Procedure for reviewing and revising the care plan when a resident experiences a status change: a.Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. d.The care plan will be updated with the new or modified interventions. f.Care plans will be modified as needed by the MDS Coordinator or other designated staff member.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 5 resident (Resident#91) reviewed for indwelling catheters. The facility failed to prevent Resident#91's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#91's face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident#91 had primary/admitting diagnoses of metabolic encephalopathy (a condition where the brain's function is impaired due to metabolic or systemic illness affecting other body systems, rather than a direct brain injury), obstructive and reflux uropathy (when flow of urine is blocked in the bladder, ureter, or urethra). Record review of Resident #91's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #91 had a BIMS score of 8 which indicated Resident #91 had moderately impaired cognition. Section H-Bladder and bowel revealed Resident #91 had an indwelling catheter. Record review of Resident #91's care plan dated 5/10/2025 revealed Resident #91 had a foley catheter Obstructive and reflux uropathy Date initiated 07/30/25 and revised on 07/30/25, Intervention/tasks listed Resident #91 had a 16 french 10 milliliters balloon ( the size of the catheter) indwelling position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #91's Order Summary printed 08/3/25 revealed an order to Change the Foley Catheter 16 # French with a 10 milliliters balloon every 30 days and if plugged out or dislodged as needed. The orders included Foley catheter care every shift and as needed with a start date of 04/29/25. During an observation conducted on 08/3/25 at 09:50 AM, Resident #91's foley catheter bag was noted laying on the floor on the right side of Resident #91's bed. During interview with CNA B on 08/3/25 at 10:35 AM, CNA B was informed and shown the catheter bag laying on the floor. She stated the foley bag should not be touching the floor. CNA B stated by the foley bag touching the floor, Resident #91 could be at risk for infection. During interview with LVN A on 08/3/25 at 10:45 AM, LVN A was informed and shown the catheter bag laying on the floor. She stated it should not be touching the floor. LVN A put on gloves after sanitizing hands with hand sanitizer and hung the foley bag on Resident#91's bedframe. She replied that a negative outcome of the foley catheter bag being on the floor was the catheter wouldn't drain well and pick up bacteria from floor. LVN A stated that she received infection control training very often, about once a month, which included hand washing, enhanced barrier precautions, foley catheter care, and equipment sanitation and avoiding cross contamination. During interview with the ADON on 08/6/25 at 1:12 PM, she stated that once a foley change was completed, she ensured she got yellow drainage, and that the catheter was placed properly. The ADON said that she ensured the bag was not touching the floor and ensured it had a privacy cover. The ADON stated that if the catheter bag did touch the floor, the resident would be at risk of infection. She stated that the inservices for Infection Control were done about once a week. She stated that in-services were done about once a month on catheter changes. During interview with the DON on 08/7/25 at 9:53 AM, she stated that catheters should be on the side of the bed, not on the part that went up and down, so it did not fall, but on the frame. The DON stated, no, it should not be touching the floor, if on the floor not necessary a problem because if open something going could go in but it was a closed system. She stated they would be thinking of ways to prevent bags from touching the floor on residents with low lying beds, perhaps putting another bag to serve as a barrier. As per the DON there was no policy on Foley Catheters. Record Review of Policy Titled Infection Prevention and Control Program with implemented date May 13, 2023, 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.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure foods were properly stored, labeled, and dated.2. The facility failed to ensure the DM's hands were washed and gloves was worn during the assistance of food preparation. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Include:Observation of the kitchen counter on 08/03/25 at 9:20 AM revealed the following:1. 1 container of Thick-It (a brand of food and beverage thickener designed to help people with swallowing difficulties) covered with foil. Observation of the walk-in refrigerator on 08/03/25 at 9:26 AM revealed the following:1. 1 bag of sliced melons - date was not legible 2. 1 crate of onion which had loose onions out of the bag - not labeled or dated 3. 1 bell pepper in a cardboard box - not labeled or dated In an interview on 08/03/25 at 9:47 AM, the DA stated the cook that last used the thick-it, should have placed a plastic lid on the container and not foil. The DA stated if the container was not closed properly, the container was at risk of contamination or spoilage. The DA stated whoever received and put away the food items was responsible for items to be labeled and dated. The DA stated the dates needed to be easy to read. The DA stated if food items was not labeled, the cooks or kitchen staff would not know when food arrived or was opened. The DA stated improper labeling put residents at risk for illness. During an observation on 08/04/25 at 10:45 AM, the DM did not wash her hands nor put on gloves to assist the cook with preparing pureed meals. With bare hands, the DM picked up a dirty blender off the meal prep counter and took it to get washed. The DM returned with a washed blender and placed it on the food prep counter for the cook to use. The DM then took a clean disposable bag and lined a clean metal food container with the bag. The metal food container was placed next to the cook for the cook to pour out the pureed meal he was going to finish pureeing. When the cook finished pureeing the meal, he removed the plastic bag from the metal container and discarded it. The cook then washed his hands, put on gloves, and placed a new disposable bag into the metal container. The cook then proceeded to pour the pureed meal into the metal container. The DM took the dirty food blender that had just been used to get washed. The DM returned to the meal prep counter and started collecting the trash around the counter. In the entire meal preparation time, the DM did not wash her hands nor apply gloves when assisting the cook. In an interview on 08/04/25 at 11:05 AM, the DM stated that all staff was responsible for ensuring items were stored, labeled and dated. The DM stated every item opened, should have an open date in the refrigerator, freezer, and dry storage. The DM stated if food items was not properly labeled and dated, staff may be unaware of when the items was opened, increasing the risk of food spoilage and potential illness for residents. The DM stated dates should have been legible to read to make it easy for staff to discard when needed. The DM stated if food items was not properly labeled or stored, it would have increased the risk of food getting spoiled or it would cause potential illness for the residents. The DM stated when she was helping the cook with meal preparation, she simply forgot to wash her hands and put gloves on. The DM stated the consequences for not having washed her hands or wearing gloves would be food borne illnesses and could make residents sick. In an interview on 08/04/25 at 11: 14 AM, the cook stated he had worked at the facility for about nine months. The cook stated he would generally prepare the pureed meals on his own but appreciated the DM helped him today. The cook stated he was nervous and concentrated on his task that he did not notice the DM did not have gloves on, nor that she did not wash her hands. The cook stated it was important to wash one's hands and use gloves when preparing food because food could have been cross contaminated, and residents could have become ill. Record review of the Food Storage Policy dated 06/01/19 revealed the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.1. Dry storage room d. To ensure freshness, store opened and bulk items in tightly covered containers.2. Refrigeratorsd. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Record review of the Employee Sanitation Policy dated 10/01/18 revealed the following: Policy: The Nutrition & Food service employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to maximize the risk of infection and food borne illnesses. 5. Hand Washinga. Employees must wash their hands and exposed portions of their arms at designated hand washing facilities at the following times: iv. Immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles v. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks vii. After engaging in other activities that contaminate the hands.6. Use of Gloves c. Use single use gloves for one task ci. Change gloves: i. Between each food preparation task.ii. After touching items, utensils or equipment not related to task.iv. When leaving food preparation area for any reason.

Based on observation, interview and record review, the facility failed to ensure each resident received assistance devices to prevent accidents for one (Resident #110) of three residents reviewed for transfers. CNA E failed to use a footrest to transfer Resident #110 from resident's room to shower room. The failure placed the residents, who required one or two people to assist with transferring, at risk for injury.Findings included: Record review of Resident #110's face sheet dated 8/5/25 revealed a [AGE] year-old male admitted originally on 6/20/25. His diagnoses included, cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery (a stroke where part of the brain is damaged due to a blockage or narrowing of a blood vessel, but the specific cause of the blockage is not identified), unsteadiness on feet, other abnormalities of gait and mobility. Review of Resident #110's Comprehensive Plan of Care, dated 6/20/25, revealed Resident #110 was totally dependent on staff to wheel at least 150 feet in a corridor or similar space. Review of Resident #110's MDS assessment, dated 6/25/25, revealed the resident was totally dependent for assistance with transfers. Observation on 8/05/25 at 10:35 a.m. revealed CNA E was wheeling Resident #110 to the shower room. The resident was dragging his feet, and the resident's foot was between the wheelchair and the door frame. The surveyor intervened to prevent injury to the right foot by telling CNA E that the resident's foot was between the wheelchair and door frame. During an interview on 8/05/25 at 10:35 a.m. CNA E said that the resident had footrests, but she forgot to put them in the wheelchair. CNA E said that she was only transferring the resident from the room to the shower room, and it was a short distance. CNA E said that Resident #110 could had been hurt because his foot was stuck between the wheelchair and the door frame. During an interview on 8/07/25 on 9:57 a.m. the DON revealed the facility expected staff to always use footrests on residents that needed them. The DON said that the negative outcome of transferring the resident without the footrest was that Resident #110 had a high potential risk for injury. Record review of the facility's Incidents and Accidents Policy date implemented 08/15/2022 revealed: it is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 5 residents reviewed for comprehensive care plans. 1. The facility failed to update Resident #10's oxygen order in his care plan. These failures could lead to residents not receiving needed care and/or consideration from staff as care is provided and/or receiving improper care/treatment. Findings Included: 1.Record review of Resident #10's admission record dated 08/3/2025 reflected a [AGE] year-old male with an admission date of 6/18/2025. Pertinent diagnoses included Tracheostomy status (the presence of a tracheostomy, a surgical procedure that creates an opening in the trachea to allow breathing), acute respiratory failure with hypoxia (is a serious medical condition where the lungs are unable to adequately oxygenate the blood and/or remove carbon dioxide). Record review of Resident #10's Quarterly MDS assessment, dated 07/8/2025 revealed he received oxygen therapy while a resident. Record review of Resident #10's person-centered care plan, initiated date 7/22/2025 reflected Resident #10 used oxygen therapy related to acute respiratory failure status post tracheostomy status. Intervention included oxygen settings: oxygen settings via tracheostomy collar at 6 liters per minute continuous. Record review of Resident #10's physician order dated 08/3/2025, revealed oxygen at 2 LPM via trach tube every shift for hypoxia. During an observation of Resident #10 on 08/3/2025 at 9:50 a.m., the oxygen level on the oxygen concentration machine was at 1.5Liters Per Minute via tracheostomy. Resident #10 was in bed with head of the bed slightly elevated. No signs of respiratory distress noted. In an interview on 08/3/2025 at 9:55 a.m., LVN A, stated she was the nurse for Resident #10. LVN A said the Oxygen was set at 1.5 Liters Per Minute. She stated the oxygen setting was supposed to be at 2 Liters Per Minute per physician orders. She stated that she checked the settings at the beginning of her shift. She was not sure who might have moved it. LVN A stated that she checked Resident #10's oxygen tubing and saturation this morning. She stated that she usually checks the oxygen once a day and as needed. LVN A stated that the negative outcome to keeping Resident# 10's oxygen setting at 1.5 Liters Per Minute was that resident could go into respiratory distress or oxygen level might drop. During an interview on 08/6/25 at 08:26 AM the ADON stated the care plan should have been updated by whomever received the order for the oxygen when they received it. ADON stated if the care plan was not updated could affect the Resident #10 by not receiving the oxygen that he required. During an interview on 08/7/25 at 09:50 AM DON stated that she was responsible to update the care plan for Resident #10, but she missed it. DON stated the care plan had to be updated to give the resident the best care and to verify if the interventions were effective. The DON stated care plans were created upon admission within 48 hours, updated 14 days after admission, quarterly, and upon change of condition. The DON stated Resident #10 was at risk of not receiving the proper oxygen that he required. Record review of facility's policy titled Comprehensive Care Plans with a date implemented 10/24/25 revealed the following: it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for wound care. LVN A failed to communicate and provide treatment for the Resident #1's skin tear. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety. Finding included: Record review of Resident #1's face sheet dated 07/3/25 indicated Resident #1 was a [AGE] year-old female and admitted on [DATE] with diagnoses including diabetes mellitus type 2 (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels), essential hypertension (a condition where blood pressure is consistently elevated without a known underlying medical cause). Record review of Resident #1's MDS assessment dated [DATE] revealed a BIMS score of 5 (indicates a severe cognitive impairment). Record review of Resident #1's care plan initiated dated 05/21/24 indicated Resident #1 had limited mobility related to weakness, interventions revealed Monitor/Document/Report as needed any signs and symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. During an interview and observation on 06/19/25 at 10:42 a.m., Resident #1 was lying in her bed with the call light in her hand. Resident #1 was not able to recall this incident. During an interview on 6/29/25 at 2:50 p.m. CNA B stated that she showered Resident #1 and resident didn't have a skin tear during the shower. CNA B said that the Resident's family member was putting lotion and told her that Resident #1 had a skin tear. CNA B stated that she told LVN A that Resident #1 had a skin tear. During a phone interview on 6/19/25 at 3:20 p.m. LVN A stated that CNA B told him that Resident #1 had a skin tear. LVN A stated that she went to Resident's #1 room and cleansed the skin tear and he forgot to call the doctor because he got busy with another resident. LVN A said that a negative outcome could be the skin tear could get infected. During an interview on 6/19/25 at 3:30 p.m. the ADON stated that nurse was supposed to assess Resident #1 and report the skin tear to the doctor, and carried out the doctor's orders. The ADON stated that LVN A had to fill out a form of the change of condition and notify the responsible party. During an interview on 6/19/25 at 4:15 p.m. the DON stated that what she knew about this incident was that LVN A went and saw Resident #1 and cleansed the skin tear. The DON said that LVN A had an emergency with another resident and forgot to contact the doctor to informed about the skin tear. The DON stated that Resident #1 was at risk for infection due to the skin tear was not treated for 2 days. DON said there was no negative outcome with Resident #1. DON said that she monitors during the morning meetings to prevent this from happening again and inservices staff on how to respond when a skin tear happens. Record Review of a facility's Notification of Changes Policy with a implemented date 10/24/22 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, the resident's representative when there is a change requiring notification

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents (Resident #1) reviewed for clinical documentation and medical records accuracy. The facility failed when Resident #1's June 2025 MAR order for Midodrine was inaccurately dated, as well as the ADON had never signed the MAR that Resident #1's Midodrine was administered on 06/13/2025. This deficient practice could place residents at risk for incomplete or inaccurate clinical records, which could lead to miscommunication, a delay in services, or a potential decline in the resident's health. The findings included: Record review of Resident #1's face sheet, dated 06/21/25, revealed a [AGE] year-old male with an original admission date of 08/01/24, and a recent admission date of 05/23/25. Diagnoses included Chronic Pulmonary Edema (a condition characterized by abnormal buildup of fluid in the lungs), Adult Failure to Thrive (a condition that affects appetite, weight, and activity), Peripheral Vascular Disease (a disorder of the blood vessels outside of the heart), End Stage Renal Disease (advanced state of kidney failure that occurs with the gradual loss of kidney function), and Type 2 Diabetes (a condition that affects how the body uses insulin and sugar). Record review of Resident #1's Quarterly MDS assessment, dated 05/21/25, revealed a BIMS score of 10, indicating moderately impaired cognition. Record review of Resident #1's care plan, initiated 08/02/24, revealed Resident #1 was a full code. Record review of Resident #1's care plan, initiated 02/06/25, revealed Resident #1 was resistive to care and resistive to following dietary and fluid restriction orders, as well as refused dialysis treatments at times. Record review of Resident #1's care plan, initiated 08/22/24, revealed Resident #1 had hyperlipidemia related to hypertension, and hypertension related to lifestyle choices. Record review of Resident #1's care plan, initiated 08/22/24, revealed Resident #1 had a potential for fluid volume overload related to kidney failure. Record review of Resident #1's physician orders, started and stopped 06/14/25, revealed an order for Midodrine 10 MG, give 1 tablet by mouth every 8 hours as needed for hypotension if blood pressure was below 100/60. Order was entered by LVN-E. Record review of Resident #1's June 2025 MAR revealed blood pressure on the morning of 06/13/24 was 121/72, so Resident #1's routine hypertension medications were administered, to include Amlodipine, Lisinopril, Clonidine, and Carvedilol. Resident #1's blood pressure on 06/13/25 at 4:00 PM was 82/48, so routine hypertension medications were withheld, to include Carvedilol and Clonidine. This same MAR revealed the order for Midodrine as: Midodrine 10 MG, give 1 tablet by mouth every 8 hours as needed for hypotension if blood pressure was below 100/60, start date 06/14/25, and stop date 06/14/25. The Midodrine signature box was left blank. In an interview with the ADON on 6/21/25 at 8:51 AM, she stated she was here on 6/13/25 when Resident #1 came back from dialysis and started having low blood pressure issues. She stated Resident #1 was doing okay other than he looked pale and tired. She stated she tried to get Resident #1 to lay down, but he refused. She stated Resident #1 was not complaining about anything, but when the nurse on the floor checked his blood pressure, it was really low. She stated she was trying to help the new nurse out, so she was the one who called the doctor and got the order for the Midodrine, and she administered the Midodrine to Resident #1. She stated she should have put the order in herself instead of letting the new nurse put the order in for her, since she was the one who obtained the order. The ADON also stated she was the one who should have signed the MAR since she was the one who administered the Midodrine to Resident #1. In an interview with the DON on 06/21/25 at 9:57 AM, she stated the order for Midodrine was obtained from the physician by the ADON on 06/13/25, and the ADON should have put the order in, but LVN-E, who was the nurse on the floor that evening, ended up putting the order for the Midodrine in the system for the ADON. She stated he was still new and learning, so when he put the order in the system he should have clicked the start now box, but because he did not, the order did not show to start until the next day, which was why it was transcribed wrong in the MAR. She stated the ADON was the one who should have signed the MAR since she was the one who gave the Midodrine. In an interview with LVN-E on 6/21/25 at 11:22 AM, LVN-E stated Resident #1 got the Midodrine on his shift, and he was stable throughout the night. He stated the ADON gave the Midodrine to Resident #1, but he entered the order. He stated he may have entered the order wrong because the order was obtained, and the medication was given on 06/13/25 not 06/14/25. He stated the ADON was busy trying to help him, and her shift was over, and she was trying to leave, so he put the order in for her. He also stated he was unsure why the MAR was never signed. Record review of the facility's Medication Policy, implemented 10/24/22, revealed 10. Review MAR to identify medication to be administered. 17. Sign MAR after administered. Record review of the facility's Documentation Policy, implemented 10/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for one (Resident #1) of six residents reviewed for quality of care The facility failed to ensure WCN A treated Resident #1's wound on her left buttock per doctor's order. This failure had the potential to affect residents receiving wound care could experience infection, worsening of the wounds, and pain. The findings included: Record review of Resident #1's Face Sheet, dated 08/19/2024, revealed a [AGE] year old female admitted on [DATE] with the diagnoses of: Diverticulosis of large intestine (a medical condition that causes small pouches, called diverticula, to form in the walls of the gastrointestinal tract, usually in the large intestine), Type 2 Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), dementia (a group of thinking and social symptoms that interferes with daily functioning such as forgetfulness, limited social skills, and thinking abilities so impaired that it interferes with daily functioning). Record review of Resident #1's Minimum Data Set assessment dated [DATE] revealed she: -had unclear speech -usually understood self and usually understood others -had a brief interview of mental status score of 00-severly impaired cognition -was always incontinent of bowel and bladder -had Diabetes Mellitus Record review of Resident #1's comprehensive care plan dated 05/24/2024 documented, FOCUS: o [Resident #1] has MASD of the left and right buttocks r/t increased moisture Date Initiated: 12/26/2023 Revision on: 12/28/2023 GOAL: o The resident will have no s/sx of infection of MASD through the review date. Date Initiated: 12/28/2023 Revision on: 12/28/2023 Target Date: 08/22/2024 INTERVENTIONS/TASKS: o Avoid scratching and keep hands and body parts from excessive moisture. Date Initiated: 12/26/2023 CNA LN RN o Increase out of bed activity as tolerated. Date Initiated: 12/26/2023 [CNA LN RN] o Specialty chair in place while out of bed Date Initiated: 08/16/2024 [LN RN CNA] Record review of Resident #1's physician's orders revealed, Start Date: 08/15/24 Order Summary: Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to left buttock topically every day shift for trauma/injury Cleanse wound to left buttock with saline pat dry with gauze skin peri-wound apply Santyl/Calcium Alginate cover with dry protective dressing qd and PRN if soiled or dislodged. AND Apply to left buttock topically as needed for trauma /injury Cleanse wound to left buttock with saline pat dry with gauze skin peri-wound apply Santyl/Calcium Alginate cover with dry protective dressing qd and PRN if soiled or dislodged. Record review of Resident #1's Treatment Administration Record revealed no nurse check off of wound care to left buttock for 08/15/24, 08/16/24, 08/17/24, 08/18/24, 08/19/24, 08/20/24 or 08/21/24. Record review of Resident #1's wound care measurements of the left buttock revealed: -On 08/07/24: Non-Pressure wound of the left buttock full thickness (Site 11): 4.0 x 2.5 x 0.1 cm Surface area: 10.00 cm2 -On 08/14/24: Non-Pressure wound of the left buttock full thickness (Site 11): 7.5 x 4.0 x 0.1 cm Surface area: 30.00 cm2 -On 08/20/24: Non-Pressure wound of the left buttock full thickness (Site 11): 2.0 x 1.9 x 0.3 cm Surface area: 3.80 cm2 Record review of Progress Note on 08/14/24 at 05:22 PM revealed, NURSING - Skin/Wound Note written by WCN A: Late Entry: Note Text: Patient seen per WCD wound to right and left buttock has deteriorated due to infection, generalized decline of patient, also self-inflicts scratches to buttock area and all over body, new orders received and carried out, Covid positive visiting made aware of change of wound status and new orders, verbalized understanding. Record review of Progress Note on 08/14/24 05:40 PM Change of Condition Note written by [WCN]: Late Entry: Signs/Symptoms Details: wounds to right and lt (left) buttock exacerbated, started 08/14/2024, since started it has gotten: Stayed the same Things that make the condition worse: patient causes self-inflicted scratches to bilateral buttocks and generalized body . Record review of Progress Note on 08/19/24 at 11:30 AM Nurse Note written by [WCN]: Note Text: assessment performed on wounds which appear to be improving evidenced by decreased drainage, left buttock wound decreased in surface area, call placed to [WCD] and updated on findings stated will be making a follow-up visit this pm. Record review of Progress Note on 08/20/24 at 03:00 AM Nurse Note written by [LVN B]: Note Text: WCD rounded at facility for wound care assessment and treatment for pt. Gave new orders for STAT: -CBC, CMP, Prealbumin, and HGB -New orders for Only up in chair for meals only with gel cushion. [WCD[ also recommended to give pt Tylenol 650 mg PRN for pain to wounds. Orders were input and carried out, pending labs to be drawn in AM. Observation and interview on 08/19/24 at 03:45 PM of wound care on Resident #1 by Wound Care Nurse assisted by CNA C. Obwervation revealed the WCN applied cream to sacral wound and wound on right buttock. Observation revealed no cream was applied on left buttock and left buttock was not cleaned. WCN saw wound on left buttock and she said she thought the doctor said it was healed. WCN went out to cart and brought in Santyl to cover wound. WCN patted wound with normal saline, dried with dry gauze, and applied Santyl. In an interview on 08/19//24 at 04:26 PM, WCN stated she thought the order for the left ischium was the wound on the left side (buttock). WCN stated she had not treated the wound on the left buttock. In a telephone interview on 08/19/24 at 05:30 PM, WCD said it did not matter if that wound were treated or not since the 15th (08/15/24). WCD stated the ischium would be the important wound. He stated Resident #1 was non-compliant and was a scratcher. He said they had all Resident #1's wounds about closed and then she got COVID and deteriorated all over again. He said he was stopping by tonight (08/19/24) or tomorrow (08/20/24) to check on Resident #1. He said WCN was very good and he did not complain to the facility about the care the resident was getting. He was telling the facility of Resident #1's rapid deterioration after getting COVID. He said he came to the facility on ce or twice and sometimes more, and the facility and the WCN were fantastic. He said that the wound on Resident #1's left buttock started by the resident picked and scratched. In an interview on 08/20/24 at 09:15 AM CNA D stated she first started noticing Resident #1's wounds getting worse around August 9, 2024. CNA D stated she started noticing it get bad when Resident #1 was in isolation for COVID and she reported it to the nurse. CNA D stated she could not remember who the nurse was. CNA D stated Resident #1 scratched a lot. She said the nurses put cream on her that seemed to help. CNA D stated when she noticed a change on a resident, she notified the nurse right away and documented in their computer. CNA D stated she had been caring for Resident #1 since her arrival last year on Halloween (10/31/24). CNA D stated they kept Resident #1's nails short. CNA D stated they were trained on incontinent care at least once a month with hands-on demonstrations. In an interview on 08/20/24 at 09:25 AM, CNA E stated she had worked with Resident #1 for a few months. CNA E stated Resident #1 scratched a lot. CNA E stated nurses would put cream on Resident #1. CNA E stated the cream seemed to work. CNA E stated she noticed Resident #1's wound getting worse around 08/09/24. CNA E stated she was going to give Resident #1 a bed bath and noticed wounds getting worse. CNA E stated they reported wounds to got worse to the nurse . In an interview on 08/20/24 at 09:45 AM, DON stated both CNA D and CNA E were interviewed and they gave a statement. DON stated she thought the doctor (WCD) was upset because a resident he used to treat, their insurance would no longer pay to have him treat since their wounds had healed. In a telephone interview on 08/20/24 at 02:20 PM with RN F stated she was the weekend wound care nurse at facility. She said the weekend of August 10th - 11th , Resident #1's wounds were worse and she notified during report. RN F stated that past weekend (August 17th and 18th), there were new orders in the computer for Resident #1 and her wounds had improved. RN F stated she did not put any notes in the computer, she only passed information on at report. RN F stated she did wound care on all wounds. In an interview on 08/20/24 at 02:55 PM, WCN stated she had worked with WCD for a long time. She said he was upset about insurance not paying anymore for a resident that he had treated. She said the doctor thought maybe the facility could help out so he could treat the resident, but they could not. In a telephone interview on 08/20/24 at 05:20 PM, WCD stated Resident #1 had deteriorated from having COVID. WCD stated there was no question the facility and the wound care nurse took care of residents. He said the WCN was great and kept him updated on any changes to residents. He said he had been updated on Resident #1's wounds and deterioration while having COVID. WCD stated hewent to the facility at least once a week to assess Resident #1, more if needed. WCD stated with Resident #1 having COVID and her comorbidities, she deteriorated quickly. WCD stated WCN kept him updated on all his residents' conditions. He said since Resident #1 was out of isolation and no longer had COVID, she was starting to improve. WCD said he was the one to let the facility know of interventions. In an interview on 08/21/24 at 01:30 PM, DON stated every morning, they were notified of new orders and the WCN met with the team to go over new orders and measurements of wounds. DON stated if wounds were not treated, there was a possibility of the wound deteriorating and infection. DON stated she may start going on rounds with the WCD and the WCN. In an interview on 08/21/24 at 02:00 PM, ADON A stated before wound care, he would double check the doctor's order and if he needed clarification, he would call the doctor and ask for clarification. ADON A stated if a wound went untreated, it could cause infection or deterioration of the resident. ADON A stated he just started as ADON at the facility. Review of the facility's Physician Visits and Physician Delegation Policy dated 10/24/22 revealed, Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of the residents. The policy did not address the nurse following physician orders.

47828 Based on interview and record review the facility failed to ensure the resident had the right to be free from neglect, for one of four residents (Resident #250) reviewed for neglect: CNA C stated she was aware Resident #250 required 2-person assistance with a bed bath but proceeded to give care to the resident alone resulting in the resident falling and fracturing her left femur. The non-compliance for Resident #250 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/15/2024 and ended on 03/15/2024. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of neglect resulting in serious injuries, harm, impairment, or death. The findings were: Record review of Resident #250's face sheet dated 06/11/2024 reflected a [AGE] year-old female with an admitted [DATE] and an initial admitted [DATE]. Resident #250 had a discharge date of [DATE]. Resident #250's relevant diagnoses included dementia (memory loss), muscle weakness, contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left and right knee, lack of coordination, pain to left and right knee, and chronic obstructive pulmonary disease (restricted airflow and breathing problems). Record review of Resident #250's quarterly MDS assessment dated [DATE] reflected a BIMS score 09, which indicated Resident #250's cognition was moderately impaired. Resident #250's functional abilities for shower/bathe was substantial/maximal assist (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) Record review of Resident #250's quarterly Care Plan assessment dated [DATE] revealed an ADL problem Resident #250 has an ADL self-care performance deficit r/t confusion, dementia. Date initiated 12/08/2017 and revised on 08/03/23. ADL interventions, BATHING/SHOWERING: The resident is totally dependent on (2) staff to provide (shower)(M-W-F) and as necessary. Date Initiated: 12/08/2017, Revision on: 08/27/2021. Record review of Resident #250's x-ray report dated 03/15/2024 reflected she had a displaced comminuted slightly overlapped distal left femoral metaphyseal fracture. Fracture was documented on the change of condition. In an interview on 06/12/2024 at 1:35 p.m., CNA C said she had been employed by the facility for 3 years prior to being terminated on 03/15/2024. CNA C said she received training in ADL's when she first got hired and annually. She said she knew where to check to see if a resident was a 1 or 2 person assist when it came to ADL's. CNA C said she would either check the resident's POC or ask the charge nurse. CNA C said she knew Resident #250 was a 2 person-assist for bathing but still decided to bed bathe her by herself on 03/15/2024. She said 03/15/2024 was not the first time she bed bathed Resident #250 by herself. CNA C said the other times, Resident #250 had longer rails and said it was easier. CNA C said on 03/15/2024, Resident #250 had shorter rails. She said she was not sure when the rails were changed. CNA C said on 03/15/2024, while bed bathing Resident #250 she turned her to the side to wash her back and her legs slipped off the bed. CNA C said she tried to grab her, but Resident #250 was wet and slippery and not able to hold on to her. CNA C said resident fell to the floor. CNA C said immediately pressed the call light and started yelling for help. She said she rushed over to where Resident #250 landed and stayed with her until a nurse arrived. CNA C said her charge nurse responded quickly and Resident #250 was assessed. She said once her charge nurse assessed Resident #250, she stepped out of the room. CNA C said she was told Resident #250 was taken the local hospital to be evaluated because she sustained a bump to her face and a scrape to her back. CNA C said she was removed from the floor and later that day was terminated. CNA C the facility was fully staffed, and she was trained to follow the residents care plan. CNA C said she took sole responsibility and knew she did wrong by bathing Resident #250 by herself. CNA C said she thought it would be easy to give Resident #250 a bed bath by herself because she had done it before. CNA C said if she had followed Resident #250's care plan, it could have prevented the fall. An interview on 06/12/2024 at 2:37 p.m., LVN H said Resident #250 was a 2 person-assist for bathing. She said she was the charge nurse for Resident #250 on 03/15/2024. LVN H said she was tending to a resident across from Resident #250's room when she was told by a CNA (does not remember name) Resident #250 had fallen. She said she immediately went to Resident #250's room and found her on the floor. LVN H said Resident #250 was wet and unclothed. She said she noticed Resident #250 had discoloration to her forehead, but her vitals were within range. LVN H said she called Resident #250's doctor who ordered for her to be sent to local hospital for evaluation. LVN H said she asked CNA C to explain what had happened. She said CNA C told her Resident #250 slipped when she tried to turn her sideways to wash her back. She said she immediately removed CNA C from the floor and advised the DON and the Administrator. An interview on 06/12/2024 at 3:37 p.m., the DON said on 03/15/2024, she was informed by LVN H Resident #250 had fallen. She said she immediately started an investigation, and it was concluded CNA C did not follow Resident #250's care plan and bed bathed her alone. The DON said Resident #250 was sent to the hospital because she sustained a deformity on her head and complained of pain. The DON said she immediately pulled CNA C to the side and questioned her as to what happened. The DON said CNA C admitted to knowing Resident #250 was a 2 person assist for showers/baths and took full responsibility. The DON said she sent CNA C home after the incident on 03/15/2024 and upon completing her investigation, CNA C was terminated on same day. An interview on 06/12/2024 at 4:00 p.m., the Administrator said CNA C did not follow Resident #250's care plan which required a 2 person assist for bathing. He said after their investigation, CNA C was terminated on 03/15/2024. He said other CNA's were in-serviced on the following topics: ANE, CNA's to follow care tasks to assist resident according to always care plan and transfers and repositioning. Record review of facility's policy on Abuse, Neglect, and Exploitation dated 08/15/22 reflected: Policy: 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. Policy Explanation and Compliance Guidelines: 3. The facility will provide ongoing oversight and supervision of staff in order to assure that it's policies are implemented as written. The Administrator was notified on 06/26/2024 at 4:45 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #250 in an IJ situation on 03/15/2024. The facility implemented the following interventions: Record review of CNA C Employee Counseling Report, dated, 03/15/2024 reflected she received a level two offense for failure or unwillingness to perform work as required or directed .failing to meet job expectation .failure to comply with safety guideline(s) as outlined in the Employee Guide and Safety. The Incident description indicated failure to follow plan of care per acre task when providing care to resident. Resident had a fall with injury. Record review of CNA's Personnel Action Form dated 03/15/2024 reflected she was terminated. Under manager's comment a note reflected failure to follow proper care plan for care. Employee included in self-report for injury to a resident. CNA's were in-serviced on 03/15/2024 after the incident on CNA's to follow care task to assist resident according to care plan at all times and transfers and repositioning. An observation on 06/27/2024 at 9:10 a.m. Resident #13 was observed during his bed bath and no discrepancies were observed. An observation on 06/27/2024 at 9:45 a.m. Resident #62 was observed during his bed bath and no discrepancies were observed. An interview on 06/12/2024 at 2:15 p.m., CNA E said she received training on ADL's when she was first hired and annually after. She said she knew to check resident's POC and/or ask her charge nurse to see if a resident was a 1 or 2 person assist for their ADL's. An interview on 06/12/2024 at 2:30 p.m., CNA F said she received training on ADL's when she was first hired and annually after. She said she knew to check resident's POC and/or ask her charge nurse to see if a resident was a 1 or 2 person assist for their ADL's.

Based on interviews, and record reviews the facility failed to ensure that the residents environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Residents #250) reviewed for accidents hazards and supervision. The facility failed to ensure Resident #250 was assisted by two care providers during a bed bath which resulted in her rolling out of bed onto the floor and sustaining a left femoral fracture. This failure could place residents at risk of accidents and injury. The non-compliance for Resident #250 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/15/2024 and ended on 03/15/2024. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of neglect resulting in serious injuries, harm, impairment, or death. The findings include: Record review of Resident #250's face sheet dated 06/11/2024 reflected a [AGE] year-old female with an admitted [DATE] and an initial admitted [DATE]. Resident #250's relevant diagnoses included dementia (memory loss), muscle weakness, contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of left and right knee, lack of coordination, pain to left and right knee, and chronic obstructive pulmonary disease (restricted airflow and breathing problems). Record review of Resident #250's quarterly MDS assessment dated [DATE] reflected a BIMS score 09, which indicated Resident #250's cognition was moderately impaired. Resident #250's functional abilities for shower/bathe was substantial/maximal assist (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) Record review of Resident #250's quarterly Care Plan assessment dated [DATE] reflected an ADL problem Resident #250 has an ADL self-care performance deficit r/t confusion, dementia. Date initiated 12/08/2017 and revised on 08/03/23. ADL goal was Resident #250 will maintain current level of function through the review date. Date initiated: 12/08/2017 and revision date on: 03/15/2024. ADL interventions, functional performance: shower/bathe self: the resident requires substantial/maximal assistance for shower/bathe. Date initiated: 12/14/2023 and revised on 03/15/2024.Bathing/Showering: the resident is totally dependent on (2) staff to provide (shower) (M-W-F) and as necessary. Date initiated: 12/08/20217 and revised on: 08/27/2021. Record review of Resident #250's x-ray report dated 03/15/2024 reflected she had a displaced comminuted slightly overlapped distal left femoral metaphyseal fracture. Fracture was documented on the change of condition. In an interview on 06/12/2024 at 1:35 p.m., CNA C said she had been employed by the facility for 3 years prior to being terminated on 03/15/2024. CNA C said she received training in ADL's when she first got hired and annually. She said she knew where to check to see if a resident was a 1 or 2 person assist when it came to ADL's. CNA C said she would either check the resident's POC or ask the charge nurse. CNA C said she knew Resident #250 was a 2 person-assist for bathing but still decided to bed bathe her by herself on 03/15/2024. She said 03/15/2024 was not the first time she bed bathed Resident #250 by herself. CNA C said the other times, Resident #250 had longer rails and said it was easier. CNA C said on 03/15/2024, Resident #250 had shorter rails. She said she was not sure when the rails were changed. CNA C said on 03/15/2024, while bed bathing Resident #250 she turned her to the side to wash her back and her legs slipped off the bed. CNA C said she tried to grab her, but Resident #250 was wet and slippery and not able to hold on to her. CNA C said resident fell to the floor. CNA C said immediately pressed the call light and started yelling for help. She said she rushed over to where Resident #250 landed and stayed with her until a nurse arrived. CNA C said her charge nurse responded quickly and Resident #250 was assessed. She said once her charge nurse assessed Resident #250, she stepped out of the room. CNA C said she was told Resident #250 was taken the local hospital to be evaluated because she sustained a bump to her face and a scrape to her back. CNA C said she was removed from the floor and later that day was terminated. CNA C the facility was fully staffed, and she was trained to follow the residents care plan. CNA C said she took sole responsibility and knew she did wrong by bathing Resident #250 by herself. CNA C said she thought it would be easy to give Resident #250 a bed bath by herself because she had done it before. CNA C said if she had followed Resident #250's care plan, it could have prevented the fall. An interview on 06/12/2024 at 2:37 p.m., LVN H said Resident #250 was a 2 person-assist for bathing. She said she was the charge nurse for Resident #250 on 03/15/2024. LVN H said she was tending to a resident across from Resident #250's room when she was told by a CNA (does not remember name) Resident #250 had fallen. She said she immediately went to Resident #250's room and found her on the floor. LVN H said Resident #250 was wet and unclothed. She said she noticed Resident #250 had discoloration to her forehead, but her vitals were within range. LVN H said she called Resident #250's doctor who ordered for her to be sent to local hospital for evaluation. LVN H said she asked CNA C to explain what had happened. She said CNA C told her Resident #250 slipped when she tried to turn her sideways to wash her back. She said she immediately removed CNA C from the floor and advised the DON and the Administrator. An interview on 06/12/2024 at 3:37 p.m., the DON said on 03/15/2024, she was informed by LVN H Resident #250 had fallen. She said she immediately started an investigation, and it was concluded CNA C did not follow Resident #250's care plan and bed bathed her alone. The DON said Resident #250 was sent to the hospital because she sustained a deformity on her head and complained of pain. The DON said she immediately pulled CNA C to the side and questioned her as to what happened. The DON said CNA C admitted to knowing Resident #250 was a 2 person assist for showers/baths and took full responsibility. The DON said she sent CNA C home after the incident on 03/15/2024 and upon completing her investigation, CNA C was terminated on same day. An interview on 06/12/2024 at 4:00 p.m., the Administrator said CNA C did not follow Resident #250's care plan which required a 2 person assist for bathing. He said after their investigation, CNA C was terminated on 03/15/2024. He said other CNA's were in-serviced on the following topics: ANE, CNA's to follow care tasks to assist resident according to always care plan and transfers and repositioning. Record review of Facility's policy on Quality of Care revised on 08/20212 reflected: Each resident will receive the necessary nursing, medical, and psychosocial services to attain and maintain the highest possible mental and physical functional status as defined by the comprehensive assessment and plan of care . These nursing, medical and psychosocial needs will be identified in the Resident Assessment, and addressed in the Comprehensive Care Plan and the Medical Record to reflect that the interventions in the following clinical situations were maintained. The Administrator was notified on 06/26/2024 at 4:45 p.m., that a past non-compliance IJ situation had been identified due to the above failures. It was determined these failures placed Residents #250 in an IJ situation on 03/15/2024. The facility implemented the following interventions: Record review of CNA C Employee Counseling Report, dated, 03/15/2024 reflected she received a level two offense for failure or unwillingness to perform work as required or directed .failing to meet job expectation .failure to comply with safety guideline(s) as outlined in the Employee Guide and Safety. The Incident description indicated failure to follow plan of care per acre task when providing care to resident. Resident had a fall with injury. Record review of CNA's Personnel Action Form dated 03/15/2024 reflected she was terminated. Under manager's comment a note reflected failure to follow proper care plan for care. Employee included in self-report for injury to a resident. An interview on 06/12/2024 at 2:15 p.m., CNA E said she received training on ADL's when she was first hired and annually after. She said she knew to check resident's POC and/or ask her charge nurse to see if a resident was a 1 or 2 person assist for their ADL's. An interview on 06/12/2024 at 2:30 p.m., CNA F said she received training on ADL's when she was first hired and annually after. She said she knew to check resident's POC and/or ask her charge nurse to see if a resident was a 1 or 2 person assist for their ADL's. CNA's were in-serviced on 03/15/2024 after the incident on CNA's to follow care task to assist resident according to care plan at all times and transfers and repositioning. An observation on 06/27/2024 at 9:10 a.m. Resident #13 was observed during his bed bath and no discrepancies were observed. An observation on 06/27/2024 at 9:45 a.m. Resident #62 was observed during his bed bath and no discrepancies were observed.

Based on interview and record review, the facility failed to ensure that a resident's CPR/advance directive/physician orders were followed for 1 (Resident #1) of 6 residents reviewed for CPR, in that: LVN A found Resident #1 unresponsive and LVN A told RN B. Both LVN A and RN B failed to check Resident #1's code status, which was a full code, causing a delay in resuscitation. The resident expired in the facility. The facility failed to ensure staff were trained on how to locate a resident's code status. This failure could affect residents with advance directives and physician orders in place. An Immediate Jeopardy was identified to have occurred from [DATE] to [DATE]. This was determined to be a Past Non-compliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. Findings Included: Record review of Resident #1's face sheet revealed Resident #1 was a [AGE] year-old man who was admitted to the facility on [DATE]. Review of Resident #1's [DATE] order summary report revealed Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's annual minimum data sheet dated [DATE] revealed a brief interview for mental status score of fifteen which indicated cognitively intact. Activities of daily living for mobility functionality revealed assistance needed from one staff. Walk in room required setup help only. Toilet use and personal hygiene revealed assistance needed from one staff. Record review of Resident #1's care plan dated [DATE] revealed Resident #1 was a full code. This problem area had the following interventions: -If resident has a [CONDITION(S)], initiate CPR and call 911. Notify MD/RP and follow MD orders after notification. date initiated: [DATE]. revision on: [DATE] -Keep crash cart well supplied and ready for use at all times. date initiated: [DATE]. revision on: [DATE]. -Mark chart and all pertinent documents with FULL CODE. date initiated: [DATE]. revision on: [DATE]. Resident #1's [DATE] order summary report revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's provider investigation report related to incident 3 revealed on [DATE] Resident #1 was found unresponsive by LVN A at approximately 7:20 a.m. LVN A had last checked on Resident #1 at 7:05 a.m. and Resident #1 was identified as stable and sleeping. During an interview on [DATE] at 2:01 p.m., RN B said LVN A told her Resident #1 was unresponsive and was a DNR. RN B said she was working on the short-term side and was busy with other patients. She said she felt there was no urgency since LVN A told her Resident #1 was a DNR. She said she eventually let the Director of Nursing know, about fifteen to twenty minutes later. RN B said after what happened with Resident #1, they received an in-service regarding resident's code status. All staff were re-trained to know where they can access resident's code status in the record and at the nurse's station. They were also trained to immediately check for code status when a resident is found unresponsive. During an interview on [DATE] at 4:13 p.m., LVN A said on [DATE] at approximately 7:20 a.m., she found Resident #1 unresponsive. LVN A said the last time she checked on Resident #1 was at 7:05 a.m. and he was stable and sleeping. LVN A said she assumed Resident #1 was a DNR and she did not check his record to verify this. LVN A said she checked Resident #1 for vital signs and she did not find any. LVN A reported this to RN B. LVN A said she could not recall the most recent time she checked Resident #1's clinical record for code status. LVN A said she did not check Resident #1's record for code status since she thought he was a DNR. LVN A said since she thought Resident #1 was a DNR, that is why she did not perform CPR. During an interview with the Administrator and Director of Nursing on [DATE] at 4:10 p.m., the Director of Nursing said LVN A assumed Resident #1's code status was DNR. The Director of Nursing said she was informed by staff Resident #1 was unresponsive. They verified Resident #1's code status, realized he was a full code, and administered CPR and 911 was activated. The Director of Nursing said she can not recall at what time they initiated CPR. The Director of Nursing said LVN A was terminated. The Director of Nursing said all staff were trained on [DATE] that if a resident was found unresponsive, immediately check code status and if full code immediately initiate CPR and call 911. Staff were trained where to find the code status of a resident. An audit was also conducted of all clinical records to ensure the code statuses were accurate. At each nurse's station there are binders with resident's advance directive information. These binders were also checked and verified to contain accurate code status information. Record review of the facility policy titled, Advance Directives, with a revision date of [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. If the resident indicates that he or she has not established advance directives, the family staff will offer assistance in establishing advance directives. The plan of care for each resident will be consistent with his or her documented Advance Directives. On [DATE] at 7:30 p.m. the Administrator and Director of Nursing were notified of a past noncompliance IJ from [DATE] to [DATE]. The facility took the following actions to correct the non-compliance on [DATE]. The actions taken by the facility were included in the provider investigation report for incident # 3. All nursing staff were re-educated on identifying resident code status and the protocol to follow for full-code statuses. Review of the in-service training report dated [DATE] revealed twenty-five nursing staff were trained. Surveyor was able to verify this was done and staff understood the correct protocol by interviewing thirteen nursing staff from [DATE] to [DATE]. The facility also audited all residents records for accuracy of code statuses. Surveyor reviewed six clinical records which revealed the code status listed in the order summary report matched the code status on the face sheet and care plan. The facility also audited the advance directive book located at both nurse's stations which includes copies of the resident's face sheets which have the resident's code status. Surveyor reviewed both advance directive books and found that the code statuses were accurate for the facility's eighty-five residents.

Based on interview and record review, the facility failed ensure each resident received adequate supervision and assistance devices to prevent accidents, for one Resident (R#1) of two residents reviewed for falls. 1) The facility failed to ensure R#1's physician-ordered lap tray was in place. 2) R#1 suffered an unwitnessed fall. 3) R#1 sustained a [MEDICAL CONDITION] femur. This failure could place residents with lap trays at risk for injuries. The findings were: Record review of R#1's (MONTH) 2019 Order Summary Report revealed R#1 was [AGE] years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Orders included: May have lap tray while up in W/C (wheelchair). Release at least Q (every) 2 (two hours). Release at meals, during activities and to provide care. Every shift related to Dementia in Other Disease classified elsewhere with behavioral disturbance. Order date was 04/02/19. Start date was 04/10/19. Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated 04/16/19, revealed R#1: -was rarely/never able to make himself understood, -was sometimes able to understand others (responded adequately to simple, direct communications only), -had moderately impaired cognitive status (decisions poor, cues/supervision required), -required extensive assistance from two staff for bed mobility, transfers, dressing, toilet use and personal hygiene, -had range of motion limitations to both sides of lower extremities (hips, knees, ankles, feet), -used a wheelchair for mobility, -was frequently incontinent of bowel and bladder, and, -had two falls with no injuries and one fall with injury (except major) - (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain). Record review of R#1's Care Plan, dated 02/24/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Intervention was, Referral to therapy. Record review of R#1's Care Plan, dated 03/09/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Interventions were, Changed wheelchair to high backed wheelchair to assist in upright position. and Replace nonskid with dysem (non-slip material). Record review of R#1's Care Plan, dated 03/19/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Intervention was, Saddle cushion to assist in resident ability to maintain upright position. Record review of R#1's Care Plan, dated 03/29/19, revealed R#1 had an unwitnessed fall, cont (continues) to thrust hips up, unable to maintain upright position in wheelchair, slid from chair. No inuries noted. The intervention was to use the lap tray to assist R#1 to maintain an upright sitting position. Record review of R#1's incident report dated 05/05/19 at 3:00 p.m. revealed: Upon walking into the room, patient (R#1) was found on restroom floor sitting position facing the commode, holding onto side rail with right hand. Wheelchair found next to commode. Patient could not recall how fall occurred. Patient (R#1) attempted to lift himself off the floor while holding onto side rail. Informed patient (R#1) to be still until further assessment. Full range of motion noted in upper extremities. Range of motion unable to be assessed in lower extremities due to sitting position. Vitals unable to be obtained due to combative behavior. Patient then transferred to wheelchair by two CNAs (certified nurse aides). Then transferred to bed. Obtained vitals, skin assessment done - no abrasions or discolorations noted. Pain displayed when moving patient during brief change. Pain noted when moving right knee/leg. Same incident report indicated: Head to toe assessment done, no noted skin abrasions/deformity or discolorations. Vitals obtained, Patient placed on routine neurological checks. Continued to monitor behavior. RP (responsible party) and Physician notified. [MEDICATION NAME] 650 mg (milligrams) was offered, however refused. Record review of R#1's Progress Notes (Nursing notes), dated 05/05/19 at 10:00 p.m., revealed: S/P (status [REDACTED]. Patient is unable to recall how fall occurred. Vitals obtained: BP (blood pressure) 118/65, T (temperature) 98.0, P (pulse) 60, RR (respiration) 18, O2 (oxygen) 97. Full range of motion bilateral upper extremities. Unable to assess range of motion in lower extremities due to history weakness. No discoloration or skin abrasions noted. Minor swelling and pain to right knee noted upon transferring patient to bed. RP and Physician contacted. X-ray ordered of right knee and hip as per physician. Will continue with neurological checks and monitoring change in condition. Patient in bed, supine, at lowest level, call light within reach. Record review of R#1's Progress notes, dated 05/05/19 at 11:31 p.m., revealed: Nurse came on shift received report from out going nurse to call Resident's RP/(family member) after report. Resident was reported to have had an unwitnessed fall at appx (approximately) 3:00 p.m. Resident was assessed. No distress noted. Neuros intact, speech unchanged. Denies pain but stated will take when offered. He became upset for waking him up refused. RP was phoned and he reports due to a previous occurrence, he is requesting to send (R#1) out to hospital ER (emergency room ) for acute medical attention, studies and observation. He was advised that mobile X-ray just finished with (R#1) and he resumed his request to send him out. He stated his (family member) is on her way from home to go with him. On call advised. Paper work ready. Am nurse to notify MD (Medical Doctor) of family request. Continue to monitor until transfer. R#1 was not interviewed as he was out to the hospital during the investigation. In an interview on 05/09/19 at 9:05 a.m., the Director of Nurses (DON) said R#1 was aggressive with staff when providing care, and R#1's aggression was care planned. The DON said R#1 was found by the toilet, on the floor. The DON said R#1 was facing the toilet and his wheelchair was next to the toilet. The DON said no one saw R#1's lap table in the restroom. The DON said R#1 could remove the lap table on his own. The DON said the lap table was later found in the shower room. The DON said R#1 could not go into the shower room because it was locked. The DON said the nurse assessed R#1 and R#1 was not complaining of pain. The nurse called the doctor and R#1's RP. The DON said R#1's family requested for R#1 to be sent out to the hospital. The DON said the X-rays for R#1 had already been done at the facility. The DON said the X-rays showed a fracture of R#1's right femur. In an interview on 05/09/19 at 11:00 a.m., CNA A said she did not remember if she got R#1 up on the morning of 05/05/19. CNA A said she did not remember if R#1 had the lap table on his wheelchair during her shift (6:00 a.m. to 2:00 p.m.). CNA A said that, after lunch on 05/05/19, CNA A and CNA B changed R#1 in the restroom. CNA A said R#1 did not have the lap tray on his wheelchair at that time. CNA A said R#1 needed to have the lap tray at all times. CNA A said R#1 could remove the lap tray by himself and, at times, the lap tray had been found in the halls or in R#1's room. CNA A said R#1 was placed in the hallway in his wheelchair, without a lap tray, after they changed R#1. CNA A said she should have asked CNA B to stay with R#1 while she looked for the lap tray. In an interview on 05/09/19 at 11:10 a.m., CNA B said she did not get R#1 up on the morning of 05/05/19. CNA B said she knew R#1 had to have the lap tray while up to wheelchair. CNA B said R#1 could remove the lap tray. CNA B said she did not remember seeing the lap tray on R#1's wheelchair during her shift (6:00 a.m. to 2:00 p.m.). CNA B said she did not remember seeing the lap tray on R#1's wheelchair when R#1 was taken to the restroom. CNA B said she and CNA A placed R#1 in the hall without the lap table. CNA B said she did not tell the incoming shift that R#1 did not have the lap tray. In an interview on 05/09/19 at 11:35 a.m., Licensed Vocational Nurse (LVN) D said CNA C told her that R#1 was on the floor in the restroom. LVN D said R#1 was on the floor, facing the commode, and holding on to the grab bar to get up. R#1's wheelchair was next to the commode. R#1 was combative while taking vitals and pushing the CNA. LVN D said there was no lap tray in the restroom. LVN D said later a CNA found R#1's lap tray in the locked shower room. In an interview on 05/09/19 at 12:15 p.m., CNA C said she did not get a report from the previous shift (6:00 a.m. to 2:00 p.m.) that R#1 did not have the lap tray on the wheelchair. CNA C said she did not check at the beginning of her shift (2:00 p.m. to 10:00 p.m.) to see if R#1 had the lap tray while up to the wheelchair. CNA C said later she heard a scream and went into R#1s room. CNA C said she saw R#1 on the floor in the restroom. CNA C said she went to notify LVN D about R#1 being on the floor. CNA C said she did not see the lap tray in the restroom. CNA C said later on she found R#1's lap tray in the locked shower room. Review of the facility's policy on Falls, revised (MONTH) (YEAR), indicated: The staff will identify appropriate interventions to reduce the risk of falls.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent neglect, for one Resident (R#1) of four residents reviewed for neglect. 1) The facility failed to ensure R#1's lap tray was in place. 2) R#1 suffering an unwitnessed fall. 3) R#1 sustained a [MEDICAL CONDITION] femur. This failure could place residents with lap trays at risk for injuries. The findings were: Review of the facility's policy on, Reporting of Alleged Abuse to Facility Management, dated (MONTH) (YEAR), revealed the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Record review of R#1's (MONTH) 2019 Order Summary Report revealed R#1 was [AGE] years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Orders included: May have lap tray while up in W/C (wheelchair). Release at least Q (every) 2 (two hours). Release at meals, during activities and to provide care. Every shift related to Dementia in Other Disease classified elsewhere with behavioral disturbance. Order date was 04/02/19. Start date was 04/10/19. Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated 04/16/19, revealed R#1: -was rarely/never able to make himself understood, -was sometimes able to understand others (responded adequately to simple, direct communications only), -had moderately impaired cognitive status (decisions poor, cues/supervision required), -required extensive assistance from two staff for bed mobility, transfers, dressing, toilet use and personal hygiene, -had range of motion limitations to both sides of lower extremities (hips, knees, ankles, feet), -used a wheelchair for mobility, -was frequently incontinent of bowel and bladder, and, -had two falls with no injuries and one fall with injury (except major) - (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain). Record review of R#1's Care Plan, dated 02/24/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Intervention was, Referral to therapy. Record review of R#1's Care Plan, dated 03/09/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Interventions were, Changed wheelchair to high backed wheelchair to assist in upright position. and Replace nonskid with dysem (non-slip material). Record review of R#1's Care Plan, dated 03/19/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Intervention was, Saddle cushion to assist in resident ability to maintain upright position. Record review of R#1's Care Plan, dated 03/29/19, revealed R#1 had an unwitnessed fall, cont (continues) to thrust hips up, unable to maintain upright position in wheelchair, slid from chair. No inuries noted. The intervention was to use the lap tray to assist R#1 to maintain an upright sitting position. Record review of R#1's incident report dated 05/05/19 at 3:00 p.m. revealed: Upon walking into the room, patient (R#1) was found on restroom floor sitting position facing the commode, holding onto side rail with right hand. Wheelchair found next to commode. Patient could not recall how fall occurred. Patient (R#1) attempted to lift himself off the floor while holding onto side rail. Informed patient (R#1) to be still until further assessment. Full range of motion noted in upper extremities. Range of motion unable to be assessed in lower extremities due to sitting position. Vitals unable to be obtained due to combative behavior. Patient then transferred to wheelchair by two CNAs (certified nurse aides). Then transferred to bed. Obtained vitals, skin assessment done - no abrasions or discolorations noted. Pain displayed when moving patient during brief change. Pain noted when moving right knee/leg. Same incident report indicated: Head to toe assessment done, no noted skin abrasions/deformity or discolorations. Vitals obtained, Patient placed on routine neurological checks. Continued to monitor behavior. RP (responsible party) and Physician notified. [MEDICATION NAME] 650 mg (milligrams) was offered, however refused. Record review of R#1's Progress Notes (Nursing notes), dated 05/05/19 at 10:00 p.m., revealed: S/P (status [REDACTED]. Patient is unable to recall how fall occurred. Vitals obtained: BP (blood pressure) 118/65, T (temperature) 98.0, P (pulse) 60, RR (respiration) 18, O2 (oxygen) 97. Full range of motion bilateral upper extremities. Unable to assess range of motion in lower extremities due to history weakness. No discoloration or skin abrasions noted. Minor swelling and pain to right knee noted upon transferring patient to bed. RP and Physician contacted. X-ray ordered of right knee and hip as per physician. Will continue with neurological checks and monitoring change in condition. Patient in bed, supine, at lowest level, call light within reach. Record review of R#1's Progress notes, dated 05/05/19 at 11:31 p.m., revealed: Nurse came on shift received report from out going nurse to call Resident's RP/(family member) after report. Resident was reported to have had an unwitnessed fall at appx (approximately) 3:00 p.m. Resident was assessed. No distress noted. Neuros intact, speech unchanged. Denies pain but stated will take when offered. He became upset for waking him up refused. RP was phoned and he reports due to a previous occurrence, he is requesting to send (R#1) out to hospital ER (emergency room ) for acute medical attention, studies and observation. He was advised that mobile X-ray just finished with (R#1) and he resumed his request to send him out. He stated his (family member) is on her way from home to go with him. On call advised. Paper work ready. Am nurse to notifiy MD (Medical Doctor) of family request. Continue to monitor until transfer. R#1 was not interviewed as he was out to the hospital during the investigation. In an interview on 05/09/19 at 9:05 a.m., the Director of Nurses (DON) said R#1 was aggressive with staff when providing care, and R#1's aggression was care planned. The DON said R#1 was found by the toilet, on the floor. The DON said R#1 was facing the toilet and his wheelchair was next to the toilet. The DON said no one saw R#1's lap table in the restroom. The DON said R#1 could remove the lap table on his own. The DON said the lap table was later found in the shower room. The DON said R#1 could not go into the shower room because it was locked. The DON said the nurse assessed R#1 and R#1 was not complaining of pain. The nurse called the doctor and R#1's RP. The DON said R#1's family requested for R#1 to be sent out to the hospital. The DON said the X-rays for R#1 had already been done at the facility. The DON said the X-rays showed a fracture of R#1's right femur. In an interview on 05/09/19 at 11:00 a.m., CNA A said she did not remember if she got R#1 up on the morning of 05/05/19. CNA A said she did not remember if R#1 had the lap table on his wheelchair during her shift (6:00 a.m. to 2:00 p.m.). CNA A said that, after lunch on 05/05/19, CNA A and CNA B changed R#1 in the restroom. CNA A said R#1 did not have the lap tray on his wheelchair at that time. CNA A said R#1 needed to have the lap tray at all times. CNA A said R#1 could remove the lap tray by himself and, at times, the lap tray had been found in the halls or in R#1's room. CNA A said R#1 was placed in the hallway in his wheelchair, without a lap tray, after they changed R#1. CNA A said she should have asked CNA B to stay with R#1 while she looked for the lap tray. In an interview on 05/09/19 at 11:10 a.m., CNA B said she did not get R#1 up on the morning of 05/05/19. CNA B said she knew R#1 had to have the lap tray while up to wheelchair. CNA B said R#1 could remove the lap tray. CNA B said she did not remember seeing the lap tray on R#1's wheelchair during her shift (6:00 a.m. to 2:00 p.m.). CNA B said she did not remember seeing the lap tray on R#1's wheelchair when R#1 was taken to the restroom. CNA B said she and CNA A placed R#1 in the hall without the lap table. CNA B said she did not tell the incoming shift that R#1 did not have the lap tray. In an interview on 05/09/19 at 11:35 a.m., Licensed Vocational Nurse (LVN) D said CNA C told her that R#1 was on the floor in the restroom. LVN D said R#1 was on the floor, facing the commode, and holding on to the grab bar to get up. R#1's wheelchair was next to the commode. R#1 was combative while taking vitals and pushing the CNA. LVN D said there was no lap tray in the restroom. LVN D said later a CNA found R#1's lap tray in the locked shower room. In an interview on 05/09/19 at 12:15 p.m., CNA C said she did not get a report from the previous shift (6:00 a.m. to 2:00 p.m.) that R#1 did not have the lap tray on the wheelchair. CNA C said she did not check at the beginning of her shift (2:00 p.m. to 10:00 p.m.) to see if R#1 had the lap tray while up to the wheelchair. CNA C said later she heard a scream and went into R#1s room. CNA C said she saw R#1 on the floor in the restroom. CNA C said she went to notify LVN D about R#1 being on the floor. CNA C said she did not see the lap tray in the restroom. CNA C said later on she found R#1's lap tray in the locked shower room.

Based on interview and record review, the facility failed to ensure residents were free from neglect, for one Resident (R#1) of four residents reviewed for neglect. 1) The facility failed to ensure R#1's lap tray was in place. 2) R#1 suffering an unwitnessed fall. 3) R#1 sustained a [MEDICAL CONDITION] femur. This failure could place residents with lap trays at risk for injuries. The findings were: Record review of R#1's (MONTH) 2019 Order Summary Report revealed R#1 was [AGE] years-old and was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Orders included: May have lap tray while up in W/C (wheelchair). Release at least Q (every) 2 (two hours). Release at meals, during activities and to provide care. Every shift related to Dementia in Other Disease classified elsewhere with behavioral disturbance. Order date was 04/02/19. Start date was 04/10/19. Record review of R#1's Quarterly Minimum Data Set (MDS) assessment, dated 04/16/19, revealed R#1: -was rarely/never able to make himself understood, -was sometimes able to understand others (responded adequately to simple, direct communications only), -had moderately impaired cognitive status (decisions poor, cues/supervision required), -required extensive assistance from two staff for bed mobility, transfers, dressing, toilet use and personal hygiene, -had range of motion limitations to both sides of lower extremities (hips, knees, ankles, feet), -used a wheelchair for mobility, -was frequently incontinent of bowel and bladder, and, -had two falls with no injuries and one fall with injury (except major) - (skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain). Record review of R#1's Care Plan, dated 02/24/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Intervention was, Referral to therapy. Record review of R#1's Care Plan, dated 03/09/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Interventions were, Changed wheelchair to high backed wheelchair to assist in upright position. and Replace nonskid with dysem (non-slip material). Record review of R#1's Care Plan, dated 03/19/19, revealed R#1 slid out of his wheelchair and fell . No injuries noted. Intervention was, Saddle cushion to assist in resident ability to maintain upright position. Record review of R#1's Care Plan, dated 03/29/19, revealed R#1 had an unwitnessed fall, cont (continues) to thrust hips up, unable to maintain upright position in wheelchair, slid from chair. No inuries noted. The intervention was to use the lap tray to assist R#1 to maintain an upright sitting position. Record review of R#1's incident report dated 05/05/19 at 3:00 p.m. revealed: Upon walking into the room, patient (R#1) was found on restroom floor sitting position facing the commode, holding onto side rail with right hand. Wheelchair found next to commode. Patient could not recall how fall occurred. Patient (R#1) attempted to lift himself off the floor while holding onto side rail. Informed patient (R#1) to be still until further assessment. Full range of motion noted in upper extremities. Range of motion unable to be assessed in lower extremities due to sitting position. Vitals unable to be obtained due to combative behavior. Patient then transferred to wheelchair by two CNAs (certified nurse aides). Then transferred to bed. Obtained vitals, skin assessment done - no abrasions or discolorations noted. Pain displayed when moving patient during brief change. Pain noted when moving right knee/leg. Same incident report indicated: Head to toe assessment done, no noted skin abrasions/deformity or discolorations. Vitals obtained, Patient placed on routine neurological checks. Continued to monitor behavior. RP (responsible party) and Physician notified. [MEDICATION NAME] 650 mg (milligrams) was offered, however refused. Record review of R#1's Progress Notes (Nursing notes), dated 05/05/19 at 10:00 p.m., revealed: S/P (status [REDACTED]. Patient is unable to recall how fall occurred. Vitals obtained: BP (blood pressure) 118/65, T (temperature) 98.0, P (pulse) 60, RR (respiration) 18, O2 (oxygen) 97. Full range of motion bilateral upper extremities. Unable to assess range of motion in lower extremities due to history weakness. No discoloration or skin abrasions noted. Minor swelling and pain to right knee noted upon transferring patient to bed. RP and Physician contacted. X-ray ordered of right knee and hip as per physician. Will continue with neurological checks and monitoring change in condition. Patient in bed, supine, at lowest level, call light within reach. Record review of R#1's Progress notes, dated 05/05/19 at 11:31 p.m., revealed: Nurse came on shift received report from out going nurse to call Resident's RP/(family member) after report. Resident was reported to have had an unwitnessed fall at appx (approximately) 3:00 p.m. Resident was assessed. No distress noted. Neuros intact, speech unchanged. Denies pain but stated will take when offered. He became upset for waking him up refused. RP was phoned and he reports due to a previous occurrence, he is requesting to send (R#1) out to hospital ER (emergency room ) for acute medical attention, studies and observation. He was advised that mobile X-ray just finished with (R#1) and he resumed his request to send him out. He stated his (family member) is on her way from home to go with him. On call advised. Paper work ready. Am nurse to notifiy MD (Medical Doctor) of family request. Continue to monitor until transfer. Record review of In-Service Report, dated 05/06/19, revealed a staff training session was conducted on, Abuse and Neglect. Record review of In-Service Report, dated 05/06/19, revealed a staff training session was conducted on, Restraints/Devices. Summary of training was, All staff to ensure that residents are using any devices that have been implemented for resident's safety. Record review of In-Service Report, dated 05/06/19, revealed a staff training session was conducted on, Reporting incidents and accidents to supervisor call immediately . R#1 was not interviewed as he was out to the hospital during the investigation. In an interview on 05/09/19 at 9:05 a.m., the Director of Nurses (DON) said R#1 was aggressive with staff when providing care, and R#1's aggression was care planned. The DON said R#1 was found by the toilet, on the floor. The DON said R#1 was facing the toilet and his wheelchair was next to the toilet. The DON said no one saw R#1's lap table in the restroom. The DON said R#1 could remove the lap table on his own. The DON said the lap table was later found in the shower room. The DON said R#1 could not go into the shower room because it was locked. The DON said the nurse assessed R#1 and R#1 was not complaining of pain. The nurse called the doctor and R#1's RP. The DON said R#1's family requested for R#1 to be sent out to the hospital. The DON said the X-rays for R#1 had already been done at the facility. The DON said the X-rays showed a fracture of R#1's right femur. In an interview on 05/09/19 at 11:00 a.m., CNA A said she did not remember if she got R#1 up on the morning of 05/05/19. CNA A said she did not remember if R#1 had the lap table on his wheelchair during her shift (6:00 a.m. to 2:00 p.m.). CNA A said that, after lunch on 05/05/19, CNA A and CNA B changed R#1 in the restroom. CNA A said R#1 did not have the lap tray on his wheelchair at that time. CNA A said R#1 needed to have the lap tray at all times. CNA A said R#1 could remove the lap tray by himself and, at times, the lap tray had been found in the halls or in R#1's room. CNA A said R#1 was placed in the hallway in his wheelchair, without a lap tray, after they changed R#1. CNA A said she should have asked CNA B to stay with R#1 while she looked for the lap tray. In an interview on 05/09/19 at 11:10 a.m., CNA B said she did not get R#1 up on the morning of 05/05/19. CNA B said she knew R#1 had to have the lap tray while up to wheelchair. CNA B said R#1 could remove the lap tray. CNA B said she did not remember seeing the lap tray on R#1's wheelchair during her shift (6:00 a.m. to 2:00 p.m.). CNA B said she did not remember seeing the lap tray on R#1's wheelchair when R#1 was taken to the restroom. CNA B said she and CNA A placed R#1 in the hall without the lap table. CNA B said she did not tell the incoming shift that R#1 did not have the lap tray. In an interview on 05/09/19 at 11:35 a.m., Licensed Vocational Nurse (LVN) D said CNA C told her that R#1 was on the floor in the restroom. LVN D said R#1 was on the floor, facing the commode, and holding on to the grab bar to get up. R#1's wheelchair was next to the commode. R#1 was combative while taking vitals and pushing the CNA. LVN D said there was no lap tray in the restroom. LVN D said later a CNA found R#1's lap tray in the locked shower room. In an interview on 05/09/19 at 12:15 p.m., CNA C said she did not get a report from the previous shift (6:00 a.m. to 2:00 p.m.) that R#1 did not have the lap tray on the wheelchair. CNA C said she did not check at the beginning of her shift (2:00 p.m. to 10:00 p.m.) to see if R#1 had the lap tray while up to the wheelchair. CNA C said later she heard a scream and went into R#1s room. CNA C said she saw R#1 on the floor in the restroom. CNA C said she went to notify LVN D about R#1 being on the floor. CNA C said she did not see the lap tray in the restroom. CNA C said later on she found R#1's lap tray in the locked shower room. Review of the facility's policy on, Reporting of Alleged Abuse to Facility Management, dated (MONTH) (YEAR), revealed the following: Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Based on observation, interview, and record review, the facility failed to implement their policy and procedures that prohibit neglect for one of six residents reviewed for neglect. The facility failed to provide pain relief for R#1 when the facility recognized that R#1 exhibited pain by trembling, grimacing and clenching his fists daily for at least two months. -The resident grimaced, moaned, and trembled each time he was moved during care to include repositioning every two hours, incontinent care every two hours, pressure ulcer treatment daily and range of motion therapy daily. -Staff were aware that the resident suffered pain daily when moved due to his contractures. -The facility did not provide pain intervention prior to planned and routine care and services, causing R #1 to grimace, moan, and tremble. -The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This failure resulted in an Immediate Jeopardy (IJ) on 08/01/12. While the IJ was removed on 08/02/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to provide pain relief affected R #1 by not receiving pain relief when moved approximately fifteen times per day for two months, and medicated four times with [MEDICATION NAME] in two months, could place 77 residents receiving pain management at risk for unrelieved pain. Findings were: Review of R#1's Face Sheet dated 04/03/12 revealed an admission date of [DATE]. Review of R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R#1 exhibited protective body movements or postures related to pain that were observed by staff, with a frequency of one to two days out of the previous five days; R#1 was totally dependent on staff for all Activities of Daily Living (bed mobility, transfers, toileting, bathing); R#1 had Functional Limitation in Range of Motion (ROM) to both the upper and lower extremities; R #1 was unable to speak, or express ideas or wants. Review on 07/31/12 of R#1's Care Plans revealed there was no Care Plan related to pain. Review on 07/31/12 of R#1's Pain Evaluation dated 04/02/12 revealed staff scored R #1's pain level at a 6 out of 10, which represented the following pain characteristics: Facial Expression "Facial Grimacing"; Body Language "Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out"; Consolability "Unable to console, distract or reassure." Review on 07/31/12 of R#1's Physician order [REDACTED].-5). The Physician order [REDACTED]." On 07/30/12 at 3 p.m., family member (FM) "A" stated that R #1 was in pain every day she visited him. She would visit R #1 for approximately one hour per day, seven days per week. FM "A" stated she (FM "A") complained to staff that she knew R #1 was in pain by his moaning and facial grimacing, but that staff did not respond to her compliants. On 07/31/12 at 11:05 a.m., surveyor observed the following during incontinent care for R#1 with Certified Nurse Aides (CNAs) "A" and "B": R #1 was lying quietly in bed on his back. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "A" and "B" turned R #1 onto his left side. R #1 immediately began to moan loudly, his face grimaced, both of his arms began to shake and tremble, and his right hand formed into a fist. CNAs "A" and "B" then turned R #1 onto his right side. R #1 continued to moan loudly, grimace, and tremble. CNAs "A" and "B" then positioned R #1 onto his back to move him up in bed. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately ten minutes. The CNAs "A" and "B" did not attempt to alleviate R #1's pain during care. After CNAs "A" and "B" finished giving care to R #1, he no longer moaned, grimaced or shook. On 07/31/12 at 11:15 a.m., surveyor observed the following during pressure ulcer treatment for [REDACTED].#1 was lying on his back in bed quietly. CNAs "A" and "B" turned R #1 onto his right side. R #1 began to moan loudly, his face grimaced and both of his arms began to shake and tremble. After wound care, CNAs "A" and "B" turned R #1 onto his left side. R #1 moaned loudly, grimaced and trembled. CNAs "A", "B" and LVN "I" did not attempt to alleviate R #1's pain during care. LVN "I" stated that she had never taken care of R #1 before but felt his moaning, grimacing and trembling was due to pain. LVN "I" stated she was not responsible for administering pain medication to R #1 but was "sure the other nurses do." Review on 07/31/12 of R #'1 Treatment Orders dated 04/02/12 through 07/31/12 revealed R#1 received pressure ulcer treatment to his buttocks daily. On 07/31/12 at 1:30 p.m., CNA "B" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by moaning, grimacing and shaking when he was moved in bed and that he was moved every two hours. CNA "B" stated she reported to the nurse each time R#1 had pain. On 07/31/12 at 3:10 p.m., Restorative Aide (RA) "C" stated R#1 received Range of Motion (ROM) exercises seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, knees, fingers, wrists, shoulders, and forearms. RA "C" stated she regularly performed ROM exercises to R#1 for approximately five days per week, Monday through Friday. RA "C" stated she could tell that R#1 was in pain during ROM exercises because, "he grimaced and moaned." RA "C" stated she had not reported that R#1 was in pain to the nurses because, "when we are done with ROM, he stops grimacing." Review on 07/31/12 of R #1's Nursing Restorative Care Program records revealed ROM exercises were performed on R #1 seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, fingers, wrists, shoulders, and forearms: 04/27/12 through 04/30/12; 05/01/12 through 05/31/12; 06/01/12 through 06/30/12 and 07/01/12 through 07/31/12. On 07/31/12 at 4:30 p.m., Registered Nurse (RN) "E" (2 p.m. to 10 p.m. shift) stated that she could tell R#1 was in pain during routine care by his facial expressions and moaning. RN "E" stated R#1 was moved from side to side every two hours for repositioning and incontinent care, and that he exhibited signs that he was in pain when he was moved. RN "E" stated the CNAs were, "good about reporting signs of pain." RN "E" stated that there was an order for [REDACTED].#1 on 07/31/12. RN "E" said it was not reported to her on 07/31/12 that R#1 had pain during ROM exercises. Review on 07/31/12 of R#1's Medication Administration Records (MAR) for the following months revealed Tylenol PRN was administered: -April 2012: none -May 2012: on 05/20/12 at 10 a.m. for an elevated temperature, indicated on the front and back of the MAR -June 2012: on 06/29/12 (no time) for an elevated temperature, indicated only on the front of the MAR -July 2012: none Review on 07/31/12 of R #1's MAR for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: none -May 2012: none -June 2012: on 06/26/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 4 p.m. and 8 p.m. for grimacing with "some relief" as the result, indicated on the back of the MAR -July 2012: on 07/14/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 8:30 p.m. for facial grimacing with "some relief" as the result, indicated on the back of the MAR Review on 07/31/12 of R #1's Narcotic Count Record for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: on 04/05/12 at 4:00 p.m. -May 2012: none -June 2012: on 06/26/12 at 4:00 p.m. and 8:00 p.m.; on 06/27/12 at 12:00 a.m. -July 2012: on 07/14/12 at 8:30 p.m. On 07/31/12 at 4:45 p.m., the DON revealed the nursing staff were responsible for administering pain medications to residents when they exhibited signs of pain. The DON stated he was not aware that R#1 had pain when he was repositioned and given incontinent care every two hours. On 08/01/12 at 11:30 a.m., Licensed Vocational Nurse (LVN) "F" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by facial grimacing and that with "even the slightest movements, he grimaces." LVN "F" stated that R#1 was repositioned and given incontinent care every two hours. LVN "F" stated that, during the first two weeks in July, 2012, he had administered pain medication to R#1 approximately six times because R#1 was in pain. LVN "F" stated he could not remember what pain medication he had administered then, but had administered R#1 Tylenol the morning of 08/01/12. Review on 08/01/12 of R #1's MAR for the month of August 2012 revealed no pain medication documented that it was given to R #1. LVN "F" stated that he had forgotten to document on 08/01/12 that he had administered Tylenol PRN to R #1 "around 8 a.m. this morning." On 08/01/12 at 3:55 p.m., surveyor observed the following with CNAs "G" and "H" while repositioning R#1: R #1 was lying quietly in bed. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "G" and "H" turned R #1 onto his right side and pulled him up in bed. R #1 immediately began to moan loudly, his face grimaced, and both of his arms began to shake and tremble. CNAs "G" and "H" then raised R #1's left leg to place a pillow between R #1's legs. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately five minutes. After CNAs "G" and "H" finished giving care to R #1, he no longer moaned, grimaced or shook. On 08/01/12 at 4:00 p.m., CNA "G" (2 p.m. to 10 p.m. shift) stated that while repositioning R#1 on 08/01/12 at 3:55 p.m., R#1 exhibited signs of pain by grimacing, moaning, and shaking. CNA "G" stated R#1 was repositioned and given incontinent care every two hours and that he exhibited signs of pain each time he was repositioned. CNA "G" stated she had reported to the nurse that R#1 had pain every day she had worked which was four days per week, for the past two months. On 08/01/12 at 4:05 p.m., CNA "H" (2 p.m. to 10 p.m. shift) stated that R#1 exhibited signs of pain by grimacing and closing his eyes, and that he exhibited those signs when he was repositioned every two hours. CNA "H" stated she reported to the nurse when R#1 exhibited signs of pain. Record review of the facility's Administering Pain Medications Policy dated September 2003 revealed: "General Guidelines: 4. Be familiar with the physiologic and behavioral signs of pain" and "Steps in the Procedure: 4. Obtain objective information through assessment: (a) Behavioral responses to (acute) pain; (1) facial wrinkling/grimacing, (3) crying or moaning, (5) increase in body movements; 6. Administer pain medications as ordered." On 08/01/12 at 6:05 p.m., an IJ was identified and the DON, Administrator, and Owners were informed of the IJ at 6:05 p.m. On 08/01/12 at 7:45 p.m., the facility submitted a Plan of Removal which contained the following: 1. Resident identified to have been affected by the alleged deficient practice: -A comprehensive assessment was performed on R #1 on 08/01/02 at 6:20 p.m. -R #1 was noted to have pain rated at a 4 out of 10 upon manipulation of his left upper and lower extremities. -The physician was notified on 08/01/12 and an order for [REDACTED]. -The Charge Nurse was to assess R #1's pain every 4 hours and notify the physician if the pain medication was not effective. -R #1's Care Plan was updated. -On 08/01/12 at 7:22 p.m., R #1 was noted to be free from pain. 2. Residents with the potential to be affected by the alleged deficient practice: -All residents in the facility will be screened for pain management with physicians notified of residents with unrelieved pain. -All new admissions will be screened and have proper pain management plan of care put into place. -All nursing staff will be inserviced on each shift on proper pain assessment and management. -The Assistant Director of Nurses will daily review all residents to verify that proper pain mangement is being conducted. A written report will be provided to the DON daily. -DON will monitor daily the screenings to verify it is being conducted. Written report provided to the Administrator. -Administrator will daily monitor the DON report to verify screenings are being done. On 08/01/12 at 7:45 p.m., the DON stated that R #1 was assessed on 08/01/12 at 6:20 p.m., with his left arm manipulated to apply a blood pressure cuff. The DON stated that R #1 showed symptoms of pain by grimacing, frowning and clenching his fists. The DON stated that R #1 had received a dose of [MEDICATION NAME] on 08/01/12 at 6:30 p.m. At 7:22 p.m., staff manipulated R #1's left arm and there was no pain noted. Surveyor verified through record review on 08/01/12 and 08/02/12 that R #1 was administered [MEDICATION NAME] every four hours from 08/01/12 through 08/02/12 as ordered. On 08/02/12 at 11:15 a.m., surveyor observed the following with CNAs "J" and "K" during repositioning of R #1: R #1 was lying quietly in bed on his left side. CNAs "J" and "K" turned R #1 onto his right side and propped a pillow behind his back. R #1 did not moan, grimace or tremble. CNA "K" stated that R #1's pain "was better." Through observations, interviews and record reviews, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 08/02/12 at 2:50 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. The facility's undated Abuse Prevention Policy and Procedure Manual Chapter 1 revealed: page 5, "Our residents have the right to be free from abuse, neglect"; page 22 entitled Recognizing Signs and Symptoms of Abuse/Neglect, (1)(b) Signs of/Actual Physical Neglect, bullet six, "Inadequate provision of care"; page 36 entitled Investigating Allegations of Neglect, Policy Interpretation and Implementation, (1) "Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or the deterioration of a resident's physical or mental condition...Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death"; and page 41 entitled Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, "The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures." Record review of the facility's physician's orders [REDACTED]. On 08/02/12 at 4:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on observation, interview, and record review, the facility failed to implement their written policy and procedures that prohibit neglect for one of six residents reviewed for neglect. The facility failed to provide pain relief for R#1 when the facility recognized that R#1 exhibited pain by trembling, grimacing and clenching his fists daily for at least two months. -The resident grimaced, moaned, and trembled each time he was moved during care to include repositioning every two hours, incontinent care every two hours, pressure ulcer treatment daily and range of motion therapy daily. -Staff were aware that the resident suffered pain daily when moved due to his contractures. -The facility did not provide pain intervention prior to planned and routine care and services, causing R #1 to grimace, moan, and tremble. -The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This failure resulted in an Immediate Jeopardy (IJ) on 08/01/12. While the IJ was removed on 08/02/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to provide pain relief affected R #1 by not receiving pain relief when moved approximately fifteen times per day for two months, and medicated four times with [MEDICATION NAME] in two months, could place 77 residents receiving pain management at risk for unrelieved pain. Findings were: The facility's undated Abuse Prevention Policy and Procedure Manual Chapter 1 revealed: page 5, "Our residents have the right to be free from abuse, neglect"; page 22 entitled Recognizing Signs and Symptoms of Abuse/Neglect, (1)(b) Signs of/Actual Physical Neglect, bullet six, "Inadequate provision of care"; page 36 entitled Investigating Allegations of Neglect, Policy Interpretation and Implementation, (1) "...Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death"; and page 41 entitled Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures, "The administrator assumes the responsibility for the overall coordination and implementation of our facility's abuse prevention program policies and procedures." Review of R#1's Face Sheet dated 04/03/12 revealed an admission date of [DATE]. Review of R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R#1 exhibited protective body movements or postures related to pain that were observed by staff, with a frequency of one to two days out of the previous five days; R#1 was totally dependent on staff for all Activities of Daily Living (bed mobility, transfers, toileting, bathing); R#1 had Functional Limitation in Range of Motion (ROM) to both the upper and lower extremities; R #1 was unable to speak, or express ideas or wants. Review on 07/31/12 of R#1's Care Plans revealed there was no Care Plan related to pain. Review on 07/31/12 of R#1's Pain Evaluation dated 04/02/12 revealed staff scored R #1's pain level at a 6 out of 10, which represented the following pain characteristics: Facial Expression "Facial Grimacing"; Body Language "Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out"; Consolability "Unable to console, distract or reassure." Review on 07/31/12 of R#1's Physician order [REDACTED].-5). The Physician order [REDACTED]." On 07/30/12 at 3 p.m., family member (FM) "A" stated that R #1 was in pain every day she visited him. She would visit R #1 for approximately one hour per day, seven days per week. FM "A" stated she (FM "A") complained to staff that she knew R #1 was in pain by his moaning and facial grimacing, but that staff did not respond to her compliants. On 07/31/12 at 11:05 a.m., surveyor observed the following during incontinent care for R#1 with Certified Nurse Aides (CNAs) "A" and "B": R #1 was lying quietly in bed on his back. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "A" and "B" turned R #1 onto his left side. R #1 immediately began to moan loudly, his face grimaced, both of his arms began to shake and tremble, and his right hand formed into a fist. CNAs "A" and "B" then turned R #1 onto his right side. R #1 continued to moan loudly, grimace, and tremble. CNAs "A" and "B" then positioned R #1 onto his back to move him up in bed. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately ten minutes. The CNAs "A" and "B" did not attempt to alleviate R #1's pain during care. After CNAs "A" and "B" finished giving care to R #1, he no longer moaned, grimaced or shook. On 07/31/12 at 11:15 a.m., surveyor observed the following during pressure ulcer treatment for [REDACTED].#1 was lying on his back in bed quietly. CNAs "A" and "B" turned R #1 onto his right side. R #1 began to moan loudly, his face grimaced and both of his arms began to shake and tremble. After wound care, CNAs "A" and "B" turned R #1 onto his left side. R #1 moaned loudly, grimaced and trembled. CNAs "A", "B" and LVN "I" did not attempt to alleviate R #1's pain during care. LVN "I" stated that she had never taken care of R #1 before but felt his moaning, grimacing and trembling was due to pain. LVN "I" stated she was not responsible for administering pain medication to R #1 but was "sure the other nurses do." Review on 07/31/12 of R #'1 Treatment Orders dated 04/02/12 through 07/31/12 revealed R#1 received pressure ulcer treatment to his buttocks daily. On 07/31/12 at 1:30 p.m., CNA "B" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by moaning, grimacing and shaking when he was moved in bed and that he was moved every two hours. CNA "B" stated she reported to the nurse each time R#1 had pain. On 07/31/12 at 3:10 p.m., Restorative Aide (RA) "C" stated R#1 received Range of Motion (ROM) exercises seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, knees, fingers, wrists, shoulders, and forearms. RA "C" stated she regularly performed ROM exercises to R#1 for approximately five days per week, Monday through Friday. RA "C" stated she could tell that R#1 was in pain during ROM exercises because, "he grimaced and moaned." RA "C" stated she had not reported that R#1 was in pain to the nurses because, "when we are done with ROM, he stops grimacing." Review on 07/31/12 of R #1's Nursing Restorative Care Program records revealed ROM exercises were performed on R #1 seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, fingers, wrists, shoulders, and forearms: 04/27/12 through 04/30/12; 05/01/12 through 05/31/12; 06/01/12 through 06/30/12 and 07/01/12 through 07/31/12. On 07/31/12 at 4:30 p.m., Registered Nurse (RN) "E" (2 p.m. to 10 p.m. shift) stated that she could tell R#1 was in pain during routine care by his facial expressions and moaning. RN "E" stated R#1 was moved from side to side every two hours for repositioning and incontinent care, and that he exhibited signs that he was in pain when he was moved. RN "E" stated the CNAs were, "good about reporting signs of pain." RN "E" stated that there was an order for [REDACTED].#1 on 07/31/12. RN "E" said it was not reported to her on 07/31/12 that R#1 had pain during ROM exercises. Review on 07/31/12 of R#1's Medication Administration Records (MAR) for the following months revealed Tylenol PRN was administered: -April 2012: none -May 2012: on 05/20/12 at 10 a.m. for an elevated temperature, indicated on the front and back of the MAR -June 2012: on 06/29/12 (no time) for an elevated temperature, indicated only on the front of the MAR -July 2012: none Review on 07/31/12 of R #1's MAR for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: none -May 2012: none -June 2012: on 06/26/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 4 p.m. and 8 p.m. for grimacing with "some relief" as the result, indicated on the back of the MAR -July 2012: on 07/14/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 8:30 p.m. for facial grimacing with "some relief" as the result, indicated on the back of the MAR Review on 07/31/12 of R #1's Narcotic Count Record for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: on 04/05/12 at 4:00 p.m. -May 2012: none -June 2012: on 06/26/12 at 4:00 p.m. and 8:00 p.m.; on 06/27/12 at 12:00 a.m. -July 2012: on 07/14/12 at 8:30 p.m. On 07/31/12 at 4:45 p.m., the DON revealed the nursing staff were responsible for administering pain medications to residents when they exhibited signs of pain. The DON stated he was not aware that R#1 had pain when he was repositioned and given incontinent care every two hours. On 08/01/12 at 11:30 a.m., Licensed Vocational Nurse (LVN) "F" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by facial grimacing and that with "even the slightest movements, he grimaces." LVN "F" stated that R#1 was repositioned and given incontinent care every two hours. LVN "F" stated that, during the first two weeks in July, 2012, he had administered pain medication to R#1 approximately six times because R#1 was in pain. LVN "F" stated he could not remember what pain medication he had administered then, but had administered R#1 Tylenol the morning of 08/01/12. Review on 08/01/12 of R #1's MAR for the month of August 2012 revealed no pain medication documented that it was given to R #1. LVN "F" stated that he had forgotten to document on 08/01/12 that he had administered Tylenol PRN to R #1 "around 8 a.m. this morning." On 08/01/12 at 3:55 p.m., surveyor observed the following with CNAs "G" and "H" while repositioning R#1: R #1 was lying quietly in bed. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "G" and "H" turned R #1 onto his right side and pulled him up in bed. R #1 immediately began to moan loudly, his face grimaced, and both of his arms began to shake and tremble. CNAs "G" and "H" then raised R #1's left leg to place a pillow between R #1's legs. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately five minutes. After CNAs "G" and "H" finished giving care to R #1, he no longer moaned, grimaced or shook. On 08/01/12 at 4:00 p.m., CNA "G" (2 p.m. to 10 p.m. shift) stated that while repositioning R#1 on 08/01/12 at 3:55 p.m., R#1 exhibited signs of pain by grimacing, moaning, and shaking. CNA "G" stated R#1 was repositioned and given incontinent care every two hours and that he exhibited signs of pain each time he was repositioned. CNA "G" stated she had reported to the nurse that R#1 had pain every day she had worked which was four days per week, for the past two months. On 08/01/12 at 4:05 p.m., CNA "H" (2 p.m. to 10 p.m. shift) stated that R#1 exhibited signs of pain by grimacing and closing his eyes, and that he exhibited those signs when he was repositioned every two hours. CNA "H" stated she reported to the nurse when R#1 exhibited signs of pain. Record review of the facility's Administering Pain Medications Policy dated September 2003 revealed: "General Guidelines: 4. Be familiar with the physiologic and behavioral signs of pain" and "Steps in the Procedure: 4. Obtain objective information through assessment: (a) Behavioral responses to (acute) pain; (1) facial wrinkling/grimacing, (3) crying or moaning, (5) increase in body movements; 6. Administer pain medications as ordered." On 08/01/12 at 6:05 p.m., an IJ was identified and the DON, Administrator, and Owners were informed of the IJ at 6:05 p.m. On 08/01/12 at 7:45 p.m., the facility submitted a Plan of Removal which contained the following: 1. Resident identified to have been affected by the alleged deficient practice: -A comprehensive assessment was performed on R #1 on 08/01/02 at 6:20 p.m. -R #1 was noted to have pain rated at a 4 out of 10 upon manipulation of his left upper and lower extremities. -The physician was notified on 08/01/12 and an order for [REDACTED]. -The Charge Nurse was to assess R #1's pain every 4 hours and notify the physician if the pain medication was not effective. -R #1's Care Plan was updated. -On 08/01/12 at 7:22 p.m., R #1 was noted to be free from pain. 2. Residents with the potential to be affected by the alleged deficient practice: -All residents in the facility will be screened for pain management with physicians notified of residents with unrelieved pain. -All new admissions will be screened and have proper pain management plan of care put into place. -All nursing staff will be inserviced on each shift on proper pain assessment and management. -The Assistant Director of Nurses will daily review all residents to verify that proper pain mangement is being conducted. A written report will be provided to the DON daily. -DON will monitor daily the screenings to verify it is being conducted. Written report provided to the Administrator. -Administrator will daily monitor the DON report to verify screenings are being done. On 08/01/12 at 7:45 p.m., the DON stated that R #1 was assessed on 08/01/12 at 6:20 p.m., with his left arm manipulated to apply a blood pressure cuff. The DON stated that R #1 showed symptoms of pain by grimacing, frowning and clenching his fists. The DON stated that R #1 had received a dose of [MEDICATION NAME] on 08/01/12 at 6:30 p.m. At 7:22 p.m., staff manipulated R #1's left arm and there was no pain noted. Surveyor verified through record review on 08/01/12 and 08/02/12 that R #1 was administered [MEDICATION NAME] every four hours from 08/01/12 through 08/02/12 as ordered. On 08/02/12 at 11:15 a.m., surveyor observed the following with CNAs "J" and "K" during repositioning of R #1: R #1 was lying quietly in bed on his left side. CNAs "J" and "K" turned R #1 onto his right side and propped a pillow behind his back. R #1 did not moan, grimace or tremble. CNA "K" stated that R #1's pain "was better." Through observations, interviews and record reviews, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 08/02/12 at 2:50 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Record review of the facility's physician's orders [REDACTED]. On 08/02/12 at 4:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on observation, interview, and record review, the facility failed to use the results of the comprehensive resident assessment to develop a comprehensive care plan to include measurable objectives and timetables for one of eight (R #1) residents reviewed for care plans. Resident #1 was assessed and determined to be at risk for pain, but these risks were not addressed in the comprehensive care plan. Failure to address pain management for residents in the comprehensive care plan has the potential to place 77 residents at risk of harm by leaving staff unprepared to provide needed care. R #1 was not provided pain relief when the facility recognized that R#1 exhibited pain by trembling, grimacing and clenching his fists daily for at least two months. -The resident grimaced, moaned, and trembled each time he was moved during care to include repositioning every two hours, incontinent care every two hours, pressure ulcer treatment daily and range of motion therapy daily. -Staff were aware that the resident suffered pain daily when moved due to his contractures. -The facility did not provide pain intervention prior to planned and routine care and services, causing R #1 to grimace, moan, and tremble. -The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This failure resulted in an Immediate Jeopardy (IJ) on 08/01/12. While the IJ was removed on 08/02/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to provide pain relief affected R #1 by not receiving pain relief when moved approximately fifteen times per day for two months, and medicated four times with [MEDICATION NAME] in two months, could place 77 residents receiving pain management at risk for unrelieved pain. Findings were: Review of R#1's Face Sheet dated 04/03/12 revealed an admission date of [DATE]. Review of R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R#1 exhibited protective body movements or postures related to pain that were observed by staff, with a frequency of one to two days out of the previous five days; R#1 was totally dependent on staff for all Activities of Daily Living (bed mobility, transfers, toileting, bathing); R#1 had Functional Limitation in Range of Motion (ROM) to both the upper and lower extremities; R #1 was unable to speak, or express ideas or wants. Review on 07/31/12 of R#1's Care Plans revealed there was no Care Plan related to pain. Review on 07/31/12 of R#1's Pain Evaluation dated 04/02/12 revealed staff scored R #1's pain level at a 6 out of 10, which represented the following pain characteristics: Facial Expression "Facial Grimacing"; Body Language "Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out"; Consolability "Unable to console, distract or reassure." Review on 07/31/12 of R#1's Physician order [REDACTED].-5). The Physician order [REDACTED]." On 07/30/12 at 3 p.m., family member (FM) "A" stated that R #1 was in pain every day she visited him. She would visit R #1 for approximately one hour per day, seven days per week. FM "A" stated she (FM "A") complained to staff that she knew R #1 was in pain by his moaning and facial grimacing, but that staff did not respond to her compliants. On 07/31/12 at 11:05 a.m., surveyor observed the following during incontinent care for R#1 with Certified Nurse Aides (CNAs) "A" and "B": R #1 was lying quietly in bed on his back. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "A" and "B" turned R #1 onto his left side. R #1 immediately began to moan loudly, his face grimaced, both of his arms began to shake and tremble, and his right hand formed into a fist. CNAs "A" and "B" then turned R #1 onto his right side. R #1 continued to moan loudly, grimace, and tremble. CNAs "A" and "B" then positioned R #1 onto his back to move him up in bed. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately ten minutes. The CNAs "A" and "B" did not attempt to alleviate R #1's pain during care. After CNAs "A" and "B" finished giving care to R #1, he no longer moaned, grimaced or shook. On 07/31/12 at 11:15 a.m., surveyor observed the following during pressure ulcer treatment for [REDACTED].#1 was lying on his back in bed quietly. CNAs "A" and "B" turned R #1 onto his right side. R #1 began to moan loudly, his face grimaced and both of his arms began to shake and tremble. After wound care, CNAs "A" and "B" turned R #1 onto his left side. R #1 moaned loudly, grimaced and trembled. CNAs "A", "B" and LVN "I" did not attempt to alleviate R #1's pain during care. LVN "I" stated that she had never taken care of R #1 before but felt his moaning, grimacing and trembling was due to pain. LVN "I" stated she was not responsible for administering pain medication to R #1 but was "sure the other nurses do." Review on 07/31/12 of R #'1 Treatment Orders dated 04/02/12 through 07/31/12 revealed R#1 received pressure ulcer treatment to his buttocks daily. On 07/31/12 at 1:30 p.m., CNA "B" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by moaning, grimacing and shaking when he was moved in bed and that he was moved every two hours. CNA "B" stated she reported to the nurse each time R#1 had pain. On 07/31/12 at 3:10 p.m., Restorative Aide (RA) "C" stated R#1 received Range of Motion (ROM) exercises seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, knees, fingers, wrists, shoulders, and forearms. RA "C" stated she regularly performed ROM exercises to R#1 for approximately five days per week, Monday through Friday. RA "C" stated she could tell that R#1 was in pain during ROM exercises because, "he grimaced and moaned." RA "C" stated she had not reported that R#1 was in pain to the nurses because, "when we are done with ROM, he stops grimacing." Review on 07/31/12 of R #1's Nursing Restorative Care Program records revealed ROM exercises were performed on R #1 seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, fingers, wrists, shoulders, and forearms: 04/27/12 through 04/30/12; 05/01/12 through 05/31/12; 06/01/12 through 06/30/12 and 07/01/12 through 07/31/12. On 07/31/12 at 4:30 p.m., Registered Nurse (RN) "E" (2 p.m. to 10 p.m. shift) stated that she could tell R#1 was in pain during routine care by his facial expressions and moaning. RN "E" stated R#1 was moved from side to side every two hours for repositioning and incontinent care, and that he exhibited signs that he was in pain when he was moved. RN "E" stated the CNAs were, "good about reporting signs of pain." RN "E" stated that there was an order for [REDACTED].#1 on 07/31/12. RN "E" said it was not reported to her on 07/31/12 that R#1 had pain during ROM exercises. RN "E" stated it was the facility' policy to use each residents MAR indicated [REDACTED]. Review on 07/31/12 of R#1's Medication Administration Records (MAR) for the following months revealed Tylenol PRN was administered: -April 2012: none -May 2012: on 05/20/12 at 10 a.m. for an elevated temperature, indicated on the front and back of the MAR -June 2012: on 06/29/12 (no time) for an elevated temperature, indicated only on the front of the MAR -July 2012: none Review on 07/31/12 of R #1's MAR for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: none -May 2012: none -June 2012: on 06/26/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 4 p.m. and 8 p.m. for grimacing with "some relief" as the result, indicated on the back of the MAR -July 2012: on 07/14/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 8:30 p.m. for facial grimacing with "some relief" as the result, indicated on the back of the MAR Review on 07/31/12 of R #1's Narcotic Count Record for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: on 04/05/12 at 4:00 p.m. -May 2012: none -June 2012: on 06/26/12 at 4:00 p.m. and 8:00 p.m.; on 06/27/12 at 12:00 a.m. -July 2012: on 07/14/12 at 8:30 p.m. On 07/31/12 at 4:45 p.m., the DON revealed the nursing staff were responsible for administering pain medications to residents when they exhibited signs of pain. The DON stated he was not aware that R#1 had pain when he was repositioned and given incontinent care every two hours. The DON stated that R #1 did not have a care plan related to pain. On 08/01/12 at 11:30 a.m., Licensed Vocational Nurse (LVN) "F" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by facial grimacing and that with "even the slightest movements, he grimaces." LVN "F" stated that R#1 was repositioned and given incontinent care every two hours. LVN "F" stated that it was the facility's policy to use each residents MAR indicated F" stated he had not looked at R #1's comprehensive care plan. LVN "F" stated that, during the first two weeks in July, 2012, he had administered pain medication to R#1 approximately six times because R#1 was in pain. LVN "F" stated he could not remember what pain medication he had administered then, but had administered R#1 Tylenol the morning of 08/01/12. Review on 08/01/12 of R #1's MAR for the month of August 2012 revealed no pain medication documented that it was given to R #1. LVN "F" stated that he had forgotten to document on 08/01/12 that he had administered Tylenol PRN to R #1 "around 8 a.m. this morning." On 08/01/12 at 3:55 p.m., surveyor observed the following with CNAs "G" and "H" while repositioning R#1: R #1 was lying quietly in bed. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "G" and "H" turned R #1 onto his right side and pulled him up in bed. R #1 immediately began to moan loudly, his face grimaced, and both of his arms began to shake and tremble. CNAs "G" and "H" then raised R #1's left leg to place a pillow between R #1's legs. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately five minutes. After CNAs "G" and "H" finished giving care to R #1, he no longer moaned, grimaced or shook. On 08/01/12 at 4:00 p.m., CNA "G" (2 p.m. to 10 p.m. shift) stated that while repositioning R#1 on 08/01/12 at 3:55 p.m., R#1 exhibited signs of pain by grimacing, moaning, and shaking. CNA "G" stated R#1 was repositioned and given incontinent care every two hours and that he exhibited signs of pain each time he was repositioned. CNA "G" stated she had reported to the nurse that R#1 had pain every day she had worked which was four days per week, for the past two months. On 08/01/12 at 4:05 p.m., CNA "H" (2 p.m. to 10 p.m. shift) stated that R#1 exhibited signs of pain by grimacing and closing his eyes, and that he exhibited those signs when he was repositioned every two hours. CNA "H" stated she reported to the nurse when R#1 exhibited signs of pain. Record review of the facility's Administering Pain Medications Policy dated September 2003 revealed: "General Guidelines: 4. Be familiar with the physiologic and behavioral signs of pain" and "Steps in the Procedure: 4. Obtain objective information through assessment: (a) Behavioral responses to (acute) pain; (1) facial wrinkling/grimacing, (3) crying or moaning, (5) increase in body movements; 6. Administer pain medications as ordered." On 08/01/12 at 6:05 p.m., an IJ was identified and the DON, Administrator, and Owners were informed of the IJ at 6:05 p.m. On 08/01/12 at 7:45 p.m., the facility submitted a Plan of Removal which contained the following: 1. Resident identified to have been affected by the alleged deficient practice: -A comprehensive assessment was performed on R #1 on 08/01/02 at 6:20 p.m. -R #1 was noted to have pain rated at a 4 out of 10 upon manipulation of his left upper and lower extremities. -The physician was notified on 08/01/12 and an order for [REDACTED]. -The Charge Nurse was to assess R #1's pain every 4 hours and notify the physician if the pain medication was not effective. -R #1's Care Plan was updated. -On 08/01/12 at 7:22 p.m., R #1 was noted to be free from pain. 2. Residents with the potential to be affected by the alleged deficient practice: -All residents in the facility will be screened for pain management with physicians notified of residents with unrelieved pain. -All new admissions will be screened and have proper pain management plan of care put into place. -All nursing staff will be inserviced on each shift on proper pain assessment and management. -The Assistant Director of Nurses will daily review all residents to verify that proper pain mangement is being conducted. A written report will be provided to the DON daily. -DON will monitor daily the screenings to verify it is being conducted. Written report provided to the Administrator. -Administrator will daily monitor the DON report to verify screenings are being done. On 08/01/12 at 7:45 p.m., the DON stated that R #1 was assessed on 08/01/12 at 6:20 p.m., with his left arm manipulated to apply a blood pressure cuff. The DON stated that R #1 showed symptoms of pain by grimacing, frowning and clenching his fists. The DON stated that R #1 had received a dose of [MEDICATION NAME] on 08/01/12 at 6:30 p.m. At 7:22 p.m., staff manipulated R #1's left arm and there was no pain noted. Surveyor verified through record review on 08/01/12 and 08/02/12 that R #1 was administered [MEDICATION NAME] every four hours from 08/01/12 through 08/02/12 as ordered. On 08/02/12 at 11:15 a.m., surveyor observed the following with CNAs "J" and "K" during repositioning of R #1: R #1 was lying quietly in bed on his left side. CNAs "J" and "K" turned R #1 onto his right side and propped a pillow behind his back. R #1 did not moan, grimace or tremble. CNA "K" stated that R #1's pain "was better." Through observations, interviews and record reviews, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 08/02/12 at 2:50 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Record review of the facility's physician's orders [REDACTED]. On 08/02/12 at 4:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for one of six (R #1) residents reviewed for pain management. The facility failed to provide pain relief for R#1 when the facility recognized that R#1 exhibited pain by trembling, grimacing and clenching his fists daily for at least two months. -The resident grimaced, moaned, and trembled each time he was moved during care to include repositioning every two hours, incontinent care every two hours, pressure ulcer treatment daily and range of motion therapy daily. -Staff were aware that the resident suffered pain daily when moved due to his contractures. -The facility did not provide pain intervention prior to planned and routine care and services, causing R #1 to grimace, moan, and tremble. -The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This failure resulted in an Immediate Jeopardy (IJ) on 08/01/12. While the IJ was removed on 08/02/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to provide pain relief affected R #1 by not receiving pain relief when moved approximately fifteen times per day for two months, and medicated four times with [MEDICATION NAME] in two months, could place 77 residents receiving pain management at risk for unrelieved pain. Findings were: Review of R#1's Face Sheet dated 04/03/12 revealed an admission date of [DATE]. Review of R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R#1 exhibited protective body movements or postures related to pain that were observed by staff, with a frequency of one to two days out of the previous five days; R#1 was totally dependent on staff for all Activities of Daily Living (bed mobility, transfers, toileting, bathing); R#1 had Functional Limitation in Range of Motion (ROM) to both the upper and lower extremities; R #1 was unable to speak, or express ideas or wants. Review on 07/31/12 of R#1's Care Plans revealed there was no Care Plan related to pain. Review on 07/31/12 of R#1's Pain Evaluation dated 04/02/12 revealed staff scored R #1's pain level at a 6 out of 10, which represented the following pain characteristics: Facial Expression "Facial Grimacing"; Body Language "Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out"; Consolability "Unable to console, distract or reassure." Review on 07/31/12 of R#1's Physician order [REDACTED].-5). The Physician order [REDACTED]." On 07/30/12 at 3 p.m., family member (FM) "A" stated that R #1 was in pain every day she visited him. She would visit R #1 for approximately one hour per day, seven days per week. FM "A" stated she (FM "A") complained to staff that she knew R #1 was in pain by his moaning and facial grimacing, but that staff did not respond to her compliants. On 07/31/12 at 11:05 a.m., surveyor observed the following during incontinent care for R#1 with Certified Nurse Aides (CNAs) "A" and "B": R #1 was lying quietly in bed on his back. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "A" and "B" turned R #1 onto his left side. R #1 immediately began to moan loudly, his face grimaced, both of his arms began to shake and tremble, and his right hand formed into a fist. CNAs "A" and "B" then turned R #1 onto his right side. R #1 continued to moan loudly, grimace, and tremble. CNAs "A" and "B" then positioned R #1 onto his back to move him up in bed. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately ten minutes. The CNAs "A" and "B" did not attempt to alleviate R #1's pain during care. After CNAs "A" and "B" finished giving care to R #1, he no longer moaned, grimaced or shook. On 07/31/12 at 11:15 a.m., surveyor observed the following during pressure ulcer treatment for [REDACTED].#1 was lying on his back in bed quietly. CNAs "A" and "B" turned R #1 onto his right side. R #1 began to moan loudly, his face grimaced and both of his arms began to shake and tremble. After wound care, CNAs "A" and "B" turned R #1 onto his left side. R #1 moaned loudly, grimaced and trembled. CNAs "A", "B" and LVN "I" did not attempt to alleviate R #1's pain during care. LVN "I" stated that she had never taken care of R #1 before but felt his moaning, grimacing and trembling was due to pain. LVN "I" stated she was not responsible for administering pain medication to R #1 but was "sure the other nurses do." Review on 07/31/12 of R #'1 Treatment Orders dated 04/02/12 through 07/31/12 revealed R#1 received pressure ulcer treatment to his buttocks daily. On 07/31/12 at 1:30 p.m., CNA "B" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by moaning, grimacing and shaking when he was moved in bed and that he was moved every two hours. CNA "B" stated she reported to the nurse each time R#1 had pain. On 07/31/12 at 3:10 p.m., Restorative Aide (RA) "C" stated R#1 received Range of Motion (ROM) exercises seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, knees, fingers, wrists, shoulders, and forearms. RA "C" stated she regularly performed ROM exercises to R#1 for approximately five days per week, Monday through Friday. RA "C" stated she could tell that R#1 was in pain during ROM exercises because, "he grimaced and moaned." RA "C" stated she had not reported that R#1 was in pain to the nurses because, "when we are done with ROM, he stops grimacing." Review on 07/31/12 of R #1's Nursing Restorative Care Program records revealed ROM exercises were performed on R #1 seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, fingers, wrists, shoulders, and forearms: 04/27/12 through 04/30/12; 05/01/12 through 05/31/12; 06/01/12 through 06/30/12 and 07/01/12 through 07/31/12. On 07/31/12 at 4:30 p.m., Registered Nurse (RN) "E" (2 p.m. to 10 p.m. shift) stated that she could tell R#1 was in pain during routine care by his facial expressions and moaning. RN "E" stated R#1 was moved from side to side every two hours for repositioning and incontinent care, and that he exhibited signs that he was in pain when he was moved. RN "E" stated the CNAs were, "good about reporting signs of pain." RN "E" stated that there was an order for [REDACTED].#1 on 07/31/12. RN "E" said it was not reported to her on 07/31/12 that R#1 had pain during ROM exercises. Review on 07/31/12 of R#1's Medication Administration Records (MAR) for the following months revealed Tylenol PRN was administered: -April 2012: none -May 2012: on 05/20/12 at 10 a.m. for an elevated temperature, indicated on the front and back of the MAR -June 2012: on 06/29/12 (no time) for an elevated temperature, indicated only on the front of the MAR -July 2012: none Review on 07/31/12 of R #1's MAR for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: none -May 2012: none -June 2012: on 06/26/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 4 p.m. and 8 p.m. for grimacing with "some relief" as the result, indicated on the back of the MAR -July 2012: on 07/14/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 8:30 p.m. for facial grimacing with "some relief" as the result, indicated on the back of the MAR Review on 07/31/12 of R #1's Narcotic Count Record for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: on 04/05/12 at 4:00 p.m. -May 2012: none -June 2012: on 06/26/12 at 4:00 p.m. and 8:00 p.m.; on 06/27/12 at 12:00 a.m. -July 2012: on 07/14/12 at 8:30 p.m. On 07/31/12 at 4:45 p.m., the DON revealed the nursing staff were responsible for administering pain medications to residents when they exhibited signs of pain. The DON stated he was not aware that R#1 had pain when he was repositioned and given incontinent care every two hours. On 08/01/12 at 11:30 a.m., Licensed Vocational Nurse (LVN) "F" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by facial grimacing and that with "even the slightest movements, he grimaces." LVN "F" stated that R#1 was repositioned and given incontinent care every two hours. LVN "F" stated that, during the first two weeks in July, 2012, he had administered pain medication to R#1 approximately six times because R#1 was in pain. LVN "F" stated he could not remember what pain medication he had administered then, but had administered R#1 Tylenol the morning of 08/01/12. Review on 08/01/12 of R #1's MAR for the month of August 2012 revealed no pain medication documented that it was given to R #1. LVN "F" stated that he had forgotten to document on 08/01/12 that he had administered Tylenol PRN to R #1 "around 8 a.m. this morning." On 08/01/12 at 3:55 p.m., surveyor observed the following with CNAs "G" and "H" while repositioning R#1: R #1 was lying quietly in bed. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "G" and "H" turned R #1 onto his right side and pulled him up in bed. R #1 immediately began to moan loudly, his face grimaced, and both of his arms began to shake and tremble. CNAs "G" and "H" then raised R #1's left leg to place a pillow between R #1's legs. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately five minutes. After CNAs "G" and "H" finished giving care to R #1, he no longer moaned, grimaced or shook. On 08/01/12 at 4:00 p.m., CNA "G" (2 p.m. to 10 p.m. shift) stated that while repositioning R#1 on 08/01/12 at 3:55 p.m., R#1 exhibited signs of pain by grimacing, moaning, and shaking. CNA "G" stated R#1 was repositioned and given incontinent care every two hours and that he exhibited signs of pain each time he was repositioned. CNA "G" stated she had reported to the nurse that R#1 had pain every day she had worked which was four days per week, for the past two months. On 08/01/12 at 4:05 p.m., CNA "H" (2 p.m. to 10 p.m. shift) stated that R#1 exhibited signs of pain by grimacing and closing his eyes, and that he exhibited those signs when he was repositioned every two hours. CNA "H" stated she reported to the nurse when R#1 exhibited signs of pain. Record review of the facility's Administering Pain Medications Policy dated September 2003 revealed: "General Guidelines: 4. Be familiar with the physiologic and behavioral signs of pain" and "Steps in the Procedure: 4. Obtain objective information through assessment: (a) Behavioral responses to (acute) pain; (1) facial wrinkling/grimacing, (3) crying or moaning, (5) increase in body movements; 6. Administer pain medications as ordered." On 08/01/12 at 6:05 p.m., an IJ was identified and the DON, Administrator, and Owners were informed of the IJ at 6:05 p.m. On 08/01/12 at 7:45 p.m., the facility submitted a Plan of Removal which contained the following: 1. Resident identified to have been affected by the alleged deficient practice: -A comprehensive assessment was performed on R #1 on 08/01/02 at 6:20 p.m. -R #1 was noted to have pain rated at a 4 out of 10 upon manipulation of his left upper and lower extremities. -The physician was notified on 08/01/12 and an order for [REDACTED]. -The Charge Nurse was to assess R #1's pain every 4 hours and notify the physician if the pain medication was not effective. -R #1's Care Plan was updated. -On 08/01/12 at 7:22 p.m., R #1 was noted to be free from pain. 2. Residents with the potential to be affected by the alleged deficient practice: -All residents in the facility will be screened for pain management with physicians notified of residents with unrelieved pain. -All new admissions will be screened and have proper pain management plan of care put into place. -All nursing staff will be inserviced on each shift on proper pain assessment and management. -The Assistant Director of Nurses will daily review all residents to verify that proper pain mangement is being conducted. A written report will be provided to the DON daily. -DON will monitor daily the screenings to verify it is being conducted. Written report provided to the Administrator. -Administrator will daily monitor the DON report to verify screenings are being done. On 08/01/12 at 7:45 p.m., the DON stated that R #1 was assessed on 08/01/12 at 6:20 p.m., with his left arm manipulated to apply a blood pressure cuff. The DON stated that R #1 showed symptoms of pain by grimacing, frowning and clenching his fists. The DON stated that R #1 had received a dose of [MEDICATION NAME] on 08/01/12 at 6:30 p.m. At 7:22 p.m., staff manipulated R #1's left arm and there was no pain noted. Surveyor verified through record review on 08/01/12 and 08/02/12 that R #1 was administered [MEDICATION NAME] every four hours from 08/01/12 through 08/02/12 as ordered. On 08/02/12 at 11:15 a.m., surveyor observed the following with CNAs "J" and "K" during repositioning of R #1: R #1 was lying quietly in bed on his left side. CNAs "J" and "K" turned R #1 onto his right side and propped a pillow behind his back. R #1 did not moan, grimace or tremble. CNA "K" stated that R #1's pain "was better." Through observations, interviews and record reviews, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 08/02/12 at 2:50 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Record review of the facility's physician's orders [REDACTED]. On 08/02/12 at 4:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on observation, interview and record review the facility DON failed to monitor licensed nursing staff and the Administrator failed to monitor the DON to ensure pain relief was provided for one of six (R #1) residents reviewed for pain management when the facility recognized that R#1 exhibited pain by trembling, grimacing and clenching his fists daily for at least two months. -The resident grimaced, moaned, and trembled each time he was moved during care to include repositioning every two hours, incontinent care every two hours, pressure ulcer treatment daily and range of motion therapy daily. -Staff were aware that the resident suffered pain daily when moved due to his contractures. -The facility did not provide pain intervention prior to planned and routine care and services, causing R #1 to grimace, moan, and tremble. -The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This failure resulted in an Immediate Jeopardy (IJ) on 08/01/12. While the IJ was removed on 08/02/12, the facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Failure to provide pain relief affected R #1 by not receiving pain relief when moved approximately fifteen times per day for two months, and medicated four times with [MEDICATION NAME] in two months, could place 77 residents receiving pain management at risk for unrelieved pain. Findings were: Review of R#1's Face Sheet dated 04/03/12 revealed an admission date of [DATE]. Review of R#1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R#1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R#1 exhibited protective body movements or postures related to pain that were observed by staff, with a frequency of one to two days out of the previous five days; R#1 was totally dependent on staff for all Activities of Daily Living (bed mobility, transfers, toileting, bathing); R#1 had Functional Limitation in Range of Motion (ROM) to both the upper and lower extremities; R #1 was unable to speak, or express ideas or wants. Review on 07/31/12 of R#1's Care Plans revealed there was no Care Plan related to pain. Review on 07/31/12 of R#1's Pain Evaluation dated 04/02/12 revealed staff scored R #1's pain level at a 6 out of 10, which represented the following pain characteristics: Facial Expression "Facial Grimacing"; Body Language "Rigid, fists clenched, knees pulled up, pulling or pushing away, striking out"; Consolability "Unable to console, distract or reassure." Review on 07/31/12 of R#1's Physician order [REDACTED].-5). The Physician order [REDACTED]." On 07/30/12 at 3 p.m., family member (FM) "A" stated that R #1 was in pain every day she visited him. She would visit R #1 for approximately one hour per day, seven days per week. FM "A" stated she (FM "A") complained to staff that she knew R #1 was in pain by his moaning and facial grimacing, but that staff did not respond to her compliants. On 07/31/12 at 11:05 a.m., surveyor observed the following during incontinent care for R#1 with Certified Nurse Aides (CNAs) "A" and "B": R #1 was lying quietly in bed on his back. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "A" and "B" turned R #1 onto his left side. R #1 immediately began to moan loudly, his face grimaced, both of his arms began to shake and tremble, and his right hand formed into a fist. CNAs "A" and "B" then turned R #1 onto his right side. R #1 continued to moan loudly, grimace, and tremble. CNAs "A" and "B" then positioned R #1 onto his back to move him up in bed. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately ten minutes. The CNAs "A" and "B" did not attempt to alleviate R #1's pain during care. After CNAs "A" and "B" finished giving care to R #1, he no longer moaned, grimaced or shook. On 07/31/12 at 11:15 a.m., surveyor observed the following during pressure ulcer treatment for [REDACTED].#1 was lying on his back in bed quietly. CNAs "A" and "B" turned R #1 onto his right side. R #1 began to moan loudly, his face grimaced and both of his arms began to shake and tremble. After wound care, CNAs "A" and "B" turned R #1 onto his left side. R #1 moaned loudly, grimaced and trembled. CNAs "A", "B" and LVN "I" did not attempt to alleviate R #1's pain during care. LVN "I" stated that she had never taken care of R #1 before but felt his moaning, grimacing and trembling was due to pain. LVN "I" stated she was not responsible for administering pain medication to R #1 but was "sure the other nurses do." Review on 07/31/12 of R #'1 Treatment Orders dated 04/02/12 through 07/31/12 revealed R#1 received pressure ulcer treatment to his buttocks daily. On 07/31/12 at 1:30 p.m., CNA "B" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by moaning, grimacing and shaking when he was moved in bed and that he was moved every two hours. CNA "B" stated she reported to the nurse each time R#1 had pain. On 07/31/12 at 3:10 p.m., Restorative Aide (RA) "C" stated R#1 received Range of Motion (ROM) exercises seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, knees, fingers, wrists, shoulders, and forearms. RA "C" stated she regularly performed ROM exercises to R#1 for approximately five days per week, Monday through Friday. RA "C" stated she could tell that R#1 was in pain during ROM exercises because, "he grimaced and moaned." RA "C" stated she had not reported that R#1 was in pain to the nurses because, "when we are done with ROM, he stops grimacing." Review on 07/31/12 of R #1's Nursing Restorative Care Program records revealed ROM exercises were performed on R #1 seven days per week for a total of 15 minutes each day, by straightening out and rotating his elbows, fingers, wrists, shoulders, and forearms: 04/27/12 through 04/30/12; 05/01/12 through 05/31/12; 06/01/12 through 06/30/12 and 07/01/12 through 07/31/12. On 07/31/12 at 4:30 p.m., Registered Nurse (RN) "E" (2 p.m. to 10 p.m. shift) stated that she could tell R#1 was in pain during routine care by his facial expressions and moaning. RN "E" stated R#1 was moved from side to side every two hours for repositioning and incontinent care, and that he exhibited signs that he was in pain when he was moved. RN "E" stated the CNAs were, "good about reporting signs of pain." RN "E" stated that there was an order for [REDACTED].#1 on 07/31/12. RN "E" said it was not reported to her on 07/31/12 that R#1 had pain during ROM exercises. Review on 07/31/12 of R#1's Medication Administration Records (MAR) for the following months revealed Tylenol PRN was administered: -April 2012: none -May 2012: on 05/20/12 at 10 a.m. for an elevated temperature, indicated on the front and back of the MAR -June 2012: on 06/29/12 (no time) for an elevated temperature, indicated only on the front of the MAR -July 2012: none Review on 07/31/12 of R #1's MAR for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: none -May 2012: none -June 2012: on 06/26/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 4 p.m. and 8 p.m. for grimacing with "some relief" as the result, indicated on the back of the MAR -July 2012: on 07/14/12: on the 2 p.m. to 10 p.m. shift, indicated on the front of the MAR; at 8:30 p.m. for facial grimacing with "some relief" as the result, indicated on the back of the MAR Review on 07/31/12 of R #1's Narcotic Count Record for the following months revealed [MEDICATION NAME] PRN was administered: -April 2012: on 04/05/12 at 4:00 p.m. -May 2012: none -June 2012: on 06/26/12 at 4:00 p.m. and 8:00 p.m.; on 06/27/12 at 12:00 a.m. -July 2012: on 07/14/12 at 8:30 p.m. On 07/31/12 at 4:45 p.m., the DON revealed the nursing staff were responsible for administering pain medications to residents when they exhibited signs of pain. The DON stated he was not aware that R#1 had pain when he was repositioned and given incontinent care every two hours. On 08/01/12 at 11:30 a.m., Licensed Vocational Nurse (LVN) "F" (6 a.m. to 2 p.m. shift) stated that R#1 exhibited signs of pain by facial grimacing and that with "even the slightest movements, he grimaces." LVN "F" stated that R#1 was repositioned and given incontinent care every two hours. LVN "F" stated that, during the first two weeks in July, 2012, he had administered pain medication to R#1 approximately six times because R#1 was in pain. LVN "F" stated he could not remember what pain medication he had administered then, but had administered R#1 Tylenol the morning of 08/01/12. Review on 08/01/12 of R #1's MAR for the month of August 2012 revealed no pain medication documented that it was given to R #1. LVN "F" stated that he had forgotten to document on 08/01/12 that he had administered Tylenol PRN to R #1 "around 8 a.m. this morning." On 08/01/12 at 3:55 p.m., surveyor observed the following with CNAs "G" and "H" while repositioning R#1: R #1 was lying quietly in bed. Both knees and elbows were bent at an approximate ninety degree angle. R #1's left hand was formed into a fist. There was no contracture to his right hand. CNAs "G" and "H" turned R #1 onto his right side and pulled him up in bed. R #1 immediately began to moan loudly, his face grimaced, and both of his arms began to shake and tremble. CNAs "G" and "H" then raised R #1's left leg to place a pillow between R #1's legs. R #1 continued to moan loudly, grimace, and tremble. The care performed lasted approximately five minutes. After CNAs "G" and "H" finished giving care to R #1, he no longer moaned, grimaced or shook. On 08/01/12 at 4:00 p.m., CNA "G" (2 p.m. to 10 p.m. shift) stated that while repositioning R#1 on 08/01/12 at 3:55 p.m., R#1 exhibited signs of pain by grimacing, moaning, and shaking. CNA "G" stated R#1 was repositioned and given incontinent care every two hours and that he exhibited signs of pain each time he was repositioned. CNA "G" stated she had reported to the nurse that R#1 had pain every day she had worked which was four days per week, for the past two months. On 08/01/12 at 4:05 p.m., CNA "H" (2 p.m. to 10 p.m. shift) stated that R#1 exhibited signs of pain by grimacing and closing his eyes, and that he exhibited those signs when he was repositioned every two hours. CNA "H" stated she reported to the nurse when R#1 exhibited signs of pain. Record review of the facility's Administering Pain Medications Policy dated September 2003 revealed: "General Guidelines: 4. Be familiar with the physiologic and behavioral signs of pain" and "Steps in the Procedure: 4. Obtain objective information through assessment: (a) Behavioral responses to (acute) pain; (1) facial wrinkling/grimacing, (3) crying or moaning, (5) increase in body movements; 6. Administer pain medications as ordered." On 08/01/12 at 6:05 p.m., an IJ was identified and the DON, Administrator, and Owners were informed of the IJ at 6:05 p.m. On 08/01/12 at 7:45 p.m., the facility submitted a Plan of Removal which contained the following: 1. Resident identified to have been affected by the alleged deficient practice: -A comprehensive assessment was performed on R #1 on 08/01/02 at 6:20 p.m. -R #1 was noted to have pain rated at a 4 out of 10 upon manipulation of his left upper and lower extremities. -The physician was notified on 08/01/12 and an order for [REDACTED]. -The Charge Nurse was to assess R #1's pain every 4 hours and notify the physician if the pain medication was not effective. -R #1's Care Plan was updated. -On 08/01/12 at 7:22 p.m., R #1 was noted to be free from pain. 2. Residents with the potential to be affected by the alleged deficient practice: -All residents in the facility will be screened for pain management with physicians notified of residents with unrelieved pain. -All new admissions will be screened and have proper pain management plan of care put into place. -All nursing staff will be inserviced on each shift on proper pain assessment and management. -The Assistant Director of Nurses will daily review all residents to verify that proper pain mangement is being conducted. A written report will be provided to the DON daily. -DON will monitor daily the screenings to verify it is being conducted. Written report provided to the Administrator. -Administrator will daily monitor the DON report to verify screenings are being done. On 08/01/12 at 7:45 p.m., the DON stated that R #1 was assessed on 08/01/12 at 6:20 p.m., with his left arm manipulated to apply a blood pressure cuff. The DON stated that R #1 showed symptoms of pain by grimacing, frowning and clenching his fists. The DON stated that R #1 had received a dose of [MEDICATION NAME] on 08/01/12 at 6:30 p.m. At 7:22 p.m., staff manipulated R #1's left arm and there was no pain noted. Surveyor verified through record review on 08/01/12 and 08/02/12 that R #1 was administered [MEDICATION NAME] every four hours from 08/01/12 through 08/02/12 as ordered. On 08/02/12 at 11:15 a.m., surveyor observed the following with CNAs "J" and "K" during repositioning of R #1: R #1 was lying quietly in bed on his left side. CNAs "J" and "K" turned R #1 onto his right side and propped a pillow behind his back. R #1 did not moan, grimace or tremble. CNA "K" stated that R #1's pain "was better." Through observations, interviews and record reviews, the survey team determined that the interventions documented in the facility's Plan of Removal were implemented and the IJ was removed effective 08/02/12 at 2:50 p.m. The facility remained out of compliance for actual harm at a scope of pattern due to the facility was still monitoring the Plan of Removal. Record review of the facility's physician's orders [REDACTED]. On 08/02/12 at 4:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.